DentalUpdate

October 2020 . Volume 47 . Number 9

„ Restorative Dentistry: Dens Evaginatus – ‘Addition Beats Subtraction’

„ Oral Surgery: Coronectomy: not just for Wisdom Teeth

„ Radiology: Update on Ionizing Radiation Regulations 2017 (IRR 2017) and Ionizing Radiation
Medical Exposure Regulations 2018 (IRMER 2018) − Relevance to the Dental Team

 


 
  


  


 
  

  
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701 COMMENT
Begonias
FJ Trevor Burke
703 GUEST EDITORIAL
Dentistry and COVID-19 – Time to Rethink
our Prescribing Patterns?
RL Caplin
706 RESTORATIVE DENTISTRY
Dens Evaginatus – ‘Addition Beats
Subtraction’
K Ayub, S Khan and M Kelleher
CPD Aims, Objectives and Learning
Outcomes: To explain the problems of dens
evaginatus and of modern management
strategies.
Enhanced CPD DO C
714 ORAL SURGERY
Coronectomy: not just for Wisdom Teeth
B Owen, G Oliver, L Macey-Dare and G Knepil
CPD Aims, Objectives and Learning
Outcomes: To present a novel case of
coronectomy to an infra-occluded lower left
first molar coronectomy to avoid inferior
alveolar nerve damage, and facilitate
orthodontic treatment.
Enhanced CPD DO C
719 RESTORATIVE DENTISTRY
A Combined Digital-Conventional Workflow
to Fabricate a Removeable Partial Denture
for a Patient with a Severe Gag Reflex
RB O'Leary and AL Gunderman
CPD in Dental Update in partnership with
EDITORIAL DIRECTOR
FJ Trevor Burke
Professor of Dental Primary Care,
University of Birmingham School of
Dentistry
EXECUTIVE EDITOR
Angela Stroud
EDITORIAL BOARD
Avijit Banerjee
Professor of Cariology and Operative
Dentistry
Faculty of Dentistry, Oral & Craniofacial
Sciences, King’s College London
Subir Banerji
Programme Director MSc in Aesthetic
Dentistry
Faculty of Dentistry, Oral & Craniofacial
Sciences, King’s College London
Steve Bonsor (c/o RCPSG)
The Dental Practice
21 Rubislaw Terrace
Aberdeen AB10 1XE
Andrew Chandrapal
GDP, Bourne End Dental
October 2020
CPD Aims, Objectives and Learning
Outcomes: To understand the uses,
advantages and limitations of digital
workflows in fabricating removable partial
dentures.
Enhanced CPD DO C
729 GENERAL DENTISTRY/PAEDIATRIC DENTISTRY/
ORTHODONTICS
Supernumerary Teeth: an Overview for the
General Dental Practitioner
MJ Meade
CPD Aims, Objectives and Learning
Outcomes: To highlight how timely
diagnosis and appropriate management may
reduce potential problems associated with
supernumerary teeth.
Enhanced CPD DO C
739 ORAL SURGERY
Rhinosinusitis Update
C Hopkins
CPD Aims, Objectives and Learning
Outcomes: To review current management
strategies of rhinosinusitis.
Enhanced CPD DO C
747 ENDODONTICS
Controversies in Endodontic Access Cavity
Design: a Literature Review
M Maqbool, TY Noorani, JA Asif, SD Makandar
and N Jamayet
CPD Aims, Objectives and Learning
Outcomes: To compare and contrast the
Bourne End, Bucks
Len D'Cruz
GDP, Woodford Dental Care, Woodford Green,
Essex
Chris Deery
Professor of Paediatric Dentistry, School of
Clinical Dentistry, Sheffield S10 2TA
Ian Dunn
Specialist Periodontist
Rose Lane Dental Practice
Liverpool L18 8AG
Ken Hemmings
Consultant
Eastman Dental Hospital, London WC1X 8LD
Edwina Kidd
Emerita Board Member
c/o George Warman Publications
Unit 2, Riverview Business Park,
Walnut Tree Close, Guildford GU1 4UX
Mike Lewis
Professor of Oral Medicine
School of Dentistry, Cardiff University
Cardiff CF14 4XY
INSIDE THIS ISSUE
different types of endodontic access cavity
designs based on the current available
evidence.
Enhanced CPD DO C
755 RADIOLOGY
Update on Ionizing Radiation Regulations
2017 (IRR 2017) and Ionizing Radiation Medical
Exposure Regulations 2018 (IRMER 2018) −
Relevance to the Dental Team
KK Grewal and N Heath
CPD Aims, Objectives and Learning
Outcomes: To understand the new revisions
to IRR and IRMER guidance and appreciate its
implications to dental practice.
Enhanced CPD DO C
761 COVID-19 COMMENTARY
Coronavirus Disease 2019 (COVID-19)
Diagnostics: a Primer
L Samaranayake, N Kinariwala and RAPM Perera
767 LETTERS TO THE EDITOR
769 BREAKING NEWS: COVID-19 AND DENTISTRY
L Samaranayake
770 I LEARNT ABOUT DENTISTRY FROM THAT
771 TECHNIQUE TIPS
The Role of Fibre-reinforced Composite Posts
in Children
AS Dhadwal, SJ McKaig and A Casaus
774 CPD QUESTIONS
Louis Mackenzie
GDP and Clinical Lecturer
University of Birmingham School of Dentistry
and King's College London
Tara Renton
Professor of Oral Surgery, King's College London Dental
Institute
David Ricketts
Professor of Cariology and Conservative Dentistry,
Dundee Dental Hospital
Jonathan Sandler
Professor and Consultant Orthodontist, Chesterfield and
North Derbyshire Royal Hospital
Damien Walmsley
Professor of Restorative Dentistry, University of
Birmingham School of Dentistry
Cover Picture: A Grey Seal pup playfully biting
at the camera dome. Location - Farne Islands, UK.
Highly Commended, British Wildlife Photography
Awards 2019 (Courtesy of Nicholas More,
Photographer, Exmouth Devon).
DentalUpdate
 Don’t forget to renew your
patient’s Duraphat prescription

76% of patients
prefer the taste of
Duraphat 5000 ppm #,1

Effective prevention for patients at increased caries risk*

• 5000 ppm Fluoride Toothpaste prevents cavities by arresting and reversing primary
root and early fissure caries lesions2-5
Prescribe Duraphat 5000 ppm Fluoride Toothpaste and support patient adherence:
• 89% of consumers agree that taste is an important
factor when using a toothpaste**
• Prescribing a product with a preferred taste may be
important to enhance patient adherence 1.1% Sodium Fluoride

Be confident prescribing Colgate Duraphat , the brand your patients know and trust† ® ®

# Compared to generic 5000 ppm high fluoride toothpaste. * Patients ≥ 16 years at increased caries risk. ** Colgate UK Consumer Survey on Cosmetic Toothpaste. 504 participants. Feb 2020. † YouGov Omnibus for Colgate® UK, data on file
June 2015. Claim applies only to the Colgate® brand.
References: 1. Data on file. Preference Survey. January 2020 (n=82). 2. Baysan A et al. Caries Res 2001;35:41-46. 3. Schirrmeister JF et al. Am J Dent 2007;20. 212-216. 4. Ekstrand et al. Geodent 2008;25:67-75. 5. Ekstrand et al. Caries Res
2013;47:391–8.
Colgate® Duraphat® 5000 ppm Fluoride Toothpaste - Name of the medicinal product: Duraphat® 5000 ppm Fluoride Toothpaste. Active ingredient: Sodium Fluoride 1.1%w/w (5000ppm F-). 1g of toothpaste contains 5mg fluoride (as sodium
fluoride), corresponding to 5000ppm fluoride. Indications: For the prevention of dental caries in adolescents and adults 16 years of age and over, particularly amongst patients at risk from multiple caries (coronal and/or root caries). Dosage
and administration: Brush carefully on a daily basis applying a 2cm ribbon onto the toothbrush for each brushing. 3 times daily, after each meal. Contraindications: This medicinal product must not be used in cases of hypersensitivity to the
active substance or to any of the excipients. Special warnings and precautions for use: An increased number of potential fluoride sources may lead to fluorosis. Before using fluoride medicines such as Duraphat, an assessment of overall fluoride
intake (i.e. drinking water, fluoridated salt, other fluoride medicines - tablets, drops, gum or toothpaste) should be done. Fluoride tablets, drops, chewing gum, gels or varnishes and fluoridated water or salt should be avoided during use of
Duraphat Toothpaste. When carrying out overall calculations of the recommended fluoride ion intake, which is 0.05mg/kg per day from all sources, not exceeding 1mg per day, allowance must be made for possible ingestion of toothpaste
(each tube of Duraphat 500mg/100g Toothpaste contains 255mg of fluoride ions). This product contains Sodium Benzoate. Sodium Benzoate is a mild irritant to the skin, eyes and mucous membrane. Undesirable effects: Gastrointestinal
disorders: Frequency not known (cannot be estimated from the available data): Burning oral sensation. Immune system disorders: Rare (≥1/10,000 to <1/1,000): Hypersensitivity reactions. Legal classification: POM. Marketing authorisation
number: PL00049/0050. Marketing authorisation holder: Colgate-Palmolive (U.K.) Ltd. Guildford Business Park, Midleton Road, Guildford, Surrey, GU2 8JZ. Recommended retail price: £7.99 (51g tube). Date of revision of text: February 2015.

www.colgateprofessional.co.uk www.colgatetalks.com
 Comment

Authors' Information
Dental Update invites submission of articles
pertinent to general dental practice. Articles should
be well-written, authoritative and fully illustrated.
Manuscripts should be prepared following the
Guidelines for Authors published in the April
2015 issue (additional copies are available from the
Editor on request). Authors are advised to submit Trevor Burke
a synopsis before writing an article. The opinions
expressed in this publication are those of the
authors and are not necessarily those of the editorial
staff or the members of the Editorial Board. The
journal is listed in Index to Dental Literature, Current
Begonias
Opinion in Dentistry & other databases.
Subscription Information In the background of the coronavirus pandemic, which puts little other than life and death
Full UK £137 | Digital Subscription £110 into perspective, it is not easy to see beyond the current crisis. Dentists in the UK, and
Retired GDP £93 many worldwide, are facing financial and clinical difficulties which could never have been
Student UK Full £51 | Foundation Year £95 foreseen. In that regard, dentists in much of the rest of the world seem to be managing to
11 issues per year run their dental surgeries without the untested demands that we see in the UK.
Single copies £24 (NON UK £35) In recent issues, Dental Update has brought readers many articles on COVID-19
Subscriptions cannot be refunded. and its implications for the dental team and their patients. However, there will be a time
For all changes of address and subscription when dentists and their patients will again worry about how long the restorations placed
enquiries please contact: in their teeth will last, rather than worrying about the implications of COVID-19 on their
treatment. Dental Update will therefore plan largely to return to its raison d’etre of bringing
Dental Update Subscriptions
high quality, well-illustrated articles of relevance to general dentistry and publishing
Mark Allen Group, Unit A 1–5, Dinton Business Park, fewer articles solely related to COVID-19, albeit with the rider that, should we receive
Catherine Ford Road, Dinton, Salisbury SP3 5HZ an important COVID-related paper, it will be published, and we will continue to publish
FREEPHONE: 0800 137201 Professor Samaranayake’s most useful COVID-19 Commentary for as long as he considers it
Main telephone (inc. overseas): 01722 716997 relevant.
E: subscriptions@markallengroup.com Is it too soon to discuss whether anything good has come from the pandemic?
Managing Director: Stuart Thompson
Perhaps, but there are some initiatives which are worthy of mention, namely:
„ British Airways’ new disembarkation by row number is one, as it removes the scrum
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October 2020 DentalUpdate 701

 Comment
which occurred when the seat belt sign
was turned off.
„ Many former commuters will be
more relaxed while working from
home, rather than standing on a
crowded train for hours. In this
regard, European data suggest that
three-quarters of jobs in the highest
paid quartile can be done remotely,
compared with only 3% in the lowest
quartile. Indeed, is working from home
a privilege confined to the well paid?1 It
is something that dentists will never be
able to do!
„ Bob Dylan released, on his YouTube
channel on 27 March 2020, his 17
minute epic ‘Murder Most Foul’
(which addresses the assassination
of President John F Kennedy in 1963)
as a gift to his fans. A variety of
commentators have seen the release
and content of the song directly
related to the COVID-19 pandemic.
Rolling Stone deputy editor2 praised the
release, stating that the song ‘is really
about the ways that music can comfort
us in times of national trauma’.
In clinical matters, the
following are among the initiatives
worthy of mention:
„ Remote diagnosis, as discussed in
recent issues of Dental Update, has
reduced travelling for patients.
„ Minimally invasive dentistry is a
certain winner, as clinicians increasingly
search for ways of treating their
patients without the need for an
Aerosol Generating Procedure.
„ Prevention is more important now
Farewell to Angela Stroud
Angela Stroud, Executive Editor of
Dental Update, has been central to
the production of every issue for
over 20 years (which amounts to well
over 200 issues), plus every issue of
Orthodontic Update! It is she who has
checked the grammar, spelling and
style of each accepted article (known
in the business as subbing), as well as
receiving submitted articles, sending
them to me and co-ordinating the
peer review of those who I have
decided should be put into that
process. This is an enormous amount
of work, which has resulted in the
attractive journal that subscribers
receive. Her attention to detail is
superb: this was evident in a recent
702 DentalUpdate
than ever. restrictions are increasing in the UK and,
I like growing flowers. At the more stringently, in Birmingham. These
beginning of May each year, I plant begonia are necessary evils when we might want
tubers. This year was not an exception, and to draw close to each other. The future
the blooms have been as good as ever! has always been uncertain, but is more
Perhaps, recent events should prompt us uncertain now. Nevertheless, there remains
to remember the simple pleasures that hope that we will begin to adapt to the
COVID-19 cannot remove and draw comfort new normal − for as long as it takes.
from them, such as presented here. For the
begonias (illustrated here and overleaf ), References
it would be the end of everything if they 1. O’Connor S. Welcome to the digital
ceased blooming. John Lennon is widely gig economy. I News, 17 September
attributed to be the author of the comment 2020.
‘Everything will be okay in the end. If it’s 2. Vosick-Levinson S. https://
not okay, it’s not the end’. In that regard, en.wikipedia.org/wiki/Murder_
the new normal is not normal, and, as Most_Foul_(song) Rolling Stone, 27
Cynthia Gorney3 put it – ‘In perilous times, March 2020.
our deepest human impulse is to draw 3. Gorney C. We are not made for this
close to each other − the very thing we’ve new normal. National Geographic July
been told not to do’. As I write, lockdown 2020; 238: 21−23.
issue when she spotted that there were
two references in the bibliography of
an article, but no reference to them in
the text!
It is therefore with sadness
that I report that she plans to retire
after this issue. I, and all members of
the Editorial Board, and the team at
Guildford, wish her a long and happy
retirement. At last, she will have time
to enjoy exploring nature and perhaps
identifying new bird species which
she has not previously encountered.
Angela, your hard work over the years
is much appreciated by me, and also,
I am sure, by the readers of Dental
Update.
FJ Trevor Burke
Editorial Director
October 2020
 Enhanced CPD DO C
Robert L Caplin
Dentistry and COVID-19 – Time to
Rethink our Prescribing Patterns?
Dent Update 2020; 47: 703–704
There is no doubt that COVID-19 has
forced changes in many aspects of working
practices and none more so than in
clinical dentistry. I would like to offer my
congratulations to the Dental Update team
for providing articles that are relevant to the
‘new ways of working’.
Of particular interest is the
dentistry that we, as practitioners, can
provide without recourse to the turbine
and aerosol generating procedures (AGPs),
and I believe that COVID-19 obliges us to
reconsider what our aims of treatment are
with respect to restorative dentistry.
The restorative options open
to a practitioner are many and varied and
yet there is a fundamental question that a
practitioner needs to ask when considering
the holistic approach to oral health – ‘What
am I trying to achieve in restoring this
tooth?’1
It is known that there will be
much variation between dentists as to how
best to treat a tooth and this variation will
essentially stem from the practitioner’s view
as to what is required to achieve longevity
for both the tooth and the restoration.
We, as dentists, are being asked to predict
the future. I suspect that there is an
overwhelming urge for dentists to recreate
the original shape of the tooth in question
Robert L Caplin, Senior Teaching Fellow
and General Dental Practitioner, Faculty
of Dentistry and Oral and Craniofacial
Sciences, Guy’s Hospital, London SE1
9RT, UK. (email: bob@rlcaplin.com)
October 2020
GuestEditorial
without giving consideration to the
various factors that may be unique
to that patient and that tooth. It is
necessary to put the W into the Hole!
Not to look at the HOLE in the tooth
but the WHOLE patient. Ideally, we
would wish to restore Form, Function
and Features, but in the real world
this is not always possible, and so the
question needs to be asked – ‘What
do I do here?’2
The following example
illustrates the wide variety of
responses to a clinical situation. The
lower left first molar in Figure 1 had
classical cracked tooth syndrome Figure 1. Lower left first molar with classical
over a period of two years. Eventually, cracked tooth syndrome.
the mesio-lingual cusp fractured
away and the symptoms subsided.
The patient attended for a routine Composite/Gold/Ceramic;
examination three months after this
6. Remove all of the amalgam and
event, not seeking help or advice at
replace – direct restoration – Composite;
the time because the tooth was not
7. Remove all of the amalgam and
causing any problems. The remaining
replace – indirect restoration –
tooth was intact, vital and without
Composite/Gold/Ceramic;
any visible fracture lines. What to
8. Remove all of the amalgam and have
do about the missing cusp? May I
cuspal coverage – direct restoration –
suggest the following options:
Composite;
1. Nothing;
9. Remove all of the amalgam and have
2. Cover the exposed dentine with a
cuspal coverage – indirect restoration –
thin layer of GIC;
Gold/Ceramic/Metal Ceramic;
3. Build up the cusp − direct
restoration – GIC/Composite/ 10. Remove all of the amalgam and have
Amalgam; full coverage – indirect restoration –
Gold/Ceramic/Metal Ceramic.
4. Remove some of the amalgam and
There is a wide spectrum
replace – direct restoration – GIC/
Composite/Amalgam; here from non-invasive (non-AGP) to
5. Remove some of the amalgam considerable tooth tissue removal in the
and replace – indirect restoration – provision of a crown or an onlay (AGP).
DentalUpdate 703
GuestEditorial

How are we going to choose? The 3. How much additional tooth tissue procedures has given us the opportunity
risks and benefits of all the treatment will need to be removed in order to to reflect on our clinical decision-making
options should be discussed with make the tooth theoretically ‘stronger’ and to reconsider: what are the aims of
the patient3 and the acronym BRAN with cuspal coverage?; treatment? The answer has to be what is
is a useful aide memoire: B – Benefit; 4. Whatever restorative option is in the patient’s and the dental team's best
R – Risk; A – Alternative; N – Nothing. selected, how easy will it be to manage interest; now that is something to think
We should be considering this for the situation should the restoration about!
every treatment we propose. What fail?
is likely to happen if we don’t do Management of the biofilm
References
anything? As some of these options is the essence of successful treatment.
will best be performed with high- A restoration shaped to allow access 1. Glick M, Williams DM, Kleinman DV,
speed handpieces and hence aerosol to all areas for the removal of plaque Vujicic M, Watt RG, Weyant RJ. A new
generation, it may be that COVID-19 will enable the patient to maintain definition for oral health developed
can help concentrate our minds and a healthy tooth; no plaque equals by the FDI World Dental Federation
perhaps lean us towards the less (non- no caries or periodontal disease. opens the door to a universal
AGPs) rather than the more invasive Therefore, does a tooth like this need definition of oral health. JADA
possibilities. to be restored to form and function 2016; 147: 915−917. :https://doi.
In considering the decision, and at what price (in terms of tooth org/10.1016/j.adaj.2016.10.001
I would like to pose four questions: tissue and financial cost) if the patient 2. Caplin RL. Grey Areas in Restorative
1. How much of the patient’s chewing is comfortable? Does it matter if our Dentistry − Don’t Believe Everything You
function has been compromised by the direct restoration ‘fails’ (what does that Think. J and R Publishing, 2015: p67.
loss of one cusp?; mean?) in a few years? A ‘patch up’ can 3. General Dental Council. Standards
2. If the missing cusp is restored, will it easily be replaced. for the Dental Team. London: General
be brought into occlusion or will it be Perhaps COVID-19 and the Dental Council, 2012 (www.gdc-uk.
kept out of occlusion?; attendant worry of aerosol generating org).

