DentalUpdate

June 2020 . Volume 47 . Number 6

„ Guest Editorial: The Aerosol Generating Procedure: How a Phrase Lost It Way Within the Maze
of COVID-19 and Dentistry

„ COVID-19: Getting Back to Work: Lessons from Around the World

„ COVID-19: Suggestions for Non-Aerosol or Reduced-Aerosol Restorative Dentistry (for as Long

as is Necessary)
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 INSIDE THIS ISSUE

469 COMMENT
The new norm, for as long as it takes:
getting out of the (dental) confinement
FJ Trevor Burke
471 GUEST EDITORIAL
The Aerosol Generating Procedure: How
a Phrase Lost Its Way Within the Maze of
COVID-19 and Dentistry
D O’Hooley
476 GUEST EDITORIAL
Counselling for Registrants facing GDC
Practice Committees
R Baker
480 COVID-19
Getting Back to Work: Lessons from
Around the World
D McNee
CPD Aims, Objectives and Learning
Outcomes: To understand the new
Standard Operating Procedures (SOPs)
emerging to prevent viral transmission
of SARS-CoV-2.
Enhanced CPD DO C
485 COVID-19
Suggestions for Non-Aerosol or
Reduced-Aerosol Restorative Dentistry
(for as Long as is Necessary)
FJT Burke, L Mackenzie and P Sands
CPD Aims, Objectives and Learning
Outcomes: To review procedures that
minimize or do not require aerosol use.
Enhanced CPD DO C
494 RESTORATIVE DENTISTRY
Cracked Tooth Syndrome Diagnosis Part
1: Integrating the Old with the New
O Bailey and J Whitworth
CPD Aims, Objectives and Learning
Outcomes: To explain the pathogenesis
and clinical features of cracked tooth
syndrome (CTS) and review established
and new diagnostic tests.
Enhanced CPD DO C
500 ORAL AND MAXILLOFACIAL SURGERY
The Maxillary Sinus: What the General
Dental Team Need to Know Part 3:
Maxillary Sinus Disease of Endodontic
Origin
JC Darcey, GW Bell, RI MacLeod and C
Campbell
CPD Aims, Objectives and Learning
Outcomes: To recognize that not all
thickening of the maxillary sinus lining
is related to odontogenic disease and
to ensure that endodontic technique
does not contribute to inflammation and
infection of the maxillary sinus.
Enhanced CPD DO C
510 ORAL AND MAXILLOFACIAL SURGERY
Is Less More? A Conservative
Multidisciplinary Approach to
Ameloblastoma
H Mohamedbhai, D Dasgupta, C Hubbett
and N Ali
CPD Aims, Objectives and Learning
Outcomes: To inform the management
and improved outcome in certain cases
of unicystic ameloblastoma associated
with an unfavourably positioned third
molar tooth.
Enhanced CPD DO C
515 GENERAL PRACTICE
Remote Working in Dentistry in a
Time of Crisis – Tools and their Uses
K Parker and M Chia
CPD Aims, Objectives and Learning
Outcomes: To have an understanding
of remote working in healthcare and
the tools available to facilitate this. To
appreciate how remote working can
be used in Dentistry and aid patient
care.
Enhanced CPD DO C
527 DENTAL EDUCATION
The Impact of COVID-19 on Dental
Education and Training
F Doughty and C Moshkun
CPD Aims, Objectives and Learning
Outcomes: To explore the impact of
SARS-CoV-2 on dental education and
training.
Enhanced CPD DO C
531 COVID-19 COMMENTARY
COVID-19 and Dentistry: Perspectives
of an Unfolding Pandemic
L Samaranayake
534 LETTERS TO THE EDITOR
536 TECHNIQUE TIPS
Resin Infiltration Technique on
Enamel Opacities and White Spot
Lesions (WSLs)
S Khan and K Ayub
538 CPD QUESTIONS

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
Len D'Cruz University of Birmingham School of Dentistry
University of Birmingham School of
GDP, Woodford Dental Care, Woodford Green, and King's College London
Dentistry 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 Professor of Restorative Dentistry, University of
Dentistry Eastman Dental Hospital, London WC1X 8LD
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, Cover Picture: Diamond, carbide burs, polishing
The Dental Practice Walnut Tree Close, Guildford GU1 4UX discs and stones and acrylic polishing burs - we
21 Rubislaw Terrace
Aberdeen AB10 1XE are all united against COVID-19. Soon dentists
Mike Lewis will be allowed to use us again!’ (Courtesy of
Professor of Oral Medicine Malgorzata Tarry, Dental Officer for
Andrew Chandrapal School of Dentistry, Cardiff University
GDP, Bourne End Dental Cardiff CF14 4XY NHS Shetland.)

June 2020 DentalUpdate

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June 2020
Comment
Trevor Burke
The new norm, for as long as it takes:
getting out of the (dental) confinement
Somehow, to me, the term used in France, le confinement, seems to describe what we have all
been going through appropriately as (other than the meaning that we previously associated
it with, namely, deliverance or childbirth), it can be roughly translated to captivity, detention
or indeed confinement. The majority of readers of Dental Update are general dentists, so
they will not need to be reminded about the profound consequences of the confinement,
social distancing and so forth, all of which have prevented the operation of dental practices
in the way that we used to consider normal, with the various financial sequelae to that,
notwithstanding the inconvenience to, and in some cases suffering by, patients. Despite the
mixed up way that the announcement was made, the good news is that a date has been set for
the re-opening of dental practices in England.
There is no doubt that the coronavirus is highly contagious and that additional steps,
over and above the old norm, now have to be taken and these will necessarily disrupt the
throughput of patients. Dentists, however, are adaptable and, to some extent, the profession
has been here previously. Before the advent of AIDS and increasing awareness of hepatitis B
and C, customary practice was to carry out treatment, including extractions, while not wearing
gloves or mask. It was generally only for surgical extractions that gloves were considered
desirable − tell me the logic of that! I changed to routine glove wearing when my attention
was drawn to a paper published in 1982, results of which indicated that blood products were
present under the fingernails of dentists (attending a conference) who had not seen a patient
for five days,1 the inference being that such blood products could readily harbour blood-borne
viruses. The cartoon in Figure 1 was drawn in the early days of glove wearing by dentists, when
there was significant opposition to the practice. With the arrival of HIV and hepatitis B and C,
however, we started taking infection control more seriously, sheathing air and water lines: the
photograph in Figure 2 was taken by me in the 1980s when we started doing this. There was
no evidence that this would be beneficial to the safety of patients or clinicians, in a similar way
that dental surgeries in the UK were closed in March 2020 when there was little or no evidence
that they would be a vector for transmission of the coronavirus. At the time of writing, when
the easing of the lockdown is proving to be more difficult than its introduction, the re-opening
of dental practices seems to be causing great soul-searching. At the time that I alluded to
above, when an awareness of HIV and hep B dawned, changing the surgery between patients
began to take increased time: no longer could a surgery be changed around with a quick rub
with an alcohol wipe (which was probably of little or no value anyway), but the dental team
adapted to the new norm then. We realized that the hot air oven was not a sterilizer, and
we bought and used autoclaves and changed gloves between patients. Readers will not be
surprised to learn that there was no enhancement of NHS fees for the increased time required
for the various procedures. The dental team have always been at risk to infections carried by
patients, so we used PPE to reduce the risk, although it was not possible to reduce the risk
to an absolute zero. Now is the time for a further adaptation for the dental team, a further
stepping up of PPE, although, again, it may never be possible to reduce the risk to zero.
On the other hand, might there be a way that changing clinical techniques might
DentalUpdate 469
 Comment
Figure 1. The early days of glove wearing: a cartoon drawn by R.Keith Harrison to demonstrate that the
addition of flavourings to gloves might improve glove acceptability for patients!
Figure 2. Sheathing handpiece leads circa 1989.
help? Many of the articles in this issue have
been specially commissioned to help with
this − many thanks are due to the authors
who have produced these at short notice.
First, taking a COVID-oriented medical history
from the patient, perhaps in a phone call
prior to their visit, could help identify those
470 DentalUpdate
patients at risk. The use of rubber dam may
help the spread of potentially contaminated contained in this issue will be of value to readers,
aerosol in the environment, given that
Samaranayake and co-workers reported
that the use of rubber dam reduced up to
70% saliva or blood-borne aerosol particles
within a 3-foot distance of the operational
field.2 Given that a recent survey of UK
dentists’ behaviour indicated that rubber
dam was used for operative dentistry by 31%
of respondents to a questionnaire to 500
dentists,3 it looks like there will be a surge in References
demand. Once the dam has been applied,
it also seems sensible to swab the tooth
pre-treatment with a sodium hypochlorite
solution, such as used for the disinfection
of root canals. There might also be a surge
in demand for hand scaling instruments,
given the demise, for the time being, of the
ultrasonic scaler.
I realize that 80% of our readers
are general dentists and I, along with them,
want to try and facilitate their urgent return
to working in their practices. Readers are
directed to the opinion piece by Dominic
O’Hooley on aerosols and are also directed
to the paper by Damien McNee on how
dentists are getting back to work across
the world. (I am advised by colleagues from
Germany that many dentists there did not
stop working at all.) Both of these papers are
based upon documents originally prepared for
the British Association for Private Dentistry. I
am also delighted that Professor Samaranayake
has offered to keep updating readers, issue by
issue, on the progress of COVID-19, in the same
way as he did for Dental Update during the AIDS
epidemic in the 1980s. His first ‘Commentary’
is in this issue. And, what if we could manage
our restorative dentistry without an aerosol,
or a reduced aerosol? I, with my excellent
co-authors Louis MacKenzie and Peter Sands,
have prepared a paper giving suggestions on
how this could be achieved. There is some good
news from a recent publication.4 Only half of the
patients seen by NHS dentists required ‘active’
treatment − defined in the paper as restorative
or periodontal treatment, while the other half
did not require ‘active’ treatment. Surely, as a
starting point, it should therefore be possible,
when dental practices re-open, to commence
carrying out, more or less immediately, non-
active treatments such as examinations and
other non-invasive treatments? That would be a
start.
I hope that the information
and I fervently hope that, by the time you
receive the issue of Dental Update after this one,
life will have returned to what I will term the
new norm and that we have identified a method
of working which does not greatly decrease
throughput of patients, without endangering
the lives of the dental team and patients alike.
1. Allen AL, Organ RJ. Occult blood
accumulation under the fingernails: a
mechanism for the spread of blood borne
infection. J Am Dent Assoc 1982; 105:
455−459.
2. Samaranayake L, Reid J, Evans D. The
efficacy of rubber dam isolation in reducing
atmospheric bacterial contamination. J Dent
Child 1989; 56: 442−444.
3. Burke FJT, Wilson NHF, Brunton PA, Creanor
S. Dental practice in the UK in 2015/16 Part
4: Changes since 2002. Br Dent J 2019; 226:
279−285.
4. Lucarotti PSK, Burke FJT. Patient history
as a predictor of future treatment need?
Considerations from a dataset containing
over nine million courses of treatment.
Br Dent J 2019; 228: 345−350.
June 2020

Dominic O'Hooley
BDS, MFDS RCS(Eng), MFDS RCPS(Glasg), Dentist with special interest in Dental Implants
Peripatetic at three practices in West Yorkshire
The Aerosol Generating Procedure:
How a Phrase Lost Its Way Within
the Maze of COVID-19 and
Dentistry
Dent Update 2020; 47: 471–475
‘Life, is of course a misnomer, since viruses,
lacking the ability to eat or respire, are
officially dead, which is in itself intriguing,
showing as it does that the habit of predation
can be taken up by clusters of molecules that
are in no way alive.’
Barbara Ehrenreich
Any guest editorial on COVID-
19, an opinion piece by another title,
has to be predicated on the notion of
‘incompleteness’. In this case, I have elected
to update my previous essay on aerosols
and dentistry, as our knowledge base has
expanded but remains a jigsaw puzzle,
pieces missing, perhaps never to be found.
It is also the case that, since the date I wrote
this piece, things may well have evolved
further in this rapidly changing crisis.1
We are at a crossroads for the
whole future of dentistry as a scientifically-
based healing profession, balanced, as
much of it is, with the requirement for the
business of dentistry to thrive. On one
hand, our absolute requirement to ‘first, do
no harm’ has to somehow remain steadfast,
as we are compelled to make life-defining
decisions regarding our businesses, our
financial security and preserving any
joie de vivre we may have had for our
profession before this ghastly virus slinked
June 2020
GuestEditorial
its loathsome way into our lungs.2,3 depressed. What we need to do, however,
is break this down a lot further, to start to
Aerosol generating procedures get a handle on real, perceived and also
− a false flag operation irrational, fear-based risks.
I am not sure that it helps the
Aerosol science is an enormous subject,
situation that the World Health Organization
both in scope, breadth and depth, with
definition of aerosol generating procedures,
many prestigious peer-reviewed journals
which does not include dentistry, is at
presenting on an incredible array of fields,
odds with the UK one, which does include
genres and minutiae, linked, somehow, by
certain procedures. One of the tasks that I
the word ‘aerosol’. It is human nature to start
feel we should pursue, as a profession, is to
going down the proverbial rabbit hole; one
clarify where our dental specific scientific
fascinating article leading to another, yet
guidance is coming from. When we are
another followed by still another.
seeing other countries re-establishing
I have had to remain disciplined
wide provision of practice-based dentistry,
here, but let us define an aerosol, and
with minimal changes to pre-COVID-19
then take a look at dental aerosols, and
PPE, I think it is vital that we know who is
the procedures, or otherwise, where these
providing our scientific advice, so that we
happen.
can perform due diligence upon it and
An aerosol is a suspension of
inform the narrative.4,5
fine solid or liquid droplets in air or some
I propose to use three groupings
other gas. Aerosols can be natural or
in my attempt to provide clarification:
anthropogenic.
„ Type 1 − Respiratory aerosols;
Dental aerosols are not one
„ Type 2 − Clean Water Anthropogenic
thing, they are at least three groups.
aerosols;
When we hear the term Aerosol
„ Type 3 – ‘Mixed’ aerosols.
Generating Procedure (AGP) used in relation
to dentistry during the current time of crisis,
many people immediately think of the high- Type 1 – Respiratory aerosols
speed drill, the ultrasonic tip of the scaler, Breathing produces aerosol, in other
or the 3 in1 syringe with both buttons words, a complex continuum of respiratory
DentalUpdate 471
 GuestEditorial
secretion droplets from the large − more
than 20 μm in diameter, through small
droplets − 5−20 μm in diameter, to the
aerosolized droplets − less than 5 μm in
diameter. As diameter, and thus mass,
decreases, the relative influence of gravity
also decreases, as the influence of air
diffusion increases. Large droplets drop to
earth quickly, smaller ones, more slowly,
tiny ones − well they may not drop for a
very long time.6
Unfortunately, this is a gross
simplification, so bear with me as I ramp
up the complexity. Dependent on the
temperature, humidity and air-flow speed
of the atmosphere we breathe into, droplets
in all three groups can desiccate at variable
rates to become dried bodies called droplet
nuclei. The smaller droplet nuclei become
less affected by gravity and more by the
diffusion of the air. Thus, they can float in
the air as aerosol.7,8
Accordingly, we can have
a combination of dried droplet nuclei
and tiny respiratory droplets within the
aerosolized component of our respiration.
In addition, we have droplets that drop over
a range of distances from our mouths and
noses, dependent on their size and speed.9
We produce expiratory aerosols
during tidal breathing through both our
mouths and also our noses. As we speak,
shout and sing, the quantity of these
increases. Interestingly, lower frequency
(bass tone) sounds produce more, as do
increased decibels.10,11
Once we factor in ballistic
droplet events, such as coughing or
sneezing, a recent study suggests that
droplets can be measured 8 metres away
from the subject immediately post-sneeze,
and the aerosol disperses widely using air
currents to follow a complex dispersal path
that even the latest computer modelling
struggles to depict.12
Both us, our patients and
everybody within our dental surgery are
producing this Type 1 aerosol, all the time. If
we were not, we would be dead!
Type 2 – Clean Water
Anthropogenic aerosols
Type 2 is what some of us may have
envisaged when we think of AGPs. The
plume of spray from our well-adjusted,
high-speed handpiece, the mist
472 DentalUpdate
surrounding the tip of our ultrasonic scaler
or the haze coming from our 3 in 1 when
we push both buttons down. For many
years, we have used antimicrobials to keep
our waterlines free of microbial biofilms,
and so it is fair to say that the combination
of droplets and aerosol emitted by these
devices is made up of clean water. You could
argue that residual biofilm may be present,
as well as lubricating oil, particularly if the
equipment has been excessively lubricated.
Not ideal if trying to prepare a tooth for an
adhesive restoration!13,14
During the COVID-19 crisis,
much discussion has centred upon adding
viricidal agents to the water supply of our
air turbines, ultrasonic scalers and 3 in 1s.
Obviously, a lack of human toxicity, coupled
with an absence of detrimental effects on
the physical integrity of the equipment,
is vital, but just as important is that any
purported chemical addition actually has
a viricidal effect on SARS-CoV-2, when it
enters the mouth. It would also be useful if
the effect could remain for the entire clinical
procedure being undertaken.
Type 3 – ‘Mixed’ aerosols
This is my tentative definition of the
complex result as our clean water
combination of high velocity water
flow, individual multi-sized droplets and
aerosol impacts on the structures of the
oral cavity. The pools of saliva with its
measurable SARS-CoV-2 virion load.15 The
moist, complex surface of the tongue,
the hard surfaces of the teeth and, on
occasion, the hard-walled sides of the
cavity being prepared. We then add the
various other fluids also present within the
mouth, respiratory secretions from post-
nasal drip or via the oropharynx, blood
and gingival crevicular fluid (GCF) too.16
Further to this complex mix, we must then
remember the likelihood of various viable
and denatured viral particles, bacterial
endotoxin, pulverized plaque biofilm,
enamel and dentine particulates, restorative
materials all mixing with that clean water, or
antimicrobial/water mix, coming from our
dental equipment.
This extremely variable set of
circumstances creates various outcomes:
„ Spatter of mixed constituent/size droplets
bouncing back out of the mouth, possibly
caught within the spinning vortex of the
high-speed bur, to be increased in both
velocity and range of directions, by that
complex airflow generated therein;
„ Droplets disturbed from pooled oral
fluids due to perturbation by the high
velocity water flow and droplets from the
dental equipment;
„ Finally, aerosol as droplets desiccate
to droplet nuclei, or by the Venturi effect
of the complex air flows created by the
instruments;17
I advised that it was very
complex. We should now consider the
ways to reduce the volume, distribution,
constituents and potential pathogenicity of
these various droplet/aerosol categories.
Let’s talk about aerosol
mitigation
Before I go into more detail on High Volume
Aspiration (HVA), I will briefly touch on
other fairly simple measures that we can
take to affect the specifics of the aerosols
we generate.
Pre-operative rinses can
introduce a viricidal agent into the oral
commissure, but the limited studies
available suggest that, although three
commonly used chemicals; Hydrogen
Peroxide 1.5%, Povidone Iodine 1% or
Hypochlorous Acid 0.05%, are all suitably
viricidal, their microbial substantivity is
poor.18
Perhaps a pre-operative nasal
spray could be used instead/as well?
Povidone Iodine has been looked at for this
purpose.19
For many years, it has been clear
that rubber dam use is associated with a
large reduction in what I termed Type 3
mixed aerosols. Obviously, this is procedure
specific but, in my view, the adoption
of rubber dam as a requirement during
appropriate dental procedures has many
benefits, both related to the current crisis
but also from the viewpoint of improved
restorative outcomes and, perhaps,
reducing perceived patient resistance to it,
as rubber dam becomes ‘the standard’ in
our post-COVID world.20,21
High Volume Aspiration (HVA)
and adjuncts
When we achieve that state of ‘flow’ time
receding into the background as dentist/
DCP and dental nurse subconsciously
June 2020

establish mutual behavioural pattern
recognition and optimization so that true
four-handed dentistry can occur. The tissues
expertly retracted by judicious use of the
aspirator, as the operating field remains
free of excess moisture and conditions are
created for the best possible outcome.22 I
think we all instinctively know two things.
When the aerosol/aspiration interface is
poorly controlled, it makes dental artistry
more like a Chaos Painting by Marc Quinn,
than the spare, architectural mastery of an
Edward Hopper.23,24 Secondly, even when
the dental team are working together in
perfect harmony, it is rare that our face
shields don’t reveal our inability to control
the droplet and aerosol miasma entirely.25
Many studies use high-speed
video and/or UV visible dyes to help
quantify this imperfect system of dental
aspiration: videos of the halo of mist
billowing vertically above the laminar flow
of aerosol entering the aspirator, the mist
then dispersing widely, including directly
into the facial zone of the operator.26
No scientific study has
compared violent expiratory events such as
coughing, sneezing or choking (what can
be termed, ballistic droplet events), with
mechanically created dental aerosols. Many
studies of bioaerosol use standardized
solutions containing the microbes or
virions, aerosolized by nebulizers and kept
optimally dispersed for extended periods
in technical apparatus, such as Goldberg
Drums. This standardization is required
for statistically relevant results, but these
laboratory-based experiments bear little
relation to our dental surgery-based
experiences.27
That being said, we instinctively
know that high volume aspiration removes
the majority of droplets and aerosol. Once
we have ensured that our aspiration system
is working as well as it can be, let’s look at
methods to increase that majority.
As complex aerosol, droplet and
particulate mixtures enter the aspirator,
the science of gaseous flow resistance is
important. It seems intuitive to me that
widening the orifice of the aspirator tip will
improve the clearance of our generated
aerosol. This obviously depends on
maintenance of the pressure differential
between the aspirator motor-created
vacuum and the opening of the tip.
Now, I don’t want to blow all
June 2020
our minds with a treatise on flow resistance
differentials, gaseous conductance,
Knudsen and orifice-related choked flow,
but I do want us all to reflect that, as
the aerosol/droplet mix goes down the
aspirator tube, the flow resistance is partly
friction between the gas/aerosol particles,
but also friction between the gas and the
pipe walls. That is why a smooth, clean bore
is so important.28
Several companies have
attempted to address this, by providing
either ready-made or 3D printer-ready
adaptors for our existing HVA systems.
These have far larger orifices, with a gradual
reduction with bore volume as you progress
towards the tubing, to optimize gas flow. No
formal scientific studies exist at the current
time, looking to quantify the percentage
improvement in aerosol clearance achieved
by these devices.29
What about External Oral
Suction Apparatus, of which many
systems are commercially available? Often
presented as a free-standing wheeled unit
with a universally hinged rigid tube and
large orifice, these can be positioned in
front of the patient’s mouth, hopefully still
allowing adequate access for the dental
team. Many of these machines contain
HEPA filters, UV-light sources and plasma
filtration to provide a safe air exhaust.
The noise, reduction in access and cost
have prevented these systems becoming
mainstream prior to the current crisis.
Regarding expensive pieces of
new kit for our surgeries; floor-standing,
wall- and ceiling-mounted air purifier
systems have become popular, with
anecdotal evidence that some corporate
dental companies are buying these in
bulk for their dental surgery estates. There
is no evidence that floor-standing units
provide any reduction in infective risk for
SARS-CoV-2, and for the wall- and ceiling-
mounted units, research showing their
use within hospital-based laminar flow
or vertical ventilation system operating
theatres confounds any positive effect
they may have on any airborne measure
of infectivity.30,31 In my opinion, buying
expensive, unproven bits of kit such as
these as a gesture to show your staff and
patients that you are thinking about their
comfort and safety is a relatively noble
gesture. Where I get concerned is where a
spurious safety differential is used to attract
GuestEditorial
new patients. We are scientists, not snake
oil sellers.
Do we have evidence that
dental aerosols transmit SARS-
CoV-2?
No, we don’t. In fact, there is no evidence
of aerosolized SARS-CoV-2 as the primary
infective vector from any study worldwide.
This includes, but is not limited to, aerosols
of dental origin.
Now, that doesn’t mean that
SARS-CoV-2 hasn’t been detected from
collected aerosols. In vitro studies have
not only shown the virus within aerosol
(nebulizer-sourced aerosol, suspended
via Goldberg Drum aerosol stabilizing
apparatus).32,33
A preprint study from the
University of Nebraska medical Centre
suggested airborne transmission of viral
RNA as one putative possible mode of
spread to explain viral shedding into the
environment, alongside droplets, fomites,
toileting (faecal spread) and direct patient-
to-patient contact spread.34
In addition to this study, a study
in Nature, discussed the aerodynamic
analysis of a proxy measure of the virus
(viral RNA), within two Wuhan hospitals. This
was undetectable or very low within patient
wards but was higher inside patient toilets
and a soiled PPE doffing area.35
What these studies have not
done is either grow live virus from collected
virions from aerosol or shown infective
potential.
Perhaps it is worth looking at
super-spreader events?
I am sure many of you are aware of the
term ‘super-spreader’. These individuals
who, for only partially elucidated reasons,
seem to infect a greater number of people
with any specific pathogen than the mean.
Some reports suggest that 80% of the
transmission potential for a given pathogen
is from about 20% of the given population.
The super-spreaders are in this group.36,37
What about Super-Spreader Events (SSEs)?
Are these caused by super-spreaders? Well,
that isn’t clear. An SSE is a geographical and
chronological occasion where a notable
cluster of infections occur that are far in
excess of the mean background infectivity
events (secondary attack rate) for that
DentalUpdate 473
 GuestEditorial
pathogen. A high specificity and frequency
of infections originating from one place at
one time.38
Specifically, for SARS-CoV-2, the
documented SSEs have common features;
reduced social distancing, lots of close
face-to-face speaking, raised voices due to
background noise, intimacy such as kissing
and sharing alcoholic beverages/cigarettes,
social events such as birthday parties and
funerals and all being indoors.
What is really interesting though
are the events not associated with SSEs;
going to the cinema or a concert, travelling
by bus, train or aeroplane, working in an
open cubicle office. Lots of people in close
proximity but not talking in raised voices
with reduced social distancing and/or the
social lubricant of alcohol perhaps?
For me, this adds weight to
the primary infectivity vectors of ballistic
droplets and direct contact, whilst
suggesting airborne spread is not causing
SSEs.
However, are we up close
and personal with our patients? We are,
but we use well tested PPE, our surgical
masks and face shields preventing droplet
contamination of the wet areas of our
faces. When we speak with our patients, we
use the hush socially accepted norms of
the professional clinical environment. Not
one SSE has been reported from a dental
surgery worldwide.39,40
So, what about returning to
Dentistry?
The dental-specific scientific evidence base
that has been used to advise Public Health
England (PHE) and downstreamed to the
Office of the Chief Dental Officer (OCDO),
has been anonymous in source and has
lacked transparency in content. Despite
members of the Scientific Advisory Group
for Emergencies (SAGE), and its relevant
subcommittees, New and Emerging
Virus Threats Advisory Group (NERVTAG),
Scientific Pandemic Influenza Group
on Modelling (SPI-M) and Independent
Scientific Pandemic Influenza Group on
Behaviours (SPI-B), electing, in the vast
majority to be named, the source of dental
specific advice remains unknown.
This creates two specific serious
issues:
1. Due-diligence of the dental specific
474 DentalUpdate
scientific advice cannot be undertaken by the
affected group − the dental profession and,
specifically, wet-fingered dentists/DCPs.
2. The credentials of the scientific advice
sources cannot be verified, with specific
credence to their dental-specific knowledge
and experience.
Conclusions
As a profession, we risk being led down a
path towards new working practices that
will fundamentally change the nature of our
working lives. Surely it is vital that we are
able to ensure that any measures that are
taken are scientifically valid, evidence-based
and can withstand the scrutiny of the ones
affected − us?
It is clear from the lack of
evidence of excess dental team SARS-CoV-2
infection rate or mortality worldwide that
our well-tested standards of cross infection
control, PPE and universal precautions, did a
good job of protecting us all.
Careful pre-screening of our
patients, for COVID-19 infection/pre-exposure
status, co-morbidities and risk factors is
prudent and sensible.
A false distinction between AGPs
and non-AGPs must not be allowed to define
our practice of Dentistry going forwards. Our
being alive is an AGP.
COVID-19 is likely to remain with
us in the long term. It is facile to imagine
that it will just suddenly go away. Thus, we
must remain coolly rigorous, objective and
dispassionate in our analysis of the risks and
benefits of any direction we take.
As bringers of health, we must
continue to engage with the science and
challenge the passive acceptance of poor,
arbitrary or confused guidance, wherever it
may come.
We are all responsible for our
futures. The time to stand united is here.
References
1. O’Hooley D. British Association of Private Dentistry.
FaceBook. [Online] 24 April 2020. https://m.
facebook.com/groups/220670435816057?view=
permalink&id=235128627703571
2. Farooq I, Ali S. COVID-19 outbreak and its monetary
implications for dental practices, hospitals and
healthcare workers. Postgrad Med J 2020.
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‘disaster’ for dental care in Cornwall. Cornwall Live
[Online] 17 April 2020. https://www.cornwalllive.
com/news/cornwall-news/dentist-says-
coronavirus-crisis-disaster-4053471
4. WHO. Emergencies preparedness, response.
World Health Organization. [Online] June 2007.
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infections/prevention_control/en/
5. PHE. Coronavirus (COVID-19): guidance and
support. GOV.UK. [Online] 3 May 2020. https://
www.gov.uk/government/publications/
wuhan-novel-coronavirus-infection-
prevention-and-control/covid-19-personal-
protective-equipment-ppe#summary-of-ppe-
recommendations-for-health-and-social-care-
workers
6. Wurie F. Characteristics of exhaled particle
production in healthy volunteers: possible
implications for infectious disease. F1000 Res 2013;
2: 14.
7. Sze To GN, Wan MP, Chao CHY, Fang L, Melikov A.
Experimental study of dispersion and deposition
of expiratory aerosols in aircraft cabins and impact
on infectious disease transmission. Aerosol Sci Tech
2009; 466−485. (Online)
8. Xie X, Li Y, Chwang AT, Ho PL, Seto WH.How far
droplets can move in indoor environments −
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9. Xie X, Li Y, Sun H, Liu L. Exhaled droplets due to
talking and coughing. 2009. J Royal Soc Interface
2009; 6: S703−S714.
10. Tang JW, Gao CX, Cowling BJ, Koh GC, Chu D,
Heilbronn C et al. Absence of detectable influenza
RNA transmitted via aerosol during various
human respiratory activities − experiments from
Singapore and Hong Kong. PLoS One 2014; 9:
e107338.
11. Hamner P, Dubbel I, Capron A, Ross A, Johnson J,
Lee J et al. High SARS-CoV-2 attack rate following
exposure at a choir practice − Skagit County,
Washington. Centers for Disease Control and
Prevention, Morbidity and Mortality Weekly
Report March 2020.
12. Bourouiba L.Turbulent gas clouds and respiratory
pathogen emissions potential implications for
reducing transmission of COVID-19. JAMA 2020.
doi: 10.1001/jama.2020.4756. Online ahead of
print.
13. Pong AS, Dyson JE, Darvell BW. Discharge of
lubricant from air turbine handpieces. Br Dent J
2005; 198: 637−640.
14. Barbeau J, Tanguay R, Faucher E, Avezard C, Trudel
L, Coté L, Prévost A. Multiparametric analysis of
waterline contamination in dental units. Appl
Environ Microbiol 1996; 62: 3954−3959.
15. To KKW, Tsang OTY, Yip CCY, Chan KH, Wu TC.
Consistent detection of 2019 novel coronavirus in
saliva. Clin Infect Dis 2020.
June 2020

