DT UK No. 1+2, 2016

News / The role of the hygienist in the 21st century / Becoming a principal - now what? / Plaque - sugar - obesity - diabetes and smoking / The sweet miracle of xylitol / Ortho Tribune United Kingdon Edition No. 1+2 - 2016

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DTUK0116_01_Title 25.02.16 14:53 Seite 1

DENTAL TRIBUNE
The World’s Dental Newspaper · United Kingdom Edition
Published in London

www.dental-tribune.co.uk

Vol. 10, No. 1 + 2

NOW WHAT?

ORAL DISEASES

ORTHO TRIBUNE

Becoming the owner of your
own business brings challenges
for which you must ensure you
are prepared.

While blaming patients, dentists
are often failing to diagnose and
treat other contributing causative
factors.

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

” Page 12

” Page 14

” Page 17

Teeth
myth
GDC lays out three-year road map debunked
Under-fire regulator announces changes to fitness to practise process
By DTI

By DTI

LONDON, UK: New research has now
shown that oral health in the UK is
comparable to, or even slightly better
than, in the United States. The study
that was conducted by researchers
from both sides of the pond found
that compared to the British, Americans, and particularly women, have
less of their own teeth left. Furthermore, in the UK, mainly elderly people
are affected by edentulousness, but in
the US, missing teeth were found to be
more prevalent in middle age groups.
Although similar large social disparities in oral health were deemed to
exist in both countries, people with
a lower education and income generally tended to have better teeth in
Britain. The oral health status of the
wealthy and educated, however, was
much better in the United States, the
researchers found.

LONDON, UK: The General Dental
Council (GDC) has announced legislative change that will see the introduction of case examiners to streamline
its fitness to practise process. By reducing the number of cases heard by
the regulatory body, the organisation
hopes to save £1.8 million per year.
According to the GDC, case examiners will carry out the decisions
currently made by its Investigating
Committee. They will be able to make
agreements with dental professionals
to help them meet the required standards through training, allowing the
person to practise under supervision
of another registered dental professional or by allowing him or her to
work if he or she meets certain conditions.
“When someone is being investigated by the GDC, we recognise this
places the person under considerable
stress and anxiety,” commented Director of Fitness to Practise at the GDC
Jonathan Green on the change. “While
we absolutely have a duty to protect
patients by taking swift action against
those who should not be practising
dentistry, we must make the entire
process as efficient, seamless and
timely as possible by providing the
necessary support.”

By reducing the number of cases heard by the regulatory body, the GDC hopes to save £1.8 million per year.

The organisation received over
3,000 cases in 2014 according to its
annual report. Approved by both the
Houses of Parliament and the Scottish
Parliament, the new legislation will
come into effect on 13 April. It is part of
a three-year road map aimed at making dental regulation in the UK more
effective, the organisation said.
In addition to the introduction of
case examiners, improvements will
be made to the current complaints
system, which will be addressed lo-

cally when possible. Further goals are
to enhance transparency and to improve patient information.
“We want patients to be able to
make informed choices about their
care so when they visit a dentist or
dental care professional, they are
confident that the treatment they receive is from someone is who qualified and trained to deliver the best
possible care,”William Moyes, Chair of
the GDC, commented. “We also want
to help the profession to continuously

improve by using our standards as a
guide and sharing best practice to deliver the best quality of care to every
patient, in every setting, every time.”
The GDC has come under fire recently from both legislators and the
British Dental Association over an
investigation into a whistle-blower’s
complaint by the Professional Standards Authority for Health and Social Care that identified a number
of governance issues at the organisation’s top.

For the study, which was published in the Christmas edition of
the British Medical Journal, the researchers from universities in London, Boston and Bogotá, Colombia
analysed and compared data from
the British Adult Dental Health
Survey 2009 and the U.S. National
Health and Nutrition Examination
Surveys from 2005 to 2008.
It is the first study to have directly
compared oral health data between
the two countries.
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UK NEWS

Trauma at the library
Dental charity is preparing for annual congress in London

The British Library will host the annual congress of Dental Trauma UK again. © Gabriele Gelsi

By DTI
LONDON, UK: As head of the UK’s
first adult dental trauma service at
King’s College Hospital in London,
Dr Serpil Djemal has seen all types
of dental trauma ranging from
enamel fractures to all of the luxations including knocked out teeth.
What she and her team have noticed
is that most patients who have visited the service did not know what
to do when they knocked their
tooth out, let alone who to see for
help. In order to make the public
aware of this, she and an enthusiastic group of individuals including
Dr Aws Alani, also a consultant in restorative dentistry at King’s College
Hospital, founded Dental Trauma
UK in 2014.

In March, the young charity is already going hold its second annual
congress at the British Library in
London. Over the course of this day,
Serpil will introduce experts in the
field of restorative dentistry, trau-

matology and endodontics including restorative consultant James
Darcy from Manchester and Paul
McCabe from Ireland to discuss
aspects of dental trauma and give
practical tips how to best manage
them. Attending the conference will
allow participants to earn 5 CPD
points.

“There is clearly a knowledge and
skill gap in the dental market as dental trauma is not brilliantly covered
in the dental curriculum and most
dentists are seldom confronted
with dental trauma in their careers,"

she said. "As a result many do not
have the necessary skills for managing trauma in the first place and
even if they acquire some skills, they
are not retained because of lack of
practice.”
The premier conference held at
the same location in 2015 attracted

Dental Tribune United Kingdom Edition | 1+2/2016

over 130 participants and membership of the charity (£30 per year) is
already at 290. So far, interest has
been great for this year with 100
dentists, nurses and technicians
registered for the meeting. As a
member of Dental Trauma UK they
not only get a 50 per cent discount
on their congress registration fee
but also access to free CPD after the
conference in the form of lectures
and videos of how to manage cases.

IMPRINT

“It is all about practical application and what to do to save teeth and
smiles. Our aim is to inform general
dental practitioners so they can deliver the best care for their patients
who may be unfortunate to suffer a
dental trauma”, Serpil explains.

COPY EDITORS:
Sabrina RAAFF, Hans MOTSCHMANN

The main focus of the charity is
to raise awareness amongst the
general public, particularly groups
that are often confronted first with
dental trauma like teachers or paramedics on how dental trauma occurs and what to do about it. A few
campaigns are being been planned
including selfie-your-smile and
what to do in the immediate aftermath of knocking an adult tooth
clean out of the mouth. A couple of
celebrities are already signed up to
help support these.
“It is really simple; we want anyone and everyone to know that if
they knock an adult tooth out of
their mouth, they should pick it up
by the crown, lick it clean if it is dirty
and stick it back into position. Whilst
the tooth may not last forever, doing
this within the first 5 minutes wiIl
give the tooth the best chance of
survival” Serpil said. “So, PICK IT
LICK IT STICK IT is what she and her
team recommend”.
Registration for the 2016 congress
is still open at: dentaltrauma.co.uk/
Dental+team/Conferences.aspx

CBT successful in reducing phobia
By DTI

factors in the study were identified
as drilling and having an injection.

LONDON, UK: The latest government figures estimate that one in
ten people in the UK suffer from
dental anxiety. New research from
King’s College London involving
pretreatment use of cognitive behavioural therapy (CBT) has shown
that the method is largely effective
in helping patients overcome their
fear of treatment.
In a study involving patients suffering from high levels of dental
phobia, the researchers found that
the overall majority were able to
undergo treatment without sedation
after having undergone therapy at
the Dental Institute Health Psychology Service at Guy’s and St Thomas’
NHS Foundation Trust. Only six per
cent of the patients surveyed had to
be treated with sedation.
“Our study shows that after on
average five CBT sessions, most
people can go on to be treated by
the dentist without the need to be

Newton recommended that, despite the positive outcome, CBT
should be viewed as complementing sedation services rather than
as an alternative, the two together
providing a comprehensive care
pathway for the ultimate benefit of
patients. Furthermore, patients
should be carefully assessed by
trained CBT practitioners, since
they could be suffering from additional psychological conditions.

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Torsten OEMUS
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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

Published by DTI.
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With CBT a therapist aims to help patients change their feelings and behaviours by
restructuring their thinking and breaking negative thought cycles. © Pressmaster

sedated,” said Tim Newton, lead
author and Professor of Psychology
as Applied to Dentistry.
A short-term therapy, CBT has
been shown to help with depression
and a number of anxiety-related
disorders, such as obsessive–com-

pulsive disorder and bulimia. Typically, over six to ten sessions, a therapist aims to help patients change
their feelings and behaviours by
restructuring their thinking and
breaking negative thought cycles.
According to the researchers, the
most common anxiety-inducing

“CBT provides a way of reducing
the need for sedation in people with
a phobia, but there will still be those
who need sedation because they
require urgent dental treatment or
they are having particularly invasive treatments,” he said.
Over one-third of those patients
surveyed in the study showed signs
of general anxiety, while one in
ten had depression or suicidal
thoughts.

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 to subscribe
our weekly Dental Tribune UK
e-newsletter.

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The DTI publishing group is composed of the world’s leading
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[4] =>

DTUK0116_04_News 25.02.16 14:57 Seite 1

UK NEWS

Dental Tribune United Kingdom Edition | 1+2/2016

Cochrane finds crowns
superior to dental fillings
By DTI
DUNDEE, UK: The Cochrane Oral
Health Group in Manchester has recently updated one of its reviews, finding any kind of preformed crown to be
superior to fillings in the treatment of
severely decayed primary molars and
primary molars that have undergone
pulp treatment. The results also suggest that out of all fitting methods, the
Hall technique causes the least discomfort and problems for patients.
Named after its inventor, a Scottish
dentist, the Hall technique uses a pre-

formed metal crown that is fitted over
the tooth with no local anaesthetic,
carious tissue removal or tooth preparation. First introduced a decade
ago, it was originally developed as a
non-invasive treatment for decayed
primary molars.
For their review, the researchers
looked at the clinical outcomes of
several studies comparing fillings
with crowns that were fitted with
either conventional methods or the
Hall technique. They also included
studies that compared preformed
crowns with non-restorative caries

management, as well as preformed
metal crowns with preformed white
crowns.
While the review found no evidence
of the superiority of one crown type
to another, the results showed
that teeth restored with preformed
crowns compared with fillings are less
likely to develop problems or cause
pain over time.
“Crowns are recommended for
restoring primary molars that have
had a pulp treatment, are very decayed or are badly broken down.

Photo showing a preformed metal crown fitted with the Hall technique.

However, few dental practitioners
use them in clinical practice,” the
researchers said in the report.

mary teeth restored with preformed
crowns or with fillings was in any way
related to the extent of their decay.

With the review, the researchers
originally sought to determine
whether the clinical outcome of pri-

The review updates a previous
version on the subject, originally
published by the group in 2007.

New discovery helps strengthen
bonding of titanium implants to bone
By DTI
BRISTOL, UK: Scientists at the University of the West of England (UWE) in
Bristol have discovered a new way to
improve the bond between
titanium implants and bone.
They found that a bioactive
lipid called lysophosphatidic
acid (LPA) interacts with
vitamin D to enhance boneforming cell function. Based
on this finding, the researchers have developed
an LPA coating for titanium
implants to help strengthen
the bonding properties of
implants to bone.
“Many implants used in
surgery are made out of
titanium. These include joint
replacements, screws and
plates for fixing broken
bones and dental implants,”
said Dr Jason Mansell, a senior lecturer in Biomedical
Sciences at UWE Bristol, who
led the study.

“Implants work well when the patient’s own bone joins onto the titanium using the body’s own natural
healing processes. When this join
forms properly it is extremely strong,

however in some cases, the patient’s
bone fails to join strongly to the titanium and therefore the prosthesis
works loose and ultimately fails,”
Mansell explained.

Although the success rates of
dental implants are high, ranging
between 88 and 99 per cent in the literature, several factors, such as bone
quality and quantity, as well as infection, can cause dental implants
to fail, making reimplantation
necessary. The new LPA coating,
developed by the researchers
could further improve the success rate of dental implant treatments.

