PILOT AIMS to KEEP DENTISTS on the RIGHT SIDE of the LAW Clinical: Earn up to Four Hours of Verifiable CPD in This Issue

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GDC THE ‘WORST MAKING THE  REGULATOR IN UK’ STREETS SAFER CONTACT DETAILS Managing editor: David Cameron A recent PSA report Medics Against [email protected] has put the dental Violence has reached Editor: Bruce Oxley regulator at the bottom more than 17,000 Tel: 0141 560 3050 of a league of nine school children across [email protected] 11 healthcare bodies 32 Scotland since 2009 Advertising sales manager: Ann Craib Tel: 0141 560 3021 MILESTONE FOR RECORD NUMBERS [email protected] CLASS OF 2015 FOR DENTAL SHOW Design: Renny Hutchison, John Pender, Felipe Perez Dundee dean is The 2015 event saw Sub-editor: Wendy Fenemore presented with a pair more than 1,600 Subscriptions: Lauren Adger of white gloves to mark delegates through the Tel: 0141 561 0300 every final year student doors at Braehead [email protected] 13 passing at first sitting 38 Arena in Glasgow PILOT AIMS TO ORAL CANCER SUPPORT DENTISTS DETECTION

Deputy CDO With cases of oral introduces a pilot cancer increasing, project that aims to dentists have a crucial keep dentists away role to play in the early 28 from the GDC 54 detection of the disease DENTISTRY’S NORTHERN STAR This is another example of the BDA Kirsty Rodger, winner of the DCP Star award in London stepping at the Scottish Dental in to rule over Awards, talks about her 78 career so far Scottish committees 46 and it is exactly why © CONNECT PUBLICATIONS 2015 The copyright I and some others in all articles published in Scottish Dental magazine is resigned reserved, and may not be reproduced without permission. KIERAN FALLON Neither the publishers nor the editor necessarily agree VISIT 14 with views expressed in the magazine. ISSN 2042-9762 WWW.CONNECTMEDIA.CC

03 SCOTTISH DENTAL MAGAZINE SDC Group is a newly-established group of dental practices, providing high quality, patient-focused dental care throughout Scotland. Our portfolio of clinics is continuing to grow over the coming months, with multiple new centres opening across the country. We are currently recruiting for all members of our dental teams, particularly in our newest clinics of Dumfries and Oban. Both of these sites are fully refurbished to the highest standard with computerisation, digital radiography and brand new surgical and dental equipment. SDC Group enables full clinical freedom and support for all of our sta in our modern, compliant facilities. We o er excellent rates of remuneration, CPD support and full administrative assistance to allow our dentists to focus solely on their patients. As part of an expanding group of practices, we also o er opportunities for part ownership in the growing corporate. If you are a committed, enthusiastic individual and would like to be part of this expanding group, please send your CV to [email protected]

Looking to sell your practice? Looking to retire from dentistry? Tired of the administrative burden of owning a dental practice? As well as allowing part-ownership of our existing clinics for our dentists, SDC Group is always looking to acquire established dental practices. If you are at this stage of your career, becoming part of SDC Group will allow you to either realise the value of your hard work in retirement, or to continue with your dental career while freeing up your working time to concentrate on what you do best – looking after your patients.

If you are interested in selling your practice, or are interested in your practice merging with SDC Group, please email [email protected]

“high quality patient-focused dental care”

www.sdcgroup.co.uk WITH BRUCE OXLEY, EDITOR Get in touch with Bruce at Editorial [email protected]

hatting with dentists at compared to an assessment it carried out the recent Scottish Dental in 2013/14. Show, it was striking just RELIEVING Despite the GDC’s assurances that it how often the conversation is working harder than ever to get its own C turned to the GDC and the processes right, is it really any wonder then pressure under which many practitioners feel THE PRESSURE that that BDA asks how bad it must get they are now working. Even the remotest before someone intervenes? possibility of having to face a fitness to Clearly, government will not intervene practise hearing is enough to strike fear into directly with GDC business. But the the heart of the most skilled and ethical of ON DENTISTS initiative taken by deputy chief dental officer professionals. Tom Ferris and his colleagues, and which is One highly respected dentist, renowned Government-led pilot reported in this issue of Scottish Dental, is for his dedication and commitment to the to be warmly welcomed. They have come highest possible standards of patient care, aims to help dentists up with a 10-point check list through which summed it up when he said: “The thought dentists can benchmark their own, and their of making even the smallest mistake that steer clear of the GDC practice’s, performance. might lead to a complaint to the GDC ramps up the pressure on me every time I walk into The initiative taken my practice. It is like having this huge weight on your shoulders. We are all human and by deputy chief dental mistakes will happen. But to live under this The ever increasing anger and officer Tom Ferris and pressure should not be acceptable.” resentment directed towards the GDC by his colleagues, is to be Of course it is essential to have a the profession is simply fuelled this month regulator. There can be no argument with the news that the dental regulator came warmly welcomed about that. Patients must be protected bottom of a list of nine similar bodies whose Ferris is at pains to point out that this is and the profession must be governed. standards were examined by the Professional not about discipline. This is about education, But consistently, practitioners are arguing Standards Authority (PSA). prevention and supporting dentists to keep that far too many cases involving minor, The PSA highlights that the GDC failed them out the clutches of the GDC. often administrative, breaches of the strict to meet a total of seven of its standards The project is only at the pilot stage and professional guidelines are being brought of good regulation. On fitness to practise, is being trialled in just four health board before the all-powerful disciplinary the GDC fully met only one of the 10 areas. But the potential is huge. committees where entire careers, standards, and failed to meet six others, It is a bold step and one that the professional reputations and indeed representing what the PSA describes as profession should applaud and give its livelihoods are at stake. a significant decline in its performance full support to… for everyone’s sake.

WE COULDN’T HAVE DONE IT WITHOUT...

TOM1 FERRIS GRAHAM2 OGDEN STEVE3 BONSOR ADRIAN4 STEWART (ON THE NEW GOVERNMENT PILOT) (ON ORAL CANCER DETECTION) (ON MATERIALS SELECTION) (ON ENDODNOTICS) Deputy CDO Tom Ferris formed Professor Graham Ogden is a Steve Bonsor is an online tutor on the Queen’s University Belfast graduate the working group for the ‘Quality professor of oral surgery and MSc in Primary Dental Care at the EDI Adrian Stewart works in practice and Improvement and Supporting honorary consultant at Dundee as well as lecturing on applied dental limited to endodontics in Edinburgh Better Practice’ pilot. Dental Hospital and School. materials at Aberdeen Dental School. and Northern Ireland.

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1410027_Dürr Dental_AZ_Produktfamilie_Janina_210x297+3mm_ENG.indd 1 22.10.14 10:51 HAVING HIS SAY Arthur Dent is a practising NHS dentist in Scotland Insider [email protected]

APPROPRIATE REMUNERATION How do we follow the SDCEP guidelines, being paid according to the SDR and still manage to run a business? Something’s got to give

he SDCEP guidelines for Prevention and Treatment We need an SDR of Periodontal Disease which is fit for modern in Primary Care were purposes, and allows us T published in June 2014. to carry out the SDCEP These are a set of excellent, well researched and pragmatic guidelines which we should guidelines properly, and all follow. with fair remuneration The Statement of Dental Remuneration (SDR) makes this impossible to achieve without either incurring further financial periodontal therapy will require longer losses, or breaking the rules. appointments than those receiving dental SDCEP states that we should “ensure prophylaxis”. that full mouth periodontal charting is I have supposed that this refers to the performed annually in patients who scored standard 10A, fee for which we receive BPE 4 in any sextant at baseline and in £13.45. It is commonly thought that it costs patients who scored 3 in more than one £80-100 per hour to run a dental surgery – sextant at baseline”. The SDR makes it quite even with our (reduced) allowances it is very clear that a 1C exam may only be claimed hard to see how it can be cost effective to once every 24 calendar months. This would do this. The guidelines also ask for a recall mean 20 minutes spent annually on pocket interval of two to six months in the first year charting and other baseline indices without – but we are unable to recall more frequently remuneration. ABOVE: guidelines no longer achievable than every three months. For our 1A exam fee of £8.60, SDCEP We need an SDR which is fit for modern also expects us to provide advice on purposes, one which allows us to carry out smoking cessation, alcohol, healthy eating the SDCEP guidelines properly and with and plaque control at the recall appointment. advice states (6.1) that “sufficient time is fair remuneration. Patients deserve to have We still need to carry out an extra-oral and required at each recall appointment to periodontal treatment and maintenance intra-oral examination of soft tissues and carry out long-term maintenance effectively carried out properly. And we deserve our dental examination for this fee. The and patients undergoing supportive to be remunerated appropriately.

the BDA didn’t submit separate research evidence for Scotland at the DDRB In relation to the statement regarding a CORRECTION on Scotland to the DDRB. The BDA hearing in London. 400 per cent increase in ticket prices, the insist that it did in fact submit separate The author also referred to author was referring to the prices when The British Dental Association has raised research which is formulated by SDPC’s redundancies in Scotland. We would the event was held in Dunblane. However, some issues concerning Arthur Dent’s remuneration committee and validated by like to clarify that this was a voluntary both the author and Scottish Dental previous article (p7, May 2015), which we the BDA. In addition to written evidence, redundancy and there is no evidence that magazine acknowledge that the statement wish to clarify. the chair of SDPC, Scottish Council and the loss of the post has affected the ability was inaccurate and misleading, and we In paragraph four, the author stated that national director of BDA Scotland give oral of elected members to do their work. apologise for any inconvenience caused.

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PAGE The show was a sell-out, registrations were well up on last year and a record number of people attended the awards 38 ALAN RAMSAY

RISK MANAGEMENT School, will present two sessions: the dry mouth PROJECT TO and sensory changes in CUT ‘FITNESS TO the orofacial region and managing mucosal disease PRACTISE’ CASES in primary care. The government is taking Among the others action in an attempt to cut the presenting will be consultant number of Scots dentists being oral and maxillofacial surgeon brought unnecessarily before Nayeem Ali whi will present GDC disciplinary committees. on managing the temporo- The chief dental officer’s mandibular joint (TMJ) and office has launched a new pilot facial pain. project that aims to provide And Jeremy Rees, practitioners with a 10-point consultant restorative dentist, checklist against which Cardiff Dental School, will they can benchmark their give two sessions: food, drink own performance and so and dental erosion; and the minimise risk. composite Dahl approach. The pilot comes at a time Full programme, booking of soaring levels of concern information and speaker among dentists in Scotland biographies are available at: about the potential of being www.bda.org/scottishscientific hauled before the Fitness to Practise committees. PRACTICE ACQUISITIONS It is being led by deputy CDO Tom Ferris, who told DENTAL GROUP Scottish Dental magazine: TAKEOVER “This is absolutely about supporting practices and A Falkirk-based dental allowing dentists to see their group has secured a own performance and their ABOVE: Deputy CDO Tom Ferris is leading the charge on dentist performance £1.2 million deal to take over practice’s performance. It will two Edinburgh dental practices also enable them to benchmark and set its sights on doubling their performance and help in size by 2020. them to improve. quality improvement group CONFERENCE AND EXHIBITION BeDental, which already “It is also about assisting was formed to take the has a practice in Falkirk, as well a practice that is having project further. LEADING LIGHTS as Moodiesburn and Possilpark problems and helping The group, chaired by May ON THE PODIUM in Glasgow, has bought over individual clinicians at a very Hendry, dental practice adviser neighbouring practices Ocean early stage. None of this is at NHS Ayrshire and Arran, A number of Scotland’s Drive Dental Practice and disciplinary at all.” identified 10 key indicators leading dental clinicians are Vitaliteeth Dental Spa in Leith. The pilot, which is initially covering every aspect of to be among the speakers at The two practices bring being trialed by four NHS clinical practice on a clinician this year’s Scottish Scientific more than 13,000 patients boards – Ayrshire and Arran, and practice level. Conference and Exhibition. to the group, which is led by Dumfries and Galloway, NHS National Services The event, sponsored by principal dentist and clinical Lothian and Forth Valley – is Scotland was commissioned MDDUS, will take place on director Atif Bashir. He said: a combination of the Scottish to build an online ‘dashboard’ 4 September 2015 at Glasgow’s “We’re excited to be growing Government’s quality strategy to bring together and display Crowne Plaza Hotel. and having not one, but two and a project looking into all the information to support It will include a special practices in Edinburgh is a supporting better practice dentists in the pilot areas. address by the Chief Dental huge step forward for us. that was being carried out by The pilot will be assessed Officer for Scotland, Margie “At both Ocean Dental speciality trainee in dental on a regular basis and Taylor, who will present on and Vitaliteeth, we have public health Emma O’Keefe. progress will be reported the current challenges facing overhauled the entire Ferris took the proposal to the relevant boards and dentistry in Scotland. operation. Quite simply, it is to Chief Dental Officer committees involved. Alexander Crighton, about putting the needs and (CDO) Margie Taylor, and Turn to page 28 for a closer honorary clinical senior wellbeing of patients at the a sub-group of the CDO’s look at the pilot lecturer at Glasgow Dental heart of everything we do.”

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 GDC ‘WORST HEALTH REGULATOR IN UK’ Professional Standards is delivering real improvements in the protection of dental patients.  Authority places body at In a statement, the GDC said that TOP HONOUR BRINGS the bottom of a list of nine the PSA report confirmed that in NOW A SPECIAL SMILE the areas of guidance and standards, TRENDING A Scots children’s charity has education and training, and registration, won the prestigious National he BDA has expressed its alarm the GDC is performing well. Oral Health Promotion Group at a report into the performance The GDC said: “The PSA has Patron Prize at the recent NOHPG Conference. of the GDC that puts the reported on data collected between Action for Sick Children organisationT bottom of a league September 2013 and September 2014, 1/5 Scotland’s Special Smiles Dental of nine healthcare regulators. which confirms what was already FACT Project took the top honour. The Professional Standards known, namely, that in this period One in five people Dr Albert Yeung, consultant believe fluoride in dental public health at NHS Authority (PSA) published its findings the GDC was faced with an increased Lanarkshire and a member of the last month and revealed that the GDC number of complaints and a significant to be a marketing gimmick, despite ASCS Project Advisory Group failed to meet a total of seven of its pressure on resources. evidence it has in Lanarkshire, nominated the standards of good regulation. “The transformation programme been proven to work Special Smiles had carried On Fitness to Practise, the GDC fully we have put in place is already yielding reduce decay by out in the Board area for the NOHPG prize. met only one of the 10 standards, and results in this area and we are confident at least 40 per cent* The project helps children failed to meet six others, representing that it will continue to deliver improved with additional support needs, what the PSA described as a significant performance.” using ASCS’s Dental Play decline in its performance compared to GDC Chief Executive and Registrar, resources, to look after their teeth and help to reduce any an assessment it carried out in 2013/14. Evlynne Gilvarry (pictured left), said: worries about visiting the dentist. BDA Chair, Mick Armstrong, “The GDC has set out a clear vision ASCS chairman Professor said: “Yet again, GDC registrants that puts the patient at the Richard Olver said: “Since 2009 must acknowledge that they heart of its work. The PSA our Special Smiles project has worked in partnership with are being regulated by the report recognises much of NHS boards in various parts of worst health regulator in the excellent work being Scotland and we are delighted the UK. It is difficult to done by the GDC on a that this has been recognised understand how badly daily basis. We are not in this way.” At the recent IAPD the GDC has to perform complacent, however, Congress in Glasgow, the Special before someone actually and are fully focused on Smiles work in Lanarkshire intervenes.” the need to see through was a finalist in the poster However, the GDC our current reforms and competition, finishing as runner- mounted a staunch defence deliver improvements * up in the Bright Smiles-Bright Source: Futures Award category. of its performance, claiming in the area of Fitness The British Dental that a major change programme to Practise. Health Foundation

than adults to have attended progress we have made since RECORD HIGH FOR PATIENT an appointment. 2007 in improving people’s The figures also show that access to an NHS dentist, REGISTRATIONS IN SCOTLAND dental registration levels are with nearly two million more More Scots are now registered likely to be registered than the same, at 90 per cent, for people registered under this with a dentist than ever before, adults, at 93 per cent compared children living in the most and Government,” she said. new statistics have revealed. to 87 per cent. least deprived areas of Scotland. “It is encouraging to see The figures show that 88 per Of those registered, Public health minister that 93 per cent of children in cent of the Scottish population 74 per cent had seen their Maureen Watt welcomed the Scotland are registered and that – 4.7 million people – are now dentist within the last two statistics. “This is fantastic this rate remains high across all registered. Children are more years, with children more likely news, and shows the real sections of society.”

11 SCOTTISH DENTAL MAGAZINE IN FOCUS

SCOTLAND’S CLASS OF 2015 Catriona Xanthe Ross, Matthew John Dickie, Kate McKenna, We list the names set to pop up at dental Jennifer Elizabeth Sands, Ciara Dunleavy, Lauren McPhillips, practices around the country as the next Nirmal Pravinchandra Nurul Nadia Ataillah John McQueen, Shah, Emran, Ashleigh Janet Meikle, generation of professionals pick up their Simon James Shannon, Jonathan Fitzpatrick, Lucy Marie Morgan, Nurul Munirah Hayley Margaret Foulds, Sarah Andrea Mossey, Mohammad Sohaimi, Bachelor of Dental Surgery degrees Paul William Gallacher, Zoe Mullaney, Patrick James Steed, Ross Ian Gallacher, Kathleen Margaret Ryan James Stewart, Colin Gordon, ABERDEEN BDS Marwa JAQA Albulushi, Arran Eleanor Lang, Murphy, Rory Lamont Stewart, Neil David Gordon, GRADUATES 2015 Adnan Ihsan Ali, Michaela Laverty, Rachel Mussen, Emma Summers, Jinan Safa Hashim, Bashar Namat Behnam Victoria Anne Wakefield Mohammed Al-Khairulla, Maria Louise Taheny, Nina Louise Haveron, Sukhdev Singh Parhar, Abu Al-Soof, Lawson, Ruth Baidoo, Jennifer Helen Tanzilli, John James Perry, Megan Elizabeth Joshua Liam Daniel Craig Hogg, Suzanne Buckley, Neha Thummalapenta, Amy Grace Porter, Broadley, St.Clair Low, Gillian Catherine Howie, Anna Chrystal, Kirstin Livingstone Jaspal Singh Purba, Rachael Sarah Burgess, Heather Jane Lundbeck, Lauren Humphries, Jasmin Dingri, Walker, Hazel Ellen Reid, Michael John Byrne, Kamal Kapil Madhok, Esther Elizabeth Johns, Matthew Doswell, Andrew James Wilson, Darragh Thomas Byrne, Rebecca Louise Manson, Robert Kirke, Stewart Robertson, Michelle Gardner, Stephanie Louise Aoife Frances Cannon, Rebecca Masterson, Shona Lambie, Louise Robinson, Thomas Green, Wiseman. Grace Trea Conway, John Patrick McAleavey Dominic Lamont, Peter Shankland, Trishna AM Mistry, Rachel Tracy Dack, Meabh Catherine Michael Brian John Thomas Short, Bal Singh Panesar, GLASGOW BDS Marianne Louise Dobson, McKeown, Lewis, Ryan Shum, Alan Purves, GRADUATES 2015 Eliska Jana Dvorakova, Aoife Maire McKeown, Harriet Rose Liddicott, Craig Spence, Paul Martin Roden, Louise Emma Flavell, Megan Celine McMullan, Catriona Lynn Aitken, Samuel Lockhart, Jill Symington, Elizabeth Louise Christopher Fowles, Jennifer Ann Miller, Andrew George Baird, Elaine Macdonald, Sanderson, Hira Tariq, Carly Nicole Fraser, Stewart Alexander Matthew Barr, Katielyn MacDonald, Lynsey Katie Scott, Asha Thomson, Alasdair Scott Gilmour, Milligan, Brian Beggan, Lee MacKie, Veronica Ann Smith. Shakil Umerji, Claire Catherine Norfatihah Mohd Yatim, Francesca Capaldi, Hannah MacMillan, Callum Ross Ward, W Roger Marsh, DUNDEE BDS Gilsenan, Clare Paula Murphy, Kevin James Colgan, Andrea Rose Mathieson, Callum Andrew Wemyss, GRADUATES 2015 Aidan Hannah, David Graham Murray, Becky Coulter, Benjamin David James Sebastian Antonio Grant Stephen Creaney, Jordan Matthew, David A Wilson, Fatima Anwar, Hastings, Mylchreest, Mari Nadia Dabjen, Peter Jonathan Lauren Amy Elizabeth Amir Abd Aziz, Elaine Hogan, Grainne O’Rourke, Jennifer Danks, McCreadie, Wilson, Muhammad Abu Bakar, Alexandra Holden, Salam Bashar Protty, Alan Cameron Davies, Rachel-Wong Natalie Wilson, Lohini Arul Devah Ammar Juzar Alibhai, Faye Rosemary Rice, David Devine, McDermott, Ailsa Annie Woodley, Hannah Elizabeth Agnew, Laura Catherine Kelly, Marium Rizwan, Anne Catherine Devlin, Sheryl McFarlane, Xin Hui Yeo.

ABOVE: Glasgow graduates LEFT: Aberdeen graduates RIGHT: Dundee graduates

SCOTTISH DENTAL MAGAZINE 12 HOT OFF THE PRESS: THE LATEST NEWS FOR DENTAL PROFESSIONALS

ABOVE: presenting the white gloves to Prof Hector is 2015 graduate Nirmal Shah MILESTONE FOR DUNDEE’S BDS GRADUATES or the first time since achievement. I was also hugely 2004, all 65 final year honoured to be presented BDS students at Dundee with the white gloves as they Vermilion welcomes referrals for restorative FDental School have passed their represent a special reminder of examinations at the first sitting. a memorable year.” and implant dentistry, periodontics and dental To mark the occasion, The white gloves will be hygiene, endodontics, orthodontics, oral Dundee dental dean Professor permanently displayed outside surgery and cone beam CT scanning. Mark Hector was presented the dean’s office alongside the with a pair of white gloves final year photograph to mark during the graduation the achievement. ceremony on 26 June. He This was made all the more said: “I should like to express special as all the oral health my delight and extend my science students at Dundee congratulations to all the also passed their examinations Colleagues: visit students graduating this on 19 May, marking a double www.vermilion.co.uk year. It was a marvellous celebration for the school. to make a referral, or call 0131 334 1802

Vermilion – The Smile Experts 24 St John’s Road, Corstorphine, Edinburgh, EH12 6NZ Tel: 0131 334 1802 Email: [email protected]

13 SCOTTISH DENTAL MAGAZINE

Vermilion_Mar15.indd 1 13/07/2015 09:09 IN FOCUS

PAGE We would do well as a profession to more proactively contribute to the political and policy discourse 58 DAVID CONWAY BDA PULLS PLUG ON SCOTTISH SURVEY

ractitioners have reacted member of the SDPC and one angrily to the BDA’s of those involved in proposed decision to pull their formation of the new Scottish supportP for a survey of Scottish Association of Local Dental dentists’ attitudes to the GDC Committees, said: “This is just hours before it was due to another example of the BDA in be sent out. London stepping in to rule over The survey was scheduled Scottish committees and it is to be distributed on 6 July to exactly why I and some others all Scottish GDPs asking if resigned from the BDA last they thought the GDC was still year. It encapsulates all that fit for purpose and whether is wrong at the moment with they would support a separate the BDA.” Scottish regulator. Robert Donald, chair of Scottish Dental magazine the Scottish Dental Practice understands that Principal Committee, said: “SDPC is Executive Committee (PEC) disappointed that the BDA has chairman Mick Armstrong, ABOVE: Mick Armstrong is believed to have stopped BDA from sending survey decided to withdraw support personally intervened and for the survey, but we will stopped BDA staff sending potentially disruptive and was providing administrative carry it out ourselves using out the survey, saying that the divisive. support and was going to post Survey Monkey. questions related to Scottish A source close to the SDPC out the survey. “Scottish GDPs will be Dental Practice Committee said: “All SDPC wanted to do “Then, at the 11th hour, the contacted and invited to (SDPC) policy, but that it was was survey dentists to see what chair of the PEC has stepped in participate over the next “not BDA policy”. their thoughts were. And, in and said it is not BDA policy, we few days.” He is also said to have fact, the BDA was initially are not doing it.” The BDA was contacted, described the exercise as quite supportive of that. It And Kieran Fallon, former but refused to comment.