16. Zemouri C, de Soet H, Crielaard W, Laheij A. A
scoping review of bio-aerosols in healthcare
and the dental environment. PLoS One 2017; 12:
e0178007.
17. Grundy JR. Enamel aerosols created during use
of the air turbine handpiece. J Dent Res 1967; 46:
409−416.
18. Howe M. The Dental Elf. National Elf
Service (Online) 4 May 2020. https://www.
nationalelfservice.net/dentistry/oral-medicine-
and-pathology/mouthwash-reduce-levels-
covid-19-mouth/
19. Kirk-Bayley K, Combes J, Sunkaraneni S,
Challacombe S. The Use of Povidone Iodine Nasal
Spray and Mouthwash During the Current COVID-19
Pandemic May Reduce Cross Infection and Protect
Healthcare Workers. SSRN, 2020.
20. Cochran MA, Miller CH, Sheldrake MA. The efficacy
of the rubber dam as a barrier to the spread of
microorganisms during dental treatment. J Am
Dent Assoc 1989; 119: 141−144.
21. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B.
Transmission routes of 2019−nCoV and controls in
dental practice. Int J Oral Sci 2020; 12: 9.
22. Finkbeiner BL. Four-handed dentistry revisited.
J Contemp Dent Pract 2000; 1: 74−86.
23. Jones J. ‘We are all Edward Hopper paintings
now’: is he the artist of the coronavirus age? The
Guardian.com. (Online) 27 March 2020. https://
www.theguardian.com/artanddesign/23020/
mar/27/we-are-all-edward-hopper-paintings-
now-artist-coronavirus-age
24. Smith S, Quinn M. Evolving as an Artist and Social
Welcome to Dr Ian Dunn, BChD, MFGDP, MSc(Perio)
Specialist Periodontist
I and the team at Dental Update are
delighted to welcome Ian to the Dental
Update Editorial Board. Ian qualified from
Leeds in 1998 and went into general
practice in the North-West of England.
In 2001, he was awarded Membership of
the Faculty of General Dental Practice.
In 2002, he joined the teaching staff
at Liverpool Dental Hospital in the
Periodontology Department, where he
became the Undergraduate Teaching
Lead in Periodontics and a Senior Clinical
Teacher in Periodontics, a role he held for
5 years until 2018. In 2010, he completed
his MSc in Periodontology and, in 2013,
he was admitted to the GDC Specialist List
in Periodontics.
Ian is the Perio Lead for the
Faculty of General Dental Practitioners
June 2020
Chronicler. The New York Times. (Online) 13 August
2015. https://www.nytimes.com/2015/08/14/
arts/marc-quinn-evolving-as-an-artist-and-
social-chronicler.html
25. Roberge R. Face shields for infection control: a
review. J Occ Environ Hygiene 2016; 13: 235-242.
26. Fogh CL, Byrne MA, Andersson KG, Bell KF, Roed
J, Goddard AJH, Hotchkiss DV. Quantitative
Measurement of Aerosol Deposition on Skin, Hair
and Clothing for Dosimetric Assessment. Final
Report. International Nuclear Information System,
1999.
27. Asadi S, Bouvier N, Wexler AS, Ristenpart WD. The
coronavirus pandemic and aerosols: Does COVID-
19 transmit via expiratory particles?. Aerosol Sci
Tech 2020; 54: 1−4.
28. Browne LWB. Deposition of particles on rough
surfaces during turbulent gas-flow in a pipe.
Atmos Environ 1974; 8: 801−816.
29. Harrel SK, Barnes JB, Rivera-Hidalgo F. Reduction
of aerosols produced by ultrasonic sealers. J
Periodontol 1996; 67: 28−32.
30. Mora M, Mahnert A, Koskinen K, Pausen M,
Oberauner-Wappis L. Microorganisms in confined
habitats: microbial monitoring and control of
intensive care units, operating rooms, cleanrooms
and the International Space Station. Front
Microbiol 2016; 7: 1573.
31. James M, Khan WS, Nannaparaju MR, Bhamra JS,
Morgan-Jones R. Suppl2: M7: current evidence for
the use of laminar flow in reducing infection rates
in total joint arthroplasty. Open Orthop J 2015; 9:
495−498.
and runs their short course in Periodontics:
he leads the Perio components of the FGDP
Restorative Diploma.
Ian spends three days a week
in private practice in the North-West of
England, where he takes referrals for all
aspects of Periodontology. He is the British
Society of Periodontology (BSP) regional
representative for Merseyside and Cheshire,
and serves on their Council as Commercial
Liaison Officer. In 2014, he was also elected
to the BSP Faculty.
As can be seen from this
impressive CV, Ian will bring a wealth of
practical periodontal experience to the
Board and ultimately to the readers of
Dental Update. Ian, you are most welcome.
FJT Burke
Editorial Director
GuestEditorial
32. Fears AC, Klimstra WB, Duprex P, Hartman A, Weaver
SC, Plante KS et al. Comparative dynamic aerosol
efficiencies of three emergent coronaviruses and
the unusual persistence of SARS-CoV-2 in aerosol
suspensions. Europe PMC, 2020. doi: https://doi.
org/10.1101/2020.04.13.20063784.
33. van Doremalen N, Morris DH, Holbrook MG, Gamble
A, Williamson BN, Tamin A et al. Aerosol and surface
stability of SARS-CoV-2 as compared with SARS-
CoV-1. New England J Med 2020; 382: 1564-1567.
34. Santarpia JL, Rivera DN, Herrera V et al Transmission
potential of SARS-CoV-2 in viral shedding observed
at the University of Nebraska Medical Center.
Medrxiv, 2020.
35. Liu Y, Ning Z, Chen Y, Guo M, Liu Y, Gali NM et al.
Aerodynamic analysis of SARS-CoV-2 in two Wuhan
hospitals. Nature 2020. doi: 10.1038/s41586-020-
2271-3.
36. Stein RA. Super-spreaders in infectious diseases. Int
J Infect Dis 2011; 15: e510−e513.
37. Wong G, Liu W, Liu Y, Zhou B, Ya Bi, GF Gao. MERS,
SARS, and Ebola: the role of super-spreaders
in fectious disease. Cell Host Microbe 2015; 18:
398−401.
38. Liu Y, Eggo RM, Kucharski AJ. Secondary attack rate
and superspreading events for SARS-CoV-2. The
Lancet 2020; 395(10227): e47.
39. Kay J. COVID-19 superspreader events in 28
countries: critical patterns and lessons. Quillette 23
April 2020.
40. Washburn P. A quiet practice − acoustical treatment
of the dental office. J Am Dent Assoc 1960; 60:
340−343.
DentalUpdate 475
 GuestEditorial
Robert Baker
BDS, LDS, MFDS RCPS(Glas), MSND RCS(Edin), MSc, Bristol, DPDM Exeter
Farmer, Monchique, Portugal
Counselling for Registrants facing
GDC Practice Committees
Abstract: This paper argues that dentists should act in a professional manner and take a collegiate approach to establish a support
system for ‘colleagues in need’ when facing General Dental Council Fitness to Practice Committees similar to that provided for doctors in
comparable circumstances.
CPD/Clinical Relevance: The incidence of an allegation made to the GDC, which are associated with registrants’ mental and behavioural
disorders, and subsequently avoiding difficult procedures, was 3.57 per 100 dentists in 2017.
Dent Update 2020; 47: 476–478
Like the medical profession, there has
been considerable unease within the
dental profession regarding the regulatory
processes in recent years. Several
publications have suggested that it has
been found wanting.1-10
Similarity of regulation
between the dental and
medical professions
Dentists and doctors are each one of the 32
regulated occupations. Both professions are
regulated by bodies established by UK law,
the General Dental Council (GDC) and the
General Medical Council (GMC), respectively.
Both of which provide:
„ Checking of the quality of education and
training standards;
„ Maintenance of a register;
„ Standard setting;
„ Investigation of complaints and decisions
regarding the registrant’s Fitness to Practice
[FtP].
Both Councils are themselves
regulated by the Professional Standards
Authority for Health and Social Care, which
sets the standards for regulators in their
document Standards of Good Regulation.11
476 DentalUpdate
So there is a very strong similarity
between their regulatory processes.
Problems with regulation
Whilst there has been little research
into the dental regulatory process, there
has been into the medical regulatory
process.
A GMC survey noted doctors’
loss of confidence in regulation appears
to be driven by concerns about:12
„ Doctors’ wellbeing during the process,
including stress levels;
„ The amount of time that such
investigations can take; and
„ Recent data on suicide rates among
doctors under investigation.
Stress during regulation
Research13 found:
„ Doctors who were subjected to
investigation within the previous 6
months were twice as likely to harbour
thoughts of self-harm or suicide than
those who either hadn’t experienced a
complaint or had had a complaint longer
ago;
„ Doctors referred to the GMC were
most at risk of mental ill health, 26%
suffering depression, 22% suffering
anxiety and 15% having thoughts of self-
harm;
„ Defensive practice was common, with
79% of those who had experienced a
complaint saying that they had changed
their clinical practice as a result. They
used tactics such as avoiding difficult
tasks, ordering too many investigations
and, in some cases, acting against their
professional judgment;
„ Of those who had been subject to
a complaint, 1 in 5 felt victimized for
having raised concerns about poor
clinical or managerial practice, and
almost four out of 10 (38%) said that
they felt bullied during the investigation.
British Medical Association
(BMA) for Doctors unit head, Mike Peters,
said: ‘The research highlights the stress of
going through a complaints procedure
and, importantly, how this may have an
effect on a doctor’s practice with possible
subsequent patient safety implications.’14
There is published anecdotal
evidence that dental registrants also
find the process stressful.10 Speaking
directly to dental registrants who have
June 2020

FtP Stage Target Time Mean% Outside Target
Initial assessment 10 days 1%
Investigation 6 months 43%
Initial hearing 9 months 48%
Table 1. GDC FtP stages, target time and percentage failure to meet them. GDC Annual Report 2018.15
Sources
to the FtP process.
Alcoholics anonymous
With regard to FtP, a GMC
BDA Benevolent Fund
survey12 found: 45% of doctors say that they
Bar Pro Bono Unit
are either ‘not very confident’ or ‘not at all
British Doctors and Dentists Group
confident’ in the regulation of doctors by
Carers UK
the GMC. Of General Practitioners, 49% are
Citizens Advice
‘not very’ or ‘not at all confident’ − more
Dentists’ Health Support Programme
than doctors in any other role. If this level of
[DHSP]
disquiet were to be replicated by surveying
Dyspraxia UK
the dental profession it would be of greater
Mind BLMK
significance as a greater proportion of
NHS Practitioner Health Programme
dentists are general dental practitioners.
Narcotics Anonymous
Niall Dickson, GMC Chief
Practitioner Advice and Support Scheme
Executive, said:14
[PASS]
‘Some distress is therefore
Refuge
inevitable, but the onus is on us to do
Samaritans
whatever we can to reduce the fear and
Scope
upset doctors experience, without in any
Turn2Us
way compromising our duty to investigate
Victim Support
thoroughly in order to protect patient safety.’
Table 2. GDC: What support is available during In 2012, the GMC first
fitness to practise procedures?21
commissioned the BMA to run the Doctor
Support Service following a successful pilot
in 2012. Since then, the contract has been
extended and it has provided assistance to
experienced the process, it is clear that the
process was extremely stressful. hundreds of doctors. The Doctor Support
Service19 provides:
„ ‘6 hours of telephone support, subject
Time
to availability, from the time a complaint
The GDC does not meet its own aspirational
is received by the GMC until the matter is
target times (Table 1). Res ipsa loquitur.
concluded. Or from the time you receive
notification from the GMC that your license
Suicide to practice is at risk.
Doctors and dentists in the USA have „ Face to face support, subject to
similar suicide rates, 1:87 and 1:67, availability of supporters, on the first day of
respectively.16 A GMC report17 found that a hearing and one further day if the hearing
28 doctors committed suicide whilst runs for more than a day.
under FtP investigations between 2005 „ An orientation visit on the morning of
and 2013. No survey has been published your hearing, if you would find it useful
regarding dentists, but a dentist in Wales to look around the hearing room before
was reported to have committed suicide it starts. You can arrange this with your
in 2010 after being prosecuted for fraud.18 supporter.
However, this is a topic we are reluctant to „ Or watch a tour of the hearing centre.’
talk about. Inevitably, some registrants of The GMC also advises which
both professions have allegations reported protection provider (Medical Protection
relating to mental and behavioural issues Society) provides its members access to
which may be accentuated by stress related counselling for stress as a result of receiving
June 2020
GuestEditorial
and dealing with complaints, clinical
negligence claims, disciplinary matters, and
other medico-legal issues.20 It also provides
a list of alternative sources. The GDC also
acknowledges that the regulatory process
is stressful to registrants, but does not fund
a support service. It states that its staff have
been trained by the Samaritans. The GDC
does not advise that Dental Protection
provides a counselling service for its
members, but provides contact details of
other resources available (Table 2).
Since its formal adoption in
1996 by the Royal College of Physicians
and Surgeons of Canada, the CanMEDS
competency framework has become
the most widely accepted and applied
physician competency framework in the
world. It represents the work of hundreds
of College Fellows and volunteers. It
is based on: empirical research, sound
education principles and broad stakeholder
consultation. CanMEDS recognizes that, to
provide optimal patient care, healthcare
professionals should promote a collegiate
culture that recognizes, supports and
responds effectively to colleagues in need.22
It is very clear that colleagues
facing the GDC’s FtP process are colleagues
in need. The failure of the Dental Profession
to follow the example of doctors and
provide a national dentist support
service for dentists facing the regulator’s
FtP process is a clear failure to support
colleagues in need and thus a shameful
example of a lack of professionalism.
Apart from responding to
colleagues in need, a service should
hopefully reduce the risk to patients
of traumatized registrants returning to
practice without any follow up.10
Conclusion
The GMC has stated: ‘This is a time of
unprecedented unease regarding regulation.
Individually and collectively registrants should
rise to the occasion by making time to think,
talk and work together.’23
Registrants should reflect that,
in 2017, the GDC received 1,643 concerns,24
of these 1,48925 related to dentists. There
were 41,705 dentists on the register in 2017.
The risk of an individual registrant having
a concern made in 2017 was 1,489/41,705
= 3.57 cases per 100 dentists. There but for
the Grace of GOD goes any one of us.
Our objective should be to
DentalUpdate 477
 GuestEditorial
establish a national support service,
free for all dental registrants who have
concerns made to the GDC. Individually,
registrants should:
„ Encourage the British Dental
Association as the representatives of
the Dental Profession to lobby: the
Department of Health and Social Care; the
Professional Standards Authority; and the
General Dental Council.
„ Write directly to Nadine Dorries MP,
Parliamentary Under Secretary of State
(Minister for Patient Safety, Suicide
Prevention and Mental Health).
Can you really afford to pass by on the
other side of the road?
Conflict of Interest
The author declares that there are no
conflicts of interest.
References
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2016. Available at: https://www.
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(Accessed March 2020).
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TRACKING SURVEY 2016. Available at:
https://www.gmc-uk.org/-/media/
documents/gmc-tracking-survey-
2016---final-report_pdf-73541068.
pdf (Accessed March 2020).
13. Bourne T et al. Doctors’ perception of
support and the processes involved
in complaints investigations and
how these relate to welfare and
defensive practice: a crosssectional
survey of the UK physicians BMJ
Open 2017; 7:e017856. doi:10.1136/
bmjopen-2017-017856.
14. British Medical Association. Stand by
me: surviving a GMC investigation.
2015 Available at: https://www.
bma.org.uk/news/2015/february/
stand-by-me-surviving-a-gmc-
investigation (Accessed March 2020).
15. General Dental Council (GB). Annual
Report and Accounts 2018. Available
at: https://www.gdc-uk.org/docs/
default-source/annual-reports/
annual-report-and-accounts-2018-
final.pdf?sfvrsn=7b0e96c3_4
(Accessed March 2020).
16. Mental Health Daily. Top 11 Profession
with Highest Suicide Rates. Available
at: shttps://mentalhealthdaily.
com/2015/01/06/top-11-professions-
with-highest-suicide-rates/ (Accessed
March 2020).
17. Horsfall S. General Medical Council
(GB). Doctors who commit suicide
while under GMC fitness to practise
investigation 2014. Available at:
https://www.gmc-uk.org/-/media/
documents/Internal_review_
into_suicide_in_FTP_processes.
pdf_59088696.pdf (Accessed March
2020).
18. The Free Library Dentist found dead
at former practice. 2010. Available at:
https://www.thefreelibrary.com/
Dentist+is+found+dead+at+
former+practice.-a0237349249
(Accessed March 2020).
19. British Medical Association. GMC
investigation support − Doctor support
service. 2019. Available at: https://
www.bma.org.uk/advice/work-life-
support/your-we
llbeing/doctor-support-service
(Accessed March 2020)
20. General Medical Council (GB). Medical
Defence Organisations. Available at:
https://www.gmc-uk.org/concerns/
information-for-doctors-under-
investigation/support-for-doctors/
managing-your-health/support-
resources (Accessed March 2020).
21. General Dental Council (GB). What
support is available during fitness to
practise procedures? Accessible at:
https://www.gdc-uk.org/raising-
concerns/handling-concerns-about-
dental-practice/support-during-
fitness-to-practise (Accessed March
2020).
22. Canadian Royal College of Physicians
and Surgeons. CanMEDS Framework
1996 Available at: https://protect-eu.
mimecast.com/s/YIK8CVm1mIlol1
kTGanoy?domain=royalcollege.ca
(Accessed March 2020).
23. General Medical Council (GB). Medical
professionalism matters. Report and
recommendations. 2016. Available at
https://www.gmc-uk.org/-/media/
documents/mpm-report_pdf-
68646225.pdf (Accessed February
2020).
24. General Dental Council (GB). General
Dental Council Annual Report and
Accounts. 2017. Available at: https://
www.gdc-uk.org/docs/default-
source/annual-reports/
gdc_annual_report_2017-(2).
pdf?sfvrsn=f35bd8dc_2 (Accessed
March 2020).
25. Grady J. Business Intelligence Manager.
General Dental Council (GB). Personal
Communication 26.03.2020.
CPD ANSWERS
April 2020
1. C 6. C
2. A 7. B
3. D 8. C
4. B 9. C
5. C 10. A
June 2020
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 COVID–19 Enhanced CPD DO C

Damien McNee

Getting Back to Work: Lessons

from Around the World
Abstract: Standard Operating Procedures (SOPs) and their implications will play a fundamental role in the phased re-introduction of
clinical dentistry post COVID-19. These SOP documents will continually be updated as new scientific rationales emerge. Each individual
SOP will have key themes dictating how dental appointments are managed, emanating from the initial work of Peng et al (2020). This
article provides a snapshot into how some countries are adapting to the changes, and demonstrating the wide variances seen. The article
is intended to draw parallels between how each country is responding differently to prevent undue transmission of the SARS-CoV-2 virus in
the dental setting.
CPD/Clinical Relevance: Those involved with implementation of emerging SOPs into their clinical practice will be required to understand
why these new protocols are necessary and how they will act to prevent viral transmission of SARS-CoV-2.
Dent Update 2020; 47: 480–484

Introduction
Two versions of this article exist. The first
was written after countless hours spent
collating (and translating!) standard operating
procedures (SOPs) from around the world.
These were then presented against a
backdrop of the virus to show how these SOPs
vary internationally. Upon completing the
article, in fact I was finishing the conclusion,
when I became aware that The Cochrane
Dental Services Evidence Review (CoDER)
Working Group had put together very similar
information, in a more formal and scientific
manner.1 This is an incredibly important
document, and one that gives real insight into
what key elements are consistent throughout
their SOPs. This article therefore is aimed
at GDPs who may want to recognize the
important key features of any SOP and why
they are set out the way they are. The article
Damien McNee, BDS, MSc, PgCert
(Law&Ethics), Communication
Sub-Committee Member, BAPD
General Dental Practitioner,
Amsel&Wilkins, 26 High Street, Banbury,
OX16 5EG, UK.
480 DentalUpdate
follows on from the initial piece written on
behalf of the BAPD.2
Any SOP will have a backbone of
key principles designed to provide barriers
to the transmission of SARS-CoV-2. Many of
these protocols are based on work carried
out after SARS-CoV-1, which displayed many
transmission similarities to SARS-CoV-2. The
main body of work to which I have referred to
help structure this article is by Peng et al.3
What we, as GDPs, really need
to know is why we are doing this? What key
principles should we be adhering to and what
impacts may this have on us professionally and
personally?
SARS-CoV-2 − The virus and route
of transmission
As described by Zhang et al, SARS- CoV-2 is a
newly identified, novel member of the human
coronavirus originating in the Wuhan province
of China.4 The disease caused by SARS-CoV-2
has been named COVID-19 by the World
Health Organization. The clinical symptoms of
the disease include fever, dry cough, fatigue,
lymphopenia, anosmia and loss of taste, in
infected patients. The main portal of entry into
our bodies is via ACE-2 receptors, into which
‘spike proteins’ on the coronavirus surface bind.
The Importance of ACE-2 receptors in
transmission dynamics
Possible transmission routes (as described
by Peng et al3) include direct and indirect
transmission such as coughs, sneezes, and
droplets (including aerosol) spread via oral,
nasal and eye mucous membranes. Evidence
cited by Wang et al also suggests that the
SARS-CoV-2 virus can be transmitted through
fomites (objects or materials which are likely
to carry infection).5 There are several pre-print
papers (at the time of writing) which suggest
SARS-CoV-2 remains stable within faeces
for several hours and urine for 3−4 days. In
addition, Liu et al raise the possibility of the
virus remaining stable on plastic, stainless
steel, glass, ceramics, wood, latex gloves and
surgical masks for seven days.6
The virus itself enters cells
through the ACE2 cell receptors, which are
found abundantly within the respiratory
tract, and it is widely purported that dental
practice personnel may be at an increased
risk of infection. Tissue distribution of the
ACE2 protein (as studied by Hamming et al7)
highlighted the roles of both respiratory tract
tissue and small intestinal tissue as portals of
entry for the earlier SARS-CoV virus. A more
recent study by Zhang et al reaffirms the
similarities between these two viruses in terms
June 2020

