DentalUpdate

May 2022. Volume 49. Number 5

„ Restorative dentistry: Revisiting the functionally generated path technique: is this an

aid to predictable digital occlusal design? Part 1
„ TMD: Temporomandibular disorders. Part 2: non-surgical management
„ Restorative dentistry: An update on radiation caries
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 Inside this issue

367 Comment the signs, symptoms and management of

EDITORIAL DIRECTOR Runny or not? non-neoplastic salivary gland diseases, when
FJ Trevor Burke FJT Burke to refer patients to secondary care and the
Emeritus Professor, University of Birmingham clinical features suggestive of malignancy.
EXECUTIVE EDITOR
371 Restorative Dentistry Enhanced CPD DO C
Fiona Creagh Revisiting the functionally generated path
technique: is this an aid to predictable 409 Restorative Dentistry
EDITORIAL BOARD digital occlusal design? Part 1: introduction An update on radiation caries
Avijit Banerjee and background H Bradley, K Cowan, B Owen, S Rahman and
Professor of Cariology and Operative Dentistry, Faculty
T Bereznicki, R Patel and M Clark W Keys
of Dentistry, Oral and Craniofacial Sciences,
King's College London CPD Aims, Objectives and Learning CPD Aims, Objectives and Learning
Subir Banerji
Outcomes: Readers should understand Outcomes: The reader should understand
Programme Director MSc in Aesthetic Dentistry, Faculty the occlusal schemes that would benefit the aetiology, prevention, presentation and
of Dentistry, Oral and Craniofacial Sciences, from using the functionally generated path management of radiation caries.
King's College London technique, particularly when providing Enhanced CPD DO C
Steve Bonsor milled restorations using a digital workflow.
The Dental Practice, 21 Rubislaw Terrace, Aberdeen Enhanced CPD DO C 416 Endodontics
Daniel Brierley
Senior Clinical Teacher and Honorary Consultant in Oral
Surgical endodontics under the microscope:
and Maxillofacial Pathology, Sheffield University
380 TMD and Physical Therapies principles and practice
Temporomandibular disorders. Part 2: non- F Javed, S Habib and R Ghafoor
Andrew Chandrapal
GDP, Bourne End Dental, Bourne End, Bucks surgical management CPD Aims, Objectives and Learning
Len D'Cruz
E Foster-Thomas, M James, C Outcomes: The reader should understand
GDP, Woodford Dental Care, Woodford Green, Essex Crawford, P Clarke, F Oluwajana and the basic principles and techniques
Chris Deery C Lancelott-Redfern of direct operating microscopes for
Professor of Paediatric Dentistry, School of Clinical CPD Aims, Objectives and Learning endodontic microsurgeries.
Dentistry, Sheffield Outcomes: To present the relevant self- Enhanced CPD DO C
Ian Dunn management, psychological and physical
Specialist Periodontist, Rose Lane Dental management strategies employed and
Practice, Liverpool 424 Caries Management
clarify the role of physiotherapists in the
Pynadath George Minimum intervention oral care delivery for
management of TMD.
General dental surgeon with practice limited to implant children: developing the oral healthcare team
dentistry and prosthodontics, Liverpool Enhanced CPD DO C
S Young, B Dawett, A Gallie, A Banerjee and
Ken Hemmings C Deery
Consultant, Eastman Dental Hospital, London 388 Special Care Dentistry
CPD Aims, Objectives and Learning
Edwina Kidd Cannulation: an update for dentists
Outcomes: To describe the implications of
Emerita Board Member, c/o MA Dentistry Media Ltd, Unit B Zaidman, S Spence, C Boynton and D Lewis
2, Riverview Business Park, Walnut Tree Close, Guildford
using the oral healthcare workforce scope of
CPD Aims, Objectives and Learning
practice in the delivery of MIOC in general
Mike Lewis Outcomes: The reader should be able
Professor of Oral Medicine, School of Dentistry, practice to children.
to describe the anatomy of common
Cardiff University, Cardiff Enhanced CPD DO C
cannulation sites and understand the
Louis Mackenzie
equipment available for cannulation as
GDP and Clinical Lecturer, University of Birmingham
well as be able to evaluate its risks and
432 COVID-19 Commentary
School of Dentistry and King's College London
SARS-CoV-2 Omicron variant and the future
Tara Renton relative contraindications, and demonstrate
of the pandemic
Professor of Oral Surgery, King's College London an awareness of how to deal with any
L Samaranayake
Dental Institute complications that may arise.
Enhanced CPD DO C CPD Aims, Objectives and Learning
David Ricketts
Professor of Cariology and Conservative Dentistry, Outcomes: The reader should understand
Dundee Dental Hospital
395 Paediatric Dentistry the reasons for the high global prevalence of
Jonathan Sandler Common dental anomalies affecting the SARS-CoV-2 Omicron variant, particularly
Professor and Consultant Orthodontist, Chesterfield and its BA.2 subvariant, and the implications for
North Derbyshire Royal Hospital
patients with cleft lip and palate
R Sanghvi and N Bhujel the dental practice.
Damien Walmsley
CPD Aims, Objectives and Learning Enhanced CPD DO C
Professor of Restorative Dentistry, University of
Birmingham School of Dentistry Outcomes: The reader should demonstrate
knowledge of the common dental anomalies 437 Technique Tips
and understand the role of GDPs in the Lateral thinking: the laterally closed tunnel
CPD IN DENTAL UPDATE management of patients with CLP. technique for root coverage. A case series
IN PARTNERSHIP WITH Enhanced CPD DO C DS Raindi and H Halai
CPD Aims, Objectives and Learning
403 Oral Medicine Outcomes: The reader should understand
An overview of the diagnosis and the evolution of tunnelling techniques in
Cover Picture: Courtesy of Dr Zana Hussein
management of non-neoplastic salivary periodontal plastic surgery and describe an
Aziz, Orthodontist Specialist, Iraq.
A dentist is a doctor, engineer and artist gland pathologies aesthetic alternative to the free gingival graft.
in order to bring out beautiful smiles and N Sethi, AJ Booth, N Patel and G Merrick Enhanced CPD DO C
make the world brighter. CPD Aims, Objectives and Learning
Outcomes: The reader should understand 442 CPD questions
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May 2022
Comment
FJ Trevor Burke
Runny or not?
When designing resin composite materials, manufacturers have to balance, among
other things, the degree of filler loading, filler particle size and resin viscosity, given that
these are factors in the viscosity/runniness of the material, although viscosity-modifying
resins can also be added. Given that a more and more frequently asked question
(FAQ) at my presentations on posterior composite is – ‘is it sinful to heat composite
before placement of a restoration, and/or, should I be buying a composite heater’, it is
my feeling that the practice of heating composite is increasing. Here I must make full
disclosure and acquaint readers with my personal view on viscosity of resin composites
– I like them to maintain their shape, ie be sculptable, and by this I mean that I like
them to stay exactly where they are placed after shaping. Why? For posterior composite
restorations, if at all possible, I look at the shape of the (sound) tooth or the previous
restoration and, if that has been functioning well from an occlusion viewpoint, I then
try to remember its shape and replicate that in my final restoration. This is important,
because if the restoration initially is overcontoured/too high/too bulbous, then it will
take (patient’s and clinician’s) time shaping the restoration to a correct shape with a
turbine and/or discs. Not good for either the patient or the clinician. For treatment of
tooth wear with additive composite at an increased occlusal vertical dimension, use of
a sculptable composite, which stays where it is placed, facilitates freehand placement of
the restorations, without the need for a putty matrix. Martin Kelleher is obviously also in
this camp, given that a technique tip that he provided in the second of his two excellent
McNamara’s Fallacies papers on the restoration of worn teeth1 was to keep the resin
composite material in the fridge until the clinician is ready to use it, in order to make it
more sculptable!
The follow up question to the FAQ on heating composites often is – does
heating influence the properties of the material? The literature is replete with in vitro
experiments that demonstrate that increasing temperature of the resin composite
does lead to a decrease in the viscosity of the material, and, in the work of Loumprinis
and co-workers,2 the decrease varied from 30% to 82% in different materials (and
between 40% and 90% in a different study3), although there was no difference in
viscosity for the flowable composites that they heated. I assume that clinicians
who heat their composites do that to achieve runniness, but, for sure, they cannot
be pleased by a related finding in this paper, namely, that the stickiness of the
materials generally increased after heating. This is surely one of the biggest bugbears
for clinicians who may then end up purchasing non-stick coated instruments in
order to overcome the problem, or dip the placement instrument in resin to stop
it sticking – not a good idea – because by doing so, the surface of the composite is
diluted with the resin and this may adversely affect its physical properties. My view
is that, if the composite material sticks to your instruments, one should change one’s
composite, there being plenty of resin composite materials around that do not stick
to instruments. But, on the other hand, the clinician who heats the composite to make
it less viscous will have to accept the stickiness as a necessary evil! In that regard, for
composites at room temperature, there is a delicate balance, given that, while the
resin composite material should not stick to the packing instrument, conversely, the
material should be sticky enough to adhere to the bonding agent in the prepared
cavity. On the subject of stickiness, Ertl and co-workers4 determined that materials
DentalUpdate 367
Comment

with reduced filler loading, which correspondingly results in a
greater fraction of resin matrix, showed higher stickiness.
Another problem in clinical dentistry when using dental
composites (but possibly any material?) are porosities and voids
in restorations. Opdam et al5 considered that the risk of voids and
porosities increased when the material sticks to filling instruments
because air will be entrapped. Indeed, these authors stated that
‘restoring minimal preparations in the absence of porosities and
voids was very difficult to achieve’. They also found that placing a
layer of flowable composite that was left uncured, directly followed
by injecting a medium-viscous composite, was the technique
that resulted in the most homogeneous restoration, something
that they subsequently termed that the ‘snowplough technique’.
Furthermore, Tyas et al6 pointed out that a marginal opening
appears when the material sticks to the condenser, ie stickiness of
dental materials is not a good idea.
A further advantage of pre-heating composites became
apparent in the results of in vitro work by Wagner and colleagues.7
In extracted third molars prepared for 10 Class II cavities
(with the cervical margins on cementum) per group and resin
composite restorations placed using four different materials/
techniques, their results indicated that pre-heating the composite
resulted in significantly less microleakage at the cervical margin,
although delaying light curing by 15 seconds was considered
‘counterproductive’ as this led to increased microleakage. To
me, that seems to indicate that the composite heating scenario,
therefore, is not as simple as it might have seemed – the clinician
needs to work fast to avoid this problem!
For a complete appraisal of the runniness/stickiness issue,
I consulted the paper by da Silva et al.8 In their appraisal, they
reviewed four papers on the heating composite subject. They
concluded that reducing the viscosity of the composite by
warming it, allows the material to be injected into the preparation,
rather than having to use hand instruments. These workers7 also
considered that the warm composite technique allowed handling
characteristics similar to those of flowable composite, while
achieving the benefits of the superior mechanical properties
associated with the use of heavily filled restorative composite.
The reduced viscosity also facilitated improved adaptation to
cavity walls and decreased gap formation, compared with room
temperature. In addition, the physical properties of the resin
composite were found to not be affected by pre-heating. Indeed,
one study found that mechanical properties following cure
were improved.
Another expressed worry has been that the higher temperature
of the warmed composite might adversely affect pulpal health.
However, this may not be perceived as a problem, given that
composite cools quickly on placement, and the tooth acts as a
make the material less easy to use in my hands. And, as ease of use
has been considered to lead to better clinical results,8 the price, for
me, seems too high. On the other hand, there appear to be clinical
benefits, and da Costa et al considered the learning curve to be
‘shallow and the propensity for adverse events low’.
This brief review has indicated that there are benefits and
downsides to heating composite before use. So, why the apparent
trend towards runniness? I am obviously missing something!
Hopefully, readers in the runny camp will write and tell me!
References
1. Kelleher MGD. McNamara’s fallacies in dentistry. 2: Tooth surface loss
fallacies. Dent Update 2021: 48: 343–356.
2. Loumprinis N, Maier E, Belli R et al. Viscosity and stickiness of dental
resin composites at elevated temperatures. Dent Mater 2021; 37: 413–
422. https://doi.org/10.1016/j.dental.2020.11.024
3. Al-Ahdal K, Silikas N, Watts DC. Rheological properties of resin
composites according to variations in composition and temperature.
Dent Mater 2014; 30: 517–524. https://doi.org/10.1016/j.
dental.2014.02.005
4. Ertl K, Graf A, Watts D, Schedle A. Stickiness of dental resin composite
materials to steel, dentin and bonded dentin. Dent Mater 2010; 26:
59–66. https://doi.org/10.1016/j.dental.2009.08.006
5. Opdam NJ, Roeters JJ, de Boer T et al. Voids and porosities in class I
micropreparations filled with various resin composites. Oper Dent 2003;
28: 9–14.
6. Tyas MJ, Jones DW, Rizkalla AS. The evaluation of resin composite
consistency. Dent Mater 1998; 14: 424–428. https://doi.org/10.1016/
s0300-5712(99)00017-2
7. Wagner WC, Aksu MN, Neme AM et al. Effect of pre-heating resin
composite on restoration microleakage. Oper Dent 2008; 33: 72–78.
https://doi.org/10.2341/07-41
8. da Costa JB, Hilton TJ, Swift EJ Jr. Critical appraisal: preheating
composites. J Esthet Restor Dent 2011; 23: 269–275. https://doi.
org/10.1111/j.1708-8240.2011.00461.x
9. Burke FJ, Liebler M, Eliades G, Randall RC. Ease of use versus clinical
effectiveness of restorative materials. Quintessence Int 2001; 32: 239–
242.
Call for Technique Tips
Do you have an interesting and handy tip, which describes a
technique, with plenty of illustrations and a minimum of text,
to share in Dental Update?
Then please send it to Fiona Creagh –
fiona.creagh@markallengroup.com for review.
Technique
Tips

Technique Tips

heat sink, resulting in composite temperatures equivalent to

Technique Tips

Technique Tip
Technique Tips s s
Techniqued Tip y Splinting traum
patient safet atized teeth
Using clinical photos and simple digital analysis to aid in keeping and
recor
porcelain resto
rations
that are resto
red with
Improving

body temperature. complete denture aesthetics Dent Update

2022; 49: 177–181
Dent Update 2022; 49: 354–356 2022; 49: 273
Dent Update
The manageme
for nt of luxated
continual care teeth involves
repositioning
Oral health in the UK has improved over „ The upper lip support and incisal length part of our on-going
instrument.5 Modification of the wax record , we are splinting them and teams, particularly
As when there
the past 30 years, as such, there has been a rims is a simple way of creating the overall
relative to the resting lip is adjusted within the profession well- for
weeks depending a period of 2–4 associated mandibula is an
our patients, and accurate
shapes that define the dentures’ optimum as usual. have complete on the type should be avoided, r fracture. These
marked increase in the number of people
required to technique tip displaceme of
records. This if at all possible,
1–5
„ The centreline and canine lines are
forms. In complete denture construction, it is nt injury. 1 The the manageme
retaining teeth and a steady decline in documented splinting the aim of in
teeth is to stabilize nt of dental
such records. trauma alone,

In summary, it’s a matter of personal preference! It is necessary

the prevalence of edentulous patients.1 generally accepted that the maxillary incisal
marked as normal. because they
complements to facilitate
healing of the them splint teeth
The impact of this is that the routine „ The incisal plane is assessed by
plane should be parallel to the interpupillary ligament. 2 There periodonta damage the
gingival tissues
rigidly, can
fabrication of de novo complete dentures line. The occlusal plane should be set parallel
observing the patient from directly in are many designs l even act to and may
has reduced, thus, making it more difficult to the ala-tragal line (Camper’s line),4,5 as is
front with the nurse holding the Fox’s Case report with a mobile
and materials
used to splint extrude teeth. 3
The composite
man presented including the teeth,
and orthodonti
for general dental practitioners to gain commonly seen in the dentate patient. The occlusal plane guide in situ. The wax A 68-year-old quadrant (URQ). popular composite wire splint can c
upper right of wire splint, and be regarded
the necessary experience to acquire this exception to this would be if the patient had
is adjusted incrementally until the tooth in the swelling or
discharge.
peri-apical
radiograph the titanium
trauma splint standard due as the
was no soreness, with 1. Long cone
and the fibre
splint. 2,3 to being predictable gold Figure 1. Labial
skill set. This problem is not confined to a cant in their previous natural dentition and
clinician feels the incisal plane is parallel There fit and healthy, Figure cost-efficient and view of the
Historically, with
existing qualified dentists but is apparent wished for this to be incorporated into their
to the interpupillary line on the Fox’s He was medically known allergies. I/O: the URQ.
for extended
teeth were
splinted between compositethe bond strength
teeth at presentation
.
s or
maxillary complete denture.5 occlusal plane guide. no medication lly involved. periods with
rigid approximately and enamel
being
in the undergraduate cohort. A reduction – Class 2, periodonta fracture into
immobilization,
but 29 MPa. 6
The Fox’s occlusal plane guide or„ The occlusal plane is assessed by mobility
showed a horizontal located several

to purchase additional equipment, but the cost is fairly low.

in the availability of edentulous cases have shown studies However, it
The radiograph but there was
no fragment were ted that cannot be used
any device giving a horizontal plane observing the patient from the side and
to apical third, and the root complimen to an increased this approach leads the teeth that when
for undergraduate teaching has been
in the mid photographs are to be splinted
reported in the literature, which may be as reference, such as a wooden spatula, can adjusted incrementally until the clinician position. The ation of Andersson et
risk of ankylosis. 2,4 porcelain restoration have
history of trauma. shown the radiograph sive document al demonstra s on the labial
low as two cases per student in some UK be used to assess whether the occlusal feels that it is parallel to the ala-tragal was the comprehen and also teeth subjected ted that surface (crowns
The patient had fully extracted, taking or veneers).
schools.2,3 While all of the stages involved rims are parallel to the interpupillary line
line on the Fox’s occlusal plane guide. that the tooth the tooth being need for stimulation
to masticatory
This Technique
and the ala-tragal line. In the authors’ and it was explained ultimately, would eliminated
the potential goes ‘A tooth and
of the extracted thus heralding
resulted in less
simple alternative Tip describes a
in complete denture fabrication are equally
poor prognosis,
and
also explained . As the saying can help 2. Photograph the
ankylosis,
approach
experience, judging whether the lines It was another radiograph word,’ thus Figure way forward with traumatized to
important and can be read about in more Step 2: image capture
require an extraction. of the horizontal a thousand the root.
the flexible
splint for shorter teeth that have splinting
detail in relevant textbooks, we focus on are parallel can be challenging for the
Any device with digital photograph to the nature picture speaks and accurate, of time. 5 periods been restored previously
inexperienced operator, or in situations that, owing require removal to have complete with porcelain
providing a method for practitioners who are capturing capabilities can be used to take tooth might s with the in our duty The Internation restorations. Figure 2. Occlusal
where the patient cannot remain upright fracture, the discussion ented records. al Association view of the teeth
inexperienced, or who infrequently fabricate a clinical photograph of the patient. The There were ons. The well-docum of Dental Traumatolo
regulations. at presentation

For clinicians like myself, who prefer a stiffer, more sculptable

in sections. meeting the Case 1 .
complete dentures, to verify the aesthetic
and still, owing to a movement disorder (eg
authors’ preference is that clinical images possible complicati sinus providers on and Social
recommen Care gy (IADT)
patient about tooth to the maxillary Standards 20 of the Health ds flexible splinting
Huntington’s disease, Parkinson’s syndrome,
are taken using a digital SLR camera with the an with Ethical that Regulation Activities) Regulations
traumatized of A medically
prescription of their maxillary occlusal rim proximity of possibility of Compliance authors declare teeth for 2 or fit and healthy
cerebral palsy). either a ring or twin flash. While it is not there was the occurred and Interest: The Act 2008 (Regulated at: www.cqc.org seen .uk/ 4 weeks as female was 45-year-old „UR3 distal
before delivery to the technician. meant that Conflict of in Table 1. The seen in a specialist caries;
The technique described below can which, if it conflict of interest. 2014. 2015.
Available _for_ only exception clinic 3 weeks „ UR1 and
The ‘jaw registration stage’ is often within the remit of this article to discuss
oro-antral fistula, by the they have no Informed consent s
was
/files/201502
for cervical
10_guidance
ons_ 1/3 root fractures,
is after
trauma UL1 displaced
alleviate the guesswork from this aspect of would be managed sites/default should when she collided a bicycle accident in position; and locked
erroneously considered to be solely detailed clinical photography, the following
was minimal, if more severe,
then Informed Consent:individual participant n_meeting_
the_regulati be splinted
for 4 months. 1
which
with a car, resulting restored with
the jaw registration procedure and allow
standard settings can be used to produce review, but all providers_o 2022). in displaceme bonded-to-metal porcelain-
about recording the static intermaxillary clinician on care or to a
specialist obtained from (accessed February There are a number nt of three of
the occlusal rim to be modified before
high quality, reproducible, portrait images: the article. final_01.pdf (UK).
and types
Practice of materials incisor teeth. her upper clinical crowns crowns with the
relationship in centric relation. However,
progressing to the denture construction’s referral to secondary Local measures should included in of General Dental of
and record splints used by clinicians appearing short
„ Shutter speed: 1/200 seconds 4. Faculty involved of their normal and out
McCord and Grant4 highlighted the would be necessary. of excessive clinical examination in the manageme
„ UL2 displaced positions;
wax-trial stage.
„ Aperture: F11(portrait) as the avoidance Guidelines: trauma,2016.
practice guidelines.
nt of dental
be taken, such sneezing or coughing.
the
importance of creating and outlining the Standards for with
ntent/the most commonly Clinical presentatio and locked

composite, the learning curve to a new placement technique,

References keeping. Good
as Dental Council. used design
nt.uk/wp-co n (Figures 1 restored with in position;
form of the upper denture during this visit to „ ISO: 400 (portrait) exertion, such a possibility.
Other 1. General 2013. Available https://cgde being the composite At presentatio and 2) composite and
Technique the area was Guidance 4.1. Available at: n-and- n, 3
achieve an optimal aesthetic result. In clinical „ White balance flash setting: ETTL Suturing of the possibility of
pain, dental team. org/Assets/p
df/ 1/08/Clinica
and orthodonti
l-examinatio
c wire splint. traumatic incident,weeks after the normal position. out of its
such as ards.gdc-uk. uploads/202 (accessed
splinting teeth
text.pdf When the following
practice, dentists receive upper and lower „Magnification: Infinity complications, and at: https://stand 20Team. ing-3e-final- noted: were
Step 1: adjustment of the upper occlusal rim trismus, bleeding 20for%20the
%20Dental% record-keep the titanium
in the mixed
dentition, Radiograph
„ The upper occlusal rim is inserted into
wax rims, usually either on shellac or acrylic „ File type: LARGE JPG swelling, bruising, mentioned. The patient Standards% „ Florid gingival
also February 2022). February 2022). useful
Practice (UK).trauma splint is very s
The peri-apical
bases that are duly shaped into the desired the mouth and the clinician should Once the clinician feels that the aesthetic infection were pdf (accessed keeping standards: of General Dental because. 2018. the malleability around the
inflammation (Figure 3) and
to treatment. Dental record www. 5. Faculty criteria for dental makes radiography
it easier traumatized standard occlusal upper
form of the upper denture at the chairside. assess the rim’s stability and retention. prescription of the upper occlusal rim is fully consented the tooth, as expected, 2. NHS England. Available at: to negotiate
ntent/ teeth
On extracting of the tooth approach. 2019. Selection misaligned
nt.uk/wp-co gaps and with subgingiva
l calculus deposits (Figure 4) revealed:radiographs
Wax is a suitable material for making record „ The patient is sitting upright, and the complete, a clinical photograph (Figure 1) is a consensus ecord-
Available at:
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and distal aspect was .uk/publicat
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localized to
the lingual „Good bone
rims as it can be added to, subtracted headrest is adjusted so that their head is taken while standing directly in front of the the coronal mesial root england.nhs oach/ gingival
removed. The tooth dards-a-con
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2022). ligatures
used by maxillofaci are
margins;
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levels;
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elevated out.

added to the stickiness of the warmed composite, makes me feel

2022). al missing teeth crown margins,
then gently with no other (accessed February . Guidance
for
UL4,6,7,8, LL6,8 UR4,6,7,8, margin below crown
y extracted to Commission the level of
was successfull photograph was taken 3. Care Quality d), Cert and LR6,7,8; bone, patent the crestal
A Kajal
FFGDP(Lon root canal, loss
Kasim Butt, BDS, MJDF RCS Eng, PgCert Dent Ed, Specialty Registrar in Restorative Dentistry, Sheffield Teaching Hospitals NHS complications. tooth. The extracted tooth , ILM(Lond), B Patel, MChd/BChd periodontal
ligament space;
of
Foundation Trust. Kalpesh Prajapat, BDS, MFDS, RCS Ed, General Dental Practitioner, Abbey House Dental Practice, Stone. show the whole (Ireland), MSc(Lond) Serpil Djemal
BDS,
, BSc Oral Science,
MFDS RCSEd,
), MGDS,RCS .co.uk email: serpil.djem MSc, MRD, RCS, FDS Former DCT2,
Abdulrahman Elmougy, BDS, MFDS RCS, MSc, FDS RCS Ed, Consultant and Honorary Senior Clinical Lecturer in Restorative Dentistry, nd), MJDF(Lond sukimurbay@hotmail ate 273
al@nhs.net (Rest dent), Restorative
, MFGDP(Lo email: DentalUpd RCS Dip Dentistry;
Sheffield Teaching Hospitals NHS Foundation Trust. ), FDS(Lond) Islands. Ed, Consultant King’s College
Murbay, BDS(Manc Bay, Cayman February 2022 in Restorative Hospital NHS
email: kasim.butt1@nhs.net Sukhdeep Practice, Camana Dentistry, King’s Trust.
FICD, Private College Hospital
Ment RCS Eng, 07/03/2022
11:04 NHS Trust.
354 DentalUpdate April 2022 pg177-181

that going to the runny side and changing my technique would

Tech Tips_Patel.indd
March 2022 177
DentalUpdate
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pg354-356 Technique Tips.indd 354 07/04/2022 09:25
273
Tips.indd
pg273 Technique
07/02/2022
12:53

368 DentalUpdate May 2022

 Restorative Dentistry
Enhanced CPD DO C

Tom Bereznicki

Rohit Patel and Megan Clark

Revisiting the Functionally

Generated Path Technique:
Is this an Aid to Predictable
Digital Occlusal Design? Part 1:
Introduction and Background
Abstract: Registering a pre-existing occlusal scheme is paramount to the long-term success of a fixed restoration(s) and a requirement
when working conformatively, whether in analogue or digital format. Part 1 of this two-part series highlights those occlusal schemes that
provide difficulties using established techniques in arriving at a predictable restoration requiring minimal occlusal adjustments chairside.
Part 2 introduces the theory of the functionally generated path (FGP) technique, and two cases involving implant-retained restorations will
be used to highlight the benefit of adopting this technique into the digital workflow in the provision of occlusally precise restorations.
CPD/Clinical Relevance: This article provides an overview of difficult occlusal schemes and identifies those that would benefit from using
the functionally generated path technique in the provision of occlusally correct restorations.
Dent Update 2022; 49: 371–378

Occlusion is of key importance in the occlusal relationship is fundamental to of adjustment before having to be remade.
provision of a long-lasting and functional being able to provide a restoration that Part 1 of this two-part series highlights
restoration. Particularly when working is predictable and accurate, with minimal those difficult occlusal cases that would
conformatively, it is imperative that the occlusal adjustments required chairside at benefit from the use of the functionally
correct information is provided to the the fit appointment. This information is just as generated path (FGP) technique to help
laboratory to fabricate the appropriate important if working with a digital format as avoid some of these errors by providing an
restoration. Therefore, understanding errors can be amplified and may go unnoticed accurate and predictable occlusal scheme
occlusion and the challenges faced when until the final fit. Milled zirconia restorations for the final restoration. Part 2 explains the
patients do not conform to the ideal Class I can generally only undergo a limited degree FGP technique and its adaptation from
its analogue background to the digital
workflow. Two cases of implant-retained
Tom Bereznicki, BDS(Edin), MFDTEd, MFDSEng, MCGDent, Visiting Clinical Specialist restorations are used to demonstrate the
Teacher, Department of Primary Dental Care, King’s College London; Private Practice, technique step by step.
Dawood & Tanner, Wimpole Street, London. Rohit Patel, BDS, MFDS RCS Ed, Clinical Jose-Luis Ruiz and Gordon Christensen
Tutor, Department of Restorative Dentistry, Queen Mary, University of London; General have ‘three golden rules’ in their approach
Practice, Brickfields Dental, Chelmsford. Megan Clark, BDS(Hons), BSc(Hons) AKC, Oral to occlusion.1,2 These ‘rules,’ outlined
Surgery, Speciality Trainee, Newcastle. below, represent an occlusion in the
email: tom.bereznicki@kcl.ac.uk ideal world, and an occlusion to aim for

