Dental Update – October 2020 Volume 47 . Number 9

80 Pages·2020·7.592 MB·English

by  Trevor Burke, Angela Stroud

DentalUpdate
October 2020 . Volume 47 . Number 9
(cid:132)(cid:132) RReessttoorraattiivvee DDeennttiissttrryy:: DDeennss EEvvaaggiinnaattuuss –– ‘‘AAddddiittiioonn BBeeaattss SSuubbttrraaccttiioonn’’
(cid:132)(cid:132) OOrraall SSuurrggeerryy:: CCoorroonneeccttoommyy:: nnoott jjuusstt ffoorr WWiissddoomm TTeeeetthh
(cid:132)(cid:132) RRaaddiioollooggyy:: UUppddaattee oonn IIoonniizziinngg RRaaddiiaattiioonn RReegguullaattiioonnss 22001177 ((IIRRRR 22001177)) aanndd IIoonniizziinngg RRaaddiiaattiioonn
MMeeddiiccaall EExxppoossuurree RReegguullaattiioonnss 22001188 ((IIRRMMEERR 22001188)) −− RReelleevvaannccee ttoo tthhee DDeennttaall TTeeaamm
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INSIDE THIS ISSUE
701 COMMENT CPD Aims, Objectives and Learning different types of endodontic access cavity
Begonias Outcomes: To understand the uses, designs based on the current available
FJ Trevor Burke advantages and limitations of digital evidence.
workflows in fabricating removable partial Enhanced CPD DO C
703 GUEST EDITORIAL dentures.
Dentistry and COVID-19 – Time to Rethink Enhanced CPD DO C 755 RADIOLOGY
our Prescribing Patterns? Update on Ionizing Radiation Regulations
RL Caplin 729 GENERAL DENTISTRY/PAEDIATRIC DENTISTRY/ 2017 (IRR 2017) and Ionizing Radiation Medical
Exposure Regulations 2018 (IRMER 2018) −
ORTHODONTICS
706 RESTORATIVE DENTISTRY Relevance to the Dental Team
Supernumerary Teeth: an Overview for the
Dens Evaginatus – ‘Addition Beats KK Grewal and N Heath
General Dental Practitioner
Subtraction’ CPD Aims, Objectives and Learning
MJ Meade
K Ayub, S Khan and M Kelleher Outcomes: To understand the new revisions
CPD Aims, Objectives and Learning
CPD Aims, Objectives and Learning to IRR and IRMER guidance and appreciate its
Outcomes: To highlight how timely
Outcomes: To explain the problems of dens implications to dental practice.
diagnosis and appropriate management may
evaginatus and of modern management Enhanced CPD DO C
reduce potential problems associated with
strategies.
supernumerary teeth.
Enhanced CPD DO C 761 COVID-19 COMMENTARY
Enhanced CPD DO C
Coronavirus Disease 2019 (COVID-19)
714 ORAL SURGERY Diagnostics: a Primer
739 ORAL SURGERY
Coronectomy: not just for Wisdom Teeth L Samaranayake, N Kinariwala and RAPM Perera
Rhinosinusitis Update
B Owen, G Oliver, L Macey-Dare and G Knepil
C Hopkins
CPD Aims, Objectives and Learning 767 LETTERS TO THE EDITOR
CPD Aims, Objectives and Learning
Outcomes: To present a novel case of
Outcomes: To review current management
coronectomy to an infra-occluded lower left 769 BREAKING NEWS: COVID-19 AND DENTISTRY
strategies of rhinosinusitis.