of ACE-2 receptors as portals of transmission.8
The lungs play a key role in viral replication due
to their increased surface area and high rate of
cellular viral processing. As well as the lungs,
ACE2 receptors are found in high quantities
on the luminal surface of intestinal epithelial
cells, suggesting that this could be a major
transmission route for SARS-CoV-2. There are, as
yet, insufficient studies to confirm transmission
of SARS-CoV-2 faeco-orally according to the
WHO,9 but this may well be an intense area of
research in the coming months.
Airborne or aerosol transmission
and its impediment is rapidly becoming the
crux of how dentistry will look ‘post-COVID-19’.
Direct droplet spread, short and long distance,
is an accepted transmission pathway, but
Santarpia et al also highlighted that viral
shedding can be detected in normal passive
breathing by those who may be asymptomatic
or only mildly ill with COVID-19.10 In the dental
environment, there is likely to be greater aerosol
disturbance within corridors and surgeries as
staff move around the building therefore, in
effect, carrying it around the building through
the air. From this, it can be deduced that
breathing, coughing and sneezing are aerosol
generating procedures, just of a differing type
to that seen with a dental handpiece. Often,
these more natural processes are less controlled
than the production of a dental aerosol under
rubber dam isolation, with the potential to
be a more dominant vector for SARS-CoV-2
transmission. To date there have been no
confirmed cases of COVID-19 related to the
generation of dental aerosols.
International approaches to
infection control
Additional risk mitigation measures and
PPE are going to dominate social media,
dental literature and clinical practice for the
foreseeable future. It is beyond the scope of this International Trauma Guide website. The BDA
article to detail these, however, NHS England
will release what they view as an appropriate
SOP in due course.11 Looking abroad may
provide some insight as to how best to
implement various aspects of enhanced cross-
infection protocols, and what can be expected
over here in the UK.
Patient pre-visit triage and screening
Rationale
Patient pre-visit triage is seen as a key
component of many SOPs, as this allows for
appropriate assessment of risk. This is usually
June 2020
COVID–19
carried out over the phone 24 hours in advance, component of this is a temperature check
by asking a series of questions to determine using a contactless thermometer, assessing for
current COVID status. Ideally, a patient temperatures of below 37.3 degrees.3 This will
displaying symptoms of COVID-19 should then be followed up by a series of questions
be encouraged not to attend the practice, determining current health status and risk of
and instead advised to self-quarantine. If it is contracting/transmitting SARS-CoV-2.
deemed essential that these patients are seen,
then this may be on an emergency basis only, Which methods have been adopted internationally
possibly at the end of a clinical session. This regarding patient evaluation?
will help reduce viral shedding in the clinical There seems to be some variation seen on
environment. Another essential component of how this should be approached, with the
this stage is to look at ways to appoint specificAustralian Dental Association recommending
patients according to relative risk. For instance,
key questions, but no temperature check. The
if a patient is elderly, or has more complex recommended questions are:
medical conditions, these patients may be „ If the patient has travelled overseas in the
exposed to lower levels of risk by being seen past 14 days;
earlier in the day, when the practice is quieter „ If the patient is displaying symptoms of
and any aerosols have settled over night. COVID-19 such as a fever or a cough;
„ If the patient has had any contact with a
Which methods have been adopted internationally confirmed or suspected COVID-19 patient.
regarding pre-visit screening? In the Republic of Ireland, a verbal
Certainly, these approaches are being checking for fever or respiratory symptoms
implemented in Australia, China, France, Italy is required but a temperature check is not
and the provinces of Canada, where patients mandatory. In Germany, assessment of
are being seen face to face. The Republic of risk should be confirmed again verbally
Ireland has released its SOP document,12 with but without any specific recommended
telephone pre-screening as key to their SOP.13 In questioning. Canada considers a temperature
Germany, there are no recommended qualifying of over 38 degrees as an indicative sign of
questions but more basic questioning to infection.
establish if the patient is displaying COVID-19 Attempts are being made by some
symptoms in the previous two weeks. countries to ascertain patient attitudes to
One approach which is gathering risk as part of the patient evaluation. These
traction is the increasing use of ‘teledentistry’. are often consent forms and examples of
The BDA have produced guidance on these can be seen in Canada, the USA and
appropriate considerations when using also the UK, via an internet search engine
these platforms for their members. The enquiry. The layout and questions posed are
Australian Dental Association have an open often variations of a theme, with a signature
access document on how to get the best out required to verify absence of COVID-19
teledentistry consultations.14 Both resources symptoms. Although the primary rationale
encourage the appropriate history-taking behind these forms may be questionable,
and onward referral pathways. Helpfully, the they do standardize the pre-evaluation
ADA have a direct, easy access link to the questioning, allow recording and analysis of
the results, as well as ensuring that patients
document contains information on patient do have a basic understanding of any
safety and awareness for the clinician on the potential elevation in risk.
potential for these calls to be recorded by the
patient.15 Hand hygiene
Rationale: Transmission of infective droplets
Patient evaluation can occur directly and, as such, maintaining
Rationale: Assessment of patients upon hand hygiene is vital. Faeco-oral transmission
presentation at the clinical setting is essential is now a suspected transmission route and
to re-confirm the pre-visit screening. This will is becoming a focal point of cross infection
act as a second level of defence in preventing control procedures within a hospital setting.
symptomatic patients from entering the The risk of transmission through inadequate
treatment facility and posing a risk to others. hand hygiene is from both the clinician and
As recommended by Peng et al, a key the patient. It would seem logical to ensure
DentalUpdate 481
 COVID–19
patients have optimum hand hygiene when
entering the practice to reduce transmission
spread through touching of fomite surfaces.
Hand hygiene is therefore key for both the
clinician and the patient.
Which methods have been adopted
internationally with regards to hand hygiene?
Studies emerging from China, such as Meng
et al16 and Peng et al,3 both reinforce the
importance of hand hygiene, given that the
virus can remain infective upon surfaces for
several days. According to Peng et al, the
infection control department of the West
China Hospital of Stomatology in Sichuan
have proposed a ‘two before and three after’
hand-washing protocol.3 Both these studies
focus on dentist-patient transmission.
In Australia, the guidance is to
ensure that an alcohol-based hand-rub is
available to patients in the waiting room, but
no specificity on its use. There is guidance
on clinician hand hygiene following the
WHO hand-washing guidelines.17 The ADA
dental portal has access to ‘Cough Etiquette’
posters reinforcing the messages on how to
control droplet transmission from a patient
perspective.
In Canada, patient hand hygiene
is promoted upon patient entry to the
facility in both the SOPs of Alberta and
Saskatchewan. Newfoundland suggests
having hand sanitizer available but no
jurisdiction on its use. This can be compared
with Ontario, for instance, where hand
hygiene is insisted upon when the patient
enters the practice with 70−90% alcohol-
based hand-rub.
The Republic of Ireland guidance
recommends practices promote hand
hygiene and cough etiquette, advising hand-
washing upon entry to the practice for all
people, as well as glove disposal (if they are
wearing gloves). In France, the protocol is
again to provide hand gel for patients in
reception, as well as posters to reinforce
techniques for clinicians.
Personal protective equipment
Rationale: According to Peng et al, the main
role of PPE is to act as a barrier to droplet
and contact transmission, both direct and
indirectly.3 As SOPs from around the world
are developed and published, it seems that
there are some variables noted on how
barrier methods are applied.
482 DentalUpdate
Which methods have been adopted rinsing the isolated field with Sodium
internationally with regards to PPE? Hypochlorite first.18
Starting at the epicentre of the pandemic, China In terms of handpiece use,
were early adopters of PPE staging, dependent France has recommended speed increasing
upon risk.3,16 Triaging staff, such as receptionists, handpiece usage, whilst Spain has
wore masks, disposable cap and work clothes. recommended restorations only that do not
For staff working on patients not displaying require a high speed, especially during initial
signs of COVID-19, N95 masks, gloves, gowns, re-opening phase. The Cochrane (CoDER)
caps, shoe covers and face shields were worn. document should be consulted for a more
For patients displaying signs of COVID-19, these detailed overview of how many countries are
usual precautions plus full body protective managing AGPs and handpiece usage.1 Again,
clothing was adopted. the variance is substantial.
In Australia, PPE is worn in
accordance with risk status of the dental
Discussion
patient. Low risk clinical and epidemiological
This document is far from exhaustive,
risk patients are treated using standard
and it would require a vast quantity of
PPE. Higher risk patients are treated using
work to compare every detail of each
FFP2 masks and gowns. In France, there is a
individual standard operating procedure
recommendation that non-clinical staff wear
(SOPs). However, what hopefully has been
masks and visors (only if a splatter screen not
demonstrated is the wide variance in
present). Protective glasses or face shields
approaches taken internationally. The same
are recommended, as well as FFP2 masks
five themes form the backbone of patient
(but only during AGPs), as are surgical gowns.
management throughout any of the SOPs
The Republic of Ireland has suggested that
standard precautions plus goggles or a visor is considered. Thorough consideration and
satisfactory for AGPs on asymptomatic patients. application of these five themes will hopefully
The additional use of gowns and respirator minimize patient risk.
It seems clear that there is no
masks, if patients are displaying COVID-19
positive signs, is recommended. Head covering real consensus on how best to categorize
or profile risk. In some instances, risk is
and shoe covers have not been recommended.
solely based upon the patients presenting
symptoms, for example in France, if the
In-surgery protocols
patient is asymptomatic, then both urgent
Rationale: The rationale for additional in-surgery and non-urgent treatment can be carried out.
protocols is simply to further reduce droplet Other countries have adopted SOPs which
and contact transmission of SARS-CoV-2. also risk profile the procedure. This is where
most variance is seen. The Republic of Ireland
Which methods have been adopted internationally states that, if community transmission is low,
in relation to in-surgery protocols? then there is insufficient evidence to restrict
Looking again at the Peng and Meng studies AGP use. Sweden and Germany have adopted
emanating from China,3,16 pre-procedural similar standpoints. Other countries, such as
mouthrinses with 1% Hydrogen Peroxide or Canada, quantify risk in terms of procedure
0.2% Povidone are recommended. Peng et al and risk of aerosol transmission.
suggest rubber dam is effective at removing The most difficult element of
70% of airborne particles within the operative comparison, of course, has been the wide
field and should be used alongside high volume variety of clinical approaches taken and
suction and a four-handed dentistry technique.3 looking for comparisons. This can be very
The Australian Dental Association difficult as, in countries such as Canada,
support the use of pre-operative mouthwash, the guidance changes between provinces,
as well as rubber dam, where possible. The meaning that, within one country, there may
Canadian provinces also support these be several different SOPs. It is important,
measures. The Republic of Ireland, however, however, not to overlook the fact that there
found the evidence for mouthwashes is is a sound evidence base to support the fact
insufficient to support their use. In France, that transmission of SARS viruses can be
mouthwash is recommended − again Hydrogen prevented in controlled environments. Then
Peroxide or Povidone Iodine alongside rubber there are, of course, some excellent studies
dam usage, however, this guidance stipulates which support the use of barrier mechanisms
June 2020
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 COVID–19
that the many dentists around the world
would consider standard. Seto et al studied
transmission of SARS within a hospital setting
and found that, when all four of the following;
surgical (or N95) masks, gowns, gloves and
hand-washing, were used, then these staff
members did not contract SARS-CoV-1.19 These
precautions would provide adequate protection
in non-aerosol generating conditions. The
authors concluded that prevention of droplet
and contact spread was key to preventing
transmission of this virus.
One dentally relevant difference
between SARS-CoV-1 and SARS-CoV-2 is that
the main viral shedding period for SARS-
CoV-1 is when the patient is displaying signs
of febrile illness. SARS-CoV-2 patients show
significant viral shedding whilst asymptomatic.
Young et al and Cheng et al demonstrated that
hand hygiene and mask wearing by patients,
alongside N95 mask, hand hygiene, gowns,
gloves, goggles and face shield, was adequate
to prevent transmission of SARS-CoV-2 during
AGPs.20,21
The requirement for sufficient
evidence base is now at the forefront of
our professional minds. Once again we are
turning our heads to the science and find
that it is lacking in quantity and/or quality to
substantiate significant clinical changes. It
must not be forgotten that the end users of
these decisions are dentists, their staff, and
their patients. Time will tell what the upsurge in
demand will have on supply chains and pricing.
One doesn’t have to search too hard on social
media forums to see how inflated costs of PPE
are concerning for practice owners. Moreover,
the reported practical difficulties of respirator
mask usage may see compliance issues
developing in the future.
Financially, the cost of the
additional PPE will need to be covered from
either the top or middle of the balance sheet,
and different practices will have varying
approaches to this. Coupled with reduced
patient flow through, possible economic
recession and air settling periods, dental
practices may find the coming months or years
financially challenging.
Conclusion
SARS-CoV-2 has identical routes of transmission,
irrespective of geographical location. The
variance seen internationally in preventing
transmission of this virus reflects both the
paucity of scientific evidence, but also
484 DentalUpdate
the multifactorial nature of spread and
susceptibility. What is most important, is that
those working within the dental profession
recognize the key transmission routes of the
SARS-CoV-2 virus, and the most effective ways
to impede this. It must not be overlooked that
modern clinical dentistry has cross infection at
its core. There is substantial evidence to suggest
that these measures alone are sufficient to
prevent excessive transmission of SARS viruses
through droplet or contact spread.
References
1. COVID-19 Dental Services Evidence Review (CoDER)
Working Group. Recommendations for the re-opening
of dental services: a rapid review of international
sources. 2020 Available at: https://oralhealth.
cochrane.org/sites/oralhealth.cochrane.org/files/
public/uploads/covid19_dental_reopening_rapid_
review_13052020.pdf
2. McNee D. BAPD Document. Worldwide COVID-19
responses: Looking over the garden fence published
via BAPD Facebook page, 6 May 2020.
3. Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission
routes of 2019-nCov and controls in dental practice. Int
J Oral Sci 2020; 12: 9.
4. Zhang J, Dong X, Cao Y, Yuan Y, Yang Y, Yan Y, Akdis C,
Gao Y. Clinical characteristics of 140 patients infected
with SARS-CoV-2 in Wuhan China. Allergy 2020; Feb 19:
1-12. doi: 10.1111/all.14238. Online ahead of print.
5. Wang To KK, Tsang O T-Y, Yip C C-Y, Chan K-H, Wu T-C,
Chan J M-C et al. Consistent detection of 2019 Novel
Coronavirus in saliva. Clin Infect Dis 2020; ciaa149.
Available at : https://doi.org/10.1093/cid/ciaa149
6. Liu Y, Li T, Deng Y, Liu S, Zhang D, Li H et al. Stability of
SARS-CoV-2 on environmental surfaces and in human
excreta. 2020. Pre-print available at: https://doi.
org/10.1101/2020.05.07.20094805
7. Hamming I, Timens W, Bulthuis M, Lely A, Navis G,
van Goor H. Tissue distribution of ACE2 protein, the
functional receptor for SARS coronavirus. A first step in
understanding SARS pathogenesis. J Pathol 2004; 203:
631−637.
8. Zhang H, Penninger J, Zhong Y, Slutsky A. Angiotensin-
converting enzyme2 (ACE-2) as SARS-CoV-2 receptor:
molecular mechanisms and potential therapeutic
target. Intensive Care Med 2020; 46: 586−590.
9. World Health Organization. Modes of transmission
of virus causing COVID-19: implications for IPC
precaution recommendations. Scientific Brief- https://
www.who.int/news-room/commentaries/detail/
modes-of-transmission-of-virus-causing-covid-19-
implications-for-ipc-precaution-recommendations
10. Santarpia J, Rivera D, Herrera V, Morwitzer M, Creager H,
Santarpia G. Transmission potential of SARS-CoV-2 in
viral shedding observed at the University of Nebraska
Medical Center. 2020. Available at: https://doi.
org/10.1101/2020.03.23.20039446
11. NHS England (March 2020). Issue 3 − Preparedness
letter for primary dental care. Available at: NHS
England- Preparedness letters for primary dental
care. Available at: https://www.england.nhs.uk/
coronavirus/publication/preparedness-letters-for-
dental-care/
12. Health Protection Surveillance Centre. COVID-19:
Guidance on Managing Infection Related Risks in
Dental Services. Available at: https://www.hpsc.
ie/a-z/respiratory/coronavirus/novelcoronavirus/
guidance/infectionpreventionandcontrol
guidance/dentalservices/
13. Irish Dental Association. COVID-19 Patient
Flow: Essential Dental Care. 2020. Available at:
https://www.dentist.ie/_fileupload/Covid%20
19/2020_04_05%20ida_covid-19%20
patient%20flow%20chart.pdf
14. Australian Dental Association. Guidelines for
Teledentistry. 2020. Available at: https://www.ada.
org.au/
Covid-19-Portal/Cards/Dental-Profesionals/
Practice-Policies/ADA-Guidelines-for-Teledentistry
15. BDA Coronavirus update (22 March 2020). Available
at: https://bda.org/advice/Coronavirus/
Pages/Updates-from-week-commencing-16-
March-2020.aspx
16. Meng L, Hua F, Bian Z. Coronavirus Disease 2019
(COVID-19): Emerging and future challenges for
dental and oral medicine. J Dent Res 2020; 99:
481−487.
17. World Health Organization. Clean Care is Safer Care.
Available at: https://www.who.int/gpsc/5may/
resources/posters/en/
18. French Dentists Association guidance. Available at:
http://www.ordre-chirurgiens-dentistes.
fr/index.php?id=161&tx_ttnews%5Btt_
news%5D=999&cHash=8a65337
d9f447fe973745e3fb45d702f
19. Seto W, Tsang D, Yung R, Ching T, Ng T, Ho M, Ho L,
Peiris J. Effectiveness of precautions against droplets
and contact in prevention of nosocomial transmission
of severe acute respiratory syndrome (SARS). Lancet
2003; 361(9368): 1519−1520.
20. Young B, Ong S, Kalimuddin S et al. Epidemiologic
features and clinical course of patients infected
with SARS-CoV-2 in Singapore. JAMA 2020; 323:
1488−1494
21. Cheng V, Wong S-C, Chen J, Yip C, Chuang V, Tsang
O et al. Escalating infection control response to the
rapidly evolving epidemiology of the coronavirus
disease 2019 (COVID-19) due to the SARS-CoV-2 in
Hong Kong. Infect Control Hosp Epidemiol 2020; 41:
493−498.
June 2020
 Enhanced CPD DO C COVID–19

FJ Trevor Burke

Louis Mackenzie and Peter Sands

Suggestions for Non-Aerosol or

Reduced-Aerosol Restorative
Dentistry (for as Long as is
Necessary)
Abstract: The advent of coronavirus and the associated disease COVID-19 has led to the closure of dental practices in the UK and, indeed,
in many parts of the world. In order to get dental practices operating again, it is suggested that it is necessary to adopt a new way of
working. Principal among concerns has been the potential carriage of droplets (from an infected patient) into the aerosols resulting
from the use of the turbine handpiece and from ultrasonic and sonic scalers, and other instruments used in restorative dentistry (current
terminology being Aerosol Generating Procedures [AGPs]). It is therefore the aim of this paper to review restorative techniques and suggest
those which are appropriate to aerosol-free, or reduced-aerosol restorative dentistry.
CPD/Clinical Relevance: With anxieties regarding aerosol generating procedures abounding, it may be helpful to review procedures which
either reduce or avoid these AGPs.
Dent Update 2020; 47: 485–493

The advent of coronavirus and the associated
disease COVID-19 has led to the closure of
dental practices in the UK and, indeed, in many
FJ Trevor Burke, DDS, MSc, MDS,
MGDS, FDS(RCS Edin), FDS RCS(Eng),
FFGDP(UK), FADM, Professor of Primary
Dental Care, University of Birmingham
School of Dentistry, 5 Mill Pool Way,
Birmingham B5 7EG, Louis Mackenzie,
BDS, General Dental Practitioner,
Birmingham, Clinical Lecturer, University
of Birmingham School of Dentistry
and Head Dental Officer, Denplan,
Winchester and Peter Sands, MSc,
BDS, LDS, MFGDP, General Dental
Practitioner, Abingdon, and Part-Time
Lecturer, University of Birmingham,
School of Dentistry, 5 Mill Pool Way,
Birmingham B5 7EG, UK.
June 2020
parts of the world. At the time of writing, dental
practices in many countries have re-opened
and, in some countries, practices did not close.
The “green light” to re-open dental practices in
the UK has therefore come later than in many
places. In order to get dental practices operating
again, the authors suggest that it is necessary to
adopt a new way of working. Principal among
concerns has been the potential carriage of
infected droplets (from an infected patient) into
the aerosols resulting from the use of the turbine
handpiece and from ultrasonic scalers, and
other instruments used in restorative dentistry
(current terminology being Aerosol Generating
Procedures [AGPs]). It may be of interest to
note that the World Health Organization has
produced a list of AGPs in healthcare and
dentistry is not mentioned.
It is therefore the aim of this
paper to review restorative techniques and
suggest those which are appropriate to
aerosol-free, or reduced-aerosol restorative
dentistry.
The solution to ultrasonic
instrumentation in periodontal treatment
is simple − a return to hand scaling and an
increased focus on prevention. The solution to
the aerosol-generating procedures in restorative
dentistry is not quite so straightforward, but
the authors suggest that there are a variety of
techniques which can be used without the need,
or with a significant reduction in the need, for a
turbine handpiece.
The new armamentarium
The authors suggest that the new
armamentarium without an aerosol or with a
reduced aerosol will include the following:
„ A speed increasing handpiece attached to
an electric motor to be used when absolutely
necessary: these offer a considerable reduction
in aerosol emission compared to a turbine,
DentalUpdate 485
 COVID–19
a b
Figure 1. (a) Fractured buccal cusp. (b) MI composite repair. (c) Restoration at 5 years.
and that the aerosol may be proportional
to the revolutions per minute of the rotary
instrument (AS Brietenbach (NSK UK), personal
communication, May 2020). However, at
present, there is ongoing research with a view to
elucidating this more fully;
„ High volume suction;
„ Rubber dam isolation;
„ Hypochlorite solution, as used for disinfecting
root canals, to disinfect the tooth surfaces
exposed through the rubber dam (not as a pre-
operative mouthrinse);
„ Hand scalers;
„ A reliable dentine bonding agent and resin
composite material;
„ Glass ionomer restorative materials (resin-
modified and conventional);
„ Stainless steel crowns;
„ Stainless steel bands with associated
placement and removal devices;
„ Bioactive restorative materials, eg Biodentine
(Septodont, France);
„ Temporary/provisional restorative materials.
Different restorative challenges
The authors propose to examine the various
cavity types and tooth preparations which
are common in restorative dentistry in light
of aerosol-free or reduced-aerosol dentistry.
However, it may first be appropriate to reinforce
the concept of reparative dentistry, rather than
the wholesale removal/replacement of defective
restorations.
Reparative dentistry
Igor Blum and Nairn Wilson have been the
vanguard in promotion of the repair concept,
providing a large number of publications on
the subject.1-6 In that regard, in a recent paper,
Blum7 considered that ‘replacement of failing
restorations, particularly those with localized
defects, may be considered as excessively
interventional as most of the restorations may
486 DentalUpdate
c the defect is adjacent to an existing composite
be clinically and radiologically sound’, citing the
fact that a replacement restoration often leads to
unnecessary sacrifice of tooth structure and an
acceleration of the tooth on the restoration cycle.
Notwithstanding the fact that every intervention
on a tooth carries with it the risk of pulpal damage
and, as Blum states ‘misuse of the patient’s
time and financial resources.’ Furthermore, in a
review of the literature, Blum and Özcan8 stated
unequivocally that ‘restoration replacement
should be considered as the last resort when
there are no other viable alternatives’. Their
review also assessed the literature on survival of
repaired restorations, concluding that ‘numerous
longitudinal clinical studies have shown that
restoration repairs in permanent teeth are able to
significantly increase the lifetime of restorations
and the restored tooth unit’.
Readers are also directed to the
paper by Green and colleagues9 in which
they describe, in detail, the long-term clinical
management of deteriorating/failing restorations,
utilizing the 5Rs principles, namely, reviewing,
resealing, refurbishment, repair and, where
necessary, replacement, thereby ‘encouraging the
preservation of tooth structure and extending the
clinical life of the tooth-restoration complex’.
Given the minimally invasive nature of
repairs, it is considered that the majority of these
may be carried out with a minimum of operative
intervention and that, indeed, only debridement of
the defect may be needed, ie may be carried out
by way of aerosol-free dentistry.
Which materials are appropriate
for repairs? It goes without saying that these
should be materials which are adhesive to tooth
substance, namely, resin composite (in conjunction
with a dentine bonding agent), and glass ionomer
(GI) and its derivatives.
Composite repair
If the defect to be repaired is adjacent to an
amalgam restoration, then either composite or
amalgam may be considered appropriate, but if
restoration, then resin composite may be
considered as the appropriate material, having
first roughened/cleaned the adjacent surface
(for example using a diamond bur without
water, run slower than normal) before applying
a dentine bonding agent. Minor mechanical
retention may be considered necessary if the
adjacent composite restoration has not been
recently placed, as there will be minimal or
no unpolymerized resin to bond to. Figure 1
presents the repair/restoration of a fractured
buccal premolar cusp.
Glass ionomer (GI)
Early versions of this material had poor wear
resistance and low mechanical properties,10
therefore reinforced GIs are considered
appropriate, although they still have less than
ideal fracture and wear resistance and the
potential for dissolution in weak organic acids
(such as are found in plaque), which afflicts GI
materials in general. However, the potential
of GIs to adhere to tooth substance may be
considered to outweigh these disadvantages
(Figures 2 and 3).
Resin Modified Glass Ionomers
(RMGIs) are also appropriate, especially given
that these materials have largely overcome
the problem of dissolution. The more recently
introduced successor to Fuji IX, Equia Forte (GC),
holds promise in the authors’ opinion, given
the improvements in its physical properties
(such as 20% improved flexural strength, 21%
improvement in acid resistance, 40% better
wear resistance) claimed by the manufacturers,
although not yet verified by independent
testing. The application of 20% polyacrylic acid
solution (such as GC Cavity Conditioner) prior
to placing the restoration will provide improved
adhesion of the GI.
A conventional GI, such as that
repairing the fractured cusp of the upper
premolar for a 70-year-old patient (Figure 4)
will adhere to enamel and dentine (and also
potentially micromechanically to the amalgam
‘cliff face’) but might not be considered a
definitive long-term restoration because of
the material’s poor wear resistance and less-
than-ideal aesthetics: however, it may provide
a solution until such time as the landscape
changes re COVID-19, and when the remaining
amalgam is removed and the tooth restored
with a cusp-replacement composite (Figure 5).
A crown is not indicated here because research
has indicated poor performance in posterior
June 2020
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 COVID–19
Figure 2. A ‘patchwork molar’ − one cusp
repaired with resin composite, another with GI.
a „ In all cavity configurations removal of the
b sensitivity, food stagnation, compromised
Figure 3. (a, b) Stabilizing GI restoration without
the use of high-speed instrumentation.
teeth,11 and the fact that the only remaining
tooth substance (the palatal cusp) would have
to be reduced during crown preparation: the
composite restoration is therefore much more
biologically and financially friendly. It is the
authors’ view that this treatment could be carried
out without AGPs, given that the non-retentive
amalgam should be readily removed. There
is some evidence indicating the satisfactory
performance of such large cusp-replacement
resin composite restorations.12,13
488 DentalUpdate
General suggestions for
restorative dentistry
„ Use rubber dam (RD) routinely: rather than
placing only for restoration placement, as in
pre-pandemic times. It should be applied prior
to cavity preparation as, if it is necessary to use
a turbine or speed-increasing handpiece, it
could be anticipated that the aerosol will pose
Figure 4. Fractured premolar cusp temporarily less of a threat with RD in place. Research is
repaired with GI. ongoing on this subject;
„ Swab the tooth pre-operatively with
hypochlorite (as used in root canal
disinfection);
„ Use the most minimal cavity preparation;
biofilm from the tooth surface is important
in achieving a good bond to resin-based or
GI materials. Tooth preparation will mostly
achieve this but, if parts of the tooth to
Figure 5. Tooth in Figure 4: amalgam and
GI removed and tooth restored with cusp which the restoration will be bonded are not
replacement composite. prepared in any way, then there is likely to be
biofilm on the surface. It is suggested that a
brief prophylaxis using pumice and water in a
While resin composite may be the slow handpiece should remove the biofilm.
material of choice for large cusp replacement
restorations, other materials which are adhesive Class V cavities
to tooth substance, such as RMGI, may also be A proportion of Class V cavities are non-
appropriate (Figure 6). carious, and will require treatment due to
Repairing fractured/chipped metal-ceramic aesthetics, or for protection against further
restorations abrasive wear. Such cavities are the simplest
A technique whereby fractured or chipped metal to treat using aerosol-free adhesive dentistry,
ceramic restorations may be repaired using the given that these will be readily accessible
Cojet (3M ESPE) system has previously been to a slow handpiece or hand instruments.
described in Dental Update.14,15 This will generally Results of a survey of 1,000 Class V cavities
only apply to anterior crowns or bridges where placed in UK dental practices16 indicated that
there is an aesthetic compromise, as opposed to RMGI provided the best results at 5 years
chipped posterior metal-ceramic crowns, which (75% survival), with composite providing 68%
are often, in the experience of the authors, of success. It may therefore be considered that, if
little or no concern unless there is a sharp edge. aesthetics is the overriding concern, composite
Briefly, this involves the use of silica-coated should be used but, if not, then RMGI will
alumina particles being directed at the fractured provide the optimum results. Conventional
surface (be it metal or ceramic) using an intra-oral GIs produced the worst results (51% survival),
sandblaster under rubber dam, the application so these may not be recommended. Large
of a silane solution, an opaquer, followed by restorations performed less well. Furthermore,
resin composite to effect the repair. Although it is worth noting that, if the dentine surface
this technique necessitates the use of an intra- was roughened (for example by a steel bur
oral sandblaster, this is not an aerosol (Table 1), in a slow handpiece), the results improved,
so may be considered appropriate during the this finding being appropriate for GI and
current situation. Figures 7, 8 and 9 present the resin composite restorations. This finding is
repair of a crown which was being removed: the confirmed by a meta-analysis by Heintze and
patient decided that she could not tolerate any colleagues17, and the value of roughening a
further treatment and left the surgery. Subsequent sclerotic Class V dentine surface is confirmed
examination did not reveal any defects at the by Gwinnett and Kanca18 and by Zimmerli and
crown margin (other than at the gingival margin), colleagues.19 Figures 10 a and b present the
so the crown defect was repaired. restoration, using RMGI, of abrasion cavities
June 2020