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704 DentalUpdate October 2020
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 RestorativeDentistry Enhanced CPD DO C

Khawer Ayub

Sadia Khan and Martin Kelleher

Dens Evaginatus − ‘Addition Beats

Subtraction’
Abstract: This case describes the presentation of dens evaginatus on a maxillary central incisor in an 8-year-old Caucasian male, its
subsequent monitoring and later management. Dens evaginatus is a dental anomaly most commonly noted as an accessory tubercle
on the occlusal surface of premolars and the palatal aspect of incisors as a talon cusp. Complications can result in loss of pulp vitality,
sometimes causing periapical periodontitis. Clinicians should be aware of the presentation and the advantages of different approaches to
the management of dens evaginatus.
CPD/Clinical Relevance: To raise awareness of dens evaginatus in dental professionals working in primary and secondary care.
Dent Update 2020; 47: 706–712

Dens evaginatus (DE) is a rare dental
developmental anomaly that is found in
teeth where the enamel outer surface
appears to have an anatomic anomaly, or
an extra cusp in the form of a tubercle, or
both. The tubercle is composed of an outer
enamel layer, a dentine core and prominent
pulp tissue, which can extend to the main
part of the pulp.1
Upper incisors are less frequently
affected than premolars, which are the
most common teeth to display extra
cusps. These can occur bilaterally and can
Khawer Ayub, BDS, MFDS RCPS(Glas),
Specialty Registrar in Restorative
Dentistry, King’s College Hospital Dental
Institute and William Harvey Hospital,
(email: khawer.ayub@nhs.net), Sadia
Khan, BDS, MFDS RCPS(Glas),
Dental Core Trainee, Birmingham
Dental Hospital and Martin Kelleher,
BDS, MSc, FDS RCS(Ed), FDS RCS, FDS
RCS(Eng), Consultant in Restorative
Dentistry, Department of Restorative
Dentistry and Traumatology, King’s
College Hospital Dental Institute,
London, UK.
706 DentalUpdate
be symmetrical. The occlusal surfaces of
posterior teeth and labial or palatal surfaces
of anterior teeth are commonly affected.2,3
The prevalence of DE ranges
from 0.06% to 7.7%, depending on race.4,5
DE occurs more commonly in Asian
patients6 and has been reported to have
higher rates amongst Chinese7 populations.
DE is more common in men than women,5
and occurs more frequently in the mandible
than the maxilla.8 Patients with Ellis-van
Creveld syndrome, Mohr syndrome,
Rubinstein-Taybi syndrome and Sturge-
Weber syndrome are at a higher risk of
having DE.9-12
Cause
The exact aetiology of DE remains
unclear and it might be an isolated
anomaly. However, it is thought to arise
from an aberrant folding of the inner
enamel epithelium and subjacent ecto-
mesenchymal cells of the dental papilla
into the stellate reticulum of the enamel
organ during the bell stage of tooth
development.3,4
Mitchell first reported a horn-like
projection of a maxillary central incisor in
1892.13 Since then, the literature has offered
varying terms for what is now known
as DE, including tuberculated premolar,
evaginated odontoma, Leong’s premolar,
occlusal enamel pearl, odontome of axial
core type and talon cusp.
Dens evaginatus can be
associated with a number of dental issues
and anomalies including:14,15
„ Occlusal disharmony;
„ Aesthetic problems;
„ Supernumerary teeth;
„ Odontomes;
„ Megadonts;
„ Shovel-shaped incisors with prominent
marginal ridges (Figure 1);
„ Peg-shaped lateral incisors;
„ Exaggerated cusp of Carabelli;
„ Labial grooves (Figure 1).
Diagnosis
The appearance of DE usually makes the
diagnosis easy, but knowing exactly what
to do about the pulpal status at any given
time can be more difficult, particularly
when there are no signs or symptoms of
pulpal necrosis.8 In assessing a developing
tooth with DE, it can be problematic to
differentiate between a periapical lesion
due to a tooth being dead and the normal
October 2020

Figure 1. Shovel-shaped UR1 with prominent
marginal ridges and a labial groove.
Figure 2. View of the upper right central incisor
(UR1) showing DE on the labial surface.
Figure 3. Lateral view of UR1 showing labial
extent of the tubercle.
Figure 4. Close up view showing UR1.
periapical radiolucency of an immature
apex.
Sensibility testing on immature
teeth can be misleading, as they are known
October 2020
Figure 5. Labial view following orthodontic
treatment and loss of the tubercle.
Figure 6. UR1 being acid etched.
Figure 7. Frosty surface of the UR1
demonstrating high free surface energy. One
bottle adhesive systems are not acidic enough,
and they do not allow that necessary ‘check
etching’ first, to ensure that the surface of the
etched enamel has high enough free surface
energy before proceeding further with the
bonding.17
to give unreliable results. Occasionally,
DE can be seen radiographically prior to
eruption.16
Case report
A young Caucasian male presented with
his parents when he was about 8 years old.
It was obvious what the problems were
(Figures 2, 3 and 4). The upper right central
incisor was malformed with an unsightly
and irregular, rough-looking, disto-labial
RestorativeDentistry
surface with an obviously protruding pearl.
Explanations were given to the patient
and his concerned parents about the ‘dens
evaginatus’ condition. The acronym ‘BRAN’
was used to draw attention to the Benefits,
Risks Alternative (doing) Nothing.
After some discussions ‘doing
nothing’ was chosen because both the
patient and parents were happy to wait and
see to allow further pulpal development.
It was agreed that they would report any
changes, or if he was getting teased at
school. Many years passed without any
problems and he had fixed orthodontic
treatment to improve his malocclusion.
When he was 15 years old,
the appearance of the upper right central
incisor was troubling the patient and,
while part of the enamel pearl was no
longer present, it was decided to tidy the
appearance up by adding direct resin
composite to the labial aspect of the
malformed upper right central incisor tooth
(Figure 5).
Sensibility testing revealed that
the upper right central incisor was vital.
The root had completed growth and the
radiograph showed that there was no sign
of a periapical radiolucent area.
Following explanations and
consent, topical anaesthetic was applied.
The surface of the upper right central
incisor was roughened very gently with
a diamond bur to get down to a surface
that could be made reactive. It was then
etched for 20 seconds with standard 37%
phosphoric acid gel with only cotton
wool roll as isolation (Figure 6). This was
deliberate because the use of a rubber dam
involves dehydrating the teeth, which does
not help to choose the correct colour of
resin composite for the direct bonding.
The phosphoric acid was
evacuated from the surface and the area
was washed and dried to produce visibly
frosty enamel (Figure 7). That process
is called ‘check etching’. It is important
to check that a frosty etched enamel
appearance has been achieved before
proceeding further. If there is any doubt
about the surface on to which one is
attempting to bond, the etching process
needs to be repeated.
A ‘gold standard’ 3 bottle system
was therefore used for the bonding system
(Allbond 2®, Bisco, USA). The hydrophilic
resins were applied and air dried (Figure 8).
DentalUpdate 707
 RestorativeDentistry
Figure 8. Applying bonding agent to UR1.
Figure 9. Post-op restoration UR1.
Figure 10. Close-up view of UR1 restored with
composite restoration.
The unfilled resin was then
applied, blown to a thin layer and cured for
15 seconds. Charisma® shade A1 was used
freehand. The result can be seen in Figures
9 and 10 and the patient and parents
declared themselves happy with the result.
There was no post-operative pain or any
complications.
A second case highlights the
issues that can arise with late presentation
of DE. Figure 11 shows a maxillary left first
molar with a previously fractured DE on the
occlusal table.
Radiographic examination
(Figures 12, 13) revealed gross coronal
resorption due to the pulpal necrosis
caused by a fractured tubercle.
The tooth has a pink hue due
708 DentalUpdate
Figure 11. The maxillary first permanent molar
has a pink hue visible through the occlusal
surface; evidence of the inflammatory process as
a result of DE.
to the vascular changes as a result of the
fractured tubercle. In this case, endodontic
treatment was required. After gaining
access to the pulp chamber complex of
the UL6, extensive hyperaemic tissue was
removed, and a significant pulp stone noted
to be present over the canal orifices. The
pulp stone was removed with ultrasonic
instrumentation and three canal orifices
were located. Further exploration of the
access cavity confirmed an approximate
0.5 mm communication distally between
the pulp chamber and mouth at the level
of the cemento-enamel junction. It was
confirmed that the communication was
clear of inflammatory tissue and it was
sealed with a zinc-oxide eugenol-based
material. This was chosen in preference
to mineral trioxide aggregate (MTA) as it
was felt that the MTA might be susceptible
to being washed away by local saliva
during its setting process (approximately
24 hours). The pulp chamber was dressed
with non-setting calcium hydroxide paste
and sealed with a temporary restoration.
At a subsequent appointment, access
to the pulp chamber and canals was
regained, the restoration used to seal the
distal perforation was intact and the seal
was confirmed. The canals were shaped
using a combination of hand and rotary
files. Extensive exploration for an MB2
canal using microscopic illumination and
magnification was carried out and no trace
was found. Sodium hypochlorite was used
to irrigate throughout. Following shaping,
obturation was completed using a warm
vertical condensation technique and an
amalgam Nayyar core was placed. This
case highlights long-term complications
of late diagnosis of DE and importance of
early diagnosis and intervention, where it is
appropriate.
Classification
A number of classifications have been
described to categorize DE. Some of the
classifications are as follows.
Lau’s classification, which is
based on their anatomical shapes:18
„ Smooth;
„ Grooved;
„ Terraced;
„ Ridged.
Oehler’s et al classification is
based on the histology of the pulp contents
within the tubercle:19
„ Wide pulp horns (34%);
„ Narrow pulp horns (22%);
„ Constricted pulp horns (14%);
„ Isolated pulp horn remnants (20%);
„ No pulp horn (10%).
Schulge’s classification described
five categories of DE based upon the
location of the tubercle:7
1. A cone-like enlargement of the lingual
cusp;
2. A tubercle on the inclined plane of the
lingual cusp;
3. A cone-like enlargement of the buccal
cusp;
4. A tubercle on the inclined plane of the
buccal cusp;
5. Tubercle arising from the occlusal surface
obliterating the central groove.
Hattab et al’s classification,
described the features based on the
formation and extent of DE and is limited to
anterior teeth:3
„ Type 1 − Talon, a well-defined additional
cusp that projects palatally and extends at
least half the distance from the cemento-
enamel junction (CEJ) to the incisal edge
(Figure 14).
„ Type 2 − Semi-talon, an additional cusp
that extends less than half the distance
October 2020
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Figure 12. Bitewing radiograph showing a
radiolucency extending through the enamel to
the occlusal table, indicating the pulpal extension
into the fractured tubercle.
Figure 13. Periapical radiograph showing large
radiolucent abnormality within the coronal
aspect of the UL6. The radiolucency extends
from the occlusal table to the base of the pulp
chamber.
from the CEJ to the incisal edge.
„ Type 3 − Trace talon, prominent cingula.
Management
Early identification can allow for a number
of preventive strategies. If the tooth is
asymptomatic, and unlikely to encounter
occlusal trauma, then no treatment may be
required.20 A preventive regimen, including
oral hygiene instruction, application of
neutral topical fluoride and application of
fissure sealant,5,21,22 can be used alongside
regular recall.
If the tooth is likely to encounter
occlusal trauma, then a more invasive
approach may be required. This can include
gradual selective cusp grinding.23 The aim of
this is to induce formation of secondary and
tertiary dentine and hopefully cause closure
of the pulp horn. Cusp grinding can be
October 2020
Figure 14. Type 1 talon cusp based on the Hattab
et al classification.
unpredictable and cause exposure of the
pulp. It should be considered when there
is no expected pulpal extension into the
tubercle. The patient will require numerous
visits with this approach and the possibility
of sensitivity or causing pulpal death.
For teeth with a vital pulp,
direct resin composite bonded around
the vulnerable projection can be used to
reinforce the tubercle.24 Pulp and periapical
tissues assessment can be completed
annually. When there is adequate pulp
recession, the tubercle can be removed and
tooth can be restored. This may need to be
completed in conjunction with adjustment
of the opposing occluding tooth. In theory
at least, one could consider prophylactic
pulp capping,25 using mineral trioxide
aggregate (MTA) or other novel bio-ceramic
materials. In that scenario, tooth vitality
might be maintained via dentine bridge
formation.26
For immature teeth with an
inflamed pulp, a shallow MTA pulpotomy
could be performed and the tooth
then restored with contrasting colour
conventional glass ionomer, possibly along
with some superficial contrasting colour
composite. For mature teeth with inflamed
or necrotic pulps, conventional root canal
therapy can be completed, and the teeth
restored. If the teeth are discoloured, the
teeth can be restored with contrasting
colour conventional glass ionomer
cement, in case re-entry for inside/
outside bleaching is ever required.27 For
necrotic immature teeth with open apices,
apexification should be completed with the
use of MTA or an appropriate bio-ceramic
material and restored appropriately. In
some cases, where there is gross infection,
failed endodontic treatment or for
RestorativeDentistry
orthodontic reasons, extraction can be
considered.24
Discussion
Dens evaginatus is a rare dental anomaly
which commonly presents as a tubercle
on the labial surface of anterior teeth. It is
usually detected by clinical examination
alone. If the problem occurs on the
cingulum/occlusal surface of the teeth,
then the extra cusp can cause an occlusal
interference or displace the affected tooth
and/or the opposing teeth. The presence of
the tubercle can irritate the tongue when
speaking or eating and, if present on the
biting surface the extra cusp, can fracture
easily.2,8,22 It is important to diagnose DE
early, at which point close monitoring,
or any necessary intervention, can be
employed to improve long-term outcomes.
Late diagnosis can lead to pulpal
complications if and when the tubercle
fractures. Pulp involvement may present
as pulpitis, pulpal necrosis, or apical
periodontitis. The patient may not always
experience symptoms.
Conclusion
The aim of this report is to increase
awareness amongst practitioners of
the importance of early detection and
conservative management strategies.
Hopefully, this will prevent the need
for complex treatment and ultimately
improving care for patients with DE.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Reichart PA, Sukasem M. Morphologic findings in
dens evaginatus. Int J Oral Surg 1982; 11: 59−63.
2. Levitan ME, Himel VT. Dens evaginatus: literature
review, pathophysiology, and comprehensive
treatment regimen. J Endod 2006; 32: 1−9.
3. Hattab FN, Yassin OM, Al-Nimri KS. Talon
cusp − clinical significance and management.
Quintessence Int 1995; 26: 115−120.
4. Yip WK. The prevalence of dens evaginatus. Oral
Surg Oral Med Oral Pathol 1974; 38: 80−87.
5. Manuja N, Chaudhary S, Nagpal R, Rallan M.
DentalUpdate 711
 RestorativeDentistry
Bilateral dens evaginatus (talon cusp) in
permanent maxillary lateral incisors: a rare
developmental dental anomaly with great
clinical significance. BMJ Case Rep 2013; 2013:
bcr2013009184.
6. Jerome CE, Hanlon JR. Dental anatomical
anomalies in Asians and Pacific Islanders. J Calif
Dent Assoc 2007; 35: 631−636.
7. Kocsis G. Supernumerary occlusal cusps on
permanent human teeth. Acta Biol Szeged
2002; 46: 71−82.
8. Echeverri EA, Wang MM, Chavaria C, Taylor
DL. Multiple dens evaginatus: diagnosis,
management, and complications: case report.
Pediatr Dent 1994; 16: 314−317.
9. Hattab FN, Yassin OM, Sasa IS. Oral
manifestations of Ellis-van Creveld syndrome:
report of two siblings with unusual dental
anomalies. J Clin Pediatr Dent 1998; 22:
159−166.
10. Goldstein E, Medina JL. Mohr syndrome or oral-
facial-digital II: report of two cases. J Am Dent
Assoc 1974; 89: 377−382.
11. Gardner DG, Girgis SS. Talon cusps: a dental
anomaly in the Rubinstein-Taybi syndrome.
(IIHFWLYHWUHDWPHQWIRUZKLWH
VSRWV:LWK,FRQVPRRWKVXUIDFH
A quick, gentle and esthetically pleasing treatment for white spots
œ˜ӜœÌ…ÃÕÀv>ViöVœ˜½Ãˆ˜wÌÀ>̈œ˜̅iÀ>«Þ“>ŽiÈ̫œÃÈLi°
*ÀœÛi˜°œÀ>܈`iÀ>˜}iœvˆ˜`ˆV>̈œ˜Ã]vÀœ“V>Àˆœ}i˜ˆV܅ˆÌiëœÌÃ
Oral Surg Oral Med Oral Pathol 1979; 47: 519−521.
12. Chen RJ, Chen HS. Talon cusp in primary dentition.
Oral Surg Oral Med Oral Pathol 1986; 62: 67−72.
13. Mitchell W. Case report. Dent Cosmos 1892; 34:
1036.
14. Hattab FN. Talon cusp in permanent dentition
associated with other dental anomalies: review of
literature and reports of seven cases. J Dent Child
1996; 6: 368–376.
15. Davis PJ, Brook AH. The presentation of talon
cusp: diagnosis, clinical features, associations and
possible aetiology. Br Dent J 1986; 160: 84−88.
16. Naini FB, Levisianos I, Foo L, Gill DS. Pre-eruptive
diagnosis and management of occlusal dens
evaginatus in premolar teeth. Dent Update 2018;
45: 882−888.
17. Hannig M, Reinhardt KJ, Bott B. Self-etching primer
vs phosphoric acid: an alternative concept for
composite-to-enamel bonding. Oper Dent 1999;
24: 172−180.
18. Lau TC. Odontomes of the axial core type. Br Dent J
1955; 99: 219−215.
19. Oehlers FA, Lee KW, Lee EC. Dens evaginatus
(evaginated odontome). Its structure and
responses to external stimuli. Dent Pract Dent Rec
Free online training!
Contact info@dmg-dental.co.uk
to book
1967; 17: 239−244.
20. Chen RS. Conservative management of dens
evaginatus. J Endod 1984; 10: 253−257.
21. Bazan MT, Dawson LR. Protection of dens
evaginatus with pit and fissure sealant. ASDC J
Dent Child 1983; 50: 361−363.
22. Shekhar MG, Vijaykumar S, Tenny J, Ravi GR.
Conservative management of dens evaginatus:
report of two unusual cases. Int J Clin Pediatr Dent
2010; 3: 121−124.
23. Hill FJ, Bellis WJ. Dens evaginatus and its
management. Br Dent J 1984; 156: 400−402.
24. Hülsmann M. Dens invaginatus: aetiology,
classification, prevalence, diagnosis and treatment
considerations. Int Endod J 1997; 30: 79–90.
25. Yong SL. Prophylactic treatment of dens
evaginatus. J Dent Child 1974; 41: 289−292.
26. Koh ET, Ford TP, Kariyawasam SP, Chen NN,
Torabinejad M. Prophylactic treatment of dens
evaginatus using mineral trioxide aggregate.
J Endod 2001; 27: 540−542.
27. Poyser NJ, Kelleher MG, Briggs PF. Managing
discoloured non-vital teeth: the inside/outside
bleaching technique. Dent Update 2004; 31:
204−214.
̜y՜ÀœÃˆÃœÀVœœÕÀV…>˜}iÃV>ÕÃi`LÞÌÀ>Փ>°ˆÃVœÛiÀ̅i>ÌiÃÌ
܅ˆÌiëœÌÌÀi>̓i˜ÌvœÀޜÕÀÃiv>˜`ޜÕÀ«>̈i˜Ìð