LPA is a naturally occurring
fatty molecule that acts with vitamin D to promote bone-forming cell function, the researchers
discovered. “This is a very exciting discovery as few agents are
known to enhance the actions
of vitamin D on bone forming
cells. Vitamin D is vital for bone
health because it enhances bone
forming cell function. Therefore, agents that can co-operate
with vitamin D could find place
as a coating on titanium to enA team of researchers, led by Dr Jason Mansell from UWE Bristol, has discovered a new way to coat courage better bonding to the
titanium implants in order to improve their bond to bone.
patient’s bone,” Mansell said.

Based on this knowledge, the scientists developed an LPA coating for titanium implants. “We have found a way
of joining LPA onto titanium using a
simple process at room temperature.
Recently we also discovered that our
novel coating also deterred the attachment of bacteria, this is particularly
exciting as it means we have a potential dual-action titanium implant material,” Mansell stated.
The next stage of the project, which
is currently seeking further funding,
will examine the robustness and stability of the coating, as it would need
to withstand the rigors of storage,
sterilisation and the physical forces it
would be exposed to when implanted
into the body.
The study, titled “Fluorophosphonate-functionalised titanium via a
pre-adsorbed alkane phosphonic acid:
A novel dual action surface finish for
bone regenerative applications”, was
published online ahead of print in the
Journal of Materials Science: Materials
in Medicine on 24 December 2015.

Funding brings Manchester diagnostic
tech closer to market launch
By DTI
MANCHESTER, UK: New diagnostic
technology developed by a University
of Manchester spin-out that could
help detect early-stage enamel caries
faster could soon be ready to enter the
market, as the developer has recently
announced that it has received funding from a Northern England investor.
In a commitment to expand to the
North of England, Mercia Fund Man-

agement has said it will invest over
a quarter of a million pounds in the
new software, which is claimed to be
capable of spotting early caries and
other potential problems before they
develop into something more serious.
A brainchild of University of Manchester spin-out Manchester Imaging, the software uses technologies
like active shape models and active
appearance models, which are al-

ready used in medicine and face
recognition, for example, to analyse
dental radiographs in order to find
early signs of caries.
According to Manchester Imaging
CEO Tony Travers, it is the first time
that this kind of modelling has been
applied to dentistry.
Traditional methods of early caries
detection include the use of laser-

induced fluorescence or detection
gels, which may however be unreliable.
“Manchester Imaging’s computeraided dental diagnostic software has
been developed to overcome the
problems of early-stage identification through the use of pioneering
technology that pinpoints the first
traces of decay at the touch of a
button,” Travers told Dental Tribune.

“It integrates seamlessly with existing
digital X-ray and practice software.”
According to Travers, the technology could be market ready as early
as 2017. Another funding round for
investors is anticipated for this year.
In addition to caries detection,
Manchester Imaging is working on
other imaging technologies for use
in dental implantology, for example.

[5] =>

DTUK0116_05-06_Ubhi 25.02.16 14:57 Seite 1

UK NEWS

Dental Tribune United Kingdom Edition | 1+2/2016

“Prevention of sex trafficking is our
ultimate aim”
An interview with York dentist Dr Andrea Ubhi
Sex trafficking remains a major
issue in many parts of Asia, not
only in sex tourism hot spots like
in Indonesia or Thailand but also
in smaller countries like Nepal.
UK-based charity Asha Nepal
(hope for Nepal) tries to prevent
children becoming involved in the
sex trade and helps victims of trafficking and sexual abuse in the
country to re-establish themselves
in society. Dental Tribune UK spoke
about the organisation’s work and
its impact on the lives of survivors
with one of the charity’s trustees,
Dr Andrea Ubhi from York, who is
to take over as chairperson later
this year and who runs one of the
country’s leading private dental
practices.
Dental Tribune: Dr Ubhi, you run a
successful dental practice in York.
How did you first become involved
with Asha Nepal?
Andrea Ubhi: I have been involved with a few charities over
the years; however, it has been
difficult for me to find as much
time as I wanted to give to charity
work, as I have been busy building
up dental businesses, in addition
to bringing up three children.
Several years ago, I sold one of
my practices, an NHS practice, and
that reduced my workload, finally
giving me the time and money to
expand my interest in charity. Although I had never really focused
on women’s issues before, knowing that men and women are
equal in the world, I decided to become involved in Asha Nepal, as
I had been becoming increasingly
aware of the issue of trafficking
and Asha was at a small size where
I thought my management skills
would be of better use than in
a larger organisation and, frankly,
I wanted to know exactly where
my money was going.
Nepal usually does not make the
headlines when it comes to sex
trafficking. To your knowledge, how
extensive is the problem in the
country?
Although its neighbour India
has much more children involved
in sex trafficking, estimated at one
million, about 30,000 girls from
Nepal are tricked into going over
the border each year and trafficked, and they end up as sex
workers in the major cities. When
you actually consider the difference in size of population between
the two countries, proportionally
this is a large number. One of
the greatest issues is poverty.
Attending a reasonably good
school requires school fees. That
is why many children in Nepal
do not have the opportunity to
go to school. The only thing they
are often left to do is to work in

the mothers can get on their feet.
Asha has a job coordinator who
helps mothers or trafficking survivors obtain a place in a training
programme and then work.
How many of the children you
look after find their way back into
society?
All of them. In some cases in
which children have been trafficked or are victims of sexual
abuse by their own family and
are in high danger of being retrafficked, there is no hope of
safe reintegration with their own
family. Asha assigns such children
to foster families. They remain
there with Asha until they are old
enough to be integrated into society independently when they
are adults.

Dr Andrea Ubhi (second from right) with Asha Nepal children. © Asha Nepal, UK

domestic labour, often from as
young as the age of four, and they
are at risk of sexual abuse.
Once a child is in domestic
labour, there is also a high risk of
being trafficked. Sometimes, this
happens insidiously: someone
might say that he or she has a
better job in the next town, then
someone might offer the child
a job in Delhi, which in the end
turns out to be captivity in a
brothel.
How is your organisation helping
victims of sex trafficking in Nepal
itself?
Some of the girls who come to
Asha have been trafficked and
rescued from cabin bars in the
tourist district of Kathmandu.
They started as dancers and were
then forced into the sex trade.
What is great about Asha Nepal is
that it does not provide an orphanage or children’s home as such but
a transitional home. Asha seeks to
work with the child’s or teenager’s
immediate family or the extended
family to help the child/teenager
transition back safely into the
community. Asha offers counselling after trauma, provides education and a safe home, and then
Asha’s social workers work with
their families to give parenting
training, life skills and access to
safe accommodation so that the
child/teenager can return to living
at home and be reintegrated into
the community. Independence is
one of our main aims.
Asha Nepal considers the whole
picture and tries to prevent children being trafficked by providing funding to very poor families

to help give their children an
education, which in turn provides
the hope of dignified employment when the child reaches
adulthood. If children are at tending school, their families do
not allow them into domestic
servitude.

Asha Nepal also works with the
mothers of poor families; for example, the father may be unemployed, drink too much or abandon his family altogether. If there
are issues with providing for the
family, Asha Nepal assists with
emergency rent and food so that

The April earthquake last year had
a devastating effect on the country’s infrastructure. Has this affected your work and, if so, to what
extent?
When I went over in September,
they were still terrified because it
was not just only one earthquake,
but about 300. There were continual tremors and many people
were sleeping outside, even when
it was cold and raining. While the
destruction in Kathmandu was
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[6] =>

DTUK0116_05-06_Ubhi 25.02.16 14:57 Seite 2

UK NEWS

significant, in the north-eastern region almost four out of five houses
were destroyed or significantly
damaged. When we spoke with one
of the children’s ministers in that
area to find out what the need was,
she said that there were about
7,000 children displaced through
the earthquake. Throughout the
Sindhupalchowk border, guards
were checking papers of children
going out. There was such an increased risk of trafficking and they
were trying to reduce that. All chil-

Dental Tribune United Kingdom Edition | 1+2/2016

“...about 30,000 girls from Nepal
are tricked into going over the border
each year and trafficked...”
dren had to have papers that allowed them to exit the area.

Generally, our work became
more complicated and more ex-

pensive, as prices rose throughout
the earthquake period. On top of

You are soon to take over the responsibility of chairperson from retiring Asha founder Peter Bashford.
What will the focus of your work be
in the years to come?
I want to see the team consolidate. The organisation has grown
dramatically in the last two years,
going from eight to 23 employees.
Currently, we are looking after
107 children, of whom 51 are in our
residential care.

The South African Society of
Endodontics & Aesthetic Dentistry

We want to concentrate on reintegration into the community
and more community support,
which means fewer children in residential care and more supported
by our social welfare team in the
community. This way, we keep
children more independent and
prevent them from being institutionalised.

Endodontic & Restorative
Excellence at the
Apex of Africa

Christine Berthold (Canada)
Elio Berutti (Italy)
Arnaldo Castellucci (Italy)
Bernard Friedland (USA)
James L Guttman (USA)
Markus Haapasalo (Canada)
Sergio Kuttler (USA)

that, there is the recent fuel crisis
that Nepal has been facing over
the past few months, as no oil or
gas has been available from India
for political reasons. This has
slowed the country down, which
is such a shame considering how
difficult the year had already been
with the earthquake. It has also increased the cost of our work again
owing to the increased costs of
supplies because of the increasing
costs of petrol and transport.
Nepal is a landlocked country, so
everything has come through
India or China. If there is a blockade, it poses a significant problem
to the entire infrastructure in
Nepal.

However, prevention of trafficking is our ultimate aim. We have
just started a new Facebook page
for teenagers in Nepal, called
“Keeping SAFE”, to teach them to
avoid traffickers and recognise
their tricks. The page has an enormous following, with up to a quarter of a million people viewing
each post. We are also planning
to go into schools and hold presentations about the dangers of
trafficking, not only for the children but also for the teachers so
that they can teach their future
pupils about the tricks that traffickers use to force children into
domestic or sex labour and how to
avoid being trafficked.

SPEAKERS

Martin Levin (USA)
Tara Mc Mahon (Ireland)
Francesco Mangani (Italy)
John Meechan (UK)
Yoshitsugu Terauchi (Japan)
Martin Trope (USA)
Peet van der Vyver (South Africa)

Dr Ubhi, thank you very much for
the interview and good luck for the
future.

SPONSORS
SILVER

DIAMOND

BRONZE
Dr Andrea Ubhi
For further information, please visit
www.asha-nepal.org.

3-6 June 2016, Cape Town, South Africa www.ifea2016.com

[7] =>

DTUK0116_07_News 25.02.16 14:58 Seite 1

WORLD NEWS

Dental Tribune United Kindom Edition | 1+2/2016

Roots Summit 2016
Premier global forum for endodontics takes place in Dubai
By DTI
DUBAI, UAE: This year’s ROOTS
SUMMIT, which has drawn dental
professionals to various locations
all over the world in the past
decade, will take place from Nov. 30
to Dec. 3 at the Crowne Plaza Dubai
hotel in the United Arab Emirates.
Aimed at updating participants
about the latest in endodontic
treatment, an unparalleled series
of lectures and workshops will be
held by global opinion leaders in
the field.
Although the meeting will focus
exclusively on the latest techniques and technologies in endodontics, the organizers have
strongly encouraged not only dentists specializing in the field to
attend but all who have an interest
in endodontics, including general
dentists and manufacturers and
suppliers of endodontic products.
Overall, about 700 attendees are
expected.
Over the past 15 years, the ROOTS
SUMMIT has grown significantly.
The community originally started
as a mailing list of a large group of
endodontic enthusiasts in the
1990s. After the establishment of
a dedicated Facebook group three
years ago, membership increased
from 1,000 to more than 20,000.
Today, the group is composed of
members from over 100 countries.
Previous ROOTS SUMMITS have
been held in Canada, the US,
Mexico, Spain, the Netherlands,
Brazil and last year in India. These
meetings have been known for
the strength of their scientific
programs and their relevancy to
clinical practice. The lectures,
workshops and hands-on courses
scheduled for this year’s meeting
will be no exception. More than
15 distinguished experts are presenting during the conference.

izers anticipate a large turnout for
this year’s meeting. Various sponsorship opportunities are available, including booth space, as well
as sponsorships of workshops,
hands-on courses, meeting bags
and social events.