May 2022 DentalUpdate 371

Restorative Dentistry
when working in reorganized fashion, but
it must be understood that when working
conformatively, it may not be possible to
achieve all these ideals:
„ Bilateral and even occlusal contacts
around the arch.
„ Posterior tooth disclusion through
anterior and canine guidance – namely
in mandibular excursions, the anterior
teeth remain in contact, with the
posterior teeth being out of occlusion.
This is also known as a mutually
protective occlusion.
„ An unobstructed ‘envelope of function’.
Mehta and Banerji stated that:
‘The occlusal scheme is considered
to be stable (‘mutually protective’),
when the patient displays a protrusive
mandibular movement, the anterior
guidance coupled with the inclination of
the condylar path should collectively aim
to separate (or disclude) the posterior
teeth from each other, thereby avoiding
any harmful occlusal contacts which may
otherwise culminate in cuspal fractures,
repeated restoration fracture, recurrent
decementation of indirect restorations,
pathological tooth wear or fremitus.
This culminates from the fact that the
posterior teeth are closest to the fulcrum,
ie, the temporomandibular joint (TMJ)
where the forces are the highest in a
third order lever situation. In the position
of maximum intercuspation, only light
occlusal contacts should exist between
the anterior segments, with occlusal
loading primarily taking place between
the posterior teeth’.3
This leverage is clearly demonstrated
in Figure 1b, namely the closer the tooth is
to the nutcracker hinge joint, the greater
the pressures that are applied for any given
applied force. Intra-orally, the closer a single
tooth contact is to the TMJ (Figure1a), the
greater the leverage and pressures exerted,
and therefore the higher the chance of tooth
or restoration fracture.
Conformative versus
reorganized treatment
Providing the correct occlusal shape for the
final restoration(s) should ensure that:
„ The restoration fits harmoniously into
the static occlusion in the intercuspal
position (ICP).
„ The occlusal scheme in the dynamic
excursive mandibular excursions is
harmonious with the patient’s current
372 DentalUpdate
a b
Figure 1. (a) Right lateral view of a skull. (b) The principle of a nutcracker and leverage.
guidance, without introducing any
interferences posteriorly on the
new restoration.
In the provision of indirect restorations,
there is a choice between working
conformatively or in a reorganized fashion.
Working conformatively is generally the
easiest and most predictable, but largely
restricted to the provision of one or two
restorations at a time.4
When working conformatively, the
technician locates the opposing models
together and can easily build the new
occlusion into this static intercuspal position.
However, unless the models are mounted on
a semi- or fully adjustable articulator with
facebow recordings, the dynamic occlusion,
namely lateral and protrusive mandibular
excursions, can only be provided through
educated guesswork and appreciating that
final occlusal refinements will have to be
carried out at the fit appointment.
When working conformatively with a
digital workflow, occlusal planning with
or without a digital articulator will result
in a similarly predictable occlusion to
that produced working conventionally
in analogue format. Comparing digital
methods versus conventional methods, Iwaki
et al showed significant discrepancies when
one quadrant is scanned and more than one
tooth is prepared.5
Working in reorganized format usually
implies that multiple units around the mouth
are being provided, often accompanied by
changes in the vertical dimension. This type
of complex treatment must be carried out
on a semi- or fully adjustable articulator and
even then, it is challenging for the dental
technician to reproduce the full range of
mandibular excursions.
In such difficult reorganized occlusal
cases, errors can potentially be highlighted
further when using computer-aided design
and computer-aided manufacturing
(CAD-CAM) where the digital articulators
available within the software, although in
the stage of rapid development, are still in
their formative years. Furthermore, in those
cases involved with complicated occlusions,
forming restorations with occlusally correct
morphology is difficult to provide with
any degree of predictable accuracy. As this
article deals with a technique applicable only
when working conformatively, there is little
merit in describing the many steps involved
in reorganizing an occlusion, whether in
analogue or digital format.
Articulators
Analogue
Hinge and free plane articulators: the
main disadvantage of these articulators
is that they cannot reproduce any
mandibular excursions.
Regarding semi-adjustable articulators:
although condylar and Bennet angles can
be set on many semi-adjustable articulators,
as the name implies, they can only go some
way to reproducing mandibular excursions.
For more predictable accuracy these
articulators are not sophisticated enough,
particularly for the more complex occlusal
schemes encountered. Simpler semi-
adjustable articulators that only allow the
use of average settings are, correspondingly,
less accurate.
Regarding fully adjustable articulators:
these come closest to accurately reproducing
the full range of mandibular excursions as
well as factoring in any side-shift the patient
may have. The costs of these articulators and
associated orthopantographs (circa £50,000)
are too high for most practitioners to
purchase, and it can take up to half a day to
carry out all the registrations required as the
process is extremely complex. When working
conformatively to provide a single crown,
this articulator is not a viable option.6
May 2022
 Restorative Dentistry

Digital a b
A digital articulator is a computer software
tool that can simulate the movements of the
mouth as per traditional articulators within
the computer system being used.7
However, when comparing digital
methods versus conventional methods, Iwaki
et al showed if only one quadrant is scanned,
significant discrepancies occur if more than
one tooth is prepared.5 Figure 2. (a, b) Simulation photographs showing a common discrepancy in full-arch scanning.
In difficult occlusal cases, for example, Photographs courtesy of Andrew Keeling (Leeds).
lacking anterior guidance, errors can
a
potentially be highlighted further when
using CAD-CAM where the digital
articulators available within the software
are, as mentioned previously, still in their
development phase, making occlusally
correct restorations difficult to provide
with any degree of predictable accuracy.
Research has also shown that cross-arch
scanning can result in distortion of the
occlusion when using digital models unless
Figure 3. A typical custom acrylic incisal b
multiple scans are taken (Figure 2).5,8 guidance table.
Ahlholm et al confirmed these findings,
indicating that conventional impression
methods show improved accuracy in
comparison to digital techniques when
not possible. Needless to say, the success of
completing full-arch impressions.9,10
the final occlusal scheme achieved is also
In addition to this, Park et al found,
based on the level of experience of working
from a study of five intra-oral scanners
with the software.
(Cerec Omnicam, CS3500, iTero, Trios, True
However, in certain clinical situations
Definition), that each scanner had a different where, in theory, only one restoration c
acquisition method of buccal interocclusal is being planned and a conformative
record scans, interpretations of occlusal approach seems the simplest way forward,
surface and error correction algorithms, thus the occlusal schemes and mandibular
they all yielded different discrepancies.11 excursions encountered are so complex
It was also shown that each scanner and wide that current articulators, whether
has different accuracy in reproducing analogue or digital, cannot necessarily
interocclusal relationship deviations ranging reproduce the wide and unusual intra-oral
from 165 to 395 microns (CS 3500 intra- mandibular excursions with any degree of
oral scanner), with Planmeca specifically accuracy to help with occlusal planning.
showing some intra-arch variability. That is Such situations are outlined below.
not to say that the latest scanners are not
more accurate with precision to less than Figure 4. (a) Frontal view in maximum
200 microns.11 Certain severe Class II intercuspation. (b) Left buccal view including the
division 1 occlusions gold crown, which was placed when the patient
was still a teenager as a result of a cusp fracture.
Limitations of articulators In these cases, initial guidance is on the (c) Occlusal view. The patient fractured the
When working in analogue format, facebow posterior teeth before finally providing second molar while asleep. It was split vertically
recordings and the use of a high-quality anterior guidance and posterior disclusion and required extraction.
semi- or fully adjustable articulator allows (Figure 4a, b). The forces and pressures
the fabrication of a custom acrylic incisal generated by the muscles of mastication
guidance table to help refine difficult are such on the last standing teeth that
occlusal schemes in the laboratory (Figure 3). tooth chipping can occur, or, as in this case and not create interferences that were not
However, this guidance table, if using (Figure 4c), complete vertical fracture of there previously.
average settings, cannot be relied on to the last standing molar while the patient
entirely refine the occlusal morphology of was asleep and presumably bruxing. The
the planned new restoration.12 provision of an indirect restoration, such as
Class III incisal relationship
Digital occlusal planning is much more the gold crown seen in the same patient, is Jensen stated that:
difficult in complex cases because the problematic as the restoration must maintain ‘with Class III jaw relations, patients
formation of a guidance table is currently the harmony of the initial posterior guidance possess challenging changes in occlusal

May 2022 DentalUpdate 373

Restorative Dentistry
a a
b
Figure 5. Left buccal view. Frequently in Class III
cases, many posterior teeth do not meet in ICP:
guidance is provided by the posterior teeth.
Figure 6. Frontal view shows a typical Class III
malocclusion with only the posterior molars in
contact in ICP.
patterns. The interocclusal distance,
envelope of motion, chewing stroke,
tooth-to-tooth relations, and the
determinants of occlusion vary from
the criteria established for the Class
I or Class II occlusions. The lack of
anterior guidance and the added
width and length of the mandible
have a significant effect on occlusal
morphology. Several stable forms of
occlusal relationships can be found
at one time in the same dentition.
The occlusal morphology is dictated
by the condylar movements and
mandibular size’.13
The guidance created by the
occlusion in these cases is impossible to
predict, particularly as in many cases, a
considerable number of posterior teeth
are often not in occlusion (Figure 5).
Working in analogue fashion is unlikely to
allow the creation of the correct occlusal
morphology, which is in harmony with
the dentition, even if an incisal guidance
table is used. If a digital workflow is
used, digitally generated occlusions are
based on, or at least make reference to,
average tooth dimensions and typical
morphologies. Unfortunately, there
are large standard deviations in these
parameters, in part due to differences
between males and females and among
different ethnic groups within which,
concepts such as ‘the golden proportion,’
have not been found to apply.14
374 DentalUpdate
b
Figure 7. (a) Right buccal view showing c
an anterior open bite case with no anterior
guidance. (b) Occlusal view of the upper
left molars shows the unusual wear patterns
created on the palatal cusps by excursive
mandibular movements.
Anterior open bites
In severe cases, it is not unusual to find that d
the only contacts in ICP are either on the
last or the last two upper and lower molars
on each side. Consequently, guidance in
lateral and protrusive mandibular excursions
can only be provided by the posterior teeth
(Figure 6).
As with the Class III incisal relationship Figure 8. (a) Frontal view showing the teeth
cases mentioned previously, the guidance in ICP. (b) Right buccal view showing the
offered by the posterior teeth is extremely NWS interference in the right molar region
difficult to accurately reproduce using an on mandibular excursion to the patient’s left.
anterior guidance table unless sophisticated Guidance is transferred from the anterior teeth
articulators are used. As mentioned earlier on the left to the posterior teeth on the right.
these articulators are extremely expensive (c) Right buccal view of the mounted models
and time consuming. showing the large NWS interference on left
working side excursion. (d) Right buccal view
The occlusal morphology is dictated by
of the patient in left WS with anterior guidance
the condylar movements and mandibular
on the lateral incisor and canine re-introduced
size. Figure 7a shows an anterior open bite following extraction of the last standing molar
case mounted in ICP on a semi-adjustable on the lower right and elimination of the
articulator with inter arch contact only on NWS interference.
the molars. Figure 7b shows the unusual
wear facets created by mandibular
excursions over time. When working
with a digital workflow, these unusual in a natural dentition could well result in
morphologies that maintain occlusal fractured porcelain if the same contours are
harmony cannot be accurately predicted. not reproduced.15
The FGP technique, described in Part 2 of
this series, will provide a simple, quick and
inexpensive option to capture the required
Non-working side interference
occlusal scheme, whether working in digital Davies et al describe this as ‘anterior
or analogue fashion – that is to say the final guidance on the back teeth of the non-
restoration will be conformative. working side during lateral excursions’.16
The correct occlusal morphology is In the case shown in Figure 8a the patient
mandatory in the restorations provided, appears to have normal ICP. However, on a
because forces that produce wear facets left mandibular working side (WS) excursion,
May 2022
 Restorative Dentistry

guidance on that side is rapidly lost as the a a

over-erupted lower right standing molar
starts to contact the opposing last standing
upper molar creating the non-working side
interference (NWS) (Figure 8b). Although
this is far from an ideal clinical scenario, if
the patient is symptomless, treatment is not
necessarily required.
However, in this case, the patient had
grade two mobility of the last standing b b
molar on the lower right, and persistent
mild-to-moderate pain over a prolonged
period in both opposing molars. In Figure
8c, the mounted models clearly show the
interference created by the mesial drifting
and inclination of the two remaining molars
following extraction of the first molar on
the lower right many years ago. The patient
wanted a resolution to this chronic pain, so c c
the decision was taken to extract the last
standing lower unopposed molar – occlusal
reshaping was not an option as the degree
of tooth reduction required would not leave
sufficient viable tooth substance to support
a restoration. Figure 8d shows the return to
anterior guidance 2 weeks post extraction.
However, when providing posterior
restorations, particularly in cases with
Figure 9. (a) Right buccal view with the teeth Figure 10. (a) Right buccal view: the patient
a shallow overbite, care must be taken
in ICP. (b) Right buccal view showing the large in ICP. (b) Right buccal view showing initial
to ensure NWS interferences are not NWS interference on the last standing restored protrusive contact in the edge-to-edge position.
introduced with the new restoration. In the molars as well as the loss of anterior guidance as (c) Right buccal view showing further mandibular
case shown in Figure 9, the patient, new to the mandible moves into LWS. (c) Right buccal excursion in protrusive with crossover and
the practice, presented with pain in relation view of the patient in LWS following adjustment guidance now passing onto the posterior teeth.
to the upper right second premolar. As of the height of the over-contoured buccal
part of her history, the patient claimed that cusps on the crown on the opposing first molar,
the right side had never felt comfortable in turn eliminating the NWS interference and
following provision of two porcelain-fused- re-introducing anterior guidance. of the crown involved, or if unbreakable
to-metal crowns on the lower right first materials such as gold or zirconia were
and second molars – a return appointment to be provided, fracture of the opposing
to her dentist merely reassuring her that adjustments were carried out without tooth. Either way, this case highlights the
the teeth needed time to ‘settle’. Instead of mishap, and the patient immediately importance of providing restorations that
settling, the patient’s symptoms became remarked that her teeth seemed to meet conform to the occlusal harmony present,
worse. Occlusal analysis showed that, as better and she was unable to reproduce and the consequences if this principle
the mandible moved into left working side the pain. The patient called a few days is ignored.
(LWS), anterior guidance was lost as a result later to report that all her symptoms
of the painful upper premolar occluding had disappeared. Without removing the Protrusive crossover
with the over-contoured buccal cusps, crown, it is impossible to say whether
which were in a cross-bite with the crown This is described by Shillingburg et al as ‘a
insufficient buccal cusp height reduction
provided on the first molar (Figure 9b). was carried out during preparation forcing protrusive interference that occurs when
The NWS interference created elicited the the technician to over-contour, or whether distal-facing inclines of maxillary posterior
patient’s symptoms. the technician inadvertently allowed teeth contact the mesial-facing inclines
A diagnosis of occlusal trauma was their artistic licence to create this shape of mandibular posterior teeth during a
made, and the patient allowed reshaping – or indeed a combination of both. The protrusive movement’.12 In situations where
of the buccal cusps to be carried out – disappearance of the patient’s symptoms excursions go beyond the incisal edge, the
medico-legally the patient was warned that implies that the diagnosis of occlusal guidance passes from the anterior to the
there was the possibility of the porcelain trauma was correct. posterior teeth as seen in Figure 10. Provision
fracturing or perforation of the underlying This case shows how the introduction of crowns in the molar area, which can
framework during the adjustments and of such an interference could well lead, at become involved with guidance in these
that there was no guarantee that the best, to pain. In other cases, the outcome cases, can lead to discomfort, pain or failure
patient’s symptoms would disappear. The might have involved porcelain fracture of the restoration or the underlying tooth.12

May 2022 DentalUpdate 375

Restorative Dentistry
Occlusal anomalies
Cross bites with shallow anterior guidance
can lead to the presence of heavy working-
side posterior guidance, as seen in this
case. The very heavy posterior guidance is
more than likely a potential cause of tooth
fracture, as seen by the presence of severe
cracking of the enamel. Should a crown be
required on the last standing molar, it would
be preferable not to replicate, or at least
minimize, the existing occlusal scheme in
Figure 11.
Observations
It is clear from the complicated occlusal
schemes outlined, that working
conformatively in order to maintain the
occlusal scheme is extremely difficult and, if
incorrect, could well result in the provision
of an indirect restoration that may not be
in harmony with the patient’s mandibular
excursions – and these are the very cases
where occlusal harmony is paramount. If
working with traditional materials, such as
gold or porcelain fused to metal, numerous
time-consuming adjustments can be made
to the restorations without necessarily
compromising their structural integrity. The
time taken to make these adjustments can
be considerable, and the restoration may
also require to be returned to the laboratory
for reshaping and repolishing/re-glazing
prior to the final fit.
However, if working with a digital
workflow, the final restoration is, almost
certainly, likely to be milled, for example
in zirconia. Final adjustments to materials
such as milled 3, 4 or 5Y zirconia can
then be extremely time consuming, or,
worse still, impossible, resulting in an
expensive re-make.
The errors often seen are either the
restoration being in infra-occlusion or
supra-occlusion (that is to say, high in the
bite). In addition, the occlusal morphology
created can also result in either WS, NWS
and/or protrusive interferences. In turn, this
highlights the importance of recording and
reproducing a bite registration accurately in
these extremely difficult cases.
Milled zirconia restorations in
Restorations milled in zirconia in supra-occlusion
severe infra-occlusion As stated previously, major adjustments
Milled zirconia restorations in severe infra-
occlusion inevitably must be redesigned
and remade. However, there is no guarantee
of success the second time around as
similar problems with occlusal design could
376 DentalUpdate
a b
Figure 11. (a) Right buccal view showing the teeth in ICP. (b) Right buccal view showing the NWS
interferences present as the patient moves into LWS.
well be repeated. The restorations could
be altered by the addition of feldspathic
porcelain – however, as the milled zirconia
restoration was not designed as a coping
to provide the recommended support
for the addition of porcelain, it risks the
chance of delamination in function under
loading. The bond of feldspathic porcelain
to zirconia is weaker than that achieved
with the more conventional porcelain-
fused-to-metal restorations, and is generally
not recommended as a combination of
materials. This weakness is mainly due to
an absence of an oxide bond between the
feldspathic porcelain and zirconia.17 Minor
corrections to all zirconia restorations, if
made, should be carefully carried out using
diamond burs or silicone points containing
diamond particles as undue force can result
in fractures, breakages or micro-cracks from
areas of occlusal adjustment.18,19
If feldspathic porcelain is to be used over
a zirconia core, there should be adequate
framework design incorporating proper
veneering ceramic support and thickness, as
these are factors implicated in the ceramic
survival.8 One should remember that the
literature is full of half-truths about the
alleged success of veneered zirconia, where
serious ceramic delamination from zirconia,
which will obviously ruin any ‘cosmetic
benefits’, frequently gets described as a
complication rather than as a frank failure.20
Any adjustments to the original design
carried out as an afterthought are likely to
be extensive and unlikely to have the ideal
shape for supporting these additions.
can be extremely time consuming, even
impossible, on occasion. Furthermore,
fractography analysis has revealed that the
crack propagation seen originates from wear
areas and occlusal adjustments.21–23 Studies
have shown that sandblasting and sharp
indentations, even at very low loads, are
very harmful to the longevity of zirconia.24–26
Kuraray recommend the following for their
product, Katana zirconia block:
‘corrections should be made carefully, by
using a diamond bur or silicone points
containing diamond particles. Use a
copious spray of water or work on the
prosthesis while it is wet. Be careful not to
apply undue force, since this may cause
a fracture, breakage or micro-cracks from
local spot heating’.19
It would, therefore, appear prudent to
redesign and remake such restorations rather
than attempting major reshaping with the
resultant risk of failure at some point in
the future.
Conclusion
To fabricate a functionally accurate restoration
when working conformatively, a clinician
needs to be aware of multiple factors when
designing restorations for different occlusal
schemes. Although the correct occlusal
scheme could well be achieved with complex
analogue articulators, the additional time
involved in making the necessary recordings,
as well as the cost involved in the purchase
of these articulators, would preclude the use
of these techniques in everyday practice.
Working digitally, there are limitations as
outlined previously, even with the recent
advent of newer digital articulators. The cost
and complexity of the latest newcomers,
such as Modjaw (Villeurbanne, France), are so
high and rely on such a high level of operator
skill, that anything other than very regular
clinical usage would preclude their use in
general practice.
Part 2 of this series will describe a method,
the analogue FGP technique, and how it can
be easily adapted to help generate occlusally
accurate restorations digitally, avoiding the
use of digital articulators and subsequent
possible errors being introduced.
May 2022
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Restorative Dentistry
Compliance with Ethical Standards 8.
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was 9.
obtained from all individual participants
included in the article.
10.
References
1. Ruiz JL. The three golden rules occlusion. Dent
Today 2010; 29: 92–93.
2. DuPont G. 5 Requirements for Occlusal
Stability. Dawson Academy White Paper. 2013. 11.
Available at: https://dental.thedawsonacademy.
com/requirements-for-occlusal-stability
(accessed April 2022). 12.
3. Mehta S, Banerji S. The application of occlusion
in clinical practice part 1: Essential concepts
in clinical occlusion. Dent Update 2018; 45: 13.
1003–1015.
4. Wise MD. Occlusion and restorative dentistry
for the general practitioner. Br Dent J 1982; 152:
316–322. 14.
5. Iwaki Y, Wakabayashi N, Igarashi Y. Dimensional
accuracy of optical bite registration in single
and multiple unit restorations. Oper Dent 2013;
38: 309–315. https://doi.org/10.2341/12-233-L
6. Taylor P. Diagnosis, the relevance of articulation 15.
and modern occlusal practice for the busy
dental practitioner. BDA Webinar. 2020. 16.
Available at: https://tinyurl.com/y26wv5tp
(accessed April 2022).
7. Lepidi L, Galli M, Mastrangelo F et al. Virtual 17.
articulators and virtual mounting procedures:
where do we stand? J Prosthodont 2021; 30:
24–35. https://doi.org/10.1111/jopr.13240 18.
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378 DentalUpdate
Solaberrieta E, Garmendia A, Brizuela A et al.
Intraoral digital impressions for virtual occlusal
records: section quantity and dimensions.
Biomed Res Int 2016; 2016: 7173824.
Ahlholm P, Sipilä K, Vallittu P et al. Digital
versus conventional impressions in fixed
prosthodontics: a review. J Prosthodont 2018;
27: 35–41. https://doi.org/10.1111/jopr.12527
Gintaute A, Keeling AJ, Osnes CA et al. Precision
of maxillo-mandibular registration with
intraoral scanners in vitro. J Prosthodont Res
2020; 64: 114–119. https://doi.org/10.1016/j.
jpor.2019.05.006
Park J, Jeon J, Heo S. Accuracy comparison of
buccal bite scans by five intra-oral scanners. J
Dent Rehabil Appl Sci 2018; 34: 17–31.
Shillingborg HT, Hobo S, Whitsett LD et al. The
Fundamentals of Fixed Prosthodontics. 2nd edn.
Chicago, IL, USA: Quintessence, 1997; 278–282
Jensen WO. Occlusion for the Class III jaw
relations patient. J Prosthet Dent 1990; 64:
566–558. https://doi.org/10.1016/0022-
3913(90)90129-z
Shetty TB, Beyuo F, Wilson NHF. Upper anterior
tooth dimensions in a young-adult Indian
population in the UK: implications for aesthetic
dentistry. Br Dent J 2017; 223: 781–786. https://
doi.org/10.1038/sj.bdj.2017.986
Cranham J. Why porcelain chips and breaks.
Inside Dentistry 2013; 9(7).
Davies S, Gray RM. What is occlusion? Br Dent
J 2001; 191: 235–245. https://doi.org/10.1038/
sj.bdj.4801151a
Christensen GJ. Zirconia crowns: what dentists
and labs need to know in 2020! Clinicians
Report 2020; 13: 1–4.
Kuraray Europe GmbH. Frequently asked
&RQWDFW.HPGHQWIRURXUODWHVWRIIHUV
Made in England by Associated Dental Products Ltd
e: sales@kemdent.co.uk www.kemdent.co.uk
All products advertised by Associated Dental Products Ltd are
sold subject to the availability of the product. Background by Freepik
questions KatanaZirconia block. Version
07-18. 2018. Available at: https://tinyurl.com/
mryd2cpt (accessed April 2022).
19. Daou EE. The zirconia ceramic: strengths
and weaknesses. Open Dent J 2014; 8: 33–42.
https://doi.org/10.2174/1874210601408010033
20. Koutayas SO, Vagkopoulou T, Pelekanos S et al.
Zirconia in dentistry: part 2. Evidence-based
clinical breakthrough. Eur J Esthet Dent 2009; 4:
348–380.
21. Kelly RD, Kelleher MGD. Is ‘digital dentistry’
dangerous for teeth? problems associated
with zirconia and CAD/CAM restorations.
Prim Dent J 2019; 8: 52–60. https://doi.
org/10.1308/205016819826439475
22. Schmitter M, Mueller D, Rues S. Chipping
behaviour of all-ceramic crowns with zirconia
framework and CAD/CAM manufactured
veneer. J Dent 2012; 40: 154–162.
23. Sailer I, Gottnerb J, Kanelb S, Hammerle CH.
Randomized controlled clinical trial of zirconia-
ceramic and metal-ceramic posterior fixed
dental prostheses: a 3-year follow-up. Int J
Prosthodont 2009; 22: 553–560.
24. Zhang Y, Lawn BR. Fatigue sensitivity of Y-TZP
to microscale sharp-contact flaws. J Biomed
Mater Res B Appl Biomater 2005; 72: 388–392.
25. Zhang Y, Pajares A, Lawn BR. Fatigue and
damage tolerance of Y-TZP ceramics in layered
biomechanical systems. J Biomed Mater Res B
Appl Biomater 2004; 71: 166–171. https://doi.
org/10.1002/jbm.b.30083
26. Zhang Y, Lawn BR, Rekow ED, Thompson
VP. Effect of sandblasting on the long-term
performance of dental ceramics. J Biomed
Mater Res B Appl Biomater 2004; 71: 381–386.
https://doi.org/10.1002/jbm.b.30097

    
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TMD and Physical Therapies
Enhanced CPD DO C

Emma Foster-Thomas

Martin James, Charles Crawford, Pete Clarke, Funmi Oluwajana and Cathleen Lancelott-Redfern

Temporomandibular Disorders.
Part 2: Non-surgical Management
Abstract: For optimal success, a multidisciplinary team approach that uses a combination of non-surgical treatment modalities is
recommended in the care of TMD patients. In this article, the second in a series of six focusing on the diagnosis and management of
temporomandibular disorders (TMD), the importance of self-management, psychological interventions and physical therapies is discussed.
Intra-oral appliances will be covered in a dedicated article later in this series.
CPD/Clinical Relevance: Clinicians should have both an understanding and appreciation for the non-surgical management options
available to patients diagnosed with TMD.
Dent Update 2022; 49: 380–386

In Part 1 of this series, the aetiology and with TMD, to present the evidence base patient depending on the outcome of a
diagnosis of temporomandibular disorders to support their use and to provide some comprehensive biopsychosocial assessment.5
(TMD) were discussed.1 Owing to the practical suggestions for primary care These programmes involve a combination of
complexity of TMD, its management can dental practitioners to adopt. the strategies outlined in this article.
present challenges. Although general The interdisciplinary relationship
evidence-based non-surgical guidelines Physiotherapy between dentistry and physiotherapy
exist for TMD, it is important to highlight Physiotherapy is frequently chosen for the is important in TMD management. It is
that there is not one approach for all, management of TMD due to its reversibility recommended that referring clinicians
and specific patient factors need to be and relative low cost compared to other communicate clearly and refer only to
considered.2 Therapeutic interventions treatment modalities. The therapeutic physiotherapists who have postgraduate
should be patient-centred and monitored goals are to decrease pain, aid muscle training in the management of
over time for change.3 The aims of this relaxation, reduce muscular hyperactivity, musculoskeletal disorders of the head and
article are to discuss the non-surgical improve function and to improve quality neck.6 A thorough referral letter detailing
management options that are available, of life.4 Physiotherapists provide bespoke clinical findings, diagnosis and discussions
other than appliance therapy, for patients rehabilitation programmes for each to date, can help to improve a patient’s
onward journey by enabling a cohesive and
consistent therapeutic dialogue.
Emma Foster-Thomas, BDS (Hons), MFDS RCS (Glasg), Academic Clinical Fellow
in Restorative Dentistry, University Dental Hospital of Manchester. Martin James, Self-management
BDS(Hons), MJDF RCSEng, Specialty Registrar in Restorative Dentistry, University Dental There can be significant crossover between
Hospital of Manchester. Charles Crawford, BDS, MSc, MFGDP(UK), PGCT&L, Lead acute and chronic TMD signs and symptoms,
Clinician TMD Clinic, University Dental Hospital of Manchester. Pete Clarke, BDS(Hons), therefore, even though it is important to try
MFDS, MPerio, Specialty Registrar in Restorative Dentistry, University Dental Hospital and differentiate between them clinically,
of Manchester. Funmi Oluwajana, BDS (Hons), MFDS RCSEd, Specialty Registrar in many of the non-surgical treatment options
Restorative Dentistry, University Dental Hospital of Manchester; Clinical Fellow, Health
are still applicable to both situations. The
Education England Northwest. Cathleen Lancelott-Redfern, BSc(Hons), HCPC, MCSP,
signs and symptoms of TMD can be transient
TMD and Chronic Pain Specialist Physiotherapist, Royal Manchester Children’s Hospital
and self-limiting, and early adoption of
email: emma.foster3@mft.nhs.uk
invasive treatments, such as occlusal