first molar coronectomy to avoid inferior L Samaranayake
alveolar nerve damage, and facilitate Enhanced CPD DO C
orthodontic treatment. 770 I LEARNT ABOUT DENTISTRY FROM THAT
Enhanced CPD DO C 747 ENDODONTICS
Controversies in Endodontic Access Cavity 771 TECHNIQUE TIPS
719 RESTORATIVE DENTISTRY Design: a Literature Review The Role of Fibre-reinforced Composite Posts
A Combined Digital-Conventional Workflow M Maqbool, TY Noorani, JA Asif, SD Makandar in Children
to Fabricate a Removeable Partial Denture and N Jamayet AS Dhadwal, SJ McKaig and A Casaus
for a Patient with a Severe Gag Reflex CPD Aims, Objectives and Learning
774 CPD QUESTIONS
RB O'Leary and AL Gunderman Outcomes: To compare and contrast the
CPD in Dental Update in partnership with
EDITORIAL DIRECTOR
FJ Trevor Burke Bourne End, Bucks Louis Mackenzie
Professor of Dental Primary Care, GDP and Clinical Lecturer
University of Birmingham School of Len D'Cruz University of Birmingham School of Dentistry
Dentistry GDP, Woodford Dental Care, Woodford Green, and King's College London
Essex
EXECUTIVE EDITOR Tara Renton
Chris Deery Professor of Oral Surgery, King's College London Dental
Angela Stroud Professor of Paediatric Dentistry, School of Institute
Clinical Dentistry, Sheffield S10 2TA
EDITORIAL BOARD David Ricketts
Avijit Banerjee Professor of Cariology and Conservative Dentistry,
Professor of Cariology and Operative Ian Dunn Dundee Dental Hospital
Dentistry Specialist Periodontist
Faculty of Dentistry, Oral & Craniofacial Rose Lane Dental Practice Jonathan Sandler
Sciences, King’s College London Liverpool L18 8AG Professor and Consultant Orthodontist, Chesterfield and
North Derbyshire Royal Hospital
Subir Banerji Ken Hemmings
Consultant Damien Walmsley
Programme Director MSc in Aesthetic
Eastman Dental Hospital, London WC1X 8LD Professor of Restorative Dentistry, University of
Dentistry Birmingham School of Dentistry
Faculty of Dentistry, Oral & Craniofacial
Edwina Kidd
Sciences, King’s College London
Emerita Board Member

c/o George Warman Publications
Steve Bonsor (c/o RCPSG)
Unit 2, Riverview Business Park,
The Dental Practice Walnut Tree Close, Guildford GU1 4UX Cover Picture: A Grey Seal pup playfully biting
21 Rubislaw Terrace at the camera dome. Location - Farne Islands, UK.
Aberdeen AB10 1XE Mike Lewis Highly Commended, British Wildlife Photography
Professor of Oral Medicine Awards 2019 (Courtesy of Nicholas More,
Andrew Chandrapal School of Dentistry, Cardiff University Photographer, Exmouth Devon).
GDP, Bourne End Dental Cardiff CF14 4XY
October 2020 DentalUpdate
pg699 Contents October.indd 803 07/10/2020 11:48
Don’t forget to renew your
patient’s Duraphat prescription
76%
of patients
prefer the taste of
Duraphat 5000 ppm#,1
Effective prevention for patients at increased caries risk*
• 5000 ppm Fluoride Toothpaste prevents cavities by arresting and reversing primary
root and early fissure caries lesions2-5
Prescribe Duraphat 5000 ppm Fluoride Toothpaste and support patient adherence:
• 89% of consumers agree that taste is an important
factor when using a toothpaste**
• Prescribing a product with a preferred taste may be
important to enhance patient adherence
1.1% Sodium Fluoride
Be confident prescribing Colgate® Duraphat®, the brand your patients know and trust†
# Compared to generic 5000 ppm high fluoride toothpaste. * Patients ≥ 16 years at increased caries risk. ** Colgate UK Consumer Survey on Cosmetic Toothpaste. 504 participants. Feb 2020. † YouGov Omnibus for Colgate® UK, data on file
June 2015. Claim applies only to the Colgate® brand.
References: 1. Data on file. Preference Survey. January 2020 (n=82). 2. Baysan A et al. Caries Res 2001;35:41-46. 3. Schirrmeister JF et al. Am J Dent 2007;20. 212-216. 4. Ekstrand et al. Geodent 2008;25:67-75. 5. Ekstrand et al. Caries Res
2013;47:391–8.