a Instrument/device
b
Figure 6. (a−c) Glass ionomer restoration of an
MOL cavity in a lower right second permanent
molar.
with no cavity preparation.
Class I and II cavities
Ease of access to these is more problematic
than for Class V but, if the cavity preparation is
kept minimal (as in the cavity in Figure 11), the
authors suggest that access through the enamel
June 2020
COVID–19
Effect
High speed handpieces (air turbines & AEROSOL
speed increasing electric motors)
Ultrasonic and sonic scalers AEROSOL
Slow speed handpieces (burs and Splatter
prophylaxis)
Air and water syringe if used together AEROSOL
Water syringe (used alone) Splatter
Particle air abrasion Splatter
Electrosurgery units Splatter
Lasers Largely splatter
Table 1. Devices used in treatment and their effects.
Figure 7. Crown at UR4 with obvious evidence of Figure 8. Metal substructure being sandblasted
operative intervention. with Cojet Sand (3M ESPE).
to the caries lesion can be kept to a minimum
without the use of a turbine, and the remaining
caries removal carried out using hand instruments
and a slow handpiece. The use of a typical Black
Class II cavity design would be difficult without
using a turbine, notwithstanding the fact that it
is unnecessarily destructive of tooth substance
(Figure 12), therefore this is contra-indicated.
There is a paucity of research on the
success of such minimal restorations, but the work
of Nordbo et al,20 on minimal Class II restorations
followed for 7 years, albeit using materials which
Figure 9. Defect repaired with the components
may be considered outmoded at the present of Cojet (3M ESPE) and resin composite.
time, provide satisfactory data on success and a
conclusion that the saucer-shaped resin composite
restoration represents a viable treatment modality
necessary, given that this has been shown
for small cavities’, adding ‘that the time may have
to provide superior margins at 8 years when
come to include it in dental curricula as a routine
operative treatment for small Class II lesions’. using a so-called self-etch adhesive (Clearfil
During the placement of the SE, Kuraray).21 Rather than using a 3-in-1 (air/
resin composite restoration, selective etching water) syringe to wash off the etchant (with an
of the enamel (Figure 13) may be considered associated aerosol) the etchant may be removed
DentalUpdate 489
 COVID–19
a a
b b
Figure 10. (a, b) Restoration of Class V cavities
using RMGI with no cavity preparation.
with a damp cotton roll or pledget. Alternatively,
the etchant may be washed off (water only) and
the tooth dried using air alone. Better still, the use
of a Universal bonding agent in self etch mode will
obviate the need for etchant, with results of one
paper22 indicating no difference in cavity margins
when Scotchbond Universal (3M) was used in total
etch mode (ie enamel margins etched) or in self-
etch mode (ie not etched). While the instructions
for use with dentine bonding agents frequently
advise gentle air thinning to evaporate solvent, it
is suggested that this will evaporate if the layer of
bonding agent is left undisturbed for a short time.
It should be added that success with
‘posterior composites’ is dependent also upon
the operator’s knowledge of, and familiarity with,
the various technique sensitivities which have
been described by Mackenzie and colleagues.23 In
this regard, success rates of posterior composite
restorations have been evaluated in a recent
review,24 with the results indicating, both from
cohort studies and meta-analyses which fulfilled
the inclusion criteria (among these being that the
studies were based in primary care), that resin
composite restorations have acceptable survival
rates when placed in loadbearing situations in
posterior teeth, with AFRs generally within the
range 2% to 3%, which the authors consider to be
compatible with successful clinical practice. Risk
factors for premature failure include patients at
high risk of caries and the presence of a liner or
base beneath the resin composite restoration.
490 DentalUpdate
Figure 13. The majority of etchant should be
removed with a damp cotton roll rather than a
3-in-1 syringe.
free margin, or to provide retention for a Class
IV restoration then, as mentioned above, the
etchant may be removed using a damp cotton
roll or pledget. At one time there were fears that
using such a procedure, rather than using a 3-in-
1 spray, could damage the etch pattern, but such
Figure 11. (a) A mini saucer-shaped cavity design
fears have not materialized.
which is appropriate to adhesive restorative
technology. (b) Cavity in (a) restored using Filtek Crown preparations
Bulk Fill Restorative (3M). Given that preparation of a tooth for a crown
would be a challenging procedure without
using a turbine drill (with its associated aerosol),
the authors therefore suggest that crown
preparations are not appropriate to aerosol-free
or reduced-aerosol dentistry. There are other
reasons! Results of research carried out on a
10 million restoration dataset have indicated
that, when the actual survival of the restoration
is examined, crowns perform optimally, but
when the longevity of the crowned tooth is
assessed, crowns perform poorly, while direct
Figure 12. A comparison of the tooth substance
restorations do not reduce the tooth’s survival.25
prepared by a typical Black’s design Class II cavity The explanation for this is that, when a crown
and a contemporary saucer-shaped adhesive fails, it may do so catastrophically, whereas
design cavity (dark blue) direct-placement restorations may be repaired
or replaced.
Total crown failure
Given the difficulties in preparation or
Class III and IV cavities
repreparation of a tooth for crown, it would
Access to these cavity types presents less of a
appear desirable, in the current climate, to
problem, therefore these are readily amenable
‘salvage’ a crown, if possible. In that regard,
to aerosol-free dentistry. While Class III cavities
if a crown does ‘fail catastrophically’, but the
require preparation, it should not be necessary to patient retains the crown and it can be reseated,
use a turbine. Class IV cavities generally require albeit maybe not perfectly then, if the crown
little preparation (Figures 14 a and b), given that is re-seated and a sectional impression can
these arise as a result of trauma or the fracture of be taken, upon the removal of the old crown
an incisal corner in a tooth already restored with and any hand removal of soft caries, it may be
a Class III restoration. For these, often the only possible to make a provisional crown from a Bis-
preparation which is needed is the placement of Acryl material such as ProTemp (3M). This can
a short bevel along the buccal incisal edge of the be adjusted easily with a slow handpiece and
cavity: again, this may be carried out without the abrasive discs and cemented with an active resin
need for a turbine. Resin composite is the material cement. In the experience of one of the authors
of choice, and, if it is necessary to etch the cavity (PS), these have been shown to last many years
margins, in order to ensure a long-term defect- in some instances.
June 2020
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 COVID–19
a a
b
Figure 14. (a, b) Often no, or minimal,
preparation is needed for a Class IV restoration or
a composite build-up.
Alternatively, if the crown can be
recemented, following the removal of any soft
caries, then recement the crown. The problem
here is that, following the removal of the caries,
the crown may no longer ‘seat’ perfectly on the
remaining tooth structure and cementation
in the correct place, so as to conform with
the existing occlusion, can be very easily
compromised. This problem can be managed
if, prior to the removal of the crown and caries,
a ‘jig’ can be made which will allow the crown
(onlay) to be cemented in exactly the right place.
The technique is illustrated in Figures 15 a, b
and c.
In this case, a gold crown and the
entire core has come off. Some caries removal
was necessary along with some of the old gutta
percha. Prior to this, the crown was relocated
and, in this case, a Duralay ‘jig’ was constructed.
This author (PS) prefers a rigid jig as this allows
accurate reseating and ‘grips’ the restoration
better than a non-rigid material. A Duralay jig
was made prior to removal of any tooth tissue
(Figure 15b). Upon removal of caries with hand
excavation or a slow handpiece, the crown
can be relocated in exactly the same special
relationship to its adjacent tooth and antagonist
and recemented.
It is the authors’ view that crowns
generally fail, initially, at their margins and that
such marginal failures can be repaired readily
without a turbine, given that access should not
be a problem with a slow handpiece. A more
catastrophic failure of a crowned tooth presents
a more difficult restorative problem, as described with either a resin or glass ionomer cement.
above, which may only be solved by placement
of a long-term provisional crown to tide the
patient over until such times as re-preparation
492 DentalUpdate
b the mesial contact point slightly, a stainless
c without an aerosol and, as such, may become an
Figure 15. (a) Lost full coverage crown and
core. (b) Construction of Duralay ‘jig’. (c) Crown
relocated on tooth.
may be undertaken.
Stainless Steel (SS) bands
It’s not just orthodontists who need a SS band!
If a patient attends with pain
and the diagnosis is made of a cracked tooth,
conventional treatment may have involved the
provision of an indirect restoration such as a
crown or onlay. However, an alternative solution
to this which will minimize any aerosol would be
to place a SS band around the tooth and cement
In this example (Figure 16), undertaken prior
to ‘lockdown’ it was felt necessary to remove
the existing restoration, obviously creating an
aerosol, but this technique can quite easily be
used without removing the existing restoration
provided it is felt that there is no pressing reason
to do so.
Having suspected a cracked tooth,
with the affected tooth testing vital, upon the
removal of the existing restoration, a significant
crack along the internal line angle of the lingual
wall was detected. Using wedges to separate
steel band was fitted and cemented with a GI
luting cement. The tooth was then provisionally
restored with a composite resin material.
This actual restoration dates back to
2016 and presently remains in place. The patient
remains able to eat comfortably, without pain
and, while a crown might have been thought to
be a preferred option, the patient can’t see the
need for any further intervention.
Stainless steel crowns
Finally, the Hall crown is an obvious addition to
the list of treatments which can be carried out
increasingly utilized non-preparation treatment
for carious cavities of any size in primary teeth:
with minimal preparation, the technique may
also be adapted for permanent teeth.
Discussion
It has been beyond the scope of this paper
to deal with the organizational issues which
will need to be put in place in order to allow
dental practices to open safely in the current
climate, but it is hoped that some suggestions
made in this paper, while hopefully readily
achievable, will have advantages in terms of
the time required for tooth preparation. The
turbine drill facilitates fast tooth preparation
and, with slower handpieces, preparations will
take longer. However, it could be hoped that this
will be mitigated by the use of minimal cavity
preparation designs, or repairs. Patients may
require education in expecting to pay as much
(or more!) for minimally invasive techniques
which cause less damage to their teeth.
As has been stated above, it will be
necessary to try and avoid AGPs for as long as
is necessary, until clear guidance from evidence
emerges. This is going to require dentists to
be more ‘imaginative’ than in the past and
this may require us to employ techniques that
may not have the full support of ‘conventional
wisdom’ or ‘Ivory Towers’ dentistry. In that
regard, suggestions made by the authors in
this paper may be considered to fly in the face
June 2020

a therefore no reason why non-invasive treatments,
b Pal, A, Sands P, Palin WM. Five-year clinical evaluation of
Figure 16. (a) Diagnosis made of cracked tooth.
(b) Stainless steel band cemented with GI
cement.
of conventional dental wisdom and teaching.
However, the time during which this paper is
being written is unusual, difficult and frightening,
and therefore demands a new approach to
restorative dental treatments if dental practices
are to re-open for treatment of patients, some of
whom will have suffered as a result of the closures.
At the time of writing, no-one knows the duration
of this new norm for restorative dentistry: perhaps
we will ascertain, in due course, as has been
suggested by Dominic O’Hooley, writing in the
current issue, that aerosol generating procedures
can be handled satisfactorily without a major
alteration to practice procedures. If this proves to
be the case, then this article will fast be confined
to history, which is what the authors, unusually,
hope for!
It is worth adding that a significant
proportion of a dentist’s time in his/her practice
does not involve the restoration of teeth, given
the results from a recent paper which indicated
that only half of the patients seen by NHS dentists
required ‘active’ treatment − defined in the paper
as restorative or periodontal treatment.26 There is
June 2020
such as examination/diagnosis, cannot commence
at the earliest opportunity once arrangements for
social distancing and enhanced PPE are in place.
Preventive advice may be given both in practices
and remotely. With that as a starting point, it is
hoped that the aerosol-free or reduced-aerosol
dentistry suggested here will not be far behind.
Conclusions
The authors have suggested that a wide variety
of restorative dental treatments are amenable
to aerosol-free or reduced-aerosol dentistry,
with indirect preparations ruled out by being
the only treatment requiring high speed rotary
instruments. A reduction in the number of teeth
prepared for traditional crowns may be considered
an unexpected benefit of this national and
professional crisis.
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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3. Blum IR, Lynch CD, Wilson NHF. Factors influencing repair of
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direct dental restoration in posterior teeth of adults. Prim
Dent J 2014; 3: 62−67.
7. Blum IR. Restoration repair as a contemporary approach to
tooth preservation. Prim Dent J 2019; 8: 38−42.
8. Blum IR, Özcan M. Reparative dentistry: possibilities and
limitations. Curr Oral Health Rep 2018; 5: 264−269.
9. Green D, MacKenzie L, Banerjee A. Minimally invasive long-
term management of direct restorations: the ‘5Rs’. Dent
Update 2015; 42: 413−426.
COVID–19
10. Combe EC, Burke FJT , Douglas WH. Clinical Dental Materials.
USA: Kluwer Academic Publishers, 1999.
11. Burke FJT, Lucarotti PSK. The ultimate guide to restoration
longevity in England and Wales. Part 10: key findings
from a ten million restoration dataset. Br Dent J 2018; 225:
1011−1018.
12. Deliperi S, Bardwell DN. Clinical evaluation of direct cusp
coverage posterior composite resin restorations. J Esthet
Restor Dent 2006; 18: 256−267.
13. Burke FJT, Crisp RJ, James A, MacKenzie L, Thompson O,
restorations placed in a low shrinkage stress composite in
UK general dental practices. Eur J Prosthodont Rest Dent 2017;
25: 108−114.
14. Burke FJT. Repair of metal-ceramic restorations using an
abrasive silica-impregnating technique: two case reports.
Dent Update 2002; 29: 398−402.
15. Burke FJT. Repair of fractured metal-ceramic restorations
using tribochemical impregnation. Dent Update 2016; 43: 989.
16. Stewardson DA, Creanor S, Thornley P, Biggs T Burke FJT et al.
The survival of Class V restorations in general dental practice.
Part 3: five-year survival. Br Dent J 2012; 212. E14.
17. Heintze S, Ruffieux C, Rousson V. Clinical performance of
cervical restorations: a meta analysis. Dent Mater 2010; 26:
993−1000.
18. Gwinnett AJ, Kanca J. Interfacial morphology of resin
composite and shiny erosion lesions. Am J Dent 1992; 5:
315−317.
19. Zimmerli B, De Munck J, Lussi A, Lambrechts P, van Meerbeck
B. Long-term bonding to eroded dentin requires superficial
bur preparation. Clin Oral Invest 2012; 16: 1451−1461.
20. Nordbo H, Leirskar J, von der Fehr FR. Saucer-shaped cavity
preparations for posterior approximal resin composite
restorations: observations up to 10 years. Quintessence Int
1998; 29; 5−11.
21. Peumans M, DeMunck J, Van Landuyt KL, Poitevin A,
Lambrechts P, Van Meerbeck B. Eight year clinical evaluation
of a 2-step self etch adhesive with and without selective
enamel etching. Dent Mater 2010; 26: 1176−1184.
22. Burke FJT, Crisp RJ, Cowan AJ, Raybould L, Redfearn P, Sands
P, Thompson O, Ravaghi V. A randomised controlled trial of a
universal bonding agent at three years: self etch vs total etch.
Eur J Prosthodont Rest Dent 2017; 25: 220−227.
23. Mackenzie L, Burke FJT, Shortall AC. Posterior composites: a
practical guide revisited. Dent Update 2012; 39: 211−216.
24. Burke FJT, Mackenzie L, Shortall ACC. Survival rates of resin
composite restorations in loadbearing situations in posterior
teeth. Dent Update 2019; 46: 523−535.
25. Burke FJT, Lucarotti PSK. The ultimate guide to restoration
longevity in England and Wales. Part 9: Incisor teeth:
restoration time to next intervention and to extraction of the
restored tooth. Br Dent J 2018; 225: 964−975.
26. Lucarotti PSK, Burke FJT. Patient history as a predictor of
future treatment need? Considerations from a dataset
containing over nine million courses of treatment. Br Dent J
2019; 228: 345−350.
DentalUpdate 493
 RestorativeDentistry
Oliver Bailey
John Whitworth
Cracked Tooth Syndrome
Diagnosis Part 1: Integrating the
Old with the New
Abstract: This article is the first of a two-part series on cracked tooth syndrome (CTS). It seeks to aid the clinician in understanding the
pathogenesis and clinical features of the condition and review established and new diagnostic tests that will allow greater confidence and
predictability in diagnosing teeth with CTS.
CPD/Clinical Relevance: This article gives the clinician greater confidence and predictability in diagnosing teeth with CTS.
Dent Update 2020; 47: 494–499
Cracked tooth syndrome refers to the signs
and symptoms of pain in a posterior tooth
with a vital pulp, that is directly attributable
to an incomplete fracture involving the
dentine, which occasionally extends into
the pulp or periodontal ligament.1 It
commonly presents with sharp pain on
chewing and thermal sensitivity, and can
be difficult to distinguish from other pulpal
and periapical conditions2 (see later).
A crack has been defined
by Oxford Dictionaries as, ‘a line on the
surface of something along which it has
split without breaking apart’. At this point
it could be described as an incomplete
fracture (Figures 1 and 2), as there is no
Oliver Bailey, BDS(Hons), MFDS
RCSEd, PGCert Implant, FHEA, Clinical
Fellow, Newcastle University School of
Dental Sciences; GDP North East and
John Whitworth, BChD(Hons), PhD,
FDS RCS, FDS RCS(Rest), Professor of
Endodontology, Newcastle University
School of Dental Sciences, Framlington
Place, Newcastle upon Tyne, NE2 4BW,
UK.
494 DentalUpdate
visible separation of the segments divided
by the crack. Cracks can be symptomatic,
which would support a diagnosis of
CTS (Figure 1), or asymptomatic, which
would not (Figure 2). A complete fracture
would demonstrate visible separation and
independent movement of one or more
segments (Figure 3).
Dentine cracks
Internal vs external initiation
A diagnosis of CTS relies on the presence
of a painful crack within dentine, not
necessarily the overlying enamel, and the
presence of an enamel crack does not
necessarily indicate that the underlying
dentine is cracked3 (Figure 4). Cracks are
mainly initiated and propagated by occlusal
loading, with some progressing internally
from an initiation point on the external
aspect of the tooth, whilst others develop
from internal stress concentrators, such as
the line angles of cavities and propagate
externally (Figure 5). Such cracks are not
always associated with visible crack-lines in
enamel, which may complicate diagnosis,
classification and appropriate clinical
management (see later).
Enhanced CPD DO C
Propagation resistance
Dentine is a tough, resilient material, and
will resist crack propagation through the
formation of micro-cracks ahead of the
main crack. These serve to dissipate energy
and can lead to ‘crack blunting’. Unbroken
‘ligaments’ of intertubular collagen behind
the tip of the crack also serve to resist
propagation4 (Figure 5).
Critically, this suggests that a
tooth with a dentine crack is still capable
of functioning without fully removing the
crack.
Cyclical loading has a greater
propensity to propagate cracks than static
loading,5 suggesting bruxists may fare
worse than clenchers. Hydration of dentine
improves crack blunting,4 suggesting that
root-filled teeth and teeth with non-vital
pulps may be at greater risk, above and
beyond their structural compromise. Ageing
beyond around 30 years also reduces
fracture resistance.6
Aetiology
Suggested predisposing factors for CTS
include previous cavity preparation,
restorative material compaction or bonding
procedures, tooth morphology, cervical
June 2020

a a
a
Figure 1. (a) Crack (incomplete fracture) of
mesio-palatal cusp UR6. Symptoms included pain
on biting. Pain reproduced by biting pressure and
release of biting pressure on mesio-palatal cusp.
Diagnosis: CTS. (b) Oblique crack (incomplete
fracture) undermining mesio-palatal cusp UR6
evident following restoration removal.
b cusps manually (Figure 3). A probe catch,
Figure 2. Vertical crack (incomplete fracture)
in another UR6 seen running mesio-distally
following removal of caries and existing
restoration. Tooth asymptomatic, not CTS
tooth surface loss, function, parafunction
and trauma, all of which may lead to crack
initiation or propagation.1,7
Diagnosis
Diagnosis can be difficult, with many CTS
affected teeth originally misdiagnosed.2
Commonly, there is a history of pain on
chewing, and sensitivity that can range
from transient to lingering. Sensitivity is
June 2020
b c
Figure 3. (a) Pain on biting UR4. (b) Visual separation with digital pressure. Diagnosis: complete
fracture, not CTS. (c) UR4 after removal of mobile portion to assess restorability
Figure 4. (a) Reproducible pain on biting
pressure MB cusp LR6. Multiple enamel cracks
visible pre-operatively. (b) Following LR6 cavity
preparation, multiple stained cracks and fissures
confined to enamel evident. Oblique dentine
crack MB region most likely responsible for
symptoms, but not visible pre-operatively.
often elicited by thermal stimuli (mainly
cold) or sweet food and drinks.8
A crack can lead to secondary
involvement of the pulp or periodontium.
The history, clinical examination and any
tests should look to assess their potential
RestorativeDentistry
involvement, whilst considering other
aetiologies in the differential diagnosis.
Clinical examination and
visual inspection may be enhanced by
magnification and transillumination.7 The
presence of an enamel crack is often not
diagnostic in the absence of other clinical
signs. Visible crack separation, which would
give a diagnosis of a complete fracture,
can be assessed by attempting to separate
or bubbles forming at the gingival margin
adjacent to a crack as it opens and closes
under digital or biting pressure, can be an
early sign of a complete fracture. Crack
extension to the periodontium may result
in localized deep periodontal probing
depths.9
Tests should look to reproduce
the presenting symptoms predictably and
localize the source of the pain.
Reproducing thermal pain
Air from a 3-in-1 often elicits symptoms
from cracked teeth. Pulp sensibility testing
is advised, and an exaggerated response
from the affected tooth may aid diagnosis.10
The pulp may present in variable states.
Assessing whether a pulpitis is reversible
or irreversible will guide management,
however, this may be difficult until after
the crack is stabilized,11 and these clinical
diagnoses may not accurately represent
the histological diagnosis.12 Of teeth
presenting with CTS that exhibited pain
lingering for up to 45 seconds after ethyl
DentalUpdate 495
 RestorativeDentistry
Figure 5. Internally initiated crack demonstrating propagation resistance.
Figure 6. Tooth Slooth − small cupped tip allows
stable application to, and testing of, individual
cusps.
chloride application, 98% were successfully
managed, resolving pain on biting and
maintaining pulp vitality at one year.13
Reproducing pain on biting
Percussion in an occluso-apical direction is
often painless, whilst lateral percussion can
elicit characteristic symptoms.1 Rebound
pain on release of pressure is classically
described as being highly suggestive of a
diagnosis of CTS,14 however, data suggests
that pain on application of pressure is
more common than pain on release, or the
presence of both phenomena.2 Each can
cause fluid movement within or outwith the
tubules and consequent pain.15 Common
tools used to elicit these responses are
the Tooth Slooth (Professional Results, Inc,
California, USA) (Figure 6), the FracFinder
(Denbur, Oak Brook, Illinois), and cotton
496 DentalUpdate
wool rolls. Biting on cotton wool rolls
has limited application because cotton is
non-rigid, and rolls are usually too large
to be applied in a controlled manner to
individual cusps. Each cusp of all teeth in
the affected area should be assessed, and
painful responses should be checked for
reproducibility. It is important to consider
opposing teeth, as these are inadvertently
loaded during testing.
It is always prudent to check
both the static and dynamic occlusion
and consider occlusal trauma in the
differential diagnosis. A study reported
non-resolution of symptoms from a tooth
initially diagnosed with CTS and managed
with an adhesive composite restoration.16
Subsequent occlusal adjustment resolved
the pain.
Where doubt exists over the
diagnosis, a trial direct composite splint
(DCS) (also called a direct supra-coronal
resin onlay restoration or direct coronal
onlay splint) can be useful.17 If the pain
resolves after the application of non-
bonded composite, that wraps over and
constrains the cusps (Figure 7), the clinician
may be confident of a CTS diagnosis. If the
pain on biting does not resolve, it is prudent
to reconsider the diagnosis. Differential
diagnoses may include apical periodontitis,
irreversible pulpitis (uncomplicated by a
crack) and occlusal trauma.
Radiographs are useful to
identify other pathologies that may
be confused with CTS, such as pulpitis
associated with caries, or symptomatic
apical periodontitis, but are of limited value
in diagnosing undisplaced dentine cracks.
Crack classification
Many attempts have been made to
classify cracks.9,18 An ideal system would
allow prevalence data to be recorded in
defined populations and guide clinical
decision-making for individual patients.
One recent system of crack classification9
stated that the ‘location and extent of
the crack determines the treatment plan’.
However, in CTS it is often impossible to
know the location and extent of the crack
at presentation. Diagnostic testing often
gives no indication of the location or
extension of the crack(s) (Figure 8). Even
when the tooth is operatively explored, by
removing existing restorations (Figures 1
and 8), the true extension is often unclear.
A classification system should therefore
not overreach by including clinically
unknowable variables.
All that can really be ascertained
(and again this may only be possible
following operative exploration), is if
cracks run obliquely (Figures 1b and 9) or
vertically (Figures 2 and 8b). An oblique
crack that can be seen both internally in
dentine and externally in the overlying
June 2020
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 RestorativeDentistry
a c
enamel (Figure 9) may have clinical relevance,
and is therefore prudent to include in a
crack classification. Unrestored teeth with a
suspected crack should ideally not be opened
for investigation but managed by non-
destructive means, if possible (see Part 2).
The extension of a crack, in the
absence of frank manifestations of pulpal
or periodontal pathology, or an observable
exit point, is always unknown. Any attempts
to quantify the extension are therefore
unhelpful in formulating a treatment plan.
This is most often the situation faced when a
diagnosis of CTS is made. Cracks commonly
498 DentalUpdate
a
Figure 7. (a) Pain on biting from a minimally
restored LR6. Occlusal composite placed 5
years previously. Pain reproduced on release of
biting force on lingual cusps using Tooth Slooth.
Pulp responds vital to thermal testing. (b) Peri-
apical radiograph LR6 shows no obvious apical
pathology, a distal radiolucency apparently
confined to enamel and a fairly shallow occlusal
restoration. (c) Diagnostic DCS provided by direct
application of non-bonded composite resin,
1.5 mm thick on the occlusal, with extension
over buccal and lingual cusps. Patient asked to
close teeth together, explaining that the bite
will feel high. Complete resolution of painful
biting symptoms confirms the diagnosis of
CTS. (d) Diagnostic DCS removed simply. The
second article in this series will describe ongoing
management with a definitive DCS.
harbour biofilm,19 and may extend to the
pulp or the periodontium, but might not
necessarily manifest pulpal or periodontal
disease. This is reliant on the presence and
nature of the biofilm, and the host response
to it, which may often be in equilibrium.
Subtle shifts in quantity or quality of the
biofilm, or in the host response, can easily
change this balance, favouring either health
or disease. The complex dynamics seen in
the shift from biofilm-influenced health to
disease are not fully understood.20
Crack epidemiology
Cracked tooth syndrome is most commonly
Figure 8. (a) Pain on biting LR6: Symptoms
reproduced by biting pressure applied via Tooth
Slooth on disto-buccal cusp. (b) Same tooth as
in (a). Disto-buccal portion fell away on removal
of restoration, but multiple cracks noted with
central vertical crack. Diagnostic testing gave
no indication of the location or extension of the
cracks.
seen in mandibular molars, followed
by maxillary molars and then maxillary
premolars, with non-functional cusps
more commonly affected than functional
cusps.8 Finite element analysis has helped
to explain this observation by showing that
non-functional cusps generally sustain more
damaging tensile stresses, whilst functional
cusps generally sustain more favourable
compressive stresses.21 The restorative
status of affected teeth varies considerably
between studies, with the proportion of
unrestored teeth ranging from 5−60%.22,23
There are few good data on
the incidence or prevalence of CTS in
defined populations. Hilton et al reported
a ‘very high’ prevalence of cracked teeth in
an American population,24 though this is
likely to have included cracks confined to
enamel or ‘craze lines’, and asymptomatic
cracks which are therefore not teeth with
CTS. Cracks in dentine are also often
asymptomatic25 (Figure 2). One study
in an American population of patients
with observable cracks suggested that
June 2020