380 DentalUpdate May 2022


adjustment or surgery, ought to be avoided.2
There is now consensus in the literature
that the initial management strategy
for patients with TMD should involve
reversible self-management protocols.7
The importance of patient engagement
with self-management strategies should
be emphasized. Verbal advice should be
supported with written information and
reinforced at subsequent visits.7 Despite
self-management being widely discussed
in TMD literature, the supporting evidence
remains unclear due to heterogeneity
and the limited number of well-designed
experimental studies.8
Patient education
Individualized patient education is considered
to be a key aspect of TMD management; the
aims being to allow the patients to have some
control over their diagnosis, prevent further
3,9
injury and to alleviate symptoms. It is
important to explain to patients that despite
self-management strategies, some symptoms awake parafunctional activity, while offering
may persist, such as clicking.
It is thought that psychosocial factors
and parafunctional activity can play a role
in the pathogenesis and/or persistence of
4
musculoskeletal pain. Therefore, dental
practitioners should be able to provide
reassurance, a clear explanation of the
diagnosis, tailored advice to raise awareness
of parafunctional activity and sensitively
identify any potential psychological factors.10 be achieved when contributing factors,
Patient education should be delivered
using simple and understandable language
and should include the following: the nature
of the condition; predisposing, precipitating
and prolonging factors; anatomy of the
TMJ; management strategies and goals
of therapy.11 There is good evidence that
educating patients about their condition can behaviours that exacerbate their symptoms.7
in itself be effective in reducing pain.12
TMD can significantly affect quality of
life, therefore it is very important to reassure and gum, can minimize stresses on the
patients of the condition’s benign nature.13
Evidence suggests that the language selected
by clinicians can influence musculoskeletal
rehabilitation.14 For example, the words
‘degenerative’ and ‘damage’ can be alarming
for patients and have the potential to
exacerbate symptoms, particularly for
those patients who are anxious about their
condition.14 Using less evocative words like
‘irritation’ can be helpful. The overall aim of and can help to raise a patient’s awareness of
education is to provide patients with the
knowledge and confidence to self-manage
their condition during exacerbations.2
For many, normal daily functions such
as mastication and yawning can exacerbate
May 2022
symptoms. More masticatory effort is
required to eat hard and chewy foods.
Therefore, patients should be advised to
tailor their diet to one which is pain-free,
but not necessarily completely restricted to
soft foods.3 There is no consensus on diet
modification duration; however, it is sensible
to conduct a 2-week review to determine
its success and whether firmer/chewier
foods can be gradually reintroduced.7
Those patients with temporomandibular
hypermobility (subluxation) should be
advised to avoid ‘end of range’ mouth-
opening positions, for example during
yawning. Placing the tongue on the palate
during yawning will limit movement during
this action.
In the acute phase, for example when
there is short-term restricted movement
due to a displaced disc or inflamed muscle,
vigorous exercise should be avoided to
prevent further irritation.15 Resting the
mandible and avoiding aggravation of
reassurance that it is safe to use
the mandible as normally as possible within
their own tolerance, is also beneficial.
In these situations, giving reassurance
and using positive language throughout
discussions is important.14
Awareness of parafunctional behaviour
Successful management is more likely to
such as stress and oral parafunctional
habits, are addressed, particularly when
a suspected causative factor for the
TMD is overactivity through clenching or
grinding.10 Patients should be informed of
any potential parafunctional behaviours, and
recommended to monitor and avoid any
Avoiding habits, such as unilateral chewing
(where possible), chewing pens, nails
masticatory system.16
The Oral Behaviour Checklist was
designed to identify and quantify the
frequencies of oral behaviours during
both sleep and during waking hours.17
This self-reporting instrument consists of
21 questions, which are graded from 0 to
4 according to frequency. This tool can
highlight the frequency of oral behaviours
their parafunctional activity.18 It is important
that patients learn to keep their masticatory
muscles relaxed by keeping their teeth
apart, rather than in occlusion.4 Therefore, to
help break parafunctional habits, frequent
TMD and Physical Therapies
reminders throughout the day can be
beneficial to symptomatic patients. Regular
reminders to return to a resting jaw position
at predetermined intervals in the day via
phone alarms, use of apps (eg ‘No clenching’)
or sticky notes around the house/at work can
be recommended.
Thermal therapy
Localized thermal therapy can be effective
in relieving pain and relaxing muscles
in myalgia patients, by encouraging
vasodilation, which increases blood flow
to the area.19 A variety of protocols has
been presented in the literature; however,
there is no evidence for the use of one over
another. Anecdotally, when symptomatic,
the application of hot compresses to the
painful muscle for at least 5 minutes, three
times a day is useful. It is often beneficial
for hot compresses to be applied prior
to performing any prescribed exercises,
massage or before eating, particularly during
acute exacerbations.
Massage
Self-massage, in the form of kneading,
friction and stretching should be
limited to the area of discomfort or the
tense masticatory muscle.7,16 Following
demonstration, patients are mainly
advised to self-massage the masseter and
temporalis muscles, as these are the most
easily accessible. Self-massage can improve
blood circulation and reduce tension in the
masticatory muscles.20
Relaxation techniques
Chronic pain can affect emotional wellbeing
and, conversely, emotional wellbeing can
influence pain.21 Increased understanding of
ascending and descending neural pathways
has legitimized the use of more holistic
strategies.22 Positive emotional states, self-
confidence, relaxation and beliefs that pain
is manageable, may improve a patient’s pain
experience. The following strategies may
therefore be helpful: mindfulness techniques,
diaphragmatic breathing to aid relaxation and
lifestyle changes to reduce stress.23
Psychological interventions
It is widely acknowledged that oral health
can impact upon an individual’s physical and
psychological health.24 Furthermore, those
with chronic pain associated with other
comorbidities are more at risk of developing
chronic TMD pain. There is no expectation
for a dental practitioner to diagnose, discuss
DentalUpdate 381
TMD and Physical Therapies
Psychosocial screening
Does the pain affect your state of mind or mood? Yes/No If yes, ask the patient to complete PHQ-4
PHQ-4
Over the last 2 weeks, how often have you been Not at all Several days
bothered by the following problems?
Little interest or pleasure in doing things 0 1
Feeling down, depressed or hopeless 0 1
Feeling nervous, anxious or on the edge 0 1
Not being able to stop or control worrying 0 1
A score of 3 or above is considered positive for screening purposes and a referral should be offered.
Figure 1. An outline of the PHQ-4 screening tool. Adapted from Kroenke et al.25
Figure 2. Diagram demonstrating an example of an active exercise (with resistance).
or manage a psychological comorbidity,
yet recognizing when a patient may be
having particular difficulty with coping
is appropriate. Furthermore, if a patient
discloses any underlying or associated
mental health problems, it is important
to ensure that they are already receiving
appropriate support or that a referral to their
general medical practitioner is made. As
mentioned in the first article in the series,1
many screening tools are available to help
initiate communication, for example the
Patient Health Questionnaire-4 (PHQ-4). This
is an ultra-brief, reliable and valid screening
instrument that can be used by clinicians for
identifying potential cases of anxiety and
depression (Figure 1).25
Figure 3. Diagram demonstrating an example of
The biopsychosocial model proposes
a stretching exercise.
that pain arises as a result of biological,
382 DentalUpdate
More than half Nearly every day
the days
2 3
2 3
2 3
2 3
psychological and social factors. Individuals
will experience unique pain variations
depending on the interplay between these
factors. This can explain why individuals can
have very different pain experiences despite
the same level of nociception.26 Reluctance
to address psychosocial issues has been
related to inadequate training, time,
insufficient monetary incentive and cultural
ethos favouring a ‘quick fix’.31 It is important
that a patient’s feelings are not dismissed
because they play an integral part in the
pain experience and simple reassurance
can be helpful in influencing some of the
mechanisms that can inhibit pain.
Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) aims
to challenge and break down negative
thoughts, and provide management
strategies to improve state of mind.27 The
literature shows that patients with chronic
pain related to TMD may benefit from
CBT.28 CBT alone is not better than other
non-surgical interventions; however, it can
complement management of TMD.29 To
make a referral to a CBT practitioner for pain,
a dentist will need to collaborate with the
patient’s general medical practitioner.
Physical therapies
It is suggested that physical therapies
provide short-term symptomatic relief for
TMD patients; however, due to limited
evidence, there is uncertainty as to whether
these benefits are sustained long term.2
The use of physical therapies as part of a
multimodal approach, may reduce the need
for further treatment and, potentially, other
more invasive therapies, as patients are
more likely to be able to self-manage their
condition should it return.
May 2022
 TMD and Physical Therapies

Exercise group Rationale Example/s

Active (with effort from
the patient)
To relax masticatory muscles and to promote
the co-ordination of elevation and depression
jaw movements. Often used when there is
pain, muscle spasm, poor co-ordination and/or
a strength deficit
Without resistance: in front of the mirror, slowly open and
close the mouth along a straight line with the tip of the
tongue touching the palate over a five-six second period
With resistance: open the mouth with the back of a hand/a
finger under the chin resisting movement (Figure 2)

Passive (without effort To increase range of movement and prevent
from the patient) stiffness
Stretching To decrease tension and stretch shortened
muscle fibres. Often used when there is limited
range of opening and pain in myofascial and
arthrogenic TMD
Proprioceptive To improve co-ordination and reduce impaired
muscle contraction patterns. Often used when
there is difficulty initiating a movement on
command, ie lateral deviation
Table 1. Examples of exercises. Adapted from references 2, 16, 30, 31, 41.
A passive jaw mobilization system such as TheraBite (Atos
Medical, Nottingham) can be used. The instructions for use
of such a device need to be personalized to patients. The
manufacturers support the 5–5–30 protocol: five sessions
per day, five opening/closing movements, maintained for
30 seconds a stretch. Alternatively, clinicians can guide
their instructions after assessing a patient’s tolerance
Carefully open the mouth wide with the aid of a thumb
and index fingers. This stretch should be held for 30
seconds if possible (Figure 3)
Draw/apply a temporary vertical line on a mirror. In front
of this mirror, open and close the jaw while concentrating
on keeping the dental midline parallel to this vertical line

Therapeutic exercises
Therapeutic exercises are widely prescribed to
patients with TMD who present with limited
and abnormal TMJ movement patterns. These
exercises aim to restore function by reducing
inflammation, pain and muscular activity,
and promoting repair and regeneration.30 In
order for patients to accurately and safely
perform any home physiotherapy regimen, a
physiotherapist or dentist competent to do so
needs to provide thorough instructions and
motivation.30 There appears to be a distinct
lack of consensus on the optimal exercise
prescription, in particular the recommended
frequencies, durations and intensities. Table
1 illustrates some examples of frequently
recommended (but not exhaustive) exercises.
The exercises selected for a patient will
depend upon the presenting symptoms. It is
the responsibility of an experienced clinician
to know how to progress or regress each
exercise to align with the patient’s stage of
recovery and capability.
Manual therapy
Manual therapy (MT) incorporates
professionally applied joint mobilization,
manipulation and soft tissue techniques.
Trained physiotherapists use MT techniques
in conjunction with therapeutic exercises to
improve strength, co-ordination, mobility
and importantly, to reduce pain.31 It has
been proposed that these techniques
trigger neurophysiological mechanisms
that are responsible for reducing muscle
activity and relieving pain.29 The use of MT
alone, or in combination with exercise, has
shown promising treatment results for all
TMD; however, there is a lack of substantial
high-quality evidence to support its
effectiveness.31 Ultimately, the choice of
MT techniques used will depend on clinical
findings, the irritability of the tissues and the
patient’s preferences.
There are an array of mobilization and
manipulation interventions, graded from I
to V, which can be performed on the upper
cervical spine and TMJs by appropriately
trained clinicians (such as physiotherapists).
Evidence has shown that mobilization of
the cervical spine can reduce pain in those
with myofascial pain.31 Examples of TMJ
mobilization include mandibular distraction,
anterior–posterior translation and recapture
techniques for displaced discs. Although
these techniques are beyond the remit of
this article, it is important to stress that grade
V manipulation techniques, which involve a
thrusting movement, are contraindicated in
the management of TMD.32
Electrotherapy
Electrotherapy has been advocated for
the management of TMD, although the
supporting evidence is limited. The two main
modalities are transcutaneous electrical
nerve stimulation (TENS) and low-level laser
therapy (LLLT).
Transcutaneous electrical nerve stimulation
(TENS)
TENS, which is considered to be safe and
non-invasive, is now regularly used due to
its analgesic and muscle relaxing effects.33
Surface electrodes attached to a battery-
operated device are placed on the skin
surface to deliver small electrical pulses
to painful areas. This action is thought
to block the transmission of pain signals
and potentially stimulate the production
of endorphins.34 The results from studies
evaluating the effectiveness of TENS as an
adjunctive therapy for pain management in
masticatory muscles are positive; however,
due to the low number of studies, small
sample sizes and the lack of follow up, TENS
cannot yet be considered as a standard
treatment for patients with TMD.33,34
Low-level laser therapy
LLLT is thought to provide both localized
analgesic and anti-inflammatory effects
through direct light irradiation, without
causing a thermal response.35 Despite there
being no universally accepted consensus

May 2022 DentalUpdate 383

TMD and Physical Therapies
on the mechanism of action of LLLT, it
has been proposed that this therapy has
multiple actions, including improvement
of local blood circulation and reduction of
oedema.36 It is not possible to determine
the efficacy of LLLT in the management of
TMD due to the variation of its use across the
literature. Specifically, the site of application,
the frequency of applications and the
beam characteristics studied.36 For the
aforementioned reasons, it would be wise to
consider this therapy as an adjunct, rather
than an isolated intervention.
Acupuncture
Acupuncture comes under the umbrella of
complementary or alternative medicines. It is
derived from ancient Chinese medicine and
involves the insertion of small gauge needles
into defined anatomical points along a
meridian – a pathway along which vital
energy (Qi) is said to flow.37 Acupuncture
and dry needling are often confused.
Although these practices both aim to
provide relief from pain, dry needling differs
in that it involves the insertion of needles
into trigger points.
Although limited, there is evidence
to support that acupuncture provides
a short-term analgesic effect in those
with myofascial pain without restricted
mouth opening.38 The exact mechanism
for its analgesic effect is currently
unknown; however, it is theorized that it
promotes downregulation of pain signal
transmission and the release of natural
endogenous opioids.39 The success of
this adjunct could be due to its ability to
temporarily improve symptoms, allowing
self-management strategies to take effect.2
Importantly, adverse events and side
effects of acupuncture in TMD patients are
infrequently reported in systematic
reviews.40 There may be some limitations to
accessing this intervention in some regions,
due to limited numbers of sufficiently
trained clinicians.3
Conclusion
A structured approach should be taken
in the management of TMD, one that is
determined by an individual’s diagnosis
and symptoms, and escalated appropriately
in line with the patient’s response to
reversible interventions. Evidence supports
the cumulative effect of multiple reversible
interventions with a biopsychosocial
approach. A combination of relaxation
exercises with diaphragmatic breathing, self-
massage to the masticatory muscles, thermal
384 DentalUpdate
therapy, active and passive stretching and
proprioceptive exercises are suggested for
those patients with myogenic pain and/
or restricted mouth opening.7,30,41 The
close interrelationship between muscle
activity and pathogenesis of degenerative
or displacement disorders theoretically
allows the extrapolation of the conservative
measures to be beneficial for pain not
classically defined as myogenic.
When the reversible interventions
detailed in this paper are adopted at
an appropriate time, success rates of
68-95% across the subtypes of TMD (see
‘classifications’ in the first article of the
series1) have been reported.42 Success is
more likely to be achieved with a team
approach when factors such as stress,
depression, anxiety and parafunctional
activities are addressed. Furthermore, an
optimal result is more likely to be achieved
if appropriately trained health professionals
are involved in a patient’s care.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Oluwajana F, Clarke P, Foster-Thomas E et al.
Temporomandibular disorders. Part 1: anatomy,
aetiology, diagnosis and classification. Dent
Update 2022; 49: 320–328.
2. Durham J, Aggarwal V, Davies S, Harrison S.
Temporomandibular disorders (TMDs): an
update and management guidance for primary
care from the UK Specialist Interest Group in
Orofacial Pain and TMDs (USOT). 2013. Available
at: https://www.rcseng.ac.uk/dental-faculties/
fds/publications-guidelines/clinical-guidelines/
(accessed April 2022).
3. Shaffer SM, Brismee JM, Sizer PS, Courtney
CA. Temporomandibular disorders. Part 2:
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22. Carlson CR. Psychological factors associated
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TMD and Physical Therapies
with orofacial pains. Dent Clin North Am
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cden.2006.09.001
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24. Haggman-Henrikson B, Ekberg E, Ettlin DA
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29. Gil-Martinez A, Paris-Alemany A, Lopez-de-
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386 DentalUpdate
Uralde-Villanueva I, La Touche R. Management
of pain in patients with temporomandibular
disorder (TMD): challenges and solutions. J Pain
Res 2018; 11: 571–587. https://doi.org/10.2147/
JPR.S127950
30. de las Peñas CF, Jiménez JM. Temporomandibular
Disorders: Manual Therapy, Exercise, and Needling.
Handspring, 2018.
31. Armijo-Olivo S, Pitance L, Singh V et al.
Effectiveness of manual therapy and therapeutic
exercise for temporomandibular disorders:
systematic review and meta-analysis. Phys
Ther 2016; 96: 9–25. https://doi.org/10.2522/
ptj.20140548
32. Brantingham JW, Cassa TK, Bonnefin D et al.
Manipulative and multimodal therapy for upper
extremity and temporomandibular disorders:
a systematic review. J Manipulative Physiol Ther
2013; 36: 143–201. https://doi.org/10.1016/j.
jmpt.2013.04.001
33. Kato MT, Kogawa EM, Santos CN, Conti PC. TENS
and low-level laser therapy in the management
of temporomandibular disorders. J Appl Oral
Sci 2006; 14: 130–135. https://doi.org/10.1590/
s1678-77572006000200012
34. Shanavas M, Chatra L, Shenai P et al.
Transcutaneous electrical nerve stimulation
therapy: an adjuvant pain controlling modality
in TMD patients – a clinical study. Dent Res J
(Isfahan) 2014; 11: 676–679.
35. Petrucci A, Sgolastra F, Gatto R et al. Effectiveness
of low-level laser therapy in temporomandibular
disorders: a systematic review and meta-analysis.
J Orofac Pain 2011; 25: 298–307.
36. Melis M, Di Giosia M, Zawawi KH. Low level laser
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therapy for the treatment of temporomandibular
disorders: a systematic review of the literature.
Cranio 2012; 30: 304–312. https://doi.
org/10.1179/crn.2012.045
37. Longhurst JC. Defining meridians: a modern
basis of understanding. J Acupunct Meridian Stud
2010; 3: 67–74. https://doi.org/10.1016/S2005-
2901(10)60014-3
38. La Touche R, Goddard G, De-la-Hoz JL et
al. Acupuncture in the treatment of pain in
temporomandibular disorders: a systematic
review and meta-analysis of randomized
controlled trials. Clin J Pain 2010; 26: 541–550.
https://doi.org/10.1097/AJP.0b013e3181e2697e
39. Filshie J, White A, Cummings M. Medical
Acupuncture E-Book: A Western Scientific
Approach. Churchill Livingstone, 2016.
40. List T, Axelsson S. Management of TMD: evidence
from systematic reviews and meta-analyses.
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org/10.1111/j.1365-2842.2010.02089.x
41. Moraes AdR, Sanches ML, Ribeiro EC, Guimarães
AS. Therapeutic exercises for the control of
temporomandibular disorders. Dental Press J
Orthod 2013; 18: 134–139.
42. Durham J. Summary of Royal College of
Surgeons’ (England) clinical guidelines on
management of temporomandibular disorders
in primary care. Br Dent J 2015; 218: 355–356.
https://doi.org/10.1038/sj.bdj.2015.194
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Special Care Dentistry
Enhanced CPD DO C

Brooke Zaidman Sarah Spence

Camilla Boynton and Debbie Lewis

Cannulation:
An Update for Dentists
Abstract: Peripheral venous cannulation is a skill dentists may require in hospital jobs and sedation practice. This article provides a
comprehensive overview of the technique, equipment, relative contraindications and potential complications.
CPD/Clinical Relevance: To act as an update and refresher for the dental team on peripheral venous cannulation.
Dent Update 2022; 49: 388–392

Intravenous (IV) cannulation establishes a to alert medical professional of axillary be cannulated or used for venepuncture.
stable and reusable site of IV access for the lymph node clearance so a thorough Additionally, the arm with the fistula should
short-term administration of medication medical history is vital. In affected patients, be avoided when measuring blood pressure
and fluids. It is a skill frequently used by the contralateral arm should be used for to avoid any potential damage.3
Dentists in hospital practice and is essential cannulation in the dental setting.
for all conscious sedation techniques other
Risks of the procedure
than inhalation sedation.1 Dermatological infections
In order to obtain valid consent for the
Sites of cannulation that are severely broken
procedure, clinicians should be able to
or inflamed should be avoided in order to
Relative contraindications prevent further damage and symptoms.
describe the associated risks. Recognized
risks include the following.
Breast cancer-related lymphoedema
Breast cancer-related lymphoedema can be Arteriovenous fistulas
provoked by venepuncture of the ipsilateral Haematoma or bruise formation
An arteriovenous fistula is a surgically
arm and most commonly occurs in patients created connection between an artery and Haematoma or bruise formation is a
who have undergone axillary lymph node vein. They represent the preferred choice common risk of venepuncture and is
clearance. It may also affect patients who of vascular access for patients requiring caused by the leakage of blood from
have undergone sentinel node biopsy or haemodialysis for renal replacement a punctured vessel. A haematoma can
radiotherapy to the axilla.2 Patients may therapy. Arteriovenous fistulas are a appear as a swelling.4 This can occur
or may not carry warning cards or bands lifeline for these patients and should not during or after the procedure and can be
minimized by applying firm pressure to the
cannulation site following removal of the
cannula. Bruising may occur more in failed
Brooke Zaidman,* BDS, MFDS RCPS(Glas), MSc, M Spec Care Dent, Specialist in Special cannulation sites, in friable older skin or
Care Dentistry and Senior Dental Officer, Somerset NHS Foundation Trust. Sarah in those patients with certain connective
Spence,* BDS, MJDF RCS Eng, PGDipSed, MSc, M Spec Care Dent, Specialist in Special tissue diseases, vitamin deficiencies or
Care Dentistry, Somerset NHS Foundation Trust. Camilla Boynton, MA (Hons), BDS, bleeding disorders.5
MJDF RCS Eng, MSc, M Spec Care Dent, Specialist in Special Care Dentistry and Senior
Dental Officer, Somerset NHS Foundation Trust. Debbie Lewis, BDS, MCCD RCS, FDS, Dip
Extravasation/infiltration
Con Sed, M Phil, Consultant in Special Care Dentistry, Somerset NHS Foundation Trust.
This refers to the leakage of fluids into the
*Joint first authors.
surrounding tissues. It is commonly referred
email: sarah.spence8@nhs.net
to as ‘tissuing’ and can result in swelling

388 DentalUpdate May 2022


around the cannula site and pain on
administration of fluid through the cannula.
The term infiltration refers to the leakage
of non-vesicant fluids or medications,
and extravasation refers to the leakage
of vesicant (can cause blistering or tissue
injury) fluids or medications. With a pH of
around 3.0, midazolam has the potential to
cause tissue damage, but no side-effects
have been reported in the literature.6
Thrombophlebitis
Thrombophlebitis is inflammation of the
tunica intima lining of a vein. This may be
recognized as pain, swelling, erythema and/
or hardening around of the surrounding
tissue. Causes may be mechanical, for
example physical/mechanical trauma to
the vein due to movement, perhaps due
to cannulation over an area of flexion, or
thrombophlebitis may have a chemical or
bacterial cause. Other risk factors include
older age, obesity, pregnancy, synthetic
hormones, autoimmune disease (especially
Behcet’s and Buerger’s disease) and certain
coagulopathies (factor V Leiden mutation,
deficiencies in antithrombin III, protein C
and protein S).7
Infection
Catheter-related bloodstream infection
(CRBI) is a rare, but serious, complication.
It occurs when micro-organisms enter the
blood stream via the indwelling cannula.
Bacteria may be introduced during the
cannulation procedure, and thus an aseptic
technique is used. In inpatient settings,
where patients may require intravenous
access for the duration of their stay, a recent
Cochrane review found no clear difference
in rates of infection between routine
replacement (every 72–96 hours) and when
clinically indicated if thrombophlebitis was
observed.8 However, dentists working in
inpatient settings should refer to local policy.
Pain
While the patient may report pain during
cannulation, they should not feel any
discomfort once the cannula is in place, and
when flushing the cannula with saline.
Nerve damage
Venepuncture and peripheral cannulation
have been associated with nerve injuries.
These are mostly mild and temporary,
but there are case reports in the literature
of patients having sustained permanent
and severe neuropathic pain that persists
May 2022
Special Care Dentistry
after needle removal.9 The median nerve
and radial nerve both pass through the
antecubital fossa and are at risk of damage
during cannulation in this region.
Accidental arterial cannulation
Unintended arterial cannulation is a serious
complication as arterial injection of drugs has
the potential to cause peripheral ischaemia
and tissue necrosis. Clinical signs may include
severe pain, bright red pulsatile blood visible
within the chamber of the cannula and Figure 1. The basic equipment required
for cannulation.
blanching distal to the cannula.10 Most cases
of accidental arterial cannulation involve a
radial artery branches of the forearm and
hand, or are due to vascular abnormalities.
The antecubital fossa is also a potential site
for error owing to the close proximity to
arteries in this region.6 If recognized, the
cannula should be removed immediately,
and pressure applied. The patient should
be advised to expect bruising and post-
operative instruction from the NHS Blood
and Transplant Donor service recommend
the RICE method (Rest, Ice, Compression and
Elevation above the heart).11 If drugs have
been administered, then this represents an
emergency situation. The cannula should be
left in situ and medical treatment should be
sought urgently. b
Equipment
The basic equipment needed for
cannulation is shown in Figure 1 and
discussed in more detail below.
1. Tourniquets are used to produce venous
distention. For some patients, they may
also act as good distraction to offering
up a hand for cannulation. They are
latex free and can be sourced as single
use to prevent cross infection.
2. Skin cleansing swabs should be
used to clean the cannulation site.
These are either 2% chlorhexidine
gluconate in 70% isopropyl alcohol,
or povidone iodine in alcohol is
an alternative for patients with a Figure 2. (a, b) The prominent metacarpal veins
chlorhexidine sensitivity.12 on the dorsum of the hand.
3. Cannulas are colour coded according
to their gauge (G). The gauge refers to
the internal diameter of the needle.
Cannulas are individually packed
Since the introduction of the Health and
Safety (Sharp Instruments in Healthcare) and sterile.
Regulations 2013, employers have 4. Transparent film dressing, to secure the
been required to substitute traditional, cannula in place. These are sterile and
unprotected medical sharps for ‘safer single use. They are designed to be an
sharps’ wherever reasonably practical impermeable and waterproof barrier
to do so.13 For intravenous sedation, a to prevent bacterial colonization of the
22G cannula provides sufficient access. cannula site.
DentalUpdate 389
Special Care Dentistry
Basilic vein
Figure 3. The prominent veins of the antecubital fossa.
Brachial artery
Median nerve
Ulnar artery
Figure 4. Schematic diagram of arteries and nerves in the antecubital fossa, these lie deep to the
superficial veins.
5. Sodium chloride ‘flush’ 0.9% prior to
giving a drug to confirm position of
cannula. To administer, draw up with
drawing up needle into a syringe.
A sharps bin should be close to
hand, and it may be useful to have a
sterile container in which to keep the
equipment until needed.
Choosing a cannulation site
The appearance of a ‘good vein’ will
be if it is straight, visible and easily
palpable. The vein will feel bouncy
and soft, indicating a large lumen
and will refill when depressed. If the
vein is well supported by surrounding
soft tissue, it is less likely to move
during cannulation.
390 DentalUpdate
Cephalic vein
Median cubital vein
Radial nerve
Radial artery
Anatomy of cannulation site
The most common veins used for
venepuncture are the metacarpal veins,
located in the dorsum of hand, (Figure 2).
They take blood to two larger veins in
the antecubital fossa (ACF). The ACF is
H-shaped and includes the cephalic vein,
which lies laterally, and the basilic vein,
which lies medially. The median cubital vein
often unites the two main veins (Figure 3).
Anatomy will vary between individuals,
but usually, these are quite superficial. The
operator must have a good knowledge of
the related anatomy to maximize successful
cannulation and avoid any complications
such as unintentional puncture of an artery.
The antecubital fossa contains the
brachial artery and radial and ulnar nerves
(Figure 4). The brachial artery typically lies
mesial to the biceps tendon; the tendon
can be palpated by asking the patient to
flex and extend the lower arm. The pulse
of the brachial artery should be palpable
medial to the biceps tendon.
Technique
Patient positioning is important for
venepuncture. The patient should be
semi-supine, preferably with their feet up
in the dental chair.
The limb to be cannulated should
be positioned below the level of the
heart and, if possible, the patient can
use muscle action to force blood into the
veins by opening and closing their fist.
Light tapping of the vein can be helpful
as resultant histamine release results
in vasodilation.14 The dental team can
also provide invaluable support during
venepuncture via distraction techniques
(eg engaging in conversation with the
patient) or assisting with clinical holding
if required. Gauging individual patient
needs and preferences beforehand is
extremely beneficial, for example some
patients like to be informed at every stage
of venepuncture while others do not.
Steps for cannulation using a ‘Venflon Pro
Safety’ cannula
Before starting, the clinician must
ensure that informed consent (or a best
interest decision) has been obtained, all
equipment is available, hand hygiene and
donning of gloves is complete.
„ Wipe away numbing cream, if used;
„ Apply tourniquet 5–10 cm above the
cannulation site;
„Identify suitable vein – palpate
and look;
„ Apply warming source if needed;
„ Clean cannulation site with skin
cleansing swab;
„ Allow skin to dry.
„‘Fix’ the vein by applying pressure to
skin over the vein, approximately 2 cm
below the venepuncture site. The tip
of the needle in the plastic cannula
will be visible and the bevel should be
pointing upwards;
„ Insert the cannula into the vein at
approximately 30 degrees;
„ Advance the needle slowly until
flashback is seen in the hub at the
base of the cannula;
„ Once flashback is seen, level off the
cannula and advance a further 2 mm;
„ Stabilize the needle and advance the
cannula forward fully into the vein;
May 2022