STUDENT GETS TANZANIA BRUSHING An Aberdeen dental student the programme that she has “But as I progressed in toothbrushes and toothpaste is set to launch a new oral developed. my dental course, I realised are expensive. They’re just not a health programme to help She said: “When I first went the skills I was learning in priority for these people. children in Tanzania. out, I hadn’t started my dental Aberdeen could be put to good “Little was done in terms of For the past three years, course yet so I was helping use in Tanzania.” prevention. They were forced Clare Lowe has been working to do all kinds of things like Clare is going to roll out to wait until something went with the Go Make a Difference helping provide clean water the programme in the town wrong with a tooth and then charity, building a health sources and teaching of Musoma, where she has either pull it out, or consult a centre, teaching oral health general health identified a particular need for local witch doctor.” and organising surveys and education to her support. Now, however, she intends fact-gathering exercises. youngsters. “Locals use a to spends time each year However, the student frayed stick to clean returning to the village to from Westhill is now their teeth as help improve the taking her charity work community’s in the country to new oral health. levels by introducing

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What ever problem your patient may have we’re here to help Our team of clinicians Dr K A Lochhead BDS, MFGDP RCS(ENG), Clinical Director and Specialist in Prosthodontics, GDC No. 62945 Dr C Tait BDS Hons, MSc, MFDS RCS(Ed), MRD RCS(Eng), Specialist in Endodontics, GDC No. 62862 Dr P Coli DDS, PhD, Specialist in Periodontics and Prosthodontics, GDC No. 104397 Dr F Veldhuizen BDS, MFDS RCS(Ed), M Clin Dent, MRD RCS(Ed), Specialist in Prosthodontics, GDC No. 72100 Dr P Hodge BDS, PhD, FDS RCS(Ed) Specialist in Periodontics, GDC No. 56503 Dr N Heath DCR, BDS, MSc, MFDS RCS(Ed), DDRRCR, Specialist in Oral and Maxillofacial Radiology, GDC No. 70569 Mr M Paley BDS, MB ChB, FFDRCSI, FRCS, FRCSEd(OMFS), Consultant Oral & Maxillofacial Surgeon, GDC No. 64778, GMC No. 4398217 Mrs G Ainsworth BDS (Sheff ‘96) FCS RCPS Glas, MSc (Ed), MSurgDent(Ed) Specialist Oral Surgeon, GDC No. 71932 Dr Donald Thomson BDS (Edin), FDS RCSEd, FDS RCPSG, DDR RCR Specialist in Oral and Maxillofacial Radiology, GDC No. 70079 Dr N Heath DCR, BDS, MSc, MFDS RCS(Ed), DDRRCR, Specialist in Oral and Maxillofacial Radiology, GDC No. 70569 Dr R Philpott, BDS MFDS MClinDent MRD (RCSEd) Specialist in Eddodontics, GDC NO. 82646 Visiting Professor Professor L Sennerby DDS, PhD Professor in Dental Implantology, GDC No. 72826

If you would like to discuss referring a patient to the Practice please contact our friendly reception team on 0131 225 2666 visit us online at www.edinburghdentist.com

Edinburgh Dental Specialists, 178 Rose Street Edinburgh EH2 4BA. www.tele-dentist.com www.allonfourscotland.com

EDS May15.indd 1 30/04/2015 12:28 HOT OFF THE PRESS: THE LATEST NEWS FOR DENTAL PROFESSIONALS IN FOCUS Edinburgh Dental

practices downsizing. The west Specialists end of Aberdeen already had seven practices, so you have to PRACTICES’ GRANTS question why three new SDAI practices with a minimum capacity for 24,000 patients What ever problem your patient IN THE SPOTLIGHT were funded within the same NHS Grampian is square mile. There was no may have we’re here to help business case for this. reviewing whether “I believe that NHS practices receiving Grampian is guilty of mismanagement of public Our team of clinicians grants were ineligible funds and I seriously doubt its commitment to tightening its Dr K A Lochhead BDS, MFGDP RCS(ENG), scrutiny of these contracts. Clinical Director and Specialist in Prosthodontics, GDC No. 62945 n Aberdeen dentist “All these potential Dr C Tait BDS Hons, MSc, MFDS RCS(Ed), MRD RCS(Eng), who waged a one- breaches were highlighted man campaign over to NHS Grampian years ago, Specialist in Endodontics, GDC No. 62862 non-complianceA of grant and little has been done. Dr P Coli DDS, PhD, conditions by new practices There should have been a Specialist in Periodontics and Prosthodontics, GDC No. 104397 in the city, has welcomed more robust process in place NHS Grampian’s decision to from the very start – it’s Dr F Veldhuizen BDS, MFDS RCS(Ed), M Clin Dent, MRD RCS(Ed), take action. frankly embarrassing for NHS Specialist in Prosthodontics, GDC No. 72100 Three years ago, Ross Grampian to be promising McLelland (pictured), principal better compliance in future. Dr P Hodge BDS, PhD, FDS RCS(Ed) dentist at Waverley Dental It’s even possible that this is a Specialist in Periodontics, GDC No. 56503 Health Practice in Aberdeen, Dental, Portlethen Dental Care, I believe that pattern repeated across other Dr N Heath DCR, BDS, MSc, MFDS RCS(Ed), DDRRCR, spotted a drop in business. Green Dental and Deeside health boards in Scotland.” He discovered that the health Dental Care. NHS Grampian A spokesman for NHS Specialist in Oral and Maxillofacial Radiology, GDC No. 70569 board had funded several new McLelland told Scottish is guilty of Grampian said: “NHS Grampian Mr M Paley BDS, MB ChB, FFDRCSI, FRCS, FRCSEd(OMFS), practices in the local area with Dental magazine: “I’m not mismanagement of is completing a comprehensive Consultant Oral & Maxillofacial Surgeon, GDC No. 64778, GMC No. 4398217 money from the Scottish Dental against the SDAI grant review of the monitoring Access Initiative (SDAI). initiative. In principal it’s a good public funds and processes for SDAI grants. This Mrs G Ainsworth BDS (Sheff ‘96) FCS RCPS Glas, However, when he started scheme if used appropriately, I seriously doubt will be both prospective and MSc (Ed), MSurgDent(Ed) digging, he found that one but there are strict terms and their commitment retrospective, resulting in a Specialist Oral Surgeon, GDC No. 71932 practice wasn’t eligible as it was conditions attached, and I was more robust process that will a limited company and began a astonished at how lax NHS to tightening their ensure better compliance with Dr Donald Thomson BDS (Edin), FDS RCSEd, FDS RCPSG, DDR RCR campaign for an investigation. Grampian was being. scrutiny of these the grant conditions. Specialist in Oral and Maxillofacial Radiology, GDC No. 70079 Now, the board has “We now have overcapacity “These investigations confirmed that five practices in Aberdeen, with one contracts are ongoing and it would Dr N Heath DCR, BDS, MSc, MFDS RCS(Ed), DDRRCR, are being looked at and named committed NHS practice be inappropriate for us to Specialist in Oral and Maxillofacial Radiology, GDC No. 70569 them as Britedent, West End closing and several other comment further.” Dr R Philpott, BDS MFDS MClinDent MRD (RCSEd) Specialist in Eddodontics, GDC NO. 82646 Visiting Professor Professor L Sennerby DDS, PhD Professor in Dental Implantology, GDC No. 72826 PRIVATE DENTAL PRACTICES TO BE REGULATED BY HEALTHCARE IMPROVEMENT SCOTLAND Private dental clinics are to be the growing cosmetic industry in Council is very keen to have regulation new regulation regime, starting with regulated by Healthcare Improvement Scotland. The Scottish Government has of entirely private dental practices. We independent clinics next year. Scotland (HIS) from next April as a announced that all private clinics where work with relevant bodies in the other The second phase will look at If you would like to discuss referring a patient to the Practice result of recommendations to the services are provided by doctors, three administrations and are keen to certain high-risk procedures, such as please contact our friendly reception team on Scottish Government on the non- dentists, nurses, midwives and dental have similar arrangements in Scotland. dermal fillers, which are being done surgical cosmetic industry. care professionals will be regulated by “The General Dental Council in clinics provided by other health 0131 225 2666 visit us online at www.edinburghdentist.com Legislation will now be commenced HIS from April 2016. regulates the whole dental team, so practitioners. after the Scottish Cosmetic Chief executive and registrar of practices owned and run by dental care The final phase will seek to Interventions Expert Group published the General Dental Council, Evlynne professionals would also be covered.” develop a system of regulation for Edinburgh Dental Specialists, its advice on the best way to regulate Gilvarry, said: “The General Dental The report proposes a three-phase other groups of practitioners. 178 Rose Street Edinburgh EH2 4BA. www.tele-dentist.com www.allonfourscotland.com 17 SCOTTISH DENTAL MAGAZINE

EDS May15.indd 1 30/04/2015 12:28

HOT OFF THE PRESS: THE LATEST NEWS FOR DENTAL PROFESSIONALS IN FOCUS

“It is an increasing part of my work as a paediatric dentist SAFEGUARDING THE – having to get in touch with children’s services to talk to social workers. It is a significant VULNERABLE IS KEY part of our work now and I  After more than a decade of campaigning, Glasgow am very relieved that it is been Professor Richard Welbury has welcomed the GDC’s recognised by the GDC.” NOW Prof Welbury chaired the decision to recognise the reporting of abuse or neglect recent IAPD congress that saw TRENDING of children and vulnerable people as a core CPD topic more than 1,600 delegates from over 60 countries attend. IAPD president Jorge Castillo hailed peaking at a press the conference, which had the £5M conference during the theme ‘The Voice of the Child’, 25th Congress of the as “the greatest congress by the FACT InternationalS Association of IAPD ever”. The Childsmile Paediatric Dentistry (IAPD) at Prof Welbury also programme the SECC in Glasgow recently, remarked that the congress was has reportedly reduced dental Professor Welbury said that unique in its approach. He said: treatment costs safeguarding children and “It is quite innovative in that I by £5 million young people has become a am not aware of any previous a year significant element of the work paediatric conference that has of paediatric dentists. included a holistic view of the He said: “We have actually child before. Usually, dental been asking the General conferences have been related Dental Council since 2004 to dental materials or dental for this to happen, so we are traumatology, but never with very grateful that it has now a total holistic view, which the * actually happened. Voice of the Child gives us.” Source: Childsmile

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IN FOCUS

UPCOMING EVENTS Sir Winston WE'VE GOT THIS COVERED Churchill painted 1-4 JULY 11-13 SEPTEMBER 27-30 SEPTEMBER 22-24 OCTOBER 2-4 FEBRUARY 2016 IAPD Congress MFDS Part 1 International Orthodontic BDIA Dental Showcase AEEDC SECC Glasgow Revision Course Conference NEC, Birmingham Dubai under the alias Visit www.iapd2015.org for Royal College of Physicians ExCeL, London For more information, visit Visit www.aeedc.com for more information. and Surgeons of Glasgow For details, visit www. www.dentalshowcase.com more information. To find out more, visit wfo2015london.org Charles Morin. 4 SEPTEMBER www.rcpsg.ac.uk/events 30 OCTOBER 22-23 APRIL 2016 BDA Scottish Scientific 8 OCTOBER Tidu Mankoo – The Dentistry Show Conference 2015 22-25 SEPTEMBER SCED seminar: Contemporary NEC, Birmingham Crowne Plaza, Glasgow FDI World Dental Congress Treatment planning Rehabilitation of the Visit www.thedentistryshow. Compromised Dentition Isn’t it great when Visit www.bda.org to book. Bangkok, Thailand SCED, Glasgow co.uk for more information. Visit www.fdiworldental.org Email secretary@scottish Loch Lomond Golf Club 10 SEPTEMBER for details. dentistry.com to book. Email secretary@scottish 13-14 MAY 2016 you discover SCED seminar: dentistry.com to book. Scottish Dental Show Refer and restore 23 SEPTEMBER 14-16 OCTOBER Braehead Arena, Glasgow SCED, Glasgow SCED seminar: BDA Annual Presidential 3 NOVEMBER Visit www.sdshow.co.uk for something new? Email secretary@scottish Update in orthodontics and Scientific Meeting MFDS Part 2 more information, or follow dentistry.com to book. SCED, Glasgow Hilton Brighton Preparatory Course @ScottishDental on Twitter Email secretary@scottish Metropole Hotel Royal College of Physicians for the latest updates. 10-11 SEPTEMBER dentistry.com to book. Visit www.bda.org for more and Surgeons of Glasgow MFDS Part 2 information. To find out more, visit 26-28 MAY 2016 Revision Course 25 SEPTEMBER www.rcpsg.ac.uk/events The British Dental Royal College of Surgeons Preparing for retirement 22 OCTOBER Conference 2016 of Edinburgh and wealth management SCED implant seminar: 12 NOVEMBER Manchester For details, visit seminars Extraction techniques for SCED seminar: Visit www.bda.org/ www.rcsed.ac.uk Edinburgh dental implants Update in endodontics conference for more To book, email samantha. SCED, Glasgow SCED, Glasgow information. [email protected] Email secretary@scottish Email secretary@scottish or visit www.pfmdental.co.uk dentistry.com to book. dentistry.com to book. for more information.

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live, so we stayed. That background gives me an interesting angle – I’ve been part of the process of UK organisations grappling with YOU CAN PLEASE devolution from both ends of the equation and understand the frustrations. What I would say is that the BMA faces SOME OF THE many of the same issues, as do other similar organisations like the RCN. We all struggle to keep everyone happy. Nobody is getting PEOPLE, SOME things completely right, and that’s probably because there is no right answer that will suit everyone. What we should do is commit to continuing the dialogue, and doing what we OF THE TIME… can to best represent our members. Improving communication and raising the We all struggle to profile of dentistry – two of the BDA’s key keep everyone happy. priorities says Martin Woodrow Nobody is getting things completely right, and that’s probably because there is no right answer s we come towards applies to the British Dental Association as that will suit everyone the anniversary of the much as it does to any other organisation. independence referendum, One of the key issues in any debate is In that respect, there have been the tremors are still being bound to be how much power is devolved criticisms in Scotland of the BDA and what A felt across politics and from the centre (usually in London) to it does for members. But again drawing on broader society. Not just in Scotland, but other parts – be that nations, or indeed my BMA days, I have been hugely impressed across the whole of the UK. now regionally within England. And an by the range and quality of services that The consequences were certainly felt in interesting context to that debate is likely BDA members get – in comparison to their this year’s Westminster elections, and no to be the personal perspective of the medical colleagues. For example, the scope doubt will be at the polls in Scotland next key players and their views on the wider of business advice is much wider, the depth year. We’ve still got debate and disagreement political question. of the input to the review body process for about the Smith Commission proposals – do But for organisations like the BDA, there all the nations is striking, and the provision they go far enough, does the Scotland Bill are additional constraints that stem directly of high-quality continuing professional really reflect the Commission’s intentions? from its role as a trade union. Authority development is impressive. There is certainly It was the Welsh Labour MP Ron Davies simply cannot be delegated away from a no equivalent of the excellent value BDA who came up with the phrase back in trade union’s executive committee, which Scottish Scientific Conference for doctors. 1997 that “devolution is a process and not is understandably frustrating for those One of the issues I have heard, across an event”, and can it ever have seemed who would like to see greater or complete the UK, since coming to the BDA is that more appropriate? autonomy. That is not to say that things the association’s voice is not loud enough, cannot or should not be done to reflect the that we don’t get our views across like the Organisations need devolution process. The debate about how doctors. The BMA certainly gets criticised to repeatedly challenge the BDA can change is very much a live by its members for the same thing. one, with chair Mick Armstrong meeting But we can do better to raise the profile themselves as to whether Scottish colleagues in August to discuss this of dentistry, to make sure that it is a key they are fit for purpose, to very subject. part of the wider health debate. Improving reflect the constitutional I come at this whole discussion from communication, raising that profile, is one an unusual perspective. Part of my BDA of the key strategic priorities for the BDA order of things director role is to look after the advice across the UK. Dentistry is a small and But it isn’t just in big politics that there and representational services provided diverse profession and will have a much is a sense that everything has changed to members across the UK, including in better chance of getting its voice heard if it and continues to change. Across society, Scotland. My job is London-based but I live stands together. companies and organisations need to with my family in Edinburgh. The reason repeatedly challenge themselves as to is that, before joining the BDA, I was the

whether they are fit for purpose, to reflect director for the British Medical Association ABOUT THE BDA the constitutional order of things. That in Scotland. Edinburgh is a great place to Visit www.bda.org for more information

25 SCOTTISH DENTAL MAGAZINE Preparing Booking for retirement now open course 2015 Edinburgh – Friday 25 September 2015

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PILOTING28 A NEW COURSE STRIKING BACK32 AGAINST VIOLENCE DENTAL38 SHOWCASE BEST46 OF THE BEST Deputy CDO Tom Ferris outlines an Medics Against Violence is The biggest Scottish Dental Show The winners at this year’s Scottish exciting new pilot project aimed at fighting back against senseless saw more than 1,600 delegates Dental Awards are still celebrating keeping practitioners away injury. Scottish Dental meets its walk through the doors of Braehead their wins after the most successful from the GDC inspirational leader Arena in Glasgow awards night yet

ESSENTIAL EDITORIAL CONTENT FOR DENTAL PROFESSIONALS

ALL SMILES CELEBRATING THE SCOTTISH DENTAL SCENE See page 46

27 SCOTTISH DENTAL MAGAZINE INDEPTH

SUPPORTING QUALITY PRACTICE AN AMBITIOUS NEW PILOT PROJECT THAT AIMS TO SUPPORT DENTISTS IN PRACTICE AND STOP THEM ENDING UP IN FRONT OF THE GDC HAS BEEN LAUNCHED

 BRUCE OXLEY  MARK JACKSON

he nightmare of being referred supporting practices and about allowing Scottish Government’s quality strategy and to the GDC has long struck fear dentists to see their own, and their a project looking into supporting better into the heart of the profession. practice’s, performance. It will also enable practice that was being carried out by Controversial the regulator may them to benchmark their performance and speciality trainee in dental public health be, but it still has the power to help them to improve. Emma O’Keefe. Tend a career. “But it is also about assisting a practice Purely by chance, Emma, who is now Now, however, the number of that is having problems and assisting a consultant in dental public health at cases coming before fitness to practice individual clinicians at a very early stage. NHS Fife, was working alongside Tom, committees has reached such a level that None of this is disciplinary at all. All we who was tasked with implementing the the government is taking action to identify want to do is have a consistent approach – quality strategy within dentistry and they concerns as early as possible to provide that all boards will do all these stages, at the discussed what they were each working support and, by doing so, reduce the same time, to the same level and with the on. It occurred to them that it would number of dentists facing the powers same trigger.” make perfect sense to combine their two that be. The pilot, which is initially being pieces of work and form a larger and Under the guidance of Scotland’s trialled by four NHS boards – Ayrshire and broader project. deputy chief dental officer Tom Ferris, Arran, Dumfries and Galloway, Lothian Tom took the proposal to chief a new pilot has been launched called and Forth Valley – is a combination of the dental officer (CDO) Margie Taylor, ‘Quality Improvement and Supporting and a sub-group of the CDO’s quality Better Practice’. The pilot brings together improvement group was formed to take information from a range of sources to “THIS IS ABSOLUTELY ABOUT the project further. The group, chaired by get a picture of the quality of dental care May Hendry, dental practice adviser at that individual clinicians and practices are SUPPORTING PRACTICES AND NHS Ayrshire and Arran, identified 10 key providing. However, rather than singling indicators covering every aspect of clinical out underperforming dentists and failing ABOUT ALLOWING DENTISTS practice on a clinician and practice level practices, the pilot is all about early (see over). intervention to avoid problems that could TO SEE THEIR OWN, AND THEIR NHS National Services Scotland lead to, among other things, referrals to the was commissioned to build an online GDC, said Tom. PRACTICE’S, PERFORMANCE” He said: “This is absolutely about TOM FERRIS, DEPUTY CHIEF DENTAL OFFICER CONTINUED OVERLEAF>

SCOTTISH DENTAL MAGAZINE 28 Tom Ferris says that the pilot is not about discipline, it is about supporting dentists in practice

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FROM PREVIOUS PAGE> PRACTICE INDICATORS DENTIST INDICATORS never get access to the information in the 1. Practice inspection 1. NHS board concern dashboard and the preview they have seen (general and sedation) 2. Drug prescribing 2. Out of hours 3. Childsmile FVA ‘dashboard’ to bring together and display of how it will look was developed using arrangements 4. Clinical quality all the information – which comes from a dummy information. He said: “When it 3. Feedback 5. Clinical audit 6. Patient view (PDS only) range of sources such as ISD and NES as is live, I expect you would primarily see 7. Probity well as the health boards themselves – in a sea of green, because most dentists are one place. Tom explained: “These indicators working really well and there are very few all exist somewhere but at the moment dentists getting into trouble. eventual aim of it being rolled out to all 14. they are not all in one place. The end “This is really important to stress; most He said: “The pilot has been shared point is that we will be able to extract data dentists do really well and most dentists with the lead officers for all of the health automatically from the various places where want to do really well and we have to trust boards, so they are all aware of it. it sits and that will feed into the dashboard them. But there will be the odd amber, “Two boards have approached us and get updated as and when is required.” the odd red and that will show up as quite asking if they could start now. But, rather The indicators are RAG (red, amber, noticeable on the dashboard. Whereas, if than bring them in straight away, what green) scored using the traffic light system that information is kept in a drawer or if we may do is offer the new boards the with green meaning no issue or concerns, it was kept in various places as it is at the spreadsheet that almost sits underneath the to amber which indicates some concern or moment, it can be difficult to spot if there dashboard so they can start to bring things a shortfall of some degree, to red, which is something happening there.” together locally. So, when we decide to highlights serious concerns, non-compliance As the pilot progresses and the go live with the system in their board, the or multiple/major breaches. Amber and red dashboard is developed, Tom explained import is that much easier.” scores would initiate a response, ranging that the aim is for the information to be And, rather than being sceptical from advice and support for the practice or made available for individual clinicians to about the process, Tom hopes that the individual up to referral to an NHS board access and see how they compare with their profession will see this as a powerful tool performance review group, or equivalent, to peers through anonymised benchmarking for developing practices and improving discuss if further action is needed. on a health board and national level. clinicians’ clinical work. Tom explained that during the pilot Eventually, he believes that some of the He said: “I am quite excited about the the information that is being fed into information should be available to the prospect of giving dentists access to the the dashboard will not be made widely public as well, although that is expected to data to allow them to see how they are available. In fact, of the members of the be much later in the process. getting on because I think that is really sub-group, only the primary care managers He said: “There will be a discussion important. We are only just getting the currently have access. He said: “We had a down the line, probably when we are mechanics of it sorted at the moment, long debate about who should access this well into the pilot and other boards have but the next stage for the four pilot boards raw data and we decided that, for the pilot, joined, about extending the level of access. is opening up access in a secure way to not many people needed to look at it. So, Because, in the end, there should be some the practice owners and the dentists. the only people who have access to it are level of access for the DPAs, practice They will never see one another’s data, the primary care managers in each of the owners and individual clinicians. It is they won’t see their colleagues’ down pilot health boards. important that we get that right and the the road, but it will be anonymised and “If they see a change in performance logical end point is that there should be benchmarked so they can gauge where or something going from green to amber, some way that we can present some of this their data sits within the range. That is they would highlight that to the relevant information to the public. thought to be a very powerful way to person. So, it would primarily be the “But, that is way down the line and drive improvement, to see how you are dental practice adviser, but it could be the it wouldn’t be raw data. There must be a comparing to someone else. So that’s the Childsmile co-ordinator and it could be the discussion about that. We would need to bit I’m really looking forward to.” clinical director for the PDS.” find a way of presenting the information so Tom admitted that he and Margie will that it is understandable and makes sense to the public.” QUALITY IMPROVEMENT AND SUPPORTING BETTER PRACTICE WORKING GROUP However, as this is a pilot, the May Hendry – Dental Practice Adviser, NHS A&A (chair) indicators and thresholds that are in place Colin Duncan – Lay representative on Scottish Dental THAT IS THOUGHT at the start might be altered or removed Practice Board as the project develops. Tom said: “These Emma O’Keefe – Consultant in Dental Public Health, indicators are not set in stone, this was NHS Fife TO BE A POWERFUL Valerie White – Consultant in Dental Public Health, what we felt as a group were the right NHS Dumfries and Galloway indicators. If we sit down in six months Anna Slaven – Primary Care, NHS Ayrshire and Arran WAY TO DRIVE time and discover that one of the indicators David Conway – Consultant in Dental Public Health, is not really telling us anything, we could Information Services Division change it and bring something else in. Jill Ireland – Senior Analyst, ISD IMPROVEMENT, TO Greg Thomson – Primary Care Strategic Lead, NSS IT “That also goes for the thresholds Tom Ferris – Deputy Chief Dental Officer, between green, amber and red – this is the Scottish Government SEE HOW YOU ARE pilot, it’s about learning and the end point PROVIDING ONGOING ADVICE TO THE GROUP: will certainly look a lot different to what we Tony Anderson – Director, NHS Education for Scotland COMPARING TO started with.” Linda Bunney – Primary Care, NHS Dumfries and Galloway Tom expects more health boards Alison McNeillage – Primary Care, NHS Lothian to come on board, two are currently in Evelyn Hadden – Primary Care, NHS Forth Valley SOMEONE ELSE discussions at the moment, with the Alan Whittet – Dental Adviser, Dental Reference Service