DMGDentalUpdate
712 Half Page.indd 1 October 2020
02/09/2020 16:13
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 OralSurgery Enhanced CPD DO C

Brandon Owen

Graham Oliver, Lucy Macey-Dare and Gregor Knepil

Coronectomy: not just for Wisdom

Teeth
Abstract: Coronectomy is most commonly associated with the management of impacted lower third molars where complete removal
poses a high risk of inferior alveolar nerve damage. However, coronectomy may be indicated for the management of other teeth with a
significant risk of morbidity. A case of a LL6 extended coronectomy is presented. The aim was to prevent inferior alveolar nerve damage,
and ensure adequate crown and root removal to facilitate orthodontic alignment of the teeth. Surgery was aided by cone beam CT, and a
piezo-surgical technique.
CPD/Clinical Relevance: This case demonstrates the novel application of a coronectomy to manage an infra-occluded lower left first
molar, facilitating orthodontic treatment, where complete removal posed a high risk of inferior alveolar nerve damage.
Dent Update 2020; 47: 714–718

Standard coronectomy is the technique
where the crown of a tooth is sectioned and
removed just below the amelo-cemental
junction, leaving a substantial portion of
roots in situ and untouched. It is frequently
indicated for the management of impacted
lower third molars, which carry a high risk of
inferior alveolar nerve injury (IANI).1 IANI can
cause altered sensation, such as numbness
or pain to the lower lip and chin.2 This can
have a profound effect on an individual’s
ability to eat and speak, their social
Brandon Owen, BDS, MFDS, DCT1,
Oral and Maxillofacial Surgery (email:
brandonlukeowen@gmail.com),
Graham Oliver, BDS, DClinDent,
MFDS, MOrth, Orthodontic Specialty
Registrar, Lucy Macey-Dare, BDS, FDS
RCS, FDS(Orth) RCS, MSc, MOrth RCS,
Consultant Orthodontist and Gregor
Knepil, BDS, MFDS, MBChB, MRCS,
FRCS, Consultant Oral and Maxillofacial
Surgeon, Gloucestershire Hospitals
NHS Foundation Trust, Department
of Oral and Maxillofacial Surgery,
Gloucestershire Royal Hospital, Great
Western Road, Gloucester GL1 3NN, UK.
714 DentalUpdate
interactions and, as a consequence, their
quality of life.3,4
Case selection for coronectomy
is important and should be limited to vital
teeth with a high risk of IANI, in patients
who are not immunocompromised and
have good healing potential. Mobilization
of roots at the time of surgery indicates
need for extraction of the whole
tooth, and is important for patients to
understand during the consent process.
Renton et al reported a 38% failure rate of
coronectomy.5 Appropriate follow up, and
ability to manage any complications such
as infection, root migration and need for
further surgery, is also important.6
Root migration is frequent
following coronectomy. A 2015 systematic
review reported an incidence of 2%−85.3%.
Re-operation rates due to infection or
migration varied from 0.6−6.8%. It was also
reported that, if a second surgical procedure
is indicated, safer surgery may be possible
as the roots generally migrate away from
the IAN.7
This is a case report of an
‘extended’ coronectomy of a mandibular
first molar which was considered to pose
a high risk of IANI. The aim of treatment
in this case was to prevent nerve damage,
and also facilitate orthodontic alignment of
the teeth by extending the degree of tooth
structure removed.
Case report
On examination
A 13-year-old female was referred to the
orthodontic department by her General
Dental Practitioner (GDP) regarding an
unerupted LL6. The patient attended
with her father, who was deaf, and so
communication throughout was aided
with the use of British Sign Language. The
patient and parents were concerned about
the appearance of her front teeth, as well as
being aware of a ‘stuck’ tooth resulting in a
gap between the teeth. The patient had well
controlled asthma and was otherwise fit
and well. She had a dental history of trauma
to her UR2, and previously had restorative
treatment under local anaesthetic.
On examination, the patient had
an Angle’s Class II division 1 malocclusion,
on a Class II skeletal pattern with an
increased lower anterior face height.
The malocclusion was complicated by
bimaxillary crowding, an unerupted LL6
and an uncomplicated crown fracture of
October 2020

Figure 1. OPT demonstrating the position of the unerupted inferiorly displaced LL6.
a Surgical extraction would
the UR2. In centric occlusion, the overjet
was 6 mm with reduced overbite,
and the molars were a half unit II on
the right side. The oral hygiene was
satisfactory and there were occlusal
restorations in the UR6, LR6, UL6 and
UL7.
An Orthopantomogram
(OPT) revealed an unerupted, inferiorly
displaced LL6 with apices at the inferior
border of the mandible; the adjacent
LL7 was erupted and tipped mesially
over the LL6 and in close proximity to
the LL5. The roots of the LL7 showed
an intimate relation to the LL6 crown,
although there was no obvious
evidence of root resorption (Figure
1). The inferior dental canal (IDC) was
b closely related to the roots of the LL6,
with darkening of the mesial root, and
interruption of the white lines of the
IDC.
The patient was seen on
a multidisciplinary clinic, including a
consultant orthodontist, and an oral
surgeon. Due to the position of the LL6
and the risk factors relating to the IAN
identified on the OPG, the patient was
referred for a cone beam CT (CBCT)
(Figure 2). The CBCT revealed that the
four apices of the LL6 extended to the
inferior cortex. The IAN was encircled
by the apices of the LL6 with signs of
Figure 2. (a, b) CBCT demonstrating the position
notching of the mesio-lingual root.
of the IAN in relation to the LL6.
There was also suggestion of a slightly
October 2020
OralSurgery
enlarged follicle surrounding the LL6.
The patient was diagnosed with an
infra-occluded LL6, possibly due to a
mechanical failure of eruption.
Treatment options
Three management options were
considered:
1. Monitoring;
2. Surgical removal of the entire tooth;
and
3. ‘Extended’ coronectomy.
Monitoring would involve
periodic radiographic review to monitor
any potential cystic change or root
resorption; however, this would prevent
alignment of the LL7. Alignment of the
maxillary dentition would have been
possible to an extent, but would not
achieve a satisfactory result.
allow alignment of the teeth after bony
infill, but would carry a significant risk of
damage to the IAN, and risk of mandible
fracture.
An extended coronectomy
was felt by clinicians and patient to
be the best option to minimize risk of
IANI and enable the patient to pursue
orthodontic treatment following bony
infill. The concern was to ensure that
sufficient space was created to upright
the LL7. This was achieved using
measurements taken from the CBCT
to estimate the LL7 total tooth height
against the height of the mandible and
relative position of the LL6. This showed
that the crown, and the roots beyond
the furcation, had to be removed. Risks
of the surgical procedure included
requirement for extraction at time of
surgery should mobilization of the roots
occur, damage to the IAN, jaw fracture,
or need for further surgery in future if
the apices migrate away from the lower
border.
Surgery and follow-up
The procedure was undertaken as a
day case, under general anaesthetic. A
buccal sulcular incision was made and
the mental nerve identified intact. Using
a piezosaw, a buccal window of bone
was removed to access the LL6. The
crown of the LL6 was removed, as well
as root tissue, to below the level of the
DentalUpdate 715
 OralSurgery
a assault. Clinically, no pathology or signs of
b No high-quality evidence or formal
Figure 3. (a) An OPT taken 6 weeks post
coronectomy demonstrating the position of
the two remaining roots of the LL6. (b) An OPT
demonstrating early infill of bone at 5 months
post-op.
furcation. Surgicel® (Ethicon) was placed
and the surgical site closed with 4-0 Vicryl
Rapide™ (Ethicon); a 5-day prophylactic
course of co-amoxiclav was prescribed to
help reduce risk of post-operative infection.
The patient was advised to abstain from any
contact sports for 6 weeks.
The patient was reviewed
clinically and radiographically 6 weeks later
(Figure 3a); no altered sensation, pain or
numbness was reported in the distribution
of the IAN. The management plan was to
review the patient in 6 months to assess the
degree of bony infill at the surgical site and
investigate the possibility of commencing
orthodontic treatment.
Five months post-surgery,
the patient attended with pain in the
lower left quadrant following an alleged
716 DentalUpdate
mandibular fracture were evident. An OPT
excluded infection and fractures; however,
it did demonstrate early infill of bone at the
site of coronectomy (Figure 3b).
Discussion
Consideration of coronectomy is almost
synonymous with high risk mandibular third
molars, but it is an important treatment
option when any extraction poses a high
risk of IANI.
Previous case reports
guidance regarding coronectomy to
manage non-third molar teeth exists. A
report of two cases in which standard
coronectomy was used to manage infra-
occluded mandibular first permanent
molars with close relationships to the IAN
is available. However, the position of the
remaining roots prevented orthodontic
space closure.8 A further report is also
available regarding the coronectomy of
an infra-occluded LR5 and LR6, in which
there was deemed to be a high risk of IANI
with complete removal; the retained roots
also allowed preservation of the alveolar
ridge for a prosthesis.9 Coronectomy of an
infra-occluded deciduous molar has even
been reported.10 In all cases, coronectomy
was performed as an alternative to
complete removal for the primary reason of
minimizing risk of IANI. The reported cases
were successful as no IANI was reported.
Risk assessment
Radiographic assessment
Certain plain film radiographic signs
are associated with a higher risk of IANI
following third molar removal. This includes:
diversion of the inferior dental canal,
darkening of the root, interruption of the
canal lamina dura, narrowing of the root/
canal and interruption of the juxta-apical
area.6 In the presented case, darkening of
the root, interruption of the canal lamina
dura, and narrowing of the canal was
visible. A CBCT was therefore justified to
visualize the relationship of the tooth to the
nerve.
Cone beam computed tomography (CBCT)
CBCT is a highly useful diagnostic tool
for the determination of the relationship
between teeth and the IAN. CBCT signs of
increased risk of IANI includes:6
„ Loss of canal cortex >3 mm;
„ Dumb-bell distortion of IDC;
„ Lingual position of canal to roots;
„ Perforation of roots by canal;
„ Inter-radicular canal with multiple roots.
CBCT enabled the authors to
visualize the three-dimensional relationship
of the tooth, IAN and surrounding
structures to facilitate surgical planning.
CBCT can occasionally prove that the tooth
and nerve are not as intimate as indicated
by plain film alone and avoid unnecessary
coronectomy. If mobilization of roots at
the time of coronectomy occurs, enhanced
information may enable their removal with
reduced morbidity.
Furthermore, the information
gained from the CBCT helped the patient
and family to reach a more informed
decision regarding her treatment.
Patient selection
Following radiographic examination, the
patient was deemed to be at a higher
risk of IANI. Coronectomy was therefore
considered as a management option.
Standard coronectomy principles for
lower third molars were used to guide
suitability. In this case, coronectomy was
deemed appropriate, as complete removal
placed the patient at high risk of IANI, as
well as being medically fit and well with
good healing potential. The patient also
demonstrated good compliance with the
ability to attend multiple appointments.
Furthermore, the tooth was absent of any
significant pathology, such as caries in
close proximity to the pulp or periapical
pathology.
Selvi et al reported that
increasing age and females are more at risk
of an IANI.11 This may influence the decision-
making process for clinician and patient.
Piezosurgery
Piezosurgery was used in this case, since it
allows a high degree of surgical precision
for the removal of hard tissues whilst
helping to spare mechanical and thermal
damage to soft tissues.12 Better wound
healing and bone response have been
observed in comparison to conventional
rotary instruments.13 In this case, a need to
October 2020
 OralSurgery
preserve the IAN and viability of bone for
infill was especially important to facilitate
orthodontic treatment, and restore
strength to the mandible. Even in cases
of direct nerve contact with piezosurgical
instruments, the injury is more favourable
and has a better outcome in comparison to
conventional instruments.14 Furthermore,
the action of the vibrations and irrigant
help to wash away debris, improve visibility
and decrease heat generation.15
Multidisciplinary planning and orthodontic
tooth movement
This case highlights the benefits of
multidisciplinary planning between
surgeon and orthodontist to facilitate the
patient’s and clinician’s end goal of tooth
alignment with minimum morbidity. A
key consideration was the need to ensure
that there was sufficient room for mesial
apical movement of the LL7 after the
coronectomy. Failure to appreciate the
vertical space requirements would have
resulted in a futile coronectomy, inability
to upright the LL7, and potential root
resorption. During orthodontic treatment,
further radiographic reviews will be
undertaken to check that the LL7 apices
are clear of the retained roots and ensure
that the apices have not migrated following
surgery. The authors are confident that the
orthodontic uprighting process of the LL7
should be successful and relatively quick,
in part due to the effect of the regional
acceleratory phenomenon (RAP). RAP
describes the process by which noxious
stimuli induce increased remodelling and
healing of tissues, allowing for temporary
accelerated tooth movement.16,17
Interception
Early identification and appropriate referral
of problems in the developing dentition
is an important role for GDPs. Early
management can often help negate the
need for complex invasive treatment. In
this case, the patient was referred at age 13,
around 7 years after the usual LL6 eruption
date. It is possible that the position of the
LL6 could have been improved with earlier
management.
Conclusion
Patients must be presented with all
718 DentalUpdate
materially significant treatment options
to achieve informed consent. This
case illustrates the role of extended
coronectomy, assisted with CBCT and
piezosurgery, to reduce the morbidity of
orthodontic treatment in the developing
dentition. Coronectomy is an important
consideration where extraction involves
a high risk of inferior alveolar nerve
injury, and is assisted by CBCT, which
can further stratify the level of risk and
guide surgical planning. Patients must
understand all future implications of this
treatment approach. Early identification,
management and appropriate referral
are important steps in the management
of complex problems in the developing
dentition.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. O’Riordan BC. Coronectomy
(intentional partial odontectomy of
lower third molars). Oral Surg Oral
Med Oral Pathol Oral Radiol Endod
2004; 98: 274−280.
2. Renton T. Prevention of iatrogenic
inferior alveolar nerve injuries in
relation to dental procedures. Dent
Update 2010; 37: 350−363.
3. Ziccardi VG, Zuniga JR. Nerve
injuries after third molar removal.
Oral Maxillofac Surg Clin N Am 2007;
19: 105−115.
4. Smith JG, Elias L-A, Yilmaz Z,
Barker S, Shah K, Shah S et al. The
psychosocial and affective burden of
post traumatic neuropathy following
injuries to the trigeminal nerve.
J Orofac Pain 2013; 27: 293−303.
5. Renton T, Hankins M, Sproate
C, McGurk M. A randomised
controlled clinical trial to compare
the incidence of injury to the
inferior alveolar nerve as a result
of coronectomy and removal of
mandibular third molars. Br J Oral
Maxillofac Surg 2005; 43: 7−12.
6. Renton T. Update on coronectomy.
A safer way to remove high risk
mandibular third molars. Dent Update
2013; 40: 362−368.
7. Martin A, Perinetti G, Costantinides F,
Maglione M. Coronectomy as a surgical
approach to impacted mandibular
third molars: a systematic review. Head
Face Med 2015; 11: 9.
8. Chalmers E, Goodall C, Gardner A.
Coronectomy for infraoccluded lower
first permanent molars: a report of two
cases. J Orthod 2012; 39: 117−121.
9. Biocanin V, Todorović L. Coronectomy
of two neighbouring ankylosed
mandibular teeth − a case report.
Vojnosanit Pregl 2014; 71: 777−779.
10. Hussain MG, Sah SK, McHenry I. Case
report: coronectomy of an impacted
and submerged second deciduous
molar. Br Dent J 2018; 224: 20−21.
11. Selvi F, Dodson TB, Nattestad A,
Robertson K, Tolstunov L. Factors
that are associated with injury to the
inferior alveolar nerve in high-risk
patients after removal of third molars.
Br J Oral Maxillofac Surg 2013; 51:
868−873.
12. Pavlíková G, Foltán R, Horká M,
Hanzelka T, Borunská H, Šedý J.
Piezosurgery in oral and maxillofacial
surgery. Int J Oral Maxillofac Surg 2011;
40: 451−457.
13. Vercellotti T, Nevins ML, Kim DM,
Nevins M, Wada K, Schenk RK, Fiorellini
JP. Osseous response following
resective therapy with piezosurgery. Int
J Periodontics Restorative Dent 2005; 25:
543−549.
14. Schaeren S, Jaquiéry C, Heberer
M, Tolnay M, Vercellotti T, Martin I.
Assessment of nerve damage using
a novel ultrasonic device for bone
cutting. J Oral Maxillofac Surg 2008; 66:
593−596.
15. Schlee M, Steigmann M, Bratu E,
Garg AK. Piezosurgery: basics and
possibilities. Impl Dent 2006; 15:
334−337.
16. Frost HM. The regional acceleratory
phenomenon: a review. Henry Ford
Hosp Med J 1983; 31: 3−9.
17. Kim SJ, Park YG, Kang SG. Effects of
Corticision on paradental remodeling
in orthodontic tooth movement. Angle
Orthod 2009; 79: 284−291.
October 2020
 Enhanced CPD DO C RestorativeDentistry

Ronan B O'Leary

Anne L Gunderman

A Combined Digital-Conventional
Workflow to Fabricate a
Removable Partial Denture for a
Patient with a Severe Gag Reflex
Abstract: Introducing a novel approach to overcoming a profound gag reflex and aversion to conventional dental impression
procedures when fabricating a removable partial denture. The digital workflow is becoming increasingly popular in the discipline of
fixed prosthodontics. Chairside digitization of a patient’s dentition is a less invasive and more comfortable procedure in comparison to
conventional dental impression techniques. The advantages can be most relevant to patients with a profound gag-reflex. Currently, certain
challenges exist with full digitization in the discipline of removable prosthodontics. Combining digital and conventional workflows may
serve as an alternative technique to construct removable prostheses for groups who cannot tolerate conventional methods.
CPD/Clinical Relevance: Many patient groups may not tolerate conventional dental impression techniques. This method offers a
combination of existing techniques as a suitable alternative for this cohort.
Dent Update 2020; 47: 719–727