a Current diagnostic
b
Figure 9. (a, b) Oblique crack undermining
mesio-buccal cusp UL7 in dentine visible in
overlying enamel.
the greatest chance of a tooth being
symptomatic CTS was seen in patients
who had the combination of a molar
tooth with an observable distal crack that
blocked transilluminated light, though the
increase in likelihood was modest at just
over 20%. Stained cracks were less likely to
be symptomatic.7 This data does highlight
the problem of visually differentiating
crack lines which are confined to enamel
from those which extend into dentine, and
ascribing causation to a visible crack in a
painful tooth (Figure 4).
Conclusion
Patients with CTS may present with a
confusing collection of symptoms.
Successful clinical management of cracked
teeth does not always require the removal
of the crack or a segment of tooth tissue.
Current classification systems are not always
helpful in guiding clinical management.
Classification of cracks in CTS should be
limited to known parameters.
June 2020
methods may be inconclusive but,
when supported by the provision of a
diagnostic DCS that resolves the patient’s
symptoms, may reassure both the patient
and practitioner of the diagnosis.
The second article in this
series looks at the effective clinical
management of teeth, with a confirmed
diagnosis of CTS, including a discussion
of when to bond the diagnostic DCS in
supra-occlusion, when it may not be
appropriate to do so, and what to do if
it is not. The development of a decision
tree seeks to clarify the decision-making
process.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Consent: Consent was obtained from all
individual participants included in the
article.
References
1. Lynch CD, McConnell RJ. The cracked tooth
syndrome. J Can Dent Assoc 2002; 68: 470−475.
2. Abbott P, Leow N. Predictable management of
cracked teeth with reversible pulpitis. Aust Dent
J 2009; 54: 306−315.
3. Clark DJ, Sheets CG, Paquette JM. Definitive
diagnosis of early enamel and dentin cracks
based on microscopic evaluation. J Esthet
Restor Dent 2003; 15: 391−401.
4. Kruzic JJ, Nalla RK, Kinney JH, Ritchie RO.
Crack blunting, crack bridging and resistance-
curve fracture mechanics in dentin: effect of
hydration. Biomaterials 2003; 24: 5209−5221.
5. Kruzic JJ, Nalla RK, Kinney JH, Ritchie RO.
Mechanistic aspects of in vitro fatigue-crack
growth in dentin. Biomaterials 2005; 26:
1195−1204.
6. Koester KJ, Ager JW 3rd, Ritchie RO. The effect
of aging on crack-growth resistance and
toughening mechanisms in human dentin.
Biomaterials 2008; 29: 1318−1328.
7. Hilton TJ, Funkhouser E, Ferracane JL,
Gilbert GH, Baltuck C, Benjamin P et al.
Correlation between symptoms and external
characteristics of cracked teeth: findings from
the National Dental Practice-Based Research
Network. J Am Dent Assoc 2017; 148: 246−256.
e1.
8. Lubisich EB, Hilton TJ, Ferracane J. Cracked
teeth: a review of the literature. J Esthet Restor
Dent 2010; 22: 158−167.
RestorativeDentistry
9. De Moor RJGCFLG, Meire MA. And the tooth
cracked. Endodontic Practice Today (ENDO) 2014;
8: 247−266.
10. Seo D-G, Yi Y-A, Shin S-J, Park J-W. Analysis of
factors associated with cracked teeth. J Endod
2012; 38: 288−292.
11. Ailor JE Jr. Managing incomplete tooth fractures.
J Am Dent Assoc 2000; 131: 1168−1174.
12. Ricucci D, Loghin S, Siqueira JF Jr. Correlation
between clinical and histologic pulp diagnoses.
J Endod 2014; 40: 1932−1939.
13. Davis R, Overton JD. Efficacy of bonded and
nonbonded amalgam in the treatment of teeth
with incomplete fractures. J Am Dent Assoc 2000;
131: 469−478.
14. Roh B-D, Lee Y-E. Analysis of 154 cases of teeth
with cracks. Dent Traumatol 2006; 22: 118−123.
15. Brännström M. The hydrodynamic theory of
dentinal pain: sensation in preparations, caries,
and the dentinal crack syndrome. J Endod 1986;
12: 453−457.
16. Opdam NJ, Roeters JJ, Loomans BA, Bronkhorst
EM. Seven-year clinical evaluation of painful
cracked teeth restored with a direct composite
restoration. J Endod 2008; 34: 808−811.
17. Banerji S, Mehta SB, Millar BJ. The management of
cracked tooth syndrome in dental practice. Br Dent
J 2017; 222: 659−666.
18. Silvestri AR Jr, Singh I. Treatment rationale of
fractured posterior teeth. J Am Dent Assoc 1978;
97: 806−810.
19. Ricucci D, Siqueira JF Jr, Loghin S, Berman
LH. The cracked tooth: histopathologic and
histobacteriologic aspects. J Endod 2015; 41:
343−352.
20. Rosier BT, De Jager M, Zaura E, Krom BP.
Historical and contemporary hypotheses on the
development of oral diseases: are we there yet?
Front Cell Infect Microbiol 2014; 4: 92.
21. Dejak B, Młotkowski A, Romanowicz M. Finite
element analysis of stresses in molars during
clenching and mastication. J Prosthet Dent 2003;
90: 591−597.
22. Cameron CE. The cracked tooth syndrome:
additional findings. J Am Dent Assoc 1976; 93:
971−975.
23. Ehrmann EH, Tyas MJ. Cracked tooth syndrome:
diagnosis, treatment and correlation between
symptoms and post-extraction findings. Aust Dent
J 1990; 35: 105−112.
24. Hilton TJFJL, Madden T. Cracked teeth: a practice-
based prevalence survey. J Dent Res 2007; 86:
abstr: 2044.
25. Motsch A. Pulpitische Symptome als Problem in
der Praxis. Deutsche Zahnarztliche Zeitung 1992;
47: 78−83.
DentalUpdate 499
OralAndMaxillofacialSurgery Enhanced CPD DO C

James C Darcey Garmon W Bell Ian MacLeod Colin Campbell

The Maxillary Sinus: What the

General Dental Team Need to
Know Part 3: Maxillary Sinus
Disease of Endodontic Origin
Abstract: This paper, part 3 of the series, discusses the variation in maxillary sinus mucosal thickening when seen on radiographic images
and the relation to disease. The role of apical periodontitis in disease of the maxillary sinus and its lining, the stages of endodontic
treatment at which problems can arise and how these can be prevented, are considered. Complications involving extruded endodontic
materials will also be discussed.
CPD/Clinical Relevance: Apical periodontitis may very occasionally contribute to maxillary sinus infection, when the roots of teeth lie
in close relation to the sinus. Apical displacement of infection, irrigants or materials during endodontic treatment may contribute to
inflammation and infection and should be avoided.
Dent Update 2020; 47: 500–509

In this third paper on the maxillary sinus disease contributing to inflammation of

James C Darcey, BDS, MSc, MDPH
and the importance to the Dental Team, the maxillary sinus lining, or suppurative
MFGDP, MEndo FDS(Rest Dent),
the role that chronic apical periodontitis chronic maxillary sinusitis, there may have
Consultant and Honorary Lecturer in
contributes to maxillary sinus disease been bias in patient selection such that
Restorative Dentistry and Specialist
of endodontic origin is examined, the cases presented may not accurately
in Endodontics, University Dental
and the modifications to endodontic reflect the prevalence within the greater
Hospital of Manchester, Manchester,
technique needed to avoid maxillary sinus population.
M15 6FH, Garmon W Bell, BDS, MSc,
involvement are discussed. Oro-antral fistulae, and
FDC RCS FFD RCSI(OS), Associate
It is frequently reported that displaced roots of teeth are the greatest
Specialist Oral and Maxillofacial Surgery,
approximately 12% of cases of unilateral contributory factors to maxillary sinus
Dumfries & Galloway Royal Infirmary,
maxillary sinusitis are of dental origin.1 disease of odontogenic origin.4 Apical
Dumfries, DG3 8RX, Iain MacLeod,
Some authors report as high as 75% periodontitis, periodontal disease, ectopic
BDS, PhD, FDS RCS FRCR DDRRCR
prevalence.2,3 Considering the prevalence teeth or odontomes, with or without cystic
FHEA, Consultant and Senior Lecturer
of apical periodontitis in the population, involvement, may also cause maxillary
in Dental and Maxillofacial Radiology
the relatively high proportion of unilateral sinus disease.4 Dental implants with bone
and Specialist in Oral Medicine,
cases of maxillary sinusitis attributed to regenerative techniques are regarded as
School of Dental Sciences, Newcastle
odontogenic causes is not reflected in the making an increasing contribution, and will
University, Newcastle upon Tyne, NE2
work load of most Ear Nose and Throat
4BW and Colin Campbell, BDS, FDS be discussed in part 4 of this series.
surgeons, or the Oral/Oral and Maxillofacial
RCS, Specialist in Oral Surgery with sub-
surgeons who work alongside them. It is
specialty interest in Implantology, The Inflammation of the paranasal
therefore quite probable that, while there
Campbell Clinic, Nottingham, NG2 7JS, sinus lining
is an ample supply of case reports and
UK.
case series of endodontic and periodontal Inflammatory changes of the paranasal
500 DentalUpdate June 2020

Figure 1. Coronal reconstruction of a CBCT
image. The thickening of the mucosa within
the floor of the right maxillary sinus, and to a
lesser extent the floor and medial wall of the
left maxillary sinus, demonstrates inflammatory
changes. Although the ostia are not shown in this
image, they are obviously patent, and the antra
are well aerated and drained.
Figure 2. Sagittal reconstruction of CBCT
showing apical periodontitis with widening of
periodontal ligament space, and apical bone loss
involving the third and probably also second
molar. The thickening of the maxillary sinus
floor is generalized and not localized to the
site of disease, and therefore caution should be
taken when reporting the image, and making a
correlation between the apical infection and the
thickening of the maxillary sinus lining.
sinus lining are generally of an allergenic
nature, although these may also
occur due to localized or atmospheric
irritants. Changes are often identified
via co-incidential findings on computed
tomography or magnetic reasonance
imaging scans performed for purposes
other than imaging of the paranasal
sinuses.5,6 These inflammatory changes can
June 2020
range from areas of localized thickening, to
retention cysts caused by duct obstruction
in a sero-mucinous gland, or polyps and
expansile mucoceles. Mucosal thickening is
a common finding in ethmoid and maxillary
sinuses, as are retention cysts. As a result
of ostial obstruction, mucoceles can exert
pressure, causing bone expansion and
resorption. However, these are rarely found
in the maxillary sinus, presenting more
often in the frontal sinus. One presentation
of inflammatory paranasal mucosal swelling
does not necessarily progress to another.
There is little correlation
between signs of paranasal sinus lining
thickening and patient reported symptoms
of disease.7 There is little agreement on
what level of maxillary sinus thickening
is within variation of normal or related to
disease, although generalized thickening
of 5 mm or more can be associated with
increased incidence of ostial obstruction.8,9
There is a recognized cyclical variation over
a period of hours of the thickness of nasal
and ethmoid sinus mucosa as a result of
congestion related to blood flow, such that
the mucosa when viewed on cross-sectional
imaging will vary depending upon the time
of imaging.10 The maxillary sinus lining does
not show this same pattern.
Thickening of the paranasal
sinus lining has previously been identified
on plain radiographs of the paranasal
sinuses in 50% of the population, who
have no symptoms of disease and were
subsequently identified as not having
rhinosinal disease.11 Thickening of the
maxillary sinus lining has always been
visible on plain radiographic intra-oral films
and continues to be visible on modern
digital systems. With the exponential use
of Cone Beam Computed Tomographic
(CBCT) scanning in Dentistry, maxillary
sinus lining thickening is now observed
more often by dentists, as is the incidence
of apical periodontitis. However, there are
conflicting reports as to the role of apical
periodontitis and periodontal disease in
contributing to maxillary sinus thickening.
Some authors report increased thickness of
the maxillary sinus lining in association with
periodontal disease, and others reduction
in maxillary sinus thickening following
treatment of chronic dental infection.12-13
However, others have been unable to
demonstrate any significant difference in
sinus lining thickening between healthy
OralAndMaxillofacialSurgery
and unhealthy dentitions.14 Maxillary sinus
lining thickening has also been reported
in disease-free dentitions.15 There is a risk
that, as a result of the additional imaging
that is now more freely available, the Dental
Profession may be observing something
that was always there and not necessarily
related to odontogenic disease, particularly
when the patient selection is not
randomized from the general population
(Figures 1 and 2). In the process of making
observations from radiographic images
and comparing such to the presence or
absence of odontogenic disease, the matter
of aeration of the sinus and normal muco-
ciliary clearance, which contribute to sinus
function, may not be considered, nor the
presence or absence of patient symptoms.
Dome-shaped swellings of the
floor of the maxillary sinus
Retention cysts of the floor of the maxillary
sinus are a well-recognized feature of dental
radiography. Caused by obstruction of
the duct within sero-mucinous glands of
the maxillary sinus, they are of no clinical
significance on the basis that there are no
signs of loss of adjacent bone.
Being able to separate a
retention cyst from an odontogenic lesion
is a basic skill for the dental surgeon. An
odontogenic cyst will have a corticated
upper border as the area of bone apical to
the source of infection will have expanded
upwards. If the tooth that is the source
of infection remains, it is usually centrally
positioned within the cystic lesion. A
retention cyst which has arisen within the
mucosa of the sinus lining will not have
any bone involvement and, as such, will
not have a corticated upper border and
will appear opaque as compared to the
surrounding air of the sinus (Figures 3 and
4).
Anatomical relation of
maxillary teeth to maxillary
sinus − spread of infection
The apices of maxillary teeth distal to the
canine lie in close proximity to the maxillary
sinus, and this can only be evaluated by
radiography. There are many publications
reporting the relation of roots of various
teeth to the floor of the maxillary sinus,
involving a broad range of imaging
modalities. Despite the increased amount of
DentalUpdate 501
 OralAndMaxillofacialSurgery
a a
b significance.
Figure 3. (a, b) Composite image showing
important differentiating radiographic features
between retention cyst of maxillary sinus lining,
and odontogenic cyst. (a) A radiolucency
with a corticated margin arising from the
second premolar. This is a radicular cyst. (b) A
radiodensity, with no corticated upper margin
extending from the floor up into the maxillary
sinus. This is a retention cyst. The endodontically
treated first molar is not associated with the
retention cyst.
information available from CBCT, for most
diagnostic and therapeutic purposes peri-
apical radiography of maxillary teeth should
be sufficient.16,17 Periapical radiographs
should be grade 1 (National Radiological
Protection Board), with 3 mm of tissue
visible beyond the apex.18 CBCT should
not be regarded as a first line radiographic
investigation for endodontic diagnosis or
treatment.16
The radiographic artefact,
known as the lamina dura, should be
traced around each root where possible,
acknowledging that, on occasions, there
will be no bone between the roots of
posterior maxillary teeth and the lining
502 DentalUpdate
Figure 4. Intra-oral radiograph of an edentulous
alveolus showing a non-corticated radio-
opacity extending from the maxillary sinus floor.
Importantly, the adjacent bony wall is intact with
no evidence of erosion. These antral cysts are a
common finding and nearly always of no clinical
of the maxillary sinus.19 Changes can
be described from thickening of the
lamina dura, widening of the periodontal
ligament space or frank loss of lamina dura.
Condensing osteitis may be seen frequently
in the mandible but rarely in the posterior
maxilla. When a radiolucency exists, diffuse
margins may reflect recent bone loss and
well corticated margins reflect a chronic
disease process (Figures 5−7).
On rare occasions, odontogenic
infection within the maxillary sinus may
behave in a fashion similar to severe acute
bacterial rhinosinal disease by extension
into the orbit and from there intracranially.20
Involvement of the maxillary
sinus floor or mucosa in apical periodontitis
should not be regarded as a contra-
indication to conventional endodontic
treatment. On the basis that there are
no suppurative changes in the sinus,
conventional root canal treatment should
be undertaken and the lesion will resolve21,22
(Figure 8).
Length control and precision
endodontics
The primary mechanical and biological
goals of root canal treatment are to create
a shape within the canal that can be
predictably cleaned and filled.23,24 Although
it is accepted that the radiographic and
anatomical apex are rarely coincident,
shaping, cleaning and obturation within
1−2 mm of the radiographic apex is
associated with improved outcomes.25-27
From a purely endodontic perspective, over
b
Figure 5. (a, b) Composite image with periapical
radiograph showing radiolucency involving
the mesio-buccal root of the UR6 tooth. On the
periapical radiograph the corticated margin of
the maxillary sinus floor is intact. The sagittal
reconstruction of the CBCT image (note
reversed image as per reconstruction) confirms
the presence of an apical lesion with an intact
maxillary sinus floor. The adjacent mild thickening
of the maxillary sinus lining is not related to the
apical infection. Septa within sinus noted.
preparation and any subsequent over fill
or over extension of endodontic material
is associated with a significant reduction
in success of treatment.26 With respect
to preventing sinus inflammation
and disease, length control is equally
important. Not only is the maxillary sinus
in close proximity to the apices, it offers
little or no resistance to endodontic
extrusions. This potentially increases the
risk of:
„ Iatrogenic damage from over-zealous
instrumentation;
„ Iatrogenic inoculation of periapical
tissues with bacteria transferred from
within the pulp space system;
„ Separation of instruments beyond the
apex;
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 OralAndMaxillofacialSurgery
a a
Figure 6. Periapical radiograph demonstrating
apical periodontitis arising from UR5, sometimes
referred to as an antral halo, with the floor of the
maxillary sinus extending down and between
roots of teeth. The corticated margin of the apical
lesion maintains the separation of the lesion from
the maxillary sinus lining. The partly imaged,
dome-shaped, non-corticated radio-opacity
on the floor of the maxillary sinus is most likely
a retention cyst, but localized inflammatory
changes, related to the apical periodontitis,
cannot be excluded from this image alone.
b
„ Extrusion of debris into the periapical
tissues;
„ Extrusion of irrigant into the periapical
tissues;
„ Extrusion of medicaments into the
periapical tissues;
„ Extrusion of obturation materials into
the periapical tissues.
 The consequences of these
preventable complications to the sinus
are discussed below.
Transient inflammation and
post-operative pain
Routine root canal treatment is
associated with apical tissue damage,
but iatrogenic mechanical trauma from
instrumentation and introduction of
both debris and bacteria into the tissues
will result in more inflammation.28-32
The extrusion of inter-appointment
dressings, such as calcium hydroxide,
will result in inflammation because
of alkalinity that may cause transient
pain.33-35 Small debris and bacteria are
readily phagocytosed, may be removed
by muco-ciliary function, and are of
little consequence. Larger portions
that cannot be cleared will cause
inflammation, tissue damage and stasis
with infection.
504 DentalUpdate
b
Figure 7. (a, b) Composite image of dental
panoramic tomogram and coronal reconstruction
of computed tomographic scan showing erosion
of floor of maxillary sinus arising from chronic
infection of UL7, with unilateral suppurative
maxillary sinusitis. The corticated floor of the
maxillary sinus adjacent to the UL7 is missing on
the panoramic image.
Severe tissue damage,
inflammation and pain with
possible tissue necrosis
The principle irrigant of choice remains
sodium hypochlorite and the extrusion
of this apically can result in tissue
damage.36-38 This can result in immediate
severe pain, haemorrhage and swelling.
As the inflammatory reaction increases,
Figure 8. Composite image showing (a)
taurodont upper molar with apical periodontitis
extending towards maxillary sinus floor with halo
of corticated bone. (b) Response to control of
source of infection and bone healing 6 months
later with re-establishment of normal contours of
maxillary sinus floor. No maxillary sinus soft tissue
changes identified.
there may be increased swelling, bruising
and ultimately tissue necrosis, with or
without paresthesia of oral mucosa or skin
of the face, depending on the extent of
extrusion.39
Inadvertent extrusion of
hypochlorite into the maxillary sinus
airspace will rarely cause pain, as the
mucosa will protect the underlying bone.
The mucosa will experience a chemical
injury and muco-ciliary clearance will be
reduced. Most patients will only experience
an unpleasant hypochlorite taste for the
following few hours until the small volume
of hypochlorite is removed by residual
muco-ciliary function. One case report
described the need for antral access, lavage
and ultimately extraction of the tooth.38
However, as the paranasal sinuses and
nasal cavity combined produce 1.5−2.0
litres of sero-mucinous secretions per day,
the maxillary sinus should be regarded
as self-cleansing and have sufficient
volume of secretions to overcome any
June 2020

Figure 9. Intra-oral radiograph demonstrating
antroliths in the maxillary sinus. Further clinical
and radiological investigation is required to
confirm cause of antroliths.
Figure 10. Cropped coronal CT of the maxillary
antra. Note the opacification of the right maxillary
sinus extending into the ethmoid sinuses and
lateral nasal wall with the presence of variable
denser opacities within the right antrum. Further
investigation revealed the lesion to be of chronic
fungal origin, a mycetoma.
ingress of irrigant, on the basis that the
concentration is not so high as to cause
a severe chemical injury to the mucosa.
Persistent chronic sinus
inflammation and discomfort
Over extension of obturation materials
may result in a more prolonged
inflammatory response. Larger areas
of GP may become encapsulated,
whereas finer debris may result in a
more intense inflammatory response.
Either way, there may be a degree of
chronic inflammation.40 Over-extended
gutta percha can contribute to chronic
sinusitis as a result of a foreign body
producing inflammation and stasis, by
reduced muco-ciliary clearance.41,42
The risk of these sinus
complications and endodontic failure
can be reduced with the following
simple steps:
June 2020
1. Assess the proximity of apices to the sinus
before treatment to estimate the length of
the roots, and shape of roots, to quantify
the risk, and thoroughly consent the patient
to sinus-related complications.
2. Always follow a crown down procedure
to remove coronal bacteria and minimize
interferences accessing the apical anatomy.
3. Use apex locators to identify the terminus
of the canal more precisely, and ensure
instrumentation is confined to the canal
space.
4. Regularly cross reference the length
during instrumentation with the apex
locator to ensure that there is no loss of
length in curved canals.
5. Perform careful patency filing with a size
10 file only 0.5 mm beyond the terminus of
the preparation.
6. Employ judicious use of working length
radiographs if the apex-locator reading
appears inaccurate.
7. Follow instrumentation protocols
safely to minimize the risk of instrument
separation.
8. Irrigate carefully with sodium
hypochlorite using non-end-ejecting
syringes with luer-lok attachments,
measured no closer than within 2 mm
of the apex. Use gentle finger pressure
and never allow the needle to bind. Take
extra caution on wider palatal canals or
where apical anatomy may have been
compromised through iatrogenic damage
or resorption.
9. When filing either with hand files or
rotary instruments, clean the flutes between
uses, irrigate and recapitulate regularly
to prevent debris accumulating or being
extruded.
10. Minimize extrusion of intracanal
medicaments.
11. Use a cone-fit radiograph to ensure that
the GP matches the preparation.
12. Consider the use of a bioactive sealer to
promote more favourable healing.
13. Use cold condensation of gutta percha
apically, reserving thermomechanical
compaction for the rest of pulp space.
14. Avoid use of injection molded
thermoplasticized gutta percha in apices of
teeth intimately related to maxillary sinus.
Safe endodontic micro-surgery
When orthograde treatment has failed
and retreatment is not possible via an
OralAndMaxillofacialSurgery
orthograde approach, endodontic
surgery may be the only option
remaining to control persistent disease.
Treatment of maxillary premolars and
molars will often necessitate surgery
in close proximity to the sinus. Key
ambitions for successful surgery without
sinus complications will be:
„ Prevention of damage to the maxillary
sinus lining;
„ Prevention of displacement of root
apices into the sinus;
„ Prevention of displacement of
retrograde filling materials into the sinus;
„ Prevention of the creation of an oral-
antral fistula.
Reports suggest that damage
to the sinus lining may be common
during traditional surgery.43-46 In itself
this may have no long-term significance
as it has been demonstrated that full
regeneration of the sinus membrane
will occur around 5 months following
surgery.47,48 It may be that displacement
of materials or the failure to control
the contamination may be the main
contributory factor in the initiation or
persistence of inflammation of the sinus
tissues.
Advances in the approach
to endodontic surgery may have a
significant impact upon the risk of
adverse complications from the sinus.
The use of magnification, microsurgical
instruments, piezo and bioceramics
provide the following advantages:49
„ Smaller, more precise surgical
incisions;
„ Smaller, more precise osteotomies;
„ Controlled apical amputation;
„ Improved apical preparation using
ultrasonics;
„ Controlled apical obtruation with
biocompatible materials;
„ More precise primary closure.
Nonetheless, should the
operator be aware of damage to the
sinus lining, the placement of iodine-
soaked (if the patient is not allergic
to iodine) gauze will help reduce
the risk of displacement of the root
tip or retrograde materials into the
sinus. Patient and clinicians should be
reassured that it is unlikely that this
will have an impact upon success of
the treatment.49,50 It is important to
have discussed this possible risk with
DentalUpdate 505
 OralAndMaxillofacialSurgery
the patient pre-operatively as part of the
consenting process.
Aspergillosis of the maxillary
sinus − what is the role of
endodontic materials?
There are many case reports and case series
of Aspergillosis occurring in the presence
of extruded endodontic filling materials,
predominantly zinc oxide based materials,
and primarily gutta percha. It has been
suggested that 85% of cases of Aspergillosis
involving the maxillary sinus are related
to over extended endodontic filling
materials.51 It has also been suggested that
zinc plays a crucial role in the development
of Aspergillosis of the maxillary sinus as
the fungus requires zinc as an essential
co-enzyme to function, and with the high
zinc content in endodontic filling materials
the ideal environment is provided.52
Aspergillus species are a
group of fungi normally present in the
environment, although some warm,
damp environments will contain a
higher proportion of fungi. Therefore,
it is inevitable that everyone will
breathe aspergillus species into the
naso-pharyngeal airways on a regular
basis.53,54 What determines the outcome
is the local environment within a person’s
nasal and paranasal airspaces, and also
whether the host is immunocompetent or
immunocompromised.55
Extruded endodontic filling
materials within the maxillary sinus
will act as foreign bodies, causing local
inflammation and, if normal muco-ciliary
clearance cannot remove the irritant,
stasis will occur such that infection will
arise. Aspergillosis is one such species that
will take advantage of that stasis in the
immunocompetent individual and produce
infection. This may result in the formation
of collections of material within the sinus
airspace called mycetoma (fungus balls)
which, if time and local conditions allow,
may become calcified and can be observed
as antroliths on radiographs (Figures 9 and
10). Should Aspergillosis arise within the
maxillary sinus, diagnosis and treatment
would be undertaken by an Ear Nose and
Throat surgeon.
When fungal infection,
Aspergillosis or Mucormycosis occurs in
the immune-compromised individual, it
506 DentalUpdate
Symptoms
Recurrent recent onset unilateral epistaxis
Recent onset unexplained orofacial pain
Diplopia
Loss of sensation in maxillary division of
trigeminal nerve
Table 1. Symptoms and clinical signs that may be suggestive of malignancy of maxillary sinus. No one
single sign or symptom is indicative. Multiple signs and symptoms are needed to raise suspicion.
does so often in the absence of any dental
material and can demonstrate invasive
behaviour similar to that seen in invasive
malignancy of the maxillary sinus.56 Urgent
referral is essential should any clinical signs
or symptoms suggestive of rhinosinal
malignancy present to the Dental Team
(Table 1).
Aspergillosis is relatively rare
in developed societies with advanced
healthcare systems. Invasive Aspergillosis
of the paranasal sinuses is an increasing
problem within immunocompromised
patients, particularly with haematological
malignancy.57 However, it is invasive
pulmonary Aspergillosis in the
immunocompromised patient that
contributes most to morbidity and
mortality.58
Dispelling the concept that zinc
materials actively contribute to Aspergillosis
of the maxillary sinus is the finding that
there is no evidence of any influence on
growth between individual Aspergillus
species with differing concentrations of
zinc cement.59 Therefore, rather than zinc-
based endodontic materials contributing to
Aspergillosis infection through a chemical
route, it is more probably mediated
through the route of a local irritant causing
inflammation and stasis. This concept
is further supported by the fact that
Aspergillosis infection has been reported in
Clinical Signs
Unexplained buccal expansion of maxillary
alveolus
Recent onset trismus
Loss of corticated outline of maxillary sinus
floor or walls (radiographic sign)
Mobility of teeth in absence of periodontal
or periapical disease
Unilateral presence of soft tissue in anterior
nares
Non-healing extraction site
Spontaneous formation of oro-antral fistula
Dull tone to percussion of multiple
posterior maxillary teeth
the maxillary sinus when dental implants,
which are zinc free, have perforated the
sinus lining.60
Summary
In this paper the mechanisms of
inflammatory changes within the maxillary
sinus lining and how these present have
been discussed. The role of acute and
chronic apical periodontitis in maxillary
sinus disease of endodontic origin has also
been discussed. When using CBCT, caution
has been urged in assuming that any
thickening of the maxillary sinus lining in
the presence of dental infection is dentally
related: such thickening is also seen in the
absence of dental infection, and should
be regarded as a normal variation in the
immunological response of the sinus lining
to irritants.
The role of extruded endodontic
materials in the maxillary sinus acting as
chemical irritants, causing inflammation and
stasis, and contributing to either bacterial or
fungal infection, has been outlined.
In the final paper in this series, the role of
dental implantology in relation to maxillary
sinus health and function will be discussed.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
June 2020
 OralAndMaxillofacialSurgery
obtained from all individual participants
included in the article.
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Beyer-Olsen EM, Bjornland T. Effect of calcium
hydroxide implantation in maxillary sinus in
macaques. Endod Dent Traumatol 1987; 3:
229−232.
35. Fava LR. Calcium hydroxide paste in the
maxillary sinus: a case report. Int Endod J 1993;
26: 306−310.
36. Pashley EL, Birdsong NL, Bowman K, Pashley
DH. Cytotoxic effects of NaOCL on vital tissue.
J Endod 1985; 11: 525−528.
37. Ehrich DG, Brian JD Jr, Walker WA. Sodium
hypochlorite accident: inadvertent injection
into the maxillary sinus. J Endod 1993; 19:
180−182.
38. Kavanagh CP, Taylor J. Inadvertent injection of
sodium hypochlorite into the maxillary sinus. Br
Dent J 1998; 185: 336−337.
39. Laverty DP. A case report of accidental
extrusion of sodium hypochlorite into the
maxillary sinus during endodontic retreatment
and review of current prevention and
management. J Res Dent 2014; 2: 96−100.
40. Sjögren U, Sundqvist G, Nair PN. Tissue reaction
to gutta-percha particles of various sizes when
implanted subcutaneously in guinea pigs. Eur J
Oral Sci 1995; 103: 313−321.
41. Kapolowitz GJ. Penetration of the maxillary
sinus by overextended gutta percha cones.
June 2020