31 SCOTTISH DENTAL MAGAZINE INDEPTH

AGAINST THE ODDS THE ONCE SEEMINGLY UNSTOPPABLE TIDE OF ALCOHOL-RELATED GANG VIOLENCE IS TURNING. THE MEDICS AGAINST VIOLENCE CHARITY HAS PLAYED A PROMINENT ROLE IN AN EDUCATION INITIATIVE TO MAKE THE STREETS SAFER

 TIM POWER  MIKE WILKINSON

hen emergency medicine Christine Goodall was one of the York. However, today it’s a different consultant Alastair Ireland original founders of MAV, after being story, thanks to the impact of the Police came to work for his evening appalled at the level of senseless violence Scotland’s Violence Reduction Unit, set shift at the Glasgow Royal that was enveloping young people in up by Strathclyde Police in 2005, and the Infirmary he knew it was Glasgow. As an oral surgeon training in work of organisations like MAV and other W going to be a busy night. In oral and maxillofacial surgery at the time, community initiatives across the city. three separated cubicles his colleagues were she witnessed the bloody results of this Today, Glasgow’s – and Scotland’s – dealing with three individual stab victims. type of “recreational violence”, dealing with annual murder rate has more than halved, He described the scene: “One had his multiple facial fractures from blunt trauma from 39 in 2004-05 to 18 in 2014, with chest already open as the medics tried to – from baseball bats and fists – and also similar reductions in attempted murder, try to save his life. The other had a sword knife-related injuries, such as slashes and serious assault and people carrying knives. sticking out of his eye. Another young man the infamous “Glasgow smile”. What is interesting about the crime had horrific wounds all over his body from Ten years ago Glasgow was dubbed statistics is the reduction in the numbers multiple machete attacks. He died... well, the “murder capital” of Europe and had of young people involved: the majority of they all died.” violent assault statistics to rival New violent crime is now committed by people Alastair was describing what had in their 20s and 30s. become an all too common Saturday night Christine explained: “There really is in Glasgow around 10 years ago for a video AS AN ORAL SURGEON a sea change in attitudes. The statistics produced by Medics Against Violence speak for themselves and it’s with young (MAV). The hard-hitting production TRAINING IN ORAL AND people where the change is happening. The is being screened to show today’s messages are getting through as they are schoolchildren the dangers of alcohol- MAXILLOFACIAL SURGERY AT drinking less and not getting involved in related gang violence. violence as much as before – they are really Two hundred and fifty MAV volunteers THE TIME, SHE WITNESSED THE making this happen.” have been visiting schools since 2009 and Christine and her MAV colleagues so far have spoken to more than 17,000 BLOODY RESULTS OF average around 50 school and youth club children, mostly across the Central Belt ‘RECREATIONAL VIOLENCE’ visits a year, speaking to classes of second and also in Dundee where they run their intervention programme. CONTINUED OVERLEAF>

SCOTTISH DENTAL MAGAZINE 32 “THE STATISTICS SPEAK FOR THEMSELVES AND IT’S WITH YOUNG PEOPLE WHERE THE CHANGE IS HAPPENING”

Christine Goodall, one of the founding members of Medics Against Violence, a charity that works alongside Police Scotland’s Violence Reduction Unit to keep the issue of gang violence and knife crime high among school children

FROM PREVIOUS PAGE> “They wanted to be involved with our video and to warn others about the dangers of VIOLENCE REDUCTION UNIT to fourth years about the dangers of getting involved in violence – I think their In 2005, Strathclyde Police established drinking and getting involved in violence. words are very powerful and resonate with the multi-disciplinary Violence Reduction The team are also regular visitors to HM other young people.” Unit (VRU) to reduce all types of violent behaviour, particularly knife crime Young Offenders Institution Polmont During the group discussions after the among young men in Glasgow. The during the summer. video some of the boys admit to drinking VRU adopted a public health approach to Today, she is at the Cardinal Winning on the street and realising how this made violent crime, similar to projects in the US, Secondary School which caters for 120 them vulnerable. One admitting to being which showed that primary intervention and collaborative prevention work are children with special or additional needs in a gang and getting into fights but turned essential in reducing violence. in the east end of Glasgow, where she away from violence when he realised that In 2008, the VRU established the is giving her talk as part of the school’s he could have put his family at risk if a rival Community Initiative to Reduce Violence Health Day. gang came after him. (CIRV) programme which brought together The schoolchildren are transfixed by Christine said MAV’s message has many different agencies and professions into tackling the issue of youth violence. In an the new video, which pulls no punches. It changed over the years: “We’ve moved effort to meet the issue head on, the VRU features CCTV footage of gang violence on away from ‘don’t carry a knife’ to broader invited gang members to attend a meeting the street, graphic photography of hospital messages about keeping safe, not drinking where they were told what to expect going A&E teams trying to save stab victims, as forward: a zero tolerance police response if violence did not stop, whether they were well as thoughts of a surgeon, ambulance involved or not. But also on offer was help driver and a forensic pathologist on the “WE’VE MOVED AWAY FROM with education, training and job finding repercussions of such violence. However, from various agencies and charities if they the most powerful message comes from turned their back on violence. After the ‘DON’T CARRY A KNIFE’ TO first year, the programme had led to a 49 two young men currently under a long per cent reduction in violent offending and sentence for murder in Polmont who regret BROADER MESSAGES ABOUT a 59 per cent decrease in knife carrying the day they got involved in a mindless by those engaged with the initiative. The knife fight at the age of 14, which resulted KEEPING SAFE… AND WALKING CIRV finished in 2011 and the VRU is now in the taking of a life. engaged in other projects such as Mentors AWAY FROM TROUBLE” in Violence Prevention now operating in 50 Christine has met these boys many schools across Scotland. times and said they are truly repentant: CHRISTINE GOODALL

Christine Goodall and her MAV colleagues visit schools and youth clubs to speak on the dangers of drinking and getting involved in violence. The schoolchildren are transfixed by a MAV-produced video which pulls no punches

SCOTTISH DENTAL MAGAZINE 34 INDEPTH

MEDIC ON A MISSION Although Christine Goodall trained in academic oral and maxillofacial surgery and worked in that field for 12 years, she now splits her time between surgery and academic research. Her main research interests are alcohol and injury, particularly alcohol-related facial injury, and violence including youth violence, domestic abuse and sexual assault. She is member of the Community Oral on the street, being aware of what’s Health Research Group but she works with going on around you and walking away “THEY NOW HAVE MUCH a wide range of different professionals on research projects including fellow surgeons, from trouble. public health specialists, psychologists, “But we now emphasise to young MORE SYMPATHY FOR VICTIMS psychiatrists, nurses, statisticians, people that things have changed for the criminologists and the police. better in Scotland regarding gangs and AND THIS IS HELPING TO She has also has an interest in the role of the dental team in screening for alcohol violence, and that they are and need to be REINFORCE THEIR ATTITUDES TO misuse and domestic violence. part of maintaining that change. She explained: “I do a lot of training “This is an important message as we VIOLENCE IN GENERAL” around teaching professionals, such as want to normalise that change for them – dentists, vets, doctors, fire service and CHRISTINE GOODALL even hairdressers, to raise the issue of to make them realise that if they are not domestic abuse so they can signpost people changing like others then they are actually towards help. unusual. This is powerful because kids have “If someone came into a surgery with a a great desire to be like their peer group.” more sympathy for victims and this is black eye, a lot of dentists would not bring it After each session the children are helping to reinforce their attitudes to up because they are very unsure about what to do about it. It’s not that they are ignoring given feedback forms to assess what they violence in general.” it, it’s that they worry about opening that big picked up from the video and group Christine is able to give MAV sessions can of worms. discussions. to three classes at the school before she “I give them tools to have that She added: “Feedback shows that we’ve has to rush off at lunchtime to get back to conversation with the person which limits their involvement but helps them signpost been effective in raising awareness and, to her day job, which she splits between oral people to organisations that are more expert an extent, in changing attitudes to violence. surgery for the NHS and academic research at dealing with this situation.” “Some kids say they have learned they based at the Glasgow Dental Hospital and The service has been going since 2010 should not get involved in violence and that School and the University of Glasgow. and since then about 700 dentists have undergone the training. they should walk away, but many – and “I’m very grateful to Professor Jeremy “I’ve developed the service along with the this is a common theme – also say they Bagg, head of the dental school, who is very Violence Reduction Unit and provide the have changed the way they think about supportive of this initiative as it is part of training. I’m now looking at making it the victims of violence. A lot of them have the university’s mission to engage with the sustainable with more trainers on board,” the perception that victims of violence are community. It’s ironic as I would not have added Christine. ‘losers’, but now they realise that some been able to do these talks ten years ago If you are interested in domestic people are victims for no fault of their own – I would have been too busy to get out of violence training, contact Christine at – sometimes it’s just down to bad luck. hospital because of the prevalence of these [email protected] “They are saying they now have much kind of assaults.”

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 BRUCE OXLEY  MIKE WILKINSON

he Scottish Dental Show was a University of Glasgow, as well as Scottish Dental magazine, said: “It’s been sell-out success this year, attracting show regulars Professor Paul Tipton and another cracker this year – the show was record numbers and offering Ashley Latter. a sell-out, registrations were well up on even more – proving that it is the Attendances at the lectures broke last year and a record number of people must-attend event for the Scottish records too, with 250 delegates attending attended the show and the awards. The T Dental community. Professor Gibson’s first talk on oral cancer; amazing success of this year’s show demon- Taking place over Friday 29 May and nearly 190 turning out for Lee McArthur’s strates that this really is the must-attend Saturday 30 May, the event saw nearly infection control talk, and just under 170 event for the dentistry sector in Scotland.” 1,800 people walk through the doors of listening to Rachel Bell from the MDDUS’s Braehead Arena, a 30 per cent increase on talk, entitled ‘I’m a GDC registrant, get me VIDEO last year. out of here!’ The official Scottish Dental Show video The trade show was also fully booked Initial feedback from delegates has is now online, so head to our YouTube with more than 140 exhibitors, and the been extremely positive, with more than channel to see what all the fuss is about. response has been so great that the 2016 90 per cent rating the show as ‘Excellent’ The video aims to give a snapshot of exhibition hall is already nearly half full as or ‘Good’. The speaker selection got a big what has become the biggest annual dental companies rush to return to the event at thumbs up as well, with 89 per cent saying exhibition and conference in Scotland. Braehead on 13 and 14 May next year. the choice of lecturers was either ‘Excellent’ Visit bit.ly/SDS15video to see if you The lecture programme again featured or ‘Good’. made the cut. a world-class line-up of more than 40 When asked if they would be attend- speaker sessions and workshops, offering ing the Scottish Dental Show in future, 68 up to eight hours of verifiable CPD. Among per cent said ‘Definitely’ with 28 per cent IF YOU ATTENDED THE SCOTTISH DENTAL SHOW the speakers were some of the leading saying they would ‘Possibly’ be back. AND HAVEN’T RECEIVED YOUR CERTIFICATE YET, EMAIL [email protected] AND WE’LL figures of the dental profession, such as Alan Ramsay, managing director of SEND IT OUT. ALSO, IF YOU HAVEN’T FILLED IN Professor Edward Lynch of the University Connect Publications, which organises THE FEEDBACK QUESTIONNAIRE, VISIT BIT.LY/ of Warwick and Prof John Gibson from the the Scottish Dental Show and publishes SDS15FEEDBACK

SCOTTISH DENTAL MAGAZINE 38 INDEPTH

DELEGATE TESTIMONIALS “BRILLIANT WAY TO “FELT THE SHOW WAS “I REALLY ENJOYED “THE LECTURES I “FIRST TIME GAIN CPD, WELL WELL ORGANISED AND IT. THE SPEAKERS ATTENDED BROUGHT ATTENDING AND WAS ORGANISED AND WELL THE LECTURES AND MADE IT A REALLY ME UP TO DATE VERY IMPRESSED. PRESENTED – FAB!” STALLS WHERE VERY INTERESTING DAY” AND WERE VERY WELL DONE AND HELPFUL” INFORMATIVE” THANK YOU!”

39 SCOTTISH DENTAL MAGAZINE INDEPTH

SCOTTISH DENTAL MAGAZINE 40 Left: Diamond sponsors Leca Dental Laboratory

Top right: Professor John Gibson’s talk on the Saturday was packed to the rafters

Right: Keynote speaker, Professor Edward Lynch

41 SCOTTISH DENTAL MAGAZINE INDEPTH

SCOTTISH DENTAL MAGAZINE 42 Top right: Philip Friel’s implant workshop proved hugely popular again

Left: Sandy Littlejohn from Platinum sponsors DTS talking with delegates

Bottom left: Delegates were encouraged to use the hashtag #SDShow15 when tweeting about the show

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dent 2015 WINNING SMILES THE 2015 SCOTTISH DENTAL AWARDS WERE A TRUE CELEBRATION OF THE INDUSTRY IN SCOTLAND

 BRUCE OXLEY  MIKE WILKINSON

r Elizabeth Saunders received you can achieve. If you don’t try, you will to Jonathan Dougherty of Kilmarnock the Scottish Dental Lifetime never know what is possible.” Dental Care; the Crown Dental Group in Achievement Award to a rapturous In summing up Elizabeth, who in Aberdeen won the Dental Team Award and reception at the Thistle Hotel retirement plans to spend more time with the Digital Strategy Award was picked up in Glasgow. The 2015 Scottish her five grandchildren and her country by Dental Studios Scotland. DDental Awards saw just under 400 garden in Perthshire, said: “I know I have Scottish Dental Awards judge Margaret guests rise to their feet to acclaim the been very lucky and, indeed, privileged, to Ross accepted the Unsung Hero Award on winner of the night’s most prestigious have the career I had in what could well behalf of Dr Jon Victor, who was unable prize. Dr Saunders’ career spanned nearly have been the best of times. I do hope I to attend, and the Laboratory of the Year 40 years and she dedicated a large part of made a meaningful and lasting contri- award was presented to Leca Dental that to the practice, teaching and research bution to the teaching and practice of Laboratory from Glasgow. in the field of endodontics. endodontics in Scotland.” The Business Manager/Administrator A past president of both the British Deveron Dental Centre in Huntly of the Year went to Liz Alexander of Endodontic Society and the Royal Odonto- was the other big winner on the night as Southwest Smile Centre in Stranraer and Chirurgical Society of Scotland, she practice principal Morven Gordon-Duff Newton Stewart; the Community Award also served on the editorial board of the picked up Employer of the Year and dental was presented to Linsey Paton of the International Endodontic Journal during nurse and practice manager Kirsty Rodger Tryst Dental Practice in Stenhousemuir, her illustrious career. was named DCP Star. while the Style Award was picked up by In her acceptance speech, she remarked G1 Dental in Glasgow was named Glasgow Southside Orthodontics. with pride that women are no longer in the Practice of the Year; Samuel Barry Lemon minority compared to when she started of Bluewater Dental in Lochwinnoch out on her dental career. And she had this picked up the Dentist of the Year gong, and TO SEE THE OFFICIAL VIDEO OF THE 2015 piece of advice for the women in the room: Donna Morrison of The Dental Directory SCOTTISH DENTAL AWARDS, “I would encourage you to step out of your was named Scottish Dental Representative VISIT BIT.LY/SDA15VIDEO IF YOU WANT TO FIND OUT MORE ABOUT THE comfort zone, to aim higher than you think of the Year. 2016 AWARDS, VISIT WWW.SDAWARDS.CO.UK OR you are capable of, higher than you think The Young Dentist Award was handed FOLLOW @SCOTTISHDENTAL ON TWITTER.

SCOTTISH DENTAL MAGAZINE 46 INDEPTH

Dr Elizabeth Saunders received the 2015 Scottish Dental Lifetime Achievement Award

47 SCOTTISH DENTAL MAGAZINE INDEPTH

SCOTTISH DENTAL MAGAZINE 48 dent 2015

Top row from left: Laboratory of the Year winners Leca Dental; Employer of the Year Morven Gordon-Duff; Young Dentist Jonathan Dougherty; DCP Star Kirsty Rodger and (top right) the Style Award winners Glasgow Southside Orthodontics

Middle row from left: Digital Strategy winners Dental Studios Scotland; Business Manager/ Administrator of the Year Liz Alexander; Community Award winner Linsey Paton; and (middle right) 2015 Scottish Dental Lifetime Achievement Award winner Elizabeth Saunders

Bottom row from left: Practice of the Year G1 Dental; Dentist of the Year Samuel Barry Lemon; The Dental Directory’s Donna Morrison, winner of the Scottish Dental Representative Award; and (right) the Dental Team Award winners, Crown Dental Group

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53 SCOTTISH DENTAL MAGAZINE CLINICAL

RAISING OUR SUSPICIONS: COULD THIS BE AN ORAL CANCER? ORAL CANCER

With the number of cases on the increase, dentists have a key role to play in the early detection of the disease and in raising patients’ awareness of the risks of cancer

 GRAHAM OGDEN

he early detection of oral cancer has now What can we do to help minimise such an event? become a recommended topic by the General Reasons why a patient may pursue a case of negligence Dental Council (GDC) for Continuing against a dentist in respect of oral cancer are: T Professional Development (CPD). The importance of raising our suspicions for any lesion • Failure to identify a lesion in the mouth was brought home to me as I was writing this paper. The • A failure to consider the lesion might be a cancer and brother of a medical friend had just been diagnosed with thus miss the opportunity to make an early diagnosis mouth cancer at the age of 54. No obvious risk factors were • Failure to refer to a specialist present and yet, despite going to his GP with a persistent • Claims for damages following the consequences of a ulcer, it was more than two months until he was referred. failure to detect the cancer at an early stage My doctor friend called me for advice regarding her • A perception by the patient that the dentist had not brother on the day I received feedback on a lecture I’d given to taken their concerns seriously. some medical students doing their cancer prevention module. Despite presaging my lecture with the reasons why medics Key questions to consider when assessing the malignant needed to be as genned up on this as the dentists, one student potential of an oral lesion: still felt it was more important for dentists than themselves (presumably a reflection on the numerous other topics 1. What risk factors are present? competing for their attention within the medical curriculum). Tobacco The GDC based their recommendation in part due to While the number of cigarettes consumed within the UK an increasing number of patients who are claiming (rightly has dropped profoundly over the last 25 years or so (from a or wrongly) that their dentist failed to diagnose their mouth staggering 102 billion in 1990), the reduction in the number cancer and, as such, are suing them for negligence. Other of smokers has not been as dramatic. Approximately 20 per reasons include an increasing number of cancer cases (hence cent of the population in Scotland still smoke. Although novel increased likelihood of seeing a patient with oral cancer,) approaches to certain groups have had some success (e.g. and the life-threatening nature of this disease (the later it is “Give it up for baby” – a smoking cessation intervention for diagnosed, the worse the outcome for the patient). pregnant women in Scotland, organised by Paul Ballard and It used to be an anecdote that a dentist might only see two NHS Tayside) – there is still a long way to go. cases of oral cancer in their entire career. But was or is that Clinicians should be actively involved in raising awareness actually true? There may be a need to recalculate this because, of the potential detrimental effects of smoking on oral health although there are many more dentists now than, say 30 years and giving smoking cessation advice. A key question to ask the ago, the incidence of oral cancer has risen sharply (threefold) patient with a clinically suspicious lesion is “Do you smoke?” over that time period without a marked increase in size of At least 75 per cent of oral cancers are associated with population. We recently recalculated this and arrived at a tobacco use. conservative estimate of one case every 10 years, with two With the increase in cost, many people are turning to 1 potentially malignant lesions seen every month. hand-rolled cigarettes because they are cheaper but they

SCOTTISH DENTAL MAGAZINE 54 may lack an effective filter. Key additional questions include Studies have shown that there is recording type of tobacco use, number of years they have smoked and daily quantity consumed. a 40 per cent underestimation of Don’t forget ecigarettes, although in theory devoid of what people claim they drink, when the usual carcinogens found in tobacco, are still unregulated compared with actual alcohol sales and hence their exact content is not always known. More than three million ecigarettes were sold in the UK in 2012. However, many patients find Allen Carr’s bookEasy Way to Stop Smoking an effective alternative to other techniques such as nicotine replacement therapy. FIGURE 1 Typical textbook Alcohol appearance of an advanced oral cancer As with tobacco, it is worth asking about their use of alcohol, Reproduced from as this is an important risk factor for oral cancer, particularly Dental Update (ISSN when combined with tobacco use. The Government, and 0305-5000), by permission indeed all the Royal Colleges, support the guidance as regard of George Warman low-risk drinking. For men this is currently considered as Publications (UK) no more than four units in a day or 21 units in a week (for Ltd women it is no more than three units in a day and 14 units in a week) with at least two days free of alcohol. Obtaining a reliable alcohol history isn’t always easy, partly because many patients don’t know the alcohol unit FIGURE 2 content of what they drink, but also because we are often Note atrophic red economical with the truth. Studies have shown that in the area of early cancer UK there is a 40 per cent underestimation of what people surrounded by satellites claim they drink, when compared with actual alcohol sales. of white keratoses We have gathered data regarding drinking habits and understanding of alcohol guidelines over several years during our annual Mouth Cancer Awareness Week campaigns at the University of Dundee. There is a tendency for students to underestimate the number of units of alcohol in a pint of beer. When this is combined with the frequency that they admit to binge drinking (defined as at least six units in any one session for women, and at least eight units for men), then many students would appear to be drinking at a level that FIGURE 3 would trigger a brief alcohol intervention. Early oral cancer affecting buccal The development of an appropriate intervention for 2 sulcus. Note the dental practice is currently being explored . areas of diffuse keratosis and atrophy surrounding Human Papilloma Virus (HPV) the ‘whorl’ of slightly The subtypes ( associated with both cervical cancer and oral raised, reddened cancer) are HPV 16 and HPV 18. It is more often associated mucosa with oropharyngeal cancer than oral cancer. The virus interferes with the tumour suppressor gene, P53 that protects us against cancer .The HPV virus disables the protective effect of the P53 gene allowing those mutations which retain the cell’s ability to replicate, to further develop on its journey to potentially becoming a cancer. Infection with HPV can erythema may be lost. Although much is made of the white be transitory , with HPV 16 and HPV 18 acquired through patch its malignant transformation rate is probably less than oro-genital contact. Perhaps not the easiest question to ask five per cent whereas that of the erythroplakia is at least 80 of a patient visiting their dentist! Jaime Winstone’s BBC3 per cent (far more significant). programme “Is oral sex safe?” is well worth viewing. Having said that, the most significant leukoplakia’s Don’t forget that a patient doesn’t have to have an obvious are those that are large and non-homogenous. Far more risk factor. important and more frequently associated with asymptomatic early oral cancer are the so-called speckled leukoplakia’s 2. What is its colour? (erythroleukoplakia). (‘Red is a mean mean colour’) While I’m sure Steve Harley didn’t have oral cancer in mind 3. What does the early oral cancer look like? when he wrote that song, it seems peculiarly apposite. The early asymptomatic cancer presents in a far more Red is a far more significant colour when it comes to subtle way than many of the textbooks might suggest. The early manifestation of oral cancer, yet leukoplakia is often identification of an oral cancer that has raised, rolled hard considered the most frequent precancerous lesion. By focusing on the white element, the issue of any surrounding CONTINUED OVERLEAF>