The digital workflow is established now as a teeth1-6 as well as dental implants,7,8 in the three-dimensional (3D) images over a
clinically acceptable method of fabricating discipline of fixed prosthodontics. One of broad surface area during the chairside
single unit crowns or short-span fixed the main advantages of this workflow is digital impression procedure. The literature
partial dentures (FPDs), both on natural from the perspective of patient comfort. suggests that such error accumulation can
Direct chairside digitization of a patient’s reach clinically relevant levels of inaccuracy
dentition is a less invasive and more in full-arch digital dental impressions.10-14
Ronan B O’Leary, BA, BDentSc, Dip
comfortable procedure in comparison to Furthermore, when fabricating removable
PCD, MFD(RCSI), MAcadMEd, Senior
conventional dental impression techniques partial dentures (RPDs), practical issues
House Officer in Restorative Dentistry,
using either irreversible hydrocolloids can arise when attempting to process
Division of Restorative Dentistry
or elastomeric impression materials. The polymethylmethacrylate (PMMA) to partial
and Periodontology, Dublin Dental
literature suggests that this patient comfort denture frameworks, if milled or 3D printed
University Hospital, Lincoln Place,
factor is most relevant in patients who resin mastercasts are used.
Dublin 2 D02 F859 (email: olearyrb@
experience a profound gag reflex.9 This case report discusses a
tcd.ie), and Anne L Gunderman, BS,
However, currently, direct novel approach, combining the digital
DDS, MS, Diplomate of the American
chairside digitization is considered to be and conventional workflows, to fabricate
Board of Prosthodontics, Senior Lecturer
less predictable for the fabrication of cross- a metal-ceramic FPD, single crown and
Graduate Prosthodontics, Trinity
arch frameworks,10-13 such as those that cobalt-chromium framed RPD for a patient
College Dublin/Dublin Dental University
might be fabricated in the discipline of with a particularly severe gag reflex,
Hospital; Private Practice Limited to
removable prosthodontics. This is because within the context of a staged treatment
Prosthodontics, Fitzwilliam Square,
of the effect of error accumulation that plan. This case report will discuss how
Dublin 2, D02 CY65, Ireland.
occurs during the stitching of multiple procedural difficulties were overcome by
October 2020 DentalUpdate 719
 RestorativeDentistry
a a
b dentition.15 More complex treatment
b options, involving fixed rehabilitation with
c 3-unit FPD and single unit crown and then
c to restore the posterior dentition with an
Figure 1. (a) Retracted frontal view (pre-
operative) showing existing provisional FPD
and deep vertical overlap. (b) Maxillary occlusal
view (pre-operative) showing Kennedy II mod II
arch. Note the UR2 is an edentulous space with
a provisional FPD. The maxillary incisors are
retroclined. (c) Mandibular occlusal view (pre-
operative). The mandible is a Kennedy I arch with
severely atrophied posterior ridge form.
switching between digital and conventional
techniques at relevant stages during these
clinical procedures.
Case report
The patient is a 61-year-old female with no
relevant medical history who presented to
the senior house officer restorative clinic
seeking a fixed prosthodontic replacement
for her recently extracted upper right lateral
incisor tooth. She was also troubled by
her lack of posterior teeth, both from an
aesthetic as well as a functional perspective.
The upper right lateral incisor tooth was lost
to a non-restorable crown-root fracture 6
months prior to presentation. A provisional,
PMMA FPD had been fabricated to restore
this site prior to referral to the senior house
officer restorative clinic. On intra-oral
examination, a Class II division 2 incisor
720 DentalUpdate
Figure 2. (a) Definitive tooth preparations.
Note the soft tissue health from wearing a
well-adapted provisional, supragingival finish
lines and the patient demonstrating good oral
hygiene. The soft-tissue contour of the UR2
site has also been adapted by the provisional
FPD. (b) Virtual mastercast of the definitive
tooth preparations. (c) Virtual mastercast of the
definitive tooth preparations (occlusal view). Note
the reductions for a metal-ceramic restoration,
with additional reduction in the cingulum area to
account for rest-seats incorporated into the metal
palatal surfaces of the restorations.
relationship, complicated by deep vertical
overlap and a lack of posterior support, was
noted. The maxilla was a Kennedy II mod II
arch, whilst the mandible was a Kennedy
I arch with severely atrophied posterior
ridge form. The periodontal status was
stable, oral hygiene was fair, however, there
was no evidence of periodontal pocketing
beyond 2 mm and there was no evidence of
bleeding on probing. (Figure 1a−c).
On presentation to the operator,
the patient reported profound difficulty
with the severity of her gag reflex during
dental procedures, particularly impression-
taking procedures with conventional
elastomeric impression materials. The gag
reflex was so strong that several episodes
of vomiting had occurred during dental
procedures in the past. In spite of these
difficulties, the patient was determined
to seek a treatment solution which would
enable her in wearing a partial denture in
recognition of the necessity of posterior
teeth in protecting the remaining anterior
dental implants and bone augmentation,
were rejected by the patient, and the
combined fixed and removable partial
denture treatment option was accepted as
her preferred option.
The aims of treatment were to
restore the maxillary labial segment with a
RPD, using a staged approach to overcome
the profound gag reflex and assess the
patient’s tolerance of a maxillary partial
denture.
Clinical and laboratory
procedures
Tooth preparations in the maxillary labial
segment were refined in order to achieve
adequate retention and resistance form
with supragingival margin placement
(Figure 2a), and a virtual mastercast was
fabricated by chairside digitization using
a 3Shape Trios® (3Shape, Copenhagen,
Denmark) intra-oral scanner (Figure 2b
and c). At the dental laboratory, uniformly
cut-back copings were prepared by
computer-aided-design (Figure 3a and b)
and were machine fabricated in cobalt-
chromium using the selective laser melting
(SLM) additive manufacturing technique
(Figure 3c and d). The crown and FPD
were surveyed and incorporated cingulum
rest seats and a guide-plane on the distal
surface of the UR3. A metal try-in was
carried out to verify the fit and occlusal
relationship of the copings (Figure 4a and
b), following which aluminous porcelain
was hand-stacked at the dental laboratory
(Figure 5a and b). The definitive metal-
ceramic units were cemented with glass
ionomer cement (Ketac™ Cem, 3M ESPE,
Minnesota, USA).
With no improvement in the
patient’s profound gag reflex, a novel
approach was used for fabrication of the
cobalt-chromium framed RPD, whilst
avoiding slow-setting conventional
elastomeric impression procedures. The
October 2020
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 RestorativeDentistry
a a
c verify fit and occlusion. (b) Occlusal view showing
d
b mastercast. (b) RPD framework on the 3D printed
Figure 3. (a) CAD metal copings (on virtual
mastercast) for the crown UL1 and 3-unit FPD
UR1–UR3. (b) Uniformly cut-back CAD metal
copings (on virtual mastercast). Occlusal view
shows the cingulum rests incorporated into
the metal and guide-plane on the distal of the
UR3. (c) Metal copings on the 3D printed resin
mastercast. (d) Occlusal view. Note how the
metal is not polished at this stage. It allows for
adjustment prior to sending it back to the lab for
addition of the ceramic and polishing.
maxillary denture-bearing area, including
the dentition and mucosa, was recorded
by chairside digitization using a 3Shape
Trios® intra-oral scanner. From this intra-
oral scan, a partial denture framework was
prepared by CAD (Figure 6a) and, again, was
machine-fabricated in cobalt-chromium
by SLM (Figure 6b). The cobalt-chromium
722 DentalUpdate
a
b
Figure 4. (a) Metal copings tried in the mouth to
occlusal contacts and adjustments.
Figure 5. (a) The finished metal-ceramic crown
and FPD returned from the laboratory. (b) The
finished metal-ceramic crown and FPD returned
from the laboratory. The palatal surface is in
metal and includes the cingulum rest seats and
the guide-plane on the distal of UR3.
partial denture framework was tried in the
patient’s mouth. Several cycles of fit-check
adjustments were required to permit full
and accurate seating of the framework
until a clinically acceptable framework fit
was achieved by this method. The patient
tolerated the full seating of the framework
well, with limited exacerbation of her gag
reflex.
In order to capture the
Figure 6. (a) CAD RPD framework on the virtual
resin model.
mucosal aspect of the denture-bearing
area accurately, a conventional functional
impression was made in zinc oxide eugenol
(Kelly’s® Z.O.E. Impression Paste, Waterpik,
Colorado, USA) using a custom tray
attached to the partial denture framework
(Figure 7a and b). At this point, it was
necessary to fabricate a conventional
gypsum model of the maxilla to permit
heat processing of PMMA to the partial
denture framework. As such, the framework,
complete with custom impression of the
denture-bearing mucosa, was picked up
into a fast-setting alginate impression, and
poured immediately to form a conventional
denture mastercast. Denture teeth and
PMMA were heat-processed to the cobalt-
chromium framework using the flask,
pack and press technique (Figure 8a, b
and c). The RPD was definitively fitted and
the patient has adapted well to her new
prosthesis (Figure 9a, b and c). Given that
this combined digital and conventional
workflow has been successful in fabricating
the maxillary removable prosthesis, and
October 2020

a a
b
Figure 7. (a) Border moulding and functional
impression made using the metal framework. (b)
Functional impression for the region of the distal
extension in the right posterior maxilla.
given the adaptation of the patient to this
removable prosthesis in the context of her
gag reflex, the next stage of the treatment
plan is to begin fabrication of a mandibular
RPD using a similar workflow.
Discussion
Patient groups
Conventional elastomeric impression
materials take several minutes to set in the
mouth. This can be a very long, unpleasant
and, in rare instances, dangerous experience
for patients. Groups affected include
those with a profound gag-reflex, but also
patients with learning impairments, patients
with temporomandibular joint disorders,
children, and those who are at risk of
aspiration. Bateman and Saha16 reported
a case of a 72-year-old man following
aspiration of dental impression material.
The patient required hospitalization and
passed away 33 days later in respiratory
arrest. They also identified three other cases
in the literature reporting aspiration of
impression material.17-19 For patients with
dysphagia, reducing reliance on flowable
impression materials in the mouth may
October 2020
a
b
c
Figure 8. (a) The processed denture (occlusal
view) showing the palatal ring major connector
to minimize material on the palate. (b) The
processed acrylic in the right buccal flange
showing good adaptation/contour after using
this method. (c) The advantages of using a
cobalt-chromium framework allowed minimal
thickness of material on the palate.
reduce aspiration risk for those susceptible.
By using intra-oral scanners, the
use of traditional materials can be reduced.
In this regard, without physical material
in contact with the oral and pharyngeal
tissues, the potential for gag-reflex
activation may be reduced. This should be
true if the reason for gagging was caused
by a physical stimulus and not a mental
trigger. Dickinson and Fiske developed a
classification in 2005, including the causes
of gagging. They included a ‘Gagging
Prevention Index’, which was graded by
the level of treatment that was possible to
carry out, taking into account the severity
of gagging experienced.20,21 The use of intra-
oral scanners have the potential to reduce
RestorativeDentistry
Figure 9. (a) The final fixed and removal
prostheses in situ (Smile). The clasp at UR3 and
the gingival margins are not normally visible.
(b) Anterior view. (c) Maxillary occlusal view.
the severity on this scale, without changing
to a compromised alternative treatment
plan.
For patients with
temporomandibular joint disorders, this
method allows for breaks in the scan
process in an effort to reduce symptoms of
fatigue on wide mouth opening.
Challenges with chairside
digitization
Chairside digitization presents challenges
when trying to obtain highly accurate cross-
arch dental prostheses.22 Error accumulation
that occurs during the stitching of multiple
3D images over a broad surface area across
the arch can lead to clinically relevant levels
of inaccuracy. A second cause of error in
digital acquisition of the dentition is the
occlusal relationship in both static and
dynamic relations. This is compounded
by partially dentate patients that fall into
the Kennedy Class I and II categories.
This case required model generation and
accurate interocclusal record techniques
DentalUpdate 723
 RestorativeDentistry
involving a semi-adjustable articulator.
The complexities of this case required
both accurate articulator mounting,
and accurate dynamic lateral and
protrusive replication, to ensure that
the restorations conformed to the
patient’s existing occlusal parameters,
and canine and protrusive guidance
were controlled. A re-organized occlusal
approach can present with even more
profound challenges for a purely digital
workflow.22
Cobalt-chromium
frameworks for RPDs previously had
high financial and time costs due to the
casting of the metal alloys. It is likely,
as these alternative methods become
more established, manufacturing
time and costs will reduce. The initial
setting-up costs for the chairside digital
equipment is a potential barrier to some
practitioners at this time.
Removable partial
dentures with distal extensions should
incorporate maximum functional
extension of the denture-bearing area.
Intra-oral scanners do not operate in the
same way that impression materials do
to achieve this, such as border moulding
to achieve a functional impression. The
intra-oral scanner will only capture a
snapshot of the tissues in their retracted
state, which is not truly based on
functional movements. The argument
can also be made that scanners lack
the muco-compressive properties of
impression material. The clinical impact
of this is not fully understood at this
moment in time.
Lastly, in a digital workflow
when adding acrylic to the metal
framework, the options are limited.
As no mastercast is required for the
SLM method of framework fabrication,
one is only supplied if requested, and
this comes in the form of a 3D printed
resin model fabricated from the scan.
The resin model prohibits the use of
heat-cured PMMA as the technique of
flask, pack and press is not compatible
with this. The resin model cannot be
destroyed to retrieve the processed
denture as predictably as a stone
model can be. Currently, in fully digital
workflows, cold-cure alternatives are
used which can have compromised
material properties compared to
724 DentalUpdate
pressure-moulded, heat-activated resins,
such as reduced transverse strength
and increased porosity.23 The described
method in this report suggests an
alternative way to simply convert to
conventional techniques at a relevant
stage to take advantage of the benefits
of heat-cured PMMA.
Conclusion
Although patients with a profound gag
reflex may initially reject a removable
prosthesis, a carefully designed cobalt-
chromium RPD may be a suitable
option, as it was in this case. By using a
surveyed crown and FPD, it maximized
the success of the removable prosthesis.
This permitted the patient to still
have a restored UR2 should she not
have tolerated the RPD. Other natural
tooth preparations were minimal and
the intra-oral scans were not invasive
or traumatizing to the patient. The
necessary conventional techniques were
more easily controlled by the use of
customized trays and control of material
setting properties by temperature and
technique manipulation. As can be
seen in Figure 8, the metal was thin and
streamlined and the palatal ring major
connector minimized the chances of
activating the gag-reflex. Try-in stage
of the framework is likely to be a good
indicator, if the patient will tolerate
the prosthesis. In summary, cobalt-
chromium RPDs may be one option
to be considered in a partially dentate
patient with a history of a gag reflex
if the prosthesis is designed well, the
patient is willing, and an appropriate
technique is used.
Acknowledgements
The authors would like to thank Mr
Dan Mulcare and Mr Ken Hall for the
laboratory work and Dr David
McReynolds for his guidance in writing
this.
This was a finalist case for the
Gary Pollock prize at the BSRD Autumn
Scientific Meeting 2018
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent
was obtained from all individual
participants included in the article.
References
1. Anadioti E, Aquilino S, Gratton D,
Holloway J, Denry I, Thomas G et al.
3D and 2D marginal fit of pressed
and CAD/CAM lithium disilicate
crowns made from digital and
conventional impressions.
J Prosthodont 2014; 23: 610−617.
2. Seelbach P, Brueckel C, Wöstmann
B. Accuracy of digital and
conventional impression techniques
and workflow. Clin Oral Invest 2012;
17: 1759−1764.
3. Zarauz C, Valverde A, Martinez-
Rus F, Hassan B, Pradies G. Clinical
evaluation comparing the fit
of all-ceramic crowns obtained
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impressions. Clin Oral Invest 2015;
20: 799−806.
4. Syrek A, Reich G, Ranftl D, Klein
C, Cerny B, Brodesser J. Clinical
evaluation of all-ceramic crowns
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of active wavefront sampling. J Dent
2010; 38: 553−559.
5. Abdel-Azim T, Rogers K, Elathamna
E, Zandinejad A, Metz M, Morton D.
Comparison of the marginal fit of
lithium disilicate crowns fabricated
with CAD/CAM technology by using
conventional impressions and two
intraoral digital scanners. J Prosthet
Dent 2015; 114: 554−559.
6. Almeida e Silva J, Erdelt K, Edelhoff
D, Araújo É, Stimmelmayr M, Vieira
L et al. Marginal and internal fit
of four-unit zirconia fixed dental
prostheses based on digital
and conventional impression
techniques. Clin Oral Invest 2013; 18:
515−523.
7. Abdel-Azim T, Zandinejad A,
Elathamna E, Lin W, Morton D. The
influence of digital fabrication
options on the accuracy of dental
implant–based single units and
complete-arch frameworks. Int J
Oral Maxillofac Implants 2014; 29:
1281−1288.
8. Lee S, Betensky R, Gianneschi G,
Gallucci G. Accuracy of digital
October 2020
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 RestorativeDentistry

versus conventional implant
impressions. Clin Oral Implants Res
2014; 26: 715−719.
9. Ahlholm P, Sipilä K, Vallittu P,
Jakonen M, Kotiranta U. Digital
versus conventional impressions in
fixed prosthodontics: a review.
J Prosthodont 2016; 27: 35−41.
10. Ender A, Mehl A. Accuracy of
complete-arch dental impressions: a
new method of measuring trueness
and precision. J Prosthet Dent 2013;
109: 121−128.
11. Ender A, Mehl A. In-vitro evaluation
of the accuracy of conventional
and digital methods of obtaining
full-arch dental impressions.
Quintessence Int 2015; 46: 9−17.
12. Güth J, Edelhoff D, Schweiger J, Keul
C. A new method for the evaluation
of the accuracy of full-arch digital
impressions in vitro. Clin Oral Invest
2015; 20: 1487−1494.
13. Kuhr F, Schmidt A, Rehmann P,
Wöstmann B. A new method for
assessing the accuracy of full arch
impressions in patients. J Dent 2016;
55: 68−74.
14. Nedelcu R, Olsson P, Nyström I, Rydén
J, Thor A. Accuracy and precision of
3 intraoral scanners and accuracy of
conventional impressions: a novel in
vivo analysis method. J Dent 2018;
69: 110−118.
15. Wiens J, Priebe J. Occlusal stability.
Dent Clin N Am 2014; 58: 19−43.
16. Bateman G, Saha S. Aspiration of
dental impression material − a
case report. Dent Update 2017; 44:
986−987.
17. Cameron S, Whitlock W, Tabor M.
Foreign body aspiration in dentistry:
a review. J Am Dent Assoc 1996; 127:
1224−1229.
18. Erren JP, Schipmann R. [Right-sided
recurrent retention pneumonia of
changing localization after aspiration
of dental impression material
with almost complete casting of a
segmental bronchus in a previously
healthy woman]. Pneumologie 1995;
49: 601−603.
19. Sopena B, Garcia-Caballero L, Diz P,
De la Fuente J, Fernandez A, Diaz JA.
Unsuspected foreign body aspiration.
Quintessence Int 2003; 34: 779−781.
20. Dickinson C, Fiske J. A review of
gagging problems in dentistry: 1.
Aetiology and classification. Dent
Update 2005; 32: 26−32.
21. Dickinson C, Fiske J. A review of
gagging problems in dentistry: 2.
Clinical assessment and management.
Dent Update 2005; 32: 74−80.
22. McReynolds D, O’Sullivan M. Pushing
the envelope of digital dentistry. J Ir
Dent 2019; 65: 333−338.
23. Anusavice K, Shen C, Rawls R. Phillips’
Science of Dental Materials. 12th edn. St.
Louis: Elsevier Saunders, 2012.