Report of two cases. Clin Prev Dent 1985; 7: 28−30.
42. Bjørnland T, Haanaes HR, Marhrethe E, Beyer-
Olsen S. Sinusitis caused by endodontic materials
displaced into the maxillary sinus. Endod Dent
Traumatol 1987; 3: 37−40.
43. Ericson S, Finne K, Persson G. Results of
apicoectomy of maxillary canines, premolars
and molars with special reference to oroantral
communication as a prognostic factor. Int J Oral
Surg 1974; 3: 386−393.
44. Ioannides C, Borstlap WA. Apicoectomy on molars:
a clinical and radiographical study. Int J Oral Surg
1983; 12: 73−79.
45. Rud J, Rud V. Surgical endodontics of upper
molars: relation to the maxillary sinus and
operation in acute state of infection. J Endod 1998;
24: 260−261.
46. Freedman A, Horowitz I. Complications after
apicoectomy in maxillary premolar and molar
teeth. Int J Oral Maxillofac Surg 1999; 28: 192−194.
47. Selden HS. The interrelationship between the
maxillary sinus and endodontics. Oral Surg Oral
Med Oral Pathol 1974; 38: 623−629.
48. Benninger MS, Sebek BA, Levine HL. Mucosal
regeneration of the maxillary sinus after surgery.
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Otolaryngol Head Neck Surg 1989; 101: 33−37.
49. Kim S, Kratchman S. Modern endodontic surgery
concepts and practice: a review. J Endod 2006; 32:
601−623.
50. Watzek G, Bernhart T, Ulm C. Complications of
sinus perforations and their management in
endodontics. Dent Clinic North Am 1997; 41:
563−583.
51. Legent F, Billet J, Beauvillain C, Bonnet J,
Miegeville M. The role of dental canal fillings in the
development of Apergillus Sinusitis. A report of 85
cases. Arch Otorhinolaryngol 1989; 246: 318−320.
52. Giardino L, Pontieri F, Savoldi E, Tallarigo F.
Aspergillus mycetoma of the maxillary sinus
secondary to overfilling of a root canal. J Endod
2006; 32: 692−694.
53. Nolard N, Detandt M, Beguin H. Ecology of
Aspergillus species in the human environment. In:
Aspergillus and Aspergillosis. Vanden Bossche H,
MacKenzie DWR, Cauwenbergh G (eds). Boston,
MA: Springer, 1998.
54. Mousavi B, Hedayati MT, Hedayati N, Ilkit M,
Syedmousavi S. Aspergillus species in indoor
environments and their possible occupational
and public health hazards. Curr Med Mycol 2016;
1 12/03/2020 16:07
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2: 36−42.
55. Saral R. Candida and Aspergillus infections in
immunocompromised patients: an overview. Rev
Infect Dis 1991; 13: 487−492.
56. Tamgadge AP, Mengi R, Tamgadge S, Bhalerao SS.
Chronic invasive aspergillosis of paranasal sinuses:
a case report with review of the literature. J Oral
Maxillofac Pathol 2012; 16: 460−464.
57. van de Peppel RJ, Visser LG, Dekkers OM, de
Boer MGJ. The burden of invasive Aspergillosis in
patients with haematological malignancy: a meta-
analysis and systematic review. J Infect 2018; 76:
550−562.
58. Kanj A, Abdallah N, Soubani AO. The spectrum of
pulmonary aspergillosis. Respir Med 2018; 141:
121−131.
59. Odell E, Pertl C. Zinc as a growth factor for
Aspergillus sp. and the antifungal effects of root
canal sealants. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1995; 79: 82−87.
60. Sato FR, Sawazaki R, Berretta D, Moreira RW, Vargas
PA, de Almeida OP. Aspergillosis of the maxillary
sinus associated with zygomatic implant. J Am
Dent Assoc 2010; 141: 1231−1235.
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01691 684165
DentalUpdate 509
 OralandMaxillofacialSurgery Enhanced CPD DO C

Hussein Mohamedbhai

Debipriya Dasgupta, Charlotte Hubbett and Nayeem Ali

Is Less More? A Conservative

Multidisciplinary Approach to
Ameloblastoma
Abstract: This case report outlines a novel conservative surgical approach to the management of a unicystic ameloblastoma with the use
of marsupialisation, enucleation, cryotherapy and orthodontic extrusion to enable successful treatment without neurological damage or
deformity. It has been increasingly recognized that conservative treatment of unicystic ameloblastomas, instead of wide local excision, can
reduce morbidity whilst maintaining an acceptably low recurrence rate. Several case series have also demonstrated orthodontic extrusion
of impacted third molars in moving the apex of the roots away from the inferior alveolar nerve. This is possibly the first case report of the
combination of these two procedures in an adult with a large unicystic ameloblastoma.
CPD/Clinical Relevance: This is not an infrequently seen neoplasia: this paper therefore has the opportunity to inform management of
this condition amongst clinicians.
Dent Update 2020; 47: 510–514

Case report
CH, a 22 year-old woman, presented via her
general dental practitioner (GDP) with an
asymptomatic swelling, which was noted on
routine examination. There was no relevant
medical history and no family history to
Hussein Mohamedbhai, MRCS, BM,
BDS, MMedSc, Oral and Maxillofacial
Surgery ST1, Debipriya Dasgupta,
MRCS, MBBS, BDS, BSc, Oral and
Maxillofacial Surgery ST3, Oral and
Maxillofacial Surgery Department,
Whipps Cross Hospital, London E11
1NR, Charlotte Hubbett, BSc, MBBS,
FY1 in Emergency Medicine at Newham
University Hospital and Nayeem Ali,
FRCS, FDS, MBBS, BDS, Consultant
Oral and Maxillofacial Surgeon, Oral
and Maxillofacial Surgery Department,
Whipps Cross Hospital, London E11 1NR,
UK.
510 DentalUpdate
note. She had never smoked and only drank
alcohol occasionally. On examination, she
was found to have a hard mass, along the
posterior lower right buccal sulcus of the
lower right second molar (LR7) extending to
the alveolar ridge. This mass was tender to
palpation. The LR7 was vital and the lower
third molar (LR8) unerupted. Otherwise the
examination was normal and there was no
palpable cervical lymphadenopathy.
A radiographic image (Figure 1)
demonstrated a unilocular, well-corticated
radiolucency measuring 40 mm in diameter
extending from distal of the LR7 to the
angle of the mandible and 50% of the
ramus. Although some characteristics were
typical of a dentigerous cyst, the margins of
the cyst seemed to be in contact with the
cemento-enamel junction of the unerupted
LR8. Other features were atypical, including
the resorption of the distal root of the LR7.
In addition, the cyst showed evidence of
causing displacement of the LR8 distally.
CT imaging (Figure 2) demonstrated that
the lingual plate and mandibular cortical
border were intact, as well as showing the
inferior alveolar nerve was buccal to the
LR8. Incisional biopsy of the abnormality
and aspiration of its contents demonstrated
the histological findings of a cyst lined by
thin odontogenic epithelium. The stroma
showed myxoid changes with nests of both
active and resting odontogenic epithelium.
A diagnosis of unicystic ameloblastoma was
made.
Subsequently, CH underwent
marsupialisation of the cyst (and the cavity
was packed with Bismuth Iodine Paraffin
Paste (BIPP) impregnated ribbon gauze). The
post-operative radiograph is presented in
Figure 3. The cyst cavity was irrigated with
normal saline and chlorhexidine solution
and the pack was changed fortnightly
for 6 months and until the volume of the
cyst had decreased substantially. From
serial radiographs, after 6 months, the cyst
diameter on radiographs had reduced by 23
mm, approximately 58% in size (Figure 4), as
well as also demonstrating that the wisdom
tooth had also moved.
June 2020
 OralandMaxillofacialSurgery

The aim was to reduce the

size of the ameloblastoma sufficiently for
planned enucleation, cryotherapy and
extraction of the associated teeth. This
was to minimize the risk of recurrence
occurring deep in the mandible. However,
a further concern was the close association
of the roots of the unerupted LR8 with the
mandibular canal, which would result in a
high chance of nerve injury. Consequently,
the LR8 was extruded orthodontically with
a gold chain attached to a bracket on the
UR8 (Figure 4). This was effective in moving
the tooth further away from the ID nerve,
but complicated by debonding of the
Figure 1. Orthopantomogram taken on first presentation, demonstrating well defined radiolucency
chain. CH then underwent extraction of
alongside an unerupted LR8 in the posterior mandibular region.
the LR8, with simultaneous enucleation of
the ameloblastoma. Following cryotherapy,
liquid nitrogen and a probe with KY jelly to
form a good iceball with three freeze/thaw
cycles was performed to the bony cavity,
with care taken to retract and protect the
surrounding soft tissues.
Six-monthly interval follow-
up, for two years, has demonstrated no
evidence of either clinical or radiographic
recurrence. CH has full and normal inferior
dental nerve sensation, no deformity (Figure
5), and no long-term complications.

Patient perspective
The first words I remember my surgeon
saying to me were ‘That thing is the size
of a satsuma’. They were not words I
had been expecting to hear, as I was
absolutely convinced, until he turned the
monitor towards me and showed me my
x-ray picture, that everything was fine. I
had had no symptoms at all, just a small
swelling in the back of my mouth that I Figure 2. CT imaging taken pre-operatively, demonstrating the intact lingual plate and mandibular
had assumed was my unerupted wisdom cortical border, as well as showing the inferior alveolar nerve was buccal to the LR8.
tooth but, on a routine dental examination,
my dentist explained that she could not
see the tooth on the x-ray and she referred
me for a two-week wait. Admittedly,
seeing the huge tumour and how I had an
eggshell thickness of jawbone left scared
me, and it opened up so many questions:
‘What happens next?’ ‘Will my face look
the same?’ ‘What would have happened if
it hadn’t been found?’. I started Googling
and found a young woman in the US with
a near identical tumour who had had a
hemimandibulectomy and reconstruction
Figure 3. The post-operative radiograph following marsupialisation of the cyst and the cavity being
with a bone, and was worried that I,
packed with Bismuth Iodine Paraffin Paste (BIPP) impregnated ribbon gauze.
too, would be left with large scars and a
June 2020 DentalUpdate 511
 OralandMaxillofacialSurgery
Figure 4. Orthopantogram demonstrating resolution of the ameloblastoma and a gold chain attached
to the crown of the LR8 to extrude the tooth orthodontically.
Figure 5. Post-operative radiograph 2 years post treatment showing resolution of the ameloblastoma.
different face.
My surgeon was very reassuring
and, whilst I was aware that my treatment
was experimental in many ways, and that
there were setbacks in my treatment, such
as difficulties in fitting the bracket and chain
to evert the tumour, it seemed he had no
doubts that it would be successful. I believe
any surgery requires trust between the
surgeon and the patient, but I was surprised
at how big the trust was that the facial
surgery required of me. Our faces are so
entwined with our identities; so part of who
we are. I am very lucky to have been treated
by a team who earned that trust from me,
and I am very grateful to have a face that is
mine.
Discussion
Ameloblastoma is a benign odontogenic
neoplasm of the mandible and maxilla
that rarely exhibits malignant behaviour. It
512 DentalUpdate
accounts for 1% of all tumours in the oral
cavity. Generally, it occurs between the
third and fifth decades, the most frequently
affected site being the mandibular
posterior molar region, which accounts
for 60% of all cases.1 Whilst asymptomatic,
an ameloblastoma usually presents as a
swelling. The tumour enlarges within the
jaw slowly, displacing teeth, resorbing
roots and perforating through the cortical
bone.2 An ameloblastoma develops from
the epithelium involved in the formation of
teeth, the reduced enamel epithelium and
odontogenic cyst lining.3
Despite being benign, an
ameloblastoma has a high recurrence rate.4
This is why, classically, an ameloblastoma
has to be removed with wide local excision,
involving 1−1.5 cm of normal bone
around the margin. Often this necessitates
reconstruction, often with free tissue
transfer of a composite flap. This traditional
treatment has numerous complications,
such as functional and masticatory changes,
facial deformities, as well as neurological
sequelae from sacrificing the inferior
alveolar nerve.5
An ameloblastoma can be
classified into one of four types:
1. Conventional/multicystic;
2. Unicystic;
3. Peripheral; and
4. Desmoplastic.
Each subtype can present and
behave differently, having implications
upon treatment. Unicystic ameloblastomas
typically present at a younger age than
conventional ameloblastomas. Many
present similarly to a dentigerous cyst with
an unerupted third molar, thus histological
confirmation is mandatory.3
Unicystic lesions, by definition of
having a single cyst cavity, are well localized
by the fibrous capsule of the cyst, and only
rarely broach the peripheral tissues. This has
formed the basis of why ameloblastomas
may be successfully managed with
conservative treatment (marsupialisation or
enucleation).6 The aim of marsupialisation
is to reduce the size of the tumour. The
decompression of the internal contents by
marsupialisation promotes remodelling of
bone and osteogenesis. Once the tumour
volume has been sufficiently reduced in
size, it can then be treated by enucleation
and/or cryotherapy. This approach has the
benefits of maintaining pulp vitality, the
inferior alveolar nerve and preventing jaw
fracture.2
However, treatment of an
ameloblastoma remains controversial.
Due to debate over recurrence rates
and the relative rarity of this tumour,
there is clinical uncertainty over which
treatment is most effective. Some case
series have shown the lowest recurrence
with resection,7 and that most recurrent
cases occur after enucleation or excision.8
Recently, case series have shown success at
conservative treatment. A series involving
15 patients, with a mean 4-year follow-
up, demonstrated no recurrence with
marsupialisation followed by enucleation
of unicystic ameloblastoma in adolescents.9
Others have replicated this.10,11 The success
of this form of treatment mostly depends
on the histological nature, as well as other
factors such as age, surgical technique and
the size of the tumour.12
Along with the risks of treatment
June 2020
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 OralandMaxillofacialSurgery
of the ameloblastoma, there are the risks of
extraction of the unerupted LR8. The close
association of the LR8 with the mandibular
canal increases the risk of damage to the
inferior alveolar nerve. In the present case,
the additional conservative option of
orthodontic extrusion of the third molar
enabled an extraction which greatly reduced
the risk of nerve injury. Previous studies have
reported that between 3 weeks to 2 months
of traction will result in radiographic evidence
of the roots moving 1 mm to 3 mm from the
inferior dental canal.13 Meta-analysis of 123
with a high risk of neural damage has shown
success using orthodontic extrusion, with no
record of permanent injury.14
It is evident that, whilst these
two conservative techniques are rarely
employed, they do have an evidence base
with demonstrated efficacy and safety.
However, the use of these two techniques in
conjunction, in the case of the conservative
management of a unicystic ameloblastoma, is
particularly novel.
A similar report has been published
by Takahashi et al.15 However, a key difference
in the report, compared with the present
case, is the fact that the patient was 7 years
old. The majority of the published reports
of conservative management of unicystic
ameloblastomas relate to patients below
20 years old. Indeed, there is a paucity of
evidence for this conservative management
in older patients. There are different
limitations of both marsupialisation and
orthodontic uprighting in an adult, namely
the lower rate of bone turnover and success
rates. This present report adds to the limited
body of literature by demonstrating efficacy
of this conservative treatment in adults with
unicystic ameloblastoma.
A patient perspective was included
here to highlight the key features which the
patient remembered and felt were important.
As well as the obvious, such as maintaining
aesthetics and function, it is important to
highlight the trust which patients must
place in this lengthy treatment course.
Inspiring this trust is especially relevant
when dealing with possible life-changing
consequences and experiencing setbacks
in treatment. As highlighted by the patient
account, a key factor to building this trust is
clear communication. Clearly explaining the
diagnosis, treatment options, and evidence
base helps to abate patient’s fears. This is
essential in a case like the present one, where
514 DentalUpdate
the treatment will be complex, and time and
effort needs to be taken with the patient to
explain and listen.
As with all management options,
there are limitations. One must consider the 6.
time frame, which can take an average of 9
months to enable full eruption.14 Also, there
is the reliance upon patient compliance
to tolerate, and attend, for both repeated 7.
pack changes and orthodontic treatment.
Finally, in those patients with a recurrent
ameloblastoma, there is a stronger argument
8.
for more aggressive management. Due to
the ongoing risk of recurrence, as with any
treatment of ameloblastoma, long term
annual follow-up is warranted.
9.
Summary
This case report outlines the effective
conservative management of a large
unicystic ameloblastoma with the added
complication of an unfavourably positioned
unerupted lower wisdom tooth. The report 10.
demonstrates the efficacy of the combination
of conservative surgery and orthodontic
treatment in management.
Compliance with Ethical Standards 11.
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. 12.
References
1. Sham E, Leong J, Maher R, Schenberg
M, Leung M, Mansour AK. Mandibular
ameloblastoma: clinical 11 experience 13.
and literature review. ANZ J Surg 2009; 79:
739−744.
2. Laborde A, Nicot R, Wojcik T, Ferri J, Raoul G.
Ameloblastoma of the jaws: Management
and recurrence rate. Eur Ann Otorhinolaryngol 14.
Head Neck Dis 2017; 134: 7−11.
3. Odell EW. Cawson’s Essentials of Oral Pathology
and Oral Medicine 9th edn., London: Elsevier,
2017.
4. Lau SL, Samman N. Recurrence related
to treatment modalities of unicystic 15.
ameloblastoma: a systematic review. Int J
Oral Maxillofac Surg 2006; 35: 681−690. doi:
10.1016/j.ijom.2006.02.016.
5. Ooi A, Feng J, Tan HK, Ong YS. Primary
treatment of mandibular ameloblastoma
with segmental resection and free fibula
reconstruction: Achieving satisfactory
outcomes with low implant prosthetic
rehabilitation. J Plast Reconstr Aesthet Surg
2014; 67: 498−505.
Gardner DG, Pelcak AM. The treatment
of ameloblastoma based on pathologic
and anatomic principles. Cancer 1980; 46:
2514−2519.
Pogrel MA, Montes DM. Is there a role
for enucleation in the management of
ameloblastoma? Int J Oral Maxillofac Surg
2009; 38: 807−812.
Sampson DE, Pogrel MA. Management of
mandibular ameloblastoma: the clinical
basis for a treatment algorithm. J Oral
Maxillofac Surg 1999; 57: 1074−1077.
Meshram M, Sagarka L, Dhuvas J, Anchlia S,
Vyas S, Shah H. Conservative management
of unicystic ameloblastoma in young
patients: a prospective single centre trial
and review of the literature. J Maxillofac
Oral Surg 2017; 16: 333−341. doi: 10.1007/
s12663-016-0987-2. Epub 2016 Dec 20.
Kim H, Nam E, Yoon S. Conservative
management (marsupialisation) of unicystic
ameloblastoma: literature review and a case
report. Maxillofac Plast Reconstr Surg 2017;
39: 38.
Huang IY, Lai ST, Chen CH, Chen CM, Wu
CW, Shen YH. Surgical management of
ameloblastoma in children. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2007;
104: 478−485.
Dolanmaz D, Etoz OA, Pampu A, Kalayci A,
Gunhan O. Marsupialization of unicystic
ameloblastoma: a conservative approach
for aggressive odontogenic tumors.
Indian J Dent Res 2011; 22: 709−712. doi:
10.4103/0970-9290.93461.
Ma ZG, XIE QY, Yang C, Xu GZ, Cai XY, Li JY.
An orthodontic technique for minimally
invasive extraction of impacted lower
third molar. J Oral Maxillofac Surg 2013; 71:
1309−1317; doi 10.1016/J.joms.2013.03.025.
Motamedi MRK, Heidarpour M, Siadet S,
Motamedi AK, Bahreman AA. Orthodontic
extraction of high risk impacted mandibular
third molars in close proximity to the
mandibular canal: a systematic review. J
Oral Maxillofac Surg 2015; 73: 1672−1685.
Takahashi S, Idaira Y, Sato T, Asada Y,
Nakagawa Y. Unicystic ameloblastoma
in a child treated with a combination of
conservative surgery and orthodontic
treatment: a case report. J Clin Pediatr Dent
2019; 43: 121−125. doi: 10.17796/1053-
4625-43.2.9. Epub 2019 Feb 7.
June 2020
 Enhanced CPD DO C
Kate Parker
Matthew Chia
Remote Working in Dentistry in
a Time of Crisis – Tools and their
Uses
Abstract: This article provides an overview of tools which enable remote working in Dentistry. It assesses the availability of tools for use
in three areas of remote working in healthcare: video conference calls between professionals, apps for patients to send photographs to
clinicians and platforms for telemedicine clinics and highlights the main features of common tools.
CPD/Clinical Relevance: Remote working in healthcare has become increasingly popular during the COVID-19 pandemic and an
understanding of how this remote working can be utilized in Dentistry, and the associated benefits, is relevant to all clinicians.
Dent Update 2020; 47: 515–526
Coronavirus Disease 2019, or more commonly
COVID-19, is a global healthcare crisis with
an unprecedented number of deaths and
countries taking extraordinary action to
try and control the spread of the virus.1,2
During COVID-19, healthcare resources have
been directed to fight the pandemic with
the cancellation of the majority of routine
medical treatment and the cessation of
routine Dentistry.3 In the United Kingdom,
COVID-19 has led to the implementation of
countrywide measures to curb the spread
Kate Parker, BDS(Hons), BA(Hons),
MJDF RCS(Eng), MOrth RCS(Eng),
FDS(Orth) RCS(Eng), Orthodontic
Senior Specialty Registrar, Eastman
Dental Hospital and Croydon
University Hospital and Matthew
Chia, BDS, MFDS RCS(Eng), MSc,
MOrth RCS(Eng), FDS(Orth) RCS(Eng),
Consultant Orthodontist, Clinical
Lead in Orthodontics and Restorative
Dentistry, Croydon University Hospital,
530 London Road, Thornton Heath CR7
7YE, UK.
June 2020
of the virus and to help save lives, including;
social distancing, self-isolation and shielding.1
To enable these social distancing measures,
the use of technology has allowed flexible and
remote working. This has been embraced in
healthcare and implemented in a variety of
contexts during this time of crisis.
Technology for remote working
in healthcare
Although remote working is already used in
many industries, it has not previously been
widely used in healthcare. During COVID-
19 it has been necessary to rethink many
conventional ways of working, including
utilizing remote working with the use of;
video conference calling for professionals,
apps that allow patients to share photographs
with clinicians and the use of telemedicine
clinics. When using these tools it is imperative
that the highest standards of patient care
are maintained, which is emphasized by the
General Medical Council statement that ‘digital
and technological advances may present a
more convenient way for patients to access
healthcare, but it is important that these
services do not compromise standards of care
GeneralPractice
and patient safety’.4
Video conference calling for
professionals
Video conference calls allow individuals or
groups of people to participate in a call with
real time audio and visual input, which is
beneficial compared to an audio telephone
call as it simulates a traditional face-to-face
meeting with the associated advantages of
building rapport, aiding understanding and
facilitating discussions.5 However, there are
limitations associated with video calling,
including; lack of physical face-to-face contact,
delay in the audio-visual feedback and the
need for appropriate technology and internet
connection to host the call effectively.6
Apps for patients sharing
photographs with clinicians
Sharing photographs between friends and
family is common practice, however, the use
of apps for patients to share photographs
with clinicians is currently less common.
Nevertheless, in times when patients are
unable to attend appointments, it may be
DentalUpdate 515
 GeneralPractice

Topic Search Terms Used

Video conference calling for professionals „ Video call

„ Video conference
„ Video conferencing
„ Video conference call
„ Video group call
Apps for patients to share photographs with clinicians „ Patient share photos/photographs with clinician
„ Patient share photos/photographs with doctor
„ Share patient photos/photographs
„ Patient share photos/photographs
„ Share clinical photos/photographs
„ Share medical photos/photographs
Telemedicine clinics „ Telemedicine
„ Teledentistry
„ Teleconsultation
„ Video consultation
„ Patient video consultation
„ Video clinic
„ Patient video call
Table 1. The search terms used for each topic.