MAJOR
EXHIBITION

MEET
BUYERS

PRODUCT
LAUNCHES

FIND A UK
DEALER

EXHIBITOR
SATISFACTION

INTERNATIONAL
PACKAGES

For the summit in Dubai, the
organizers have partnered with
Dental Tribune International (DTI)
and the Dubai-based Centre for
Advanced Professional Practices
(CAPP) for the first time. With its
international network, composed
of the leading publishers in dentistry, DTI reaches more than
650,000 dental professionals in
90 countries through its print,
online and educational channels,
as well as a number of special
events.
Over the past decade, CAPP has
been able to establish first-class
standards for continuing dental
education programs not only in the
UAE but also across the Middle East.
Since 2012, CAPP has been affiliated
with DTI as a strong local partner
in the Middle East.
Based on the successes of previous ROOTS SUMMITS, the organ-

Online registration for the
ROOTS SUMMIT is now open at
www.roots-summit.com. Dental
professionals are also invited to
join the ROOTS Facebook group
and like the ROOTS SUMMIT 2016
Facebook page.

BOO
YOU K
STA R
ND

NOT JUST
ALL MOUTH.
The only event where you can reach
all sectors of the UK dental market.
For more information call
+44(0)20 7348 5270 or
email dentistry@closerstillmedia.com

PRACTICE OWNERS
& MANAGERS

DENTISTS

DENTAL HYGIENISTS
& THERAPISTS

DENTAL NURSES

TECHNICIANS
& CDTs

[8] =>

[9] =>

DTUK0116_09_Sharma 25.02.16 14:58 Seite 1

Dental Tribune United Kindom Edition | 1+2/2016

WORLD NEWS

European Aligner Society paves
way for future orthodontics
By Claudia Duschek, DTI
VIENNA, Austria: The increasing
number of adult patients seeking
orthodontic treatment but expressing concerns regarding aesthetics and comfort, has given rise
to alternatives to conventional
fixed appliances over the past
decade. Until now, however, there
has been no independent forum
for examining aligners as a primary orthodontic appliance. At the
first congress of the European
Aligner Society (EAS), Dental Tribune
spoke with Ritesh Sharma, Marketing Director at Align Technology,
about how the establishment of
the independent aligner body
could change the way orthodontics
is practised.
“The struggle we faced prior to
the establishment of the EAS was
that we did not have an independent forum to validate the claims
of manufacturers. In addition, the
foundation of such an independent body was essential from the
consumer’s point of view. Patients
needed an institution from which
they could obtain independent
advice,” Sharma told Dental Tribune
in Vienna. “About two years ago,
at our European advisory board
meeting in Brussels, we therefore
discussed the idea of launching
an aligner society with the orthodontists who went on to become
founding members of the EAS,
including Dr Les Joffe, who was

one of the first orthodontists to
treat patients with Invisalign in
the UK. We received an overall
very good response from all parties
involved.”

and therefore have considerable
expertise in the field,” Sharma said.

as the rapidly growing importance
of digital technologies.

Today, over 30 per cent of an
estimated 2.6 million orthodontic

“In the absence of knowledge,
people take what they get. Through

tem,” Sharma said. To this end, the
EAS is targeting both orthodontists
and general dentists.
“Moreover, orthodontics needs
to keep pace with technological
advancements,” he explained.
“Brackets and wires have been
used for orthodontic treatment
for more than 150 years with hardly any adaptation to modern technology. We believe that patients
should not be treated with technologies that are obsolete.”
That the first EAS congress attracted more than 300 participants
from Europe, which is considered
the most significant market for
aligner treatment, as well as from
Asia and the Middle East, reflects
the importance of aligners in orthodontics today. “The congress
surpassed our expectations. About
five years ago, aligners were not
widely accepted by orthodontists.
They were rather considered an inferior plastic device. The attention
the first EAS congress received
shows the progress we have made
in the past few years developing
the system to treat more complex
malocclusions and educating orthodontists about the potential it
gives them to expand their clinical
treatment portfolio. It really shows
that aligners are becoming the new
norm,” Sharma said.

Ritesh Sharma

Align Technology, a market
leader in aligner therapy, believed it
important not to interfere with the
establishment of the independent
body. “In the launch of the society, it
was not our job to influence but to
bring in the right people—people
who have been working successfully with aligners for a long time

cases a year worldwide are suitable
for Invisalign treatment, but only
3–4 per cent of patients are actually
treated with this clear aligner system. According to Sharma, this is
soon to change through increasing
awareness of the benefits of alternative treatment options among
patients and dentists alike, as well

the work of the EAS, we want to
ensure that patients know that
they have a choice and do not have
to accept metal braces. However,
our efforts can only succeed if dentists believe that aligners are the
right choice for the patient. Therefore, the primary aim of the society
is to educate dentists on the sys-

“As a supporter of the society,
we are facilitating the coming
together to change the behaviour
and mind set of dentists regarding orthodontics. This cannot be
achieved by one company, only
through the combined efforts of
experienced clinicians and manufacturers. It is exciting to be a part
of this,” he concluded.

New dental alert system aims at
improving patient safety in Europe
By DTI

or justification of the restriction,
concerned regulators may request
further information.

STRASBOURG, France: Requiring
dental regulators in countries
within the European Economic
Area (EEA) to inform each other
once a dental professional has
been prohibited or restricted from
practising, the newly implemented
European Alert Mechanism aims
at improving transparency in
European dentistry.

“We are delighted that this system has come into effect, it gives
patients much greater visibility
and security when it comes to their
oral health,” commented Dr Nigel
Carter, OBE, Chief Executive of the
British Dental Health Foundation,
on the new legislation. “This will
hopefully lead to an improvement
in standards of dental practice
Europe-wide and more public trust
in dentistry.”

The new EU legislation, which
came into effect on 18 January, provides that a Europe-wide alert be
issued within three days of a decision
to prohibit, suspend or restrict a professional’s practice—even on a temporary basis—in another EEA state.
As a minimum, national regulatory bodies, such as the General
Dental Council in the UK or the
National Board of Health and Welfare in Sweden, will need to include
the respective professional’s name,

as well as his or her date and place
of birth, in order to allow other regulators to identify that individual.

Furthermore, the alert must indicate the period for which the restriction applies, including the date

on which this decision was made.
Although the alert must not contain any background information

In this context, Carter pointed
to the increasing trend of dental
tourism and the potential pitfalls
associated with it. Although some
countries still do not have any formal system of registration for dentists, Carter expressed his belief that
“mechanisms such as this make for
a much more transparent profession
and greater patient protection.”

[10] =>

DTUK0116_10_Business 25.02.16 15:05 Seite 1

BUSINESS

Dental Tribune United Kingdom Edition | 1+2/2016

How to succeed in the Middle East
By Dental Tribune International
The Middle East is considered one of
the fastest growing dental markets
worldwide. Quality and innovative
technology have been at the centre
of interest for the region’s dentists,
practitioners and manufacturers as
dentistry has advanced from basic
treatment to state-of-the-art oral
health care. A record number of
companies from the UK took the
opportunity to exhibit at this year’s
UAE International Dental Conference and Arab Dental Exhibition
(AEEDC). Dental Tribune spoke to
three first-time exhibitors about the
problems and promises of entering
the market.
Ten years ago, one could hardly
have imagined a spike in interest
in 3-D printing in Middle Eastern
digital dental laboratories. Now,
the region’s dental industry is rapidly adopting new technologies
such as intra-oral scanning and
CAD/CAM to keep up with the
rising demands of its increasingly
affluent patients. Digital dentistry,
a technological revolution most
UK dental practices are already familiar with, has entered the region
within the last few years. Interest
from the Middle East in modern
dental instruments, however, is not
limited to digital solutions. Dentists have begun to look for highquality endodontic and implant
systems, as well as discovered cosmetic dentistry as the next rising
star in the region. The dental industry in the UK, a market with
significant domestic growth owing

to its wide range of products and
companies, has been promoting
its expertise at trade fairs in the
region, such as AEEDC.
The first UK pavilion at AEEDC
was established in 2010 with eight
companies exploring the
market and its numerous business opportunities. Since then,
the number of professional visitors has doubled, from 20,000 to
more than 40,000 in 2016,
and so has the number of
UK companies. “The UK
pavilion contained 15 UK exporters and we are delighted
that this represented a 50 per
cent increase in the size of the
UK pavilion compared with
our last attendance in 2014,”
remarked Edmund Proffitt,
Policy and Public Affairs
Director at the British
Dental Industry Association (BDIA). “The
Middle Eastern
and Gulf region
markets continue to offer
significant sales
opportunities
for UK dental
exporters as countries continue to invest in the provision of
dental services. The opening
up of the Iranian market also provides a host of new sales opportunities for UK exporters.”

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Tribune Group GmbH is an ADA CERP provider. ADA CERP is a service of
the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not
approve or endorse individual courses or instructors, nor does it imply
acceptance of credit hours by boards of dentistry.

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contact us at tel.: +49-341-484-74134
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Tribune Group GmbH is designated as an Approved PACE Program Provider by the Academy
of General Dentistry. The formal continuing dental education programs of this program
provider are accepted by AGD for Fellowship, Mastership and membership maintenance
credit. Approval does not imply acceptance by a state or province board of dentistry or AGD
endorsement. The current term of approval extends from 7/1/2014 to 6/30/2016.
Provider ID# 355051.

Iran—the next big
market?
For many British companies,
both AEEDC and Dubai have
been considered an excellent
opportunity to expand into
the Gulf and Middle
Eastern markets
such as Iran. For
instance,
daily

two-hour flights between Tehran and Dubai have
long fostered trade between the
two countries, while European
and American companies have yet
to profit from the short distance.
At the trade fair, many exhibitors
noted a significant increase in visitors from Iran, a welcome result of
the suspended United Nations’
sanctions that hindered business
for years. The UK government
has now seen the opportunity
to transfer its technical expertise
to Iran and therefore encourage
its industries to reinvest in the
country. As competition for dental
products is still relatively low, it
seems like the right time for the
British dental industry to enter
the market.
Quality Endodontic Distributors
was established in 1989 in Peterborough in the UK at a time when
the endodontic materials and
methods we take for granted today
were at their very beginnings. The
supplier of rubber dams, lubricants
and endodontic instruments chose
to exhibit in Dubai because the
market promises new opportunities for growth. “We went to Chicago
before, but the trend moved across
to Dubai. Here, we primarily met
dentists, dealers and manufacturers from the region. It is important
to build up a dealer network here to
succeed,” said Edward R.S. Conduit,
sales and marketing director of the
company.
OsteoCare Implant System was
already working with distributors

from Kuwait when it decided to
pursue further opportunities in
the region and exhibit at AEEDC.
The company looked for dealers
for each country instead of targeting the whole region.
“In order to succeed, dental
companies need to raise brand
awareness and partner with as
many local distributors as possible, as regional differences
exist,” according to Head of
Operations Dave Stephens.
“We particularly looked
for distributors in the UAE.
We have had incidental
sales for about 20 years,
but the business has
quite changed in this
time.

The competition
for implants has increased at
home and abroad so we had to
make sure our products remained
visible. We are not into fast trends,
but assure simplicity and quality
made in Britain. We provide dental
implant systems for all ranges, as
well as also hands-on courses on
placing them correctly.”