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 Enhanced CPD DO C GeneralDentistry/PaediatricDentistry/Orthodontics

Maurice J Meade

Supernumerary Teeth: an Overview for

the General Dental Practitioner
Abstract: Supernumerary teeth can develop in any location of the mandible or maxilla and may have a significant impact on the
developing dentition. This paper reviews the prevalence, aetiology and classification of supernumerary teeth. It also describes their clinical
characteristics and management options. A case report involving the interdisciplinary management of delayed eruption of central incisors
due to the presence of a supernumerary tooth is outlined.
CPD/Clinical Relevance: Timely diagnosis and appropriate management may reduce the potential problems associated with
supernumerary teeth. General dental practitioners should be aware of the clinical characteristics and management options related to
supernumerary teeth.
Dent Update 2020; 47: 729–738

undetected at, or exfoliate prior to,

A supernumerary tooth is one that has
developed in addition to the normal
complement of teeth within the
dentition.1,2 Supernumerary teeth can
occur in isolation or, less commonly,
in association with a number of
developmental medical disorders.3
They may be single or
multiple, unilateral or bilateral, and
can occur in the maxilla and/or
mandible.1,2,4 Supernumerary teeth
are thought to occur in the maxilla up
to 10 times more frequently than the
2 appear to be present in the primary
mandible. The most common location
involving one or two supernumerary
teeth only is the premaxilla followed
by the mandibular premolar region.
The mandibular premolar region,
however, appears to be the site in
which multiple supernumerary teeth
are most frequently located.4
Maurice J Meade, BDS, MDPH,
MFDS RCS(Edin), MJDF RCS(Eng),
DClinDent(Ortho), MOrth RCS(Edin),
Orthodontic Unit, The School of
Dentistry, The University of Adelaide,
South Australia, Australia, (email:
maurice.meade@adelaide.edu.au).
October 2020
Supernumerary teeth can
cause problems during development
of the dentition and may require
removal and interdisciplinary
management in some situations. The
aims of this paper are to:
„ Review the prevalence, aetiology
and classification of supernumerary
teeth; and
„ Describe their clinical characteristics
and management options.
In addition, a case report
involving the interdisciplinary
management of delayed eruption
of two maxillary central incisors due
to the presence of a supernumerary
tooth is outlined.
Prevalence
The prevalence of supernumerary
teeth in the primary dentition
ranges from 0.3 to 0.8%, and in the
permanent dentition from 1.2 to
3.5%.4 Supernumeraries in the primary
dentition, however, may be under-
reported. As spacing is commonly
present in the primary dentition,
supernumerary teeth may erupt into
reasonable alignment and remain
initial dental inspection.1
Males appear to be more
likely than females to present with
a supernumerary in the permanent
dentition.4,5 Ratios from 1.3:1 to
2.64:1 have been reported.6,7 The
broad range of ratios may be due to
the wide variety of methodologies
adopted in assessing supernumerary
teeth and may reflect the varying age
ranges and populations assessed.7
Sexual dimorphism does not
dentition.1 Those who present with
a supernumerary in the primary
dentition, however, may demonstrate
a higher prevalence of supernumerary
teeth in the permanent dentition.8
The majority of
patients present with one or two
supernumerary teeth.9 Although
multiple supernumerary teeth can
occur in isolation (Figure 1), they are
more commonly seen in patients with
an associated syndrome or medical
disorder (Table 1).3,10 In rare cases, the
presence of multiple supernumerary
teeth may be an important indicator
of an undiagnosed medical disorder.11
DentalUpdate 729
 GeneralDentistry/PaediatricDentistry/Orthodontics
Cleft lip and/or palate
Classical Ehlers-Danlos syndrome
Cleidocranial dysplasia
Ellis-Van Creveld syndrome
Familial adenomatous polyposis/
Gardner’s syndrome
Fabry disease
Hypermobile Ehlers-Danlos syndrome
Incontinentia Pigmenti
Kreiborg-Pakistan syndrome
Nance-Horan syndrome
Neurofibromatosis Type 1
Opitz GBBB syndrome
Papillon-League syndrome
Robinow syndrome [Dominant form]
Rubinstein-Taybi syndrome [RSTS1]
Trichorhinophalangeal syndrome
Table 1. Medical disorders associated with
supernumerary teeth.
The syndromes and medical disorders
most frequently associated with
supernumerary teeth are cleft lip and
palate (CLP), cleidocranial dysplasia
(CCD) and familial adenomatous
polyposis.3,6
The prevalence of
supernumeraries in patients with CLP
is reportedly between 1.9 and 10%
and they are thought to be a result
of disruption of the dental lamina
during cleft formation.6,12 They are
the second most common anomaly
found in the cleft area.12 Patients
with a history of anterior conical or
tuberculate supernumerary teeth at
an early age have a one-in-four chance
of later developing single or multiple
supernumerary premolars.7
CCD is a rare autosomal
dominant developmental disorder.
Associated characteristics include
persistent open cranial sutures,
hypoplasia/aplasia of the clavicles and
730 DentalUpdate
Figure 1. A dental pantomagram indicating 3 supernumerary teeth in the mandibular premolar
regions and 1 supernumerary impeding eruption of the maxillary right second molar.
dental anomalies including multiple
unerupted supernumerary teeth.13
A recent review, however,
has suggested that some disorders
where few individuals display the
presence of supernumerary teeth could
be coincidental rather than a true
association.3
Aetiology
The aetiology of supernumerary
teeth is not fully understood.1,6,14
Environmental and genetic factors have
been implicated. Three main theories
have been proposed:2,4,7,15
1. Atavistic theory: Suggests that
supernumerary teeth were the result
of phylogenetic reversion to extinct
primates with three pairs of incisors.
2. Dichotomy theory: Suggests that
the tooth bud splits into two equal or
different-sized parts, resulting in the
formation of two teeth − one normal
and one dysmorphic.
3. Dental lamina hyperactivity theory:
Involves localized and independent,
conditioned hyperactivity of the
dental lamina. A supplemental form
develops from the lingual extension
of an accessory tooth bud, while the
more rudimentary forms develop from
proliferation of the epithelial remnants
of the dental lamina.
The available evidence
appears to support the dental lamina
hyperactivity theory and discount 8the
Atavistic and Dichotomy Theories.
Current thinking indicates a genetic
or, more likely, a multifactorial basis to
supernumerary development.1,5,6
A genetic basis is suggested
as supernumeraries appear to:
„ Run in families: Studies have
shown that children of parents with
supernumerary teeth have an increased
risk of their development;16
„ Display sexual dimorphism: A sex-
linked transmission may explain the
greater prevalence of supernumerary
teeth in males;17
„ Demonstrate ethnic variation:
Prevalence, for example, has been
reported to be greater among African-
Americans;18
„ Be associated with some medical
disorders and syndromes;3,4
„ Be associated with other dental
anomalies: Patients with supernumerary
teeth may have larger ‘normal’ teeth
compared with those who have no
supernumerary teeth, particularly in the
mesio-distal dimension.19,20 In addition,
there appears to be a significant
association between supernumerary
teeth and invaginated teeth.7,21
October 2020
 GeneralDentistry/PaediatricDentistry/Orthodontics

Type of Supernumerary Frequency (%) Common Locations Typical Clinical Appearance

Conical 75 Anterior maxilla (commonly between „ Small
central incisors) „ Triangular/conical/peg-shaped crown
„ Normal root development
„ May be inverted
„ Usually erupts palatally, rarely labially
„ Usually isolated
Tuberculate 12 Anterior maxilla „ Barrel-shaped with multiple tubercles
„ Deviant or absent root development
„ Rarely erupts
„ Commonly prevents eruption of central incisor
„ Frequently in pairs
„ Late forming
Supplemental 7 Any location (most commonly a „ ‘Normal’ tooth appearance
permanent maxillary lateral incisor) „ Last in series
„ Usually erupts
Odontome 6 Anterior maxilla (compound) and „ Calcified dental tissues that are either:
posterior mandible (complex) - Compound: discrete structures similar to fully
developed teeth; or
- Complex: poorly organized tissues with minimal
similarity to normal tooth
„ Radiographically: mixed radio-opaque area
surrounded by radiolucent band
Table 2. Supernumerary teeth classified according to morphology.

Type of Supernumerary Characteristics

Mesiodens „ Conical or triangular crown
„ Small and short
„ Located between the maxillary central incisors
„ Usually palatal to the incisors
„ Sometimes lying in the line of the arch or labially
Paramolar „ Supernumerary molar
„ Usually rudimentary
„ Located buccally or lingually/palatally to one of the molars or interproximally buccal to
the second and third molar
Distomolar „ Located distal to the third molar
„ Usually rudimentary
„ Rarely delays the eruption of associated teeth
Parapremolar „ Forms in the premolar region and resembles a premolar
Table 3. Supernumerary teeth classified according to location.

Investigations into tooth
development in the mouse have also
demonstrated a genetic premise for
supernumerary tooth formation. Although
a genetic element is the component most
closely associated with supernumerary
teeth, transcription factors and separate
October 2020
molecular signalling pathways are likely to
play a part too.6,22
For example, it has been shown
that inappropriate regulation by the RUNX2
gene (involving the transcription factor
CBFA1) of the activity of the signalling
molecule called Sonic Hedgehog (Shh)
may be involved in the formation of
supernumerary teeth in individuals with
CCD.1,22
Classification of supernumerary
teeth
Supernumerary teeth are usually
DentalUpdate 731
 GeneralDentistry/PaediatricDentistry/Orthodontics
c
Figure 2. (a) Supplemental upper left lateral
incisor (frontal view). (b) Supplemental upper
lateral incisor (side view). (c) Supplemental upper
lateral incisor (occlusal view).
Figure 3. Supplemental lower right lateral incisor
(occlusal view).
classified according to morphology
(Table 2) or location (Table 3). A
supernumerary tooth that has a
similar morphology to a ‘normal’
tooth is described as eumorphic,
whereas supernumeraries that
bear little resemblance to ‘normal’
732 DentalUpdate
Figure 4. DPT indicating a supplemental maxillary central incisor.
teeth are described as dysmorphic.23
Supplemental types (Figures 2−4) are
most likely to erupt, followed by conical
and tuberculate.6 Figure 5 shows an upper
right unerupted distomolar.
Although odontomas and
supernumeraries have been classified
as separate entities, they appear to
be the manifestation of the same
odontogenic hyper-productive process
from an etiopathogenetic and a clinical
perspective.24 As a result, odontomas are
commonly classified as a morphological
supernumerary variant.
Clinical characteristics of
supernumerary teeth
A supernumerary tooth may just be a
‘chance’ discovery on a radiograph and
have no effect on the dentition.7,23 In many
instances, however, a variety of effects can
be seen and may be the first indication of
the presence of a supernumerary.
Delayed or prevention of eruption of
permanent teeth
The most common complication from a
supernumerary tooth is failure of eruption
of a permanent maxillary incisor.9,25
Delayed eruption of associated teeth has
been reported to occur in up to 60% of
Caucasians with supernumerary teeth.26
Figure 1 shows a supernumerary tooth
impeding the eruption of an upper right
second permanent molar tooth.
Displacement or rotation of permanent teeth
A supernumerary tooth located between
the roots of adjacent teeth may obstruct
root approximation, resulting in a
diastema. Displacement may vary from a
mild rotation to complete displacement.7,9
Crowding
Erupted supplemental teeth most often
cause crowding, although eruption of any
supernumerary type can result in crowding
(Figure 2).9,27
Incomplete space closure during orthodontic
treatment
A previously undiagnosed or a late
developing supernumerary may prevent
space closure during orthodontic
treatment.23,28
Pathology
Dentigerous cyst formation is a
complication that may be associated
with a supernumerary tooth.29 Root
resorption, dilaceration and abnormal root
development of associated permanent
teeth have been reported to occur in
association with supernumerary teeth, but
all are rare occurrences.7,30
Additional manifestations
Migration of the supernumerary into the
nasal cavity and hard palate has been
reported in the literature but is very
uncommon.31,32
October 2020
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Nobody expects
the unexpected.
This morning before practice John
was playing football with his son in the At Dentists’ Provident, we understand the impact illness
garden. He didn’t expect that simple or injury can have, not just on your health and wellbeing
game to result in a fall that caused a but on your work and lifestyle as well. An illness or injury
broken ankle and to not be able to return can put your life on hold at any time and that’s where we
to the surgery for a number of weeks… come in; supporting you through the tough times until
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With over a hundred years’ of experience in caring for

dental professionals just like you, our members trust us to
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Protecting your lifestyle. Securing your future.

To find out more visit our website at www.dentistsprovident.co.uk / www.dentistsprovident.ie
or call our member services consultants on 020 7400 5710

Dentists’ Provident is the trading name of Dentists’ Provident Society Limited which is incorporated in the United Kingdom under the Friendly Societies Act 1992 (Registration
Number 407F). Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority in the United
Kingdom (Firm Reference Number 110015) and regulated in the Republic of Ireland by the Central Bank of Ireland for conduct of business rules (Firm Reference Number C33946).
Calls are recorded for our mutual security, training and monitoring purposes. These case studies are for illustration purposes only and not based on real individuals. They are not
designed to provide financial advice, nor are they intended to make any recommendations regarding the suitability of our plans for a particular individual.