Figure 5. Instant Heat Compress with
instructions for use on packet.
„ Occlude the vein, remove the needle
and remove the tourniquet;
„Dispose of the needle into a sharps bin;
„ Place the bung on the end of
the cannula;
„ Secure the cannula with the transparent
film dressing;
„Flush the cannula with 0.9% saline to
ensure correct positioning – note any
resistance, pain or swelling around the
site which may indicate extravasation.
Cannula removal
„ Remove the transparent film;
„ Remove the cannula and place straight
into a sharps bin;
„ Provide pressure with a cotton wool roll
simultaneously;
„ Check that the bleeding has stopped;
„ Place sticky tape over cotton wool roll
(eg Transpore, 3M, USA) or replace with
a sterile plaster.
Aids to cannulation
Although the insertion of an intravenous
cannula is usually straightforward,
there are instances when it can prove
a challenge. Multiple attempts at
cannulation can heighten anxiety and
perception of pain, create stress for both
the patient and dentist, and delay or
prevent sedation or treatment.15 Factors,
such as extremes of age, obesity, history
of IV drug abuse, patients who have
experienced repeated IV access due to
their medical conditions or small, non-
May 2022
visible, non-palpable veins, can increase
the complexity of the procedure. In some
cases, modified techniques or the use of an
adjunctive method may be necessary.
Adjunctive methods
to cannulation
Heat packs
Application of heat results in vasodilation
and can improve visibility of the vein for
cannulation. Heat packs such as the single-
use ‘DMI Sol-R Instant Heat Compresses’
(USA) can be purchased for use (Figure
5). This particular product should not
be applied directly to the skin and so
single-use paper towels can be used to
wrap the compress or the patient may
bring their own clean and thin towel to
surgery. The heat from this product lasts for
approximately 15 minutes.
If heat packs are not available,
insulated gloves may be worn prior to the
appointment. Alternatively, the patients’
hand may be placed in a bowl of warm
water to produce vasodilation.
Topical anaesthetic creams
Pre-procedural application of topical
anaesthetic creams, such as EMLA (Eutectic
Mixture of Local Anaesthetics, AstraZeneca,
UK), has been proven to be effective at
reducing discomfort associated with
cannulation in both children and adults16
and may be particularly useful for highly
anxious patients. Occlusive film dressings
keep the cream over the site for sufficient
time and should be provided by the dental
team. Various formulations are available
and need to be applied 30–60 minutes
prior to cannulation for optimum effect (as
per manufacturer instructions). However,
creams can cause vasoconstriction,
blanching and erythema, which may make
cannulation more difficult.17
Another consideration is that some
patients with cognitive disabilities may
not tolerate the cream or dressings. It can
therefore be helpful to explain the cream
and dressings with imagery (eg alternative
augmentive communication techniques)
and/or to place gloves/bandages over the
cream and dressings after application to
prevent patients removing them.
Manual blood pressure cuff
A manual blood pressure cuff inflated to
60–80mmHg may be used as an alternative
to a tourniquet18 and, anecdotally, may
be more successful for some patients or
Special Care Dentistry
operators. However, a recent randomized
control trial showed no benefit over the use
of a disposable elastic tourniquet.19
Infrared vein finder
Vein finders such as Accuvein (AccuVein
Inc, USA), Vasculuminator, (Pontes Medical,
USA), VeinViewer (B Braun Medical Inc,
Germany) and Veinsite (Vascular Solutions
Inc, USA) are devices that emit an infrared
laser light to detect superficial veins. An
image of the veins is projected back onto
the skin surface in real time improving the
visualization of already visible/noticeable
veins and allowing the identification of
deeper veins. Evidence has shown that
infrared vein finder technology improved
general visibility of veins including in
patients with obesity and those of African
and Asian ethnicities.20
Ultrasound-guided cannulation
Ultrasound can be used to visualize vessels
and can increase the likelihood of successful
cannulation in patients with difficult
venous access.21 The use of ultrasound for
this purpose has grown in use in central
venous cannulation, and may be an option
that is accessible to clinicians working in
hospital environments.
Summary
This article provides an update in
peripheral venous cannulation for
dentistry. The authors have outlined
the indications, relevant anatomy of
common cannulation sites, recommended
equipment and additional aids to improve
technique. Cannulation risks and relative
contraindications have also been discussed.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Intercollegiate Advisory Committee for Sedation
in Dentistry. Standards for conscious sedation in
dentistry. 2020. Available at: www.rcseng.ac.uk/
dental-faculties/fds/publications-guidelines/
standards-for-conscious-sedation-in-the-
provision-of-dental-care-and-accreditation/
(accessed February 2022).
2. Jakes AD, Twelves C. Breast cancer-related
lymphoedema and venepuncture: a review
and evidence-based recommendations. Breast
DentalUpdate 391
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392 DentalUpdate
Cancer Res Treat 2015 Dec; 154(3): 455–461. https://doi.org/10.1007/s10549-
015-3639-1
3. Siddiky A, Sarwar K, Ahmad N, Gilbert J. Management of arteriovenous
fistulas. BMJ 2014; 30: 349 g6262. https://doi.org/10.1136/bmj.g6262
4. Buowari YO. Complications of venepuncture. Adv Biosci Biotechnol 2013; 4:
126–128.
5. Scully C, Dios PD, Kumar N. Special Care in Dentistry. Handbook of Oral
Healthcare. Philadelphia: Churchill Livingstone Elsevier 2007.
6. Lake C, Beecroft CL. Extravasation injuries and accidental intra-arterial
injection. Cont Educ Anaesthes Crit Care Pain 2010; 10: 109–113.
7. National Institute for Health and Care Excellence. Superficial vein
thrombosis (superficial thrombophlebitis) 2020. Available at: https://tinyurl.
com/2p89v5w5 (accessed February 2022).
8. Webster J, Osborne S, Rickard CM, Marsh N. Clinically-indicated replacement
versus routine replacement of peripheral venous catheters. Cochrane
Database Syst Rev 2019; 1: CD007798. https://doi.org/10.1002/14651858.
CD007798.pub5
9. Stevens RJ, Mahadevan V, Moss AL. Injury to the lateral cutaneous nerve of
forearm after venous cannulation: a case report and literature review. Clin
Anat 2012; 25: 659–662. https://doi.org/10.1002/ca.21285
10. Lim WY, Raghavan KC. Identification and confirmation of suspected
unintended peripheral arterial cannulation during anaesthesia. Proc
Singapore Healthcare 2017; 26: 203–205.
11. NHS Blood and Transplant Donor Information. Arterial Puncture 2012.
Available at: https://nhsbtdbe.blob.core.windows.net/umbraco-assets-
corp/17900/inf809.pdf (accessed February 2022).
12. Loveday HP, Wilson JA, Pratt RJ et al; UK Department of Health. epic3:
national evidence-based guidelines for preventing healthcare-associated
infections in NHS hospitals in England. J Hosp Infect 2014; 86 Suppl 1: S1–70.
https://doi.org/10.1016/S0195-6701(13)60012-2
13. Health and Safety Executive. Health and Safety (Sharp Instruments in
Healthcare) Regulations; guidance for employers and employees 2013.
Available at: https://www.hse.gov.uk/pubns/hsis7.htm (accessed February
2022).
14. Bowden T. Peripheral cannulation: a practical guide. Br J Cardiac Nurs 2010;
5: 124–131.
15. Rodriguez-Calero MA, Fernandez-Fernandez I et al. Risk factors for difficult
peripheral venous cannulation in hospitalised patients. Protocol for a
multicentre case-control study in 48 units of eight public hospitals in Spain.
BMJ Open 2018; 8: e020420. https://doi.org/10.1136/bmjopen-2017-020420
16. Bond M, Crathorne L, Peters J et al. First do no harm: pain relief for the
peripheral venous cannulation of adults, a systematic review and network
meta-analysis. BMC Anesthesiol 2016; 16: 81. https://doi.org/10.1186/s12871-
016-0252-8
17. Bjerring P, Andersen PH, Arendt-Nielsen L. Vascular response of human skin
after analgesia with EMLA cream. Br J Anaesth 1989; 63: 655–660. https://doi.
org/10.1093/bja/63.6.655.
18. Tran T, Lund SB, Nichols MD, Kummer T. Effect of two tourniquet techniques
on peripheral intravenous cannulation success: a randomized controlled
trial. Am J Emerg Med 2019; 37: 2209–2214. https://doi.org/10.1016/j.
ajem.2019.03.034
19. World Health Organization. WHO guidelines on drawing blood: best
practices in phlebotomy 2010. Available at: https://tinyurl.com/565a5hz7
(accessed February 2022).
20. Chiao FB, Resta-Flarer F, Lesser J et al. Vein visualization: patient characteristic
factors and efficacy of a new infrared vein finder technology. Br J Anaesth
2013; 110: 966–671. https://doi.org/10.1093/bja/aet003
21. Egan G, Healy D, O’Neill H et al. Ultrasound guidance for difficult peripheral
venous access: systematic review and meta-analysis. Emerg Med J 2013; 30:
521–526. https://doi.org/10.1136/emermed-2012-201652
May 2022
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 Paediatric Dentistry
Enhanced CPD DO C

Risha Sanghvi

Nabina Bhujel

Common Dental Anomalies

affecting Patients with
Cleft Lip and Palate
Abstract: Patients with cleft lip and/or palate (CLP) have increased experience of dental anomalies compared to unaffected individuals. This
article describes the common dental anomalies, namely, enamel defects, hypodontia, anomalies in tooth shape or form, supernumerary
teeth, ectopic and impacted teeth, and tooth transposition. The respective prevalence and potential implications on dental health are also
discussed alongside the role of the general dental practitioner.
CPD/Clinical Relevance: This article highlights the common dental anomalies for those with cleft lip and/or palate, and identifies clinical
presentations that require GDPs’ contribution to patients’ dental care.
Dent Update 2022; 49: 395–401

Cleft lip and/or palate (CLP) is the most The timeline for cleft lip and primary These timelines are essential to reduce
common congenital abnormality, with palate repair is generally between 3 and the burden and impact of compromised
a reported incidence of between 1:600 6 months, and that for cleft palate at dental health on the patient’s
and 1:700 live births.1 Patients with CLP 6–9 months. At this stage, preventive overall wellbeing.
commonly have impaired facial growth, advice should be reinforced, including It has been proposed that dental
difficulties with speech, feeding and advice on breastfeeding, bottle-feeding anomalies form part of an extended
hearing, psychological problems, dental and toothbrushing. Four- to six-monthly cleft phenotype.4,5 With this in mind,
disease and anomalies.1 dental reviews should then continue and the importance of identification
The NHS standard contract for CLP with the primary care dentist to reinforce and management of dental anomalies
services states that children born with preventive advice and to monitor primary specified in the NHS standard contract,
CLP must have early dental intervention.1 tooth eruption, noting any dental the aim of this review is to summarize
This involves a combination of primary caries or dental anomalies.3 A specialist the common dental anomalies
and secondary/tertiary care. By 6 months paediatric dentist should conduct a associated with CLP. In doing so,
of age, the cleft team should provide formal dental review at least at the age primary dental care practitioners will
oral health advice. Patients should of 5 years. Before the age of 10 years, it have increased awareness of these
subsequently have a dental review by 1 is essential that the paediatric dentist anomalies, thereby facilitating improved
year of age by their primary care dentist.2 reviews any child with dental anomalies.1 communication with paediatric cleft
dentists to ensure that patients are
reviewed in a timely manner in line
with recommendations.
Risha Sanghvi, BDS (Lond), MFDS RCS (Ed) PGCert (Dent Ed), MSc, Specialty Registrar in The most common dental
Paediatric Dentistry; Nabina Bhujel, BDS (Aus), MFDS RCPS (Glasg), M(Paed Dent) RCPS
anomalies affecting patients with CLP
(Glasg), D Clin Dent (Paed Dent), FDS (Paed Dent) RCS (Eng), Consultant in Paediatric
are hypodontia, supernumerary teeth,
Dentistry; Guy’s and St Thomas’ NHS Foundation Trust, London
developmental defects of enamel,
email: risha.sanghvi@nhs.net
anomalies in tooth shape and size,

May 2022 DentalUpdate 395

Paediatric Dentistry
Figure 1. An upper occlusal photographic view
showing hypodontia in the form of missing URB
and ULB, and hypoplastic enamel affecting the
ULA and URA.
Figure 2. An upper occlusal radiograph
demonstrating a megadont tooth UR1 and
microdont tooth UL1. Hypodontia is also
apparent in the form of missing upper lateral
incisors in both the primary and permanent
dentition in the cleft site.
including double teeth, ectopic, impacted
teeth and transposed teeth, natal or
neonatal teeth and root anomalies. These
will be discussed in further detail.
Developmental absence
of teeth
Hypodontia refers to the developmental
absence of any teeth excluding third
molars. The overall prevalence in the
general population has been reported
as 1% in the primary dentition6 and 6%
in the permanent dentition,7 with the
lower second premolar being the most
commonly missing tooth. The aetiology
is thought to be genetically determined,
either as isolated gene mutations such as
MSX1, or as part of a syndrome, such as
ectodermal dysplasia, Down syndrome or
Van der Woude syndrome.8 Environmental
aetiological factors have also been
considered, including trauma, irradiation
and infections, such as osteomyelitis.
Hypodontia has been widely reported
as having a higher prevalence in CLP
children.9–11 This may be as a consequence
396 DentalUpdate
Figure 3. A dental panoramic tomograph (DPT) showing hypodontia in the form of missing UR5 and
UL5 and an ectopic UL6 with distal root resorption of the ULE evident. Delayed eruption of the UL1 and
UL2 and rotation of the is also evident.
Figure 4. An upper occlusal photographic view
showing hypoplastic enamel affecting ULA
and URB. An erupted supernumerary tooth is
apparent distal to the ULA.
of the structural abnormality.12 Shapira
et al, in their multicentre study, found
an overall prevalence of 77% in the
permanent dentition of CLP patients.
The authors found that the upper lateral
incisors on the cleft side were the most
frequently missing teeth. On the non-cleft
side, the most commonly missing teeth
were maxillary second premolars.11 Other
studies have reported a lower prevalence
of 53% and 46%.9,13 Suzuki et al reported
a prevalence of 16% in the primary
dentition.13 The evidence suggests that the
overall reported prevalence of hypodontia
in patients with CLP is significantly higher
than unaffected individuals in both the
primary and permanent dentition. The
primary and permanent upper lateral
incisors are the most commonly missing
teeth (Figures 1 and 2); however, other
teeth, including premolars, may be missing
(Figure 3). Hypodontia is more likely to
occur in the cleft region. Dentists must
be vigilant to identify teeth that have not
erupted as expected within ‘normal’ dental
development timelines because these may
be congenitally missing. If missing teeth
are suspected, appropriate radiographic
examination should be undertaken.
If delayed loss of a primary molar has
occurred in one or two quadrants, an
intra-oral peri-apical radiograph should
be taken. If delayed loss is present in three
or four quadrants, a dental panoramic
tomograph (DPT) is indicated. If infra-
occluded primary teeth are evident in a
patient over 10 years of age, a peri-apical
radiograph or DPT should be taken if infra-
occlusion is evident in one quadrant, or
two or more quadrants, respectively.14
Advice should be sought from
paediatric, orthodontic and restorative
colleagues for medium- and long-term
treatment planning. In cases where
premolars are missing, the aim should
be to retain primary molars until a
definitive orthodontic plan is made.
Healthy retained primary molars should
be protected with the use of fissure
sealants.15 If primary molars are carious,
but restorable, restoration should be
considered in the form of stainless steel
crowns for occlusal or proximal caries,16
or composite restoration for occlusal
caries.17 If unrestorable caries or severe
infra-occlusion is evident, extraction will be
required and multidisciplinary input should
be sought for replacement options and the
requirement of space maintenance.
May 2022

Figure 5. A long cone peri-apical (LCPA)
radiograph showing anomalous crown
morphology of the ULB. An unerupted
supernumerary tooth is also evident.
Supernumerary teeth
Supernumerary teeth refer to teeth or
teeth-like structures, which occur in
addition to the normal complement of 20
teeth in the primary dentition, or 32 teeth
in the permanent dentition. They can
be classified according to their location
(mesiodens, paramolar, distomolar)
or morphology (conical, odontome,
supplemental, tuberculate). The overall
prevalence in individuals without CLP is
thought to be 1% in the primary dentition
and 2% in the permanent dentition.18
Supernumerary teeth have been reported
as the second most common dental
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Figure 6. A lower occlusal photographic view
showing molar incisal hypomineralization
affecting the LL6, LR6 and incisal edges of LR1
and LR2.
anomaly affecting the cleft area19,20 in both
the primary (Figure 4) and permanent
(Figure 5) dentition, with a reported
prevalence of 22% in the permanent
dentition.21 Supernumerary teeth can
result in failure of eruption of adjacent
teeth, particularly upper central incisors.
The incidence of this will be increased for
the odontome and tuberculate types.22
Crowding, rotations and displacement of
adjacent teeth may also occur, as well as
root resorption, dilaceration or arrested
root development of adjacent teeth.
Removal of supernumerary teeth would
be readily considered when failure of
eruption or damage to adjacent teeth
has occurred.23
Developmental defects
of enamel
Developmental enamel defects (DDE)
are frequently observed in patients with
CLP.24 The aetiology of these defects in
patients with CLP is unclear, but it has
been hypothesized that they may occur
secondary to metabolic or nutritional
deficiencies, or surgical interventions
Paediatric Dentistry
Figure 7. A photograph in occlusion showing a
microdont UR1 and UR2 and hypomineralized
enamel affecting the UR2 and UR1 incisal edges.
Figure 8. A photograph in occlusion showing a
double tooth LRB and LRC and hypodontia with a
missing URB.
during palate repair, resulting in altered
blood supply to developing tooth germs.25
Hypoplastic enamel (Figure 4) and
hypomineralized enamel (Figure 6) are
the most frequent enamel defects seen
in patients with CLP. Hypoplastic enamel
represents a quantitative defect due to
deficient enamel matrix secondary to
disturbance during the secretory stage
of amelogenesis. Hypoplastic enamel will
typically appear hard and translucent
with a reduced thickness, and may exhibit
pitting or grooves. Hypomineralized
enamel represents a qualitative enamel
defect occurring due to disturbances
in enamel matrix mineralization. Teeth
will demonstrate white, yellow or brown
opacities, and will be prone to wear and
post-eruptive breakdown. Patients with
enamel defects may experience sensitivity,
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DentalUpdate 397
Paediatric Dentistry

Figure 9. A left oblique lateral radiograph

showing a germinated ULB. The UL2 is present in
this case. Hypodontia of the UL5 and LL5 is also Figure 10. A DPT showing an ectopic UL5 that is mesially angled. Hypodontia is also present with a
apparent. missing UR5 and the UR2, UL1 and UL2 are microdont.

pain and aesthetic concerns. Furthermore,

it has been well reported that it can be
difficult to achieve local anaesthesia in
hypomineralized teeth.26 In light of this,
consideration should be given to the use of
inhalation sedation, anaesthetic adjuncts,
such as intraligamental infiltrations
and pre-operative treatment with
fluoride varnish.27–29
Early identification and protection of
teeth with DDE is essential. Prevention
should be provided to patients in the form
of oral hygiene instruction, diet advice
and fluoride varnish application as per
the Delivering Better Oral Health Toolkit.3
Children should be treated as at high risk
Figure 11. A DPT showing transposition of the UL3 with the UL4. Hypodontia is also present in the
of dental caries, and fissure sealants should
form of a missing UR5 and the LL3 is vertically impacted. A supplemental, rotated UR2 is also present.
be placed on teeth with enamel defects.
Agents such as casein phosphopeptide
amorphous calcium phosphate can be
used to encourage remineralization and
desensitization. In posterior teeth with due to spacing and irregular crown shape.
This can have psychological effects on
post-eruptive breakdown or dental caries,
self-esteem and confidence. Furthermore,
restorations or extractions may need to
diminutive permanent lateral incisors
be considered.30
can be associated with centreline shifts,
reduced overjets and impacted maxillary
Anomalies in shape and size canines, which can increase orthodontic
Developmentally missing teeth are often and surgical burdens.32 Figure 12. An extra-oral photograph showing a
associated with an overall reduction in Double teeth have also been natal tooth in the cleft region.
tooth size.31 Patients with CLP may have frequently found in patients with CLP
teeth with anomalous size or shape, (Figure 8). They are thought to occur
commonly permanent lateral incisors.19 more commonly in the primary dentition
Microdont teeth, teeth smaller than normal and in the mandibular arch.13 Double primary dentition, a double tooth may be
for the individual tooth type (Figure 7), teeth can be more prone to dental caries indicative of subsequent hypodontia of the
macrodont teeth, teeth larger than normal or periodontal disease due to poor plaque permanent tooth, mainly affecting upper
for the particular tooth type (Figure 2), or control and subgingival fissure extent. lateral incisors. However, the permanent
teeth with abnormal crown morphology Anterior crowding and compromised tooth may still be present as normal
(Figure 5) can cause aesthetic concerns aesthetics may also occur. If in the (Figure 9).33

398 DentalUpdate May 2022


Figure 13. A DPT showing taurodont first permanent molars, characterized by enlarged pulp
chambers. A supplemental UR2, rotated UL2 and ectopic UL3 can also be seen.
Ectopic and impacted teeth
Ectopic teeth are those that have erupted
into an atypical position. In the general
population, the most common teeth
to erupt in an atypical position are first
permanent molars and permanent
canines, with a prevalence of 4% and 1.5%,
respectively.34,35 Although there is limited
literature on the reported prevalence in
patients with CLP, it may be up to 31–45%
(Figures 3 and 10).36
Ectopic or impacted teeth can result in
root resorption of adjacent teeth, crowding
or displacement of adjacent teeth and
pathology, such as cystic formation.35,37
Furthermore, management of these
teeth can be complex with patients
often requiring surgical and orthodontic
intervention for exposure and bonding
of impacted teeth. It is important that
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dental development in patients with CLP is
monitored. Asymmetrical eruption of teeth
should be investigated and upper canine
teeth should be palpated from the age of
8 years.37
Ectopic teeth have also been
associated with other anomalies, including
hypodontia and microdontia,38 and a
holistic approach to examination and
diagnosis must be considered, alongside
referral to secondary care.
Transposition
Transposition of teeth refers to the
interchange in position of two adjacent
permanent teeth. It is classified as either
complete, whereby the entire crown and
root of the teeth have exchanged places
or incomplete when the roots remain in
their normal position but the crown is
Paediatric Dentistry
Figure 14. An LCPA radiograph showing dens
invaginatus affecting both the UR1 and UL1 and a
microdont UL2.
transposed.39 The upper permanent canine
is the most frequently transposed tooth
and reported prevalence is low at 0.6%.40
Prevalence in CLP patients has been
reported as 14% (Figure 11).41
Management of transposed teeth can
be challenging, and early identification
of abnormal eruption paths is beneficial
to enable early orthodontic intervention
to correct tooth position.39 If transposed
teeth have erupted, composite masking in
combination with bleaching in those over
the age of 18 years can be considered to
improve the aesthetic appearance.
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DentalUpdate 399
Paediatric Dentistry
Natal and neonatal teeth
Natal teeth are teeth that are present in
the oral cavity at birth, while neonatal
teeth are those that erupt in the first
30 days of life. These teeth may be
part of the normal complement of 20
deciduous teeth. They are usually conical
in shape with a yellow/brown colour. The
prevalence in the general population is
varied, but is considered to be between
1:800 and 1:30,000.42 A higher prevalence
of natal (Figure 12) and neonatal teeth
has been found in patients with CLP. A
study reported the incidence to be 2% in
patients with unilateral CLP and up to 10%
in patients with bilateral CLP.43
Identification of these teeth and
referral to secondary care is essential
to prevent associated complications,
including difficulties with feeding,
traumatic injury to the ventral tongue and
mobility, with subsequent aspiration risk.
If an aspiration risk is suspected, removal
should be considered, either by GDPs
or specialists. If teeth are mobile with
no aspiration risk, appropriate follow up
should be arranged to ensure there is no
increase in mobility.
Root and pulp
morphological anomalies
Taurodontism, and dens invaginatus and
dens evaginatus have been associated
with CLP patients. Taurodontism refers
to teeth with enlarged pulp chambers,
root shortening and apical positioning
of the pulpal floor with lack of a cervical
constriction at the cemento-enamel
junction (Figure 13). Teeth can be
classified as hypotaurodont (slightly
enlarged pulp chamber), mesotaurodont
(moderately enlarged pulp chamber)
and hypertaurodont (very enlarged pulp
chamber).44 The reported prevalence in
a general population is considered to be
0.25–11.3%.45,46 Permanent molar teeth are
most affected.47
Patients with CLP have been found
to be significantly more likely to have
taurodontism.48 Taurodontism can increase
the difficulty of endodontic treatment
due to abnormal pulp morphology and
thin pulp floors. Furthermore, orthodontic
treatment may be challenging due to
reduced anchorage value and increased
tendency of root resorption.
Dens invaginatus (Figure 14) and
dens evaginatus refer to developmental
malformations of tooth resulting in
an invagination or tubercle formation,
400 DentalUpdate
respectively. Upper permanent lateral
incisors are most frequently affected.49
Despite being rarely found, these
anomalies have been reported to be more
prevalent in CLP cohorts.50 It is essential
that these teeth are identified early. If
palatal pits are present in dens invaginatus
cases, they should be sealed to reduce
the risk of loss of vitality. If loss of vitality
does occur, endodontic treatment can
be challenging. In dens evaginatus case,
tubercles should be sealed. If occlusal
interferences are present, the opposing
occluding surface can be minimally
reduced and fluoride varnish applied.
Discussion
Analyses of the above dental anomalies
in patients with CLP suggest that the
prevalence of dental anomalies is higher
in this cohort compared to unaffected
individuals. This is demonstrated in
published literature. Tannure et al
conducted a systematic review and meta-
analysis of six studies and concluded
that there was a higher number of dental
anomalies in the permanent dentition
in patients with CLP than unaffected
individuals. This included hypodontia,
microdontia, supernumerary teeth, tooth
malposition, abnormalities in tooth
morphology and tooth impaction.24
Furthermore, a retrospective study
analysing the records of 162 patients with
CLP found that 94% of patients had at
least one dental anomaly, and 34% had
two or more anomalies.51 A recent service
evaluation of 62 18-month-old babies with
CLP found that 57% of patients presented
with a dental anomaly – hypodontia,
hypomineralization or hypoplasia, and
emphasized the importance of early
dental review and intervention in this
group of patients.52
Alongside this predilection for certain
anomalies, there also appears to be a
relationship between cleft formation and
tooth formation with dental anomalies
more commonly appearing in the cleft
site.24 This has been evidenced through
the identification of common genetic
factors contributing to dental anomalies
and clefts.4,53 Hypodontia appears to
be the most commonly found dental
anomaly, followed by supernumerary
teeth.54 The teeth most commonly
affected are the maxillary lateral incisors
and premolars.5 The severity of the
anomaly may be correlated with the
severity of the cleft, and patients may
present with multiple anomalies.55
Based on the robust evidence that
CLP patients are at higher risk of dental
anomalies, NHS England, in their published
service specification for patients with
CLP, has highlighted the importance
of patients with dental anomalies
having a dental review by a specialist
paediatric dentist before the age of 5
years.1 Through revision of the common
anomalies, and associated problems, it is
clear to see why this is the case. Patients
with dental anomalies require early
identification and intervention to prevent
deterioration and avoid potentially severe
problems. A multidisciplinary approach is
important, with GDPs, paediatric dentists,
orthodontists and restorative dentists
to enable holistic treatment planning,
promote patient wellbeing, minimize
dentally related negative psychosocial
effects and reduce the long-term burden
of dental care that this cohort of patients
will require. GDPs have an essential role
in the provision of preventive advice in
line with Delivering Better Oral Health
guidelines. Enhanced measures should be
followed as per this toolkit for CLP patients
with anomalies predisposing them to
dental caries.3
Conclusion
Patients with CLP will require significant
medical intervention throughout their
lifetime. Awareness of the increased
prevalence of certain dental anomalies and
facilitating early intervention is paramount
in reducing the dental burden on these
patients. A shared-care approach is
required by primary and secondary/tertiary
dental services to enable optimal care
and support to be provided to this cohort
of patients.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. NHS England. NHS Standard Contract for Cleft Lip and/
or palate services including non-cleft velopharyngeal
dysfunction (VPD) (All Ages): Schedule 2 – The Services
A. Service Specification D. 2013. Available at: https://
www.england.nhs.uk/wp-content/uploads/2013/06/
d07-cleft-lip.pdf (accessed March 2022).
2. British Society of Paediatric Dentistry. Dental Check by
One . Available at: https://www.bspd.co.uk/patients/
dental-check-by-one (accessed March 2022).
3. Public Health England. Delivering better oral health: an
evidence-based toolkit for prevention. 017. Available
at: https://www.gov.uk/government/publications/
May 2022

delivering-better-oral-health-an-evidence-based-
toolkit-for-prevention (accessed March 2022).
4. Vieira AR, McHenry TG, Daack-Hirsch S et al. Candidate
gene/loci studies in cleft lip/palate and dental
anomalies finds novel susceptibility genes for clefts.
Genet Med 2008; 10: 668–674. https://doi.org/10.1097/
GIM.0b013e3181833793
5. Menezes R, Vieira AR. Dental anomalies as part of
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in primary teeth and their correlation with the
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Dent Child 1995; 62: 412–417.
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of the maxillary central incisor. Dent Pract Dent Rec
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and management of supernumerary teeth. Dent
Update 2008; 35: 510–520. https://doi.org/10.12968/
denu.2008.35.8.510.
24. Tannure PN, Oliveira CA, Maia LC et al. Prevalence of
dental anomalies in nonsyndromic individuals with
cleft lip and palate: a systematic review and meta-
analysis. Cleft Palate Craniofac J 2012; 49: 194–200.
https://doi.org/10.1597/10-043
25. Carpentier S, Ghijselings E, Schoenaers J et al. Enamel
defects on the maxillary premolars in patients with
cleft lip and/or palate: a retrospective case-control
study. Eur Arch Paediatr Dent 2014; 15: 159–165.
https://doi.org/10.1007/s40368-013-0078-8
26. Weerheijm KL. Molar incisor hypomineralization
(MIH): clinical presentation, aetiology and
management. Dent Update 2004; 31: 9–12.
27. Mathu-Muju K, Wright JT. Diagnosis and treatment
of molar incisor hypomineralization. Compend Contin
Educ Dent 2006; 27: 604–610.
28. Discepolo KE, Suher Baker DMD. Adjuncts to
traditional local anesthesia techniques in instance of
hypomineralized teeth. N Y State Dent J 2011; 77: 22.
29. Fayle SA. Molar incisor hypomineralisation:
restorative management. Eur J Paediatr Dent 2003; 4:
121–126.
30. Willmott NS, Bryan RAE, Duggal MS. Molar-incisor-
hypomineralisation: a literature review. Eur Arch
Paediatr Dent 2008; 9: 172–179.
31. Baccetti T. A clinical and statistical study of etiologic
aspects related to associated tooth anomalies in
number, size, and position. Minerva Stomatol 1998;
47: 655–663.
32. Khan S, Gill D, Bassi GS. Management of microdont
maxillary lateral incisors. Dent Update 2014; 41: 867–
874. https://doi.org/10.12968/denu.2014.41.10.867
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of ‘double teeth’in children and adolescents. Int J
Paediatr Dent 2012; 22: 419–426.
34. Husain J, Burden D, McSherry P et al. Clinical
Standards Committee of the Faculty of Dental
Surgery, Royal College of Surgeons of England.
National clinical guidelines for management of
the palatally ectopic maxillary canine. Br Dent
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sj.bdj.2012.726 {AQ: Please check details are correct}
35. Hennessy J, Al-Awadhi EA, Dwyer LO, Leith R.
Treatment of ectopic first permanent molar teeth.
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at: https://doi.org/10.12968/denu.2012.39.9.656
36. Larson M, Hellquist R, Jakobsson OP. Dental
abnormalities and ectopic eruption in patients with
isolated cleft palate. Scand J Plast Reconstr Surg hand
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palatally ectopic maxillary canine. 2016; {AQ: Please
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38. Bjerklin K, Kurol J, Valentin J. Ectopic eruption of
Paediatric Dentistry
maxillary first permanent molars and association with
other tooth and developmental disturbances. Eur J
Orthod 1992; 14: 369–375.
39. Shapira Y, Kuftinec MM. Tooth transpositions – a review
of the literature and treatment considerations. Angle
Orthod 1989; 59: 271–276.
40. Chattopadhyay A, Srinivas K. Transposition of teeth
and genetic etiology. Angle Orthod 1996; 66: 147–152.
41. Campbell RE, Levin L, Mauseth SE, Hu J, Zheng S,
Wilson S, Saal H et al. Prevalence of transposed teeth
as seen on panoramic radiographs in children with
cleft lip and palate. Cleft Palate Craniofac J 2014; 51:
e88–93. https://doi.org/10.1597/12-292.
42. Cunha RF, Boer FA, Torriani DD, Frossard WT. Natal and
neonatal teeth: review of the literature. Pediatr Dent
2001; 23: 158–162.
43. De Almeida CM, Gomide MR. Prevalence of natal/
neonatal teeth in cleft lip and palate infants. Cleft
Palate Craniofacial J 1996; 33: 297–299.
44. Shaw JCM. Taurodont teeth in South African races. J
Anat 1928; 62(Pt 4): 476.
45. Ruprecht A, Batniji S, El-Neweihi E. The incidence of
taurodontism in dental patients. Oral Surg Oral Med
Oral Pathol 1987; 63: 743–747.
46. Madeira MC, Leite HF, Niccoli Filho WD, Simões S.
Prevalence of taurodontism in premolars. Oral Surg
Oral Med Oral Pathol 1986; 61: 158–162.
47. Shifman A, Chanannel I. Prevalence of taurodontism
found in radiographic dental examination of 1,200
young adult Israeli patients. Community Dent Oral
Epidemiol 1978; 6: 200–203.
48. Weckwerth GM, Santos CF, Brozoski DT et al.
Taurodontism, root dilaceration, and tooth
transposition: a radiographic study of a population
with nonsyndromic cleft lip and/or palate. Cleft
Palate Craniofac J 2016; 53: 404–412. https://doi.
org/10.1597/14-299
49. Alani A, Bishop K. Dens invaginatus. Part 1:
classification, prevalence and aetiology. Int Endod J
2008; 41: 1123–1136.
50. Akcam MO, Evirgen S, Uslu O, Memikoğlu UT. Dental
anomalies in individuals with cleft lip and/or palate.
Eur J Orthod 2010; 32: 207–213.
51. Nicholls W. Dental anomalies in children with cleft lip
and palate in Western Australia. Eur J Dent 2016; 10:
254–258.
52. Sanghvi R, Vaidyanathan M, Bhujel N. The dental
health of cleft patients attending the 18-month-old
clinic at a specialised cleft centre. Br Dent J 2019; 227:
199–202. https://doi.org/10.1038/s41415-019-0608-9
53. van den Boogaard M-JH, Dorland M, Beemer FA,
van Amstel HKP. MSX1 mutation is associated with
orofacial clefting and tooth agenesis in humans. Nat
Genet 2000; 24: 342–343.
54. Rullo R, Festa VM, Rullo R et al. Prevalence of dental
anomalies in children with cleft lip and unilateral and
bilateral cleft lip and palate. Eur J Paediatr Dent 2015;
16: 229–232.
55. Ranta R. A review of tooth formation in children with
cleft lip/palate. Am J Orthod Dentofac Orthop 1986; 90:
11–18.
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DentalUpdate 401
 Oral Medicine
Enhanced CPD DO C