Understanding
the dos and don’ts
OsteoCare approached UK Trade
& Investment (UKTI) and the BDIA
and spoke to business advisors
before planning its show participation. UKTI and BDIA offer numerous training opportunities to
help companies to identify their
markets and establish a considered pathway before starting to
export. They advise that UK companies still seek legal advice and
work with established networks.
Successful export to the Middle
Eastern and Gulf states further
requires Arabic-speaking people
living in the same time zone.
Although language has not been
a barrier, as English has dominated business in Dubai and most
of the region, Arabic remains the
world’s fourth most important
language on the Internet after
English, Chinese and Spanish,
according to Google. Hence, any
UK company looking for online
sales could significantly increase
traffic and customer engagement
by setting up a website in Arabic.
Also, it is good to know that pay-

ment by credit card, which is quite
common in the UK, has not
reached the same level of acceptance as cash in the Middle East.
Enlighten Smiles, a London-based
manufacturer of tooth whitening
systems
based
on

hydrogen peroxide or
carbamide peroxide, was another
first-time exhibitor. The company
drew a large crowd to its stand
owing to the region’s rising demand for whitening solutions
not based on light. “Cosmetic dentistry is an aspiring if not giant
market in the Middle East. Our
syringes, pastes and complete kits
with home and office gels made
quite an impression in Dubai,”
said Dr Sanjay Patel, Director of
Enlighten.
“There is still an educational
process taking place in the region,”
he added. “I would compare this
market to the situation in Europe
ten years ago. Now, this market is
asking for light-activated products while we stopped using lights
in 2006 in favour of our new
whitening solutions. Dubai succeeds at bringing together countries that are relatively close by,
such as Egypt and India. Here in
Dubai, we also experienced strong
interest from Sudan, a market we
would not have thought about before. Now, the process of turning
interest into actual distributors
and clients will take at least a year.
This is how business works here.”
Even though the UK remains
Enlighten’s most important market, management decided early on
to export to Germany, the Netherlands, Finland, Spain and France.
While a number of companies in
the UK are still pursuing success in
the domestic market, there are numerous opportunities abroad and
it would appear that the Middle
East is certainly one of them.

[11] =>

DTUK0116_11_Wilson 25.02.16 15:17 Seite 1

Dental Tribune United Kingdom Edition | 1+2/2016

TRENDS & APPLICATIONS

The role of the hygienist in the 21 century
By Victoria Wilson, UK
Since the recent launch of the Emirates Dental Hygienists’ Club in the
UAE, it could not be a more appropriate time to discuss the growing role
of the hygienist in the twenty-first
century. The prevalence of preventable dental disease within the region
prevails, and the need for a focus on
the core strategy to overcome such
disease needs to be addressed.
The dental hygiene profession
was founded over 100 years ago by
Alfred Fones in the US for the promotion of oral health and prevention of disease. The fundamental
ethical responsibility of the dental
hygienist is the pursuit of the promotion and restoration of oral
health. The dentist’s role certainly
encompasses the promotion of
oral health and prevention of disease in diagnosis and operative
care; however, it is important to
highlight that the main difference
is that the scope of practice for a
dentist is far greater than for a dental hygienist. This is where the significance lies in the strengths and
key focus of these dental care professionals and the key role of both

in overall sustainable oral health
care for every patient in serving the
public.
In a recent survey carried out
among dental professionals in the
UAE, it became evident that a very
small percentage of dentists actually work with dental hygienists. It
found further that a limited number of dentists are proactive about
integrating hygienists into their
practice model. This highlights the
potential requirement to further
incorporate dental hygiene into
dentistry if the existing inequalities of oral disease are to be overcome. This will require an extended
workforce of dental hygienists, the
expansion of educational facilities
and further efforts towards including dental hygienists in existing
practices in both public and private
health care.
Another recent survey carried
out in the region asked dentists
how many of their patients are
healthy. Regrettably, only a very
small percentage reported having
patients with good oral health. This

again highlights the need for the
skill set of the dental hygienist in
oral health promotion and prevention of disease.
According to the findings of a
further survey in the region, dental
hygienists felt that very little of
their total skill set was being
utilised. This reflects the further
need to ensure current dental hygienists’ skills are being used to the
maximum potential.
In a European report, it has been
identified that the UK, Spain, Sweden and Switzerland are ranked as
the healthiest in Europe in relation
to the low prevalence of severe periodontal disease, supporting the
role of the dental hygienist in countries where a facilitative medicolegal framework exists to allow the
inclusion of dental hygienists in
effective periodontal care. It has
also been identified in an international report that oral health needs
and the delivery of care are partly
mismatched, indicating a further
need for the development and integration of the role of the dental

hygienist. It has been proposed that
advancing education in dental
hygiene will achieve better oral
and overall health for more people,
by transforming the way dental
hygiene graduates are prepared
for the future to serve the health
and wellness needs of society. Increasing clarity on the identity of
the profession will affect how it is
perceived by the public. In order to
reach this point, every member of
the dental team needs to be fully
on board regarding the role of the
dental hygienist and invest time in
achieving the optimal success.
A global re-evaluation of requirements is needed to ensure that there
is greater utilisation of hygienists
in the provision of dental care with
efficient and effective use of health
care resources. Through evaluating
the dental profession’s ability to
provide care within the core skill
sets, it is mandatory that the necessary steps be taken to ensure maximum effectiveness of an integrated
dental and health care profession
to optimise on reducing the prevalence of preventable dental disease.

It has been advised in a recent
extensive report that future public
health care policies will be orientated towards recommending behavioural support and adopting
the common risk factor approach
for oral health promotion.
Dental hygienists in public
health care settings can positively
affect patients by offering preventive care outreach services.
Improvement in the quality of life
for individuals was noted through
improved health outcomes.

Victoria Wilson
currently lives in
Dubai working
as a Dental
Hygienist at Dr
Roze & Associates Dental
Clinic. She is also founder and
president of the
first official Dental Hygienists Organisation in the Middle East under the
Emirates Medical Association and
Dubai Dental Society. Wilson can be
contacted at victoria@dradubai.com.
AD

[12] =>

DTUK0116_12_Maskery 25.02.16 15:05 Seite 1

TRENDS & APPLICATIONS

Dental Tribune United Kingdom Edition | 1+2/2016

Becoming a principal, now what?
By Amanda Maskery, UK
Buying your first dental practice is a
major milestone in your career and
your life. But while it brings opportunities, becoming the owner of your
own business also brings challenges
for which you must ensure you are
prepared. It is enormously impor-

tant that you be aware of what you
are taking on before you decide to
become a principal and entrepreneur, and it is essential you seek advice if in any doubt.
From the moment you begin to
consider taking on your own practice, you need to be considering

your position. Can you secure sufficient funding to purchase your
own practice? Beware of the pitfalls
of a “cheap” practice. Thorough due
diligence is crucial and your lender
will require assurance of this.
Exiting your current practice
also needs careful consideration;

can you commit to handing in
your notice before you exchange
contracts? This may affect the
timescale of the transaction if not
planned properly.

negotiation of the purchase agreement, and the requisite associate
agreement, might colour the relationship when running the practice post-completion.

There is also the issue of the
outgoing principal and whether to
retain his or her services. Fraught

You must also be au fait with your
regulatory requirements and will
need to make an early application
to the Care Quality Commission to
become a registered provider. This
will require an up-to-date check
with the Disclosure and Barring
Service, which may take several
months.

SCIENCE

LEARNING THE «WHY» AND THE «HOW»
IN REGENERATIVE THERAPY

However, post-completion, once
you take ownership of your practice, the considerations are ongoing. Much more of your time will
be taken up with administration,
which is something that is often underestimated. If you have targets,
be they units of dental activity or
purely financial, you must ensure
you are continuing to maintain the
level and quality of treatment.

PRACTICE

Through proper planning, securing a well-negotiated purchase
agreement and carrying out thorough due diligence, you should be
in a position to immediately begin
working and be able to start seeing
and treating patients as soon as
possible.

INTERNATIONAL SYMPOSIUM

OSTEOLOGY

MONACO
21 – 23 APRIL 2016

WWW.OSTEOLOGY-MONACO.ORG

There are also the risks and requirements of being a business
owner. Are policies of insurance up
to date? Are you aware of the key
commercial contracts at your practice and their terms? Do you know
your duties to your employees and
associates and their entitlements
under their contracts of employment? Furthermore, if you are a
sole trader, you will have personal
liability for business debts to your
creditors. Financial planning is
also crucially important, on both
a business and personal level.
Regulation is another area of responsibility, and you must ensure
you can maintain your practice and
treatment to the requisite regulatory standard. You must have a set of
policies in place should the local area
team or Care Quality Commission
come calling.

Language

Speakers / Moderators

English
Clinical Forum 1 with simultaneous
translation into French, German, Italian
and Russian

Antoun Hadi I Araújo Maurício I Aroca Sofia I Becker Jürgen I Benic Goran I Beschnidt
Marcus S. I Bonnet Franck I Bornstein Michael I Bosshardt Dieter I Buser Daniel I Cairo
Francesco I Carvalho da Silva Robert I Chappuis Vivianne I Chen Stephen I Chiapasco
Matteo I Cortellini Pierpaolo I Cosyn Jan I Dagnelid Marcus I Dahlin Christer I De Sanctis
Massimo I Derks Jan I Fickl Stefan I Fontana Filippo I Giannobile William V. I Giesenhagen
Bernhard I Gruber Reinhard I Grunder Ueli I Haas Robert I Hämmerle Christoph I Happe
Arndt I Hermann Frederic I Holst Stefan I Jepsen Karin I Jung Ronald E. I Kasaj Adrian
Kielhorn Jan I Kim David I Koo Ki-Tae I Lang Niklaus P. I Malet Jacques I McClain Pamela K.
Merli Mauro I Neukam Friedrich W. I Nevins Marc I Nevins Myron I Nisand David
Rebele Stephan I Renouard Franck I Rocchietta Isabella I Roccuzzo Mario I Rothamel
Daniel I Russe Philippe I Salvi Giovanni I Sanz Mariano I Scheyer Todd I Schlee Markus
Schlegel Karl Andreas I Schmelzeisen Rainer I Schwarz Frank I Sculean Anton I Simion
Massimo I Thoma Daniel I Urban Istvan I Van de Velde Tommie I Wagner Wilfried I Weyer
Nils I Wise Roger I Zabalegui Ion I Zucchelli Giovanni I Zuhr Otto

Venue
Grimaldi Forum, Monaco

Organisation
Osteology Foundation
Landenbergstrasse 35
6002 Lucerne | Switzerland
phone +41 41 368 44 44
info'osteology.org

Scientific Chairmen
Friedrich W. Neukam, Germany
Myron Nevins, USA

What may seem like a minefield
of considerations and obligations
need not be if you enter into your
journey to principal with your eyes
open, fully aware of what is to come.
Should you ever be in doubt about
any aspect, it is essential you seek
specialist advice.

Amanda Maskery
is one of the UK’s
leading den tal
lawyers. She is
Chair of the Association of Specialist Providers to
Dentists (ASPD) in
the UK and a Partner at Sintons law
firm in Newcastle. Amanda can be contacted
at amanda.maskery@sintons.co.uk.

[13] =>

LONDON’S TOP 10
ATTRACTIONS

1. BRITISH
MUSEUM
The world-famous British
Museum exhibits the works
of man from prehistoric to
modern times, from around
the world. Highlights include
the Rosetta Stone, the
Parthenon sculptures and
the mummies in the Ancient
Egypt collection. Entry is
free but special exhibitions
require tickets.

6. SCIENCE
MUSEUM
From the future of space
travel to asking that difficult
question: “who am I?”, the
Science Museum makes
your brain perform Olympicstandard mental gymnastics.
See, touch and experience
the major scientific advances
of the last 300 years; and
don’t forget the awesome
Imax cinema. Entry is free
but some exhibitions require
tickets.