Google Bing App Store Google Play

BlueJeans Babble Cloud BlueJeans Google Duo
FaceFlow FaceFlow Google Hangouts Google Hangouts
Google Duo Free Conference Go to Meeting Go to Meeting
Google Hangouts Google Hangouts Hola Hola
Go to Meeting Go to Meeting House Party Microsoft Teams
Microsoft Teams Microsoft Teams Microsoft Teams Skype
Pow Wow Now Skype Skype Video Duo
Skype Video Duo We Chat We Chat
Zoom Zoom Zoom Zoom
Table 2. The main results for video conference calling for professionals.

helpful for patients and clinicians to be able
to use such platforms to facilitate clinicians
giving advice to patients in the absence of a
traditional appointment.
Telemedicine clinics
The ability to have a video consultation with
a patient can be useful when patients are
unable to attend a face-to-face appointment
or to obviate the need to attend an
appointment.7,8 Video consultations are
referred to as ‘telemedicine’ clinics, which
describes any ‘medical service provided
remotely via information and communication
516 DentalUpdate
technology’.4
Telemedicine can reduce clinic
space requirements, decrease costs and
improve the efficiency of a service.9,10 When
compared to telephone consultations, video
consultations have the benefit of allowing
the clinician to gain visual information and
diagnostic clues, as well as the advantage
of the therapeutic presence of the clinician
being greater than via an audio telephone
call.11 Clinicians and patients communicate
by video in the same way as an in-person
consultation, with both reporting high
levels of satisfaction.12-14 Telemedicine is only
appropriate in certain circumstances and
clinicians should always ensure that the same
standards of care are given in both video and
face-to-face consultations.4
Data Protection
The General Data Protection Regulation
(GDPR) applies to the processing, handling
and storage of data within the European
Union.15 Therefore, when using technology for
remote working in healthcare, it is essential
that the GDPR rules and regulations are
complied with. It is advisable that all devices
are appropriately secured, that two-factor
June 2020
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 GeneralPractice

Tool Features
Google „ Good integration with Gmail
Hangouts „ Free and paid options available
„ No limit to meeting duration
„ Up to 10 individuals can participate in the same meeting or up to 25 individuals with Google App for Work
„ Can share screens

Go to Meeting „ Not associated with a specific operating system

„ Free and paid options available
„ No limits to meeting duration
„ Up to 25 individuals can participate in the same meeting
„ Prices start at £9.50 per month − as price increases more individuals can participant in meetings and more ability
to share and collaborate on documents
„ Can share screens
„ Virtual whiteboard
„ Can record meetings and have searchable transcript

Microsoft Teams „ Fully integrated with Office 365

„ Used in collaboration with NHS Mail
„ Free with Office 365
„ No limit to meeting duration
„ Simple to create ‘teams’ within an organization, more complex to create ‘teams’ outside an organization
„ Up to 10,000 individuals can participate in the same meeting
„ Can see up to four video screens at the same time
„ Can share screens
„ Can collaborate on documents
„ Can blur background to minimize distractions
„ Can record meetings and have searchable transcript

Skype „ Provided by Microsoft

„ Free
„ No limit to meeting duration
„ Up to 50 individuals can participate in the same meeting
„ End to end encryption
„ Can share screens
„ Unable to collaborate on documents
„ Can record meetings which are stored for up to 30 days

Zoom „ Not associated with an operating system and can be used with any operating system
„ Free and paid options available
„ Free option − 40 minutes limit to meeting duration
„ Different price options have different limits to meeting duration and number of participants allowed
„ Up to 1000 meeting participants and 10,000 viewers
„ Can see up to 49 video screens at the same time
„ End to end encryption
„ Can share screens
„ Can share documents without having to upload files
„ Can have virtual background or blur background to minimize distractions
„ Can record meetings and have searchable transcript
„ Can have a meeting room where meeting participants wait before being let into the meeting by the host
„ Can create different breakout groups within the same meeting

Table 3. The main features of the five most common tools for video conference calling for professionals.

June 2020 DentalUpdate 519

 GeneralPractice

Google Bing App Store Google Play

AppwoRX AppwoRX Clinical Cam AppwoRX
Capture Proof Clinical Cam Epitomyze Clinical Cam
Epitomyze Epitomyze iConnect Epitomyze
Hospify Hospify MedShare Hospify
Med Photo Manager Med Photo Manager MedXStream MedShare
Pic Safe MedXStream myBody myData Pic Safe
Rx Photo Pic Safe Pic Safe RxPhoto
The Doctor RxPhoto RxPhoto Smart Share
Zen Snap Share Smart Share Smart The Doctor
Table 4. The main results for apps for patients to share photographs with clinicians.

authentication is used for accessing any apps
or platforms that contain patient information,
and that no patient data is stored on any mobile
devices.16
During COVID-19, the National
Health Service (NHS) produced specific
information governance guidance
in consultation with the Information
Commissioner’s Office on the use of information
technology during the pandemic.17,18 The
guidance advises that, during the pandemic,
clinicians are permitted to use personal
devices to communicate with patients and
host video consultations and that ‘off-the-
shelf’ applications can be used where there
is no practical alternative and if the benefits
outweigh the risks.17,18
Aim
The aim of this article is to assess the availability
of tools for remote working in dentistry and
to summarize the characteristics of the most
common tools available.
Materials and method
The three main topics assessed were:
1. Video conference calling for professionals;
2. Apps for patients to share photographs with salient features of these tools are shown in
clinicians;
3. Telemedicine clinics.
Common search terms for each
topic were established by the authors and
piloted. The final search terms used are shown participate in the same meeting with audio
in Table 1. The search terms were entered into
Google, Bing, the Apple App Store and Google share screens. The main differences were: if
Play search functions on 3/4/2020 and the
520 DentalUpdate
results were recorded and assessed. Any non-
English results were excluded. The results were
assessed by the two authors (KP and MC) and
a third assessor was consulted to mediate and
achieve a consensus in cases of disagreement.
The five most common results for each topic
were then assessed in more detail with
information collated on their main functions.
Results
Overall, the four different search platforms used
returned largely similar results for the different
search terms used for each topic and there was
consistent agreement between the assessors
regarding the most common results for each
topic.
Video conference calling for
professionals
The main results for video conference calling
for professionals for the four different search
platforms are shown in Table 2.
The five most common results
across the different search platforms were:
Google Hangouts, Go to Meeting, Microsoft
Teams, Skype and Zoom, all of which were
found on all four of the search platforms. The
Table 3.
The five most common tools for
video conference calling had many similarities,
including allowing multiple individuals to
and visual feedback, and allowing users to
meeting participants could collaborate on
documents, if meetings could be recorded,
and if meetings were encrypted. Some tools
are free to download whilst others have
different payment options, with the main
differences being that, as the price increases,
more participants can join a meeting and the
limits of meeting durations are increased or
removed.
Apps for patients to share
photographs with clinicians
The main results for apps for patients to
share photographs with clinicians for the four
different search platforms are shown in Table
4.
The five most common results
across the different search platforms were:
Clinical Cam, Epitomyze, Hospify, Pic Safe
and RxPhoto, the main features of which are
shown in Table 5.
The results for apps for patients
to share clinical photographs with clinicians
were variable. Some of these results were for
apps designed specifically for this use such
as Hospify and Pic Safe, however, more often
the results found were for apps aimed at
clinicians using their mobile phones to take
photographs rather than using traditional
medical photography equipment (Clinical
Cam, Epitomyze, RxPhoto).
Telemedicine clinics
The main results for telemedicine clinics for
each of the four search platforms are shown
in Table 6.
The five most common results
June 2020
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 GeneralPractice

Tool Features
Clinical Cam „ App designed for clinicians taking clinical photographs on their mobile phone
„ Data stored securely
„ All data regularly deleted from mobile device
„ Can document patient consent
„ Can securely transfer photographs to email
„ Service has to be paid for
Epitomyze „ App designed for clinicians taking clinical photographs on their mobile phone
„ Allows standardized photographs to be taken
„ Can capture, securely store and share photographs
„ Unlimited data storage
„ Service has to be paid for
Hospify „ App designed for patients to share photographs with clinicians
„ Approved and recommended by NHS App Library
„ Free
„ Users telephone numbers and email addresses are not revealed, therefore clinician and patient confidentiality is
protected
„ Can create groups of users to share photographs and messages
„ End to end encryption
„ Messages and photographs are accessed using a 6 digit code
„ Messages and photographs are automatically deleted from the server after delivery and from mobile phones after
30 days
„ Web based version of the app also available − stores data for longer and is designed for healthcare organizations
„ Hospify Hub also available − for teams of people using mobile and web version, free for up to 10 users, different
payment plans for more users
Pic Safe „ App designed for patients to share photographs with clinicians
„ Free
„ Documents patient consent
„ As well as photographs, audio and video files can be recorded and sent
„ Encrypts files prior to sending and deletes all data after sending
„ Files can be sent securely via email, text message or WhatsApp
„ Data can be securely transferred to hospital server and uploaded to patient medical records
RxPhoto „ App designed for clinicians taking, cataloguing and managing clinical photographs
„ Allows high quality photographs to be taken using mobile phone
„ Designed as an alternative to conventional medical photography hardware
„ Has positioning templates to facilitate taking consistent photographs
„ Digital patient consent forms available
„ Photographs can be annotated and marked up
„ Photographs are encrypted and stored on the Cloud
„ Service has to be paid for
Table 5. The main features of the five most common tools for apps for patients to share photographs with clinicians.

found across the search platforms were: Attend
Anywhere, EMIS Health, LIVI Connect, Nye
Phone and Ortus i-Health, the most salient
features of which are shown in Table 7.
The search results for tools for
telemedicine clinics were varied, with the most
common tools providing a range of functions,
however, the majority of results did have the
feature of enabling telemedicine clinics and
could be used within an existing service.
June 2020
Discussion
At present there are a large number of different
tools available to enable remote working which
provide a range of different functions. Platforms
to enable conference calling between multiple
individuals using live video and audio input
and feedback are commonly available. There
are many different providers of such tools, all
of which were easy to find using the search
platforms used. The ease of identifying such
tools for conference calling may be due to
their common use across multiple industries.
The most common tools for
conference calling had largely similar features,
with the minor differences not obvious
without a more in-depth assessment. The
main differences between the platforms
were the number of individuals who could
participate in a meeting, the number of
individuals that can be seen on screen at
DentalUpdate 523
 GeneralPractice
Google Bing
AMC Health accuRx
Attend Anywhere Attend Anywhere
Babylon Health e-clinic
ClineCall Healthcare Egton
CureMD EMIS Health
EMIS Health LIVI Connect
Egton MDLive
MDLive Nye Phone
Nye Phone Ortus i-Health
Ortus i-Health Wellola
Table 6. The main results for telemedicine clinics.
any one time and the ability to share and
collaborate on documents. All platforms are
straightforward to use and therefore may be
chosen based on an individual’s requirements,
personal preference and any existing use within
organizations.
During COVID-19, many meetings,
collaborations and teaching episodes have
used video conference calling, where previously
these were carried out face-to-face. This has
demonstrated the flexibility in how video
calling can be utilized in healthcare. Depending
on the success of this during COVID-19, it will
be interesting to see if its use becomes common
practice following COVID-19.
The results for apps designed for
patients to share photographs with clinicians
were varied, with only some of the results being
for apps or tools designed for this purpose.
Apps that were designed for clinicians to take
photographs were commonly found and such
apps were not designed for patient use. These
results have been included as it accurately
reflects the search results and shows that it was
not easy to find apps or tools aimed for patient
use. This may be a common difficulty facing
patients and clinicians when searching for such
tools.
The search topic with the least
consistent results was telemedicine clinics. This
may be due to a lack of sensitivity of the search
terms used, less availability of telemedicine
software or telemedicine being less commonly
searched for. Unfortunately, the specific
features of the software often only became
clear after in-depth assessment, so it may be
challenging for clinicians to find the appropriate
524 DentalUpdate
App Store
Babylon Health
Cyber Clinic
LIVI Connect
Mend Telemedicine
my GP
MyMD
Patient Journey Connect
The GP Service
Video Doctor
Wellola
tool for their desired use. The ideal position
would be to have an agreed consensus and
recommendation for a telemedicine software
or platform in Dentistry.
Overall, there is much evidence in
medicine to support the use of telemedicine,
with Table 8 summarizing the benefits for
patients and for clinicians.19-22 A recent
study in Restorative Dentistry found that
remote consultations can provide a safe and
effective consultation and were not inferior
to in-person consultations.23 It also reported
high levels of acceptability for patients and
clinicians.23
The cited limitations and barriers
of telemedicine are: technological problems,
set-up costs, staff training and the decreased
interaction of patients with healthcare
professionals.19,21 For remote working and
telemedicine to become successful in routine
practice, the appropriate technological
infrastructure and clinical protocols
are required to ensure effective patient
management and to prevent the over or
under prescription of care.19,20
During the COVID-19 pandemic,
many individuals have implemented using
technology in new ways to enable remote
working. These new ways of working have the
potential to allow Dentistry to benefit from
remote working in ways that were previously
not realised.
Suggested applications of
remote working in Dentistry
Videoconferencing: These have traditionally
Google Play
Babylon Health
Cyber Clinic
Docly
Digital GP
LIVI Connect
ManageMyHealth
my GP
Push Doctor
The GP Service
Wellola
been used in Medical Multidisciplinary Team
(MDT) clinics, but these can be used for
Dental MDTs in hospital. They may also be
utilized by the primary care practitioners
to gain referral advice from secondary
care units or specialists. This format also
allows real-time sharing of information
and radiographs and images. Finally, it can
build professional relationships between
colleagues and strengthen clinical networks.
Patient photographs: This can
enhance and supplement the diagnosis
when giving advice remotely for routine or
emergency care.
Telemedicine clinics: This can
enhance and supplement the diagnosis
when giving advice remotely for routine
or emergency care combined with both
the clinical history and physical signs. It
may also build a rapport and professional
relationships between the patients and
clinicians.
Conclusion
COVID-19 has brought about an increased
utilization of technology which enables
remote working in Dentistry. Following the
resolution of COVID-19, it will be interesting
to see if these new and innovative ways of
working are maintained and if there are any
subsequent fundamental changes to some
of our working practices.
Declaration of Interests
No potential conflicts of interests were
reported by the authors.
June 2020
 GeneralPractice

Tool Features
Attend „ Designed to be used alongside existing hospital systems
Anywhere „ Used widely across NHS Scotland and many NHS Trusts in England
„ Patient does not need to download any software, accessed via internet link which can be pinned to practice/
hospital website
„ Can be used on any device
„ Patients enter a private online waiting room whilst waiting for their consultation
„ Secure and patient data is not stored
„ Can share screens with patient
„ Can write notes to patient
„ Costs of the service are unclear
EMIS Health „ Used by some NHS GP practices and some primary and secondary care providers in Scotland
„ Primarily an electronic healthcare records management system
„ Allows patient records to be linked and multiple professionals can access and contribute to patient records to
ensure joined up care
„ Allows video consultations
„ Video consultations can be recorded to allow the clinician to refer back to the recording afterwards if required
„ Costs of the service are unclear
LIVI Connect „ Platform that enables clinicians to have video consultations with patients
„ Video consultation is started by a secure link being sent to patient
„ End to end encryption of video consultations
„ No data is stored
„ Costs of the service are unclear
Nye Phone „ Enables telephone and video calls to patients
„ Can be integrated with existing NHS systems
„ Accredited by NHS Digital
„ Widely used by many NHS GPs
„ Can be used on any device
„ Does not reveal any personal details or telephone numbers, therefore maintains patient and clinician
confidentiality
„ Fully compliant with GDPR and information governance guidelines
„ Free
Ortus i-Health „ Used by some NHS Trusts including Barts Health
„ Patients have a mobile phone app and providers have a web portal
„ Costs of the service are unclear

Table 7. The main features of the five most common tools for telemedicine clinics.

Clinician Patient

Improved clinical networks Limiting the risk and spread of infection

Increased quality of services Minimizing travel

Develop communication with patients Improved access to care

Reduced patient non-attendance Reducing stress

Cost-effective and efficient Promoting self-care and prevention

Reduced administrative workload Enhanced communication and convenience

Good experience and satisfaction Good experience and satisfaction

Table 8. The benefits of telemedicine for clinicians and patients.

June 2020 DentalUpdate 525

GeneralPractice

References
1. Government UK. Coronavirus. Available at https://www.gov.uk/coronavirus
(Accessed: April 2020).
2. National Health Service. COVID-19. Available at https://www.england.nhs.uk/
statistics/statistical-work-areas/covid-19-daily-deaths/ (Accessed: April 2020).
3. National Health Service. COVID-19 and Urgent Dental Care. Available at https://www.
england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0282-
covid-19-urgent-dental-care-sop.pdf (Accessed: April 2020).
4. General Medical Council. Regulatory Approaches to Telemedicine. Available at
https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/
research-and-insight-archive/regulatory-approaches-to-telemedicine (Accessed:
April 2020).
5. Communication iCloud. 10 Business Benefits of Video Conferencing. Available
at https://www.communicloud.com/blog/10-business-benefits-of-video-
conferencing (Accessed: April 2020).
6. ezTalks. Advantages and Disadvantages of Video Conferencing. Available at https://
www.eztalks.com/video-conference/advantages-and-disadvantages-of-video-
conferencing.html (Accessed: April 2020).
7. Chan WM, Woo J, Hui E, Hjelm NM. The role of telenursing in the provision of geriatric
outreach services to residential homes in Hong Kong.
J Telemed Telecare 2001; 7: 38−46.
8. Gray LC, Edirippulige S, Smith AC et al. Telehealth for nursing homes: the utilization of
specialist services for residential care. J Telemed Telecare 2012; 18:142–146.
9. ezTalks. Top 6 Benefits of Video Conferencing in Healthcare. Available at https://www.
eztalks.com/video-conference/benefits-of-video-conferencing-in-healthcare.
html (Accessed: April 2020).
10. Mega Meeting. The Modern House Call: The Benefits of Video Conferencing in
Healthcare. Available at https://www.megameeting.com/news/benefits-of-video-
conferencing-in-healthcare/ (Accessed: April 2020).
11. Greenhalgh T, Koh GCH, Car J. Covid-19: A Remote Assessment in Primary Care. Br
Med J 2020. doi: 10.1136/bmj.m1182. Epub ahead of print.
12. Yeung A, Johnson DP, Trinh N-H, Weng W-CC, Kvedar J, Fava M. Feasibility and
effectiveness of telepsychiatry services for Chinese immigrants in a nursing home.
Telemed J E Health 2009; 15: 336−341.
13. Wade V, Whittaker F, Hamlyn J. An evaluation of the benefits and challenges of video
consulting between general practitioners and residential aged care facilities.
J Telemed Telecare 2015; 21: 490–493.
14. Guan WJ, NI ZY, Hu Y et al. China Medical Treatment Expert Group for Covid-19.
Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020. doi:
10.1056/NEJMoa20002032. Epub ahead of print.
15. Information Commissioners Office. Guide to the General Data Protections Regulations
(GDPR). Available at https://ico.org.uk/for-organisations/guide-to-data-
protection/guide-to-the-general-data-protection-regulation-gdpr/ (Accessed:
April 2020).
16. Institute of Medical Illustrators. Available at https://www.imi.org.uk/ (Accessed: April
2020).
17. Information Commissioners Office. Data Protection and Coronavirus. Available at
https://ico.org.uk/about-the-ico/news-and-events/news-and-blogs/2020/03/
data-protection-and-coronavirus/ (Accessed: April 2020).
18. National Health Service X. Covid-19 Information Governance Advice for Health and
Care Professionals. Available at https://www.nhsx.nhs.uk/key-information-and-
tools/information-governance-guidance/health-care-professionals (Accessed:
April 2020).
19. GP. How Video Consultations can benefit Patients and the NHS. Available at: https://
www.gponline.com/video-consultations-benefit-patients-nhs/article/1401346
(Accessed: May 2020).
20. Donaghy E, Atherton H, Hammersley V et al. Acceptability, benefits, and challenges
of video consulting: a qualitative study in primary care. Br J Gen Pract 2019; 69(686):
e586−594.
21. Shaw S, Wherton J, Vijayaraghavan S et al. Advantages and limitations of virtual online
consultations in a NHS acute trust: the VOCAL mixed-methods study. Southampton
(UK): NIHR Journals Library; 2018 Jun.
22. NHS England. GP Online Services: The Key Benefits. Available at: https://www.
england.nhs.uk/gp-online-services/learning-so-far/key-benefits/ (Accessed: May
2020).
23. Martin N, Shahrbaf S, Towers A, Stokes C, Storey C. Remote clinical consultations in
restorative dentistry: a clinical service evaluation study Br Dent J 2020; 228: 441–447.

526 DentalUpdate June 2020

 Enhanced CPD DO C DentalEducation

Faye Doughty

Catherine Moshkun

The Impact of COVID-19 on Dental

Education and Training
Abstract: COVID-19 has had a huge impact on dentistry. Dental care professionals work in close proximity with patients, they are therefore
at high risk of contracting coronavirus. As of 25th March, all routine dentistry was postponed.
The pandemic has led to clinic closures, university closures and postponement of exams and interviews. This has resulted in a
deficit in clinical exposure for undergraduates and trainees. Changes in examination format have been implemented to prevent delays in
course completions. The GDC have reassured that measures are being put in place to reduce the effect of COVID-19 on training.
CPD/Clinical Relevance: This article aims to explore the impact of SARS-CoV-2 on dental education and dental training programmes in
the UK.
Dent Update 2020; 47: 527–528

The COVID-19 pandemic has brought
routine dentistry to a halt, which leaves
professionals in training programmes in
unknown territory.
The New York Times identified
dentistry as one of the highest risk
professions for contracting the virus.1 This
is due to the close working environment
clinicians are in with numerous patients and
the aerosol generating procedures (AGPs)
that they perform on a daily basis.
The Chief Dental Officer of England
released guidance on 25th March 2020
which advised clinicians to implement
the advice, analgesia and antimicrobial
(where necessary) approach.2 At this point,
Faye Doughty, BDS, Foundation
Dentist, Liverpool Scheme and
Catherine Moshkun, BDS, MFDS,
RCPS(Glasg), PGCert, Specialty Dentist in
Oral Surgery, University Dental Hospital
of Manchester, Higher Cambridge
Street, Manchester M15 6FH, UK.
May 2020
all routine dentistry was stopped until
further notice, which, by default, means
that undergraduate training, dental
foundation training, dental core training
and specialist training have reached a
clinical standstill.
Impact on Training
The General Dental Council released
a joint statement on 23rd March 2020
addressing the ‘arrangements for dental
care professional students and recent
graduates, while restrictions are in place
to control the spread of COVID-19’.3 The
guidance offers reassurance and outlines
plans to be put in place to reduce the
likelihood of delays in training and
satisfactory completion of courses.
Dental schools cease to
operate at their usual capacity due to
university closures. As a result, dental
students will miss out on the best part
of a semester of clinical sessions, leading
to an unavoidable deficit in clinical
experience. The GDC stated that, in
these cases, universities will identify
those who may require additional
support due to lack of experience.
A development plan will be put into
place for these individuals prior to
starting dental foundation training
(DFT).3
It is now compulsory for
all dental foundation trainees to sit
a clinical skills assessment prior to
commencing training.3 The clinical
skills assessment is an effective way
to identify those key areas where
more support is needed. This will
enable educational supervisors to
plan tutorials around those areas
highlighted and focus on areas of
weakness when completing ADEPTs
(a dental evaluation of performance
tool) to ensure progression is made
throughout the training year.
Many universities utilize
viva style examinations in final year.
Vivas are face to face examinations
which assess higher-level thinking.
DentalUpdate 527
 DentalEducation
These exams can no longer take place in
their usual format due to the university
closures and restrictions that have been put
in place.
Universities are exploring the
idea of utilizing technology by enabling
exams to be completed online. This
allows students to sit their final exams
as scheduled and prevents delays in
qualifying. Whilst this is a practical solution,
the different examination environment may
disadvantage some students, as it is not the
format to which they are accustomed.
The GDC statement suggests
that universities are planning to organize
multiple sittings of examinations for
final year students.3 Due to the COVID-
19 outbreak, it is entirely possible that
some students will be ill due to the virus,
impacting on their ability to sit exams as
scheduled. Dental schools across the UK are
working hard to determine what is feasible
and whether multiple sittings can be
arranged to mitigate this scenario.
Dental foundation training
is an excellent training programme that
is available to new graduates in the UK.
Foundation dentists benefit from close
supervision during their first 12 months of
real world dentistry in NHS general practice.
There are numerous learning opportunities
available through a plethora of study days.
These study days promote continued
professional development and encourage
interaction between fellow foundation
dentists.
Foundation dentists will likely
miss out on 12 or more weeks of clinical
experience and multiple study days due
to the COVID-19 pandemic. This will have
a huge impact on DFT. The targets set for
trainees will need to be revised due to the
considerable reduction in clinical exposure.
It could also have an effect on foundation
dentists’ confidence after completion of
DFT due to the unavoidable reduced clinical
experience during the year.
Health Education England is
working hard to reduce the fallout from
COVID-19 on DFT. Many study days are
being held online, allowing foundation
dentists still to benefit and learn from
experienced and knowledgeable speakers.
Tutorials between foundation dentists and
educational supervisors are also still going
ahead online. Training programme directors
have been in contact with their schemes
528 DentalUpdate
to assign tasks which can be carried out
at home, ensuring time spent outside of
clinics is productive and used to strengthen
knowledge.
COVID-19 has caused many
interruptions to training. Dental core
training (DCT) interviews, for example, were
postponed in light of the current situation.
Face to face interviews are no longer going
ahead. The selection process will be solely
based on situational judgement test scores.4
Dental core trainees are
expected to complete 24 supervised
learning events (SLEs) throughout their 12
month placement.5 SLEs can be completed
in numerous different ways such as direct
observational procedures and clinical
based discussions, etc. DCTs may no
longer be able to reach these targets as
a result of cancelled clinics and possible
redeployment.
COVID-19 has also affected
specialty training. The face to face
interviews for recruitment are no longer
going ahead. A self-assessment process
will be utilized.4 Postponement of specialty
examinations may result in delays in
training progression. This may also lead
to delays in the commencement of new
trainees.4
The GDC has stated that each
university and examining body is working
hard to set up contingency plans to reduce
the effect that COVID-19 has had on
training and examinations.3
Many departments in the NHS
are under additional pressures due to
the COVID-19 outbreak. Redeployment
of dental professionals into areas of
need is an excellent way of helping
the NHS in such unique circumstances.
At the same time, it also allows dental
professionals to experience different
healthcare environments and gain new
skills. This presents a unique opportunity
for foundation dentists, DCTs and specialist
registrars to work with healthcare
professionals that would not usually be a
part of the dental team. This is a chance
for dental professionals to grow both
professionally and personally.
With the uncertainty that
COVID-19 brings, there is still hope. The
pandemic has resulted in healthcare
professionals from all fields joining together
in a concerted effort to help those in need.
People from all professions are working
together in unity, helping however and
wherever possible. It is a proud time to be a
part of the NHS.
References
1. The New York Times. The Workers Who
Face the Greatest Coronavirus Risk.
2020. Online information available
at: https://www.nytimes.com/
interactive/2020/03/15/business/
economy/coronavirus-worker-risk.
html
2. NHS England. Issue 3, preparedness
letter for primary dental care - 25
March 2020. Online information
available at: https://www.england.
nhs.uk/coronavirus/wp-content/
uploads/sites/52/2020/03/issue-3-
preparedness-letter-for-primary
-dental-care-25-march-2020.pdf
3. General Dental Council, Dental Schools
Council, Committee of Postgraduate
Dental Deans and Directors et al. Joint
statement on arrangements for dental
and dental care professional students
and recent graduates, while restrictions
are in place to control the spread of
COVID-19. 2020. Online information
available at: https://www.gdc-uk.org/
news-blogs/news/detail/2020/03/23/
arrangements-
for-dental-and-dental-
care-professional-students-
and-recent-graduates-to-
control-the-spread-of-covid-
19?fbclid=IwAR3PgeEgcuGRLVow
PBhd6nn2-lSO5Ijr88iadl5xiSP7ao5vs
TfQZCC8Htw
4. Health Education England. Update
on dental recruitment 20th April
2020. Online information available
at: https://www.hee.nhs.uk/sites/
default/files/documents/COVID-
19%20Statement%20for%20dental
%20applicants%20-%2020%
20April%202020_1.pdf
5. UK Committee of Postgraduate Dental
Deans and Directors. Dental Core
Training Curriculum. 2016. Online
information available at: https://www.
copdend.org/postgraduate-training/
dental-core
-training-curriculum/
May 2020
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 COVID-19
Free Digital Learning
During these unprecedented times, we are faced with constant change
and information overload. Our aim is to provide you with clear, factual
information, backed up with supportive practical guidance covering both
clinical situations and your own and your colleagues’ wellbeing. All of the
digital learning resources are free to access at rcpsg.ac.uk/covid-19.