Neel Sethi

Alessandra Joelle Booth, Nikul Patel and Graham Merrick

An Overview of the Diagnosis and

Management of Non-neoplastic
Salivary Gland Pathologies
Abstract: Salivary gland pathologies can be caused by obstruction, inflammation, bacterial or viral infections and neoplasia. Patients
can present with acute or chronic presentations of salivary gland disease. Salivary gland disorders can have a significant impact on a
patient’s systemic health, oral health and quality of life. This article aims to increase awareness of salivary gland pathologies and how they
may present in practice. It aims to offer general dental practitioners an understanding of how salivary gland disease can be managed in
primary care and which conditions may warrant referral to secondary care, including suspected malignancy. The dental profession has a
duty of care to recognize pathologies and treat or refer patients. This article provides an overview of non-neoplastic salivary gland disease,
including diagnoses, management and when to refer to secondary care.
CPD/Clinical Relevance: It is important to understand the signs, symptoms and management of non-neoplastic salivary gland diseases,
and when to refer patients to secondary care.
Dent Update 2022; 49: 403–406

Salivary glands are vital to the maintenance tumours. This article focuses on non- as an acute swelling at meal times. This is
of good oral health. They are exocrine glands neoplastic salivary gland pathologies, their typically intermittent and generally resolves
that produce saliva, which is essential to diagnosis, management and the role of the over a 30-minute period after eating, as
ensure lubrication of the oral cavity, aid in general dental practitioner (GDP) in managing saliva gently oozes past the stone. The
the digestion of food and act as a buffer patients with salivary gland disease. second is obstruction by a mucous plug,
to protect the teeth. Anatomically, there which tends to happen at breakfast or after
are three pairs of major salivary glands, the Obstructive salivary disease a patient has become dehydrated, that
parotid, submandibular and sublingual glands. Obstructive salivary gland disease is the can lead to sluggish saliva flow and plug
Minor salivary glands are numerous and can most common salivary gland pathology formation. Commonly known as ‘mealtime
be found throughout the mucosa lining the to present to general dental practitioners.1 syndrome,’ saliva production stimulated by
oral cavity with the exception of the gingiva. Patients suffering from obstructive salivary the process or thought of eating causes a
Salivary gland disease can present as a range disease may complain of intermittent pain build-up of saliva in the affected gland and
of pathologies from stones, obstructions and and swelling. There are two patterns. The first consequential postprandial swelling. In
infections through to benign or malignant is related to a stone that presents classically addition to this, after a period, patients with
stones may experience repeated episodes
of bacterial infections causing suppuration
Neel Sethi, BDS(Dis), MFDS RCS Ed, PgCert Dental Core Trainee, Musgrove Park Hospital. from the gland duct opening and possible
Alessandra Joelle Booth, BDS (Hons), BSc, AKC, Dental Core Trainee, Musgrove Park systemic symptoms of fever and malaise.
Hospital. Nikul Patel, BDS, MFDS RCS Ed, Specialty Doctor Oral and Maxillofacial Surgery, Mucous plugs seldom cause infection.
Musgrove Park Hospital. Graham Merrick, FRCS, FRCS (OMFS), FDSRCS, BDS, MB
The most common cause for obstruction
ChB(Hons), Consultant in Oral and Maxillofacial Surgery, Musgrove Park Hospital.
is sialolithiasis. These are saliva stones
email: neel.sethi@nhs.net
consisting of calcium, magnesium, potassium

May 2022 DentalUpdate 403

Oral Medicine
Figure 1. Radiograph of submandibular sialolith.
Figure 2. Lower lip mucocele.
and ammonium deposits. The majority
of these cases occur unilaterally in one of
the submandibular glands. Sialolithiasis
is most commonly seen in males2 and is
thought to affect 12 in 1000 adults,3 rarely
affecting children.
Around 94.2% of sialoliths in the
submandibular gland, and 43.3% in the
parotid gland, are radiopaque,4 therefore
standard radiographs (Figure 1) and
computer tomography can be of diagnostic
value. Ultrasound sonography has been
shown to be beneficial in locating stones in
the hands of experienced radiographers.5
Sialoendoscopy is being increasingly used
both to diagnose and treat sialoliths.6
Management techniques for sialoliths
vary depending on the size and location
of the stone. In the past, there were very
few treatment options available for the
management of obstructive salivary gland
disease, and the main surgical treatment
involved the removal of the associated
gland. However, using modern techniques,
it has now been shown that over 70% of
stones can be retrieved, and only a minority
of glands require removal.4 Minimally
invasive techniques include extra-corporeal
shockwave lithotripsy, radiologically guided
basket retrieval, balloon dilation and intra-
oral stone removal.1 Surgical removal is a
well-documented technique for removing
larger stones. Interventional radiography
such as fluoroscopy-guided basket removal
404 DentalUpdate
can be used to locate and retrieve stones
within a duct.
In some cases, a sialadenectomy (surgical
excision of the affected salivary gland) may
be required, but this is not without the risk of
paralysis of the marginal mandibular nerve in
the case of the submandibular gland or the
facial nerve when treating the parotid gland.
Cases that may warrant a sialadenectomy
include multiple stones within the duct,
stones that have adhered to the duct wall,
recurrent sialoliths, large stones within the
gland itself or previous failed attempts at
retrieval of a stone.7
Sialadenitis
Infections within the salivary glands
most commonly occur in the parotid.
Acute bacterial ascending sialadenitis is
predominantly caused by Staphylococcus
aureus.8 Traditionally, it was related to
patients with a decreased salivary flow
rate, such as in older persons or those with
chronic dehydration, but this is uncommon
now, and it is normally associated with
obstruction by a stone. Usually, sialadenitis
presents as diffuse pain and swelling around
the gland. Massaging of the gland may
expel suppuration from the duct opening.
Occasionally, the infections can be severe
and patients may present with systemic
signs of infection, such as pyrexia or malaise.
Management of the condition involves
antibiotics, surgical release of pus if present,
and removal of the obstructing stone. Patient
education to encourage hydration, self-
massage of the gland and consumption of
saliva-stimulating foods, such as citric acid,
can be beneficial.
Mucoceles
Mucoceles present as rounded, localized
blue-transparent swellings on the oral
mucosa caused by an alteration in a minor
salivary gland leading to the accumulation
of mucous. While they can occur on any oral
mucosa containing minor salivary glands,
they are most commonly seen on the lower
lip and can be linked to trauma, lip biting
habits or iatrogenic causes (Figure 2). These
are predominantly mucous extravasation
cysts induced by trauma to a minor salivary
duct, and the subsequent pumping of saliva
into the loose surrounding connective tissue
(hence why they do not occur on the hard
palate). Minor salivary glands have the
unique capacity to secrete against pressure.
Ranulas describe extravasation cysts of
the sublingual gland that predominantly
present as a cystic swelling in the floor of the
mouth. They have the potential to become
plunging ranulas in instances where the
saliva passes through the mylohyoid muscles
and extend down into the neck.
Diagnosis of mucoceles is usually based
on clinical presentation and excisional
biopsy. Fine needle aspiration can be used.
Aspirate of amylase and high-protein content
would confirm the presence of saliva, and
the diagnosis of a mucocele, but observing
a thick sticky liquid is pathognomonic of
this condition.
Mucoceles are occasionally self-limiting
and may go through periods of relapse and
recurrence, but normally persist and have
to be removed. Correcting the aetiology
if trauma is a contributing factor through
removing sharp restorations or addressing lip
biting habits will aid this process.
Simple incision of the mucocele often
leads to recurrence because the excess
mucous is drained, but the affected salivary
gland remains. Surgical excision, along with
the affected saliva gland, is the conventional
treatment of choice. However, patients need
to be warned of the risk of recurrence, or
numbness from injury to small branches of
the mental nerve.
Mumps
Mumps is an infectious viral disease that
causes swelling of the parotid glands caused
by a virus from the paramyxovirus family.
Symptoms usually present as bilateral
swelling of the parotids accompanied by
systemic signs such as pyrexia, fatigue and
malaise. Although the mumps, measles
and rubella vaccine (MMR) has decreased
the incidence of the virus,9 those who are
vaccinated can still develop the disease and
the UK has seen local outbreaks.10 While rare,
complications include orchitis, encephalitis,
pancreatitis and myocarditis.11
Diagnosis is usually determined
clinically, however. Laboratory diagnosis
can be made from a saliva sample using
immunofluorescence staining or PCR to test
for the presence of the virus, or serological
testing to look for virus-specific antibodies.11
The management for mumps is
predominantly supportive therapy through
regular analgesics, promoting hydration and
bed rest. Further medical intervention should
be sought to confirm diagnosis and monitor
for complications.
Systemic disease
Salivary gland pathology can present as a
manifestation of systemic disease. Usually
May 2022

Figure 3. Frothy saliva resulting from xerostomia.
these present as diffuse, non-inflammatory
swellings of the major salivary glands. The
most common cause of sialosis is diabetes
mellitus and alcoholism.12 Other possible
causes to investigate include HIV, hepatis C
and sarcoidosis.
Xerostomia
Xerostomia is the sensation of a dry mouth
due to either a reduction in the quantity of
saliva produced, or the composition of saliva
(Figure 3). Dry mouth can impact a patient’s
speech, ability to chew, eat, swallow and
wear dentures. Drugs are the most common
cause of a reduction in salivary flow.13 This is
becoming a growing problem among those
who are older due to the high prevalence of
polypharmacy. Some of the other causes of
xerostomia are outlined in Table 1.
Several questionnaires have been
developed that can indicate whether a
patient is suffering from a dry mouth. This,
alongside a thorough medical history
assessing which medications a patient is
taking, whether they have any systemic
diseases and if they have had a history of
radiation to the head and neck can
determine potential causes for xerostomia.
Additionally, a clinical examination, such as
sialometry, can determine the severity of a
patient’s xerostomia.
Sjogren’s syndrome (SS) is an
autoimmune condition, which, when it
develops in isolation of any rheumatic
disease, is known as primary SS. Patients
with primary SS are at a higher risk of
developing non-Hodgkin’s lymphoma and
May 2022
Oral Medicine
Sjogren’s Syndrome
IgG4
Thyroid disease
Scleroderma
Sarcoidosis
Tuberculosis
Ectodermal dysplasia
Parkinson disease
Primary biliary cirrhosis
Graft vs host disease
Medication
Head and neck radiotherapy
Diabetes mellitus
HIV Figure 4. A parotid swelling, which in this
instance was diagnosed as pleomorphic
Hepatitis C adenoma.
Renal disease
Dehydration
also be informed of common habits that
Alcohol intake may further exacerbate symptoms of a dry
Tobacco use mouth, including alcohol, smoking and
caffeinated beverages.17 Patients are also at a
Table 1. A list of some of the causes of
higher risk of developing oral candidiasis and
xerostomia. Based on a figure by Millsop et al.25
sialadenitis, so should be educated about the
symptoms of these and treated accordingly
by the GDP.
may require more frequent monitoring
Sialorrhea
and regular recall intervals.14 However,
secondary SS is more common and While true hypersalivation is uncommon,
linked to other autoimmune diseases, sialorrhea can impact the quality of life of
such as rheumatoid arthritis or systemic patients with neurodegenerative disorders
such as Parkinson’s disease. If left untreated,
lupus erythematosus. Diagnosis involves
it can lead to reduced social functioning,
saliva flow rate, blood tests (specifically
skin breakdown, infection or aspiration. True
antinuclear antibodies Ro and La,
sialorrhea is due to hypersalivation, usually
rheumatoid factor and erythrocyte
linked to medication such as clozapine.
sedimentation rate), Schirmer test (a
Pseudo causes of sialorrhea result from the
measure of tear production), ultrasound
inability to clear saliva from the oral cavity,
scans and labial salivary gland biopsy.15
such as in conditions that impair a patient’s
The management for xerostomia ability to swallow, for example motor
involves advising patients to take frequent neurone disease. Management includes oral-
sips of water, sugar-free chewing gum, motor exercises, anticholinergic medication,
diabetic sweets, cholinergic drugs (eg botulinum toxin injections or, in more severe
pilocarpine), avoid dry, sharp, acidic cases, surgical intervention through gland
or citrus foods and prescribing saliva excision, denervation of glands or redirection
replacements, which come in a range of saliva duct openings.18
of modalities, such as sprays, gels and
lozenges. Reduced saliva flow predisposes
patients to an increased risk of dental decay. Neoplasia
Due to this, GDPs should consider shorter While infrequent, salivary gland tumours can
recall intervals, fluoride varnish applications, occur in the minor or major salivary glands
high-fluoride toothpaste, diet education and be either benign or malignant. Malignant
and oral hygiene advice.16 Patients should major salivary gland disease accounts for
DentalUpdate 405
Oral Medicine
6% of all head and neck cancers in the UK,
and the incidence of major salivary gland
malignancy is increasing.19 Most commonly,
salivary gland tumours are found within
the parotid gland, the majority of which are
benign. In contrast to this, while less common,
tumours in the minor salivary glands carry a
much higher risk of malignancy.
While the aetiology remains unclear,
although rare, certain factors have been
shown to increase the risk of developing
a salivary gland neoplasm, for example,
previous head and neck radiation,
Epstein–Barr virus,20 Hodgkin lymphoma,21
and immunosuppression (acquired
immunodeficiency disease).22 Some
benign salivary gland tumours, such as
a pleomorphic adenoma (Figure 4), have
a small malignant transformation risk.23
Carcinoma ex pleomorphic adenoma occurs
from either a primary or recurrent benign
pleomorphic adenoma.23
Features that should alert the clinician
to suspected malignancy include: a
rapid growing mass, any unexplained
lump or swelling, fixation of the tumour
to underlying tissues, increasing pain,
unexplained ulceration and cervical
lymphadenopathy. Salivary gland neoplasms
affecting the parotid or submandibular
glands may impinge on the facial nerve
and cause ipsilateral facial nerve weakness
or paralysis. If a patient presents with any
of the above symptoms, it is imperative
that they are referred appropriately via a
suspected cancer 2-week wait pathway.
The main treatment of choice for salivary
gland tumours is excision with or without
adjunctive radiotherapy.24,25
Summary
Salivary gland pathology is a common
presentation to the GDP. In order for these
patients to be appropriately managed,
clinicians must have a good understanding
of their presentation and treatment. It is
imperative that thorough extra- and intra-oral
clinical examinations are undertaken for all
patients. If required, further investigations
and management should be undertaken
in primary care. Although the majority
of salivary gland conditions are benign,
it is essential that patients are referred
to a secondary care or specialist service
on a 2-week wait referral pathway when
malignancy is suspected.
Acknowledgements
The authors would like to acknowledge
Professor Mike Lewis, Mr Andrew Cronin
406 DentalUpdate
and Dr Phillip Atkin from the University Dental
Hospital, Cardiff for the use of their clinical
photographs.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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15. Felix D, Luker J, Scully C. Oral medicine: 4. Dry
mouth and disorders of salivation. Dent Update
2012; 39: 738–743.
16. Public Health England. Delivering better
oral health: an evidence-based toolkit for
prevention. Summary guidance tables. 2014.
Available at: https://www.gov.uk/government/
publications/delivering-better-oral-health-
an-evidence-based-toolkit-for-prevention
(accessed March 2022).
17. Scully C. Drug effects on salivary glands: dry
mouth. Oral Dis 2003; 9: 165–176.
18. Lakraj A, Moghimi N, Jabbari B. Sialorrhea:
anatomy, pathophysiology and treatment with
emphasis on the role of botulinum toxins.
Toxins 2013; 5: 1010–1031.
19. Office for National Statistics. Cancer registration
statistics, England. Available at: https://www.
ons.gov.uk/peoplepopulationandcommunity/
healthandsocialcareconditionsand
diseasesbulletinscancerregistration
statisticsengland/2017 (accessed March 2022).
20. Mozaffari H, Ramezani M, Janbakhsh A, Sadeghi
M. Malignant salivary gland tumors and
Epstein–Barr virus (EBV) infection: a systematic
review and meta-analysis. Asian Pac J Cancer
Prev 2017; 18: 1201–1206.
21. Dong C, Hemminki K. Second
primary neoplasms among 53,159
haematolymphoproliferative malignancy
patients in Sweden, 1958–1996: a search for
common mechanisms. Br J Cancer 2001; 85:
997–1005.
22. Shebl F, Bhatia K, Engels E. Salivary gland and
nasopharyngeal cancers in individuals with
acquired immunodeficiency syndrome in
United States. Int J Cancer 2010; 126: 2503–
2508.
23. Sood S, McGurk M, Vaz F. Management of
salivary gland tumours: United Kingdom
national multidisciplinary guidelines. J Laryngol
Otol 2016; 130(S2): S142–S149.
24. To V, Chan J, Tsang R, Wei W. Review of salivary
gland neoplasms. ISRN Otolaryngol 2012; 2012:
1–6.
25. Millsop JW, Wang EA, Fazel N. Etiology,
evaluation, and management of xerostomia.
Clin Dermatol 2017; 35: 468–476.
CPD ANSWERS
MARCH 2022
1. B 6. B
2. B 7. C
3. D 8. C
4. D 9. B
5. B 10. D
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 Restorative Dentistry
Enhanced CPD DO C

Hannah Bradley

Kirsty Cowan, Brandon Owen, Shahab Rahman and William Keys

An Update on Radiation Caries

Abstract: Radiation caries describes the rapid onset and progression of dental caries in patients who have received radiotherapy to
the head and neck. The combination of salivary gland damage resulting in hyposalivation and a cariogenic diet can have catastrophic
consequences with a considerable impact on the quality of life of individuals. Caries risk must be managed at all stages of the patient’s
head and neck cancer journey from the pre-assessment to their lifelong maintenance. This paper provides an overview of the aetiology,
presentation and management of radiation caries demonstrated with clinical cases.
CPD/Clinical Relevance: With the increasing incidence of head and neck cancer, clinicians should be aware of the significance of radiation
caries, understand its specialist management and be able to contribute to the patient’s long-term management.
Dent Update 2022; 49: 409–414

Around 12,400 new head and neck cancer treatment, rehabilitation and maintenance post retrospective analysis of 95 patients who had
(HANC) cases are diagnosed annually in the treatment.6 With patients retaining their teeth received radiotherapy for HANC demonstrating
UK, and the incidence is on the rise.1 HANC for longer, the role of the team is becoming an average of 6.63 carious teeth over a mean
patients are managed in secondary care by a increasingly complex and, considering follow-up of 3.75 years.10
multidisciplinary team of specialists.2 The three HANC patients often present with poor oral Radiation-induced damage to the enamel,
main management strategies are surgery, health, the subsequent undesirable effects of dentine and the amelo-dentinal junction may
radiotherapy and chemotherapy, which may be radiotherapy on the oral cavity result in a high predispose individuals to caries.11 However,
used as a single modality or in combination.3 It risk of dental caries.7,8 Primary care dentists radiation caries is thought to develop primarily
is reported that 43–85% of HANC cases receive are increasingly likely to encounter patients as an indirect effect of radiotherapy on the
radiotherapy.1 Radiotherapy to the head and following cancer therapy presenting with salivary glands resulting in reduced quantity
neck region can have a number of adverse radiation caries and will play a key role in long- and quality of saliva in combination with a
short- and long-term complications on the term monitoring and maintenance. cariogenic diet.12,13 A reduced flow of viscous
oral cavity, with a significant impact upon the saliva with reduced buffering capacity, reduced
quality of life of patients during and post cancer clearance and a reduced pH creates a shift
therapy.4 Complications include mucositis,
What is radiation caries? in the oral microflora, favouring cariogenic
candidiasis, altered taste, osteoradionecrosis, Radiation caries describes the rapid onset bacteria, such as Streptococcus mutans and
trismus, xerostomia and radiation caries.5 and progression of dental caries in individuals Lactobacillus and the development of dental
The designated oral healthcare team, who have been exposed to head and neck caries.12–14 Table 1 summarizes the factors that
led by a restorative consultant, plays a ionizing radiation. Overt caries may be seen may contribute to radiation caries.
role throughout the journey including the within 3 months of completing treatment.9 An individual’s risk of salivary dysfunction
patients pre-assessment, oral care during Radiation caries is very common with a recent depends on their initial salivary function,
radiation dose and radiation field with
particular emphasis on volume of salivary
Hannah Bradley, BDS(Hons), MFDS RCPS(Glasg), PGCert(MedEd), former Dental Core
gland irradiation.15 Consequently, when
Trainee; Kirsty Cowan, BDS(Hons), MFDS RCPS(Glasg), Dental Core Trainee; Brandon
compared to conventional radiotherapy,
Owen, BDS(Hons), MFDS RCPS(Glasg), PGCert(MedEd), former Dental Core Trainee;
sparing of the parotid glands with use of
Shahab Rahman, BDS, MSc, MFDS RCS(Edin), Speciality Dentist in Restorative Dentistry,
intensity-modulated radiation therapy
Aberdeen Dental Hospital. William Keys, BDS, MDSc, MFDS RCPS(Glasg), FDS(Rest Dent.)
(IMRT) has been associated with a reduced
RCPS(Glasg), Consultant in Restorative Dentistry, Department of Restorative Dentistry,
incidence of xerostomia, better recovery of
Edinburgh Dental Institute.
saliva production and improved quality of
email: hbradley75@gmail.com
life.16 Adjuvant chemotherapy increases the

May 2022 DentalUpdate 409

Restorative Dentistry
biological equivalent dose of radiotherapy
and so these patients may be at greater risk of
radiation caries.17
Pre-treatment dental assessment
Patients whose treatment will affect the mouth
or jaw should have a dental assessment prior to
their cancer therapy.2 Restorative consultants
working within a multidisciplinary team are in
the best position to conduct these assessments
owing to their expertise in prevention and
management of complications, and the need
for complex oral rehabilitation.2,7,18 Patients
requiring a dental assessment are identified
at the multidisciplinary team meeting, and
assessed as soon as possible to allow sufficient
time for the required dental treatment to
be completed.6,7,13 The aims of the dental
assessment are as follows:6,7,13
„ Planning for the extraction of teeth
that are unrestorable, have a doubtful
prognosis or are at risk of future dental
disease in an area that would be at risk
of osteoradionecrosis. Extractions should
be completed at least 10 days prior to
commencing cancer therapy.
„ Planning for the restoration of the remaining
Caries prevention advice
Maintain good oral hygiene through
effective tooth brushing and
interdental cleaning
Daily use of 5000ppm fluoride toothpaste
Daily 0.05% sodium fluoride mouth rinse
Daily use of remineralizing toothpaste (eg Although the evidence suggests no significant benefit from using remineralizing
Tooth Mousse, GC, Japan) toothpastes containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)
(eg Tooth Mousse) over the use of fluoride, the free calcium and phosphate, often lacking
in patients with hyposalivation, has been shown to be beneficial for the prevention and
remineralization of root caries in HANC patients who have undergone radiotherapy22,23
Twice yearly application of fluoride
varnish (2.2% NaF)
Provide dietary advice under close liaison
with the dietitian
Sugar-free medicines should be used
where possible
Table 2. Routine caries prevention advice for HANC patients.
410 DentalUpdate
„ Reduction in quantity and quality of saliva
„ Increased nutritional requirements resulting in frequent consumption of
refined carbohydrates
„ Poor oral hygiene due to mucositis, trismus and lower prioritization of dental health
„ Altered taste resulting in a preference for cariogenic foods
„ Direct effects of radiation on the dental hard tissues
Table 1. A summary of the risk factors for radiation caries.
teeth that may be carious or have the of caries prevention strategies in HANC
potential to traumatize the soft tissues. patients. Therefore, a range of prevention
„ Avoid unscheduled interruptions to cancer methods are recommended based on the
therapy attributable to dental problems. wider evidence-base for caries prevention.
„ Prepare the patient for the anticipated Fluoride remains the cornerstone of
short- and long-term oral complications of prevention, and routine caries prevention
cancer therapy. advice is detailed in Table 2.
„ Develop a plan for prevention, oral
rehabilitation and follow-up.
Dental care during
Once dental treatment is complete, the
cancer therapy
patient should be dentally fit and have
a dentition that can be maintained and Involving the restorative consultant during
rehabilitated post therapy.7 The key to cancer therapy may help to improve the
maintaining oral health and reducing the patient’s oral comfort and reduce the risk of
risk of radiation caries is daily self-care with complications.18 The importance of prevention
an individualized preventive regimen. There cannot be underestimated and the patient’s
is limited evidence regarding effectiveness pre-planned preventive regimen should
Comments
Tooth brushing should be undertaken at least twice daily, last thing at night and on one
other occasion19
Toothpastes containing higher fluoride concentrations are more effective at
caries prevention19
In addition, application of fluoride in custom trays worn for 5–10 minutes daily has been
recommended, although the evidence shows compliance is low in HANC patients20
A daily fluoride rinse used at a different time to brushing may significantly reduce the risk
of caries19,21
The topical application of fluoride varnish has a caries-inhibiting effect and is recommended
in patients with high risk of caries19,24
An energy-dense diet may be recommended by the dietitian and should be balanced
against the patient’s risk of caries. Close liaison with the dietitian with the aim of reducing
the frequency of sugars between meals may be beneficial
A healthy balanced diet should be encouraged during the post therapy period and the
frequency and amount of sugary food and drink reduced19,25
The use of sugar free medicines should be coordinated with the oncologist.6 Where
there are no suitable alternatives, the patient should be advised to rinse their mouth
following consumption
May 2022

Figure 1. ORN presenting in the posterior
mandible following tooth extractions in a patient
previously irradiated for the management
of HANC.
b
be reinforced (Table 2). It is recognized that
the short-term side effects of radiotherapy
or chemotherapy, such as mucositis, may
indirectly increase caries risk by reducing
tolerance to oral hygiene measures.13
Consequently, management of these effects
may indirectly contribute to caries prevention.
Where effective tooth brushing is hindered due
to mucositis, a soft toothbrush may be used
in the short term. Some patients find mint-
flavoured high-fluoride toothpaste too strong
to tolerate, and alternative products should
be recommended.26 Sodium lauryl sulphate-
(SLS) free and unflavoured toothpastes (eg
OraNurse, UK) are preferred by some patients.
Taste changes during radiotherapy often result
in patients choosing cariogenic foods.6 This is
compounded by the need for an energy-dense
diet, including nutritional supplements (eg
Ensure, Abbott Laboratories, UK), resulting in
a frequent intake of refined carbohydrates.13,25
While it is recognized that this significantly
increases the risk of dental caries, this should
be balanced against the patient’s weight
and nutritional status. Close liaison with
the dietitian is recommended to reduce the
frequency of sugars between meals, in addition
to sticky foodstuffs with a low oral clearance.27
Modifications, such as consuming sugar-
containing drinks through straws, may also
be beneficial.6
Dental care post cancer therapy
Maintenance care
All HANC patients require close follow-up
with a focus on prevention owing to the
life-long increased risk of dental disease.6,18
The initial recall interval based on NICE
guidance is 3 months, although this may
later be altered based on the patient's risk
assessment.28 Patients experiencing late
complications may require longer-term follow-
May 2022
Figure 2. Radiographic progression of radiation caries in Case 1. (a) OPG pre-radiotherapy. (b) Peri-
apical images taken 18 months after the initial OPG demonstrating the classical presentation of
radiation caries at the CEJ.
up within a specialist environment. However,
where the patient has been rehabilitated and
demonstrates stable oral health, they may be
discharged to primary care for maintenance.6,7
The initial interval for radiographic monitoring
for the purpose of caries detection is 6 months,
which may be increased to 12 months if long-
term stability is evident.29
Presentation of radiation caries
The presentation of caries tends to differ
in those who have received radiotherapy.
It presents as atypical lesions affecting
surfaces normally resistant to caries including
incisal edges, cusp tips, lingual and smooth
surfaces, likely due to the lack of mechanical
cleansing from salivary flow as a result of
hyposalivation. The most common type of
radiation caries affects the cervical surface and
progresses circumferentially at the cemento-
enamel junction (CEJ) eventually resulting in
decoronation.30 Breslin and Taylor10 identified
that mandibular incisors and canines were
most commonly affected by radiation caries,
followed by the maxillary incisors and canines.
However, this was likely to be a result of fewer
Restorative Dentistry
posterior teeth as these are more commonly
extracted pre-radiotherapy.
Management of radiation caries
Management of radiation caries should aim
to reduce the risk of osteoradionecrosis
(ORN) by avoiding extractions in irradiated
sites. ORN is commonly defined as an area
of exposed devitalized bone, in a previously
irradiated field, in the absence of neoplastic
disease (Figure 1).31 Teeth should be retained
wherever possible, which may include the
need for root canal treatment, retention of
roots or decoronation. Primary care dentists
may provide routine restorative treatment,
but where there is no suitable alternative, it
has been recommended for extractions to be
referred to secondary care.6,32
The restoration of teeth in those with
radiation caries is not without its challenges,
particularly as patients may present with
extensive atypical lesions and trismus.
Composite resin, resin-modified glass ionomer
and amalgam restorations perform more
favourably than glass ionomer cements.
However, in those with poor adherence to
DentalUpdate 411
Restorative Dentistry
a a
Figure 3. Clinical presentation of radiation caries
in Case 1. (a) Decoronated LR4 demonstrating
circumferential caries at the CEJ. (b) Anterior view
demonstrating radiation caries affecting cervical
and incisal aspect of the mandibular teeth. (c)
Occlusal view demonstrating radiation caries
affecting incisal surfaces of the mandibular teeth.
fluoride regimens, glass ionomer cements
may be preferred owing to a reduced rate
of recurrent caries at the expense of regular
maintenance and replacement.33 Caries should
be managed conservatively initially with direct
restorations. Indirect restorations may be
considered in patients who are stable with a
good level of oral hygiene.6
Case reports
Case 1
A 67-year-old male diagnosed with a T4N3M0
basaloid squamous cell carcinoma (BSCC)
that affected the skin posterior to the right
ear was referred, following surgery, to the
restorative team for a dental assessment prior
to chemoradiotherapy.
The patient presented with a minimally
restored, periodontally stable lower arch and
an upper complete denture. A pre-operative
orthopantomogram (OPG) was taken
(Figure 2a). Extraction of the heavily restored
LL7 was promptly arranged. Oral hygiene
advice was given and 5000ppm fluoride
toothpaste prescribed.
The patient was reviewed 2 months post-
radiotherapy, presenting with a dry mouth, and
412 DentalUpdate
Figure 4. Radiographic progression of radiation caries in Case 2. (a) OPG pre-radiotherapy. (b)
OPG following delayed presentation post-therapy demonstrating retained roots and widespread
radiation caries.
a salivary replacement spray was prescribed.
Despite regular reviews, reinforcement of oral
hygiene advice and high-fluoride toothpaste,
the patient attended with a decoronated LR4 14
months later (Figure 3a). Clinical examination
revealed poor oral hygiene, viscous frothy saliva
and caries affecting the remaining dentition
(Figure 3b, c). Peri-apical radiographs confirmed
extensive caries (Figure 2b). A dental clearance
was performed, followed by provision of a
new complete upper denture and immediate
lower denture.
Case 2
A 63-year-old male patient diagnosed with
a right tongue base T4N2M0 squamous
cell carcinoma (SCC) was seen for a dental
assessment prior to chemoradiotherapy.
The patient was an infrequent dental
attender. An OPG was taken to assess the
dentition (Figure 4a). The UR8, UL6, LL8, LR7 and
LR8 were extracted. High-fluoride toothpaste
and 0.05% fluoride mouthwash were prescribed.
The patient failed to attend his scheduled
review. He attended 12-months post
radiotherapy reporting multiple broken
teeth. Clinical and radiographic evaluation
revealed grossly carious teeth (Figure 4b). A
full clearance was arranged and complete
dentures constructed.
Case 3
A 66-year-old male diagnosed with a T1N1M0
BSCC of the left tonsil was seen for a dental
assessment prior to chemoradiotherapy.
The patient had fair oral hygiene and a
heavily restored dentition. Multiple extractions,
including the LR7, were performed. The
patient lived a considerable distance from the
secondary care service and the general dental
practitioner (GDP) was asked to complete full-
mouth ultrasonic debridement, prescribe high-
fluoride toothpaste and replace the LR6 crown
due to marginal deficiencies (Figure 5a).
The patient failed to attend his post-
therapy review and presented 17 months later
May 2022
 Restorative Dentistry

a a

b
c

Figure 5. Periapical radiographs demonstrating

the progression and management of radiation
caries in the LR5 and LR6 of Case 3. (a) Pre-
chemoradiotherapy; (b) 17 months following the
initial image; (c) post root canal treatment and
prior to final coronal restoration.