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edges surrounding an area of ulceration that is oozing blood BY WORD is an advanced lesion that hopefully no one would miss. Unfortunately, by the time is has that appearance, such an OF MOUTH advanced lesion has had plenty of opportunity to either For those who wish to get involved invade surrounding tissues (such as bone) or metastasise to in raising awareness of oral cancer, for example during Mouth Cancer local, regional or distant lymph nodes. Awareness Week in November each Our attention as clinicians should be to focus on raising year, then see the link to “You too can our index of suspicion. High-risk sites in the UK are the raise awareness of mouth cancer” at so-called non-keratinising sites such as ventral tongue and http://bit.ly/BWTpdf The Ben Walton Trust has done floor of mouth. However, the routine screening and recording much to raise both professional in the notes of the entire oral mucosa should be mandatory, as well as public recognition of not only to help to detect an early lesion, but also to help the disease. There is also another protect yourself from any claims of negligence that you failed Scottish-based charity – https:// letstalkaboutmouthcancer.wordpress. to detect the cancer at an early stage. Such a task that takes com – which aims to achieve greater minimal time, requires no fancy expensive equipment, but recognition of the disease within the yet could make such a difference to the patient’s prognosis general population. (if a cancer is there), is ignored at our peril. (The use of dyes While we should all maintain our or techniques based upon fluorescence or cytology are still suspicions regarding any lesion within the oral cavity, we can do nothing about being evaluated or have not proved to have the sensitivity or the patient that presents to their GP in specificity to become adopted as routine tests). preference to their GDP. Or can we? I would suggest that we, as dentists, need to explain to our patients every Conclusion time they attend that we are screening The early detection of an oral cancer can quite literally save their mouth for any suspicious changes that patient’s life. In helping to raise your index of suspicion that they may not even be aware of; that when assessing the malignant potential of an oral lesion we we are trained to examine the whole should consider: mouth, not just the teeth and gums. Establishing links with local GPs • What risk factors are present? (NB tobacco and should benefit both clinicians and alcohol, HPV?) patients. The days when colleagues felt • What is its colour? (NB importance of red) referral for a second opinion implied • How long has it been present? (Review the patient to they were not capable have surely gone. But, to do that, we first have to see the ensure it has improved/resolved within two weeks or arrange lesion, i.e. examine the whole mouth urgent referral when cancer is suspected) and then consider that it might be an • Is it painful? (Pain is often a relatively late manifestation early cancer. It is for this reason that hence a non-painful ulcer should arouse suspicion) it is entirely right that oral cancer has Remember, the early lesion is often asymptomatic (no become a recommended topic for CPD by the GDC and serves as a reminder pain, no ulceration, no bleeding). Remember too that a that every time a patient attends, there patient is never too young to get oral cancer. One in 10 cases must be a careful clinical examination of now arise in those below the age of 45 years (see the Ben the entire oral mucosa. Walton Trust www.benwaltontrust.org). Where cancer is suspected, the patient should be urgently referred to be seen within two weeks. Furthermore, with an increase in oropharyngeal lesions that may spread to cervical lymph nodes, it is more important than ever that dentists should carefully check for swellings in the neck. This may be particularly important in irregular VERIFIABLE CPD QUESTIONS attenders, as that may be the one chance AIMS AND OBJECTIVES of what an early oral cancer can for early detection, which could quite • To increase the dental team’s look like ie raise our suspicions. literally save that person’s life. awareness in the detection of oral cancer EXAMPLE QUESTION • To review our understanding Which of the following of the main risk factors for statements is wrong: oral cancer a) Twice as many men are • To be familiar with what oral affected by oral cancer than ABOUT THE AUTHOR cancer looks like, particularly women Professor Graham R Ogden, is professor of oral b) You cannot get oral cancer if surgery and honorary consultant in oral surgery the early lesion. within the Division of Oral and Maxillofacial Clinical you are under the age of 30 Sciences at the University of Dundee Dental LEARNING OUTCOMES c) Red is a strong warning sign Hospital and School. After reading this article, the for early cancer reader should: d) Oral cancer can present in REFERENCES • Understand the reasons those who do not drink or do Aspects of this paper were included in the recently published paper, Ogden G Oral cancer: what do we not smoke why oral cancer has become a need to know and do? Dental Nursing 2015 11(5) recommended topic for CPD 275–278. by the GDC 1. G. R. Ogden, C. Scully, S. Warnakulasuriya & P. HOW TO VERIFY YOUR CPD • Be aware of the need to assess Speight Oral cancer: Two cancer cases in a career? Go on-line to www.sdmag.co.uk British Dental Journal 218, 439 (2015) Published for exposure to the two main and click on the CPD tab to online: 24 April 2015 | doi:10.1038/sj.bdj.2015.302 risk factors for oral cancer access all our CPD Q&As and 2. Shepherd S, et al Current practices and intention • Have an increased awareness certificates to provide alcohol related health advice in primary dental care British Dental Journal 211:322-3 2011 doi:10.1038/sj.bdj.2011.822

SCOTTISH DENTAL MAGAZINE 56 CLINICAL

AN OPEN AND SHUT CASE CASE FILES

One of the many cases that have been handled by Dental Protection, in order to demonstrate an important learning point

 HELEN KANEY

he registration of DCPs has created many undertook to try to contact the dentist on his course. benefits, not the least being the formal As it happened, the dentist telephoned during the lunch recognition for the different members of the break, and offered to see the patient that evening on his way T dental team. Dental Protection has advocated home. He opened up the surgery specially to accommodate the benefits of team working for many years and is a large the patient. As he had already anticipated, it was necessary to enough organisation to ensure that the interests of every remove the pulp of the tooth and start endodontic treatment. member of the dental team can be independently represented The patient’s pain disappeared immediately. by a different dento-legal adviser (there are now 70) should there be a dispute about clinical matters. The patient refused to pay for Fortunately, disputes between colleagues are infrequent but if they should ever arise it is important that independent the endodontic treatment on the advice is available for everyone concerned. But let’s think grounds that he thought he should positively and consider the advantages of teams when they be compensated for the earlier communicate well and work in harmony. Consider the case of a patient who recently had a large three days of pain filling placed in a molar tooth. He rang the practice three Some weeks later, the patient refused to pay for the hours after returning home to say that the tooth was starting endodontic treatment on the grounds that he thought he to hurt him. The receptionist reassured him over the phone should be compensated for the earlier three days of pain, and advised him to take analgesics. She also logged the made worse by the dentist’s unavailability and the lack of telephone conversation in the patient’s notes on the computer. emergency arrangements. The situation escalated even The following morning the patient telephoned again, further when the patient’s complaint became the subject of saying that the pain was getting worse. An appointment a formal hearing before the GDC. was offered later that morning, but when the patient was The committee completely exonerated the dentist. He examined, there was no indication of anything more than had provided emergency treatment very promptly and the normal post-operative sensitivity from a large filling. A appropriately on two occasions, and on the third occasion periapical radiograph that was taken at the time revealed he had made himself available in a situation where many nothing abnormal. other dentists might not have done. The dentist elected not A day later, the patient was waiting in the practice car to pursue the patient for the unpaid endodontic fee, offering park as the staff opened up. He had been unable to sleep all this as a goodwill gesture. night because of the intensity of the pain. He was most angry Both the dentist and the team had learned a valuable when the receptionist told him that the dentist was away for lesson from the experience, about the importance of the day on a postgraduate course. He demanded that some establishing effective emergency arrangements at times attempt should be made to reach the dentist and recall him when the dentist is away from the surgery, and of good record to the practice, or alternatively arrangements should be made keeping by himself and his staff. Without the documented for him to be seen by another local dentist. The receptionist episodes of this patient’s phone calls and appointments suggested that, if all else failed, she might be able to arrange that were offered in response, it would have made the for his local doctor to see him, but in the meanwhile she defence of the complaint so much more difficult.

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A NEW APPROACH TO DEFINING CANCER RISKS ORAL CANCER

To quote one of New York’s most famous adopted sons, Bob Dylan, and one of his most socially challenging lyrics – the times they are a changin’

 DAVID CONWAY

hange, socioeconomics and indeed New York random chance – the flip of a coin, 50/50, one in two, 50 per are relevant to this update on oral cancer risk. cent chance, it will either happen to me or it won’t. How we define oral cancer is changing. This However, risk estimates for cancer can be determined by is important not only for how the disease is undertaking studies on large groups of people, which identify C managed and its prognosis but also in terms the probability that an individual or group will develop the of the changing risk profile and factors associated with oral disease over a period of time. These studies also identify risk cancer, which in turn is essential for prevention. Oral cancer factors – characteristics or behaviours that are associated is increasingly falling into two distinct diseases: oral cavity with increased risk. We generally define risk in two ways: cancer (OCC) – “mouth cancer” and oropharyngeal cancer absolute risk and relative risk. (OPP) – “throat cancer”. Although the tumours do not always recognise such clear-cut boundaries and more often overlap Absolute risk the anatomical sites (particularly in the retromolar trigone – This is the numeric chance or probability of developing oral behind the wisdom teeth). cancer during a specified period of time. The Scottish Cancer While oral cavity cancer rates are either stable or only Registry computes this over a whole lifetime. The absolute marginally increasing, oropharyngeal cancer is the most risk of developing oral cavity cancer in Scotland in a lifetime rapidly increasing cancer in Scotland – with a threefold is estimated at 1.7 per cent, or to put it another way – about increase in incidence among men in the last decade, and 1 in 59 persons will develop oral cavity cancer at some time a 2.5-fold increase among women. Oropharyngeal cancer in their lives. For comparison, about one in 12 persons in increases are now greater than malignant melanoma, Scotland will develop lung cancer in their whole lives, while adeonocarcinoma of the oesophagus and cervical cancer about one in 2.5 persons will develop any type of cancer. 1 . In 2013 there were 494 cases of oral cavity cancer and These lifetime risks have a lot to do with other factors such 343 cases of oropharyngeal cancer diagnosed in Scotland as gender and age. A man’s lifetime risk of developing oral 2 . This changing trend of flat-lining oral cavity cancer and cavity cancer in Scotland is higher – 2.4 per cent, or about increasing in oropharyngeal cancer is a global phenomenon one in 42 men – but his risk of developing oral cavity cancer and has been related to changing population risk factors – (at a younger age) by the age of 64 is 0.7 per cent, or about 2 described as “controlling a tobacco epidemic while a human one in 135 men . 3 papillomavirus epidemic emerges” . Relative risk Risk This is a comparison or ratio rather than an absolute value. When we talk about risk we are talking about probability – It provides an estimate of the relationship between a risk the chance that an event/the disease/oral cancer diagnosis factor and outcome by comparing the number of cases will occur. Patients and the public may view risk as completely in a group of people with a particular trait or behaviour

SCOTTISH DENTAL MAGAZINE 58 A man’s lifetime risk of understanding the joint tobacco-alcohol effects and the developing oral cavity cancer in dose-response, as well as investigating the risk associated with smokeless tobacco and the benefits of quitting both Scotland is higher – about one in smoking and alcohol. 42 men – but his risk of developing INHANCE provides sufficient numbers of people who oral cavity cancer (at a younger age) never smoked or drank alcohol – thereby avoiding the problems of confounding – to identify true and precise risk estimates. by the age of 64 is about one in 135 Among “never” alcohol drinkers, cigarette smoking was associated with a two-fold increased risk of oral cavity and 7 oropharnx cancers . And heavy alcohol drinking (three or with the number of cases in a (otherwise similar) group more drinks per day vs never drinkers) among those who never of people who don’t have that trait or behaviour. The used tobacco was also linked to increased risk but only among risk of oral cavity cancer for people who smoke has been heavy alcohol consumers. However, it should be noted that those estimated at around 5.8 times higher than for those who who reported never smoking and never drinking alcohol may don’t smoke – the relative risk is 5.8. Relative risk is also differ in other ways from the wider population. The complexity presented as a percentage. In the same example the risk of the relationship with smoking and alcohol was also unpicked of oral cavity cancer is 580 per cent higher than in those in the estimates of the population attributable risk (PAR) for 4 who don’t smoke . This percentage over 100 per cent and tobacco and alcohol of 64 per cent, made up of 0 per cent for lack of an upper limit in relative risk estimates is counter- alcohol alone, 24 per cent for tobacco alone, and 40 per cent 8 intuitive. Most people would think 100 per cent is the for tobacco and alcohol combined – but remember this risk highest possible risk. But 100 per cent equates to a doubling description is mainly relevant at the population rather than of risk associated with a risk factor, while 200 per cent to a individual risk level. tripling of risk estimate. In terms of the dose-response relationship, risk for oral cancer increases with increased frequency and duration Population attributable risk of both smoking and alcohol. However, fewer cigarettes This is another way of expressing relative risk at the population per day over a longer period of time was worse (gave a level. It is the difference in the rate of disease between a greater risk for oral cancer) than more cigarettes per day population exposed to a risk factor and a population not over a shorter period of time. This contrasts with alcohol exposed to the risk factor. It is more commonly used in public consumption which found that higher intake over a shorter health policy decisions, where the burden of the disease period of time was worse (gave a higher risk for oral cancer) 9 reduction can be calculated by “hypothetically” removing the than a lower intake for a longer time . Moreover, there risk factor in question. are no safe low-intake levels associated with negligible risk – so, the old sayings: “everything in moderation including INHANCE moderation itself” or “a wee bit of what you fancy does you The most comprehensive and up-to-date data on oral good” unfortunately do not hold up here. cancer risk can be found from research by the INHANCE Smokeless tobacco in the form of snuff (powdered (International Head And Neck Cancer Epidemiology) tobacco) and tobacco chewing are not safe harm reduction Consortium (www.inhance.utah.edu). It was established alternatives some might want you to believe, with both in 2004 as a collaboration of researchers from around the associated with slight increased risk for oral cavity cancer. But world-leading large epidemiology studies of head and neck good news does exist in the form of the benefits of quitting cancer to improve the understanding of the causes, risks and – with benefits appearing immediately (one to four years) mechanisms of head and neck cancer. after stopping smoking, and equating with those who never The consortium includes data on 25,500 patients smoked after 20 years of quitting. The risk effects associated with head and neck cancer (including oral cavity cancer, with heavy alcohol consumption last a bit longer with benefits 10 oropharyngeal cancer, and larynx cancers), and 37,100 of quitting taking 20 years to emerge . controls who did not have these cancers, from 35 studies The promise of the breakthrough in identifying genetic from across the world. Overview papers have been published variants as strong markers of increased oral cancer risk 5 6 which detail INHANCE methods and research findings . has yet to fully materialise. Considerable research effort It was a privilege to be invited to participate in the 12th has found slight increased risks for oral cancer associated Annual INHANCE consortium meeting in May this year. We with the presence of genetic variants involved with alcohol convened at the Icahn School of Medicine at Mount Sinai metabolism, DNA repair pathways, and genes involved in the 6 New York City, on the weekend the new Freedom Tower was metabolism of nicotine . Similarly, there is limited evidence opened. During our meeting, we reflected on over 10 years of of dietary risk factors for oral cancer beyond confirming the INHANCE research, while at the same time looking forward protective effects associated with diets high in fresh fruit and to taking on the ongoing challenges of the increasing and vegetables (with approximately five or more fresh fruit and changing burden of head and neck cancer. vegetable portions per day conferring a 50 per cent lower risk 11 than those consuming low levels . Oral Cancer Risk The INHANCE work which our team in Glasgow have It is well recognised that smoking tobacco and heavy alcohol led on is in relation to socioeconomic inequalities and 12 consumption are the main risk factors for oral cancer. determinants of oral cancer risk . You can see from the INHANCE provides us with an opportunity to understand this risk better, including providing precise estimates of risk, CONTINUED OVERLEAF>

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reference list with 75 co-authors the extent of the international collaborative effort involved. In our analysis we identified increased risks for oral cancer associated with low education VERIFIABLE CPD QUESTIONS and income relative to those in higher socioeconomic AIMS AND OBJECTIVES positions which were not explained by smoking or alcohol To provide clinicians with: consumption, i.e. there were socioeconomic effects operating • an update on risk factors associated with oral cancer in two ways both in influencing risk behaviours (the causes • An overview of the concept of risk communication of the causes) and also more direct or explained effects • An outline of the prevention approaches for oral cancer and their from low socioeconomic circumstances to oral cancer role in prevention risk. Moreover these socioeconomic effects are of a similar LEARNING OUTCOMES magnitude (twofold increase) to risks associated with smoking Following reading and assimilating this article, clinicians will: and alcohol, and are strongest in countries where income • Be aware of the recent trends and risk factors associated with inequalities are widest. oral cancer and of the importance of separating oral cavity and oropharyngeal cancers Finally, no discussion about oral cancer, and certainly not • Be able to discuss with patients the risks associated with oral oropharyngeal cancer, can be complete without talking about cavity and oropharyngeal cancers. sex and oral HPV (human papillomavirus) infection. Oral

HPV is mainly associated with oropharyngeal cancer risk, HOW TO VERIFY YOUR CPD with up to 80 per cent of cases having HPV identified. There Go on-line to www.sdmag.co.uk and click on the CPD tab to access all our CPD Q&As and certificates are over 200 HPV types, but as for cervical cancer, HPV16 and 18 subtypes are the main high-risk oncogenic types. Increased risk for oropharyngeal cancer has been estimated as high as 15 times greater in those with oral HPV16 infection in the 13 ground breaking New England Journal of Medicine paper . However, the natural history of oral HPV infection is not Communicating risk more generally, in relation to well understood (in terms of prevalence, persistence, and treatment options and associated risks, has similar and determinants). The only large epidemiological study of oral perhaps even greater complexity for clinicians and patients, 14 HPV prevalence has been undertaken in US . They found a and is beyond the scope of this article. prevalence of 7 per cent, with slightly greater peaks (around INHANCE researchers are currently developing and 10 per cent) among 25-30 and 50-55-year-olds, and among validating a risk-prediction model that could be used to men. Risk factors identified included smoking and alcohol, identify those at highest risk of oral cavity and oropharyngeal number of sexual partners/oral sex partners, but also open cancer which could potentially guide opportunistic mouth kissing. We are currently completing a feasibility screening, and risk factor counselling interventions. study to undertake a similar study in dental practices in Such personalised risk information can be presented to Scotland – HOPSCOTCH (HPV Oral Prevalence in Scotland) individuals based on their characteristics and behaviours study ( http://www.sohrc.org/projects/hopscotch/ ). We are and can improve decision making in relation to screening 18 grateful for the outstanding support that we have received . Such risk tools already exist for presenting breast cancer from dental practices and teams across Scotland in stepping risk [ http://www.cancer.gov/bcrisktool/ ] and are widely up to this important research area, and we look forward to available for cardiovascular risk [ http://www.qrisk.org/ ]. disseminating our feasibility study findings and taking forward The major risk factors identified (above) and going forward a full population study in dental practices in due course. in this model for oral cancer risk profiling are smoking, INHANCE studies also point to a slight increased risk alcohol, and socioeconomic status, alongside age and gender for oral cancer associated with six or more lifetime sexual determinants. partners, four or more lifetime oral sex partners, and early 15 age (≤18) of sexual debut . However, it is worth noting again Prevention strategies that this research and our understanding is at a far earlier To paraphrase Johannes Clemmesen (the founder of stage, perhaps several decades behind our knowledge of the the Danish Cancer Registry), the purpose of all cancer role of HPV in cervical cancer. epidemiology studies is to prevent it. Communicating risks for oral cancer is not Understanding risk is the key first step in the pathway straightforward. I had a go at trying to explain the oral to prevention. Prevention approaches therefore depend on cancer risks associated with alcohol drinking on the BBC whether the cancer is HPV-driven or non-HPV driven. Radio 4 statistics programme More or Less [ http://www.bbc. The primary prevention for HPV-driven oral cancer is co.uk/programmes/b03qfzgx ]. I am not convinced I helped likely to be via the HPV vaccination. There is one proof of communicate this complex risk issue particularly well. This principle study which demonstrates that the HPV vaccine reflection is not helped by my students who let me know I (designed for cervical cancer prevention) prevents oral HPV sounded drunk on the interview! infection. However, more evidence is needed to fully inform policy in relation to extending the vaccination to males. Communicating risk Although the case could be (and has been in other countries) This is a key challenge for clinicians and public health argued on equity grounds, where men who have sex with practitioners. Effective risk communication can stimulate men or men who have sex with women outside of the 16 health behaviour/belief change and reduce risk levels . One vaccinated population will not benefit from the hypothetical of the major barriers to communicating risk effectively is the and assumed “herd immunity” to the population now that difficulty both patients and clinicians have in understanding girls have been widely vaccinated (~90 per cent of 12 year statistics and numbers, e.g. even among highly educated olds from 2008 in Scotland). In addition to HPV vaccination, adults in a US survey only 21 per cent correctly identified in theory HPV-driven oral cancer could be prevented via 17 that one in 1,000 was the same as 0.1 per cent . behavioural modification/safer sexual practices (i.e. condom