Colgate® Duraphat® 5000 ppm Fluoride Toothpaste - Name of the medicinal product: Duraphat® 5000 ppm Fluoride Toothpaste. Active ingredient: Sodium Fluoride 1.1%w/w (5000ppm F-). 1g of toothpaste contains 5mg fluoride (as sodium
fluoride), corresponding to 5000ppm fluoride. Indications: For the prevention of dental caries in adolescents and adults 16 years of age and over, particularly amongst patients at risk from multiple caries (coronal and/or root caries). Dosage
and administration: Brush carefully on a daily basis applying a 2cm ribbon onto the toothbrush for each brushing. 3 times daily, after each meal. Contraindications: This medicinal product must not be used in cases of hypersensitivity to the
active substance or to any of the excipients. Special warnings and precautions for use: An increased number of potential fluoride sources may lead to fluorosis. Before using fluoride medicines such as Duraphat, an assessment of overall fluoride
intake (i.e. drinking water, fluoridated salt, other fluoride medicines - tablets, drops, gum or toothpaste) should be done. Fluoride tablets, drops, chewing gum, gels or varnishes and fluoridated water or salt should be avoided during use of
Duraphat Toothpaste. When carrying out overall calculations of the recommended fluoride ion intake, which is 0.05mg/kg per day from all sources, not exceeding 1mg per day, allowance must be made for possible ingestion of toothpaste
(each tube of Duraphat 500mg/100g Toothpaste contains 255mg of fluoride ions). This product contains Sodium Benzoate. Sodium Benzoate is a mild irritant to the skin, eyes and mucous membrane. Undesirable effects: Gastrointestinal
disorders: Frequency not known (cannot be estimated from the available data): Burning oral sensation. Immune system disorders: Rare (≥1/10,000 to <1/1,000): Hypersensitivity reactions. Legal classification: POM. Marketing authorisation
number: PL00049/0050. Marketing authorisation holder: Colgate-Palmolive (U.K.) Ltd. Guildford Business Park, Midleton Road, Guildford, Surrey, GU2 8JZ. Recommended retail price: £7.99 (51g tube). Date of revision of text: February 2015.
www.colgateprofessional.co.uk www.colgatetalks.com
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Comment
Authors' Information
Dental Update invites submission of articles
pertinent to general dental practice. Articles should
be well-written, authoritative and fully illustrated.
Manuscripts should be prepared following the
Guidelines for Authors published in the April
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a synopsis before writing an article. The opinions
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Begonias
staff or the members of the Editorial Board. The
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Opinion in Dentistry & other databases.
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In the background of the coronavirus pandemic, which puts little other than life and death
Full UK £137 | Digital Subscription £110 into perspective, it is not easy to see beyond the current crisis. Dentists in the UK, and
Retired GDP £93 many worldwide, are facing financial and clinical difficulties which could never have been
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when dentists and their patients will again worry about how long the restorations placed
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high quality, well-illustrated articles of relevance to general dentistry and publishing
Mark Allen Group, Unit A 1–5, Dinton Business Park,
fewer articles solely related to COVID-19, albeit with the rider that, should we receive
Catherine Ford Road, Dinton, Salisbury SP3 5HZ an important COVID-related paper, it will be published, and we will continue to publish
FREEPHONE: 0800 137201 Professor Samaranayake’s most useful COVID-19 Commentary for as long as he considers it
Main telephone (inc. overseas): 01722 716997 relevant.
E: [email protected] Is it too soon to discuss whether anything good has come from the pandemic?
Perhaps, but there are some initiatives which are worthy of mention, namely:
Managing Director: Stuart Thompson
(cid:132) British Airways’ new disembarkation by row number is one, as it removes the scrum
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Comment
which occurred when the seat belt sign
was turned off.
(cid:132) Many former commuters will be
more relaxed while working from
home, rather than standing on a
crowded train for hours. In this
regard, European data suggest that
three-quarters of jobs in the highest
paid quartile can be done remotely,
compared with only 3% in the lowest
quartile. Indeed, is working from home
a privilege confined to the well paid?1 It
is something that dentists will never be
able to do!