with pain in lower right quadrant. Peri-apical

radiographs demonstrated caries affecting
multiple teeth (Figure 5b). A gingivectomy
followed by root canal treatment of the LR5
and LR6 was performed to avoid extraction and Figure 6. Radiographic presentation and management of radiation caries in Case 4. (a) OPG
the risk of osteoradionecrosis (Figure 5c). demonstrating failing restorations. (b) Clinical photograph demonstrating failed restorations prior
Case 4
A 58-year-old male patient with a T3N1M0
right tongue base SCC was managed with
surgery and adjuvant chemoradiotherapy. He
was referred 17 months later to the restorative
dentistry department by the ear, nose and
throat (ENT) team due to extensive dental caries.
The patient had a dry mouth with poor oral
hygiene and caries affecting multiple teeth.
Oral hygiene advice, high-fluoride toothpaste
and fluoride mouthwash were given, followed
by direct restoration of carious teeth. Over
the course of several years, secondary caries
compromised the restorability of the teeth and
those of hopeless prognosis were extracted
to further treatment. (c) OPG 17 months after image (a) showing healed extraction sockets and
restoration of teeth in upper arch.
(Figure 6a, b). A lower partial acrylic denture
with stainless steel clasps was constructed.
Porcelain metal crowns were provided
for the UR7, UR3, UR2, UR1, UL1, UL2, UL3
and UL7 with guide planes and rest seats
allowing the provision of a cobalt–chrome
denture (Figure 6c). This functioned well for
several years until the remaining lower teeth
developed caries and required extraction. A
complete denture was constructed, and the
patient was functioning satisfactorily with
the dentures.
Conclusion
Head and neck radiotherapy can have adverse
effects on the oral cavity that can affect an
individual’s quality of life. Radiation caries
is a frequent complication that is due to a
combination of factors, namely oral discomfort,
hyposalivation and a cariogenic diet. It has a
rapid onset and progression, with an atypical
presentation on surfaces usually resistant to
caries. An individualized preventive regimen,
which is reinforced pre, during and post

May 2022 DentalUpdate 413

Restorative Dentistry
radiotherapy is essential in reducing the risk
of caries. When radiation caries presents, the
aim should be to restore and retain teeth to
avoid the risk of ORN following extractions.
Primary care dentists have an important role
in the long-term maintenance and monitoring
of the HANC population and are increasingly
likely to encounter such complications in
practice. Further research is required to assess
the effectiveness of preventive measures in
the HANC population to reduce morbidity and
improve quality of life.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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1811–1814. https://doi.org/10.1007/s00520-011-
1279-5
21. Marinho VC, Chong LY, Worthington HV, Walsh
T. Fluoride mouthrinses for preventing dental
caries in children and adolescents. Cochrane
Database Syst Rev 2016; 7: CD002284. https://doi.
org/10.1002/14651858.CD002284.pub2
22. Raphael S, Blinkhorn A. Is there a place for Tooth
Mousse in the prevention and treatment of early
dental caries? A systematic review. BMC Oral Health
2015; 15: 113. https://doi.org/10.1186/s12903-015-
0095-6
23. Papas A, Russell D, Singh M et al. Caries clinical
trial of a remineralising toothpaste in radiation
patients. Gerodontology 2008; 25: 76–88. https://
doi.org/10.1111/j.1741-2358.2007.00199.x
24. Marinho VC, Worthington HV, Walsh T, Clarkson
JE. Fluoride varnishes for preventing dental
caries in children and adolescents. Cochrane
Database Syst Rev 2013; (7): CD002279. https://doi.
org/10.1002/14651858.CD002279.pub2
25. Talwar B, Donnelly R, Skelly R, Donaldson M.
Nutritional management in head and neck cancer:
United Kingdom National Multidisciplinary
Guidelines. J Laryngol Otol 2016; 130(S2): S32–S40.
https://doi.org/10.1017/S0022215116000402
26. Jawad H, Hodson NA, Nixon PJ. A review of dental
treatment of head and neck cancer patients,
before, during and after radiotherapy: part 2. Br
Dent J 2015; 218: 69–74. https://doi.org/10.1038/
sj.bdj.2015.29
27. Meurman JH, Grönroos L. Oral and dental health
care of oral cancer patients: hyposalivation, caries
and infections. Oral Oncol 2010; 46: 464–467.
https://doi.org/10.1016/j.oraloncology.2010.02.025
28. National Institute for Clinical Excellence. Dental
checks: intervals between oral health reviews.
2004. Online information available at https://www.
nice.org.uk/guidance/cg19 (accessed April 2022).
29. Faculty of General Dental Practice (UK). Selection
criteria for dental radiography standards. 2015.
Available at: https://cgdent.uk/wp-content/
uploads/2021/08/FGDP-SCDR-ALL-Web.pdf
(accessed February 2021).
30. Aguiar GP, Jham BC, Magalhães CS, Sensi LG, Freire
AR et al. A review of the biological and clinical
aspects of radiation caries. J Contemp Dent Pract
2009; 10: 83–89.
31. Dhanda J, Pasquier D, Newman L, Shaw R. Current
concepts in osteoradionecrosis after head and
neck radiotherapy. Clin Oncol (R Coll Radiol)
2016; 28: 459–466. https://doi.org/10.1016/j.
clon.2016.03.002
32. McCaul LK. Oral and dental management for head
and neck cancer patients treated by chemotherapy
and radiotherapy. Dent Update 2012; 39: 135–140.
https://doi.org/10.12968/denu.2012.39.2.135
33. Hong CHL, Hu S, Haverman T et al. A systematic
review of dental disease management in cancer
patients. Support Care Cancer 2018; 26: 155–174.
https://doi.org/10.1007/s00520-017-3829-y
May 2022
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Endodontics
Enhanced CPD DO C

Faizan Javed Saqib Habib

Robia Ghafoor

Surgical Endodontics under

the Microscope:
Principles and Practice
Abstract: The direct operating microscope has completely revolutionized the field of endodontics, leading to increased success in both
non-surgical and surgical cases. In low- and middle-income countries, microsurgical endodontics is still a developing field and procedures
that fall within this category employ higher magnification. Currently, less than 25% of dentists in developing countries employ any sort
of magnification in their practice. Basic concepts, such as microscope positioning and operator’s ergonomics, are still confusing to many
dentists, novice or experienced alike. This article introduces the benefits and general principles of direct operating microscope use in
endodontic microsurgeries.
CPD/Clinical Relevance: A better understanding of the use of dental operating microscopes in endodontic microsurgical techniques may
facilitate a more efficient workflow.
Dent Update 2022; 49: 416–422

Endodontic practice has always been an
art of precision and attention to detail,
thereby making every millimetre count. With
minute inconsistencies in root-canal filling
resulting in failures, it was only natural that
endodontists would employ magnification
for their day-to-day cases. Dental operating
microscopes (DOM) were introduced in
endodontics in the early 1990s,1,2 but
saw routine use after being mandated in
postgraduate endodontic programmes by
the American Association of Endodontics in
1998. This use led to a significant increase
in successful clinical outcomes in both non-
surgical and surgical endodontics.3,4
For dentists who were trained without
magnification, the introduction of any sort
Faizan Javed, BDS, Instructor; Saqib Habib, BDS, Resident; Robia Ghafoor, BDS,
FCPS, Assistant Professor; Operative Dentistry and Endodontics, Aga Khan University,
Karachi, Pakistan.
email: robia.ghafoor@aku.edu
of magnifying device/magnification was met
with reservation.5 Clinicians had to weigh the
benefits of a new technique against the cost
and time involved in making it an effective
investment. In a 2017 review of endodontic
re-treatment practices, Nagi et al6 reported
that less than 25% of dentists in a developing
country employed any sort of magnification.
In contrast, the use of microscopes by
endodontists in the US was 90% in 2008.7
In low- and middle-income countries,
the introduction of microsurgery in
endodontics is still in a nascent state. The
procedures that fall within the category
employ higher magnification by virtue of the
operating microscope, or less commonly the
endoscope.8,9 While foremost consideration is
given to non-surgical endodontic treatment
when a patient presents with persistent peri-
apical disease, endodontic microsurgery may
be more appropriate, if not the only option
available in certain cases. A list of indications
for endodontic microsurgery are given below:
„ Endodontically treated teeth with clinical
and/or radiographic signs of failure, where
orthograde re-treatment is unlikely to
improve upon previous results.
„ Iatrogenic or developmental anomalies
that prevent access and, by extension,
disinfection of the apical third. Such
cases include irretrievable separated
instruments, non-negotiable ledges, and
pulp canal obliteration.
„ Extrusion of obturation material or
instruments beyond the apex not
amenable to orthograde retrieval
„ Heavily restored teeth where disassembly
of the coronal structure would risk
rendering the tooth unrestorable.
„ Disassembly and orthograde re-treatment

416 DentalUpdate May 2022

 Endodontics

a b c

d e f

Figure 1. Clinical use of DOM in surgical endodontics. (a) Flap reflection and initial osteotomy preparation. (b) Root-end resection. (c) Root-end preparation. (d)
Retrograde ultrasonic preparation. (e) Inspection of prepared root end following application of methylene blue dye. Note the crack (arrow)on the palatal root
surface. (f) Root-end filling. Photo courtesy of Dr Fahad Umer.

would incur excessive cost and longer
re-treatment time.
„ Unclear diagnosis of peri-apical lesion
where specimen needs to be obtained for
histopathological analysis.
„ As a diagnostic adjunct for suspected
root fracture or perforation.
A landmark systematic review and meta-
analysis by Setzer et al10 showed that modern
microsurgical methods resulted in 95%
success, compared to a 59% success
achieved with traditional endodontic
surgery. In this review, the benefits and
general principles of DOM use in endodontic
microsurgery are discussed.
Advantages of the
operating microscope
The DOM offers a range of magnification,
usually an increase in the order of 8–40
times.11 Compared to magnifying loupes,
where any magnification over x4 requires
the practitioner to remain in a narrow range
to stay in focus, the DOM remains stable
and allows the operator to continue the
procedure in an ergonomically non-stressful
position. In loupes, the monocles are angled
inwards in order to focus on the object. This
process requires constant short distance
accommodation from the eyes and results
in fatigue and soreness of the eye muscles.
Conversely, the DOM uses distance vision,
thereby negating the stress encountered
by the use of dental loupes. However, by
far the most important benefit offered, is a
shadow-free, illuminated field of view that
helps achieve the highest standards of clinical
operation and documentation.12
In surgical endodontics, the use of DOM
has led to changes in all aspects of surgery
(Figure 1). It has substantially decreased the
risk of severance of nerve bundles and vessels.
It allows for smaller osteotomies (3–4 mm)
compared to traditional access (8–10 mm),
thereby preserving cortical bone. A smaller
resection at a minimal angle can now be made,
offering two-fold benefits: preservation of
root structure; and visualization of additional
anatomical variations and defects.13 The root
surface is inspected in detail for presence
of additional canals, isthmus, cracks, frosted
dentine and gaps at the tooth restoration
interface, the detection and management of
which leads to better surgical outcomes.14
Basic anatomy of DOMs
There are three principal components to
the DOM.
„ Supporting structure: allows a
microscope to be either free-standing,
wall- or ceiling- mounted. Its purpose
is to keep the microscope stable, while
still keeping it manoeuvrable with ease
and precision.
„ Body of the microscope: includes
components (Figure 2) that make use of
the lenses and prisms. These include
the eyepieces, binoculars, magnification
change factor and the objective lens.
„ Light source: current microscopes are
usually fitted with either xenon or LED
light sources.
Eyepieces, binoculars and magnification
Eyepieces
Eyepieces are available in various
magnifications, with x10 and x12.5 being
the most common.15 These eyepieces
have modifiable dioptre settings. Correct
dioptre settings are important because
they allow the clinician to maintain
focus while switching between different
magnification settings.
Binoculars
The binoculars allow adjustment of the
inter-pupillary distance. These need to be
manipulated until two different circles of
light merge to form a single circle. They
employ a focal length of 125 or 160 mm. The
dioptre settings and inter-pupillary distance
together, are the foremost considerations in
customizing a microscope for personal use.
For surgical endodontics, a DOM should be
equipped with 180-degree tiltable binoculars
to address the angulation requirements.
Similarly, the attached tubes should also
be inclinable to achieve a comfortable
working position.

May 2022 DentalUpdate 417

Endodontics
Figure 2. DOM components: (A) body of the microscope; (B) six-step magnification changer; (C)
brightness adjustment scale; and (D) DSLR camera attached to the digital adapter.
Magnification change factor
A series of magnifications is available with
the DOM. These may be available as a three-,
five- or six-step manual or power-zoom
changers. The manual changers (Figure 2)
can be manipulated by rotating a dial located
at the side of the microscope. Manipulation
of the power-zoom changer is carried out
with a foot control or a manual override
control knob usually placed at the head of
the microscope. The manual changers have
the disadvantage of momentary disruption
in image visualization when jumping from
one magnification to another. However,
the change in magnification is faster in
comparison to power-zoom changers.
Objective lens
The distance between the microscope and
the surgical field is determined by the focal
length of the objective lens. For surgical
endodontics, an average focal length of 200–
300 mm usually suffices. This is basically the
working distance from the operating field.
The decision is usually based on the height of
the practitioner and their most comfortable
working position. Most microscopes come
with charts explaining the impact of each
component on the total magnification. A
formula to calculate the total magnification is
as follows:
TM = (BFL/OLFL) x EM x MF
Where TM: total magnification; BFL: binocular
focal length; OLFL: objective lens focal
length EM: eyepiece magnification; MF:
magnification factor.
It is important to note that any change
418 DentalUpdate
in components that result in an increase
in total magnification will simultaneously
decrease the field of view. This is also the
reason why the highest magnification
settings are used for documentation
purposes only.
Light source
Current microscopes usually employ
either xenon or LED light sources and
light intensity can be varied using an
adjustment scale (Figure 2). Xenon lights
appear very close to natural daylight and
offer high light intensity, which allows for
crisp documentation. These lights, however,
generate heat and have short lifespans.
LED light sources have comparable colour
temperature to that of xenon lights and
therefore appear similar to daylight.
Heat is vented from the back of the light
source, resulting in increased surrounding
temperatures. LEDs, on average, have
long lifespans.
Most light sources have an orange
filter that is designed for working with
light-sensitive material, such as resin
composite. This prevents premature setting
of the materials. A green filter allows for
better contrast between blood and tissues
during surgeries. Some microscopes also
come equipped with fluorescence for
caries detection.
Individual microscope
adjustment (parfocaling)
Parfocaling refers to objective lenses
that can be adjusted with minimal or
no refocusing. When a microscope has
parfocalled objectives, it is possible to switch
from one magnification to another with no
disruption to the focus as the magnification
is changed. Failure to parfocal microscope
objectives can be inconvenient for the
operator and can increase eye strain.
The clinician should follow the following
steps for parfocal adjustment:
„ For operators who wear glasses, the
rubber cups on the eyepiece should
be completely screwed in, and the
process carried out with the corrective
glasses worn.
„ The operator should then determine
the dominant eye. Different techniques
exist for this process; however, the
authors recommend the ‘superimposition
technique’ because of its simplicity. The
clinician chooses a distant object to
focus on, while simultaneously holding
a finger or pencil with extended arms,
superimposing the near object over
the distant object. After this, one eye is
closed while the other remains open.
If the near object stays centred on the
distant object, then the eye that was
open is the dominant eye.
„ Set the dioptre settings to
extreme positive.
„ Set the microscope at the
lowest magnification.
„ Looking through the eyepiece with
the dominant eye, adjust the dioptre
setting where the reticle, appearing
as lines or concentric rings, becomes
completely focused.
„ Place a flat, non-reflecting object such
as a currency note, business card, or an
‘X’ marked on a piece of paper under
the microscope. Without changing the
dioptre settings, adjust the microscope
at the correct vertical distance until a
focused image is seen.
„ Switch to the highest magnification. Use
fine focus to account for minor changes
due to focal distance. The dominant eye
is now calibrated throughout the entire
range of magnifications.
„ Look through the non-dominant eye
and change the dioptre settings slowly
until the object under the microscope
becomes focused. This calibrates the non-
dominant eye to the dominant eye.
„ Adjust the inter-pupillary distance, until
two different circles of light merge to
form a single circle
„ For ideal results, video output should
be from the same side as the dominant
eyepiece. This will result in an exact
match in what is seen.
May 2022

Magnification Range
Low <5x
Medium 5–8x
High 8–16x
Very high 16–32x
Table 1. Recommended magnifications for different stages of surgical endodontic treatment.
Focal plane
When focusing an object using
stereomicroscopes, we observe a particular
focal plane. We can also see an area above
and below the focal plane with similar
clarity. This distance between the nearest
and farthest object that appear acceptably
focused under the microscope is called the
depth of field (DOF). It is always preferable
to work with microscopes that offer a
high DOF as this allows for better spatial
orientation. However, DOF is governed by
several parameters:
„ Magnification: the lower the
magnification, the greater the DOF;
„ Working distance: the greater the
working distance, the greater the DOF;
„ Aperture of objective lens: the smaller
the aperture of the objective lens, the
greater the DOF;
„ Accommodation of the eye: the better
the adaptability of the eye, the greater
the DOF. This decreases with age.
At higher magnifications, the depth of
field narrows significantly. For patients who
move often during the course of treatment,
maintaining focus can become difficult,
and the operator has either to reset the
microscope assembly or encourage the
patient back to their original position. In such
cases, a microscope with a variable objective
lens can be used as a fine focus knob to allow
for minor adjustments, and to save time.
May 2022
Procedures
Orientation
Assessment of the surgical site
Incision
Determining location of the root apex
Suture placement
Flap elevation
Osteotomy
Initial inspection
Suture removal
Haemostasis
Root surface inspection
Root tip identification
Retro-preparation and root-end filling
Root-end resection/root amputation
Tissue removal
Inspection of resected root end
Inspection of root-end preparation
Inspection of root-end filling
Documentation
The treatment field that can be viewed
under the microscope is termed the field of
view (FOV). It is most convenient to work
with a large FOV. Parameters governing the
FOV are as follows:
„ Magnification: the lower the
magnification, the greater the FOV;
„ Working distance: the greater the
working distance, the greater the FOV;
„ Lens system: FOV varies with lens design.
Cycling through magnification
Magnification can range significantly
between different microscopes, but
is usually in the range of x3–30. For
surgical endodontics, the recommended
magnification factors are listed in Table 1 for
different procedures.
Documentation
In order to document cases, the microscope
needs three primary components:
„ Beam splitter;
„ Adapter (mount);
„ Recording device (Figure 2).
The beam splitter, aptly named, splits the
light into two portions so that one goes
to the eyepiece (observer) and the other
portion goes to the documentation device
(eg camera). The beam splitter’s eyepiece
to documentation port ratio varies, but
is usually 50:50, 80:20 or 95:5. Some
Endodontics
cameras are able to work with low levels
of light and use the 80:20 or 95:5 ratio. This
allows more light to be diverted to the
eyepiece, which retains a bright field for
the observer. Some newer cameras, with
more pixels, require more light for adequate
documentation, and hence work better
with the 50:50 beam splitting ratio. The
adapter simply connects the beam splitter
to the documentation device. Customized
camera adapters may be needed because
the diameter of the connection varies with
different manufacturers, that is to say a
Nikon Digital single lens reflex (SLR) camera
will not fit the adapter made for a Canon
Digital SLR camera. Dedicated SLR cameras
can take high-quality photos, but may fail to
document videos with similar finesse. Some
users therefore prefer having a second port
for a dedicated video camera. These cameras
can be attached to an LCD monitor that can
display live feed and allow the clinician to
review images as soon as they are taken.
Ergonomics
Ergonomics is the science that deals with
principles and methods employed in order
to optimize human well-being and to
increase the efficiency of working system.
In microsurgical endodontics, one of the
most time-consuming tasks is to correctly
position the dental operating microscope
in relation to the patient and surgical field.
The objective of doing so is two-fold: to
enhance the visualization of the region of
surgical interest; and to reduce the incidence
of musculoskeletal disorders in dentists.
Microscope-based clinical practices carry
the inherent risk of prolonged strained
and extended neck positions, which will
eventually result in discomfort and pain
for the users. A web-based survey by
Creasy et al reported that 77% of dentists
had difficulty in proper positioning of
operating microscopes.16 Proper positioning
of the dentist and patient is of paramount
importance in performing microsurgical
endodontics. Positioning of the patient
in the dental chair varies according to
site of surgical interest and the patient’s
medical condition.
Operator position
The operator usually sits between the 10
and 2 o’clock positions around the patient’s
head depending on the quadrant being
treated. The operating chair is adjusted so
that the operator’s thighs are parallel to
the floor. The back of the operator must be
DentalUpdate 419
Endodontics

kept upright and be well supported by the a b

backrest of chair (Figure 3). Similarly, the
operator’s elbows are positioned close to the
body. Once positioned, the surgeon’s elbows
should not deviate from this centric position
throughout the procedure. This position
allows maximum fine control for mechanical
instrumentation during the procedure. Some
manufacturers have introduced chair designs
having the provision of both back support
and elbow support.

Patient position
For endodontic surgery, the patient
position in the dental chair is generally
supine (Figure 3). However, some clinicians
recommend a reverse Trendelenburg position
to position the surgical site in an elevated
working position. The patient is instructed
to lie on their side as if sleeping, this allows c d
the operator to look directly into the area of
surgical interest (Figure 3). The tilted position
of the patient head is stabilized using the
rolled surgical towels, head rest or memory
foam pillows. A useful tip while working
with high magnification is to have the dental
chair’s headrest gently touching the operator
knee so that by slightly elevating the knee, a
minor change in the focal length is obtained,
which is enough to produce fine focus. This
keeps both of operator’s hands free to work
during the procedure.17
Generally, endodontic microsurgery is
easier to perform in the maxilla as opposed
to the mandible. For procedures in the
mandibular molars, instructing the patient
to slightly move the lower jaw outward
(buccally), as in a crossbite relationship, to
better visualize the surgical area. This position
Figure 3. Operator and patient position. (a) Correct operator position. (b) Incorrect operator position.
helps the operator to directly visualize the This will result in strain at the neck and back (c) Patient position for surgery of the anterior teeth.
mesial roots of mandibular molars.17 In order (d) Patient position for surgery of the posterior teeth
to view the soft tissue of jaws under direct
vision, tilting back the headrest of the patient
with chin raised is helpful.18
start of a procedure, the microsurgical Clear and effective communication is
Lastly, when the patient and operator
positions are set, the operating microscope instruments, biomaterials, ultrasonic devices, required between the operator and dental
is adjusted. The line of sight through the computers, digital radiographs and scanners, assistant during the instrument transfer
microscope should be perpendicular to etc should be placed in a manner for easy process. This can be achieved through
the soft tissue of the surgical site. Similarly, access by the dental assistant during the verbal or non-verbal communication
the eyepieces are adjusted to the height of procedure. For this purpose, a moving cart depending upon the experience of the
the operator. or surgical trolley is recommended. There team. The instrument must be handed
should also be ample unrestricted space to over to the operator in an accurate way to
Four-handed dentistry allow passing of instruments to the operator. ensure proper grip, as the operator eyes
To enable efficient and smooth working Ideally, the dental assistant should be able are fixed on the microscope, there is risk of
processes while using the operating to see what the operator sees so that they personal injury from the sharp instruments
microscope, a close understanding between know what the operator needs during if not properly handled. Any disruption in
the dentist and the dental nurse/assistant the procedure. Some manufacturers offer the communication process may affect the
is necessary. The operational layout should co-observation tubes directly attached to quality of the procedure.
provide sufficient room for accommodating the microscope for the dental assistant to Ergonomically designed microscope
the operating microscope.15 Before the visualize the surgical site. workstations and a sound understanding of

420 DentalUpdate May 2022

Endodontics

positioning helps the clinician to perform the procedure with minimal

stress and discomfort for the patients.

Conclusion

Discover The DOM is an integral part of surgical endodontic practice and

elevates the standard of care provided to patients. In low- and
middle-income countries, universal adoption of the DOM is not a
function of time, but requires a systematic inclusion into curriculum

the magic of at the specialty level. While the present review has focused on DOM
in endodontic microsurgery, the principles of use can be applied
to many aspects of restorative dentistry, non-surgical endodontics,
periodontal and oral surgery.

Acknowledgements
We thank Dr Fahad Umer (Consultant, Operative Dentistry and
Endodontics) for the clinical cases illustrated in Figure 1.

Compliance with Ethical Standards

Conflict of Interest: The authors declare that they have no conflict
of interest.
Informed Consent: Informed consent was obtained from all individual
participants included in the article.