2. NATIONAL 3. NATURAL
HISTORY
GALLERY
The crowning glory of
MUSEUM
Trafalgar Square, London’s

4.TATE
MODERN
Sitting grandly on the
banks of the Thames is Tate
Modern, Britain’s national
museum of modern and
contemporary art. Its unique
shape is due to it previously
being a power station. The
gallery’s restaurants offer
fabulous views across the
city. Entry is free but special
exhibitions require tickets.

5.THE
LONDON
EYE

National Gallery is a vast
space filled with Western
European paintings from the
13th to the 19th centuries.
In this iconic art gallery you
can find works by masters
such as Van Gogh, da Vinci,
Botticelli, Constable, Renoir,
Titian and Stubbs. Entry is
free but special exhibitions
require tickets

As well as the permanent
(and permanently
fascinating!) dinosaur
exhibition, the Natural History
Museum boasts a collection
of the biggest, tallest and
rarest animals in the world.
See a life-sized blue whale,
a 40-million-year-old spider,
and the beautiful Central
Hall. Entry is free but special
exhibitions require tickets.

7. VICTORIA
& ALBERT
MUSEUM

8. TOWER OF 9. ROYAL
10. MADAME
LONDON
MUSEUMS
TUSSAUDS
Take a tour with one of the
Madame Tussauds, you’ll
GREENWICH Atcome
Yeoman Warders around
face-to-face with some

The V&A celebrates art and
design with 3,000 years’
worth of amazing artefacts
from around the world. A real
treasure trove of goodies,
you never know what you’ll
discover next: furniture,
paintings, sculpture, metal
work and textiles; the list
goes on and on… Entry is
free but special exhibitions
require you to purchase
tickets.

the Tower of London, one
of the world’s most famous
buildings. Discover its
900-year history as a royal
palace, prison and place
of execution, arsenal, jewel
house and zoo! Gaze up
at the White Tower, tiptoe
through a medieval king’s
bedchamber and marvel at
the Crown Jewels.

Visit the National Maritime
Museum - the world’s
largest maritime museum,
see the historic Queen’s
House, stand astride the
Prime Meridian at Royal
Observatory Greenwich
and explore the famous
Cutty Sark: all part of the
Royal Museums Greenwich.
Some are free to enter; some
charges apply.

The London Eye is a major
feature of London’s skyline.
It boasts some of London’s
best views from its 32
capsules, each weighing 10
tonnes and holding up to 25
people. Climb aboard for
a breathtaking experience,
with an unforgettable perspective of more than 55
of London’s most famous
landmarks – all in just 30
minutes!

of the world’s most famous
faces. From Shakespeare
to Lady Gaga you’ll meet
influential figures from
showbiz, sport, politics and
even royalty. Strike a pose
with Usain Bolt, get close to
One Direction or receive a
once-in-a-lifetime audience
with Her Majesty the Queen.

[14] =>

DTUK0116_14_Bain 25.02.16 15:15 Seite 1

TRENDS & APPLICATIONS

Plaque, sugar, obesity,
diabetes and smoking
Reassessing risk factors for periodontal disease
By Prof. Crawford Bain, United Arab Emirates

Dental Tribune United Kingdom Edition | 1+2/2016

group made up of 30 members.4
These included physicians, endocrinologists, nurses, ophthalmologists, dieticians, podiatrists
and lay people, but no dentists.
Its 153 pages make no mention of
dentistry or periodontal disease.
The National Institute for Health
and Care Excellence document on
Type 2 diabetes, also updated in
2014, too fails to mention dentistry
or periodontal disease.

Smoking
We have known for over 20 years
that smoking increases the risk of
periodontal breakdown. Odds ratios for developing periodontal disease as a result of smoking constitute a range: 2.5,5 3.97 for current
smokers and 1.68 for former smokers,6 and 3.25 for light smokers to
7.28 for heavy smokers.7 A smoker
with 20 pack years (20 cigarettes
per day for 20 years) is up to
600 per cent more likely to lose
teeth owing to periodontal disease,
whereas a patient with poor plaque
control has around a 15 per cent risk
of progressing to destructive periodontitis. Why then do we refer to
hygiene phase therapy when smoking is a much greater risk factor
than poor oral hygiene? How many
dentists spend as much time on
smoking cessation counselling as
on oral hygiene instruction?

Traditionally, dentists have been
taught that both dental caries and
periodontal disease develop and
progress as a direct result of patients’ over-frequent consumption
of refined sugars and patients’ failure to remove bacterial plaque effectively. Miller’s acidogenic theory
of caries development and the nonspecific plaque hypothesis based
on Loe’s work in the 1960s allow
dentists to present a simple causeand-effect explanation to patients.
Since then, the dental profession
has blamed patients’ poor oral hygiene for periodontal breakdown
and dental caries while often failing to diagnose and treat other contributing causative factors. Unfortunately, while plaque is generally
a necessary ingredient of common
dental diseases, the explanation
contained in these theories of its
pivotal role is simplistic given current knowledge. This brief article
will attempt to put the more significant risk factors in context.

Plaque
Gingivitis is a natural bodily response to bacterial accumulation
and as such is non-specific. Effective plaque removal will generally
reverse gingivitis. The concept of
inevitable progression from gingivitis to destructive periodontitis
if oral hygiene is not good is,
however, flawed. Figure 1 shows a
46-year-old patient with non-existent oral hygiene over several years.
Figure 2shows the same patient one
month later after around 90 minutes of scaling and polishing by a
student dental hygienist. He had no
active caries and no more than
ten per cent bone loss.

It has become increasingly evident that while some patients are
“susceptible” to periodontal breakdown, others are more “resistant”.
Common among these host-based
factors leading to greater breakdown are the presence of diabetes
and a smoking habit.

Diabetes
Several authors have demonstrated a clear relationship between degree of hyperglycaemia
and severity of periodontitis, and

been diagnosed, and 934,300 people have impaired glucose tolerance, a prediabetic state of hyperglycaemia, or elevated levels of
blood sugar.3
In the UK Prospective Diabetes
Study, it was shown that Type 2 diabetics who reduce their HbA1c level
by 1 per cent are 19 per cent less
likely to suffer cataracts, 16 per cent
less likely to suffer heart failure and
43 per cent less likely to suffer amputation or death due to peripheral
vascular disease.

Sugar
Traditionally, teaching on caries
prevention has focused on the
number of sugar exposures per day,
especially between meals. Academic
paedodontists suggest that provided there are two daily exposures to
fluoride in toothpaste, a maximum
of six sugar exposures a day is unlikely to lead to significant enamel
decalcification in children.
However, a large study conducted
in 2015 by Bernabé et al. evaluated
1,702 adults over 11 years and con-

as the basis of their conclusions.
Patients are only really interested
in real outcomes.

Obesity
The third National Health and
Nutrition Examination Survey
showed that body mass index was
significantly associated with periodontal disease. Other studies have
indicated a less strong association,
and with the compounding variable of blood sugar levels in prediabetics, it is presently unclear
whether obesity is in fact an independent risk factor or is associated with the established role of
diabetes. Regardless, obesity is a
known risk factor for Type 2 diabetes and cardiovascular problems, and it is part of the dental professional’s role to inform patients
of these interrelationships.
Recent research in England has
suggested that 1.4 million obese patients would benefit from gastric
band or bypass (bariatric) surgery.
Currently, around 8,000 people
a year receive the treatment on
the National Health Service (NHS).
If all 1.4 million were offered surgery, the researchers estimate it
would avert nearly 5,000 heart attacks and 40,000 cases of Type 2
diabetes over four years.
They do not, however, discuss potential costs of this surgery, which
can vary from £3,000 to £11,505, according to NHS England. Assuming
£5,000 per procedure, this would
total around an additional £7 billion in health costs. Nor is there
much discussion on death rates
(0.5 to 1 per cent with the present
skill level of surgeons). Even if
surgical skills do not diminish, we
should anticipate between 7,000
and 14,000 additional deaths.
It is likely that comprehensive
periodontal treatment of all obese/
prediabetic patients would be
significantly less costly and, hopefully, result in few if any fatalities.

Conclusion

Left: Patient at presentation (he requested extraction of all mandibular teeth).—Right: The same patient one month after
scaling and polishing (he asked how he could maintain the teeth in this condition).

the risk of cardio-renal mortality
(ischaemic heart disease and diabetic nephropathy combined) is
three times higher in diabetics
with severe periodontitis than in
diabetics without severe periodontitis. 1 Javed et al. showed
that scaling and root planing in
prediabetics reduced glycated
haemoglobin (HbA1c) by 1 per cent
at three months,2 and reductions
in HbA1c of 0.3 to 1 per cent have
been confirmed in several other
studies in both Type 1 and Type 2
diabetics. There are estimated to
be 745,940 diabetics in the United
Arab Emirates. In 304,000 of
those cases, the condition has not

Clearly, not only will control of
diabetes facilitate management of
periodontitis, but also, probably
more importantly, effective management of periodontitis is likely
to have major beneficial effects on
the serious sequelae of diabetes.
Unfortunately, the medical profession is largely ignorant of the potential benefits of establishing and
maintaining periodontal health.
The publication Type 1 Diabetes
in Adults: National Clinical Guideline for Diagnosis and Management in Primary and Secondary
Care (updated in July 2014) was
compiled by a consensus reference

cluded that “the amount of, but not
the frequency of, sugars intake was
significantly associated with DMFT
[decayed, missing and filled teeth]
throughout the follow-up period”.8
It thus appears that, at least in
adults, “how much” is more important than “how often” with regard
to sugar consumption. This is all
the more significant since DMFT
measures real outcomes over significant time spans, while many
studies on both caries and gingivitis are very short term and use
surrogate outcomes, such as decalcification on an enamel sample,
or plaque and gingivitis indices

It is clear that the simple story of
plaque control preventing progression of common dental diseases
is largely fiction rather than evidence-based fact. While effective
oral hygiene will always be a significant part of the management of
dental diseases, the modern dental
professional must be equally aware
of the other common risk factors
outlined in this article.
Editorial note: A complete list of references
is available from the publisher.

Crawford Bain,
a UK-certified
specialist in periodontics, prosthodontics and
restorative dentistry, is currently Professor
of Periodontology and Director of Post-Graduate Periodontics at the
Hamdan bin Mohammed College of
Dental Medicine in Dubai in the United
Arab Emirates. He can be contacted at
crawford.bain@hbmcdm.ac.ae.

[15] =>

[16] =>

DTUK0116_16_Horch 25.02.16 15:11 Seite 1

TRENDS & APPLICATIONS

Dental Tribune United Kingdom Edition | 1+2/2016

have found that xylitol reduces
inflammation in the case of Porphyromonas gingivalis.5 Uittamo
et al. have described the effectiveness of xylitol against Candida
albicans and the carcinogenic effect
of acetaldehyde in the oral cavity,6
which could be of interest to
smokers particularly.

The sweet
miracle
of xylitol

Xylitol cannot replace fluoride
entirely. It should rather be regarded as a valuable addition to
dental prophylaxis. Critics of xylitol often point to the effectiveness
of fluoride, but may not consider
that both substances complement
each other perfectly. Xylitol is
within reach even when no toothbrush is around. It is for a reason
that the European Food Safety
Authority (EFSA) has confirmed
health claims that chewing gum
only sweetened with xylitol is anticariogenic7 and highly effective
against caries. As a rule, as many
products containing xylitol as
possible should be used in daily
practice. In order to achieve extraordinary results in patients, the
use of chewing gum sweetened
only with xylitol is recommended.
Studies evaluated by the EFSA confirm this.

Plaque amount Strep. Mutans (CFU x 103)

By Dr Deborah Horch, Germany

Fig. 1: Xylitol was originally harvested
from birch bark.