SCOTTISH DENTAL MAGAZINE 60 use or dental (rubber) dam use for oral sex – for more ABOUT THE AUTHOR David Conway, Clinical Senior Lecturer /Honorary information see http://www.nhs.uk/chq/Pages/970.aspx ). Consultant in Dental Public Health, Community Oral Secondary prevention – whereby we interrupt disease Health Group. University of Glasgow Dental School / NHS National Services Scotland. Tel. 0141 211 9750 progression via early detection (i.e. “screening”) and early Email. [email protected] treatment – does have potential to prevent oral cancer. Twitter. @davidiconway It will remain necessary for oropharyngeal cancer for decades to come (even with the prevention prospects of the HPV vaccine) as there will be a substantial unvaccinated cohort who will suffer the future oropharyngeal cancers. Unfortunately, there is no validated “screening” method for oropharyngeal cancer (although HPV16 E6 antibody serology blood test could be promising). Problems and research evidence gaps remain in relation to oropharyngeal cancer screening include: there is no identifiable precancerous lesion (like the Pap smear detected cervical intraepithelial neoplasm (CIN)), uncertainty about effectiveness of early intervention and treatment, and demonstrable reductions REFERENCES Cancer Epidemiology 27 countries. Int J Cancer in cancer mortality. 1. Junor EJ et al (2010) Consortium. Cancer 136(5):1125-39. Oropharyngeal cancer. Epidemiol Biomarkers 13. D’Souza G, et al. The same difficulties for direct visual inspection of the Fastest increasing cancer Prev 18(2):541-50. (2007) Case-control oropharynx do not exist for comprehensive visual inspection in Scotland, especially in 9. Lubin JH, et al. (2009) study of human papillo- men. BMJ 340:c2512. Total exposure and mavirus and oropharyn- of the oral cavity, and there is some limited evidence of 2. Scottish Cancer exposure rate effects geal cancer. N Engl J Med effectiveness and cost-effectiveness of opportunistic Registry (2015) Cancer for alcohol and smoking 356(19):1944-56 19 20 Statistics. NHS National and risk of head and 14. Gillison ML, et al. screening . Research questions remain (and we have three Services Scotland. neck cancer: a pooled (2012) Prevalence of PhD students working on some of them) including: what Information Services analysis of case-control oral HPV infection in the Division. http://www. studies. Am J Epidemiol United States, 2009-2010. constitutes best practice for oral examination/screening? isdscotland.org/ 170(8):937-47. JAMA 307(7):693-703. Can risk assessment and profiling assist in focusing on Health-Topics/Cancer/ 10. Marron M, et al. 15. Heck JE, et al. (2010) Cancer-Statistics/ (2010) Cessation of Sexual behaviours and groups or on recall interval? Given low volume of disease is 3. Hashibe M, Sturgis alcohol drinking, tobacco the risk of head and neck early detection a realistic proposition? Are there inequalities EM (2013) Epidemiology smoking and the reversal cancers: a pooled analy- of oral-cavity and of head and neck cancer sis in the International in access and uptake of the opportunity to screening? And oropharyngeal carci- risk. Int J Epidemiol Head and Neck Cancer what are the barriers and facilitators to delivering screening? nomas: controlling a 39(1):182-96. Epidemiology (INHANCE) tobacco epidemic while 11. Chuang SC, et al. consortium. Int J Non-HPV driven (oral cavity cancer) prevention in or a human papilloma (2012) Diet and the risk Epidemiol 39(1):166-81. via dental practice is important. Again we have research in virus epidemic emerges. of head and neck cancer: 16. Ahmed H, et al. (2012) Otolaryngol Clin North a pooled analysis in the Communicating risk. our group ongoing in this area. The principles of prevention Am 46(4):507-20. INHANCE consortium. BMJ 344. for oral cancer should reflect the evidence from our 4. Lee YC, et al. (2009) Cancer Causes Control 17. Gigerenzer G (2002) Active and involuntary 23(1):69-88 Reckoning with risk – understanding of risk. These principles include: i) age is tobacco smoking and 12. Conway DI, Brenner learning to live with not an issue in terms of risk factors – work led by Tatiana upper aerodigestive DR, McMahon AD, uncertainty. 1st ed. tract cancer risks in a Macpherson LM, Agudo Penguin Press. London. Macfarlane, Aberdeen Dental School has shown that even multicenter case-control A, Ahrens W, Bosetti C, 18. Edwards AG, et al. among young adults with oral cancer the same risk factors study. Cancer Epidemiol Brenner H, Castellsague (2006) Personalised 21 Biomarkers Prev 12: X, Chen C, Curado MP, risk communication for smoking and alcohol dominate ; ii) risk can reduce when 3353-61. Curioni OA, Dal Maso informed decision making behaviours stop; iii) oral health assessment is an important 5. Conway DI, et al. L, Daudt AW, de Gois about taking screening (2009) Enhancing Filho JF, D’Souza G, tests. Cochrane Database first step in any prevention intervention (we must ask the epidemiologic research Edefonti V, Fabianova E, Syst Rev 4:CD001865. questions); iv) signposting and/or referring for more intensive on head and neck Fernandez L, Franceschi 19. SIGN (2006) cancer: INHANCE - The S, Gillison M, Hayes RB, Diagnosis and manage- preventive intervention services; and v) the role of tailoring INternational Head Healy CM, Herrero R, ment of head and neck advice and support to individual patients needs – recognising And Neck Cancer Holcatova I, Jayaprakash cancer. NHS Quality Epidemiology consor- V, Kelsey K, Kjaerheim Improvement Scotland. the dominant role of socioeconomic circumstances. tium. Oral Oncol K, Koifman S, La Vecchia 20 Speight PM et al. Public health and policy response needs to focus on the 45(9):743-6. C, Lagiou P, Lazarus P, (2006) The cost-effec- upstream structural causes of the causes; on what has been 6. Winn DM, et al. (2015) Levi F, Lissowska J, Luce tiveness of screening for 22 The INHANCE consor- D, Macfarlane TV, Mates oral cancer in primary defined as the “common risk factor” approach (Sheiham tium: Towards a better D, Matos E, McClean M, care. Health Technol understanding of the Menezes AM, Menvielle G, Assess 10(14):1-144, iii-iv. and Watt 2000) – risk factors for oral cancer overlap with causes and mechanisms Merletti F, Morgenstern Review. periodontal disease, with other cancers, with cardiovascular of head and neck cancer. H, Moysich K, Müller H, 21. Macfarlane TV, et Oral Dis doi: 10.1111/ Muscat J, Olshan AF, al (2010) The aetiol- disease and so on...; and on multiple risk factors – our odi.12342 Purdue MP, Ramroth H, ogy of upper aerodi- research has shown that risk factors do not exist in isolation 7. Hashibe M, et al. Richiardi L, Rudnai P, gestive tract cancers (2007) Alcohol drinking Schantz S, Schwartz SM, among young adults in – they cluster: people who smoke also drink heavily and have in never users of tobacco, Shangina O, Simonato Europe: the ARCAGE poor diets, this clustering is even more socioeconomically cigarette smoking in L, Smith E, Stucker I, study. Cancer Causes 23 never drinkers, and the Sturgis EM, Szeszenia- Control;21(12):2213-21. determined . Policy developments also need to extend to risk of head and neck Dabrowska N, Talamini 22. Sheiham A, Watt the increasing preventive focus and wider healthcare role of cancer: pooled analy- R, Thomson P, Vaughan RG(2000) The common sis in the International TL, Wei Q, Winn DM, risk factor approach: dental practitioners and teams. Head and Neck Wunsch-Filho V, Yu GP, a rational basis for And as the times they are a changin’ – we would Cancer Epidemiology Zhang ZF, Zheng T, Znaor promoting oral health. Consortium. J Natl Cancer A, Boffetta P, Chuang Community Dent Oral do well as a profession to more proactively contribute Inst 99(10): 777-89. SC, Ghodrat M, Amy Lee Epidemiol 28: 399-406 to the political and policy discourse; to advocate for 8. Hashibe M, et al. YC, Hashibe M, Brennan 23. Lawder R, Harding O, (2009) Interaction P (2015). Estimating and Stockton D, Fischbacher societal change for tackling health inequalities; to prioritise between tobacco and explaining the effect of C, Brewster DH, Chalmers research and development to tackle the burden of alcohol use and the education and income J, Finlayson A, Conway risk of head and neck on head and neck cancer DI. BMC Public Health. oral cancer – a burden on health services and society, but cancer: pooled analy- risk: INHANCE consor- 2010 Jun 11;10:330. an even greater burden of suffering on communities, sis in the International tium pooled analysis of 31 families, and patients. Head and Neck case-control studies from

61 SCOTTISH DENTAL MAGAZINE CLINICAL

MATERIAL SELECTION DENTAL MATERIALS

The final part of Steve Bonsor’s series of articles examines the factors affecting dental material selection which, he says, is far from Hobson’s choice

 STEVE BONSOR

he first two articles in this series or sharp internal line angles which would lead to stress examined how dental materials should concentrations and a plane for failure (Fig 2). be handled prior to and during clinical T placement to optimise clinical success. Influence of dental materials’ properties While this is obviously very important, failure to select an It is important that the dentist has a working knowledge of appropriate material for the situation will not yield the best the properties of the various materials which may be used clinical outcome. This article addresses the factors which for a given situation as these may have an influence on the the clinician should be mindful of during this decision selection of the chosen material. making process. For example, a cavity whose depth is less that 2mm is not indicated for dental amalgam. In this case, it is preferable for Material selection determined an alternative material to be selected such as gold alloy or by conservation of tooth tissue resin composite so that tooth tissue may be conserved (Fig 3).

Management of the disease Material selection determined In modern dentistry there has been a huge change in by clinical situation emphasis with respect to how direct restorative materials are selected. A little over a hundred years ago, in the Anatomy of the prepared cavity time of the so-called father of dentistry GV Black, the There are certain prerequisites that may determine the best dentist had a choice of only two materials – namely dental material for a given situation. For example, resin composite amalgam or gold. should only be used in cavities which have a complete Cavities, therefore, had to be prepared to accommodate circumferential enamel margin (Fig 4). This is because the the properties of the material. This resulted in sound tooth bond gained between enamel and resin composite is the tissue being needlessly sacrificed so rendering the tooth more strongest and most durable. prone to fracture and a higher incidence of pulpal death. For this reason, the American Dental Association The modern philosophy is completely opposite to what recommends that another material should be selected if a 1 it was at the turn of the 20th century. Conservation of tooth complete enamel margin does not exist . tissue is now the most important factor and this has been made possible due to the large increase in the number of Achievement of an optimal materials which are now available. The disease should be environment for placement manage, i.e. the caries removed, the cavity examined and As discussed in the second article, most dental THEN the appropriate material selected (Fig 1). materials are inherently hydrophobic and require At this point, some further preparation may be required a dry environment when they are placed. The inability to optimise the cavity to conform to the properties of the of the clinician to achieve excellent moisture control when chosen restorative material. Examples would be the removal manipulating and using these materials intra-orally will of unsupported enamel which may fracture due to its friability result in inferior results.

SCOTTISH DENTAL MAGAZINE 62 FIGURE 1 In modern dentistry there has Once the caries has been managed then been a huge change in emphasis the most appropriate material to restore with respect to how direct restora- the cavity should be tive materials are selected. A little chosen over a hundred years ago, in the time of the so-called father of dentistry GV Black, the dentist had a choice of only two materials – dental amalgam or gold

FIGURE 2 All unsupported enamel should be removed and a rounded internal Any direct restorative materials containing resin are most cavity form achieved susceptible. If the clinician is unable to achieve and maintain prior to placement adequate moisture control then an alternative, more forgiving of dental amalgam or resin based material should be considered. composite This is also the case for inherently hydrophobic impression materials such as the silicones (Fig 5). In subgingival areas, adequate moisture control may be very difficult to achieve resulting in the margins of the preparation for a cast restoration not being captured accurately, so compromising the rest of the process. Classically, this is manifested as a rolled edge in the FIGURE 3 This shallow and impression (Fig 6). If the clinician cannot achieve excellent unretentive cavity moisture control then they may be well advised to choose is not suitable for an alternative product such as a polyether which is more restoration with dental amalgam hydrophilic in nature (Fig 7). without further Some materials react with moisture. For example, if a preparation zinc containing dental amalgam alloy is contaminated with involving the water, hydrogen gas is evolved which becomes incorporated removal of sound 2 tooth tissue. The into the material resulting in its expansion . This may have cavity was restored detrimental effects such as extrusion of the material out of the with resin composite cavity or fracture of the surrounding tooth tissue. in this example

Selecting the appropriate material for mechanical reasons FIGURE 4 On occasion, the clinician may be faced with a dilemma of A cavity with a removing more tooth tissue or choosing a material whose circumferential enamel margin mechanical properties are superior. The choice between which may be dental amalgam, gold alloy or resin composite in shallow restored with resin- cavities was discussed earlier. This is also the case for indirect based composite restorations. If insufficient interocclusal clearance is present, then the clinician may reduce the amount of occlusal reduction done to maintain preparation height and therefore retention for the cast. The use of a non-precious metal alloy in preference to a precious metal alloy will be more successful (Fig 8). Such alloys are stronger, harder and have a reduced ductility than 2 precious metal alloys and may be used in sections of 0.5mm . Some of the new zirconium based ceramics may now be used FIGURE 5 Silicone is frequently in such thin section as they have sufficiently good mechanical used to seal shower properties to be used in this situation. units illustrating its inherent Biological considerations hydrophobic nature Many dental materials are bioactive (the ability to actively promote activity with the tissues) and need be to biocompatible i.e. the ability to support life and having no 2 toxic or injurious effects on the tissues . Inappropriate selection of materials which are cytotoxic will result in detrimental biological effects.

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63 SCOTTISH DENTAL MAGAZINE CLINICAL

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For example, resin modified glass ionomer cement and It is important that the advantages zinc oxide eugenol cement are contraindicated to be placed directly on pulpal tissue. and disadvantages of each material The taking and recording of a thorough and are discussed with the patient. comprehensive medical history is an essential prerequisite This is so that they are involved in prior to embarking on any treatment. Hypersensitivity reactions may occur where individuals can become sensitised the decision and they can make an to certain components in materials. The commonest allergens informed choice as to the care they are methyl methacrylate and hydroxyethyl methacrylate wish to receive (HEMA). This latter chemical is cytotoxic and is a powerful 23 dermatological sensitiser . Patients and dental staff may become sensitised to this substance if it comes into contact Furthermore, alternatives should be explained together with naked skin. Furthermore as surgical gloves are porous with their advantages and disadvantages. If there is a and this molecule small, it may permeate the material of the deviation from the original agreed treatment plan then 34 glove so accessing the skin (Fig 9). an updated one should be issued with it being signed by It is used widely in dentistry in such materials as resin the patient to confirm their acceptance. At the end of this composites, resin modified glass ionomers, compomers process, the clinician is safe from a medico-legal perspective and bonding agents to name but a few. Dental staff should with valid consent having been obtained. therefore be careful when handling these products to avoid hypersensitive reactions. This may be achieved by practising Appointment length estimation good resin hygiene and by using a no touch technique. Different techniques may result in more time being required to complete the procedure. For example, it has been reported Intermaterial chemical incompatibility that a posterior resin composite restoration takes three times Some materials may interact with each other chemically. as long to do as the commensurate amalgam restoration. It There are a number of common examples: is more difficult for the dentist to allocate the correct time • Zinc oxide eugenol and resin composite. The eugenol to the procedure if there is some uncertainty as to what the acts as a plasticiser (additives that increase the plastic- final procedure will be. ity or fluidity of a material) with the resin resulting in As mentioned above, a change of material may have incomplete setting of the composite which will result increased cost implications as more time may be required to in inferior mechanical properties and so compromising place the restoration. clinical success (2). • Self-etch bonding agents may not be used with dual Surgery set up procedure or chemical cured resin composite as they are chemi- The new approach of choosing the dental material to fit the cally incompatible. The acidic monomers required for clinical situation is clearly unhelpful for the dental nurse the etching process react with the amine initiator that is who would prefer to assemble all of the equipment and needed for the chemical curing mechanism in self- or dual- materials required for the procedure at the beginning of the curing systems (2). appointment to facilitate its efficient execution. • The catalyst used in silicone impression materials is They may be well advised to wait until the final decision poisoned by sulphur residues of which are found on latex has been made as to the material selection before getting the gloves (2). If the putty presentation of these materials is to chosen materials out of cupboards and drawers. be mixed by hand then non latex gloves should be used (Fig 10). Conclusions • The astringent Racestyptine (Septodont) and polyether Each and every dental material has advantages and impression materials react chemically resulting in gas being disadvantages. It is the responsibility of the clinician to evolved causing porosity in the cast die (2). carefully consider these together with the intended clinical The clinician should be mindful of these and other objectives. Only then can they come to a balanced decision examples and avoid potential chemical reactions when as to the best material to use in the situation which must be making material selection choices. underpinned with a thorough knowledge and understanding of all of the materials which are available and their properties. Practice management issues There are so many options that dental material selection is far from Hobson’s choice! Valid consent It is important that the advantages and disadvantages of each material are discussed with the patient. This is so that they

are involved in the decision and they can make an informed ABOUT THE AUTHOR choice as to the care they wish to receive. Sometimes the Steve Bonsor graduated from the University of Edinburgh in 1992 and in 2008 gained an MSc in Postgraduate Dental Studies from the University of Bristol. patient may request the use of a specific type of material at From 1997 until 2006, Steve was a part-time clinical teacher at Dundee Dental the outset, such as resin composite. Hospital and School and honorary clinical teacher at the University of Dundee in the sections of operative dentistry, fixed prosthodontics, endodontology If, at the end of the cavity preparation phase, the clinician and integrated oral care. He currently holds appointments at the University of feels that the preferred material is not the most appropriate Edinburgh, as an online tutor on the MSc in Primary Dental Care programme, and at the University of Aberdeen as honorary clinical senior lecturer leading material in the situation then this must be communicated the applied dental materials teaching at Aberdeen Dental School. As well as to the patient and the situation discussed. This will involve lecturing throughout the UK, Steve is actively involved in research, having published original research articles in peer-reviewed journals. His main why this is the case and what the consequences would be if research areas are photo-activated disinfection and the clinical performance it were to be used. of dental materials.

SCOTTISH DENTAL MAGAZINE 64 FIGURE 6 REFERENCES A rolled edge of 1. Statement on posterior resin-based composites. ADA Council on Scientific Affairs; ADA Council a silicone impression on Dental Benefit Programs. J Am Dent Assoc indicating moisture 1998;129(11):1627-1628.# contamination 2. Bonsor SJ, Pearson GJ. A Clinical Guide to during impression Applied Dental Materials. 1st ed. Edinburgh: Churchill taking Livingstone Elsevier; 2013. 3. Andreasson H, Boman A, Johnsson S, Karlsson S, Barregard L. On permeability of methyl methacrylate, 2-hydroxyethyl methacrylate and triethyleneglycol dimethacrylate through protective gloves in dentistry. Eur J Oral Sci 2003;111(6):529-535. 4. Tinsley D, Chadwick RG. The permeability of dental gloves following exposure to certain dental materials. J Dent 1997;25(1):65-70.

FIGURE 7 An example of a polyether impression material which is more hydrophilic than the silicones

FIGURE 8 Using metal on the occlusal surface of a metal-ceramic VERIFIABLE CPD crown requires less QUESTIONS tooth preparation so increasing AIMS AND OBJECTIVES: preparation height and retention. • To examine the factors which require Non-precious metal to be considered when selecting a dental alloys function in material for a given situation. thinner section than • To appreciate the primary objective precious metal alloys of conserving tooth tissue and to select an appropriate material which fits the clinical situation. • To offer practical advice on how the FIGURE 9 clinician may negotiate the maze of An area of erythema material selection. on the dorsal surface of this dentist’s hand LEARNING OUTCOMES caused by HEMA. • Be aware of the factors which need to This occurred be considered when dental materials are by the wiping being selected for clinical use. of instruments • Be able to illustrate such factors with contaminated with practice examples resin composite on • Understand how correct material the surgical glove selection can have a major influence on during material clinical outcome. placement EXAMPLE QUESTION: 1. A direct restorative material should be selected: FIGURE 10 a. At the outset of the appointment so that An additional silicone the dental nurse can have all equipment putty impression and material to hand material being mixed b. After the cavity has been finalised just by hands wearing prior to restoration non-latex gloves c. After the cavity has been examined after caries removal/gross preparation if required d. On the insistence of the patient.

HOW TO VERIFY YOUR CPD Go on-line to www.sdmag.co.uk and click on the CPD tab to access all our CPD Q&As and certificates

65 SCOTTISH DENTAL MAGAZINE CLINICAL

CANAL CLEANING ENDODONTICS

A review of the role of irrigation in contemporary root canal treatment

 ADRIAN STEWART

4 pical periodontitis has been established to antimicrobial or decalcifying (see table, right). 1-3 be a microbial-induced disease . The aim Mechanical instrumentation has been shown to result in of root canal treatment is the prevention the burnishing of organic material and dentine debris against 8 A or treatment of apical periodontitis by the the canal wall and into depressions and lateral anatomy . The elimination of micro-organisms from the root canal system role of decalcifying agents such as EDTA incudes chelation 4 and the prevention of subsequent recontamination . To this of the mineral content of this “smear layer” and the opening 9 end, our primary treatment modality is chemo-mechanical of access to the lateral anatomy . 5 debridement of the root canal . Mechanical cleaning of the root canal system with hand Sodium hypochlorite or rotary instruments has been shown to engage only a Sodium hypochlorite (NaOCl) is recommended as the main proportion of the root canal wall – 35 to 53 per cent of endodontic irrigant due its ability to dissolve organic tissue 9 the canal wall surface may remain untouched following and its broad anti-microbial spectrum . Its action on organic 6 preparation . Fins, lateral anatomy and communicating tissue enables it to disrupt and kill biofilms adherent to the canals render the goal of mechanical removal of all infected root canal walls. tissue impossible; therefore, after gross debridement of the Concentrations in use in endodontics range from 0.5 to vital and non-vital tissue from the canal, the main goal of 5.25 per cent. mechanical preparation is to enable chemical disinfection of 7 the root canal . Chlorhexidine The functions of endodontic irrigation include: Chlorhexidine is a bisguanide, generally used in the form • Disinfection of chlorhexidine digluconate. As a root canal irrigant, it • Degradation of pulp tissue is generally presented in 2 per cent concentration. While • Disruption of the biofilm several in-vitro studies have shown anti-microbial efficacy to • Removal of the smear layer be similar to sodium hypochlorite, some in-vivo studies have • Lubrication of endodontic instruments demonstrated chlorhexidine to be inferior, with more culture • Flushing of debris from the canal. reversals from negative to positive between visits. This is likely 10 In practice, no single irrigant achieves all of these aims to be due to its inability to dissolve pulpal remnants . and a combination regime is recommended. Saline and local The major advantages chlorhexidine has over sodium anaesthetic have each been employed, but these provide hypochlorite are lower toxicity, less objectionable smell and only a flushing and lubricating function. Irrigation with such taste and substantivity, meaning it persists on the walls of chemically inert media has been shown to be incapable of the canals. Like sodium hypochlorite, chlorhexidine lacks the 4 adequately reducing the viable microorganisms in infected ability to dissolve the smear layer . 5 root canal systems . Chlorhexidine should not be used in conjunction with Irrigants in contemporary use can be classified as sodium hypochlorite due to the formation of a precipitate

SCOTTISH DENTAL MAGAZINE 66 or flocculate. This flocculate contains para-chloroaniline ANTIMICROBIAL IRRIGANTS (PCA), which is known to be carcinogenic, although the level Sodium hypochlorite of exposure in such cases is likely to be low. The presence of Chlorhexidine the flocculate may lead to blockage of narrow anatomy and Electro-chemically activated water subsequently hinder adequate penetration of hypochlorite. Iodine-potassium-iodide Alternative concepts for antimicrobial irrigation include Hydrogen peroxide electrochemically-activated water (eg. Sterilox), laser DECALCIFYING IRRIGANTS photo activated disinfection and ozone gas filtration of the Ethylenediaminetetraacetic acid (EDTA) root canal system. Studies comparing the antimicrobial Citric acid efficacy these approaches to irrigation, with a 3 per cent sodium hypochlorite solution found all to be inferior to 11 -13 varying degrees .

Decalcifying agents Although sodium hypochlorite has the ability to dissolve organic tissue, it cannot dissolve the inorganic component of dentine. Decalcifying agents such as EDTA and citric injury with exposure to 2.5 per cent following rubber dam 17 acid are recommended for dissolution of dentinal debris leakage is recorded . and removal of the smear layer from canal walls. In addition, Rapid dissolution of vital and necrotic tissue remnants inorganic obstructions to negotiation of the root canal within the pulp canal is an essential facet of the use of sodium during preparation may be overcome with the aid of hypochlorite irrigant. No other irrigant has been shown to 9 chelation agents . dissolve pulpal remnants in the same manner. It is, therefore, It is not recommended that EDTA be used as an necessary to balance the needs for a higher concentration of alternating rinse with sodium hypochlorite due to the hypochlorite with the caveat that higher concentrations are 14 deactivation of sodium hypochlorite by EDTA . It is more likely to result in tissue damage if accidentally extruded recommended that EDTA be used as a penultimate rinse. through the apex or exposed to the mucosa. A concentration The canal is dried of sodium hypochlorite and the EDTA is of 2.5 per cent is commonly used. An alternative to increased introduced and left in the canal for one minute. This is then concentration has been experimented with ex-vivo as rinsed out and the canal dried again before the final rinse described below. with sodium hypochlorite. In this way, the smear layer is removed, opening the dentinal tubules and any lateral canals Temperature to penetration with hypochlorite. Heating the hypochlorite solution has been shown to increase There is clinical folklore that mixing sodium hypochlorite both its bactericidal and tissue dissolving effects. The capacity in the canal with EDTA and creating an acid-base reaction, of a 1 per cent solution of sodium hypochlorite at 45ºC the so-called “Champagne Effect”, aids with coronal to dissolve human pulp tissue was found to be equal to 18 transportation of debris. No evidence exists to support that of a solution of 5.25 per cent at 20ºC . No clinical 9 this claim . studies have been carried out to determine the applicability Factors that influence the effectiveness of irrigation: of this technique in-vivo, however; the benefit of using • Concentration of the irrigant heated, weaker solutions of hypochlorite is that a temperature • Temperature of the irrigant equilibrium is quickly reached within the root and extrusion • Level of corono-apical penetration of the irrigant or mucosal exposure is less likely to cause serious injury. • Volume of irrigant exchange. Corono-apical penetration Concentration Root canal irrigants are conventionally delivered using a The antimicrobial and tissue dissolution capacity of sodium side-vented needle, fitting loosely in the canal. Side venting hypochlorite are both a function of its concentration, but so and loose fit are important to reduce the risk of apical is its toxicity. Spangberg found that a 0.5 per cent solution extrusion of irrigant and to increase the flushing effect on of sodium hypochlorite was sufficient to kill most micro- debris. Vapour lock (a body of gas trapped in the apical organisms, with the exception of Staphylococcus aureus, portion of the root canal) means that penetration of the and retained the ability to dissolve necrotic tissue, though irrigant under such passive irrigation circumstances has not vital tissue. One per cent solution killed Staphylococcus been shown to be no more than 1mm beyond the tip of the 15 19 aureus and 5.25 per cent sodium hypochlorite has been needle . In order to increase the efficacy of the irrigation, found to reduce the elastic modulus and flexural strength of it is vital to: 16 human dentine, while 0.5 per cent solution does not . 1. Maximise the extent to which the needle can penetrate The risk of apical extrusion of sodium hypochlorite also 2. Activate the irrigant in order to increase the penetration militates against the use of unnecessarily high concentrations, of the root canal. although a concentration of 0.01 per cent has been demonstrated to be lethal to fibroblasts and a case of skin CONTINUED OVERLEAF>

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The needle penetration is a function of both the size of the needle and the size of the apical preparation of the canal. Apical preparations in the order of ISO size 25-30 and the use of currently available 27-30 gauge needles will enable penetration to approximately 1mm from Working Length (Figure 1). This has been found by at least one study to be the 20 most dominant factor in irrigant penetration . The preparation taper has also been found to affect irrigant exchange, with apical preparations of greater taper 21 producing greater flow of irrigant than narrow tapers .