(cid:132) Bob Dylan released, on his YouTube
channel on 27 March 2020, his 17
minute epic ‘Murder Most Foul’
(which addresses the assassination
of President John F Kennedy in 1963)
as a gift to his fans. A variety of than ever. restrictions are increasing in the UK and,
commentators have seen the release I like growing flowers. At the more stringently, in Birmingham. These
and content of the song directly beginning of May each year, I plant begonia are necessary evils when we might want
related to the COVID-19 pandemic. tubers. This year was not an exception, and to draw close to each other. The future
Rolling Stone deputy editor2 praised the the blooms have been as good as ever! has always been uncertain, but is more
release, stating that the song ‘is really Perhaps, recent events should prompt us uncertain now. Nevertheless, there remains
about the ways that music can comfort to remember the simple pleasures that hope that we will begin to adapt to the
us in times of national trauma’. COVID-19 cannot remove and draw comfort new normal − for as long as it takes.
In clinical matters, the from them, such as presented here. For the
following are among the initiatives begonias (illustrated here and overleaf), References
worthy of mention: it would be the end of everything if they 1. O’Connor S. Welcome to the digital
(cid:132) Remote diagnosis, as discussed in ceased blooming. John Lennon is widely gig economy. I News, 17 September
recent issues of Dental Update, has attributed to be the author of the comment 2020.
reduced travelling for patients. ‘Everything will be okay in the end. If it’s 2. Vosick-Levinson S. https://
(cid:132) Minimally invasive dentistry is a not okay, it’s not the end’. In that regard, en.wikipedia.org/wiki/Murder_
certain winner, as clinicians increasingly the new normal is not normal, and, as Most_Foul_(song) Rolling Stone, 27
search for ways of treating their Cynthia Gorney3 put it – ‘In perilous times, March 2020.
patients without the need for an our deepest human impulse is to draw 3. Gorney C. We are not made for this
Aerosol Generating Procedure. close to each other − the very thing we’ve new normal. National Geographic July
(cid:132) Prevention is more important now been told not to do’. As I write, lockdown 2020; 238: 21−23.
Farewell to Angela Stroud issue when she spotted that there were
two references in the bibliography of
Angela Stroud, Executive Editor of
an article, but no reference to them in
Dental Update, has been central to
the text!
the production of every issue for
It is therefore with sadness
over 20 years (which amounts to well
that I report that she plans to retire
over 200 issues), plus every issue of
after this issue. I, and all members of
Orthodontic Update! It is she who has
the Editorial Board, and the team at
checked the grammar, spelling and
Guildford, wish her a long and happy
style of each accepted article (known
retirement. At last, she will have time
in the business as subbing), as well as to enjoy exploring nature and perhaps
receiving submitted articles, sending identifying new bird species which
them to me and co-ordinating the she has not previously encountered.
peer review of those who I have Angela, your hard work over the years
decided should be put into that is much appreciated by me, and also,
process. This is an enormous amount I am sure, by the readers of Dental
of work, which has resulted in the Update.
attractive journal that subscribers
receive. Her attention to detail is FJ Trevor Burke
superb: this was evident in a recent Editorial Director
702 DentalUpdate October 2020
pg701–702 Comment October.indd 702 07/10/2020 11:48
Enhanced CPD DO C GuestEditorial
Robert L Caplin
Dentistry and COVID-19 – Time to
Rethink our Prescribing Patterns?
Dent Update 2020; 47: 703–704
There is no doubt that COVID-19 has without giving consideration to the
forced changes in many aspects of working various factors that may be unique
practices and none more so than in to that patient and that tooth. It is
clinical dentistry. I would like to offer my necessary to put the W into the Hole!
congratulations to the Dental Update team Not to look at the HOLE in the tooth
for providing articles that are relevant to the but the WHOLE patient. Ideally, we
‘new ways of working’. would wish to restore Form, Function
Of particular interest is the and Features, but in the real world
dentistry that we, as practitioners, can this is not always possible, and so the
provide without recourse to the turbine question needs to be asked – ‘What
and aerosol generating procedures (AGPs), do I do here?’2
and I believe that COVID-19 obliges us to The following example
reconsider what our aims of treatment are illustrates the wide variety of
with respect to restorative dentistry. responses to a clinical situation. The
The restorative options open lower left first molar in Figure 1 had
classical cracked tooth syndrome Figure 1. Lower left first molar with classical
to a practitioner are many and varied and
over a period of two years. Eventually, cracked tooth syndrome.
yet there is a fundamental question that a
the mesio-lingual cusp fractured
practitioner needs to ask when considering
away and the symptoms subsided.