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Caries Management
Enhanced CPD DO C

Sarah Young

Bhupinder Dawett, Amanda Gallie, Avijit Banerjee and Chris Deery

Minimum Intervention Oral Care

Delivery for Children: Developing
the Oral Healthcare Team
Abstract: This article discusses the potential use of the oral healthcare team in the delivery of minimum intervention oral care (MIOC) for
caries management in children. It summarizes opportunities and difficulties, both evidenced and anticipated, in the context of general
dental practice in the UK. Given the push to provide safe and effective care using wider members of the oral healthcare team, this article
offers insight into potential barriers and facilitators that may present in general dental practice.
CPD/Clinical Relevance: There is a belief that the wider team within general dental practice will have an increasingly important role to
play in the provision of oral and dental care.
Dent Update 2022; 49: 424–430

Teamworking enables organizations, large provided, not just solely by the dentist, but MIOC in paediatric dentistry
or small, to take advantage of the variety by other dental care professionals (DCPs). In
In England, Wales and Northern Ireland at a
of skills, knowledge, experience available general dental practice, workforce skill-mix
population level, the prevalence of dental
and the potential to make the most efficient has been encouraged for several years with
caries in children is assessed by a national
use of available resources. There has been a many advocating greater use of DCPs.1–3
shift in medicine from the solitary general Using members of an oral healthcare team survey performed every 10 years. This Child
practitioner working alone, to a team- to work collaboratively is not without its Dental Health Survey (CDHS) started in 1973
based approach, with specialists, doctors challenges, however.4 Effective evidence- and was last carried out in 2013.6 Dental
with special interests, practice nurses with based healthcare can be expressed as the caries is still a public health problem in the
extended duties, all working collaboratively. ‘right care being delivered by the right United Kingdom with nearly a half of 15
Several papers have espoused the potential people to the right people in the right year olds and a third of 12 year olds having
benefits of such an integrated team-based place at the right time’.5 This article focuses caries in their permanent teeth. The pattern
approach to the delivery of oral and dental primarily on primary care dental practice in follows social gradients, with the most
care where clinical interventions are the United Kingdom. deprived being more affected.6 It should be
noted that such epidemiological surveys do
not use radiographs in detection of caries,
Sarah Young, BSc (Hons), BDS, MJDF RCS (Eng), GDP, Hafren House Dental Practice, as exposing subjects to potentially harmful
Alfreton Derbyshire. Bhupinder Dawett, BDS MDPH, Doctoral Research Fellow, School radiation without clinical benefit is not
of Clinical Dentistry, University of Sheffield. Amanda Gallie, RDT, RDH, FAETC, MSc AMID, justified. In other countries where surveys
Dental Hygienist and Dental Therapist, Bupa Dental Care, Stamford. Avijit Banerjee, have used radiographs, the caries prevalence
BDS, MSc, PhD(Lond), LDS FDS (Rest Dent), FDS RCS (Eng), FHEA, Professor of Cariology increased markedly, as the threshold for
and Operative Dentistry/Honorary Consultant, Restorative Dentistry, Faculty of Dentistry, caries detection intensifies.7
Oral and Craniofacial Sciences, King’s College London. Chris Deery, BDS, MSc, FDS
First permanent molars and their
RCSEd, PhD, FDS(Paed Dent) RCSEd, FDS RCSEng, FHEA, Dean, Professor/Honorary
occlusal surfaces are the most susceptible to
Consultant in Paediatric Dentistry, School of Clinical Dentistry, University of Sheffield.
the caries process.8 Even current treatments
email: sarah.young55@nhs.net
provided for compromised first molars

424 DentalUpdate May 2022


Figure 1. Oral health advice delivered to parent
and child by an extended duties dental nurse.
1 Is there a clear job description?
2 Is the position full-time or part-time?
Should the applicant be employed or
3 treatments, eg therapeutic
self-employed?
4 How will performance be monitored?
Does the applicant have the
knowledge and understanding to
5
follow the minimum intervention oral
care delivery framework?
Table 1. Basic factors to consider when
determining functional team roles.
varies9 and the minimum intervention
oral healthcare (MIOC) framework may
provide an alternative pathway for avoiding
extractions.10 Children with caries in their
permanent teeth will carry any disease
burden into adulthood. Its impact on
individuals, and society, is significant
both in terms of quality of life and socio-
economic implications.
The traditional mechanistic surgical
treatment of carious lesions does not cure
the disease process.11,12 This traditional
approach, with an emphasis on ‘drilling and
filling’ teeth, which placed the dentist as the
most suitable clinician to treat the lesion,
should now be replaced with the patient-
level MIOC framework with a primary focus
on detection, diagnosis, personalized care
planning, prevention of lesions and control
of the disease process.13,14 These principles
of MIOC can apply to all oral healthcare, not
only to dental caries. This offers possibilities
for dental (or perhaps better termed, oral
healthcare) practices to use DCPs to deliver
aspects of oral healthcare (Figure 1).15–17
Benefits would include better long-
term clinical care, and an improved patient
acceptability. Minimally invasive dentistry
(MID) represents one of the four domains
of the MIOC framework where, at a tooth
May 2022
Caries Management
z Practice-based research projects/audits Community-based prevention,
{ Audits related to MIOC delivery eg school visits
{ Service evaluations
{ Research projects (local/national)
Dietary history
Social history
Radiography
Dental photography
Identify
Dentist, therapist, hygienist,
extended-duties dental nurse
Motivational interviewing
Motivation (COM-B), – behaviour management
Maintenance, Oral health promotion
Review periodicity Preventive sealants
Topical fluoride application
Recall Prevent
Dentist, therapist, hygienist,
Dentist, dental therapist,
extended-duties dental nurse,
dental nurse
dental hygienist
Minimally invasive
sealants, hall crowns
Restore
Dentist, dental therapist,
dental hygienist
Patient/public involvement (PPI)
Writing practice educational { Gaining feedback on services
material, eg newsletters, patient { Identifying research priorities
information leaflets { Arranging and chairing PPI meetings
Figure 2. Examples of MIOC domain-specific tasks that could be undertaken by suitably trained
and indemnified dental care professionals, as well as implementation supporting roles. Adapted
from Banerjee.17
level of treatment, all operative interventions care-focused primary care practice,
are biological, respecting and preserving the by employing the appropriate
dental/oral hard and soft tissues and being as people with the required strengths
minimally tissue-destructive as possible. into the right roles. This can reduce
Although the underlying domains unnecessary conflict when developing
of MIOC remain the same for patients the team and enabling integrated
throughout their life course, the actual practice. Before interviewing
components and their delivery will differ candidates, it is important that there
as ‘children are fundamentally different to is clarity with regards to the role(s)
adults’.18 A joint ORCA (European Organisation that need to be filled. The questions in
for Caries Research) and EFCD (European Table 1 may help.
Federation of Conservative Dentistry) expert
Delphi consensus statement provides
Who are the practice team members?
recommendations as to how to intervene in
children with early childhood caries, and caries In the UK an oral healthcare team may
affecting the occlusal surfaces of permanent include some or all of the following
molars. This consensus also highlighted areas GDC-registered clinical team members:
where the agreement was weak and the „ General dental practitioners;
associated research gaps.19 „ Specialists;
„ Dental therapists;
„ Orthodontic therapists;
Creating an oral
„ Dental hygienists;
healthcare team „ Extended duties dental nurses
Recruitment (EDDNs);
Effective recruitment can help ease the „ Dental nurses;
transition to a minimum intervention oral „ Clinical dental technicians.
DentalUpdate 425
Caries Management

a b
Detection/diagnosis
Prevention
Recording
carious lesions
– International Oral hygiene
Caries Detection Dental hygienist Dental therapist
Dental hygienist Dental therapist education
and Assessment
System (ICDAS)
Topical fluoride
Radiographs application
Extended-duties
Extended-duties dental nurse
dental nurse Fissure sealants
Plaque scores

Advice on use
Dental nurse Saliva testing Dental nurse of products
Reception staff

Caries risk Reception staff

assessment d
(geneal risk factor Recall
information)

c Dental hygienist Helping Dental therapist

(evaluating determine (evaluating
MI restorations
compliance) risk-based compliance)
recall. Helping
to provide
Dental hygienist Dental therapist decision
Resin infiltration makers with
information
Extended-duties relevant to
dental nurse recall interval
Hall technique
(providing determination Reception staff
feedback (listening to
Sealing defective on patient child/parent
restorations compliance, requests)
requests and
Repair and attitude)
refurbishment of
restorations
Minimally Figure 3. (a) Tasks in ‘identify’ (detection/diagnosis) domain of MIOC
invasive direct showing DCP involvement. (b) Tasks in the ‘prevent’ domain of MIOC
restorations,
including use of showing DCP involvement. (c) Tasks in ‘restore’ domain of MIOC showing
silver diamine DCP involvement. (d) Tasks in the ‘recall’ domain of MIOC showing
fluoride DCP involvement.

In addition, other non-clinical roles to
consider include:
„ Treatment co-ordinators;
„ Reception staff;
„ Practice managers;
„ Business managers.
What can they do?
When designing a practice that focuses on
MIOC delivery, it is important to understand
fully the scope of practice of each member
of the oral healthcare workforce enabling
effective integration whether it is in a single
surgery practice, a large multi- surgery
practice, or an organization which has
several practices operating. The roles for
each member of the oral healthcare team
are detailed in the General Dental Council’s
(GDC) ‘Scope of practice’.20 Provided the
individual is suitably trained, indemnified
and working under their GDC scope of
practice, some examples of how dental
care professionals can be used in the MIOC
framework can be seen in Figure 2.
The clinical parameters for each
member of the oral healthcare team
are outlined and itemized by the GDC
the ‘Scope of practice’, describing the
items and areas that a registrant has the
knowledge, expertise and skills to practice
safely in the best interest of a patient.20 In
2013, the GDC enabled direct access for
DCPs. Under direct access (excluding NHS
care in general dental practice at present),
DCPs can now see patients directly for
certain treatments without the need for
this to be prescribed by a dentist. One
aspiration of this change was to enable more
access to dental care for the population,
including children.
The diagnostic permissions for certain
DCP registrant groups originate from this
document and the term ‘diagnosis within
competence and scope’ is used. This
diagnostic list covers caries, periodontal
disease, gingival conditions, oral pathology
and oral cancer screening. Hygienists and
therapists are also taught to recognize
endodontic pathology, and would refer this
onto their dentist colleagues for treatment.
Patients can also access tooth whitening
with a prescription from a dentist. At present,
hygienists and therapists are applying
to hold prescribing rights for certain
prescription-only drugs through the medical
exemptions framework.

426 DentalUpdate May 2022

 Caries Management

Role Characteristic Example in the MIOC oral healthcare team

Planter Creative and problem solver Can help with developing practice promotional materials

Monitor/evaluator Can provide independent / logical Can help to identify any potential regulatory
views breaches, eg training needs
Co-ordinator Chairperson / effective delegator Can allocate the tasks to appropriate practice staff such as sending out
recalls, practice audits, etc

Resource investigator Can look at outside openings Helps in identifying outside organisations/stakeholders to help bring
MIOC interventions to the practice

Team worker Fosters collaboration and Someone who brings the team together with meetings and an outlet
cooperation that members scan speak freely to about concerns on how the practice
is progressing with its goals

Implementer Can put action into a workable A member who will organise MIOC activities, such as setting up a price
strategy list for MIOC interventions, arranging dates and times for MIOC practice
events
Shaper Challenges team to progress Drives the team to change and address issues such as access to care,
need for further training, and to keep up to date with research

Specialist Can provide unique insight Helps the team to keep updated on MIOC,
standard operating procedures and guidelines
Completer/finisher Helps to analyse and refine end Helps to ensure team is delivering on MIOC practice objectives, eg
result searches out staff outliers in MIOC delivery and helps address these
Table 2. Team member roles. Adapted from Belbin.21

Forming Storming Norming Performing

Team development
y
Acknowledging y
Settling into y
Improved Use of a structured, conscious approach
y
Developing
disputes a rhythm collaboration may help to aid the development of a
a common
y
Refining y
Improved y
Increased
vision (including team from a fledgling group of individuals
roles and delegation, efficiency
mission
responsibilities systems and y
Targets to a high-performing team proficient
statement)
y
Identifying pathways achieved
y
Identifying roles in the delivery of MIOC. In 1965, Bruce
resistance y
Less conflict y
Re-evaluation
Tuckman identified stages for effective
Figure 4. Stages of team development. Adapted from Tuckman.22 team development (Figure 4).22
Forming: the stage where a group comes
together, but tries to avoid conflict.
All oral healthcare team members These have been defined as ‘a tendency Members try to get to know each other,
will have a duty to keep full, accurate and to behave, contribute and interrelate but are cautious. Here the overall vision of
contemporaneous patient records when with others in a particular way’. In a team, MIOC and MID is communicated, a plan is
they are carrying out their duties with by understanding each members’ roles, drawn up and an acknowledgement of the
a patient. Figure 3 shows tasks for the one can assess how best each individual resources needed is agreed.
domains of MIOC that appropriately trained member can contribute, but also recognize Storming: here conflict is present.
and indemnified DCPs can undertake, or be allowable weaknesses. This can aid with Issues such as authority, responsibilities,
involved in. team cohesion by helping team members regulations, remuneration and appraisal
understand that there are different systems need to be addressed.
approaches, and no one is the best.
Team member characteristics Norming: at this stage the team starts
Ultimately this can help to create a
What kind of people are necessary to to become an organized unit. Working
more balanced team by understanding and
deliver MIOC goals? Dr Meredith Belbin together with a sense of purpose and
appreciating each member’s contributions.
suggested that a team must have a balance Belbin’s team roles can be used in conflict shared vision. A feeling of togetherness
in its members’ characteristics for it to management, change management, and trust is established and morale is
function efficiently.21 The member roles recruitment, coaching and leadership good.
and characteristics are outlined in Table 2. development. It must also be remembered Performing: the team is now showing
It has been observed that members that each team member can have more good productivity with goals and
assumed different roles within a team. than one role. performance indicators, such as access to

May 2022 DentalUpdate 427

Caries Management
Registrant type Total number duties roles of the registrants, and the
practices that each undertakes. There is an
acknowledgement that DCPs are not being
Orthodontic therapist 705
used to their full scope of practice. This
represents, potentially, a waste of useful
Dental therapist 3862 resources, as well as a waste of expenditure
on training and development.
Dental hygienist 7685 In delivering oral health education, for
example, team members must try to offer
Dental nurse 57597 the same advice/message/encouragement,
but differing perspectives and delivery
modes may prove helpful to the receiver
Clinical dental 365
(Figure 5). When managing children and
technician
their parents, all members of the oral
healthcare team have a responsibility to
build rapport. This is crucial because oral
Dental technician 5477 hygiene instruction, dietary advice and
encouragement for regular attendance
Table 3. The numbers of dental care professionals will be more effective when the parents/
on the UK dental register. carers are engaged and fully supportive
of the value of the care messaging that
they are receiving. The role of the team
is to help children and parents to value,
modify and improve their own behaviour.
The didactic provision of information by
itself is not sufficient to accomplish this.
The child and parent need to have the
capability, opportunity and motivation to
help behaviour change and subsequent
adherence to change.
Access to care
The use of the wider oral healthcare team
to deliver MIOC may help to improve
access to care for populations. Where
resources are scarce, and access to care is
suboptimal, the delegation of tasks to DCPs
may help deliver more interventions, by
either substituting or freeing up dentists
to concentrate on more complex operative
cases. This can result in more preventive
services being provided while maintaining
Figure 5. A DCP providing information to patient acceptance of the service.24 In
patients is just one step in effective oral health theory this sounds plausible, but in general
education practice resources. dental practice there may be several other
factors that affect such implementation.25
care, being met, members are supportive Clinical/cost-effectiveness
towards each other, which allows a degree of There is a lack of definitive evidence
autonomy and creativity. to demonstrate that use of the wider
oral healthcare team to deliver care in
general dental practice in the UK is more
Current use of DCPs clinically effective in tackling disease.26
Currently there are approximately 69,300 Some studies show that the use of DCPs in
DCPs on the dental register in the UK, with specific contexts can improve completion
the majority consisting of dental nurses of courses of treatment. However, these
(Table 3).23 were not in the context of GDP in the UK.27
Limitations of the data collected mean Studies have shown that DCPs may be just
that it is not possible to assess the extended as efficacious in diagnosing common oral
428 DentalUpdate
diseases, such as caries, periodontal disease
and oral cancer.28,29 However, further research
is warranted to support improved clinical
and cost effectiveness of MIOC in NHS
primary care.
Knowledge, skills
and attitudes
The delivery of MIOC requires all oral
healthcare professionals to have an
understanding, knowledge and familiarity
of the subject. Research has shown
wide variation in knowledge and in the
decision-making process by dentists.30–32
Questionnaire-based studies of dentists
have concluded that UK general dental
practitioners’ knowledge of MIOC is relatively
poor.33 Schwendicke et al, in their paper on
closing the gap between evidence base and
practice, also state that getting dentists who
have been trained according to a traditional
approach to change attitudes and move
to a MIOC care pathway is challenging. 34
However, the proportion of traditionally
trained professionals who make up the oral
healthcare workforce will decrease with time,
and this may become less of an issue.
Proponents argue that using the wider
oral healthcare team, especially more
recently qualified members, may well
help to support the delivery of a modern
MIOC approach.35 Given that in the UK,
current mandatory CPD requirements
do not expressly state that professionals
need to undertake training in developing
interventions, such as selective carious tissue
removal, the use of newly qualified DCPs
may help steer practices to a more minimally
invasive approach. Using the wider skillsets
of team members can give individuals a
sense of ownership and recognition of the
value of their work. A variety of tasks and
role development can improve overall work
satisfaction and performance.36 Having
a wide team composition will also mean
greater interdependence. This can bring into
play factors both easily identifiable (such
as training, age), but also more intangible
deeper-level constructs, such as personality.37
Child and parent/carer-focused
oral healthcare
Patients who are used to seeing a dentist
only, may well feel that their care is
being compromised by having a dental
professional with less scope of practice, such
as a DCP, delivering interventions. However,
studies have shown that most patients
May 2022

tend to accept care by a DCP without any
38
major concerns. A review by Dyer and
Robinson in 2016 on the acceptability of
care provided by DCPs concluded that while
most adults would accept such care, ‘care
for children was seen as less acceptable’.39
MIOC and MID may require more visits than
the traditional approach, which may affect
the acceptance by carers of children. A
systematic review showed that the majority
of research on children has included them
as objects only.40 Further research looking
into the acceptability of MIOC should involve
them as much as possible and gather their
perspectives using qualitative methods.
Delegation
To delegate effectively requires team
understanding and a knowledge of the
scope of practice of each team member.
The introduction of dental therapists into
the workforce is a relatively recent concept
in the UK. Research has also shown that
dental professionals are not very confident
in knowing the scope of practice of other
dental professionals.41 As such, effective
delegation may not be straightforward
or readily accepted. A qualitative study
by Nilchian et al concluded that a variety
of factors influenced the delegation of
paediatric patients for fissure sealants to
dental hygienists and therapists, including
payment mechanisms, remuneration factors,
child and parent attitudes, and the perceived
role of the DCP.25
The referring dentist needs to have
confidence in the ability of the team
member to whom they are referring a
patient. Dentists may find the ‘loss of control’
in delegating is a factor that hinders their
willingness to use a team-based approach
for MIOC. Ongoing sustainability will
require good leadership, staff training and
development, access to and undertaking
continuing professional development, as
well as effective business management.
Extended duties dental nurses could be
used as part of the detection stage of the
MIOC care pathway taking radiographs
and clinical photographs (Figure 6). Non-
clinical attributes of a team may also play
a significant role in achieving objectives in
MIOC care for children.
Environmental factors
MIOC delivery and a team-based approach
implies more patient contacts with
different team members. This may initially
place extra burden on a patient and their
May 2022
Caries Management
a b
c
Figure 6. (a–c) Clinical photography undertaken by a DCP to help show plaque disclosing, who then
explains its meaning and value to the patient.
carers in attending appointments, and (Figure 6) reducing the risk of litigation. The
may be especially poignant in the context keeping of contemporaneous and accurate
of a pandemic when contacts may be dental records is vital for maintaining
encouraged to be minimized. Further, good practice and may reduce risks of
future litigation.
increased appointments places additional
draw on practice resources. However, in the
long run, as the MIOC approach controls Regulation and remuneration
disease and reduces disease risk, fewer
Although there is an acknowledgement
appointments will be required from the
and an upstream drive to integrate DCPs,
patient. A full cost-efficiency analysis is
regulation and remuneration may continue
required to answer this question fully.
to be obstacles to be overcome in the UK
One potential avenue to reduce this
to enable effective implementation of DCPs
initial physical load may be the use of
into NHS primary care. As described earlier,
teledentistry for oral health promotion and
although direct access was approved by
screening.42 Teledentistry may have value for
the GDC in 2013, this is still not currently
remote consultations for those with reduced
available in NHS general dental practice.
access to care and diagnosis in high-risk,
Hence NHS dentists are still responsible for
preschool children. The use of digital
the overall course of treatment, and patients
resources including social media may also still must be seen by a GDP before care can
widen access to resources and information. be delivered by the DCP in an NHS dental
practice. This may consume extra practice
Medico-legal liability resources, and the authors recognize that
due to limited scope of practice of DCPs,
Dentists may potentially have concerns
to entirely remove this contact will need
about delegating interventions to DCPs
further discussion and acceptance. Also,
as part of a personalized care plan. Where
given that remuneration for treatment
a clinician is employed, then the practice
generally favours surgical interventions,44,45
owner will undoubtedly have liability for
practice owners and associate dentists
any oversights or negligent performance.43
may hesitate to employ DCPs if satisfactory
This vicarious liability may well deter
remuneration mechanisms for prevention
practices from using the wider skills of DCPs, are not in place.25
especially if the practice owners indemnity
does not extend to cover this. Of course, this
could be addressed by legislation, which Conclusions
aims to promote effective and efficient Dental caries in children still remains a
healthcare. The use of clinical photography, significant public health problem, with
which can be carried out by a DCP, can help high prevalence, morbidity and associated
with clinician and child/carer communication costs. Access to dental care can still be
DentalUpdate 429
Caries Management
problematic. The use of DCPs, and effective
use of their full scope of practice, has
potential to increase the access to, and
efficiency of, MIOC framework delivery,
and help meet the needs of untreated oral
diseases in a modern, biological, evidence-
based approach. The factors discussed in
this article may also apply to the use of
the skill mix in general oral care, and is not
limited to MIOC. In order for practices to
implement the wider skill mix effectively in
MIOC for children, present and anticipated
challenges will need to be overcome, both
at the local and the national level. This will
require acknowledgment of the barriers, and
a pragmatic discussion to overcome them.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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dentistry – the starting point for a lifetime of oral
health. Br Dent J 2017; 223: 205–213. https://doi.
org/10.1038/sj.bdj.2017.671
19. Splieth CH, Banerjee A, Bottenberg P et al. How
to intervene in the caries process in children: a
joint ORCA and EFCD expert Delphi consensus
statement. Caries Res 2020; 54: 297–305. https://doi.
org/10.1159/000507692
20. General Dental Practice. Scope of practice. 2013.
Available at: www.gdc-uk.org/standards-guidance/
standards-and-guidance/scope-of-practice (aaccessed
April 2022).
21. Belbin RM. Team Roles at Work. 2nd edn. Oxford:
Routledge, 2010.
22. Tuckman BW. Developmental sequence in small groups.
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h0022100
23. General Dental Council. Registration report – September
2020. Available at: www.gdc-uk.org/docs/default-
source/registration-reports/reg-report-september-
2020c138b1cac9864ebba303fed8ed94077e.
pdf?sfvrsn=3ff2b64b_5 (accessed April 2022).
24. Barnes E, Bullock A, Cowpe J et al. General dental
practices with and without a dental therapist: a survey
of appointment activities and patient satisfaction
with their care. Br Dent J 2018; 225: 53–58. https://doi.
org/10.1038/sj.bdj.2018.522
25. Nilchian F, Rodd HD, Robinson PG. Influences on
dentists’ decisions to refer paediatric patients
to dental hygienists and therapists for fissure
sealants: a qualitative approach. Br Dent J 2009;
207: E13; discussion 326-7. https://doi.org/10.1038/
sj.bdj.2009.856
26. Dyer TA, Brocklehurst P, Glenny AM et al. Dental
auxiliaries for dental care traditionally provided
by dentists. Cochrane Database Syst Rev 2014; (8):
CD010076. https://doi.org/10.1002/14651858.
CD010076.pub2
27. Arrow P, Klobas E. Child oral health-related quality of life
and early childhood caries: a non-inferiority randomized
control trial. Aust Dent J 2016; 61: 227–235. https://doi.
org/10.1111/adj.12352
28. Brocklehurst P, Pemberton MN, Macey R et al.
Comparative accuracy of different members of the
dental team in detecting malignant and non-malignant
oral lesions. Br Dent J 2015; 218: 525–529. https://doi.
org/10.1038/sj.bdj.2015.344
29. Macey R, Glenny A, Walsh T et al. The efficacy of
screening for common dental diseases by hygiene-
therapists: a diagnostic test accuracy study. J
Dent Res 2015; 94(3 Suppl): 70S–78S. https://doi.
org/10.1177/0022034514567335
30. Chana P, Orlans MC, O’Toole S et al. Restorative
intervention thresholds and treatment decisions
of general dental practitioners in London. Br Dent J
2019; 227: 727–732. https://doi.org/10.1038/s41415-
019-0849-7
31. Doméjean S, Léger S, Simon A et al. Knowledge,
opinions and practices of French general practitioners
in the assessment of caries risk: results of a national
survey. Clin Oral Investig 2017; 21: 653–663. https://
doi.org/10.1007/s00784-016-1932-y
32. Doméjean-Orliaguet S, Léger S, Auclair C et al. Caries
management decision: influence of dentist and
patient factors in the provision of dental services. J
Dent 2009; 37: 827–834. https://doi.org/10.1016/j.
jdent.2009.06.012
33. Mirsiaghi F, Leung A, Fine P et al. An investigation
of general dental practitioners’ understanding and
perceptions of minimally invasive dentistry. Br Dent
J 2018; 225: 420–424. https://doi.org/10.1038/
sj.bdj.2018.744
34. Schwendicke F, Doméjean S, Ricketts D, Peters M.
Managing caries: the need to close the gap between
the evidence base and current practice. Br Dent
J 2015; 219: 433–438. https://doi.org/10.1038/
sj.bdj.2015.842
35. Pitts N. Preventive and minimal intervention
dentistry in the undergraduate curriculum. J Dent
2011; 39 Suppl 2: S41–48. https://doi.org/10.1016/j.
jdent.2011.10.013
36. Pink DH. Drive: The Surprising Truth about What
Motivates Us. New York: Riverhead Books, 2009.
37. Rosen MA, DiazGranados D, Dietz AS et al. Teamwork
in healthcare: key discoveries enabling safer, high-
quality care. Am Psychol 2018; 73: 433–450. https://
doi.org/10.1037/amp0000298
38. Dyer TA, Humphris G, Robinson PG. Public awareness
and social acceptability of dental therapists. Br
Dent J 2010; 208: E2; discussion 16–17. https://doi.
org/10.1038/sj.bdj.2010.1
39. Dyer TA, Robinson PG. The acceptability of care
provided by dental auxiliaries: a systematic review.
J Am Dent Assoc 2016; 147: 244–254. https://doi.
org/10.1016/j.adaj.2015.09.018
40. Marshman Z, Gibson BJ, Owens J et al. Seen but not
heard: a systematic review of the place of the child
in 21st-century dental research. Int J Paediatr Dent
2007; 17: 320–327. https://doi.org/10.1111/j.1365-
263X.2007.00845.x
41. General Dental Council. Scope of practice review: final
report. 2020. Available at: https://www.gdc-uk.org/
about-us/what-we-do/research/our-research-library/
detail/report/scope-of-practice-review (accessed
April 2022).
42. Kopycka-Kedzierawski DT, Bell CH, Billings RJ.
Prevalence of dental caries in Early Head Start
children as diagnosed using teledentistry. Pediatr
Dent 2008; 30: 329–333.
43. D´Cruz L, Swanton V. The role of the foundation
dentist in the dental team and the legal liabilities for
their employer during COVID-19. BDJ in Practice 2020;
33: 20–21.
44. Calache H, Hopcraft MS, Martin JM. Minimum
intervention dentistry – a new horizon in public oral
health care. Aust Dent J 2013; 58 Suppl 1: 17–25.
https://doi.org/10.1111/adj.12046
45. Schwendicke F, Foster Page LA, Smith LA et al. To
fill or not to fill: a qualitative cross-country study
on dentists’ decisions in managing non-cavitated
proximal caries lesions. Implement Sci 2018; 13: 54.
https://doi.org/10.1186/s13012-018-0744-7
May 2022
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COVID-19 Commentary
Enhanced CPD DO C

Lakshman Samaranayake

SARS-CoV-2 Omicron Variant and

the Future of the Pandemic
Abstract: Global infections with the Omicron variant of SARS-CoV-2 have now superseded all other similar variant infections we have
witnessed thus far. The current global wave mainly caused by a descendant of the SARS-CoV-2 Omicron variant, called BA.2, is the most
prevalent in UK, and has a natural history somewhat different from its predecessors. It also appears, that the so-called COVID-19 variant
infections, in varying guises, are the harbingers of the post-COVID-19, ‘new normal’ world of the future, we have to live in. Here, we look
at key features of SARS-CoV-2 variants, particularly BA.1 and BA.2, and the reasons for their phenomenal spread, vaccine efficacy against
them, as well as the unfolding short-term outlook for the pandemic.
CPD/Clinical Relevance: To describe the reasons for the high global prevalence of SARS-CoV-2 Omicron variant, particularly its BA.2
subvariant, and discuss the attendant implications for the dental profession.
Dent Update 2022; 49: 432–435

Variants of viruses emerge incessantly, and
it is the nature’s way of preserving a species,
and in our context, the SARS-CoV-2 viral
progeny. As Charles Darwin explained in his
postulate of ‘survival of the fittest’, in order to
survive, a living being must be ‘endowed with
phenotypic characteristics which improve
chances of survival and reproduction’. We see
this explicitly in the case of SARS-CoV-2. The
original strain of SARS-CoV-2, over a short
period of 2.5 years has undergone many
genetic reincarnations ranging from Alpha, to
Lambda and the latest, the Omicron variant,
which in turn has evolved into the intractable,
sublineages BA.1 and BA.2 (Table 1).
The ravenous spread of the current global
wave of Omicron has been phenomenal
and breathtaking. For instance, there were
125 million Omicron infections per day
worldwide in January 2022 alone, which is
more than ten times the peak of the Delta
wave of April 2021.1 In a recent article in
Lakshman Samaranayake, DDS, DSc (hc), FRCPath, FRACDS, FDS RCS(Edin), Professor
Emeritus, and Immediate-past Dean, Faculty of Dentistry, University of Hong Kong.
email: lakshman@hku.hk
Lancet, Murray from the International Health
Metrics and Evaluation Foundation in US,
opined that: ‘The unprecedented level of
infection suggests that more than 50% of the
world will have been infected with Omicron
variant between the end of November 2021
and the end of March 2022’. Although the
number of global daily SARS-CoV-2 infections
has increased over 30 times in such a short
time, the reported number of overt COVID-19
cases has only increased only by six times.
This is mainly due to the proportion of
asymptomatic or mild Omicron infections,
compared with previous variant infections.1
Murray also opined that, due to such a
widespread global infection, the end of the
pandemic may be near.
Historically, the Omicron subvariants
of SARS-CoV-2 were detected almost
simultaneously in November 2021 in South
Africa. These new and profoundly different
lineages2 were a surprise to many virologists
who had anticipated that the next major
variant would descend incrementally from
the Delta variant, which was the most widely
circulating variant worldwide at that time.
Immediately thereafter, the BA.1 sub
lineage of Omicron quickly overtook Delta
as the dominant strain. Subsequently, as we
have witnessed, the BA.2 variant has stolen
a march over BA.1, and has spread faster in
many communities the world over, implying
that it has a significant selective advantage
over its sibling. The former currently accounts
for over three-quarters of all new SARS-CoV-2
infections in the UK and USA.
Incidentally, scientists are continuing to
discover Omicron subvariants/sublineages
BA.3, BA.4 and BA.5, but these have not
taken off as rapidly as BA.2. To add to the
confusion, a BA.1/BA.2 recombinant strain
has now arisen and this is termed XE (a
major proportion of its genome, including
the Spike gene, belonging to BA.2). As of
April 2022 there is some evidence of XE
community transmission within England,
but less than 1% of total sequenced cases.
Emerging data indicate that the growth rate
of XE strain is similar to BA.2, although not
its transmissibility.