Irrigant activation may be enabled either by manual FIGURE 1 or machine-assisted means. Manual techniques include Top: A 27G cutaway irrigation needle. Bottom: A 30G side-ported agitation with the delivery needle, use of endodontic needle. Middle: A Protaper F2 rotary file for comparison brushes or by manual dynamic irrigation. In this technique, a well-fitting gutta percha cone is placed into the irrigated canal and moved rapidly in and out with a 2-3mm stroke. This action is thought to create a hydrodynamic effect increasing 20 the penetration and exchange of the reagent . A drawback of manual pumping is that it is laborious (Figure 2). Machine-assisted agitation systems have come about to facilitate better penetration. Rotary brushes, such as Canalbrush, can be used in a handpiece but, again, only where the brush can penetrate. Quantec-E provides continuous irrigation during rotary instrumentation. This concept should provide for greater irrigant exchange than needle irrigation alone and this has been shown to be true in the coronal third of canals; however, this has not resulted in cleaner canal walls in the middle and 22 apical thirds of canals studied . FIGURE 2 Sonic agitation devices, such as the Endoactivator A well-fitting GP cone can be used in a rapid pumping motion for from Dentsply, work at lower frequencies than ultrasonic manual dynamic irrigation devices and demonstrate higher amplitudes of displacement. Endoactivator utilises a smooth-sided polymer tip that has been demonstrated to be resistant to fracture and passive Pressure alternating devices towards the dentinal walls of the canal (Figure 3). Devices have been introduced that create alternating Passive ultrasonic irrigation (PUI) has been demonstrated negative pressure and positive irrigation within the canal. to be highly effective in increasing both the penetration and Examples include EndoVac and RinsEndo. A study of one cleaning efficiency of irrigant solutions. Although PUI can be of these systems (RinsEndo) found that it outperformed used with intermittent irrigation, it has been demonstrated passive irrigation in the removal of a layer of stained to be most effective when applied to the completed canal collagen from the canal walls but was inferior to manual 9 26 preparation . The prepared canal is flooded with irrigant dynamic irrigation . such as sodium hypochlorite. A file is then introduced to the maximum length at which it does not bind with the canal Summary walls and activated with an ultrasonic unit. With the file tip Despite attempts to create alternative solutions and methods, free, a node of vibration is established, generating a wave of the evidence supports a regime that involves: energy that streams irrigant coronally. Endosonore files are • A solution of sodium hypochlorite with a concentration in highly effective for this technique (Figure 4). the range 1 per cent to 3 per cent While passive irrigation with sodium hypochlorite does • The use of a decalcifying agent to remove the smear layer not remove the smear layer, when a 3 per cent solution of • Ultrasonic activation of the irrigant sodium hypochlorite is used with PUI, several studies have • Adequate apical preparation and taper of the canal to 23 -24 found complete removal of the smear layer . These permit placement of the irrigant within 1mm of the apex and findings were not reproduced when the irrigant was replaced enable sufficient irrigant flow. with saline. Figure 5 shows two completed cases demonstrating The precise mode of action of PUI is unclear, but accessory anatomy that is not accessible to files, but acoustic streaming is thought to be the primary factor in which has been cleaned by irrigant penetration. debris removal. Cavitation has also been postulated as an effect. Cavitation occurs with the generation and collapse of microbubbles within the irrigant solution as the pressure ABOUT THE AUTHOR Adrian Stewart BDS, PG Dip Endo (UCL), MSc, graduated from Queen’s drops momentarily below the liquid’s vapour point. This has University, Belfast in 1992. He holds an MSc in Clinical Dentistry (restorative been shown to generate high temperatures in the micro- dentistry) from Leeds University and the Post Graduate Diploma in Endodontic Practice from the Eastman Institute, UCL. Adrian works in practice limited to environment and may explain the synergistic effect of PUI endodontics, taking referrals for non-surgical and surgical endodontics at 25 and sodium hypochlorite . 1 Manor Place, Edinburgh.

SCOTTISH DENTAL MAGAZINE 68 REFERENCES hypochlorite, chlorhexidine, EDTA, 1. Kakehashi S, Stanley HR, and citric acid. J Endod. 2012 Irrigant activation may be Fitzgerald RJ. The Effects of Apr;38(4):426-31. Surgical Exposures of Dental 15. Spangberg L, Engstrom B, enabled either by manual or Pulps in Germ-Free and Langeland K. Biologic effects Conventional Laboratory Rats. of dental materials. 3. Toxicity machine-assisted means Oral Surg Oral Med Oral Pathol. and antimicrobial effect of 1965 Sep;20:340-9.# endodontic antiseptics in vitro. 2. Moller AJ, Fabricius L, Dahlen Oral Surg Oral Med Oral Pathol. G, Ohman AE, Heyden G. [Comparative Study In Vitro]. Influence on periapical tissues 1973 Dec;36(6):856-71. of indigenous oral bacteria and 16. Sim TP, Knowles JC, Ng necrotic pulp tissue in monkeys. YL, Shelton J, Gulabivala K. Scand J Dent Res. [Research Effect of sodium hypochlorite Support, Non-U.S. Gov't]. 1981 on mechanical properties of Dec;89(6):475-84. dentine and tooth surface 3. Nair PN. Apical periodontitis: a strain. Int Endod J. [Clinical Trial dynamic encounter between root Comparative Study Randomized canal infection and host response. Controlled Trial]. 2001 Periodontol 2000. [Review]. 1997 Mar;34(2):120-32. Feb;13:121-48. 17. Serper A, Ozbek M, Calt S. 4. Excellence Cf. Root canal Accidental sodium hypochlorite- FIGURE 3 FIGURE 4 irrigants and disinfectants. induced skin injury during The Endo Activator from Dentsply An endosonic file in its adaptor Endodontics [serial on the endodontic treatment. J Internet]. 2011; Winter. Endod. [Case Reports]. 2004 5. Bystrom A, Sundqvist G. Mar;30(3):180-1. Bacteriologic evaluation of the 18. Sirtes G, Waltimo T, Schaetzle efficacy of mechanical root canal M, Zehnder M. The effects instrumentation in endodontic of temperature on sodium therapy. Scand J Dent Res. 1981 hypochlorite short-term stability, Aug;89(4):321-8. pulp dissolution capacity, and 6. Gulabivala KP, B.; Evans, G.; antimicrobial efficacy. J Endod. Ng, Y-L. Effects of mechanical [Evaluation Studies]. 2005 and chemical procedures on Sep;31(9):669-71. root canal surfaces. Endodontic 19. Ram Z. Effectiveness of Topics. 2005;10:103-22. root canal irrigation. Oral Surg 7. Hulsman MP, O.A.; Oral Med Oral Pathol. 1977 Dummer, P.M.H. Mechanical Aug;44(2):306-12. preparation of root canals: 20. Bronnec F, Bouillaguet S, shaping goals, techniques and Machtou P. Ex vivo assessment means. Endodontic Topics. of irrigant penetration and 2005;10:30-76. renewal during the final irrigation 8. Hulsmann M, Rummelin C, regimen. Int Endod J. 2010 Schafers F. Root canal cleanliness Aug;43(8):663-72. after preparation with different 21. Boutsioukis C, Gogos C, endodontic handpieces and Verhaagen B, Versluis M, hand instruments: a comparative Kastrinakis E, Van der Sluis LW. SEM investigation. J Endod. The effect of root canal taper on [Comparative Study]. 1997 the irrigant flow: evaluation using May;23(5):301-6. an unsteady Computational Fluid FIGURE 5 9. Zehnder M. Root canal Dynamics model. Int Endod J. Two teeth with accessory anatomy that has been irrigants. J Endod. [Review]. 2006 [Comparative Study May;32(5):389-98. Research Support, Non-U.S. cleaned by the reagent regime, not filing 10. Ringel AM, Patterson Gov't]. 2010 Oct;43(10):909-16. SS, Newton CW, Miller CH, 22. Setlock J, Fayad MI, BeGole Mulhern JM. In vivo evaluation E, Bruzick M. Evaluation of canal of chlorhexidine gluconate cleanliness and smear layer solution and sodium hypochlorite removal after the use of the solution as root canal irrigants. Quantec-E irrigation system and VERIFIABLE CPD J Endod. [Research Support, syringe: a comparative scanning Non-U.S. Gov't Research Support, electron microscope study. Oral QUESTIONS U.S. Gov't, Non-P.H.S.]. 1982 Surg Oral Med Oral Pathol Oral May;8(5):200-4. Radiol Endod. [Clinical Trial AIMS AND OBJECTIVES 11. Seal GJ, Ng YL, Spratt D, Comparative Study Bhatti M, Gulabivala K. An Randomized Controlled Trial]. • To gain an understanding of the crucial role of irrigants in in-vitro comparison of the 2003 Nov;96(5):614-7. endodontic therapy bactericidal efficacy of lethal 23. Cameron JA. The use of • To review the mode of action of popular endodontic irrigants photosensitization or sodium ultrasound for the removal of the • To understand the various means to improve irrigation. hyphochlorite irrigation on smear layer. The effect of sodium Streptococcus intermedius hypochlorite concentration; SEM LEARNING OUTCOMES biofilms in root canals. Int Endod study. Aust Dent J. [Research J. [Comparative Study]. 2002 Support, Non-U.S. Gov't]. 1988 • The dentist should be better able to choose the irrigant regime Mar;35(3):268-74. Jun;33(3):193-200. for their practice 12. Gulabivala K, Stock CJ, Lewsey 24. Alacam T. Scanning electron • The dentist should be able to choose means to improve the JD, Ghori S, Ng YL, Spratt DA. microscope study comparing activity of the irrigants they employ Effectiveness of electrochemically the efficacy of endodontic activated water as an irrigant irrigating systems. Int Endod • By understanding the use of irrigation, outcomes for dentist in an infected tooth model. Int J. [Comparative Study]. 1987 and patient should be improved. Endod J. [Comparative Study]. Nov;20(6):287-94. 2004 Sep;37(9):624-31. 25. van der Sluis LW, Versluis M, EXAMPLE QUESTION 13. Hems RS, Gulabivala K, Ng Wu MK, Wesselink PR. Passive 1. What is the primary cause of periapical disease? YL, Ready D, Spratt DA. An in ultrasonic irrigation of the root a. Dead pulp tissue vitro evaluation of the ability canal: a review of the literature. b. Bacteria of ozone to kill a strain of Int Endod J. [Review]. 2007 Enterococcus faecalis. Int Endod Jun;40(6):415-26. c. Trauma J. [Comparative Study 26. McGill S, Gulabivala K, Mordan d. Cyst Evaluation Studies N, Ng YL. The efficacy of dynamic Research Support, Non-U.S. irrigation using a commercially HOW TO VERIFY YOUR CPD Gov't]. 2005 Jan;38(1):22-9. available system (RinsEndo) Go online to www.sdmag.co.uk and click on the CPD tab to access 14. Rossi-Fedele G, Dogramaci determined by removal of a all our CPD Q&As and certificates EJ, Guastalli AR, Steier L, de collagen 'bio-molecular film' from Figueiredo JA. Antagonistic an ex vivo model. Int Endod J. interactions between sodium 2008 Jul;41(7):602-8.

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IN THE74 COMMUNITY 78RISING STAR Scottish Dental award winner Kirsty Rodger has gone from patient Linsey Paton explains how she has to nurse and on to practice manager put her practice at the heart of the at Deveron Dental Care in just a local community few short years

INTEGRATING DCPs INTO THE DENTAL CARE TEAM

COMMITTED LINSEY PATON TALKS ABOUT HER AWARD- WINNING WORK See page 74

73 SCOTTISH DENTAL MAGAZINE DCP FOCUS

PRACTICE MAKES PERFECT COMMUNITY PARTNER AT TRYST DENTAL PRACTICE, IT’S NOT JUST PATIENTS WHO BENEFIT FROM THEIR FOCUS ON HEALTH

 STEWART McROBERT  MARK JACKSON

ommunity means a lot to Linsey always stuck with me.” Then, at 17, she had Paton, the business manager to endure severe ulcerative colitis, which at Tryst Dental Practice in culminated in major surgery at 18. What Stenhousemuir. From the time saved her, Linsey said, was the NHS. she and her brother, encouraged After recovery, she went on to study C by a PE teacher mum, took part Sport in the Community with Business at in team sports at an early age, Linsey has Strathclyde University. Then her career took relished working with others. Picking up an unexpected twist. “I’d had a part-time job in the Community Award at the 2015 Scottish a data protection company,” Linsey explained. Dental Awards was confirmation of the “I was subsequently offered a supervisor’s role, achievements that have already been made which turned into a good career opportunity then an associate of Tryst Dental. Lesley had under her guidance at Tryst. However, as when the business was taken over by the US the opportunity to take over the practice in Linsey said: “We’ve only just started.” business, Iron Mountain.” January 2014. However, she wanted to remain The practice’s successful community A few years later, she had become Head focused on developing the clinical aspects and activity includes burgeoning links with of UK Scanning Services for another data improving patient care, so she asked if I would Stenhousemuir Football Club and Larbert protection firm when the chance to join come and help with the business aspects. High School. Among other things, these Tryst came along. “I knew Lesley Donaldson, With clearly defined roles, I had scope to have led to support for a walking football do something a bit different and thought we project and pupils delivering oral health could give it a try. I subsequently joined full presentations to their peers. “ALTHOUGH WE’VE ACHIEVED time in July 2014.” Linsey’s attachment to community In many ways, she said, her role is similar participation was strengthened during a QUITE A LOT IN A SHORT SPACE to that of a typical practice manager. The traumatic period in her teenage years. Her current focus is on developing new skills mother, who had become a special needs OF TIME, I BELIEVE WE’RE within the team, both to take the practice teacher, contracted ovarian cancer and forward and allow Linsey to give more time passed away. Linsey was just 13 at the time. ONLY AT THE BEGINNING OF to strategy development. “One of the last things she did was to remind me to think of other people in WHAT WE WANT TO DO” COMMITMENT ETHOS everything I did,” said Linsey, “and that has The ‘something different’ that Linsey mentions

SCOTTISH DENTAL MAGAZINE 74 Linsey Paton and the team at Tryst Dental Practice

is part of the practice’s ethos; its commitment this is a great way to reach people and take controlled and regulated, and most to community involvement. “We’re in a very forward the idea of partnership working in the importantly, allows students to demonstrate community-focused area, and even though dental sector. The more we’re able to send out a valid record of achievement.” we have a large catchment, patients often messages around general health and wellbeing, know each other. I am extremely keen for us the more doors will start opening.” NURSE TRAINING to play our part in that,” she said. As Linsey The contact with Stenhousemuir and Meanwhile at the practice, in addition to the established the practice’s community links, she their head of community Jamie Kirk allowed professional development work Linsey is discovered willing partners in Stenhousemuir Linsey to find out about, and meet with, Billy carrying out with colleagues, she is learning to FC and Larbert High. Brotton, head of sport at Larbert High, who be a dental nurse. “My NHS training begins in A straightforward offer of help to the also looks after the Tryst Community Sports August and there are good reasons for making football club led to Tryst’s sponsorship of a Hub. Soon, a new partnership had been this move. From a business point of view, I can walking football project for men aged over established. “We’re helping to promote events help out if we’re ever short-staffed. Perhaps 50. The practice provided initial funding, and carrying out work in the school. Among more importantly, if I understand the ins and which was then doubled by sportsmatch, the other things, I’m planning to work with a outs of the job, it makes it easier for me to Government scheme that encourages business pupil from each year group to help them put relate to the nurses, and for them to have investment in grassroots sport. together a presentation on oral health that trust in me.” Linsey added: “I met some of the guys they will deliver to fellow students. Not content with the role of pupil, Linsey who took part in the football and they were “Similarly, we are developing a dental very enthusiastic. It got me thinking that work experience programme that’s properly CONTINUED OVERLEAF>

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103308_Scotish_Dental_Mag.indd 1 23/06/2015 13:39 DCP FOCUS

FROM PREVIOUS PAGE>

is acting as tutor too, working with the NHS ABOVE: Linsey Paton, Education department as a trainer for the business manager at Tryst Dental Practice, practice managers’ vocational training scheme. the deserving winner She had originally considered undertaking the of the Community course, but the Education team persuaded Award for her work with, among others, Linsey that her business background would Stenhousemuir make her an effective trainer. So far, it has Football Club involved mentoring a practice manager from Edinburgh and she says that the seven hours she devotes every week have proved to be a rewarding experience.

SURPRISE NOMINATION This myriad activity helped Linsey stand out when it came to the Scottish Dental Awards. However, her nomination came as something of a surprise. “I was quite shocked,” she said. “Just to be shortlisted was fantastic, and on the night I was simply thinking about how good it was to be there. “Similarly, although we’ve achieved quite a lot in a short space of time, I believe we’re only at the beginning of what we want to do. In some ways, the award has come early, but it was wonderful to win, and a real vindication of the work done by all of the team here.” That success should provide a fillip as Linsey and her colleagues look to the future. “We are starting to look at new opportunities,” she said. “Our hope is that we’ll be able to put together roadshows with Stenhousemuir FC, the sports hub and, if all goes according to plan, the British Heart Foundation. “The community aspect is something I really enjoy. Every business has its stresses and its routine, but if you pursue something you genuinely believe in, and that brings happiness to you and to others, you can be content that you’ve made a difference.”

77 SCOTTISH DENTAL MAGAZINE DCP FOCUS

NORTHERN STAR IN JUST A FEW SHORT YEARS, DENTAL NURSE KIRSTY RODGER’S ENTHUSIASM AND PASSION HAVE SEEN HER TRANSFORM FROM PATIENT TO PRACTICE MANAGER

 STEWART McROBERT  BRIAN KILOH

ome people are lucky enough to possibilities with my dentist and he QUALIFICATION know what they want do in life recommended dental nursing, saying I Completing her training, Kirsty qualified from an early age – Kirsty Rodger was more than welcome to gain work as a dental nurse at the Aberdeen Dental is one. At 15, she became aware that experience at the practice.” Education Centre in January 2012. From she wanted to work in dentistry. A few days during the Easter holidays the start, she has been committed to S At 21, she’s already crammed a confirmed her thoughts; she loved the undertaking additional courses to extend great deal into a short career, and she’s atmosphere and teamwork and duly left her role. just received the DCP Star trophy at the school – still aged 15 – to seek a job by In April 2012, she qualified as a Scottish Dental Awards. sending her CV to practices in and around Childsmile nurse at the University of “When I was younger, my dentist in her home near Huntly. Highlands and Islands, Inverness. And in Banff referred me to an orthodontist in “I was invited to an interview in November 2013, Kirsty passed the NEBDN Aberdeen to have braces fitted,” recalled Inverurie, got the job pretty much on Certificate in Oral Health Education at the Kirsty. “I remember walking into the the spot, and have never looked back. I Aberdeen Dental Education Centre. surgery and realising that this was the absolutely loved it and was there for three By that time, she had moved to her kind of thing I wanted to do. I discussed years,” said Kirsty. current employer, Deveron Dental Centre in Huntly, which she joined in September 2012. “When the opportunity to work here Kirsty’s calming came, I couldn’t turn it down. nature has helped “Previously, I was travelling about 30 both adult and miles every day. Deveron is seven miles younger patients away from home, plus I’d heard really good things about the practice, and the owner, Morven Gordon-Duff, puts a high priority on continuing professional development, which is very important to me.” The practice has a 6,500-strong patient list, five dentists and three therapists, and its positive reputation appears well justified – as well as Kirsty’s achievement, Morven was named Employer of the Year at the Scottish Dental Awards. “Initially, I concentrated on nursing and carrying out Childsmile and general oral health education,” said Kirsty. “However, recently I’ve been asked to act as practice manager and that’s how I spend most of my time. To some extent, I miss being in the surgery, but enjoy helping out behind the scenes.”

SCOTTISH DENTAL MAGAZINE 78 Kirsty Rodger’s boss has praised her passion and dedication to her role

PASSIONATE in one month alone. She has also helped their colleagues coming along to support According to Morven, Kirsty is one of raise funds for Children in Need, and the Kirsty and Morven. Featured in the local the most dedicated dental nurses she has ARCHIE Foundation. press, the dual success helped reinforce worked with. “She is extremely passionate “We did the ice bucket challenge last the practice’s reputation. about her job, brilliant at putting nervous year,” Kirsty said. “Morven phoned up With those distinctions under their people at ease and is wonderful with our and said she was looking for volunteers belt, the aim now is to look forward. “At child patients. and she knew right away that I would be the moment, I’m continuing with practice “Although she is young, she has the up for it. I always grab any opportunity manager training, and I hope to take some maturity and skills to be a key member with both hands.” of the pressure off Morven, who also has for training our new dental nurses and That eagerness to help was one of two young children to care for. We want to vocational trainee dentists. Kirsty is full the reasons Kirsty picked up the DCP see the practice grow and that’s happening of great ideas and enthusiasm for the Star award. And she’s thrilled with the – we’re currently registering more than 25 practice and I never have to ask her twice recognition. “I was chuffed to win the new patients a week. to do a job.” award. I have been working very hard, but “There’s a lot happening and we have The practice puts a high priority I knew it would be worth it and pay off at recently added Six Month Smiles and facial on charity work, and Kirsty has been some point. I didn’t know Morven had put rejuvenation to our offer. As always, we instrumental in helping raise funds. Staff me forward, but she is good at recognising are looking to see what we can do to gathered £3,000 for Dentaid in 2014, mostly when someone is doing well; she won develop our service.” from stock sales. As oral health educator, Employer of the Year for a reason.” It appears the practice knows where Kirsty helped sell lots of oral hygiene The awards proved to be a great it wants to go – much like the practice products, including 20 electric toothbrushes exercise in team bonding, with many of manager.