the holistic approach to oral health – ‘What
The patient attended for a routine
am I trying to achieve in restoring this Composite/Gold/Ceramic;
examination three months after this
tooth?’1 6. Remove all of the amalgam and
event, not seeking help or advice at
It is known that there will be replace – direct restoration – Composite;
the time because the tooth was not
much variation between dentists as to how 7. Remove all of the amalgam and
causing any problems. The remaining
best to treat a tooth and this variation will replace – indirect restoration –
tooth was intact, vital and without
essentially stem from the practitioner’s view Composite/Gold/Ceramic;
any visible fracture lines. What to
as to what is required to achieve longevity 8. Remove all of the amalgam and have
do about the missing cusp? May I
for both the tooth and the restoration. cuspal coverage – direct restoration –
suggest the following options:
We, as dentists, are being asked to predict Composite;
1. Nothing;
the future. I suspect that there is an 9. Remove all of the amalgam and have
2. Cover the exposed dentine with a
overwhelming urge for dentists to recreate cuspal coverage – indirect restoration –
thin layer of GIC;
the original shape of the tooth in question 3. Build up the cusp − direct Gold/Ceramic/Metal Ceramic;
restoration – GIC/Composite/ 10. Remove all of the amalgam and have
Amalgam; full coverage – indirect restoration –
Robert L Caplin, Senior Teaching Fellow
4. Remove some of the amalgam and Gold/Ceramic/Metal Ceramic.
and General Dental Practitioner, Faculty
replace – direct restoration – GIC/ There is a wide spectrum
of Dentistry and Oral and Craniofacial
Composite/Amalgam; here from non-invasive (non-AGP) to
Sciences, Guy’s Hospital, London SE1
5. Remove some of the amalgam considerable tooth tissue removal in the
9RT, UK. (email: [email protected])
and replace – indirect restoration – provision of a crown or an onlay (AGP).
October 2020 DentalUpdate 703
pg703–704 Dentistry and COVID-19.indd 703 07/10/2020 15:35
GuestEditorial
How are we going to choose? The 3. How much additional tooth tissue procedures has given us the opportunity
risks and benefits of all the treatment will need to be removed in order to to reflect on our clinical decision-making
options should be discussed with make the tooth theoretically ‘stronger’ and to reconsider: what are the aims of
the patient3 and the acronym BRAN with cuspal coverage?; treatment? The answer has to be what is
is a useful aide memoire: B – Benefit; 4. Whatever restorative option is in the patient’s and the dental team's best
R – Risk; A – Alternative; N – Nothing. selected, how easy will it be to manage interest; now that is something to think
We should be considering this for the situation should the restoration about!
every treatment we propose. What fail?
is likely to happen if we don’t do Management of the biofilm References
anything? As some of these options is the essence of successful treatment.
1. Glick M, Williams DM, Kleinman DV,
will best be performed with high- A restoration shaped to allow access
Vujicic M, Watt RG, Weyant RJ. A new
speed handpieces and hence aerosol to all areas for the removal of plaque
definition for oral health developed
generation, it may be that COVID-19 will enable the patient to maintain
can help concentrate our minds and a healthy tooth; no plaque equals by the FDI World Dental Federation
perhaps lean us towards the less (non- no caries or periodontal disease. opens the door to a universal
AGPs) rather than the more invasive Therefore, does a tooth like this need definition of oral health. JADA
possibilities. to be restored to form and function 2016; 147: 915−917. :https://doi.
In considering the decision, and at what price (in terms of tooth org/10.1016/j.adaj.2016.10.001
I would like to pose four questions: tissue and financial cost) if the patient 2. Caplin RL. Grey Areas in Restorative
1. How much of the patient’s chewing is comfortable? Does it matter if our Dentistry − Don’t Believe Everything You
function has been compromised by the direct restoration ‘fails’ (what does that Think. J and R Publishing, 2015: p67.
loss of one cusp?; mean?) in a few years? A ‘patch up’ can 3. General Dental Council. Standards
2. If the missing cusp is restored, will it easily be replaced. for the Dental Team. London: General
be brought into occlusion or will it be Perhaps COVID-19 and the Dental Council, 2012 (www.gdc-uk.
kept out of occlusion?; attendant worry of aerosol generating org).