There is a reason that the health
departments of Italy, Japan and Finland recommend the use of xylitol
for active oral care. An increasing
number of national dental associations in Europe have also begun to
follow that recommendation.
What is so special about xylitol?
Is there any evidence to support its
claimed properties, such as being
anti-cariogenic and able to advance
enamel remineralisation? These
and other questions are matters of
current debate among experts. It is
fact that that the very extensive
Turku study, which was conducted
between 1970 and 1976 (Table I),
showed a 85 per cent reduction in
caries in patients consuming xylitol compared with a control group.1
These results sparked a wave of
follow-up studies. Many studies
conducted under the umbrella of
the World Health Organization
have since confirmed a significant
caries reduction of between 50 and
85 per cent.2–4
Why then has xylitol not become
commonplace by now and why is
it still being debated? In addition

Research center

500
400
300
200
100
0

Years 0

Control

Xylitol

Glycaemic Index
Xylitol
Milk
Muesli
Sugar
Honey
4

100

Fig. 2: Xylitol blocks streptococcus mutans. © Mäkinen KK, et al. (1989) Caries Res 23, 261-267—Fig. 3: miradent Dental Care
Chewing Gum sweetened with 100% xylitol. © Hager & Werken—Fig. 4: Molecular structure of xylitol—Fig. 5: Xylitol is also
favoured by diabetics. © D. Fritsche: „Diabetes: Der Ernährungskompass“, Gräfe und Unzer Verlag, Germany (2008)

to lack of awareness, a possible explanation could lie in economics.
Xylitol as a raw material is 20 times
more expensive than sugar in production and much more costly
than other sugar substitutes. Processing is more labour intensive, as
well as more costly, and therefore
less attractive for manufacturers.
In contrast to synthetic sweeteners
like aspartame and acesulfame, the
taste of xylitol is not prolonged.

“Xylitol cannot replace fluoride entirely.
It should rather be regarded as a valuable
addition to dental prophylaxis.”

Duration in years

Dose g / day

Reduction of caries
incidence %

1. Turku, Finland

> 85

2. USSR

3. WHO – Thailand
Polynesia
Hungary

2.3–2.7
3
2–3

20
bis 20
14–20

–
–
–
58–68
37–45

4. Montreal, Cananda

1–2

1–3,9

5. Ylivieska, Finland

7–10

59–84

6. Dayton, OH1

1.8

bis 8.5

21 months

6–7

7. Ylivieska, Finland
„Von der Mutter – Kind“
Table I: Overview of relevant studies. 1 Root surface caries

The latest analysis by German
consumer watchdog publication
ÖKO-TEST (September 2015 issue)
of a variety of chewing gums only
rated brands containing xylitol as
“good” or “very good”, while some
of the global competing products
containing other sweeteners were
rated only “fair” or “poor”. There
are plenty of good alternatives
to chewing gum, such as boiled
sweets and xylitol powder, which
compares almost one to one to
granulated sugar in its sweetness.
In order to benefit fully from its
positive properties, five grams of
xylitol a day is generally recommended. An intake of 50 grams
for adults and 30 grams for children is well tolerated. In order to
ensure that products only contain

Compared with gum containing
other sweeteners, chewing gum
only sweetened with xylitol loses
its natural flavour after about five
minutes. Therefore, synthetically
sweetened gums hold more value
for the industry. From a medical
perspective, chewing gum sweetened with xylitol becomes effective after five minutes by neutralising the significantly reduced pH
value resulting from food consumption. Despite the abovementioned evidence-based studies
on xylitol, there is need for more
research regarding the known
positive properties of this sweet
miracle. For example, Park et al.

xylitol and no other sweeteners,
the list of ingredients should be
checked.
Editorial note: A list of references is available from the publisher

Dr Deborah Horch
is a practising
dentist in Korschenbroich in
Germany. She can
be contacted at
de.horch@gmx.de.

[17] =>

DTUK0116_17-18_OTNimrod 25.02.16 15:12 Seite 1

ORTHO TRIBUNE
The World’s Orthodontic Newspaper · United Kingdom Edition
Published in London

www.dental-tribune.co.uk

Vol. 10, No. 1+2

INTERVIEW

MANAGEMENT

SHORT-TERM ORTHODONTICS

Dr Graham Gardner about the
European Aligner Society and the
importance of aligners in orthodontics.

Practice consultant Lina Craven,
Dynamic Perceptions, explains
what it takes to build the ultimate
practice team.

Conservative smile design for
the general dentist. Three cases
involving the Inman Aligner appliance.

” Page 20

” Page 21

” Page 22

From straightforward to complex cases
The new NimrodAligner and why it can be the ultimate orthodontic removable aligning system
By Nimrod Tal & Lauren Flannery
As a dental practitioner, helping your
patient look to improve their smile
by undergoing orthodontic treatment with one of the many aligning
systems available can be a very
daunting decision to make when it
comes to choosing the right system.
Whatever their lifestyle, the attributes most commonly sought after
are typically comfort, discreteness
and for the treatment time to be as
speedy as possible. Depending on
the case, it can sometimes be quite
difficult to achieve all of these aims
within one single aligning system,
as each are designed to achieve very
specific and individual movements,
and not all are designed to do this
with the whole arch.
As an orthodontic laboratory, we
are introduced to hundreds of very
individual cases on a weekly basis,
where more often than not patients
will have specified that the above
attributes are key to their decision
making process when we assess for
the appliances that will be best suited
to their particular case. After having
been faced so regularly with the task
of assisting our clients to make the
decision that will benefit their patients in as many aspects as they
can, we had a thought—what if the
advantages of each of these aligning
systems were combined, and the
disadvantages eliminated? It was
from this that the idea of our brand
new NimrodAligner stemmed.
Designed to move from 5-5 in all
directions, and also widen the molars
(Fig. 1), the NimrodAligner comprises
of lingual and labial arch wires attached to individual cups that seat on
each tooth with the aid of a composite anchor, and a connecting bar to
seat on the palate or the lingual area,
that are attached to molar cups. After
having spent four years researching
the most effective components and
combining them using prototypes
with 3-D printers, we have combined
the biomechanics of straight wire,
Clear Aligners and a spring aligner
to reduce the downsides of having
treatment considerably and focus
more on the positive features.
Typically most common with
adolescents, fixed brackets appear

Figs. 1–5: Designed to move
from 5-5 in all directions,
and also widen the molars,
the NimrodAligner comprises of lingual and labial
arch wires attached to individual cups that seat on
each tooth with the aid of
a composite anchor, and a
connecting bar to seat on
the palate or the lingual
area, that are attached to
molar cups.

and are typically only at their most
active in just the first seven days.
On the other hand with the
NimrodAligner, NiTi wires ensure
that the pressure is gentle, yet provide continuous support.

to be decreasing in popularity,
mostly due to the fact that they are
not particularly aesthetically pleasing and can therefore encourage a
feeling of embarrassment for adults
when in public. Combined with
hours of clinical time spent fitting
and repositioning the individual
brackets, hygienic problems owing
to not being able to brush or floss
properly, as well as the discomfort of
their often sharp exterior both labially and lingually, it is no surprise
that they are not as often requested
as more popular removable aligners. The NimrodAligner has the
fixed brackets arch wires biomechanics incorporated within the removable appliance so clinical time
is extremely minimal. The teeth and
gums can also be cleaned to the
proper standard and at only 2 mm
in thickness (Fig. 5) – as opposed to
the standard 3 to 3.5 mm thickness
of fixed brackets – so the overall feel
is very anatomically friendly.

Multiple Clear Aligner trays can
also become very tedious for both
patient and dentist, particularly
when frequent appointments are
necessary and stages of interproximal reduction (IPR) have to be carried
out. IPR can be a huge factor in the
progress of Clear Aligners as each
aligner is made to incorporate the
necessary IPR after each stage and the
fit of following trays will be affected
if not enough has been done. This is
not a problem for the NimrodAligner
as it will not affect the fit of the appliance if there has been insufficient
IPR on the previous appointment.
The patient can continue to wear
it and IPR can be completed where
necessary on the next appointment.

Clear Aligners are the most
anatomically friendly appliances
on the market today, and are
mostly popular because of just how
discreet they are. Despite these
advantages, the force and pressure
induced during the initial days of
wear can be very painful. Although
a sign that they are working as
they should, the aligners tend to
become passive as time passes

Similarly, spring aligners can
also continue to be worn and fit
correctly in between appointments if not enough IPR has been
done previously, however they’re
widely known for limited movement to just four incisors. It may be
good for labial/lingual movement
using the ‘squeeze’ effect, and some
rotation, but Clear Aligners can
often be required to finish.

Fc{FeFkcØ¥Fc:ec%

%
c)kUFc:
- welcome to the leading annual dental fair in Scandinavia

SCANDEFA invites you to exclusively meet the Scandinavian dental market
and sales partners in wonderful Copenhagen.
Why exhibit at SCANDEFA?

Who visits SCANDEFA?

SCANDEFA is a leading, professional branding and
sales platform for the dental industry.
In 2016 we are pleased to present Scandefa with
ƋƵŅü±ĜųÚ±ƼŸ±ĹÚ±ĵŅųåāåƻĜÆĬåÏŅƚųŸåŞųŅčų±ĵĵå
at the Annual Meeting. In addition to sales, branding
and customer care, the new format gives you the
ŅŞŞŅųƋƚĹĜƋƼüŅųĹåƋƵŅųĩĜĹčØŸƋ±ýÏ±ųåØŞųŅüåŸŸĜŅĹ±Ĭ
inspiration and competence development.
SCANDEFA is organised by Bella Center and held
in collaboration with the Annual Meeting organised
by the Danish Dental Association (tandlaegeforeningen.dk).

How to exhibit
Please book online at scandefa.dk or contact Sales¼ )ƻĘĜÆĜƋĜŅĹ a±Ĺ±čåų aĜ± ĬåĵåĹƋ ŅŸåĹƴĜĹčå
mro@bellacenter.dk/+45 32 47 21 33.

In 2015 over 7,500 dentists, dental hygienists, dental assistants and dental technicians visited SCANDEFA. For further statistical information please see
scandefa.dk

Where to stay during SCANDEFA?
Two busy fair days require a lot of energy, and
therefore a good night’s sleep and a delicious
breakfast are a must.
å Ņüüåų ±ĬĬ Ņü Ņƚų åƻĘĜÆĜƋŅųŸ ± ŸŞåÏĜ±Ĭ ŞųĜÏå üŅų
both our hotels, AC Hotel Bella Sky Copenhagen
– Scandinavia’s largest design hotel – and Hotel
Crowne Plaza – one of the leading sustainable
hotels in Denmark.
We also offer free and easy shuttle service transport between the airport, the two hotels and Bella
Center.

SCANDINAVIAN DENTAL FAIR
28 - 29 APRIL 2016

scandefa.dk

[18] =>

DTUK0116_17-18_OTNimrod 25.02.16 15:12 Seite 2

ORTHO NEWS

Ortho Tribune United Kingdom Edition | 1+2/2016

Figs. 6–9: By combining all of the positive aspects of different orthodontic appliances, the NimrodAligner can be suitable for most cases from straightforward to complex.
AD

In some instances, a separate expansion appliance may be required
prior to treatment, which essentially boosts costs and adds time
onto treatment overall. We have
reduced this concern by offering
this stage for such cases within
the NimrodAligner singularly.
The arch can gain molar width by
pre-setting the molars in a wider
position when it comes to making
the movements on our 3-D system,
and the connecting bar can act as
a spring thanks to its flexibility.
The rest of the teeth will continue
to be aligned during this process.

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

In more complex cases however
whereby a separate expansion appliance is unavoidable, two NimrodAligners will be provided. The caps
will not fit on the teeth that are
blocked in otherwise, so the initial
appliance will create space for the
blocked teeth. Once they have been
exposed, the second appliance would
be provided to sit on all of the teeth.