79 SCOTTISH DENTAL MAGAZINE FEATURED MAKING THE SWITCH TO IMPLANTIUM

mplantium is a leading UK-based products to dentists and enable them to try Implantium continues to extend its supplier of high-quality, cost-effective before they buy, Implantium has launched product range to encompass a wider Idental implants. Run for dentists, by its iEco-Rep kit. This interactive package variety of products which conform to the dentists, the company’s fresh approach gives dentists a comprehensive overview Implantium ethos – products which offer is continuing to revolutionise the UK of the Implantium offer, and includes a great quality, innovation and value. implant market by selling a top quality surgical kit, sinus drills, model implants “The company is run by dentists product that costs 40% less than other and full product catalogues. It also for dentists, so every product in our implant providers. incorporates an iPad packed with video catalogue has been extensively tried and demonstrations of the implants in action, tested in surgery before it makes the THE IMPLANTIUM SYSTEM IS: and gives dentists the chance to arrange grade to be incorporated in the sales • Simple to use a one-on-one consultation with one of catalogue,” said Heather Smith, sales and • Comprehensive (bone and tissue level) Implantium’s vastly-experienced dentists if marketing manager. • Substantially more cost-effective than they have any queries they’d like answering. “From biomaterials to surgical lighting other market leaders Implantium has also teamed up with and motors, Implantium aims to be much • Backed by superb training and support 2Ingis – an innovative manufacturer of more than an implant supplier. • Designed to deliver excellent guides – to bring you ImplantPilot, the “We would love potential customers to long-term results. ground-breaking surgical guide that’s contact us to consider making the switch With a total commitment to revolutionising the way dentists place to Implantium and we are certain we can innovation, quality and service, the implants. Guided surgery has been around offer considerable cost savings without company runs its own research programme for a long time yet, surprisingly, few people compromising quality.” and actively seeks innovative ideas that use it. ImplantPilot is a guided-surgery MORE INFORMATION could be developed into new products, system set up to be ultra easy to use, To find out more about Implantium, contact including the DASK – sinus lifts in half cost effective and very accurate. Visit 0845 0176 262, email [email protected] or visit www.implantium.co.uk the time and safer too – and Kerators – www.implantpilot.co.uk to find out more. an economic denture attachment system which offers savings of up to 50 per cent compared with the brand leader. And all backed by excellent customer service. To help showcase its full range of

SCOTTISH DENTAL MAGAZINE 80 IMPLANTS FOR DENTISTS BY DENTISTS

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Implantium Scottish Dental August 2015.indd 1 14/07/2015 12:47 FEATURED LISTENING TO PRACTICES

LOUISE BONE, PRACTICE CONSULTANT FOR DPAS EXPLAINS THE WAYS IN WHICH SHE CAN SUPPORT AND TAKE PRESSURE OFF YOUR TEAM

ince joining DPAS Dental Plans in 2013, my role as practice consultant Shas been to guide and support our existing and new clients through the implementation and running of practice- branded dental plans across Scotland. I’m based in Edinburgh and deal with all types of clients, from mixed practices with a majority of NHS patients and just this really sets us apart. I take the pressure a few on plan, through to fully private off the team by staying in the practice for practices that are predominantly plan as long as they need me, so I can help with only. Part of my role is about showing the every aspect of the changeover and, with practice team, as well as their patients, a dedicated customer services advisor at the benefits of being on a dental plan. But, head office, the practice know they will first and foremost, it’s about listening to into a ‘one-size-fits-all’ scheme. always be able to speak to someone who practices to find out what they really need. No matter whether the practice is understands the intricacies and individual As we provide a tailor-made solution to introducing a plan for the first time or nature of their practice. meet the requirements of each individual transferring from another provider, we MORE INFORMATION practice, I am on-hand to guide, advise and do all the necessary groundwork as an For more on DPAS’ flexible, comprehensive and effective train, without ever trying to fit our clients inclusive part of our offering and I believe dental plans, call 01747 870910 or visit www.dpas.co.uk.

St Andrews Orthodontics Limited Telephone: 01334 474203 Eden House, 35 Largo Road Dedicated Dentists Line: 01334 837900 St Andrews KY16 8NJ Fax: 01334 460742 info@standrews orthodontics.co.uk www.standrewsorthodontics.co.uk

SCOTTISH DENTAL MAGAZINE 82

St Andrews Orthodontics.indd 1 13/07/2015 16:13 LISTENING TO PRACTICES

St Andrews Orthodontics.indd 1 13/07/2015 16:13

Management

MONEY86 MANAGEMENT IN-PRACTICE87 TRAINING BUSINESS89 ADVICE 92FINANCIAL Do you know the difference between Empower your team with the Do you reduce the price of a Should you take your pension in one profit and cash flow? Mark Fowler correct training and you will see the treatment in your head before go or re-invest after withdrawal? explains the importance making a benefits in the way your business telling the patient? Ashley Latter Recent changes have thrown up a firm distinction runs for many years to come says this is a dangerous tactic number of things to think about

PRACTICAL INFORMATION FOR PRACTICE MANAGEMENT PROFESSIONALS

CASH FLOW MAINTAINING YOUR BUSINESS IN THE CURRENT CLIMATE See page 86

85 SCOTTISH DENTAL MAGAZINE MANAGEMENT

PROFIT VS CASH FLOW FEW PRACTICES HAVE A FIRM DISTINCTION BETWEEN PROFIT AND CASH FLOW

 MARK FOWLER

practice may return a good profit, pedantic reader, the bath will not leak more affordable. Just because you are used based on year-end accounts but the water FASTER, when it is fuller!). This to seeing plans that cost large amounts of owner may be in despair because represents significant monthly outgoings money, don’t expect your clients to think the profit does not reflect the true like staff salaries and associate payments. the same way as you. Practices that offer levels of operating cash within the Once the water level goes down then these finance options have much better cash flow A business. This may be leaving the holes don’t leak anymore. However, other and treatment plan take up. principal with little operating capital. holes still allow water to leak and this will 5) CONSIDER OFFERING Operating capital is crucial to maintain- keep happening until the bath runs dry. treatments that patients actually want ing a healthy business. Many large compa- Now no one can get a drink of water and as well as need. For this consider tooth nies, some of which are household names, keep the bath clean and serviceable and whitening, short-term orthodontics, have very low profit margins, perhaps 5 refill it. They have dehydrated. tooth-coloured fillings etc. per cent or lower, but continue operating The trick is to keep the bath topped up 6) MARKET what you can offer in the as healthy ventures simply because they enough to replace the water that is leaking practice. Patients will not know what you have excellent cash-flow management. In out until it is time for the larger influx of do unless you tell them. Always consider the past, dentists benefitted from healthily water to fill the bath. what it will do for the patient rather than profit margins (40 per cent or more), which This analogy represents your practice talking too technical. For example, an meant that the large margin essentially bank account and working capital. Enough implant is a screw that is placed into your buffered perturbations in cash flow. Cash money must be reaching your account to jawbone that supports a crown, but it is also management was simply to budget until the service your outgoings, pay your staff and the closest thing to a natural tooth that will next large injection of cash. As the costs of your bills in order for you to keep operat- enable you to eat apples and steak with your operation have risen due to VAT increases, ing long enough to reach the next large family without fear of a bridge or denture compliance, regulation and other costs of capital injection via NHS payments or falling out. Sell the sizzle not the sausage! running a practice, cash-flow management plan payments. 7) LEARN TO COMMUNICATE has become increasingly important. In fact, There are a few tricks and adjustments and ethically sell your treatments to superficially, one can argue that the smaller to managing cash flow that work very well. your patients. There are a number of the profit margin (and thus a smaller buffer) 1) ESCORT PATIENTS to the excellent ethical sales and communication the better the cash-flow systems need to be. reception area in order that forward courses available. It is no good having a profitable business at appointments can be discussed with the 8) MONITOR the productivity and the end of a working year if you can’t afford reception team. This way any money overheads of your associates and beware to reach this point in the first place. outstanding on the patients account can be of busy fools who drain your resources and So, picture your business as a bath communicated to the reception team. make you no money. We have witnessed with water in it. It is a quarter full. Holes 2) ASK PATIENTS HOW they would several practices where poor associates in the bath allow water to leak out and like to pay today, not would they like to pay have literally stalled the cash flow and fill cups that allow other people to drink today. Simple terminology but very powerful. sustainability of practices. the water and stay alive to help refill the 3) ASK FOR DEPOSITS up front for 9) CHASE DEBTS. bath and keep it clean and serviceable. large treatment plans, treatments that need 10) IF YOU have a pipeline of These holes represent your expenditure lab work and indeed for NHS work that treatments that patients have not returned on a monthly basis: salaries, drawings, requires multiple visits where payments for or you have clients that have expressed associate fees, lab and material costs and can be broken down. an interest in a particular (elective) fixed overheads such as rent, mortgages, 4) IF YOU CAN OFFER larger treatment then follow up with these clients. loans, telephones, IT, utilities, insurance treatment plans or private work, consider Your software should be able to run reports etc. During the month your bath may offering patients interest-free finance on patients with outstanding plans and if receive a single big top up of water (NHS options to help spread the cost of you use a treatment co-ordinator to talk schedules, plan payments etc). The water treatment. This will help case acceptance by to patients then they should be keeping a still leaks out, but some of the holes only removing objections to treatment based on record of these meetings and following up leak water when the bath is full (for the cost and make paying for treatment much with potential clients.

SCOTTISH DENTAL MAGAZINE 86 TEAM TRAINING INVESTING IN YOUR TEAM WILL HAVE A POSITIVE IMPACT ON YOUR PRACTICE LIFE

 MARK FOWLER

adly the value of “training” in inductions and practice systemisation. the information in the continuity plan, to dental practices is consistently Let me illustrate the power of this restore the telephone service. under-valued and the impact is philosophy. Last week we visited a practice The most impressive thing though, vastly under-estimated. Of course, who had embraced the concept of “systemi- other than the team work, was that it well-trained dentists are an obvious sation” and the training that goes with it. was a 17-year-old trainee reception- Sasset and qualified dental nurses or They had developed a robust induction ist who ultimately followed the plan and surgery assistants are (usually) the norm. system that lasted at least a month, after was taking ownership of talking to the However, in-practice training must go which a personal development plan and telephone company. further than the accepted qualifications, monthly reviews to support new team In this case, the practice systems in order to make a real difference. In members was the norm. Staff undergo manual formed part of the induction fact it must move practice leaders out of quarterly catch-up chats with personal process and training of the staff had their comfort zone into soft skills, staff training plans that support the practice as it up-skilled and empowered them to be able moves forward. to implement practice systems. Now, one Only that morning, their telephone would not normally expect leadership or system had stopped working and the strategy decisions to be formalised in the practice manager had been off site. The team same way for a team but it does serve to had been trained to use the systems manual illustrate the power of training, empower- to locate the practice continuity plan and ment, support and a reference manual. had contacted the telephone company, using So the next time that you moan or whinge about your team, ask yourself: are you expecting them to be mind readers? Have you trained and communicated with SO THE NEXT TIME them what your expectations are? The reality is that if there is a problem with your YOU MOAN OR team, then there is a problem with YOU as a leader or manager. Many problems within teams stem from a lack of communica- WHINGE ABOUT tion, rules, vision and expectations. The take-home message is that by empowering YOUR TEAM, ASK your team with the correct training you will be investing in the future running of your business, the future of your team members YOURSELF: ARE YOU and the future of your practice. So take team training further than the EXPECTING THEM TO yearly CPR event and consider some training in customer service or how to operate your practice systems properly. BE MIND READERS? The difference will be amazing.

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SDI Dental Limited Your Smile. Our Vision. Email [email protected] or contact www.sdi.com.au Kelly on 00800 022 55 734 www.polawhite.com.au for details of your nearest SDI representative MANAGEMENT Don’t reduce the price in your head

ASHLEY LATTER EXPLAINS HOW A 10 PER CENT REDUCTION IN YOUR PRICES CAN ADD UP TO A 29 PER CENT DROP IN PROFIT

 ASHLEY LATTER

lmost all of the dentists I have ever the words, has somehow come out as just alone, we calculated that it is costing his coached have reluctantly admitted £350. For some inexplicable reason, they’ve practice around £10,000 per year! This to being guilty of the following found the prospect of talking money so particular dentist had only been in business scenario. Faced with quoting a uncomfortable, that they’ve actually offered for five years but when I pointed out that price for a treatment, they have a discount, without even having been asked he’d already lost £50,000 through this one Astarted off with a figure of £400, for one! In this case a whopping £50 – the unnecessary discount, he was stunned. He which by the time they’ve actually uttered equivalent of almost 15 per cent. was then ashamed to admit that there were Those same dentists have also admitted many other treatments where he would to carrying out a basic procedure free of regularly undercharge his patients; by now charge because it would only take them a few though he was far too embarrassed to admit minutes to complete. what they were. On my programmes I often discuss SOUND FAMILIAR? a concept called the “10 per cent rule”. It Whenever I deliver any of my courses, concerns the harm that a regular discount I am staggered by the number of cases can do to a business. I ask the question: of undercharging that are revealed. At “What does a 10 per cent reduction in price a recent ethical sales course, one of do to your margins?” Most dentists believe my clients described how he used that it will equate to a 10 per cent reduction to knock £30 off each filling. His in profits, but the reality is much worse! price listed it at £130 but he would instead ask for just £100. HERE ARE SOME EXAMPLES OF This represents a substantial THIS IMPORTANT CONCEPT: (23 per cent) reduction, which For every £100 of sales, if your costs are £65, patients hadn’t ever requested. It it leaves a gross margin of £35. If you were to means that your patient is getting consistently reduce your prices by 10 per cent a discount and they don’t know it would mean your sales are now reduced to about it. If you are going to play the £90, while your costs will remain unchanged. above game, at least tell them that Your gross margin will then become £25. they have had a discount. By exploring this one example CONTINUED OVERLEAF>

I ASK: “WHAT DOES A 10 PER CENT REDUCTION IN PRICE DO TO YOUR MARGINS?” MOST DENTISTS BELIEVE THAT IT WILL EQUATE TO A 10 PER CENT REDUCTION IN PROFITS, BUT THE REALITY IS MUCH WORSE!

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Clyde Dental/CDC products.indd 1 16/07/2015 15:35 MANAGEMENT

FROM PREVIOUS PAGE> however, by not increasing prices to keep in self-worth and also allow him to take some line with rising costs, can in time only lead time off and invest in the practice. Because It means that in effect your profits will have to bankruptcy! of the loyalty and good will of his patients, been reduced by a staggering 29 per cent! In Recently over dinner, a dentist who was I very much doubt whether they would be this case therefore a 10 per cent reduction half way through my two-day ‘Ethical Sales many complaints either. in price is equal to a 29 per cent reduction & Communication Programme’ admitted to in profit. I am certain that most of you have me, because of the credit crunch, that he had IN CONCLUSION heard the phrase: “Turnover is vanity, and not increased his prices for five years. During 1. Stop reducing the prices of your treatment profit is sanity.” this time his costs had risen significantly, and in your head. Make sure the price that’s in Now let’s look at another example of his take home decreased significantly. your head is the same one that comes out rising costs. The introduction of additional He was in mid 50s, was working of your mouth. bureaucracy, such as Care Quality Commission incredibly long hours, with very little time 2. If you do give a discount, at least tell south of the border, and a significant rise in off and, he was extremely miserable. Yet a the patient. overheads over the past few years, have had small increase in his prices would make a 3. I am not an accountant, but get a handle on a major impact on dental practices. Using significant difference to his bottom line, to his your costs. Know your numbers. similar simple figures as before, let’s assume 4. Make sure that you regularly review your that your total sales are £100, while your price structure. If you don’t, it will have a costs are £65, again leaving a gross margin of serious impact on your bottom line. £35. Costs then go up to £70, the equivalent STOP REDUCING THE of a 7.7 per cent increase. If your prices PRICES OF YOUR TREATMENT don’t increase to reflect this, then the gross margins will come down from £35 to £30. IN YOUR HEAD. MAKE That equates to a drop of around 15 per cent. ABOUT THE AUTHOR These examples demonstrate very clearly SURE THE PRICE THAT’S Ashley Latter is internationally renowned for helping that even a small differential in cost can have dentists and their teams improve their communication a dramatic impact on profit. Many dentists IN YOUR HEAD IS THE SAME and ethical sales skills, so that practices can create more I’ve spoken to have reacted to the ongoing opportunities to deliver the dentistry that they love to ONE THAT COMES OUT do and their patients want. He writes a fortnightly email recession by freezing their prices, despite newsletter that is read by more than 12,000 dentists an increase in their overheads. They are OF YOUR MOUTH worldwide. To register for this free of charge and to read fearful that any increase in price would risk other articles similar to this topic, please visit his website losing their patients altogether. Worryingly www.ashleylatter.com

The Ethical Sales and Communication Programme Help more patients say YES ethically to your treatment plans so that you can finally deliver the dentistry you love to do and your patients WANT Glasgow 9 and 10 November 2015 (9am – 6pm)

Ask yourself these four questions… During the two days you will… Would you like more of your treatment plans Develop new skills and behaviours that will enable you to accepted and paid for by your patients? increase treatment plan acceptance rate, in an ethical way Do you feel that your treatment is worth more Learn how to communicate effectively, clearly and concisely than you are getting paid? Discover the language that excites patients to take action Are you an NHS dentist, but would like and most importantly, what you say that deters them to do more private treatments? Discuss your fees with self–confidence and finally achieve Have you ever found yourself thinking one fee in your the income your services deserve head, but by the time it comes out of your mouth you have reduced it because you believe your patient cannot pay? Build a pipeline of “The biggest mistake I have ever made was the right type of patient delaying going on your course If you have answered YES to any of these questions, to your door when I first knew about it, now that I have taken the programme then this is a MUST attend programme Your investment is several times, I get more and £1175 plus VAT. Interest more from your programme free payment plan available each time I take it” Stephen Jacobs, Dental FX For more information please call Lissa Mann on 0161 724 8728 or visit www.ashleylatter.com

The Selling Coach (HP).indd 1 15/07/2015 16:09 91 SCOTTISH DENTAL MAGAZINE MANAGEMENT

STAY OR GO? You can’t buy IF YOU DECIDE TO REINVEST THE POT ELSEWHERE WILL YOU LOSE OUT OR WILL YOU BENEFIT? IT’S A TAXING QUESTION, SAYS OUR FINANCIAL EXPERT a great reputation.

 ALASDAIR MacDOUGALL

SHOULD I STAY OR SHOULD I and a guaranteed income for life might from it. Furthermore, you would not receive TAKE MY PENSION IN ONE GO? not be appropriate, or if you have multiple the same guarantees as you would get with The April 2015 pension changes mean that pension pots and want to cash in one or two an annuity. Competitive it is now possible to take your entire pension to give you more retirement income from The tax implications of such a move subscriptions fund as a lump sum to spend as you wish. But, the beginning. might not be worth the pay off. The first there may be considerable tax implications 25 per cent of your pension pot will be in doing so. The first 25 per cent of the cash TAKING YOUR ENTIRE POT MIGHT tax-free, however the rest will be taxed as you withdraw from your pension pot will be NOT BE THE BEST OPTION income. This means you may be paying more tax-free, the rest will be taxed as income at Taking out your entire pension pot might in tax than you reap from your investment. the relevant tax rate. However, there may be not be the best option where it is likely you Don’t forget what a pension is. A charges for cashing in your entire fund, and will spend your entire retirement savings pension is a tax-efficient, long-term savings not all providers may offer this option. in a short amount of time; you are keen to vehicle, designed to provide tax-free cash Furthermore, some pension companies avoid a large tax bill; you would like a regular and income in retirement. The phrase “try Online CPD support may require that you take independent income for yourself or for your spouse and not to outlive your money” was never truer financial advice before cashing in your any dependents after you die. than it is today. Currently, personal pension entire pot. The main thing you will need to contributions can attract tax relief up to 45 consider when thinking about taking all of REINVESTING YOUR PENSION per cent, so a gross contribution of £40,000 your pension in one go is your tax situation. POT: WILL I GAIN OR LOSE? after 20 per cent basic rate tax relief at Where your combined sources of income Research conducted by MGM Advantage source, and up to a further 25 per cent relief along with your pension pot will exceed earlier this year shows that almost one third claimed via self-assessment can net down to £150,000, you will pay tax at the highest rate of people will look to reinvest their pension £22,000. Funds are invested in a tax favoured of 45 per cent. It is likely that you will pay tax pot elsewhere after withdrawal. However, environment and can be accessed in full Dedicated on your pension at source via PAYE – this MGM has warned that doing so may from age 55. could mean you are using an emergency tax substantially reduce its value. Although the The new pension freedoms also dento-legal team, code and you will later need to claim back figures also demonstrated that only 13 per facilitate generational planning, enabling experts in Scots law any overpaid tax. Spreading withdrawal of cent of those surveyed intend to withdraw pension funds to be passed to children But you cane your pension pot over a number of years can more from their pension than the tax-free and grandchildren. Unused pension funds greatly minimise the amount of tax you will allowance, 28 per cent of these people are will never form part of an Inheritance Tax pay and mean that your tax-free entitlement planning to invest their pension money calculation, as long as they remain within is also spread over several years. elsewhere. Be warned, however, that this the pension plan wrapper. Clients must could have drastic implications in terms of think very carefully and seek independent, WHEN TO THINK ABOUT defend it.e investment value. professional advice before electing to take DRAWING YOUR ENTIRE POT Other investments do not enjoy the same significant lump sums. It may be worth considering taking out your tax benefits as a pension and also you would Online entire pension pot if you need the money have to be sure of your new investment’s quickly, if you are suffering poor health performance to ensure you would benefit advisory resources ABOUT THEAUTHOR Alasdair MacDougall is “DON’T FORGET WHAT A PENSION IS. A PENSION IS A TAX-EFFICIENT, director of Martin Aitken Financial Services. To contact Alasdair, call 0141 LONG-TERM SAVINGS VEHICLE, DESIGNED TO PROVIDE TAX-FREE CASH 272 0000. Contact us This article is based on our understanding of current AND INCOME IN RETIREMENT. THE PHRASE “TRY NOT TO OUTLIVE HMRC rules and guidance, which may be subject to change. The purpose of this article is to provide technical t 0800 085 0614 YOUR MONEY” WAS NEVER TRUER THAN IT IS TODAY” and generic guidance and should not be interpreted as a person recommendation or advice. Martin Aitken Financial Services Ltd is Authorised and regulated by the Financial e [email protected] Conduct Authority. w theddu.com/scotland

SCOTTISH DENTAL MAGAZINE 92

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SCOTTISH DENTAL MAGAZINE 94 The waiting FEATURED room and reception, and the corridor leading to the surgeries

FEEL AT HOME

SPECIALIST ORTHODONTIST GAVIN CAVES NOW HAS A SPACE HE CAN CALL HIS OWN AFTER MOVING INTO HIS BRAND NEW PRACTICE CONVERSION

 BRUCE OXLEY

fter 15 years as a specialist Institute. In 2008 he left Scottish specialist orthodontist service and he soon orthodontist, Gavin Caves has now Orthodontics and moved to Edinburgh zeroed in on the historic East Lothian town moved into his brand new state-of- Orthodontics, but still kept up the clinical of Haddington. the-artA practice conversion of a traditional teaching at the EDI. It just so happened that a new NHS sandstone property (c1900), right in the In 2010, at the “tender age of 39”, a practice with an OPG machine had opened centre of Haddington. vision was born in Gavin’s mind of one day a few months earlier in the town, and Gavin qualified from Edinburgh finally having his own small and friendly so Gavin approached Ali Bilgrami, the in 1993, obtaining the class prize in practice. He began by looking around to practice owner, to discuss using one of his orthodontics, and after a year of house jobs pinpoint an area that was underserved by a surgeries as a starting point. at the Edinburgh Dental hospital he worked On 7 October, 2010, Gavin Caves for two years as a maxillofacial senior Orthodontics was born – the same day house officer, initially at the City Hospital as his daughter’s birthday, hence always in Edinburgh and then at the Queen remembered! (Hannah is now coming Margaret Hospital in Dunfermline. He up for 10). then undertook his VDP year at the dental As referrals increased and word of practice at Southfield Loan in Edinburgh. mouth spread, Gavin gradually grew his In 1997, Gavin was accepted onto business in Haddington and he finally left the three-year post-graduate specialist Edinburgh Orthodontics in January 2014, orthodontic programme at the Glasgow going full time in his new practice. Dental Hospital – qualifying in 2000 with The dream had always been to have a Membership in Orthodontics (MOrth) his own building but the problem he from the Royal College of Surgeons of encountered was that there were precious Edinburgh and an MSc from the University few available buildings in the town and of Glasgow. those that were available often weren’t Gavin then spent eight years working suitable for a dental practice – either small as an associate at Scottish Orthodontics shop fronts or huge ex-council buildings. while also teaching the orthodontic postgraduates at the Edinburgh Dental CONTINUED OVERLEAF>