Dental Webinar Recordings

COVID-19: Preparing for the challenges ahead
In this webinar, hosted by the Deans of the Dental Faculties of the UK, the Panel discussed
the challenges facing dental professionals in the coming months as we move through the
COVID-19 pandemic. This webinar was delivered live on 2 June.

Aerosols and Patient Safety: Where are we now?

This webinar took place on 19 May, and reviewed the risks of aerosol generating procedures,
the ways in which practice may have to change, and the management of patients as a result of
these changes.

COVID-19 Health and Wellbeing: Q&A with the Deans of the

Dental Faculties
In this webinar, which was hosted on the 5 May, the Deans of the Dental Faculties discussed
the extreme pressures that the pandemic has brought, which has threatening the health and
wellbeing of dental professionals, and the ways in which we can combat stress and burnout.

Managing the Emergency Dental Patient during COVID-19

This webinar took place on 21 April and features the Deans of the Dental Faculties and guests.
This digital learning provides answers to common questions about emergency dental treatment
during the pandemic.

COVID-19 Q&A with the Deans of the Dental Faculties

Professor Michael Escudier, Dean, Royal College of Surgeons of England was joined by the Deans
of the Dental Faculties for an interactive webinar on Tuesday 7 April. The session consisted of a
Q&A on how dental practice and dental surgery is coping with the COVID-19 pandemic.

If you’re looking for the latest COVID-19

updates, be sure and check our COVID-19
webpages where we’re collating as much
information as we can for our Fellows
and Members rcpsg.ac.uk/covid-19

Join our community today, add your voice and help us speak up for the profession. rcp.sg/join
 Enhanced CPD DO C
Lakshman Samaranayake
COVID-19 and Dentistry:
Perspectives of an Unfolding
Pandemic
The first of a continuing series of articles to keep the readers abreast of the current data on COVID-19 pandemic impacting dentistry
The dental health profession faces
a daunting new challenge with the
emergence of a novel viral disease,
Coronavirus Disease-19 (COVID-19), a
form of atypical pneumonia caused by
the Severe Acute Respiratory Syndrome
Coronavirus 2 (SARS-CoV-2), which may
also cause multi-system infections. At
the time of writing, this highly infectious
disease, now an unprecedented, worldwide
pandemic, has spread to more than 150
countries, infecting 5.7 million, with over
355,00 deaths. A significant proportion of
those affected are unsuspecting healthcare
workers, including dentists. The major
transmission mode of SARS-CoV2 appears
to be through droplet/aerosol spread and
related subsidiary modes, such as close
contact via virus-infested fomites.
The rapidly evolving pandemic
is highly likely to have an enormous
impact on the routine practice of dentistry,
as well as the behaviour of their close
support personnel, not only in terms of the
related morbidity and mortality, but also
the associated financial outlays entailing
Lakshman Samaranayake, DDS,
DSc, FRCPath, FRACDS, FDSRCS(Edin),
Immediate-past Dean, and Professor
Emeritus, Faculty of Dentistry, University
of Hong Kong; Visiting Professor,
University of Sharjah, UAE.
June 2020
practice management. Additionally, the
dental community has to be constantly
vigilant in the face of new facts and figures
that are incessantly emerging. COVID-19
Commentary is an attempt at providing
the reader with current perspectives of
the research findings that impact the
profession. Here are discussed in brief,
the different coronavirus infections, their
possible origins, and why new viral diseases
such as COVID-19 emerge.
More than a decade ago, in a
retrospective review on the Severe Acute
Respiratory Syndrome (SARS), when the
epicentre of infection was China and
Hong Kong, we opined that ‘… the dental
community cannot let down its guard, and
must be constantly aware of impending
infectious threats in various guises, as well as
recrudescence of disease, that may challenge
the current infection control regimen.’1
Unfortunately, with the pandemic of COVID-
19, this ominous statement has proven to
be true, as the coronavirus, which belongs
to the same family of viruses causing the
common cold, has mutated into a newer,
more infectious and a deadly form in the
guise of SARS-CoV-2 (Figure 1).
Coronavirus infections
New virus infections arise unceasingly,
always a few steps ahead of the combative
armamentarium which we humans are
unleashing upon them at the slightest hint
COVID-19Commentary
of their emergence. Such new infections
that have emerged during the last few
decades include, Ebola, Severe Acute
Respiratory Syndrome coronavirus (SARS-
CoV) and Middle East Respiratory Syndrome
coronavirus (MERS-CoV) infections, H1N1
infection, Zika Virus infection, and now
COVID-19.
According to an analysis by the
O*Net Bureau of Labor Statistics of the USA,
dentists are the professional group running
the highest risk of contracting an airborne
disease such as the COVID-19.2 Indeed,
the dental community is confronted with
this risk not only during the pandemic
period, but also once its critical acute
phase wanes, into the foreseeable future.
Alarmingly, there appears to be healthy
asymptomatic carriers of the SARS-CoV-2
in the community, and they may pose a
constant threat until the disease disappears.
Various reports indicate the community
asymptomatic carrier state ranging from
20% to, as high as 80%.3 One silver lining
in this dark cloud is the fact that other
coronavirus diseases, such as SARS and
MERS, disappeared spontaneously after the
epidemic, and it is feasible that COVID-19
may also naturally regress over a period
of time, due to waning viral infectivity on
repeated passage amongst humans.
Coronaviruses and their origins
Coronaviruses are enveloped RNA viruses
DentalUpdate 531
 COVID-19Commentary
Figure 1. SEM showing numerous SARS-CoV-2
viral particles (white spherical forms) budding
from the surface of an infected cell, after 24 hours
of laboratory culture. (Magnification x18,000).
(Image courtesy of Drs J Nicholls, K Tsia, K Lee,
Faculty of Medicine and the EM Unit, University of
Hong Kong).
distributed mainly among mammals and
birds, and cause respiratory, enteric, hepatic
and neurologic diseases. Six coronavirus
species are known to cause human disease.4
Four of them typically cause common cold
symptoms in healthy individuals, while
SARS-CoV and MERS-CoV sometimes cause
fatal illnesses (Table 1).
For a new strain of virus, such
as SARS-CoV-2, to emerge, two divergent
viruses must simultaneously infect an
intermediate host, whence the host acts as
a ‘blender’, as it were, of the two different
strains to create a brand new strain. In
the context of COVID-19, the current
genomic comparisons suggest that it is a
recombinant viral product between a bat
virus and another anonymous virus, in a
small Pangolin species. Nevertheless, this
hypothesis of the origin of SARS-CoV-2
remains to be verified.
Reasons for emergence of new
viral diseases
What are the reasons for the incessant
emergence of these diseases at almost a
constant pace over the millennia? Almost
two decades ago, an eminent committee
of the Institute of Medicine (IOM) in USA
performed a comprehensive evaluation of
why new diseases emerge and old diseases
re-emerge.5 In their subsequent seminal
report, they concluded the following
key reasons as the most likely for new
infections:
532 DentalUpdate
Year of Discovery Proper Name Synonym/s Disease
Unknown Human coronavirus Alphacoronavirus Human common
229E cold
Unknown Human coronavirus Betacoronavirus Human common
OC43 cold, infects cattle
2003 SARS coronavirus SARS-CoV1 or ‘SARS- Human respiratory
classic’ tract infections
2004 Human coronavirus HCoV-NL63, New- Human respiratory
NL63 -Haven coronavirus tract infections
2005 HKU1 Betacoronavirus Human respiratory
tract infections
2012 MERS-CoV Novel coronavirus Human respiratory
2012 and HCoV-EMC tract infections
2019 SARS-CoV2 COVID-19 virus Human COVID-19
(previously; 2019- -respiratory tract
nCoV or ‘novel (mainly) and multi
coronavirus 2019’) system infections
Table 1. Different types of coronaviruses causing human infections and the diseases they cause. Data
from various sources.
„ Societal events − economic impoverishment travel could transport people and infections
(especially in the developing world), war and from one continent to another within
civil conflicts, as well as mass population 24 hours. This, combined with the high
migration. infectivity of SARS-CoV-2, appear to be the
„ Healthcare – new medical devices, organ/ major reasons for the current pandemic. The
tissue transplantation, immunosuppression, latter qualities of the virus, and its stubborn
antibiotic abuse and contaminated blood and persistence, inform the infection control
blood products. practices in dentistry, as well the clinical
„ Human behaviour – increasing sexual routine of our profession. Hence, the focus of
promiscuity, injectable drug abuse. the next article will be SARS-CoV-2 spread, its
„ Environmental changes – deforestation, infectivity and survival in air, and on animate
drought, floods and global warming. and inanimate surfaces − a topic that is very
„ Microbial adaptation – emergence of new close to the heart of dental practice.
species from the wild (eg HIV, Ebola), changes
in virulence and toxin production and
development of drug resistance.
Key References
The IOM report was impactful 1. Samaranayake LP, Peiris JSM. Severe acute
in highlighting, for the first time, the critical respiratory syndrome and dentistry: a retrospective
importance of keeping an eye on emerging view. J Am Dent Assoc 2004; 135: 1292−1302.
infectious diseases. Indeed, this phenomenon 2. Lazaro G. The Workers Who Face the Greatest
itself has been described since ancient Coronavirus Risk. In: New York Times. New York, 2020.
times, and the currently applied concepts of 3. Ing AJ, Cocks C, Green JP. COVID-19: in the footsteps
quarantine and social distancing, to prevent of Ernest Shackleton. Thorax 2020.
further spread of the disease, has also been 4. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao
in existence from such times. To some extent, X, Huang B, Shi W, Lu R et al. A novel coronavirus
the containment of the viral diseases in from patients with pneumonia in China, 2019. N
historic times could be attributed to the Engl J Med 2020; 382: 727−733.
virtual non-existence of transcontinental 5. Lederberg J, Shope RE, Oaks SC, Jr (eds). Emerging
travel then. Hence it is not surprising that Infections: Microbial Threats to Health in the United
pandemics arise in the contemporaneous, States. Washington (DC): National Academies Press
highly connected world today, where air (US), 1992.
June 2020
Supporting our members
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 Letters
Letters to the Editor
COVID-19 crisis: the
perspective of a Dental
Foundation Trainee
We would like to share our reflections on
the current, unprecedented COVID-19
crisis from the perspective of a Dental
Foundation Trainee (DFT).
The crisis we find ourselves
in is one we would never have predicted
and has, without doubt, taken dental
professionals by surprise, in particular for
those in their DFT year.
As it stands already, the leap
from dental school to the real world of
dentistry is daunting to say the least. The
foundation year offers a bridge in the
form of a structured learning programme
and mentorship to help clinicians prepare
for their career ahead. The unplanned
disruption to this year has created worry
and uncertainty for DFTs, with the clinical
training impacted. Many DFTs are moving
to potentially more demanding associate
jobs or Dental Core Training (DCT) posts in
just three months.
Another concern of many DFTs
has been the prospect of redeployment
to help ease the workload for the National
Health Service (NHS). It is admirable to see
the keenness of so many of our colleagues,
willing and ready to volunteer, where
needed, to help in this global pandemic.
Despite the difficulties, we do find ourselves
intrigued and impressed by how our
profession and fellow colleagues, whom are
responsible for our training, have been able
to adapt over the past few months.
Our use of technology has
been interesting to observe. Despite
disruption caused by the crisis, our pre-
planned weekly study day seminars and
hands on workshops have still continued.
Lecturers and clinicians have adapted
their resources and skilfully utilized online
platforms to ensure that we can still
learn and benefit whilst respecting social
distancing guidelines. We have received
a combination of live online webinars,
webchat meetings and video conferencing,
pre-recorded lecture presentations, as well
as distant learning packages which consist
of an array of relevant resources, videos and
presentations relating to our study topic.
534 DentalUpdate
We feel credit must be given
in particular to those who have thought
outside of the box to ensure that their
teaching is still delivered in an engaging
way. Our ‘posterior restorations’ study
day was supplemented with a tooth
morphology sketching exercise, where we
had to sketch occlusal views of posterior
teeth and submit our entries online, to
compare with fellow trainees across the
Midlands (Figure 1). Another useful idea
that has been suggested to supplement
our minor oral surgery module, is to post
a disposable suture kit to DFTs so that we
may practice our suturing skills remotely.
In addition to this, there
has been a change in the national
recruitment process for DCT posts
following our DFT year. With the
assistance of Pearson Vue, Situational
Judgment Test (SJT) examinations shall
commence in June. The exam takes
a format like never before, given the
current situation, being online rather than
in the traditional examination centres. To Figure 1. Distant learning exercise example by
DFT Uzair Janjua. Credit to Lewis Mackenzie (BDS,
ensure appropriate invigilation is carried
GDP, Clinical Lecturer, University of Birmingham)
out, examinees will be required to turn on
for setting the exercise
their webcam and microphone.
There has been
overwhelming support from a number of
leading dental education organizations, have gathered two pieces of wisdom that we
such as Dentinal Tubules, Dental Juice feel are of benefit to us. Firstly, it is vital to try
and Dental Update, who have been very our best to adopt a growth mindset in times
quick to support foundation Dentists such as this, by looking for solutions to the
by generously providing free access challenges we face. Out of the box, or lateral
to their online learning material. The
thinking are key. Secondly, the importance of
deanery has been working hard with
being able to take a moment to appreciate
many of these organizations to make
and express gratitude. We must appreciate,
this possible, which we are very grateful
and be grateful for, the committed work
for. It is noteworthy that, with the
effort that many are contributing to help us
increasing number of links, resources
make the most of this difficult situation. On
and webinars being posted online and
on social media, it can be easy for one to that note, we’d like to extend our thanks to
fall into the trap of information overload! all those who are continuing to help make
It is probably wise to sift diligently the best of an unprecedented situation, both
through the resources and plan one’s within the DFT sphere and the profession as
time accordingly. We imagine this to a whole.
be a common feeling amongst many Uzair Janjua (DFT), University of
professionals. Manchester, GDP in Birmingham
This is an exceptional time, Gurpreet Bahia (DFT), University of
and it has taken us all by surprise. On Manchester, GDP in Wolverhampton
reflection, observing how this has Naeem Ashfaq (DFT), University of
affected our Foundation Training, we Manchester, GDP in Yorkshire
June 2020
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TechniqueTips
Technique Tips
Resin Infiltration Technique on Enamel Opacities and White
Spot Lesions (WSLs)
Discoloration of enamel commonly occurs
due to developmental defects, fluorosis
and post-orthodontic treatment. Enamel
discoloration can be an increasing aesthetic
concern for patients. Conventional
treatments include tailored oral hygiene,
fluoride application and remineralizing
agents in the first instance. Following this,
more invasive options may be considered,
including microabrasion and conventional
direct and indirect restorations. The
technique described shows the use of
a resin infiltration system to improve
aesthetics of white spot lesions to mask the
appearance, prevent lesion progression and
delay the restorative cycle.
Discolorations and white lesions
in anterior teeth present as a management
challenge, particularly in the younger
patient. The use of destructive techniques
creates a lifelong treatment burden
and initiates the restorative cycle. Vital
bleaching has been used with great success
for the brown lesions seen in molar incisor
hypomineralization (MIH) and fluorosis.
The white lesions associated with these
conditions and orthodontic decalcification,
have historically required more invasive
treatment. With the introduction of smooth
surface resin infiltration systems, there is
now a minimally invasive and pain-free
approach that is a successful adjunct to the
management of these lesions. Currently,
only Icon (DMG, Hamburg, Germany) is on
the market in the UK.
White spot lesions (WSLs)
are localized areas of sub-surface
demineralization under an intact enamel
layer. This demineralization produces
porosities which cause a change in the
refractive index of the enamel.1 Risk factors
can include poor oral hygiene, diet, salivary
hypofunction, fixed orthodontic appliances
and enamel defects.
Sadia Khan, BDS, MFDS RCPSG and Khawer Ayub, BDS, MFDS RCPSG, Dental Core Trainee, Birmingham Dental Hospital, Birmingham
Healthcare NHS Foundation Trust, Birmingham, UK.
536 DentalUpdate
White-spot lesions (WSLs) are
the main iatrogenic effect of orthodontic
therapy with fixed appliances.2 Nearly
one-third of orthodontic patients develop
at least one WSL as a result of poor oral
hygiene and the retention of plaque
around orthodontic appliances.3 The
prevalence of MIH in European countries
ranges from 3.6% to 25%.4 Further, a
Cochrane Review in 2015 highlighted the
prevalence of dental fluorosis of aesthetic
concern was measured at 8% where there
was 0.1 ppm of fluoride in the water
supply, 12% at 0.7 ppm and 15% at 1
ppm.5
Most commonly, the first Figure 1. Case showing generalized enamel
opacities UR5−UL5 and treatment using resin
and most important conservative
infiltrate.
management approach is through
tailored oral hygiene instructions, which
in turn may remineralize the disturbed
surface. Topical fluoride application
may be beneficial, depending on the
initial cause of the WSL,6 and also use
of casein phosphopeptide amorphous
calcium phosphate pastes. These
approaches are, of course, dependent
on patient compliance. More invasive Figure 2. Pre-op showing WSL on case showing
treatment modalities may include enamel localized enamel lesion on incisal edges UR5−
microabrasion or conventional direct and UL5. The teeth have been prepared and isolated
indirect restorations.7 under rubber dam.
Resin infiltration can be
considered an alternative approach to
prevent further lesion progression and
improve the appearance of white spot natural enamel. This helps to improve the
appearance of the WSL.8−12
lesions prior to considering invasive
treatment. This can be both on localized
enamel opacities, but also generalized Resin infiltration technique
opacities (Figure 1). The aim of this This technique tip describes the use of
method of treatment is to occlude the Icon (DMG, Hamburg, Germany) for the
porosities with low viscosity, light-cured treatment of white spot lesions on the
resin which is achieved through capillary buccal surface of anterior teeth via resin
action. The resin has a similar refractive infiltration.
index to that of enamel and, as the resin The affected teeth and any
fills the porosities, its appearance mimics adjacent should be cleaned prior to any
June 2020

treatment. This can simply be done with a
prophy brush and paste (Figure 2).
The teeth to be treated should
be isolated with conventional rubber dam
or liquid rubber dam. A bite prop or optra-
gate may be helpful for some of these
patients, particularly paediatric patients.
The lesions and surrounding
enamel are treated with a generous
application of 15% hydrochloric acid
gel (Icon-Etch) and allowed to sit for 2
minutes. The gel can be gently agitated
using a microbrush if necessary and
washed away with water for 30 seconds.
The aim of this stage is to remove
superficial discoloration and the higher
mineralized layer (Figures 3 and 4).
Next, a generous application
of ethanol (Icon-Dry) is applied to the
lesions and allowed to sit for 30 seconds.
If the WSL is no longer visible, then it can
be reasonable to assume that the lesion
will resolve following the application of
the resin.
Following steps 3 and 4, the
white appearance of the lesions should
fade. If the lesion is still visible, then steps
3 and 4 should be repeated until the lesion
diminishes. If more than 4 repetitions
are required, it may be that no further
fading can be achieved and that another
approach may have to be considered. It
may be appropriate to continue with the
suboptimal result and then revisit for what
may be a less invasive composite than if a
destructive approach had been taken from
the start.
The methacrylate-based
resin is infiltrated into the lesions (Icon-
Infiltrate) for 3 minutes, excess can be
removed and light cured for 40 seconds.
This step can be repeated to reduce
enamel porosity (Figure 5).
The rubber dam should be
removed, and the surfaces of the teeth can
be polished using polishing cups, wheels
or discs, according to preference
(Figure 6).
Conclusion
Resin infiltration is an alternative method
for management of WSL, without taking
an invasive approach. This treatment
is particularly useful in young adults
who have enamel opacities and defects.
Given the increasing trend and focus
June 2020
Figure 3. Application of acid etch to the buccal
surface of UR3 to UL4.
Figure 4. Teeth washed and dried following
application of acid etch.
Figure 5. Appearance of teeth following
application of resin infiltrate.
on aesthetics, younger adults are more
affected. Further, this gives the patients
a minimally invasive treatment and
allows for recovery of the natural tooth
appearance.
Although straightforward,
the majority of general practitioners
do not offer this service. However, this
is a treatment modality used in many
specialist NHS paediatric and some
restorative units; therefore, it is worth
considering referral for these patients to a
setting that is able to offer this treatment.
In this regard, it is more important to try
and avoid and delay the beginning of
an invasive restorative cycle, particularly
where there are other, more predictable
options available.
Acknowledgements
The authors would like to thank Dr William
Lau and Mr Daniel Sisson for their support.
TechniqueTips
Figure 6. Post-op appearance showing resolution
of WSL.
Conflict of Interests
The authors have no conflict of interest to
declare with this technique tip.
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2. Zachrisson BU, Zachrisson S. Caries incidence and
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3. Lovrov S, Hertrich K, Hirschfelder U. Enamel
demineralization during fixed orthodontic treatment
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Arch Paediatr Dent 2010; 11: 59−64.
5. Iheozor-Ejiofor Z, Worthington HV, Walsh T et al.
Water fluoridation for the prevention of dental
caries. Cochrane Database Syst Revs 2015; 6.
6. Cury JA, Tenuta LM. Enamel remineralization:
controlling the caries disease or treating early caries
lesions? Braz Oral Res 2009; 23: 23−30.
7. Ardu S, Castioni NV, Benbachir-Hassani N et al.
Minimally invasive treatment of white spot enamel
lesions. Quintessence Int 2007; 38: 633−636.
8. Paris S, Meyer-Lueckel H. Inhibition of caries
progression by resin infiltration in situ. Caries Res
2010; 44: 47−54.
9. Paris S, Meyer-Lueckel H, Kielbassa AM. Resin
infiltration of natural caries lesions. J Dent Res 2007;
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10. Mueller J, Meyer-Lueckel H, Paris S et al. Inhibition
of lesion progression by the penetration of resins in
vitro: influence of the application procedure. Oper
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11. Meyer-Lueckel H, Paris S. Improved resin infiltration
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DentalUpdate 537
 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 answer the questions online at www.dental-update.co.uk.

Q1 MCNEE 47: 480–484 Q6 DARCY ET AL 47: 500–509

Which of the following is a recognized portal of entry for Regarding disease of the maxillary sinus in relation to
SARS-CoV-2 viral transmission?: endodontics:
A. via ACE-2 receptors. A. CBCT should be regarded as a first line radiographic
B. via ACE-1 receptors. investigation for endodontic diagnosis.
C. Thermoreceptors. B. Condensing osteitis is seen frequently in the posterior maxilla.
D. Chemoreceptors. C. When the maxillary sinus is in close proximity to the root
apices, it offers little or no resistance to endodontic extrusions.
D. Inadvertent extrusion of hypochlorite into the maxillary sinus
airspace always causes severe pain.
Q2 MCNEE 47: 480–484

Which of the following is not seen as a key feature of a

Standard Operating Procedure?: Q7 DARCY ET AL 47: 500–509
A. In-surgery protocols. The amount of sero-mucinous secretions produced per day
B. Patient evaluation. by the paranasal sinuses and nasal cavity combined is:
C. Patient post-visit triage. A. 1.0−1.5 litres.
D. Hand hygiene. B. 1.5−2.0 litres.
C. 3.0−3.5 litres.
D. 10 litres.
Q3 BURKE, MACKENZIE AND SANDS 47: 485–493:
Regarding repair of defective restorations:
A. These always shorten the life of the restored tooth, Q8 PARKER AND CHIA 47: 515–526
compared with replacement restorations.
Regarding telemedicine clinics:
B. Amalgam is always the preferred material for these.
A. These always increase costs.
C. Materials which can adhere to tooth substance are not
B. Efficiency of running a clinic with these is always severely
appropriate for these.
decreased.
D. Numerous clinical studies have shown that restoration
C. Clinicians and patients communicate by video in the same way as
repairs in permanent teeth are able to increase the lifetime
an in-person consultation.
of restorations.
D. These are disliked intensely by patients and clinicians.

Q4 BAILEY AND WHITWORTH 47: 494–499 Q9 DOUGHTY AND MOSHKUN 47: 527–528
Regarding Cracked Tooth Syndrome (CTS): Regarding Foundation dentists and the COVID-19 pandemic:
A. The presence of an enamel crack always means that the A. Foundation dentists will miss out on 2 days of clinical
underlying dentine is cracked. experience.
B. Diagnosis is always simple. B. The targets set for trainees will need to be revised.
C. Commonly, there is a history of pain on chewing. C. Dental core training interviews are being held as usual.
D. Transillumination is of no help in diagnosis. D. COVID-19 has not affected specialty training.

Q5 BAILEY AND WHITWORTH 47: 494–499 Q10 KHAN AND AYUB 47: 536–537
Regarding the epidemiology of CTS: Results of a Cochrane review have indicated that, when there was
A. CTS is most commonly seen in maxillary molars. 1 ppm of fluoride in the water supply, dental fluorosis of aesthetic
B. Non-functional cusps more commonly affected than functional concern to patients was:
cusps. A. Zero.
C. Patients over 85 years of age are the most commonly affected age B. 8%.
group. C. 15%.
D. CTS is most commonly seen in mandibular molars. D. 30%.

CPD in Dental Update in partnership with DEADLINE FOR SUBMISSION: 14 SEPTEMBER 2020

10 QUESTIONS REPRESENT 4 HOURS OF CPD

ANSWERS FOR APRIL CPD ON PAGE 478

538 DentalUpdate June 2020

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