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704G 2 8D08e2n MteadleUntpa dTaestteim onial Slone Dental - Dental Update Half 180x120mm.indd 1 14/O09c/2t0o2b0 e r1 62:30120
pg703–704 Dentistry and COVID-19.indd 704 07/10/2020 11:49
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RestorativeDentistry Enhanced CPD DO C
Khawer Ayub
Sadia Khan and Martin Kelleher
Dens Evaginatus − ‘Addition Beats
Subtraction’
Abstract: This case describes the presentation of dens evaginatus on a maxillary central incisor in an 8-year-old Caucasian male, its
subsequent monitoring and later management. Dens evaginatus is a dental anomaly most commonly noted as an accessory tubercle
on the occlusal surface of premolars and the palatal aspect of incisors as a talon cusp. Complications can result in loss of pulp vitality,
sometimes causing periapical periodontitis. Clinicians should be aware of the presentation and the advantages of different approaches to
the management of dens evaginatus.
CPD/Clinical Relevance: To raise awareness of dens evaginatus in dental professionals working in primary and secondary care.
Dent Update 2020; 47: 706–712
Dens evaginatus (DE) is a rare dental be symmetrical. The occlusal surfaces of varying terms for what is now known
developmental anomaly that is found in posterior teeth and labial or palatal surfaces as DE, including tuberculated premolar,
teeth where the enamel outer surface of anterior teeth are commonly affected.2,3 evaginated odontoma, Leong’s premolar,
appears to have an anatomic anomaly, or The prevalence of DE ranges occlusal enamel pearl, odontome of axial
an extra cusp in the form of a tubercle, or from 0.06% to 7.7%, depending on race.4,5 core type and talon cusp.
both. The tubercle is composed of an outer DE occurs more commonly in Asian Dens evaginatus can be
enamel layer, a dentine core and prominent patients6 and has been reported to have associated with a number of dental issues
pulp tissue, which can extend to the main higher rates amongst Chinese7 populations. and anomalies including:14,15
part of the pulp.1 DE is more common in men than women,5 (cid:132) Occlusal disharmony;
Upper incisors are less frequently and occurs more frequently in the mandible (cid:132) Aesthetic problems;
affected than premolars, which are the than the maxilla.8 Patients with Ellis-van (cid:132) Supernumerary teeth;
most common teeth to display extra Creveld syndrome, Mohr syndrome, (cid:132) Odontomes;
cusps. These can occur bilaterally and can Rubinstein-Taybi syndrome and Sturge- (cid:132) Megadonts;
Weber syndrome are at a higher risk of (cid:132) Shovel-shaped incisors with prominent
having DE.9-12 marginal ridges (Figure 1);
Khawer Ayub, BDS, MFDS RCPS(Glas), (cid:132) Peg-shaped lateral incisors;
Specialty Registrar in Restorative Cause (cid:132) Exaggerated cusp of Carabelli;
Dentistry, King’s College Hospital Dental The exact aetiology of DE remains (cid:132) Labial grooves (Figure 1).
Institute and William Harvey Hospital, unclear and it might be an isolated
(email: [email protected]), Sadia anomaly. However, it is thought to arise Diagnosis
Khan, BDS, MFDS RCPS(Glas), from an aberrant folding of the inner The appearance of DE usually makes the
Dental Core Trainee, Birmingham enamel epithelium and subjacent ecto- diagnosis easy, but knowing exactly what
Dental Hospital and Martin Kelleher, mesenchymal cells of the dental papilla to do about the pulpal status at any given
BDS, MSc, FDS RCS(Ed), FDS RCS, FDS into the stellate reticulum of the enamel time can be more difficult, particularly
RCS(Eng), Consultant in Restorative organ during the bell stage of tooth when there are no signs or symptoms of
Dentistry, Department of Restorative development.3,4 pulpal necrosis.8 In assessing a developing
Dentistry and Traumatology, King’s Mitchell first reported a horn-like tooth with DE, it can be problematic to
College Hospital Dental Institute, projection of a maxillary central incisor in differentiate between a periapical lesion
London, UK. 1892.13 Since then, the literature has offered due to a tooth being dead and the normal
706 DentalUpdate October 2020
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