95 SCOTTISH DENTAL MAGAZINE FEATURED

FROM PREVIOUS PAGE>

However, Gavin was alerted to a former council building that had come onto the market in late 2013 and he went to have a look. Unfortunately, the space was just too big for what he needed, not to mention flats above which he had no interest in acquiring. Despite its size, Gavin knew there was potential there as it was in a great location. So, he asked the council to let him know who bought the building on the off chance that they might be interested in leasing or selling part of the premises to him in the future. In early 2014, Gavin was put in contact with the buyer who was in the process of setting up a new soft play centre in the building and was interested in selling part of the unit to him. New walls were built to partition off the new space and title deeds were drawn up. Lang and his team at SAS were the main office (which was plumbed and wired to be It took until September 2014 before the contractors at the new practice and converted into a third surgery in the future) sale of Gavin’s part of the premises went undertook all the work from the flooring and LDU. through due to issues with separating the and electrics through to the cabinets, The branding and many of the ideas space and getting all the services, such as seating and plumbing. and inspiration for the colour scheme water and electricity separated off into the Initially the building was all open and materials came from Gavin’s friends new sections. plan, with only had two internal walls, but Jane and Doug MacDowall, owners of Gavin had been recommended SAS SAS divided off the space to incorporate teviotcreative.com It was Doug’s idea to Shopfitters by colleagues and plans were a reception and waiting room with staff have the wall feature in the waiting room, already under way by the time he got quarters to the rear, including toilet, the keys in September last year. Dereck shower and locker room, two surgeries, CONTINUED OVERLEAF>

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SAS shopfitters.indd 1 15/07/2015 12:26 SCOTTISH DENTAL MAGAZINE 96

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“Gavin took me on after I was not “My 14 year old daughter has just “My daughters get anxious about all totally satisfied with treatment I had completed 18 months of braces to correct dental appointments and were very been receiving previously and worked and perfect her smile and she is over worried about a visit to the orthodontist. with me to perfect my smile. He explained the moon with the results. I can’t praise However Gavin immediately put them the treatment well and gave me a clear Gavin and his team highly enough. They at ease and reassured them and talked idea of the expected end result. During were kind, understanding, professional them through the whole process. He has consultations he was a pleasure to speak and efficient throughout the whole time a natural flair with kids and my daughters to and always kept me aware where we we were under Gavin’s care and, despite were so impressed by him they said they were in the process. I would recommend initially being a very nervous patient, my wished he was their normal dentist too. him very highly” daughter came to love her trips to the That’s a big compliment coming from orthodontist. We are very happy and them as they are not easily impressed!” Bilal Khan grateful parents!” Lorna Hill Jo Lee

ORTHODONTIC SPECIALIST GDC: 68917 T 01620 822255 F 01620 808132 BDS (Edin), FDSRCS (Edin), MSc (Glas), MOrth (Edin) E [email protected] 2 PATERSON PLACE, HADDINGTON, EAST LOTHIAN EH41 3DU W gavincaves.co.uk

Gavin Caves.indd 1 15/07/2015 16:29 FEATURED

LDU complete with washer disinfector and autoclave

FROM PREVIOUS PAGE> chairs with LED lights and handpieces practice and he sees every patient. To help by NSK. Throughout the whole practice manage the increasing number of patients, which Gavin admits has definitely grown there is wood-effect Karndean flooring, his former dental nurse Gemma Smith on him. which gives the surgeries a warmer and less is currently training as an orthodontic The recessed ceiling lighting in the clinical feel. therapist at the Edinburgh Dental Institute waiting room was a spark of inspiration In the LDU Gavin has installed a top-of- as well as in the practice. He also has from Dereck. Gavin explained that he was the-range washer disinfector and a W&H three nurses: Claire Igoe, who also covers after a warm and welcoming feel to the Lisa autoclave – which takes the water from reception; Steph Gray and Emily Weir. practice to make his patients feel at ease the mains, distills it and then drains itself Asked if he would do it again, Gavin and also to give him and his colleagues after each cycle – so the nurses never have said: “Well, hopefully I won’t have to do it a nice environment to work in. He said: to fill or empty it, much to their delight. again! But it has been a great experience. “SAS were fantastic and I’m really pleased He also has an ultrasonic bath as a back It was really exciting seeing it all come with how it has turned out. Like most up, although it spends its time being lent together and I am just delighted with orthodontists, I am quite fastidious and I to dental colleagues in East Lothian whose the outcome. was eager to get it looking just right. washer disinfectors have broken down! “It’s just great to finally have my own “SAS made the whole experience easy The reception area has a self check-in practice in my own building and we feel and they were on time and on budget, touch screen that has been a hit with really at home already. The patient’s love which was great. I couldn’t have asked for the younger patients. If the reception is it as well and I hope that I can continue more.” The whole build took three months. busy, patients can sign in and sit down to provide a great orthodontic service for The surgeries have been kitted out without waiting. my patients and colleagues for many years with white corian surfaces and Belmont Gavin is the only orthodontist at the to come.”

99 SCOTTISH DENTAL MAGAZINE Behind every successful implantologist is an Implantmed

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A4 Indesign.indd 1 24/11/2011 11:46 BUSINESS The dental associate – self-employed or not?

LANDMARK TRIBUNAL FINDING MAY HAVE and consultants in other sectors (such as construction and IT), HMRC FAR-REACHING IMPLICATIONS WITH HMRC has appeared to accept that dental  CRAIG STIRLING AND DAWN DICKSON associates are self-employed. Could this be about to change in light of the Rodrigues decision? The likelihood of future challenge peaking at the 2015 Scottish adopted in the Associates Agreement, from HMRC would appear to be quite Dental Show, Craig Stirling and the relationship between Whitecross high. The most important factors SDawn Dickson, from Davidson and Rodrigues was in fact a contract of in determining employment status, Chalmers’ specialist dental team, employment. according to the HMRC’s own guidance, addressed the main issues emerging This decision could be of profound are the very same factors which the from the landmark employment tribunal significance for the dental profession. Rodrigues tribunal considered in MORE INFO decision in Rodrigues v Whitecross It is one of only a handful of reported such detail. Craig Stirling is a Dental Care Limited and Integrated employment decisions to have expressly The Rodrigues decision should act as Partner at Davidson Chalmers. To contact Dental Holdings Limited. considered the employment status of a clear call to action for principals and him, email craig.stirling@ The tribunal considered whether dental associates. associates alike. Steps should be taken davidsonchalmers.com a dental associate engaged by The most significant repercussions now to revisit associate agreements and or call 0131 625 9191 Davidson Chalmers Whitecross Dental Care was genuinely for the profession could well be the their accompanying working practices. are legal specialists self-employed or whether he was, in tax implications of the decision, Adopting the BDA style for associate and members of the reality, an employee entitled to the should HMRC seek to challenge agreements is certainly no guarantee Association of Scottish employment protections afforded by UK the self-employed status of of safety. Dental Professionals, an association of dental employment law. dental associates. Obtaining advice from a specialist experts dedicated to The tribunal found that, Despite challenging the dental solicitor regarding your associate supporting the dental notwithstanding the nomenclature self-employed status of contractors agreements is a must. profession in Scotland.

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101 SCOTTISH DENTAL MAGAZINE BUSINESS Pensions v ISAs

 JONATHAN GIBSON In comparison, the outlay for ISAs is much smaller, mainly because there is no upfront tax relief. The 2013/14 figure for the income tax cost was £2.85bn ith the recent shake up to pensions highly tax efficient. Many – no amount is given for the CGT pensions and some changes employees also benefit from employers’ exemption. Even the Budget 2014 uplift Wto ISAs there has been a lot of contributions on top. in contributions and the cash ceiling talk as to where your long-term savings Exit on death raises different tax limit will add less than £0.6bn to the are best accumulated. The answer is… issues from those which apply when Exchequer outlay by 2018/19, according it depends. personally drawing benefits. Spouses to HMRC. The ISA benefits are clear: they can benefit from an increased ISA Anyone looking for a quick table offer full control over your investments allowance equal to the value of the of numbers to compare pensions and and unlimited access; they’re simple to deceased spouses ISA, while the ISAs will be disappointed. There are understand and are ideal for disciplined pension will become exempt on death so many variables that, in practice, an savers. For those looking for savings and before age 75. From age 75 onwards examination of individual circumstances investments that are tax efficient, with no the pension suffers tax, potentially at is what is needed. need to declare them on your tax return, a higher rate (45 per cent flat rate for Whatever your strategy, remember and no further tax to pay on any income 2015/16 and marginal tax rate in the both ISAs and pensions are simply you receive, an ISA is a perfect choice. following tax years) than the ISA tax wrappers. It’s the underlying In terms of tax considerations alone, (40 per cent IHT regardless of age). investment decisions that make the however, pensions qualify as the most Politics is a big imponderable as most difference. efficient investment there is. Higher-rate pension tax reliefs are the most obvious However, making the decision to taxpayers get up to 40 per cent tax relief low-hanging fruit for the Treasury to invest is what really matters. Using your on contributions, with additional rate pick: the tax cost of income tax and tax allowances is just a bonus with the MORE INFO taxpayers receiving up to 45 per cent tax NICs relief for pensions in 2012/13 was additional benefits of limiting how much Jonathan Gibson is the relief. The ability to withdraw 25 per cent £50 billion, while income tax raised on of your hard-earned money Chancellor director of wealth services cash, tax free, from age 55, also make pension payments was £12bn. George Osborne gets his hands on! at AAB Wealth.

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SCOTTISH DENTAL MAGAZINE 102 BUSINESS The shifting balance of the dental practice market

CHRISTIE + CO’S SPECIALIST ADVISER IN THE DENTAL SECTOR TAKES A CLOSER LOOK AT THE MOST NOTABLE THEMES IN THE PRIVATE PRACTICE MARKET  SIMON HUGHES

he shape and activity of the practices, there has recently been due to what is often perceived by many dental sector is fascinating, a recognised increase in interest, to be “guaranteed income”, we have Twith as little as 10 per cent of given the right circumstance and noticed a steady increase in enquiries practices in corporate ownership. This location. for quality private dental practices. is a particularly low figure when Speaking to practice purchasers In spite of the average goodwill value compared to other healthcare sectors on a regular basis, we tend to hear the of these practices being significantly such as pharmacy and social care. same things, whether from the most lower than for mixed or NHS, they are However, as the corporates accelerate inexperienced first-time purchaser or beginning to be regarded as better value their acquisition plans and become a more seasoned corporate or group for money. more competitive this figure is likely operator. Until recently this would be: With years of experience valuing to increase. “I’m looking for a mixed practice with businesses across many market sectors MORE INFO The private practice sales market in an NHS contract of at least £300,000, a and experts located across the UK, To discuss how particular is one that is seeing the most good UDA rate and potential to grow Christie + Co has an unparalleled Christie + Co might help constant and rapid changes. private income.” understanding of the factors that you achieve your future plans, please contact While historically, private practices However, within the past few influence the dental sector, and our Simon Hughes, director have been seen as less attractive months, as NHS and mixed practice experts can help you achieve your and head of medical, to purchasers than mixed or NHS values continued to be driven higher practice ambitions. on 020 7227 0749.

“ I ' m s e l l Ing my dental practice so I want an expert who wIll light the way at every step.” David, dental practice owner, Cardiff

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103 SCOTTISH DENTAL MAGAZINE BUSINESS Measure what matters

 IAN MAIN

thoroughly enjoyed this year’s Scottish Dental Show and commend Ithe organisers for another great event and for improving every year. It was a privilege to lecture again this year and I focused on how to ‘Explode with Growth’ in your practice. The feedback was very positive and delegates found that the key message, to paraphrase the McKinsey Maxim, was to ‘measure what matters’ in the practice and to design and consistently record the performance of the key performance indicators (KPIs) systematically. I shared with the audience some case studies of dramatic improvements made by adopting this simple methodology. In some examples the difference at net performing well (or not) against the honoured to be recognised as Scottish profit level was as much as £300,000! I sector averages? I’d be delighted to give Accountant of the Year at the Scottish also gave some insight into the numbers you a free bespoke benchmark report Accountancy & Finance Awards 2015 I would suggest as the ‘killer KPIs’ on your current performance. Just drop on the 15 June. To achieve this accolade every practice should focus on and me an email or give me a call and I will within the profession while focusing the Scottish average benchmarks for be happy to commission your report on the dental sector means a great deal achievement in each. without delay or obligation. I’d love to to me. I look forward to continuing to MORE INFO Please get in touch Are you confident your measurement help you to make a real difference in strive to deliver leading-edge services by emailing ian@ systems are efficient and well targeted? the practice. in the dental sector and to building on starkmaindental.co.uk or Do you understand if you are On a different note, I was hugely this success. phoning 0131 248 2570

CONTINUED OVERLEAF>

SCOTTISH DENTAL MAGAZINE 104 BUSINESS Dental dilemma

HOW MUCH DIFFERENCE WILL BECOMING and defer personal tax payments. This means that any profit in excess INCORPORATED MAKE TO YOUR BUSINESS? of current requirements can either be  STUART PETRIE reinvested into the business or retained as reserves for taxable distribution to shareholders at a later date. Looking forward, Entrepreneurs’ any dentists may have means that there is potentially Relief is a valuable tax relief available considered the potential limited scope to mitigate income when the time comes to sell or wind up Madvantages of incorporating tax at additional rates or to retain the business. A number of qualifying their practice into a limited company. personal allowances. There are means conditions do exist but, where these Prior to becoming incorporated, of reducing tax exposure through the conditions are met, the relief reduces it is important to examine carefully use of personal pension contributions the rate of Capital Gains Tax payable to whether there will be any impact on or charitable donations, but these items 10 per cent up to a maximum lifetime entitlement to certain NHS benefits. must also be posted to drawings as limit of £10 million, as opposed to the Seniority payments, vocational training personal expenses. 28 per cent Capital Gains Tax usually allowances, remote area allowances Alternatively, by operating as a payable by higher rate taxpayers. It is and Scottish dental grants for practice limited company, business profits will therefore a highly valuable relief when improvement may no longer be be taxed at a flat rate of 20 per cent considering any exit strategy. available, and as a result any potential – potentially producing considerable As can be seen from this article, loss of these entitlements must be annual tax savings in comparison to there is no existence of ‘one size fits all’ carefully considered. owners of unincorporated businesses. with regards to incorporation and there However, if appropriate, the key Moreover, profit can be extracted are particular complexities for dental taxation benefits and incentives that through a number of options, including practices. All potential factors should follow as a result of incorporating can salary, dividends, loans and employer therefore be considered to ensure that be significant. pension contributions. it is in the best interests of the practice Sole traders and partners will pay Therefore, in addition to lower tax and the dentists concerned. However, MORE INFO Stuart Petrie is the income tax at up to a 45 per cent tax rates, flexibility also exists in respect with the right set of circumstances and Private Client tax senior rate on their profit share regardless of of how or when profits are extracted, professional advice, there can be major manager at Anderson the level of drawings required. This providing opportunity to mitigate tax benefits for practice owners. Anderson & Brown LLP.

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105 SCOTTISH DENTAL MAGAZINE Expert accountants and advisors in the dental sector acting for numerous practices and associates throughout Scotland.

Specialisms include: > Annual accounts and tax compliance > Detailed tax planning (income, capital gains and inheritance tax) > Practice acquisition & disposal / succession > Financial forecasting / business planning for finance raising > Knowledge of NHS grants and conditions applicable > Tailored tax services for dental associates

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Dencomp_JP.indd 1 01,05,2015 09:11 I Thinking about buying a new practice? Before you go too far down the path give Jayne Clifford a call or send her an email [email protected] and she will run through the various options, scenarios and the what ifs… so that you know exactly what you are buying with no surprises.

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Impulse Dental Lab.indd 1 15/07/2015 12:23 Scottish Denture Clinic Experts in dentures and implants

Giving your patients the chance to make an informed choice about their new teeth. From dentures to full arch dental implants, BE THE CDT we work with you and your patients to deliver the best care.

“Truly a 5★ service. From my first consultation, Patient referral service through to the final fitting, friendly, efficient and professional. I can now smile with total confidence. Thank you!” Heather Arni Fast, efficient treatment “The treatment I received from staff at this clinic was first class. Diane was very friendly and helpful and put me Same day repairs and additions at ease from my first visit. Rob, who was the Clinical Technician that I saw was excellent. He took time to explain my options, prices and benefits. Rob also asked for a photo to get an idea of what my teeth had been Using the latest Zirkonzahn cad like which was a great idea. I was delighted with the service I received from cam technology and milling centre start to finish and would certainly recommend the clinic.” Jo Peffers

Based in Edinburgh and Glasgow

Robert Leggett Clinical Dental Technician RDT Dip CDT RCS Ed Your patients remain your patients

Scottish Dental Clinic, 2 Gillespie Place, Edinburgh EH10 4HS T: 0131 228 6650 W: www.scottishdentureclinic.co.uk E: [email protected] FEATURED Scottish Denture Clinic Experts in dentures and implants

Giving your patients the chance to make an informed choice about their new teeth. From dentures to full arch dental implants, BE THE CDT we work with you and your patients to deliver the best care. CLINICAL DENTAL TECHNICIAN ROBERT LEGGETT DESCRIBES HIS MISSION TO PROVIDE GREATER TRANSPARENCY TO THE ROLE OF THE CDT

 ROBERT LEGGETT “Truly a 5★ service. From my first consultation, Patient referral service through to the final fitting, friendly, efficient and professional. I can now smile with total confidence. n November 2012, Scottish Denture It is our goal to be as open and referral just yet but it wasn’t long before the Thank you! Clinic opened in Edinburgh city centre. transparent as possible. We spent time first partially dentate patient arrived and ” IThere have been some expected outcomes visiting the surrounding practices and the process of involving more of the dental Heather Arni and some twists in the road since then. It giving presentations in our clinic about a team began. has been a very challenging, but rewarding CDT’s role and Scottish Denture Clinic’s We began working with Ivy Dental, Fast, efficient treatment two and a half years, and we are looking ethos; explaining the potential advantages which is only a short drive for Scottish forward to continuing to grow our business. of working in conjunction with a CDT. Denture Clinic patients. One of the most One of the biggest challenges facing For the most part, Scottish Denture important factors is good communication. “The treatment I received from staff at this clinic a clinical dental technician (CDT) while Clinic was well received and it was more It has to be clear to the patient why they was first class. working remotely is finding a general about selecting a practice we felt we could are being referred and what to expect at Diane was very friendly and helpful and put me dental practice to work alongside in order have good communications with and the referring practice i.e. who will be seeing to fulfil the GDC scope of practice. As a most importantly give the best care to them, what their appointment will involve, Same day repairs and additions at ease from my first visit. CDT cannot make partial dentures without our patients. When we officially opened will there be a fee, and what will happen Rob, who was the Clinical Technician that I a treatment plan they must have a referral our doors to the public in January 2013, it next. The other line of communication saw was excellent. He took time to explain my path for partially dentate patients. took 30 minutes for our first enquiry and is between myself and the GDP, it is We needed to find a practice willing subsequently our first patient in the diary. important the GDP knows why the patient options, prices and benefits. Rob also asked for to work alongside the newest member of As part of our initial consultation has been referred to them. Once the GDP a photo to get an idea of what my teeth had been the DCP team. One of the hurdles to this with new patients, we sit in a comfortable, has created the treatment plan and design like which was a great idea. was the wider dental team being unsure non-clinical environment where for the patient, it is essential that this Using the latest Zirkonzahn cad of what a CDT is. To a certain extent this patients can feel at ease to express their information is passed back to the CDT to I was delighted with the service I received from is still the case, however, in the five years expectations and past problems and continue treatment. cam technology and milling centre start to finish and would certainly recommend since I qualified as a CDT I have tried to concerns before sitting in the dental chair. We have been very fortunate with Ivy the clinic. champion the CDT profession to allow One of our main advantages is we have dental and the communication couldn’t ” greater understanding of the role. It is now more time to spend with our patients. Time be better, we regularly do complex cases Jo Peffers apparent that understanding and attitudes is key when making dentures for a patient where the dentists will visit the lab to to the CDT role are now changing. There whom it may be difficult to achieve patient be involved in the technical stages. We was a certain level of scepticism about satisfaction within the time constraints of also attend Ivy to see patients with the Based in Edinburgh and Glasgow the role possibly due to some dental general practice. It also makes sense that GDP on regular occasions, especially for technicians working as denturists illegally to achieve the best result a CDT has full implant work. in the past. Hopefully this is a dying responsibility, both clinical and technically, Scottish Denture Clinic also accept Robert Leggett practice with education pathways available to meet the patient’s high expectations. referrals from general practice and it Clinical Dental Technician to allow dental technicians to do the As it happened, our first patient was has been reassuring that the number of RDT Dip CDT RCS Ed appropriate training. edentulous so there was no need for a dentists referring patients continues to grow. Scottish Denture Clinic advertise Your patients remain your patients consistently over a range of different media and patients travel to see us from the length and breadth of the country. Since Scottish Denture Clinic opened in November 2012 with a staff of two, we have grown to a team of 10. The team includes two CDTs, four prosthodontic technicians, two crown and bridge technicians, a practice manager and receptionist. We have clinics in Edinburgh and Glasgow and we also work sessions in specialist and general practices in Leith, Glasgow and Ayr.

In the next issue Robert will go into more detail on the type of work and different technologies that are used at the clinic. To contact Scottish Denture Clinic, call 0131 228 Scottish Dental Clinic, 2 Gillespie Place, Edinburgh EH10 4HS 6650 or visit www.scottishdentureclinic.co.uk T: 0131 228 6650 W: www.scottishdentureclinic.co.uk E: [email protected] 111 SCOTTISH DENTAL MAGAZINE THE KING OF CROWNS

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NEW HEAD OF WORLDWIDE PRODUCTION NEW 3I T3 SHORT IMPLANT: EURO LAUNCH

Markus Heinz is the new chief CEO of Ivoclar Vivadent, praised BIOMET 3i is pleased to announce Also, the dimensions of the production officer of the Ivoclar Markus Heinz as “a proven the launch of its new 3i T3 Short surgical instrumentation and Vivadent Group. He succeeds production expert, manager Implant in Europe. the 3i T3 Short Implant provide a Wolfgang Vogrin, who retired and leader”. The new 3i T3 Short Implant tight implant-to-osteotomy fit. in July. Robert, and chairman of the is available in 5mm and 6mm And manual platform Markus, who has supervisory board Christoph lengths and 5mm switching is comprehensive management Zeller, thanked Vogrin “for his and 6mm recommended experience, has been working contribution as manager to the diameters. for crestal for Ivoclar Vivadent since rapid development of Ivoclar The reduced bone 1985. He took over the Vivadent on a global level”. length makes preservation. responsibilities for the The build-up of the it an option for In addition, global tooth production in ceramic production centre areas of minimal BIOMET 3i is offering a 2002 and, since 2014, he in USA as well as the bone height new 3i T3 Short Implant compact has also been responsible expansion of numerous without the need for surgical kit designed specifically for the production other production vertical grafting procedures and to support site preparation and site in Schaan/ sites can all be the blasted and acid-etched 3i T3 placement of 3i T3 Short Implants. Liechtenstein. credited to the surface creates an average mean Robert Ganley, retiring Vogrin. surface roughness of 1.4μm. To find out more, call 0800 652 1233.

BEHIND EVERY SUCCESSFUL IMPLANTOLOGIST DOLBY AWARDED DENTAL CHAIR CONTRACT

IS AN IMPLANTMED… NOW ON SPECIAL OFFER Scotland’s leading dental products The Implantmed from W&H gives contra-angle handpiece. The and servicing company, Dolby you the most effective tools for easily operated foot control allows Medical, has won the contract oral surgical procedures in for improved infection control from world-renowned Italian the fields of implantology, while freeing up both hands. dental solutions business Cefla microsurgery and small-bone The integrated automatic to supply and service the Anthos surgery. The Implantmed is thread cutter function range of dental chairs in Scotland. currently on promotion from helps you especially when Anthos dental chairs are only £2,300 for a limited period. inserting implants into recognised worldwide for their It allows you to perform hard bone. This function exceptional quality, style and “Our experience, expertise implant procedures allows for thread tapping, configurational flexibility. and engineering skill positions us with maximum therefore minimising Derek Gordon, managing perfectly to sell, install and service precision. The unit compression of the bone. director of Dolby Medical, said: these dental chairs. The dental guarantees longer “Anthos is a natural partner for us. chair is at the heart of every working without To find out more, call As part of the Cefla Dental Group, practice and is critical to patient fatigue, thanks to the 01727 874 990, email Anthos is very highly regarded comfort and care so keeping this lightweight, yet powerful motor [email protected] or and Cefla is very selective when equipment in top condition is of and the ergonomically shaped visit www.wh.com deciding who to do business with. exceptional importance.”

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