I would like to subscribe to

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During our research and production stages, we aimed to create the
ultimate orthodontic removable
aligning system that could potentially be the answer to the prayers of
dentists and patients alike. We have
reduced clinical time dramatically by
removing the time-consuming hassle of fitting appliances such as fixed
brackets by providing a bespoke prealigned appliance that simply needs
to be placed on the teeth. We have
taken into consideration the fact that
multiple appliances can sometimes
be necessary to achieve the desired
result, and have eliminated the need
for this by designing the NimrodAligner in a way that allows the entire
arch to move in any direction. In case
expansion is also required, we have
this incorporated (Fig. 1).
We have adapted the force and pressure of the movement to be effective
for just sixteen hours a day, allowing
the patients to remove the appliance
for an entire eight hour working day
if they wish, to grant the roots a sufficient amount of time to recover.
By combining all of the positive aspects of the orthodontic appliances
mentioned above, the Nimrod Aligner can be suitable for most cases
from straightforward to complex.

Nimrod Tal is
the director of
NimroDENTAL
Orthodontic Solutions in London.
He can be contacted at contact@
nimrodental.co.uk

[19] =>

DTSC_A4_EN_Layout 1 04.02.14 14:23 Seite 1

www.DTStudyClub.com

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DTUK0116_20_OTGardner 25.02.16 15:18 Seite 1

ORTHO NEWS

Ortho Tribune United Kingdom Edition | 1+2/2016

“We will be able to treat pretty much
everything in the future”
An interview with Dr Graham Gardner, UK, President of the European Aligner Society
The European Aligner Society is an
international organisation established in 2013 that aims to promote
education and research in aligner
therapy. Trained in South Africa and
with 22 years of clinical experience,
Dr Graham Gardner has been running his own private practices in the
UK since 2008. In an interview with
Dental Tribune, the EAS President
shares his ideas and views about
the importance of aligners in orthodontics and about the EAS, which
he believes will become the society
for aligner therapy.
Dental Tribune: Dr Gardner, you
have been working with aligners
for more than a decade now. What
convinced you initially of this
treatment method and what are
the main advantages in your experience?
Dr Graham Gardner: From the beginning of my career in the early
1990s, a time when ceramic brackets and lingual braces became
available, I was certainly aware of
the fact that aesthetic appliances
were going to be the future of
orthodontics.
In 2001, I was fortunate to attend a certification course for Invisalign, which was truly a watershed moment in my orthodontic
career because I saw the value and
potential of aligner therapy for
both dental professionals and
patients. In my opinion, aligner
therapy opened the door for a
huge cohort of patients who would
not have considered orthodontic
therapy in the past mainly owing
to aesthetic concerns. In addition
to aesthetic benefits, aligners are
far more comfortable than fixed
appliances, as they are removable
and hence facilitate oral hygiene
during therapy. They also move
the teeth more gently with less
pressure, which is favourable with
regard to patient comfort and
from a biological perspective too.

in materials and 3-D printing will
render manufacture and the product itself more cost-effective. For
example, 3-D printers could allow
individual practices to print their
own aligners in the future.
Overall, with technological advancements and increasing patient acceptance, we will be able to
treat pretty much everything in
the future in my view.

Dr Graham Gardner.

confirm biomechanics in a far
more in-depth way than ever before, orthodontics is now catching
up with the high-tech world we
live in—it is twenty-first-century
orthodontics.
When aligners were first introduced to the market, there were
some limitations and we could
only treat mild malocclusions.
However, aligner therapy has
come of age and is now a genuine
appliance system with which

How have developments in the
European and the overseas market
differed?
Dentistry as a profession is very
conservative and dentists in the
US, for example, are perhaps a bit
more progressive. However, with
regard to aligners, I no longer really see a great difference between
Europe and America. The movement is global and I suspect the
advancements we are now seeing
in Europe will match those in
America and Asia, where aligner
therapy is also very popular.
There are always regional differences, also partly related to legal
restrictions, but the trend towards aligner therapy is a global
phenomenon.

main motivation behind the foundation of the EAS was to establish
a neutral body—an international
society that is independent of any

“...aligner therapy opened
the door for a huge cohort of
patients who would not have
considered orthodontic
therapy in the past...”

aligner company and open to all
dentists using aligners for orthodontic treatment.
The work of the EAS is characterised by three cornerstones.
The first is education, namely arranging conferences and regional
meetings and introducing clinical

Today, I treat over 75 per cent of
patients with Invisalign in my
practices.
In recent years, clear aligners have
become a favourable treatment
alternative to fixed appliances,
and the global orthodontic supplies
market is expected to reach about
US$3.9 billion (€3.6 billion) by 2020.
In your professional opinion, how
will this market develop in the near
future?
Over the past decade, aligners
have become mainstream orthodontics and I definitely see this
trend continuing and expanding.
With the technological advancements, including 3-D and CAD/
CAM, that allow the clinician to
diagnose, plan the treatment and

“...the advancements we are now
seeing in Europe will match those
in America and Asia...”
we can treat the majority of malocclusions.
At the moment, however,
aligner therapy is still a fairly expensive form of orthodontics.
Thus, I hope that improvements

How does the EAS address the
current trends in orthodontics?
Aligner therapy has seen huge
advancements over the past
decade, with an increasing number of manufacturers offering
different systems today. Thus, the

information about aligner therapy and that members can consult
for guidelines. Research is our
third column, which is currently

online forums, through which
members can interact and share
experiences and ideas. The second
column of the EAS’s philosophy
is communication. We aim to be a
neutral organisation that patients
can turn to for comprehensive

lagging behind. Eventually, we
hope to have our own aligner journal or magazine and grant annual
awards for excellence in aligner
therapy.
With the help of our sponsors,
the EAS will grow and become an
international umbrella organisation to help promote education
and research and development for
aligner therapy.
The EAS is a fairly young organisation and hosted its first congress on
13 and 14 February in Vienna. What
was the idea behind this event?
The EAS’s primary objective is
education because, obviously, education underpins every profession and without it we simply
stagnate. Therefore, we decided
that our first event should be
a congress held in the heart of
Europe offering a broad spectrum
of informative lectures and a
showcase of different systems
and products. At the first congress
in Vienna, internationally distinguished speakers shared their
views and expertise about aligner
therapy. Moreover, the event offered manufacturers an independent forum for exhibiting
their solutions.
Can dental professionals look forward to another EAS congress next
year?
Based on the success of the
inaugural event over the past
weekend, we definitely want the
congress to become a regular
event in the calendar. While we are
planning to hold the EAS congress
every two years, we will be organising smaller regional forums on
a continuous basis throughout
every year.
Thank you very much for the interview.

[21] =>

DTUK0116_21_OTCraven 25.02.16 15:21 Seite 1

ORTHO TRENDS

Ortho Tribune United Kingdom Edition | 1+2/2016

Individuals play the game, but teams
win championships
What it takes to build the ultimate practice unit
By Lina Craven, UK

do attitude makes the impossible
possible.

It is said that all teams are groups,
but not all groups are teams. What
separates the two is interdependence. A true team is focused on a
common purpose; team members
support one another and enhance
each other’s work and contribution. Andrew Carnegie captured
this accurately when he said,
“Teamwork is the ability to work
together toward a common vision.
It is the fuel that allows common
people to attain uncommon results.”
I know that achieving the ultimate team is possible, because
when I was a dental nurse many
years ago in America, I was part of
an ultimate team. What made us
great was our leader, Dr Derick
Tagawa. He and his partner had
a very clear vision and they knew
exactly what was needed from
each one of us to ensure the
practice achieved its desired results. In turn, each one of us
knew that every challenge we
faced was an opportunity for personal, professional and practice
growth.
Practices with a motivated,
focused and empowered team
produce excellent results; consequently, patient satisfaction is
high and practitioners realise
increased financial rewards.
Achieving such a team is not pie
in the sky, but it does require complete commitment from the
whole team. Based on my own experience of being a part of a highperforming team and my observations as a consultant to practices, here are my key principles
for the creation of an ultimate
team.
Do not confuse being the boss
with being a leader. Leaders set
the tone for the practice. They
lead by positive example. Successful teamwork starts at the top
with leaders who provide strategic vision and establish team
goals. Effective leaders clearly define their vision and share it with
their team to establish a common
purpose.
Any successful relationship can
only survive if values are shared,
believed and agreed upon; values
like honesty, respect, integrity,
commitment to each other, commitment to the practice success.
Shared values help to build an
effective team and to establish
its culture, conduct, rules and
policies. The key is to ensure
the entire team agrees on the
same values and is prepared to
work by them. According to the

Consistency is critical to creating the ultimate team; it fosters credibility and trust. Ken
Blanchard and Sheldon Bowles
wrote in their book Raving Fans,
“customers allow themselves to
be seduced into becoming raving
fans only when they know they
can count on you time and time
again”. This is also true for teams:
just replace the word “customers”
with “team members”. I often
hear people say things like “one
day we’re instructed to something and the next day it becomes
something else”. If you want to
be part of the ultimate team, be
consistent.

world’s finest flight demonstration team (the Blue Angels, US
Navy), “without shared values,
peak performance isn’t possible”
and “a team’s values must align
with its purpose, mission, and
actions”.
Every team member, from the
leader to the cleaner, must learn
to communicate clearly and effectively. Successful relationships
are built on positive, honest and
open feedback. Is information
shared openly and honestly in
your team? Does gossip or negative chatter exist in your practice?
Team members must learn to address concerns, deal with conflict
and accept responsibility for the
success of other team members.
When conflict occurs, it must be
dealt with honestly, directly and
openly as soon as possible and
in line with the team’s adopted
values. Foster positive attitudes
and creative thinking—attitudes
can either make or break the team
dynamics, so there is no place for
negative people.
Do all your team members have
clear and up-to-date job descriptions? Are they all qualified to
undertake their roles? Are there
written procedures for every area
of the practice? I often hear team
members say they are not sure
who is responsible for something,
or they do not have a job description, or they were promised
training when they started, but
have not yet received any owing
to the practice being too busy.
Empowerment results from clearly defined roles and practice
procedures and a shared understanding of one another’s roles.
Cross-training increases efficien-

cy and makes each person more
productive and valuable to the
team.
Each team member is a cog in
the practice’s wheel of success.
However, many are often underutilised to his or her full potential

where staff were expected to be
(from the rota) and anyone off
that day. It only took 5 minutes for
the update and 5 minutes more to
review the day before regarding
what had worked well and what
had not. It helped us to focus on
the day ahead.

It is said that what motivates individuals the most is recognition
—a pat on the back or a word of
praise here and there for a job well
done. Embrace this principle and,
although it may feel awkward at
first, if it is done often enough
it becomes a habit. Sam Walton,
founder of Wal-Mart Stores, said:
“Appreciate everything your associates do for the business.
Nothing else can quite substitute
for a few well-chosen, well-timed,

“Successful leaders embrace the power of
teamwork by tapping into the innate
strengths each person brings to the table.”
Blue Angels, US Navy
and thus become bored or complacent. Dr Tagawa believed in
providing the best training for his
staff. He also recognised that he
may lose some individuals who
desired greater career progression than the practice could offer.
He knew nevertheless that those
who remained would perform at
their peak and more than justify
his investment.
Every morning in Dr Tagawa’s
practice as part of our commitment to the team, we would meet
10 minutes prior to the start of
the day to prepare for the show.
The head receptionist had a simple but effective system for updating us with vital information,
including how many patients we
would be seeing, special recognitions (like patients’ birthdays),
identifying difficult patients,

Walt Disney once famously
said, “You can dream, create, design and build the most wonderful place in the world, but it
requires people to make the
dream a reality.” Imagine a girl
visiting Disney World hoping to
see Cinderella, but when she
encounters her, Cinderella is
chewing gum and has a can’t-do,
won’t-do attitude. Is Cinderella
playing her role? It takes the right
attitude and focused commitment from every member of the
team to turn the vision into a reality. When that patient your practice dreads is due to arrive, how
do you all respond? With “I will
not take any nonsense from this
patient today!” or “I’ll show her
who’s right!”? When we choose
the right attitude and choose to
stay true to our purpose, we will
help others to do the same. A can-

sincere words of praise. They’re
absolutely free and worth a fortune.”
Building the ultimate team
does represent a challenge, but
once achieved it is hugely rewarding. There is no point implementing one principle in isolation.
It is like baking a cake without
the eggs.