432 DentalUpdate May 2022


WHO
Pangolin lineage
nomenclature
Alpha B.1.1.7
Beta B.1.351
Gamma P.1
Delta B.1.617.2
Lambda C.37
Omicron B.1.1.529
Omicron
BA.1 (B.1.1.529.1)
(sublineage)
Omicron
BA.2 (B.1.1.529.2)
(sublineage)
Table 1. SARS-CoV-2 viral variants, their lineage, the degree of transmissibility and the vaccine effectiveness in mitigating infection. 3: Vaccine effectiveness,
after three doses of almost all current vaccines range from 85% to 90%; *: initial data are promising, but more research is required. Data from various sources.
What is the societal impact
of the currently circulating
viral variants?
Before we discuss the various viral variants,
it is instructive to evaluate their societal
impact. Not the least because we may
have to confront various, yet to emerge
SARS-CoV-2 variants or subvariants or their
siblings in the immediate future:
„ Ability to spread more quickly
As mentioned, there is ample data now
to indicate that the new variants spread
extremely rapidly within the community
compared to the ancestral parental strains.
This property was first noted in laboratory
studies where the BA.2 strain spreads almost
three to four times faster in cultured cell lines
(within flasks), in comparison to the parental
strains. Simply, the virus is becoming smarter
and more efficient in evolutionary terms.
„ Causing mainly milder and/or
asymptomatic disease
The current BA.2 variant causes milder
infection in most people infected. Most
who are affected are asymptomatic, and are
‘virtual super spreaders ‘ of infection. This has
implications for the practice of dentistry as
the disease is likely to become endemic in
many regions of the world, including UK.
„ Detection by viral diagnostic tests
According to authorities, most commercial
reverse-transcription polymerase chain
reaction (RT-PCR)-based rapid tests should
detect the variants as these tests have, built
in, multiple targets to detect the virus. Again,
the logistics of incorporating such tests into
May 2022
Earliest documented
Transmissibility
samples
UK
South Africa
Brazil
India
Peru
South Africa
South Africa
South Africa
routine dental practice is a matter that needs
urgent consideration.
„ Effective vaccine-induced immunity
Either natural infection with SARS-CoV-2, or
full vaccination with the currently available
major vaccines appear to provide over 90%
effective protection against severe COVID-
19 infection. However, a small proportion
of cases, up to 2–5% (depending on the
age) may exhibit so-called ‘breakthrough
infections’, which may either be symptomatic
or asymptomatic. Recent data indicate
that full vaccination with all three doses, or
indeed a fourth dose, of the mRNA or other
vaccines, leads to virtually full protection.3
Some jurisdictions, such as UAE, are currently
administering a fifth dose, 4–6 months after
the fourth does, despite the fact that there is
no consensus on its need.
The frequency of COVID-19 booster
vaccines for healthcare professionals is yet
unclear. It is likely that in the short term,
6-monthly vaccinations may be required,
although in the longer term, if there is
established regional endemicity with herd
immunity in the community, a longer period
between booster vaccines is likely. This
may take the form of annual vaccinations
similar to the seasonal flu vaccine prescribed
for healthcare workers, including dental
professionals. Indeed, COVID–influenza-
combination (CIC) vaccines, now in Phase 2
trial stages, have shown much promise.
BA.1 and BA.2 compared
The BA.2 variant is known to be 30–50%
more infectious than BA.1. What is the
COVID-19 Commentary
Vaccine effectiveness
(after three doses)
+++ 3
+ 3
++ 3
++++ 3
++++ 3
+++++ *
+++++ *
+++++++ *
reason for this? In general, the infectivity of
SARS-CoV-2 variants is dependent on three
major reasons. The first, is the increased
transmissibility, second, the evasion of
vaccine-induced or post-infection immunity,
so called ‘immunological escape’, leading to
breakthrough illness, and finally the temporal
waning of vaccine-induced or natural
immunity in the community.
It is now known that the increased
infectivity of the BA.2 variant is due to
unique mutations in the spike proteins. For
instance, it is known that BA.1 possesses 60
mutations that are not found in the ancestral
SARS-CoV-2, first detected in Wuhan, China.
Of these, 32 genetic changes are located
specifically in the spike or the S-protein of the
virus. In comparison, BA.2 shares many similar
mutations, but 28 are unique to the variant
itself, four of which are in the spike protein.4
As the spike proteins are the major targets
for immune cells and vaccines, the high
infectivity of BA.1 and BA.2 are not surprising.
In terms of transmissibility, researchers
in the UK have noted that it took less time
on average for someone with BA.2 to infect
another person, accelerating its spread
through communities.5 This was reinforced
by a study in Hong Kong, where researchers
estimated that during an outbreak of BA.2 in
a public housing complex, infections with the
virus doubled every 1.28 days.6
These data on the BA.2 variant indicate
that it is probably the fastest-spreading virus
in human history. Prior to the emergence of
SARS-CoV-2, the measles virus was known
to be one of the fastest, if not the fastest,
spreading respiratory viruses. However,
DentalUpdate 433
COVID-19 Commentary

compared to a person with the measles

virus who might infect 15 others in 12 SARS-CoV-2 older variants Older variant
days, a single case of the Omicron BA.2 (eg Delta)
variant infection may lead to 216 cases in Older variants of SARS-COV-2, such as
a similar period. Hence, the reason for the the Delta variant, require two different
cellular receptors, TMPRSS2 and ACE2, to
exponential case surge worldwide.
gain access to human cells. Hence, the
infectivity is limited, and selective to cells
Why the Omicron variants with both these receptors
spread faster
It appears that Omicron and its variants
exhibit significant immune-evasion
strategies compared with their predecessors.
One of the major strategies appears to be
the method by which they gain entry into
BA.2 variant
host cells. Whereas other variants rely on
two major proteins on the surface of human
cells, TMPRSS2 and ACE2, to cross the cell
membrane, Omicron seems to require only
ACE2 to inject its genome into a cell, to Omicron and sublineage
BA.1 and BA.2
be enclosed within an endosome that is
then carried to the innards of the cell for
The Omicron variant and its sublineage
subsequent viral replication (Figure 1).7 require only ACE receptors to gain access
This means that the TMPRSS2-independent to human cells. As all cells have ACE
endosomal pathway provides Omicron with receptors, this variant is more infective than
a larger array of cells (up to10 times more) previous variants
that are conducive to infection (as many
cells do not have TMPRSS2 on their exterior).
Figure 1. One reason for the high transmissibility of the Omicron sublineage, BA.2, is its selective
This certainly provides a selective survival
requirement for only ACE2 receptors on host cells for viral entry (lower panel) as compared with
advantage for the variant compared to previous variants, such as the Delta variants, which required two different receptors (TMPRSS2 as
its sibling/s. well as ACE2) for cellular entry and multiplication (upper panel). (Figure created using
Another major reason for its fast Biorender.com software.)
spread appears to be the predilection of
BA.2 to the upper, rather than the lower
respiratory tract, as in the case of the
original Wuhan strain or its derivatives, such
as the Delta strain (Figure 2). Clearly, the Omicron and its sub-variants BA.1 and BA.2
ability to replicate and profusely colonize predominantly infects the upper respiratory
system and the airway above the lungs
the upper respiratory tract implies that Omicron, BA.1, BA.2
BA.2 dissemination may occur through
routine daily activities such as talking, rapid
breathing, sneezing and coughing.
It is also known that BA.2 replication in Pre-Omicron
lung tissue is nearly 10 times less than the variants (eg Delta)
original strain, which may be the reason for
its lower disease severity. This is thought Other variants, such as Delta,
infect mainly the lower
to be due to the fact that the lungs have a
respiratory tract
more pronounced interferon response than
the upper respiratory tract and BA.2 being
more susceptible to interferon, lingers and
multiplies in the upper respiratory tract.8
(Interferon is a common antiviral chemical
that interferes with cell-to-cell spread of
viruses, hence its name.)
Figure 2. Another major reason for the extraordinary spread of Omicron subvariant BA.2 is considered
to be its greater affinity for the cellular receptors in the upper, rather than the lower respiratory tract,
Disease severity after BA.1 and in comparison to its ancestral lineage such as the Delta variant (illustrated above). Colonization of the
BA.2, and reinfections upper respiratory tract facilitates viral spread through routine daily activities such as talking, sneezing
and coughing. This also has profound implications for clinical dental practice. (Figure created using
Current evidence indicates that the classic
Biorender.com software).
COVID-19 symptoms due to the BA.2 variant

434 DentalUpdate May 2022


Figure 3. The antivirals nirmatrelvir and
ritonavir (sold as a combination drug Paxlovid,
shown above), molnupiravir and remdesivir are
extremely effective against both BA.1 and BA.2
subvariant infections (in all age groups), provided
they are taken in the early stage of the infection,
soon after a positive test.
are not more severe than those due to
BA.1, either in vaccinated people or those
who were previously infected with SARS-
CoV-2. For instance, British4 and Danish9
researchers have found that BA.2 infection
does not carry a higher risk of hospitalization
than BA.1.
According to early data, there is only a
rare possibility of reinfection with BA.2 after
BA.1 infection. 10 For instance, in South Africa,
where BA.1 was the earlier infection in a
vast proportion, BA.2 reinfection has been
relatively uncommon.
On the other hand, spread of BA.2 is
common among those in unvaccinated
groups, as was recently shown in the fifth
wave of the pandemic in Hong Kong, where
a dramatic surge in BA.2 infection occurred
with a record number of deaths in the elderly.
Conversely, the current BA.2 spike in UK is
thought to be due to the result of easing
COVID restrictions, such as lifting mask
mandates and social distancing restrictions.
A note on drugs against BA.1
and BA.2 variants
As far as the currently available major
drugs for COVID-19 are concerned, the
antiviral Paxlovid (a combination antiviral
of nirmatrelvir and ritonavir), molnupiravir
and remdesivir all remain effective against
both BA.1 and BA.2, provided they are taken
in the early stage of the disease, soon after
a positive test (Figure 3). However, most
monoclonal antibody treatments authorized
by the Food and Drug Administration seem to
be ineffective against the variants.11
May 2022
Viral variants, endemicity and
future prospects
The full capacity of SARS-CoV-2 to evolve,
through both antigenic shifts and drifts, and
to produce radically new variants is unclear.
However, the consensus is that it has a fair
degree of genetic flexibility, as it were, to
produce variants that could skirt the human
immune assault and infect human cells. The
current view of the scientific community is
that Omicron BA.1- and BA.2-like variants
will continue to emerge, driven primarily by
immune selectivity, as more and more people
receive effective vaccines, thereby reaching
herd immunity in many regions of the world.
There is much speculation that SARS-
CoV-2 will turn into a virus similar to the
influenza and the common cold virus
and hit a plateau owing to vaccines and
infection-associated immunity, akin to the
coronaviruses that cause the common cold.
However, because of the many unknowns
about SARS-CoV-2 behaviour, this remains
speculative, as yet. New vaccines against the
Omicron variants are currently in large-scale
Phase 1 and 2 human vaccine trials, and it is
hoped that they will provide longer-lasting
immunity than the initial crop of vaccines.
A notable silver lining in this dark cloud
is the technological advances in vaccine
production, including predictive tools linked to
artificial intelligence. For instance, predicting
how various pathogens evolve, and change
their surface antigenic structure, and priming
the human immune system for the next
wave of combatants is a possible pro-active
path for success. One such approach, called
‘deep mutational scanning’, entails observing
evolutionary changes in the pathogens’ surface
antigen ‘drifts and shifts’ in silico using artificial
intelligence and machine learning.12 This
means that vaccines for the next viral variant,
or indeed a new pathogen, could be predicted
far in advance and the infection nipped
in the bud, prior to becoming a full blown
pandemic. If such ambitious, technologically
driven programs bear fruit, then the COVID-19
pandemic could be relegated to history as
the last great pandemic which humankind
has endured.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Murray CJL. COVID-19 will continue but the
COVID-19 Commentary
end of the pandemic is near. Lancet 2022;
399: 417–419. https://doi.org/10.1016/
S0140-6736(22)00100-3
2. Hagen A. How ominous is the omicron
variant (B.1.1.529)? 2021. Available at: https://
asm.org/Articles/2021/December/How-
Ominous-is-the-Omicron-Variant-B-1-1-529
(accessed April 2022).
3. McMenamin ME, Nealon J, Lin Y et al. Vaccine
effectiveness of two and three doses of
BNT162b2 and CoronaVac against COVID-19
in Hong Kong. Preprint. 2022. Available at:
https://www.medrxiv.org/content/10.1101/2
022.03.22.22272769v2 (accessed April 2022).
4. Chen J, Wei GW. Omicron BA.2 (B.1.1.529.2):
high potential to becoming the next
dominating variant. ArXiv [Preprint]. 2022
Feb 10:arXiv:2202.05031v1. https://doi.
org/10.21203/rs.3.rs-1362445/v1
5. UK Health Security Agency. Investigation
of SARS-CoV-2 variants: technical briefings.
2022. Available at: www.gov.uk/government/
publications/investigation-of-sars-cov-2-
variants-technical-briefings (accessed April
2022).
6. Cheng VC, Ip JD, Chu AW et al. Rapid spread
of SARS-CoV-2 Omicron subvariant BA.2
in a single-source community outbreak.
Clin Infect Dis 2022: ciac203. https://doi.
org/10.1093/cid/ciac203
7. Meng B, Abdullahi A, Ferreira IATM et al.
Altered TMPRSS2 usage by SARS-CoV-2
Omicron impacts infectivity and fusogenicity.
Nature 2022; 603: 706–714. https://doi.
org/10.1038/s41586-022-04474-x
8. Bojkova D, Widera M, Ciesek S et al. Reduced
interferon antagonism but similar drug
sensitivity in Omicron variant compared to
Delta variant of SARS-CoV-2 isolates. Cell Res
2022; 32: 319–321. https://doi.org/10.1038/
s41422-022-00619-9
9. Fonager J, Bennedbæk M, Bager P et al.
Molecular epidemiology of the SARS-
CoV-2 variant Omicron BA.2 sub-lineage in
Denmark, 29 November 2021 to 2 January
2022. Euro Surveill 2022; 27: 2200181.
https://doi.org/10.2807/1560-7917.
ES.2022.27.10.2200181
10. Stegger M, Edslev SM, Sieber RN et al
Occurrence and significance of Omicron
BA.1 infection followed by BA.2 reinfection.
Preprint. 2022. Available at: https://www.
medrxiv.org/content/10.1101/2022.02.19.222
71112v1 (accessed April 2022).
11. Takashita E, Kinoshita N, Yamayoshi S et
al. Efficacy of antiviral agents against the
SARS-CoV-2 Omicron subvariant BA.2. N Engl
J Med 2022; 386: 1475–1477. https://doi.
org/10.1056/NEJMc2201933
12. Samaranayake L, Fakhruddin KS. Pandemics
past, present, and future: their impact on
oral health care. J Am Dent Assoc 2021;
152: 972–980. https://doi.org/10.1016/j.
adaj.2021.09.008
DentalUpdate 435
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Technique Tips
Lateral Thinking: The Laterally Closed Tunnel Technique for
Root Coverage. A Case Series
Dent Update 2022; 49: 437–440
The laterally closed tunnel is a novel
technique to achieve root coverage over
narrow recession defects. This article
presents three clinical cases completed in
private practice settings demonstrating
positive outcomes using the technique for
both single and multiple recession defects
in the anterior mandible. The techniques
are described in detail, including
appropriate case selection.
The use of tunnelling techniques for
root coverage has gained popularity within
the field of periodontal mucogingival
surgery. Historically, the tunnelling
approach was first proposed by Raetzke
in 1985 where the preparation of a
supra-periosteal envelope that allowed
for insertion of a connective tissue graft,
which was left partially exposed was
described.1 The technique evolved to treat
multiple gingival recessions, as described
by Allen in 1994, and was finally coined
the ‘tunnel’ approach by Zabalegui et al
in 1999.2,3
Zuhr et al and Aroca et al described a
modified microsurgical tunnel technique
whereby the entire gingiva-papillary
unit was coronally advanced with the
use of either anchoring sutures into the
palatal mucosa, or suspensory sutures
with composite stops to allow coverage
of the connective tissue graft.4–6 More
recently, Sculean and Allen described a
laterally closed tunnel (LCT), whereby
tension-free lateral closure of the tunnel
over isolated mandibular recession defects
is obtained following the principles of
tunnel preparation described in previous
techniques.7 A similar technique (if not
identical) has also been termed the
laterally stretched flap (LAST) by Carranza.8
Devan S Raindi, BDS Hons (Birm) MJDF RCS (Eng) MClinDent Hons (KCL) MPerio RCS (Edin) AFHEA, Specialist in Periodontics, Private
Practice, Scott Arms Dental Practice. Hiten Halai, BDS, MFDS, RCSEd, PG Dip MPerio, RCSEd DClinDent Perio, Specialist and Clinical
Teacher in Periodontics, Private Practice, Dental Specialists, Windsor. email: devan.raindi@nhs.net
May 2022
Here we present a series of cases,
performed by two different clinicians in
private practice settings, to highlight the
use of the novel laterally closed tunnel
with connective tissue graft as a viable
and effective alternative root coverage
technique over isolated mandibular incisor
recession defects.
Case 1
A 22-year-old female patient was referred
in private practice by her general dental
practitioner (GDP) regarding a localized
recession defect affecting the lower right
central incisor. The patient’s main complaint
was of tenderness on cleaning around
the LR1, and concern over the extent of
the recession defect. She was medically fit
and well, taking no medication and was
a non-smoker.
On examination there was evidence
of an RT1 defect (2017 World Workshop
Classification)/Miller Class 2 defect
(1999 classification) affecting the LR1.
The dimensions of the defect were
approximately 11 x 3 mm. There were two
frenal attachments into the mesial and
distal aspect of the LR1, impeding the
ability of the patient to adequately clean
the full extent of the recession defect, with
no keratinized tissue apical to the defect.
There was also an approximately 4–5-mm
width of apico-coronal attached gingivae
on both mesial and distal aspects of the
recession defect (Figure 1).
The options presented to the
patient were as follows:
„ Free gingival graft with
simultaneous frenectomy;
„ Laterally positioned, coronally advanced
flap with pedicle from distal LR1;
Technique Tips
„Laterally closed tunnel with autogenous
connective tissue graft.
Procedure
Local anaesthetic was given as buccal
infiltrations in the anterior mandible
and palate using lidocaine 2% with
1:80,000 adrenaline.
The procedure was split into
three stages:
„ Preparation of tunnel;
„ Harvest of connective tissue graft
from palate;
„ Closure with sutures.
Preparation of tunnel
Using a microsurgical blade (SN69, Swann
Morton), an inverse bevel incision was
made around the recession defect of
LR1. Intra-crevicular incisions were also
made around the buccal aspects of the
LR2 and LL1 to allow preparation of a
supra-periosteal tunnel with sufficient
ability to obtain primary closure with
lateral movement.
Tunnel preparation involved the use of
specific tunnelling knives (TKN1X/TKN2X,
Hu-Friedy) and a modified Orban knife
(Hu-Friedy) to ensure release of muscle
attachment from the overlying soft tissue,
including the frenula evident in Figure 1.
This involved adequate mesio-distal and
apico-coronal tunnel preparation to allow
for tension-free closure.
Harvest of connective tissue graft
The connective tissue graft was harvested
via a free gingival graft that was
subsequently de-epithelialized outside
the mouth. The graft dimensions were
DentalUpdate 437
Technique Tips
Figure 1. Pre-operative photograph LR1.
Figure 2. Photograph taken immediately after
the operation.
a was of sensitivity and concern over the
b The dimensions of the defect were
Figure 3. (a) Pre-operative situation; and (b)
4 weeks post-operatively.
Figure 4. Pre-operative situation.
approximately 10 mm in length to allow the
graft to sit on a vascularized bed at least
3 mm either side of the recession defect
and 6 mm in height.
438 DentalUpdate
Figure 5. Tunnel preparation extending to the
adjacent teeth and apically beyond the muco-
gingival junction.
Figure 6. Connective tissue graft inserted into
the tunnel and secured laterally.
Figure 7. Gingival tissues approximated laterally
and sutured using a single interrupted technique.
Suturing of graft and tunnel
The graft was introduced into the tunnel
at the LR1 and sutured to secure it against
the inner aspect of the mucosa (Figure
2). A separate sling suture (6-0 Vicryl
Rapide, Ethicon) was placed to adapt the
connective tissue graft to root surface.
Finally, single interrupted sutures (6-0
Prolene, Ethicon) were placed to close the
tunnel by approximating the lateral borders
of the recession.
The 4-week review
The patient reported significant
improvements in root coverage around the
LR1 and was very satisfied at this point. It
was noted that there was a residual 1-mm
recession associated with the LR1. Figure 3
shows the surgical site after 4 weeks
compared with the pre-operative situation.
Further follow up was anticipated.
Case 2
A 32-year-old male patient was referred
by his GDP regarding a localized recession
b
Figure 8. (a) Pre-operative situation and (b)
8 weeks post-operatively.
defect affecting the lower left central
incisor. The patient’s main complaint
rapid deterioration of the defect over
the previous 2 years. He was medically fit
and well, taking no medication and had
recently stopped smoking.
Clinical examination revealed an
RT1 defect (2017 World Workshop
Classification)/Miller Class 2 defect
(1999 classification) affecting the LL1.
approximately 7 x 3 mm. High frenal
attachments into the mesial and distal
aspect of the LL1 were noted, with a
McCall’s festoon at the most coronal
aspect of the gingival margin. There was
also an approximately 5-mm width of
apico-coronal attached gingivae on both
mesial and distal aspects of the recession
defect (Figure 4). The tooth was positioned
lingually to the adjacent teeth.
The same treatment options as in
Case 1 were presented to the patient,
and a laterally closed tunnel with an
autogenous palatal connective tissue graft
was deemed most appropriate. A similar
surgical protocol was used as described in
Case 1 (Figures 5–7). The graft was sutured
with vertical mattress sutures lateral to the
recession defect using a resorbable 6-0
suture (6-0 Resorba Glycolon). The defect
edges were then approximated using
single interrupted suturing with non-
resorbable 6-0 sutures (Mopylen 6-0). The
sutures remained in situ for 2 weeks.
The site was reviewed at 2 and
8 weeks post-operatively (Figure 8).
There was significant improvement in
May 2022
 Technique Tips

the patient’s presenting complaints.

Clinically, substantial root coverage was
achieved with a residual 1-mm defect. The
gingival tissues around the LL1 now had
a thicker phenotype, with greater than
2-mm of keratinized tissue apical to the
gingival margin.

Case 3 Figure 12. Autogenous connective tissue graft in

A 34-year-old male patient was referred situ prior to insertion into the tunnel.
Figure 9. Pre-operative situation demonstrating
by his GDP regarding persistent gum
extensive multiple recessions and associated
inflammation and soreness around his gingival inflammation.
lower anterior teeth. His medical and
social history was unremarkable.
Clinical examination revealed
RT1 defects (2017 World Workshop
Classification)/Miller Class 2 defect
(1999 classification) affecting the LR1
and LL2. The dimensions of the defects
were approximately 6 x 3 mm (LR1) and
Figure 13. Gingival tissues approximated laterally
12 x 2 mm (LL2). There was moderate
at recession sites and a coronally advancing sling
crowding of the lower anterior teeth
suture around the LL1 to compensate for post-
with the LR1 and LL2 slightly rotated and operative relapse.
buccally displaced. A high midline frenal Figure 10. Improved gingival health post
attachment was noted mesial to the LR1. hygienic phase.
Both recession defects extended to the
mucogingival junction. The oral hygiene
around these sites was suboptimal,
with supra- and subgingival plaque and
calculus deposits. Localized gingival
inflammation was also present (Figure 9).
The same treatment options as in
Cases 1 and 2 were presented to the
patient, and simultaneous laterally closed Figure 14. Post-operative healing at 8 weeks
tunnels with an autogenous palatal Figure 11. Preparation of the mucoperiosteal showing improved gingival tissue thickness and
connective tissue graft were selected tunnel and demonstration of tissue mobility. width of keratinized tissue.
(Figures 10–12). After an initial hygienic
phase, the surgical and suturing protocol
was as described in Case 2. An additional
coronally advancing sling suture was placed gingival graft. Harvesting techniques contraindicate coronal advancement of
around the LL1 to keep the tissues in an for a connective tissue graft can also tissues (either via a coronally advanced
over-corrected coronal position by 1 mm include single incision techniques, which flap or coronally advanced tunnel).
to compensate for some relapse during the result in all surgical sites having the The original technique described by
healing phase (Figure 13). possibility of primary closure, limiting Allen and Sculean included the addition
The site was reviewed at 2 and 8 weeks secondary intention healing, and the of amelogenin (Emdogain, Straumann,
post-operatively (Figure 14), and there was increased morbidity that accompanies it. Switzerland). Our cases demonstrate
substantial improvement in the clinical Furthermore, secondary intention healing significant improvements in recession
appearance and the patient’s symptoms. associated with laterally positioned flaps reduction without additional biological
The gingival tissues around both sites is avoided, which can sometimes lead to agents, which provides potential benefit
had a thicker phenotype, with a band of cosmetically unsatisfactory scar formation. for those individuals who do not wish to
attached keratinized tissue re-instated. The technique does not require have xenogeneic biomaterials for ethical/
the significant apico-coronal height of religious reasons, as well as reducing
Residual recessions of 2–3 mm were noted
keratinized tissue required for a laterally the obvious financial implications of
at both sites. The patient was now able to
positioned flap, although adjacent additional materials.
perform oral hygiene more comfortably.
keratinized tissue is still required for It must be noted that there is
adequate soft tissue handling and incomplete root coverage at 4–8 weeks,
Discussion aesthetic outcomes. The lateral closed with a residual 1–3-mm recession. While
The advantages of using a laterally closed tunnel also seems to be an appropriate this was acceptable to the patients, there
tunnel include providing improved technique where there is a shallow are modifications that could be considered
aesthetic outcome compared with a free vestibule and inserting frenula, which may to improve this. First, we cannot rule

May 2022 DentalUpdate 439

Technique Tips
out that the use of amelogenin may
have provided improved root coverage.
Furthermore, we could have coronally
positioned the connective tissue graft and
left a small exposure coronally, which is an
accepted technique, providing most of the
graft is covered. Finally, a supplemental
sling suture coronally advancing the entire
gingival unit and stabilizing the tissues at
a more coronal level could have optimized
outcomes further.
Conclusion
These cases demonstrate that, with
appropriate case selection, the laterally
closed tunnel provides an effective and
aesthetic alternative to the free gingival
graft or laterally positioned flap in the lower
anterior mandible for single and alternate
recession defects.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
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440 DentalUpdate
obtained from all individual participants
included in the article.
References
1. Raetzke PB. Covering localized areas of
root exposure employing the ‘envelope’
technique. J Periodontol 1985; 56:
397–402. https://doi.org/10.1902/
jop.1985.56.7.397
2. Allen AL. Use of the supraperiosteal
envelope in soft tissue grafting for root
coverage. I. Rationale and technique. Int
J Periodontics Restorative Dent 1994; 14:
216–227.
3. Zabalegui I, Sicilia A, Cambra J et al.
Treatment of multiple adjacent gingival
recessions with the tunnel subepithelial
connective tissue graft: a clinical report.
Int J Periodontics Restorative Dent 1999;
19: 199–206.
4. Zuhr O, Fickl S, Wachtel H et al. Covering
of gingival recessions with a modified
microsurgical tunnel technique: case
report. Int J Periodontics Restorative Dent
2007; 27: 457–463.
5. Aroca S, Keglevich T, Nikolidakis D et al.
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for high-quality predictable and enjoyable
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range of subject areas.
Learn more
For detailed course information and online
application, please visit our dedicated web
pages, or contact our programme team
with your questions.
7  
('*UHHQ#EKDPDFXN
Treatment of class III multiple gingival
recessions: a randomized-clinical trial. J
Clin Periodontol 2010; 37: 88–97. https://
doi.org/10.1111/j.1600-051X.2009.01492.x
6. Aroca S, Molnár B, Windisch P, Gera I,
Salvi GE, Nikolidakis D, Sculean A et al.
Treatment of multiple adjacent Miller
class I and II gingival recessions with
a modified coronally advanced tunnel
(MCAT) technique and a collagen matrix
or palatal connective tissue graft: a
randomized, controlled clinical trial. J Clin
Periodontol 2013; 40: 713–720. https://doi.
org/10.1111/jcpe.12112
7. Sculean A, Allen EP. The laterally closed
tunnel for the treatment of deep isolated
mandibular recessions: surgical technique
and a report of 24 cases. Int J Periodontics
Restorative Dent 2018; 38: 479–487.
https://doi.org/10.11607/prd.3680
8. Carranza N, Pontarolo C, Rojas MA.
Laterally stretched flap with connective
tissue graft to treat single narrow deep
recession defects on lower incisors. Clin
Adv Periodontics 2019; 9: 29–33. https://
doi.org/10.1002/cap.10046
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 CPD
continuing education

Test your knowledge on the content of the articles published.

The following 10 questions relate to some of the articles carried this month. Only one answer is correct.
To receive CPD credit, please answer the questions online at www.dental-update.co.uk

Q1 BEREZNICKI ET AL 49: 371–378 Q6 SETHI ET AL 49: 403–406

Regarding working conformatively from an Regarding sialolithiasis:
occlusal viewpoint: A. This is most commonly seen in females.
A. The technician should never locate the opposing B. Sialoliths are saliva stones consisting of calcium, magnesium,
models together. potassium and ammonium deposits.
B. A semi- or fully adjustable articulator is not needed. C. This often affects children.
C. This is largely restricted to the provision of one or two D. All sialoliths are radiopaque.
restorations at a time.
D. This is always more difficult than working in a
reorganized format.

Q7 SETHI ET AL 49: 403–406

Q2 FOSTER-THOMAS ET AL 49: 380–386 Regarding mucoceles:
Regarding management of TMD: A. These are caused by an accumulation of saline.
A. Individualized patient education is of no value. B. Simple excision of the mucocele alone is always a
B. The words ‘degenerative’ and ‘damage’ should always be successful treatment.
used when describing the condition to patients. C. These are usually induced by trauma to a minor salivary duct.
C. Patients do not need to tailor their diet. D. These are always self limiting.
D. Successful management is more likely when contributing
factors, such as stress and oral parafunctional habits,
are addressed.
Q8 BRADLEY ET AL 49: 409–414

Q3 ZAIDMAN ET AL 49: 388–392 Regarding radiation caries:

Regarding cannulation:
A. Dermatological infection at the cannulation site is not
a contraindication.
B. Catheter-related bloodstream infection is a
common complication.
C. A patient should not feel any discomfort once the cannula is
in place.
D. Skin cleansing swabs should never be used.
Q4 SANGHVI AND BHUJEL 49: 395–401
Regarding hypodontia:
A. This is lower in patients with CLP than in
unaffected individuals.
B. Overall prevalence in the general population has been
reported as 16% in the permanent dentition.
C. Aetiology is not thought to be genetically determined.
D. This is more likely to occur in region of a cleft.
A. Presentation of caries in affected patients is the same as in non-
irradiated patients.
B. In affected patients, overt caries may be seen within 3 months of
completing treatment.
C. Radiation does not damage enamel.
D. Osteoradionecrosis is not a problem in irradiated patients.
Q9 YOUNG ET AL 49: 424–430
Regarding dental caries as a public health problem:
A. One-tenth of 12 year-olds have caries in their permanent teeth.
B. The more affluent are more affected.
C. First premolars are most frequently affected.
D. Its impact on individuals, and society, is significant.

Q10 SAMARANAYAKE 49: 432–435

Q5 SANGHVI AND BHUJEL 49: 395–401 Regarding the Omicron virus:
A. There were 1.25 million infections per day in January 2022, worldwide.
Reported prevalence of supernumerary teeth in the permanent B. This was first identified in South America.
dentition in CLP patients is: C. There are no new subvariants of this being discovered.
A. 22% D. A single case of the Omicron BA.2 variant infection may infect 216 cases
B. 12% in a 12-day period.
C. 2%
D. Zero

DEADLINE FOR SUBMISSION: 28 JULY 2022

CPD in Dental Update in partnership with
10 QUESTIONS REPRESENT 4 HOURS OF CPD

ANSWERS FOR MARCH 2022 CPD ON PAGE 406

442 DentalUpdate May 2022

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