b c
Figure 6. (a) DPT indicating a supernumerary tooth impeding the eruption of maxillary central incisors.
(b) CBCT image of the supernumerary observed in (a). (c) CBCT image of the supernumerary tooth
observed in (a).
Management
Careful clinical and radiographic
examination is essential to identify
and localize supernumerary teeth.6
Management is dependent on
supernumerary type and position and
its effect or potential effect on the
dentition, and should be the result of
a risk-benefit assessment.33 It may be
prudent to liaise with an orthodontist
and/or an oral surgeon, particularly as
management should be undertaken in
conjunction with the correction of any
underlying malocclusion.1,14,34
A dental pantomogram
(DPT), an upper standard occlusal and/
or a long-cone periapical radiograph
may be used in combination to localize
a supernumerary tooth via the parallax
technique.35 A lateral radiograph of the
incisor region may assist in its location.9
Cone beam computed tomography
(CBCT) may be required to localize
its position more accurately and can
facilitate more precise assessment of
resorption in adjacent roots.36-39
In many situations, no
October 2020
GeneralDentistry/PaediatricDentistry/Orthodontics
intervention is necessary. If there
is considerable risk of damage to
the roots of teeth adjacent to the
supernumerary, or its position is
unlikely to obstruct tooth movement
in prospective orthodontic treatment,
then removal may not be indicated.40
Early identification and treatment of
supernumerary teeth is often advised
to minimize complications. If the
supernumerary is located close to
developing roots, however, delaying
removal until root development is
complete may be recommended.41 This
is to minimize the risk of irreversible
damage to developing roots.
Where further dental
development is anticipated or a
decision made not to remove a
supernumerary, regular monitoring of
the patient with relevant radiographic
investigation at intervals agreed
between the patient and his/her
general dental practitioner (GDP) and/
or other oral healthcare providers is
recommended.37,38
Removal is indicated if the
supernumerary:
Figure 5. Sectional DPT showing an upper right
unerupted distomolar.
„ Interferes with normal dental
development;
„ Impedes planned orthodontic tooth
movement;
„ Has associated pathology;
„ Compromises potential alveolar bone
grafting sites in patients with cleft lip
and palate;
„ Is situated at a potential implant
site.9,14,23
Removal of a supplemental
supernumerary tooth is commonly
indicated due to crowding,
displacement of adjacent teeth and
challenges associated with orthodontic
inter-arch correction, if it is retained.
Timely extraction of a supplemental
lateral incisor, for example, may result
in self-correction and satisfactory
alignment.15 In this situation, the choice
of tooth for extraction is based on:
„ Crown and root size and
morphology;
„ Degree of displacement;
„ Ease of surgical access; and
„ Periodontal considerations.
Case Report
Figures 6 a−c show the pre-treatment
radiographs and CBCT images of a
9.5-year-old Caucasian male who was
referred by his GDP to an orthodontist
regarding failure of eruption of his
maxillary central incisors. Royal College
DentalUpdate 735
 GeneralDentistry/PaediatricDentistry/Orthodontics
a a
b
b
Figure 7. (a) Space creation and traction applied
via ‘superthread’ to attachments bonded to
maxillary central incisors. (b) Continuation
of space creation and traction applied to
attachments bonded to maxillary central incisors.
a supernumerary tooth. Following
b
Figure 8. (a) Aligning of maxillary right central
incisor. (b) Continuation of aligning of maxillary
right central incisor.
of Surgeons of England guidelines
recommend that further investigation is
warranted if:
„ The maxillary central incisor does not
erupt within 6 months of its contralateral
incisor or within 12 months of eruption of
the mandibular incisors; or
„ The maxillary lateral incisor erupts
before the central incisor.25
Radiographic investigation
736 DentalUpdate
Figure 9. (a) ‘At deband’ (frontal view). (b) ‘At
deband’ (occlusal view).
revealed the presence of a
discussion with the patient’s family, it
was decided to bond attachments to the
unerupted central incisors at the same
time as removal of the supernumerary
tooth. The patient underwent a course
of sectional fixed appliance treatment to
create sufficient space, facilitate guided
traction and alignment of the incisors
(Figures 7−9). Careful post-treatment
monitoring will be required as patients
with an anterior maxillary supernumerary
tooth may be at increased risk of
developing one or more late forming
supernumerary teeth, especially in the
lower premolar region.
Conclusions
Supernumerary teeth are not uncommon
and can be associated with a variety
of effects on the dentition. The GDP
should be aware of the characteristics
that may indicate their presence,
including delayed eruption of teeth and
crowding, and should be able to carry
out appropriate clinical and radiographic
assessment. Once diagnosed,
each patient should be managed
appropriately to minimize (potential)
deleterious effects to the dentition.
This may require interdisciplinary
involvement of an orthodontist and oral
surgeon in the patient’s care.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Fleming P, Xavier G, DiBiase
A, Cobourne M. Revisiting the
supernumerary: the epidemiological
and molecular basis of extra teeth.
Br Dent J 2010; 208: 25−30.
2. Scheiner MA, Sampson WJ.
Supernumerary teeth: a review of
the literature and four case reports.
Aust Dent J 1997; 42: 160−165.
3. Lubinsky M, Kantaputra PN.
Syndromes with supernumerary
teeth. Am J Med Genet A 2016; 170:
2611−2616.
4. Rajab L, Hamdan M. Supernumerary
teeth: review of the literature and
a survey of 152 cases. Int J Paediatr
Dent 2002; 12: 244−254.
5. Brook A. A unifying aetiological
explanation for anomalies of human
tooth number and size. Arch Oral
Biol 1984; 29: 373−378.
6. Tippett H, Cobourne MT.
Supernumerary teeth. In:
Orthodontic Management of the
Developing Dentition. Cobourne M
(ed). Springer, Cham, 2017.
7. Shah A, Gill DS, Tredwin C, Naini
FB. Diagnosis and management of
supernumerary teeth. Dent Update
2008; 35: 510−520.
8. Lu X, Yu F, Liu J, Cai W, Zhao Y,
Zhao S et al. The epidemiology
of supernumerary teeth and the
associated molecular mechanism.
Organogenesis 2017; 13: 71−82.
9. Garvey MT, Barry HJ, Blake M.
Supernumerary teeth − an overview
of classification, diagnosis and
management. J Can Dent Assoc
1999; 65: 612−616.
10. Orhan AI, Özer L, Orhan K. Familial
occurrence of nonsyndromal
multiple supernumerary teeth: a
rare condition. Angle Orthod 2006;
76: 891−897.
11. Subasioglu A, Savas S, Kucukyilmaz
October 2020
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 GeneralDentistry/PaediatricDentistry/Orthodontics
E, Kesim S, Yagci A, Dundar
M. Genetic background of
supernumerary teeth. Eur J Dent
2015; 9: 153−158.
12. Akcam MO, Evirgen S, Uslu O,
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in individuals with cleft lip and/
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13. Mundlos S. Cleidocranial dysplasia:
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14. Chalakkal P, Krishnan R, De Souza
N, Da Costa GC. A rare occurrence
of supplementary maxillary lateral
incisors and a detailed review
on supernumerary teeth. J Oral
Maxillofac Pathol 2018; 22: 149.
15. Primosch RE. Anterior
supernumerary teeth − assessment
and surgical intervention in children.
Pediatr Dent 1981; 3: 204−215.
16. Kawashima A, Nomura Y, Aoyagi Y,
Asada Y. Heredity may be one of the
etiologies of supernumerary teeth.
Pediatr Dent J 2006; 16: 115−117.
17. Shilpa G, Gokhale N, Mallineni
SK, Nuvvula S. Prevalence of
dental anomalies in deciduous
dentition and its association with
succedaneous dentition: a cross-
sectional study of 4180 South Indian
children. J Indian Soc Pedod Prev
Dent 2017; 35: 56−62.
18. Harris EF, Clark LL. An
epidemiological study of
hyperdontia in American blacks
and whites. Angle Orthod 2008; 78:
460−465.
19. Khalaf K, Robinson D, Elcock C,
Smith R, Brook A. Tooth size in
patients with supernumerary teeth
and a control group measured by
image analysis system. Arch Oral Biol
2005; 50: 243−248.
20. Brook A, Griffin R, Smith R,
Townsend G, Kaur G, Davis G et al.
Tooth size patterns in patients with
hypodontia and supernumerary
teeth. Arch Oral Biol 2009; 54: S63−
S70.
21. Jimenez‐Rubio A, Segura J, Jimenez‐
Planas A, Llamas R. Multiple dens
invaginatus affecting maxillary
lateral incisors and a supernumerary
tooth. Endod Dent Traumatol 1997;
13: 196−198.
738 DentalUpdate
22. Cobourne MT, Sharpe PT. Making
up the numbers: the molecular
control of mammalian dental
formula. Semin Cell Dev Biol 2010;
21: 314−324.
23. Yassin O, Hamori E. Characteristics,
clinical features and treatment of
supernumerary teeth. J Clin Pediatr
Dent 2009; 33: 247−250.
24. Pippi R. Odontomas and
supernumerary teeth: is there a
common origin? Int J Med Sci 2014;
11: 1282−1297.
25. Seehra J, Yaqoob O, Patel S, O’Neill J,
Bryant C, Noar J, Morris D, Cobourne
M. National clinical guidelines for
the management of unerupted
maxillary incisors in children. Br Dent
J 2018; 224: 779−785.
26. Mitchell L, Bennett T.
Supernumerary teeth causing
delayed eruption − a retrospective
study. Br J Orthod 1992; 19: 41−46.
27. Ata-Ali F, Ata-Ali J, Peñarrocha-Oltra
D, Peñarrocha-Diago M. Prevalence,
etiology, diagnosis, treatment and
complications of supernumerary
teeth. J Clin Exp Dent 2014; 6: e414−
e418.
28. Shah A, Hirani S. A late-forming
mandibular supernumerary: a
complication of space closure.
J Orthod 2007; 34: 168−172.
29. Shetty R, Sandler PJ. Keeping your
eye on the ball. Dent Update 2004;
31: 398−402.
30. Sian J. Root resorption of
first permanent molar by a
supernumerary premolar. Dent
Update 1999; 26: 210−211.
31. Trejo-García W, Mendoza-Rodríguez
M, Medina-Solís CE, Veras-
Hernández MA, Lucas-Rincón SE,
Casanova-Rosado JF. Supernumerary
inversion in the palate of an infant:
report of a clinical case. Pediatria
(Asunción) 2018; 45: 237−241.
32. Chawla S, Singhal M, Yadav A.
Ectopic supernumerary tooth in
nasal cavity: a rare case report.
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116−117.
33. Meade MJ, Weston A, Dreyer CW.
Valid consent and orthodontic
treatment. Aust Orthod J 2019; 35:
35−45.
34. Bharmal RV, Furness C, Slattery D,
Campbell C. The multidisciplinary
management of unerupted
maxillary incisors. A report of
three cases. Ortho Update 2016; 9:
122−128.
35. Jacobs SG. Radiographic localization
of unerupted maxillary anterior
teeth using the vertical tube
shift technique: the history and
application of the method with
some case reports. Am J Orthod
Dentofacial Orthop 1999; 116:
415−423.
36. Liu D-g, Zhang W-l, Zhang Z-Y, Wu
Y-T, Ma X-C. Three-dimensional
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Endod 2007; 103: 403−411.
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Dentomaxillofac Radiol 2015; 44:
20140225.
39. Mossaz J, Kloukos D, Pandis N,
Suter VG, Katsaros C, Bornstein
MM. Morphologic characteristics,
location, and associated
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mandibular supernumerary teeth
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computed tomography. Eur J Orthod
2014; 36: 708−718.
40. Kurol J. Impacted and ankylosed
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Orthop 2006; 129: S86−S90.
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Determination of the optimum time
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Pediatr Dent 2010; 32: 14−20.
October 2020
 Enhanced CPD DO C OralSurgery

Claire Hopkins

Rhinosinusitis Update
Abstract: Rhinosinusitis is a common condition, affecting more than one in ten adults. This article will review current management
strategies. While multi-factorial in aetiology, odontogenic rhinosinusitis is an important subgroup that is often misdiagnosed and
recalcitrant to management. Patients with rhinosinusitis often report facial pain, but when it is severe, and mismatched in severity to
other sinonasal symptoms, facial migraine should be suspected. Finally, the risks of implantation in the setting of maxillary sinus mucosal
thickening and the need for ENT referral in such cases will be discussed.
CPD/Clinical Relevance: Sinus issues may present to a dentist as dental pain, and dental disease may itself cause sinusitis. With increasing
use of cone beam imaging, sinus pathology will be detected frequently in dental practice and this review will help to advise practitioners
on current best practice.
Dent Update 2020; 47: 739–746

Introduction
Rhinosinusitis is a condition of inflammation
of the nose and paranasal sinuses.
Rhinosinusitis is divided into acute and
chronic forms. In Acute Rhinosinusitis
(ARS) symptoms resolve within 12 weeks
(although usually within 4 weeks) and often
have an infective aetiology, while in Chronic
Rhinosinusitis (CRS), symptoms last more
than 12 weeks without complete resolution,
with multiple potential aetiologies, which
may include inflammation, infection
and obstruction of sinus ventilation.1
CRS is subcategorized into Chronic
Rhinosinusitis with Nasal Polyps (CRSwNP)
and without nasal polyps (CRSsNP), based
on visualization of polyps on rhinoscopy
or endoscopy. In a worldwide population
study, 10.9% of UK adults reported CRS
symptoms.2
Acute rhinosinusitis
Acute rhinosinusitis is usually caused by a
viral infection, and is usually self-limiting.
NICE guidance3 advocates avoidance of
Claire Hopkins, BMBCH, MA(Oxon),
FRCS(ORLHNS), DM, Professor of
Rhinology, Guy’s Hospital, Great Maze
Pond, London SE1 9RT, UK, (email:
clairehopkins@yahoo.com).
October 2020
antibiotic prescribing unless symptoms
persist for more than 10 days, or if the
patient has a high risk of complications,
or is systemically very unwell. First
choice antibiotics in such cases would
be co-amoxiclav or doxycycline. A large
number of high quality randomized trials
support restricting usage of antibiotics.4
Although antibiotics can shorten resolution
of the episode, only 1 in 20 benefits,
while 1 in 8 will develop side-effects of
antibiotic treatment. Despite this evidence,
ARS accounts for over 20% of antibiotic
prescriptions, with antibiotics being issued
in over 90% of consultations for ARS.5
Chronic rhinosinusitis
In contrast, most chronic rhinosinusitis
(CRS) is associated with inflammation as the
primary abnormality, with preservation of
drainage pathways, although acute infective
exacerbations may occur. It is thought that
the persistent inflammation found in CRS is
due to a dysfunctional host-environment,
with abnormal responses of the mucosa
to a wide variety of microbes and irritants.
Targeting inflammation is therefore
central to treatment options, rather than
targeting the microbes or simple drainage
procedures. This is reflected in the move
away from antibiotic treatment in chronic
disease. Chronic rhinosinusitis has been
shown to have significant impact on quality
of life (QOL), with symptoms such as nasal
obstruction, nasal discharge, facial pain,
anosmia and sleep disturbance.
Diagnosis of CRS is made by
the presence of two or more persistent
symptoms for at least 12 weeks without
complete resolution, one of which should
be nasal congestion/obstruction/nasal
discharge and/or facial pain/pressure/
headache or loss/reduction in smell.
Symptoms must be accompanied by
endoscopic evidence of mucopurulent
secretions, polyps or oedema or radiological
evidence of disease, as a symptom-based
diagnosis alone has high sensitivity but
poor specificity − only 50% meeting the
symptom-based definition have supporting
objective signs of disease.6
First-line treatment in CRS
usually includes a trial of intranasal
corticosteroids (INCS) and saline irrigation.
INCS have been shown to be effective in
a large number of randomized trials, with
a low incidence of adverse effects.7 This
treatment is the same for both CRS with
and without polyps, although steroid drops
may be considered for patients with polyps
to help achieve better nasal entry. Patients
should be advised that steroid sprays
work best when used regularly and do not
perform well as a rescue medication. It is
important that compliance is encouraged.
Daily large volume saline irrigation
should be recommended,8 and a number
DentalUpdate 739
 OralSurgery

a b

Figure 2. Odontogenic sinusitis, periapical

lucency and extensive opacification of the
ipsilateral sinuses. The patient developed orbital
cellulitis and an extradural collection secondary
to the odontogenic infection.

In more extensive sinus disease, or in the

presence of tumours, extended procedures
may be undertaken, including complete
ethmoidectomy, sphenoidotomy, medial
maxillectomy and median drainage of the
frontal sinuses. Use of navigation systems
Figure 1. Pre-operative CT and endoscopy images. (a) The cleft between the free posterior margin
may facilitate surgical dissection in the
of the uncinate process, marked in blue on the CT and outlined in blue on the endoscopy image setting of complex anatomical variations or
below: the ethmoid bulla is known as the hiatus semilunaris, and is key to the drainage of the anterior revision cases. Nasal polyp removal, surgery
ethmoid, maxillary and frontal sinuses. This common drainage pathway is called the ostiomeatal to manage underlying nasal abnormalities
complex. During functional endoscopic sinus surgery, the uncinate is removed along its anterior such as septal deviation, or turbinate
margin (marked in yellow) to expose the maxillary sinus ostium and the ethmoidal bulla and partitions hypertrophy may also be performed.
are removed to remove any obstruction to sinus drainage and allow topical access to the sinuses. (b) Studies have shown greater benefits in
The post-operative CT shows the widely opened sinus cavities; on the endoscopic image the frontal surgery performed at an early stage in the
recess (F) skull base and maxillary sinuses are exposed.
disease process.11 Currently, commissioning
restrictions and delays in primary care result
in 50% of patients who currently undergo
of positive pressure squeeze bottles or Patients who fail to achieve endoscopic sinus surgery waiting for more
irrigation jugs are available commercially. sufficient symptomatic control with than 5 years from the onset of symptoms
Antibiotics are not medical treatment may be considered for of CRS, potentially missing the window
recommended for routine management surgery. Surgical intervention typically of greatest benefit. Although up to 15%
of CRS, except in the setting of an acute involves endoscopic sinus surgery to of patients with CRSwNP require revision
surgery over a 5-year period, surgery
exacerbation. Patients with CRS often open and ventilate sinuses, restore normal
improves the effectiveness of ongoing
receive multiple courses of oral antibiotics mucociliary functioning and improve access
topical therapy and achieves significant
that may increase risk of antibiotic to topical steroids (Figure 1). ‘Functional’
improvements in disease-related quality of
resistance. There is little evidence for any endoscopic surgery focuses on opening
life that is maintained long term.12
benefit of short-term oral antibiotics in the ostiomeatal complex, and the key
CRS. There is weak evidence for the use of drainage pathway of the maxillary, anterior
a 12-week course of a low dose macrolide,9 ethmoid and frontal sinuses in the middle Facial pain and rhinosinusitis
in highly selected patients with CRSsNP, meatus. Inferior meatal antrostomies and Facial pain is reported by 50% of patients
although there is a small risk of cardiac sinus wash-outs are no longer performed as with CRS, but is infrequently severe and
toxicity.10 they do not improve mucociliary drainage. usually mirrors the severity of other nasal
740 DentalUpdate October 2020
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Figure 3. Right-sided maxillary mucous retention
cyst.
symptoms. When pain is severe, and is the
main presenting symptom, then a careful
history for migraines should be taken,
and key features of the pain should be
elicited. Indeed, facial pain, particularly if
reported as ‘throbbing‘ or associated with
light sensitivity, has a significant negative
predictive value in diagnosing CRS; its
presence makes CRS LESS likely.13 This is
also found when there is a mismatch in
the severity of facial pain and aural fullness
compared with the overall severity of nasal
symptoms,14 or a mismatch in the severity of
symptoms and endoscopy and radiological
scores.15
Facial migraine is commonly
misdiagnosed by both patients and
physicians as chronic or recurrent acute
rhinosinusitis; it typically presents with
severe pain over the paranasal sinuses and
is often associated with tenderness over the
glabellar area, and may be accompanied
by congestion and clear rhinorrhoea. Pain
is usually intermittent, but episodes can
be frequent and are often exacerbated
by overuse of codeine analgesia. Often
patients are given repeated courses of
antibiotics, but with limited effectiveness.
Of patients who met IHS criteria for
migraines, 84% of patients reported sinus
pressure, 82% reported pain in the sinus
areas, 63% reported nasal congestion, and
40% reported rhinorrhea at the time of
their initial consultation16 − it is therefore
easy to understand why the symptoms are
thought to arise in the sinuses. Vasodilation,
occurring as a downstream effect of
October 2020
Figure 4. Management algorithm for mucosal thickening discovered during pre-implantation
planning.
migraines, may cause sinonasal symptoms,
and may be relieved by the use of
decongestants, thereby falsely re-affirming
the diagnosis of sinogenic headache.17 In
a large series of nearly 3000 patients with
self diagnosed sinus headache, 88% were
found to have migraine and 8% tension
headaches.18
Recurrent acute rhinosinusitis
is actually very rare, and facial migraine
should certainly be considered in the
setting of frequent intermittent episodes of
facial pain in the absence of mucopurulent
discharge. Often, endoscopy or a CT scan
performed during an acute episode is
required to differentiate between the two,
as imaging performed in between episodes.
In one study of patients referred to tertiary
care thought to be having recurrent
episodes of ARS, CT performed at baseline
was normal at baseline and remained so
when repeated at the time of an acute
episode, excluding recurrent ARS in 96% of
cases:19 47% were ultimately diagnosed with
rhinitis, 37% with migraine, and 12.5% with
otherwise unspecified facial pain. Correct
and early diagnosis of migrainous headache
is important, both to achieve adequate
symptom control and to avoid unnecessary
and often repeated courses of medical, and
sometimes surgical, treatment. One patient,
OralSurgery
referred to my practice with ‘recalcitrant
recurrent acute sinusitis’, had undergone
seven sinus procedures despite no evidence
of mucosal thickening or other radiological
signs of CRS, but made an excellent
response to treatment for facial migraine.
Within specialist clinics, ‘upfront’
CT should be considered in patients with
negative endoscopy before prescribing
‘maximal medical therapy’ and reinforcing
a diagnosis of sinus disease.20 Primary care
and dental practitioners should similarly
avoid reinforcing patient perceptions of a
sinogenic headache, unless there is clear
supporting evidence on examination or
radiology.
Odontogenic sinusitis
Odontogenic sinusitis, where a dental
origin is identified clinically, radiologically,
or suggested by anaerobic predominance
on culture, may present as an acute or
chronic picture. It is estimated that 10%
of all sinusitis cases, and up to 40% of
recalcitrant maxillary sinusitis cases,21,22
have an odontogenic cause. The incidence
of odontogenic sinusitis appears to be
increasing,23 possibly related to the rising
rates of dental implantation.24 Only 50% of
patients have a history of previous dental
DentalUpdate 743
 OralSurgery
surgery or known periapical disease25
and, as dental pain is often absent,
odontogenic disease may present
directly to ENT, where the diagnosis
can be easily missed.26 Foul-smelling
unilateral mucopurulent nasal discharge
should raise suspicion of an odontogenic
sinusitis. Facial pain and pressure, nasal
obstruction and post-nasal drip may also
be reported.
Anterior rhinoscopy
and endoscopy, which may reveal
mucopurulence and oedema in the
middle meatus, and dental examination,
are helpful in making the diagnosis but
radiological imaging is essential. CT is
considered the gold standard (Figure
2), as high rates of false negatives are
reported with periapical radiography.27
Ideally, if CBCT is used, the field of view
should include the ostiomeatal complex,
the drainage pathway of the maxillary
sinus found in the superomedial aspect
of the sinus.
Anaerobic streptococci, gram-
negative bacilli and enterobacteriae are
the most commonly isolated microbes,28
although infections are usually
polymicrobial.
Initial medical management
should include nasal decongestants and
appropriate broad-spectrum antibiotics,
such as co-amoxiclav or clindamycin.
The dental origin should be addressed.
While many patients will settle with
conservative management, sinus surgery
will likely be required in up to 50% of
cases;29 this is more likely if there is a
history of preceding dental procedure
(particularly implantation) or if there
is obstruction to the drainage of the
maxillary sinus.
Management of the sinuses
prior to dental implantation
No doubt driven by a wish to avoid
iatrogenic odontogenic sinusitis, an
increasing number of patients appear
to be being referred to the NHS to
investigate incidental findings in the
maxillary sinus found on CBCT prior to
implantation.
There are currently few
published studies upon which to guide
management in such cases, although
the British Rhinological Society are in
744 DentalUpdate
the process of developing a consensus
document.
One of the most common
incidental findings is a mucosal retention
cyst (Figure 3); these are found in a third of
CT scans performed for non-rhinological
conditions and are not a manifestation
of rhinosinusitis.30 They are rarely
symptomatic and have a high recurrence
rate after marsupialisation, and therefore
treatment is not required.
Mucosal thickening is also
common in the absence of sinus disease.
A study of patients undergoing sinus
imaging for non-sinusitis causes found
that only 25% had no mucosal thickening,
with a mean Lund-Mackay score (a
staging system that quantifies the amount
of mucosal thickening on a scale of
0−24) of 4.26.31 Dental literature defines
rhinosinusitis based on radiological
thickening of the mucosa of >2 mm,32 but
this definition has poor specificity and
will include many healthy asymptomatic
patients.
The presence of mucosal
thickening on CT has been shown not to
affect the success of dental implants. In
one study, with strict inclusion criteria, 29
CBCT scans were being evaluated prior
to dental implantation. Of these, 6.9%
had minimal thickening (1−2 mm), 20.7%
of cases had moderate thickening (2−5
mm), and 65.5% had severe thickening
(>5 mm). There was a 100% success rate of
the implants with no loss of implantation
or infection.33 This is also supported by a
study by Jungner et al, in 2014, whereby
radiographic signs of sinus pathology,
opacification, polyp-like structures, and
thickening of the sinus membrane, were
not correlated to implant survival.34 A key
feature is whether the drainage pathway
of the maxillary sinus, the ostiomeatal
complex, is patent; this should be included
in the field of view on cone beam imaging
if rhinosinusitis is suspected. If the
drainage pathway is unobstructed, there
is only mild mucosal thickening and, if the
patient is asymptomatic, there is no need
for ENT assessment. In all other cases,
onward ENT referral should be made, with
transfer of the appropriate imaging. As
NHS systems are often unable to open
CDs or import images, it can be helpful to
ask the patient to take pictures of relevant
images on their smartphone. A treatment
algorithm is proposed in Figure 4.
Conclusions
Rhinosinusitis is a common chronic
condition requiring early, correct diagnosis,
medical management and, at times,
surgical intervention. Radiological imaging
may be required to distinguish between
facial migraine in the setting of normal
endoscopy.
Odontogenic sinusitis should
be considered with unilateral rhinosinusitis,
and expedient management of the dental
cause will result in resolution in over 50%
of cases.
Mild mucosal thickening and
mucous retention cysts in the maxillary
sinus are not contra-indications to dental
implantation, but ENT assessment is advised
if the sinus drainage is obstructed.
Compliance with Ethical Standards
Conflict of Interest: The author declares that
that there is no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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Otol 2012; 126: 43−46.
24. Lopes LJ, Gamba TO, Bertinato JV,
Freitas DQ. Comparison of panoramic
radiography and CBCT to identify
maxillary posterior roots invading the
maxillary sinus. Dentomaxillofac Radiol
2016; 45: 20160043.
25. Maillet M, Bowles WR, McClanahan
SL, John MT, Ahmad M. Cone-beam
computed tomography evaluation of
maxillary sinusitis. J Endod 2011; 37:
753−757.
26. Cartwright S, Hopkins C. Odontogenic
Sinusitis an underappreciated
diagnosis: our experience. Clin
Otolaryngol 2016; 41: 284−285.
27. Shahbazian M, Jacobs R. Diagnostic
value of 2D and 3D imaging in
odontogenic maxillary sinusitis: a
review of literature. J Oral Rehabil 2012;
39: 294−300.
28. Brook I. Sinusitis of odontogenic origin.
Otolaryngol Head Neck Surg 2006; 135:
349−355.
29. Mattos JL, Ferguson BJ, Lee S.
Predictive factors in patients
undergoing endoscopic sinus surgery
for odontogenic sinusitis. Int Forum
Allergy Rhinol 2016; 6: 697−700.
30. Kanagalingam J, Bhatia K, Georgalas
C, Fokkens W, Miszkiel K, Lund VJ.
Maxillary mucosal cyst is not a
manifestation of rhinosinusitis: results
of a prospective three-dimensional
CT study of ophthalmic patients.
Laryngoscope 2009; 119: 8−12.
31. Ashraf N, Bhattacharyya N.
Determination of the “incidental”
Lund score for the staging of chronic
rhinosinusitis. Otolaryngol Head Neck
Surg 2001; 125: 483−486.
32. Cagici CA, Yilmazer C, Hurcan C, Ozer
C, Ozer F. Appropriate interslice gap
for screening coronal paranasal sinus
tomography for mucosal thickening.
Eur Arch Otorhinolaryngol 2009; 266:
519−525.
33. Maska B, Lin GH, Othman A et al.
Dental implants and grafting success
remain high despite large variations in
maxillary sinus mucosal thickening. Int
J Implant Dent 2017; 3: 1.
34. Jungner M, Legrell PE, Lundgren S.
Follow-up study of implants with
turned or oxidized surfaces placed
after sinus augmentation. Int J
Oral Maxillofac Implants 2014; 29:
1380−1387.
CPD ANSWERS
July/August 2020
1. C 6. B
2. C 7. B
3. C 8. B
4. A 9. B
5. B 10. B
October 2020
 Enhanced CPD DO C Endodontics