Lina Craven is
founder and Director of Dynamic Perceptions,
an orthodontic
m a n a g e m e nt
consultancy and
training firm in
Stone in the UK,
and has many
years of practice-based experience. She
can be contacted at info@linacraven.com

[22] =>

DTUK0116_22-23_OTChayah 25.02.16 15:21 Seite 1

ORTHO TRENDS

Ortho Tribune United Kingdom Edition | 1+2/2016

and should look for any skeletal discrepancies. Compromises
must be signed off.

Conservative smile design
for the general dentist
1

By Dr Rami Chayah, Lebanon

Abstract
This article discusses the advantages of short-term anterior tooth
alignment using the Inman Aligner
system, particularly for general dentists. The article will give a brief description of the Inman Aligner appliance and its use in short-term orthodontics, and it will answer three major
questions the general dentist should
ask himself or herself during the treatment planning process. In support of
this treatment modality, three case
scenarios general dentists see daily
will be given as examples.

Treatment
concept
and case
presentation

treatment or Class II or III treatment.
Only certain types of movements are
possible and some patients will still

need conventional orthodontic treatment or indirect restorations. Certain
criteria should be met before treat-

ment proceeds. At consultation, other
orthodontic alternatives should be offered. The dentist must quote for the
long-term retention maintenance

Dentists need to consider three
questions about treatment during the
treatment planning process. The first
question: can the patient’s teeth be

Introduction
General dentists face the daily challenge of performing instant veneers
for patients with misaligned anterior
teeth who refuse orthodontic treatment, many of whom regard fixed
orthodontic treatment as too long
a commitment for achieving their
desired aesthetic results. In today’s
fast-paced life, some patients are not
prepared to wait or to go through
long treatments.1, 2 One of the greatest
benefits of short-term anterior alignment is that many people who would
refuse comprehensive orthodontic
treatment may accept short-term removable alignment techniques such
as the Inman Aligner system.
The Inman Aligner is a simple removable appliance, a modification
of the removable spring retainer. It
uses super-elastic coil springs to apply
highly efficient light and consistent
forces on both the labial and lingual
surfaces of the anterior teeth (Figs. 1 & 2).
The appliance is fabricated on a cast
on which, based on a surgical model,
the anterior teeth needing correction
have been removed and reset in the
ideal position in wax on the working
cast.3 When the patient wears the appliance, the built-in forces generated
by the spring coils will correct the
misaligned anterior teeth (Fig. 3).
What distinguishes the Inman
Aligner appliance from other shortterm orthodontic systems such as
Invisalign (Align Technology) and
Six Month Smiles is its low cost, low
risk and short learning curve for general practitioners. Only one appliance
is used from the start to the end of
the treatment. Sometimes, several
clear aligners may be used to de-rotate
resistant canines. The system is well
received by patients because it is fast
and relatively cheap. It also accommodates today’s active lifestyle. Usually,
most cases take from six to 16 weeks.
Patients can take the appliance out
during meals or work meetings.
As with any other treatment techniques, the Inman Aligner has its
limitations. Hence, case selection is
imperative, as the Inman Aligner is
not suitable for posterior orthodontic

Fig. 1: Inman Aligner appliance.—Fig. 2: Illustration of the Inman Aligner showing the appliance components.—Fig. 3: Inman Aligner appliance in the mouth. Case 1—Fig. 4:
Frontal view with the teeth in occlusion before treatment.—Fig. 5: Frontal view with slightly open bite showing the status of the teeth before treatment.—Fig. 6: Frontal view
with the teeth in occlusion after alignment and bleaching.—Fig. 7: Close up frontal view of the maxillary teeth after ABB.—Fig. 8: Right side view of the maxillary teeth before ABB.
—Fig. 9: Right side view of the maxillary teeth after ABB.—Fig. 10: Left side view of the maxillary teeth before ABB.—Fig. 11: Left side view of the maxillary teeth after alignment
and bleaching.—Fig. 12: Full face before treatment.—Fig. 13: Full face after treatment.—Fig. 14: Frontal view showing the patient’s natural smile before treatment.—Fig. 15:
Frontal view showing the patient’s natural smile after treatment.—Fig. 16:Full face showing the patient’s natural smile before treatment.—Fig. 17:Full face showing the patient’s
natural smile after treatment.—Fig. 18: Occlusal view showing the maxillary arch before treatment.—Fig. 19: Occlusal view showing the maxillary arch after treatment.

[23] =>

DTUK0116_22-23_OTChayah 25.02.16 15:21 Seite 2

ORTHO TRENDS

Ortho Tribune United Kingdom Edition | 1+2/2016

fixed without orthodontic treatment
in a very short period? In order for the
general dentist to answer this question, he or she should first establish
whether the patient does not wish
to pursue orthodontic treatment because of the time commitment and
cost. Would he or she also refuse
short-term anterior tooth alignment?
Would the occlusion be improved
even though a Class I molar or Class I
canine relationship may not be
achieved? Patients may prefer shortterm alignment techniques because
of the shorter treatment time and
the lower cost.
Case 1
The first case presented is a good
example of a scenario relevant to
the question above. The patient was
a young woman at college who presented at my office requesting a full
smile makeover of 20 veneers; she
desired a “Hollywood smile” as expressed in her own words. Her complaint was the retracted maxillary
right and left central incisors, the incisal edge wear on the maxillary central incisors and mandibular anterior
teeth, the pointy shape of the maxillary and mandibular canines, and
the yellow colour of her teeth overall
(Figs. 4 & 5). It could be argued that it
would be highly unethical to prepare
the sound enamel, transforming her
ten maxillary teeth into stumps, for
the rest of her life, especially at this
young age. After long discussion and
explanation of the disadvantages of
the shortcut route of preparing her
teeth for ceramic veneers, this option
was excluded. Several other options
were available and discussed with her,
but because she wanted a smile enhancement in a short period of time,
conventional fixed orthodontic treatment was also excluded. After checking her bite, it was observed that there
was insufficient interocclusal space
to shift the maxillary central incisors
forwards without opening the bite.
However, the patient accepted use of
the Inman Aligner system owing to its
short treatment time and flexibility
regarding being able to take the appliance off during the day while eating.
The treatment plan was to follow
the ABB protocol (alignment, bleaching and bonding). This concept still
constitutes a smile makeover but in
a very conservative manner. Taking
into consideration her age and her
sound enamel tissue, this was agreed
to be the most progressive means of
carrying out her smile enhancement.
First, her maxillary teeth were aligned
using the Inman Aligner with an
expander for nine weeks. Two extraclear aligners were used in the last
two weeks of treatment to de-rotate
the maxillary left lateral. Once the
maxillary teeth had been aligned
and in the last two weeks of treatment,
the teeth were bleached with customfitted super-sealed trays (Fig. 6). Now
that the teeth had been straightened
and whitened, the patient became
more aware of the differential wear
on the incisal edges of her anterior
maxillary and mandibular teeth.
Incisal edge bonding using composite was completed using a simple
direct technique. The patient was
very happy with the final result
(Figs. 7–19).

Case 2
The second question to be considered regarding treatment: would
some of the teeth be aggressively
prepared or end up with root canal
treatment if treated with restorative
dentistry without alignment and
would the overall outcome be better
with alignment rather than without?
This question addresses the ethical
dilemma general dentists face every
day. We often have cases with overlapping anterior central incisors in
our office.
The patient presented in this case
was bothered by the look of his overlapping maxillary central incisors
(Figs. 20 & 21). His mandibular teeth
were also crowded, but for some reason, his concern was only with his
maxillary teeth. He had started to
hide his smile in front of his friends,
feeling embarrassed to show his
maxillary teeth. After the full orthodontic examination and discussion
about all of the treatment options,
including comprehensive orthodontic treatment, the patient chose the
removable Inman Aligner system
owing to its flexibility in that the
wearer is able to remove the appliance for several hours a day and
because of its short treatment time.
The maxillary left central incisor
would have been aggressively prepared had it been treated restoratively.7–9 By using a simple anterior
alignment technique, the treatment
took only eight weeks to straighten
the teeth and a great deal of sound
enamel tissue was preserved by conservatively resolving the unattractive appearance of the maxillary
teeth (Figs. 22 & 23).

24a

24b

Case 2—Fig. 20: Frontal view showing the overlapping central incisors before treatment.—Fig. 21: Side view showing the overlapping
central incisors before alignment.—Fig. 22:Frontal view showing the teeth after alignment.—Fig. 23:Side view showing the teeth after
alignment.—Figs. 24a & b: Side views showing the moderately crowded and worn teeth before treatment.

dentine of the incisal edges (Fig. 25).
The patient initially requested instant
veneers to resolve his smile problem,
but after mocking up the design directly in his mouth, he was discouraged from pursuing this option owing
the amount of tissue that would be
lost. The aggressive preparation of

The treatment plan was to align
the teeth first and then to reassess the
restorative work needed (Fig. 26). The
appliance was used for 12 weeks and
only worn for 16 to 18 hours a day. During the last three weeks of alignment,
the patient began to bleach his teeth.
By week 12, the teeth were straight and

loss. This clinical approach guarantees that the strength of bonding to
the enamel is much greater.

Conclusion
The goal of this article is to encourage general dentists to reflect
on the importance of considering
short-term tooth alignment alone
or in conjunction with restorative
dentistry when treating patients.
Hopefully, these three questions and
cases will prompt readers in thinking
through the process of this treatment modality.
Disclosure: Dr Chayah is the trainer for
Inman Aligner Training in the Middle East.
He provides hands-on full-day certificate
courses to general practitioners.

Acknowledgement: I wish to thank Dr Tif
Qureshi, the founder and Director of Inman
Aligner Training in London, for his mentoring and sharing the last case in this article.
Editorial note: A complete list of references
is available from the publisher.

Case 3—Fig. 25: Occlusal view showing the tooth misalignment.—Fig. 26: Occlusal view showing the result of treatment.—Fig. 27: Maxillary
teeth after alignment to reassess the restorative work needed.—Fig.28:Natural-looking thin maxillary veneers owing to aligning the teeth first.

Case 3
The third question to be considered: will the teeth require restorative
work anyway, even after alignment?
The case presented serves to
demonstrate the necessity of aligning
the teeth even before placing ceramic
veneers.10–13 The patient in this case
exhibited moderate misalignment
with major anterior edge wear due to
occlusal trauma. In addition, the teeth
were darkened through years of stains
being absorbed through the worn

the tissue was explained to him using
the occlusal image of his maxillary
teeth. After an extensive orthodontic
examination and discussion of the
options, the patient refused fixed orthodontic treatment, as well as clear
aligners. He refused the first option
because he did not want anything
fixed in his mouth, and he refused
the second option because of the
proposed time involved. The Inman
Aligner system was introduced to the
patient, and he quickly accepted this
option owing to the short treatment
time and removability.

white (Fig. 27). At this point, a direct
mock-up was done to show the
patient the smile design that could be
achieved with composite. He felt that
the teeth were still flat and wanted a
fuller smile. Because we had aligned
the teeth, only minimal preparation
was needed as evident from the waxup and the decision was made to fabricate ceramic veneers instead (Fig. 28).
This case shows that for complex situations and considering patients’ high
aesthetic demands, pre-alignment is
essential to produce minimally invasive veneers with minimal enamel

Dr Rami Chayah
runs a cosmetic
dental practice
in Lebanon with
an emphasis on
minimally in vasive dentistry.
He seeks to share
his passion for
photographic and
video production and believes that
through his personalised dental approach, he can demonstrate a more
positive way of practising dentistry,
helping other dentists to view the
dental domain in a different way.
You can reach Dr Chayah through his
social media: facebook.com/ramichayah
and http://instagram.com/ramichayah
www.inmanalignertraining.com

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