Manahil Maqbool Tahir Yusuf Noorani

Jawaad Ahmed Asif, Saleem D Makandar and Nafij Bin Jamayet

Controversies in Endodontic
Access Cavity Design: a Literature
Review
Abstract: The purpose of this article is to compare and contrast the different types of endodontic access cavity designs based on the
current available evidence. Four types of access cavity designs, namely, traditional endodontic access cavity design (TEC), contracted/
conservative endodontic access cavity design (CEC), ultra-conservative or ninja endodontic access cavity design (NEC) and truss
endodontic access cavity design (TREC) have been suggested, and the latter three are currently in the limelight. Studies in vitro have
been performed comparing the TECs, CECs, TRECs and NECs; except for the TECs, the other three types have not undergone clinical trials
on patients. The choice of endodontic access cavity design affects fracture strength of the tooth, but remnants of pulpal tissue, due to
ineffective instrumentation, can cause root canal treatment failure.
CPD/Clinical Relevance: Root canal treatment with new access cavity designs has been proposed. However, there is lack of evidence to
support such practices. It is important to consider the potential deleterious effects of such access cavity designs rather than emphasizing
the preservation of tooth structure alone.
Dent Update 2020; 47: 747–754

Although the role of caries removal
and root canal disinfection cannot be
overemphasized, there is considerable
Manahil Maqbool, BDS, MSc,
Postgraduate Student, Paediatric
Dentistry Unit, Tahir Yusuf Noorani,
DDS, MResDent, FRACDS, Senior
Lecturer, Conservative Dentistry Unit
(email: dentaltahir@yahoo.com), Jawaad
Ahmed Asif, BDS, MOMS, FRACDS,
Senior Lecturer, Oral and Maxillofacial
Surgery Unit, Saleem D Makandar,
BDS, MDS, Senior Lecturer, Conservative
Dentistry Unit and Nafij Bin Jamayet,
BDS, Grad DipClinSc, MScDent, Senior
Lecturer, Prosthodontics Unit, School
of Dental Sciences, Universiti Sains
Malaysia, Health Campus, 16150 Kubang
Kerian, Kota Bharu, Kelantan, Malaysia.
October 2020
controversy regarding the size of the
preparation of the access cavity and the
parameters of the preparation of the root
canal. The need for dentine conservation
cannot, however, be understated.1 Direct
access to the root canal system is one of
the purposes of an endodontic access
cavity. The traditional endodontic access
cavity (TEC) design focuses on the inclusion
of all pulp horns and the removal of the
roof of the pulp chamber so that the
coronal portion of the root canal system is
sufficiently debrided (Figure 1 a, b).2 This
approach has been contested by the radical
design of the access cavity that has been
proposed in recent years. It stressed the
preservation of pericervical dentine (PCD)
and suggested that it was not necessary to
unroof the pulp chamber completely.1 The
interest in minimally invasive endodontics
is enabled by new technologies and
techniques that maximize residual dentine.3
The designs of the endodontic access cavity
and cumulative loss of tooth structure
appear to influence the fracture strength of
endodontically treated teeth greatly.4 The
amount of the residual dental substance
could be affected by the preparation of
the endodontic access cavity. Therefore,
inspired by the minimally invasive concept
of restorative dentistry, a conservative
endodontic access cavity (CEC) (Figure 1 c,
d) preparation was proposed to preserve
as much tooth structure as possible.1 Some
endodontists underlined this principle by
creating ultra conservative endodontic
access cavities ‘ninja’ and ‘truss’ (NEC and
TREC, respectively).5,6 An NEC is a small
cavity on the occlusal surface that should
enable the clinician to find and access all
the orifices of the canal system (Figure 1 e,
f ).2 The other approach is orifice-directed
DentalUpdate 747
 Endodontics
Figure 1. An artist’s impression showing the different access cavity designs and the possible amount of
tooth structure removal in a mandibular molar (a−b) TEC, (c−d) CEC, (e−f) NEC, (g−h) TREC.
Figure 2. A radiograph showing the pericervical dentine (PCD), which is the most common area
of catastrophic restorative/root fracture and should be preserved. Additionally, overhanging pulp
chamber roof that should be preserved is also shown.
design (also called the ‘truss’ access cavity)
in which separate cavities are prepared
to approach the mesial and distal canal
systems in a mandibular molar (Figure
748 DentalUpdate
1 g, h), whereas for maxillary molars the
mesiobuccal and distobuccal canals are
accessed through one cavity and the
palatal canal through another.7 The purpose
of this article is to describe the various
newly proposed endodontic access cavity
designs, review the literature, and suggest
best clinical practice based on the current
available evidence.
Access cavity preparation
The access cavity preparation generally
refers to the part of the cavity from the
occlusal table to the canal orifices. Black’s
principles of cavity preparation, including
outline, convenience, retention, and
resistance forms, speculate the basis of
TEC. The outline form of the endodontic
cavity must be correctly shaped and
positioned to establish complete access for
instrumentation, from cavosurface margin
to apical foramen. Convenience form,
as conceived by Black, is a modification
of the cavity outline form to establish
greater convenience in the placement of
intracoronal restorations. Later, removal
of the remaining carious dentine and
defective restorations in an endodontic
cavity preparation is necessary. It must be
removed for three reasons:
1. To eliminate as many bacteria as possible
from the interior of the tooth mechanically;
2. To eliminate the discoloured tooth
structure that may ultimately lead to
staining of the crown;
3. To reduce the risk of bacterial
contamination of the prepared cavity.8
Another important reason to
eliminate undermined and unsupported
tooth structure is to evaluate whether
the tooth is restorable or not, and also to
minimize the possibility of tooth fracture
in future. It is imprudent and unlikely that
a clinician would leave the structure of the
diseased tooth intact to create a textbook
access cavity.9 In 2010, Clark and Khademi
introduced the concept of contracted
endodontic access cavity design, in a series
of case reports.10 The basis of a CEC was
kept in terms of saving the pericervical
dentine (PCD) and leaving small overhangs
of the pulp chamber roof behind. The most
important tooth structure responsible for
long-term survival is considered to be the
PCD, the dentine structure located 4 mm
below and 4 mm above the alveolar crest1
(Figure 2), which serves as the neck of the
tooth and is responsible for distribution
of functional and mechanical stresses
inside the tooth.11,12 More of the occlusal
October 2020
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tooth structure can be sacrificed than
the cervical tooth structure, as the key
pericervical tooth structure should
remain as unaltered as possible.1 A new
contracted access cavity, using a different
set of burs than those used for TEC,
was suggested. In a CEC, measurement
reference points may change; for
example, in the past, the reference for the
mesial canals of mandibular molars was
often the corresponding MB cusp. Now
it may be found as a reference more to
the distal, as it would preserve PCD and
overhanging dentine. The simultaneous
placement of 4 or 5 gutta-percha points
for a cone fit radiograph in the more
constricted access may be difficult
without trimming to eliminate binding.
Clark and Khademi recommended
not removing the pulp tissue under
the overhang until the obturation was
finished; that way the operator only has
to clean it once.10
Another approach to the
conservation of tooth structure is the
orifice-directed design (TREC) (also
known as the ‘truss’ access cavity) in
which separate cavities are prepared.
The main objective of these access cavity
designs is to preserve strategic dentine
(ie to leave a dentine bridge between
the two cavities thus prepared).2 In TREC,
the cavities are prepared over the mesial
and distal canals of the mandibular
tooth, respectively, guided by computed
tomographic images. The pulp chamber
roof is maintained beneath the ‘truss’ of
the tooth structure, between the mesial
and distal cavities.2 However, TREC
significantly impaired the debridement of
the pulp chamber.5 Only one case report
has been published so far regarding a
‘truss’ type cavity design, however, no
follow-up of this case was presented.13
Hence, the long-term outcome of this
type of treatment is unknown. Another
ultra-conservative technique has recently
been introduced, which is also known as
the ‘ninja’ access cavity design.6 An NEC
is actually an even smaller access cavity
than the one made for a CEC on the
occlusal surface, that should enable the
clinician to find and access all the orifices
of the canals, but there is not sufficient
data or literature discussing this type.
However, the NEC could jeopardize the
complete removal of infected pulp tissue
October 2020
Endodontics
Figure 3. Diagrammatic view of the three access cavities in maxillary anterior teeth: (a) lingual
cingulum access cavity; (b) lingual conventional access cavity; (c) incisal straight-line access cavity.
Adapted from Mannan et al. 14
from the pulp chamber and make canal of canals, irrespective of the access cavity
instrumentation more difficult and less safe. design. However, the incisal straight-line
access cavity allowed a larger proportion
Histological evaluation of the root canal walls to be instrumented
as compared to the conventional lingual
In a study conducted on mandibular molars,
access cavity and the cingulum access
one type of CEC design (Truss access) was
cavity.14 Nevertheless, it is still uncertain
tested, to acertain whether it was able to
what happens to the incisal part of the
debride the pulp chamber completely or
pulp chamber in incisal straight-line and
not, and to evaluate the remaining pulp
lingual cingulum access, as no histological
tissue (RPT) in both experimental group the
evaluation was performed to identify any
(TREC) and control group (TEC). Although
remaining pulp tissue under the pulp horns.
both groups showed the presence of RPT
Whether the pulp remnants and possible
in the pulp chamber, the amount in the
remaining bacterial biomass would later
TEC group was significantly lower than
be troublesome for the patient or not, is
that of the TREC group. There was no
still unknown. Further investigations are
substantial difference in RPT present in
required to establish the prognosis of
the isthmus (within the canals) between
root canal treatment in both anterior and
the TEC and TREC groups at any level.2
posterior teeth with these new designs.
Only the area of the pulp chamber under
Furthermore, no study has been done so far
the truss was assessed, which could serve
to identify possible remaining pulp tissue
as a nutritional source for the remaining
in the pulp chamber in other CEC and NEC
bacterial biomass, leading to persistent
designs. This holds relevance as the pulp
infection. The results of this study showed
chamber is not completely unroofed and
two important findings: the pulp chamber
remaining infected pulp tissue under the
showed a significantly reduced amount of
pulp horns may lead to contamination
remaining pulp tissue in TEC compared to
of the rest of the root canal system and
TREC access, and there was no difference
subsequent failure.
in the amount of remaining tissue in the
root canals, close to and at the isthmus
area of the root thirds between the two Fracture testing
access cavity designs. In another study, Fracture tests are used primarily to compare
the effect of different access cavity designs the fracture strength or fracture resistance
(lingual cingulum, lingual conventional of teeth. Various studies that compared the
and incisal straight-line) (Figure 3) on the fracture resistance of endodontically treated
ability of endodontics files to plane the root teeth with different access cavity designs
canal walls in maxillary anterior teeth was are listed in Table 1.
tested.14 It was found that instrumentation It has been shown that
did not allow the entire root canal wall to conservative endodontic access cavity
be instrumented during the preparation designs, specifically the ‘ninja’ and ‘truss’
DentalUpdate 751
Endodontics
Author Purpose of Study
Krishan et al 15
Assess impacts of conservative
endodontic cavity on root canal.
Instrumentation and resistance
to fracture.
Moore et al21 Assess impacts of contracted
endodontic cavities (TEC vs
CEC) on instrumentation and
biomechanical responses.
Chlup et al18 Assess fracture behaviour of
teeth with conventional and
mini-invasive access cavity
designs (TEC vs CEC).
Plotino et al16 Assess fracture strength of
endodontically treated teeth
with different access cavity
designs (TEC, CEC, NEC).
Rover et al22 Assess influence of access cavity
design (TEC, CEC) on root canal
detection, instrumentation
efficacy, and fracture resistance.
752 DentalUpdate
Methodology
Intact extracted human teeth
assigned to CEC & TEC groups.
Pre- and post-canal treatment
micro CT was done. UCL and
DVL for each tooth type was
analysed. Fracture loading
using Instron Universal Testing
Machine done.
Intact extracted human molars
assigned to CEC & TEC groups.
Pre- and post-canal treatment
micro CT was done. Linear strain
gauge was attached to teeth
and were subjected to load
cycles (50−150 N) in the Instron
Universal Testing machine,
and the axial micro strain was
recorded.
Intact extracted human teeth
were assigned to CEC & TEC
groups. All specimen teeth
embedded in the resin and
loaded until fracture using
Instron Universal Testing
Machine.
Extracted human teeth were
assigned to control (intact
teeth), TEC, CEC, or NEC groups.
Teeth were endodontically
treated and restored. Specimens
then loaded to fracture in a
mechanical material testing
machine. The maximum load
at fracture and fracture pattern
(restorable or unrestorable)
were recorded.
Extracted intact molars were
scanned with micro–computed
tomographic imaging and
assigned to CEC or TEC group.
After root canal preparation
non-instrumented canal area,
hard tissue debris accumulation,
canal transportation, and
centring ratio analysed. After
cavity restoration fracture
resistance test done.
Outcomes
CEC compromised canal
instrumentation
only in the distal canals of
lower molars, but it conserved
coronal dentine, which
increased fracture resistance. No
difference in fracture resistance
in anterior teeth with different
access cavity designs.
CECs did not impact
instrumentation efficacy and
biomechanical responses
compared with TECs. No
difference between groups in
terms of fracture resistance.
No significant difference
between CEC and TEC in terms
of fracture resistance but higher
fracture load was required for
CEC.
NEC did not increase fracture
strength compared with CEC.
Teeth with TEC access showed
lower fracture strength than the
ones prepared with CEC or NEC.
No associated benefits with
CECs could be proved as
compared to TEC. Lower ability
of root canal detection and
higher incidence of canal
transportation was noted with
CEC.
October 2020
 Endodontics

Author Purpose of Study Methodology Outcomes

Sabeti et al 23
Assess impact of access cavity For tapering assessment, 30 Increasing root canal taper can
design (CEC & NEC) and sound distobuccal roots of reduce fracture resistance. NEC
root canal taper on fracture maxillary molars were randomly in comparison with CEC had no
resistance. assigned to 1 of 3 groups, 0.04 significant impact on fracture
taper, 0.06 taper, or 0.08 taper. resistance.
After canal preparation fracture
resistance was tested using a
universal testing machine.

Corsentino et al5 Assess influence of access cavity
design (TEC, CEC, TREC) and
remaining tooth substance on
fracture strength.
Sound molar teeth were
selected. After access cavity
preparation, all test teeth were
endodontically treated and
restored. The specimens were
then loaded to fracture in a
universal loading machine.
TREC & CEC do not increase
the fracture strength of endo
treated teeth, rather the loss of
mesial and distal ridges reduced
fracture strength of teeth
significantly.

Özyürek et al24 Assess the effects of endodontic Intact molar teeth were TREC did not increase the
access cavity preparation randomly assigned to TEC or fracture strength of teeth.
design (TEC, TREC) and different TREC group (with one marginal No difference in the fracture
restorative base material on the wall missing), restored with strength between teeth with
fracture strength. either SDR or EverX posterior as TEC or TREC when the same
base material. Sample loaded base material was used
after restoration until fracture.
Abbreviations: UCL − Untouched Canal Wall; DVL − Dentine Volume Removed; CEC − Conservative Endodontic Access Cavity; TREC −
Truss Endodontic Access Cavity; TEC − Traditional Endodontic Access Cavity; NEC − Ninja Endodontic Access Cavity.
Table 1. List of studies that compared the effects of different access cavity designs on the fracture strength and instrumentation efficacy. Studies published
until 31 December 2018 were included.

types, are successful in maintaining the
pericervical dentine, and hence increasing
the fracture resistance of the tooth. However,
a group of researchers concluded that it
was the loss of the mesial or distal marginal
ridge that affected the fracture resistance
of endodontically treated teeth rather than
the access cavity design itself.5 Furthermore,
Krishan et al15 found no advantage of
conservative access cavity design over
traditional design in terms of fracture
resistance in anterior teeth. Another study
compared teeth with different access cavity
designs and sound teeth. It was found that
unrestorable type fractures after fracture
testing were noted considerably more often
than the restorable type in access teeth,
irrespective of the access cavity design.16
Besides, a huge limitation to the findings of
the previous studies is that all of them were
performed in vitro on almost non-carious
October 2020
teeth, and the age of the patients, from
whom the teeth were extracted, was not
recorded. As with the increasing age of the
patient, the brittleness and hence the fracture
ability of a tooth increases,17 it is necessary
that the age be considered and mentioned.
Furthermore, all these studies used static
loading to determine the fracture strength.
Ideally, cyclic loading, as compared to static
loading, would correspond better to the
natural loading during chewing. Additionally,
there was no simulation of periodontal
ligament in most of these studies. Although
this simulation is necessary, a standardized
periodontal ligament simulation model has
not yet been introduced.18
The challenges and changes
Bio-minimalism recognizes that the
pericervical dentinal (PCD) zone is essential
to support the residual coronal tooth
structure during functional loading stress,
and acts ostensibly to minimize cuspal
flexion during mastication.9 However,
the fracture strength of endodontically
treated teeth could also be affected by
insufficient dental residue, due to the
caries causing the loss of one or more
dentinal walls.19 Fortunately, technological
advances in armamentarium has brought
the objectives of minimally invasive
endodontics closer. Cone beam computed
tomography aids the clinician in avoiding
the removal of excessive hard tissue by
allowing assessment of the angulation and
orientation of the root canals.9 Despite
the limited clinical evidence for the use
of contracted access cavity designs,
the growing interest and technological
advances in image-guided endodontics
can prove to be a paradigm shift in root
canal treatment.2 Besides, we now have
DentalUpdate 753
 Endodontics
files and finishers that adjust to the original
canal shape, scrape biofilm in a way similar
to periodontal scalers and make it easier
for irrigants to act on exposed microbes.9
Furthermore, with the advent and use of the
dental operating microscope, root canals
can be detected and cleaned optimally,
even through minimally invasive endodontic
access cavities. However, currently there is
little evidence (mainly from in vitro studies)
available to prove that conservative and
ultra-conservative access cavity designs
are advantageous over their traditional
counterpart, especially when the need to
clean the root canal adequately remains
an overarching objective of non-surgical
endodontic treatment.2 Besides, no clinical
trials have been reported so far on patients
with these newly introduced contracted
cavity designs. Additionally, owing to the fact
that pulpal remnants were seen in the pulp
chamber while examining the histological
sections of the ‘truss’ type CEC,2 the long-
term success rate is unknown. Perhaps case
selection (based on multifactorial evaluation,
including the condition of the pulp, vital
or necrotic), level of difficulty (presence
of calcifications, curvatures, etc) and
accessibility, in addition to the equipment
and facilities available, would serve as a
reason in which conservative access cavities
could be prepared for certain cases without
compromising the ability to locate all canals
and the efficiency of subsequent root canal
treatment procedures.20
Conclusion
Currently, there is no conclusive evidence
to suggest that conservative or ultra-
conservative access cavity design can help
retain endodontically treated teeth longer
by increasing their fracture resistance.
Furthermore, there is no conclusive evidence
that the biological principles (complete
disinfection) of endodontic treatment can be
adequately achieved with these conservative
access cavity designs. Hence, conservative
or ultra-conservative access cavity designs
should be used with extreme caution.
Perhaps the objective of conservative
cavity preparation should be avoided from
‘removing the smallest possible tooth
structure’ to ‘removing as little as necessary’.
Besides, to validate these newly introduced
access cavity designs, more research needs to
be conducted, as the studies remain few and
754 DentalUpdate
fragmentary.
Acknowledgement
The authors acknowledge the financial
support in preparation of this article
from Universiti Sains Malaysia (short-
term research grant scheme no. 304/
PPSG/6315195).
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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human tooth. Int J Oral Sci 2014; 6: 61−69.
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S. Impacts of contracted endodontic cavities
on instrumentation efficacy and biomechanical
responses in maxillary molars. J Endod 2016; 42:
1779−1783.
22. Rover G, Belladonna FG, Bortoluzzi EA, De-Deus G,
Silva EJNL, Teixeira CS. Influence of access cavity
design on root canal detection, instrumentation
efficacy, and fracture resistance assessed in
maxillary molars. J Endod 2017; 43: 1657−1662.
23. Sabeti M, Kazem M, Dianat O et al. Impact of access
cavity design and root canal taper on fracture
resistance of endodontically treated teeth: an ex
vivo investigation. J Endod 2018; 44: 1402−1406.
24. Özyürek T, Ülker Ö, Demiryürek EÖ, Yılmaz F. The
effects of endodontic access cavity preparation
design on the fracture strength of endodontically
treated teeth: Traditional versus conservative
preparation. J Endod 2018; 44: 800−805.
October 2020
 Enhanced CPD DO C Radiology

Kuljit K Grewal

Neil Heath

Update on Ionizing Radiation

Regulations 2017 (IRR 2017)
and Ionizing Radiation Medical
Exposure Regulations 2018 (IRMER
2018) − Relevance to the Dental
Team
Abstract: The introduction of the new European Basic Safety Standards Directive in 2013 outlined clear responsibilities and requirements
for all professionals involved in radiodiagnostic and radiotherapeutic procedures. Its guidance has since been transcended and
incorporated into the revised IRR 2017 and IRMER 2018 national guidelines. The revisions to the guidelines have implications for all health
professionals involved in undertaking radiation exposures, including dentists, doctors, medical physics staff and radiographers.
CPD/Clinical Relevance: Dentists need to appreciate the revisions in IRMER 2018 and IRR 2017 guidance and incorporate these changes
into clinical practice to ensure good practice.
Dent Update 2020; 47: 755–760

The new European Basic Safety Standards
Directive was unanimously adopted in
2013.1 It incorporates recommendations
issued by the International Commission
on Radiological Protection, as well as
Kuljit K Grewal, BDS, MFDS(Glas),
GDP, HHS Dental Practice, Hounslow,
(email: ksanghera06@hotmail.com) and
Neil Heath, DCR(R), BDS, MSc(Newc)
MFDS(Edin), FDS RCPS(Glas), DDR
RCR, Consultant at Newcastle Dental
Hospital, Richardson Road, Newcastle
upon Tyne NE2 4AZ, UK.
October 2020
operational expertise and latest
scientific evidence. The directive has
since been embedded into UK law by
revision of IRMER 2018 and IRR 2017
guidance. The purpose of this article is
to shed light on some of the changes
introduced and highlight its relevance
to the dental team.
IRR 2017
IRR 2017 predominantly focuses on
radiation exposure to employees
and the public. It is regulated in
dental practice by the Health and
Safety Executive (HSE). The revision
of the guidelines required all dental
practices to register with the HSE, at a
fee of £25 by the 5th February 2018,
to acknowledge the use of dental
X-ray equipment. This is due to the
graded approach utilized by HSE,
whereby dental radiation exposures
are perceived as ‘intermediate risk’. In
light of a material change, such as a
change of address, it would necessitate
the employer to register again.2 Under
previous regulations, employers were
only obligated to inform the Health
and Safety Executive of the use of
DentalUpdate 755
 Radiology
Figure 1. The key areas that need to be covered as part of the induction process when new staff are
enrolled into the Radiology Department at Newcastle Dental Hospital.
ionizing radiation for dental radiography
purposes.
Key changes in IRR 2017
Appointment of Medical Physics Experts
(MPE)
IRR 2017 places a clear emphasis on
the employer to appoint a competent
certified person to fulfil the role of
Medical Physics Expert (MPE), a term
used in IRMER and/or Radiation
Protection Adviser (RPA). It highlights
the need for the MPE to meet a set
criteria of competence, and actively
be involved in assessing patient dose
and quality assurance of radiography
equipment.
Unintended or accidental exposure
In the event of an unintended or
accidental exposure, the new guidelines
756 DentalUpdate
stress the need for greater transparency
to ensure all parties are informed of the
incident and the outcome of analysis of
the exposure. Under this legislation and
a duty of candour, this is then required
to be relayed to the patient. The IRMER
practitioner and IRMER referrer must
also be informed. The authors of this
paper deem a ‘clinically significant’
exposure to be:
„ Any over exposure or unintended
dose that results in an additional risk to
the patient of more than 1 in 1000;
„ Any over exposure or unintended
dose that is likely to result in a tissue
effect (ie skin reddening);
„ An exposure which compromises a
dose limit set for the lens of the eye.
IRR 2017 also states that the
dose limit to the exposure of the
lens of the eye has been reduced to
20 mSv compared to the previous limit
of 150 mSv. This is due to the increased
radiosensitivity of the lens, a caveat to
this implementation being the use of
dedicated eye dosimeters to measure
exposures accurately. These are doses
much higher than any dentist should
receive.
Definition of ‘classified’ and ‘non-classified’
outside workers
Furthermore, the revised IRR 2017
makes a differentiation between outside
workers, depending on whether they
are ‘classified’ or ‘non-classified’. A
classified worker being an ‘employee
receiving an effective dose greater than
6 mSv a year or an equivalent dose
greater than 15 mSv per year for the
lens of the eye, who carries out services
in a controlled area’. Such a dose should
not be experienced by the dental team.
A non-classified outside
worker is permitted to work and provide
services within the controlled area,
‘however would not be exposed to
an effective dose greater than 6 mSv
a year or an equivalent dose greater
than 15 mSv per year for the lens of the
eye’. Therefore, these workers may be
engineers or contractors, respectively.
Now all employees who undertake work
in a radiation-controlled area, who are
likely to surpass public dose limits, must
have radiation monitoring and training.
This would not normally include the
dental team in their normal role.
IRMER 2018
IRMER 2018 primarily ensures that
patients are protected from harm when
exposed to ionizing radiation. It applies
to all radiation exposures undertaken
as part of medical or dental diagnosis,
exposures as part of health screening
programmes, and those participating
in diagnostic or therapeutic research
programmes. Its key principles focus
on justification of exposures and
optimizing diagnostic doses to keep
them As Low As Reasonably Practicable
(ALARP).
Revisions of IRMER 2018
Carers and comforters
The revision of IRMER makes a clear
October 2020
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 Supporting your
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Dental_Update_Nov19 (10/19)

Figure 2. The information leaflet available to patients to read in advance of taking the radiograph.
reference to carers and comforters. In the
dental environment it would be those
willingly and knowingly remaining in
the controlled area during the radiation
exposure to support the patient, ie a parent
with a child. The revision stresses that
informed consent must be elicited from the
carer in advance, with the net benefit of the
October 2020
exposure outweighing any health detriment
posed to both the carer and patient.
Practically, for the dental team this may
involve presenting some dose comparisons
to real-life risks.
Quality assurance programmes
Another add-on in IRMER 2018 is the
Radiology
greater emphasis placed on quality
assurance programmes and audit
to ensure exposure dosages are
regularly reviewed and equipment
periodically maintained to enhance
performance. The requirements differ
for CBCT and other dental imaging
equipment, and so clinicians must
be aware of this.3 Currently, there is
uncertainty as to whether exposure
dosages used with intra-oral sets
need to be clinically documented
with every exposure. In standard
dental surgery, this may simply
involve documentation of exposure
factors KVp, mA and time. Many
DPT and CBCT machines now give
access to/flag up a Dose Reference
Level (DRL), which gives a record that
can be used by medical physicists.
This practice of recording individual
exposures would fit with the
aspiration to build large datasets,
so that national radiation dosages
used in dentistry can be harvested
for audit. It is the recommendations
of these authors that this is best
practice.
Adequate training for practitioners and
operators
The roles and duties of the IRMER
referrer, practitioner and operator
remain unchanged. The new revision
does stress the necessity for better
availability of referral criteria, the use
of diagnostic reference levels and
encourages better communication
between all duty holders. The content
of training requirements remains
largely unchanged, however, there
is an aspiration to educate more in
diagnostics, with reference to more
emphasis on the fundamentals of
radiological interpretation being
taught to delegates. Figure 1
demonstrates the key areas that are
covered as part of a routine induction
to a radiology department.
Informed consent
A further change incorporated in
the IRMER guidelines states that ‘the
employer’s procedures must provide
that, where appropriate, written
instructions and information are
DentalUpdate 759
Radiology

provided to [the] patient……[and] the individual concerned is

informed in advance about the risks of the exposure’.4 How this
will be applied to clinical practice is currently under debate.
The writers of this paper currently provide patients with written
guidance (Figure 2) prior to exposure and acquire verbal
informed consent following a brief discussion with the patient.
years of leading This allows patients to be well versed in the risks and benefits
of the exposure, and opens up dialogue for patients to ask
clinical success
c
clinica questions if any concerns are present.

’Non-medical imaging exposures’ is substituted for ‘medical-legal

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exposures’
’Non-medical imaging exposures’ relates to undertaking
imaging that is of no health benefit to the individual. In
dentistry, this may be for the purpose to age assess specific
populations, such as asylum seekers. This is unethical practice,
however, but may still be performed by certain public
authorities. Other groups who may fall into this category
include research subjects and the military. The new revision
stresses that employers need to have a set of procedures
in place for such requests and appropriate documentation
prepared.
Conclusion
In conclusion, the revised guidelines changed little, but require
more information recording, exchange and justification prior
to radiation exposures, especially when carers and comforters
are involved. The small amendments are essentially add-ons to
encourage further transparency in the event of an accidental
exposure, and to ensure good clinical practice. Efficient
induction of new staff and follow-up audit continue to underpin
these measures.

Compliance with Ethical Standards

Conflict of Interest: The authors declare that they have no
conflict of interest.

References
1. European Society of Radiology (ESR). Summary of the
European Directive 2013/59/Euratom: essentials for
Fully interchangeable
e with Locator™ health professionals in radiology. Insights Imaging 2015; 6:
abutments, inserts and tools. 411−417.
2. Horner K. Updated: new regulations on xray use − likely
Fits Straumann, Nobel, Astra, Ankylos implications of IRR17 and IRMER18. Faculty of General
and all popular Implant Systems! Dental Practice (FGDP), 2017
3. Guidance on the Safe Use of Dental Cone Beam CT (Computed
Tomography) Equipment. HPA CRCE 2010. ISBN 970-0-
Call Trycare now and book a 85951-681-5.
free demonstration 4. Health and Safety. The Ionising Radiation (Medical Exposure)
Regulations 2018. Online article available at: https://
assets.publishing.service.gov.uk/government/uploads/
01274 885544 system/uploads/attachment_data/file/627847/
www.trycare.co.uk
Annex_I_-_Draft_IR_ME_R_2018_Regulations.pdf
760 DentalUpdate October 2020
 Enhanced CPD DO C
Lakshman Samaranayake Niraj Kinariwala
Coronavirus Disease 2019
(COVID-19) Diagnostics: a Primer
Dent Update 2020; 47: 761–765
The Coronavirus disease 2019 (COVID-
19) pandemic, caused by the severe acute
respiratory syndrome coronavirus 2 (SARS-
CoV-2), seems to have spared no single
community. Rapid and accurate identification
of COVID-19 patients are the mainstay for
breaking the chain of community infection
and controlling the pandemic. There are
now a bewildering array of diagnostic tests
available to detect COVID-19 at various stages
of infection. In this, the fourth article in the
COVID-19 Commentary series, we describe
the basics of current clinical diagnostics,
including molecular and serological testing
approaches, and summarize their advantages
and limitations.
Preamble
The current pandemic of COVID-19 is an
infectious disease caused by SARS-CoV-2
Lakshman Samaranayake, DDS,
FRCPath, FDS RCPS, FDS RCS(Ed),
Professor Emeritus, Faculty of Dentistry,
The University of Hong Kong, Hong
Kong, (email: lakshman@hku.hk),
Niraj Kinariwala, MDS, PhD, Associate
Professor, Karnavati School of Dentistry,
Karnavati University, Gujarat, India
and RAPM Perera, BDS, PhD, Research
Assistant Professor, Li Ka Shing Faculty
of Medicine, The University of Hong
Kong, Hong Kong.
October 2020
RAPM Perera
which originated in Wuhan, China in
late 2019. It is now known that the
median incubation period of COVID-19
is approximately 5 days (range: 2 to 14
days), and a large proportion of those
infected become symptomatic within
two weeks or so (range: 8 to 16 days).1
The recovery period for mild infection
is 2 weeks, although in severe cases
this may last up to 6 weeks. In the
most severe infections, the time from
symptom onset to death may range
between 2 to 8 weeks, depending on
various co-factors, such as the extant
co-morbidities.
In the early pre-symptomatic
phase, the index case unknowingly
transmits the infection to others prior
to symptom development and, on the
contrary, a small proportion of infected
individuals never develop symptoms
(so called ‘asymptomatics’) and may act
as ‘silent spreaders’ of the infection in
the community. These two elements
of the disease development have
made the spread of COVID-19 virtually
uncontrollable, leading to the current
pandemic.
In the absence of efficacious
therapeutics and a vaccine, as yet, to
combat the infection, the mainstay of
prevention and spread of COVID-19 is
the early diagnosis of the disease, with
the help of an array of diagnostic tests
that are currently available. According
COVID-19Commentary
to the World Health Organization
(WHO) and US Food and Drug
Administration (FDA), over 450 tests
have been developed thus far for rapid
identification of COVID-19 patients in
clinical and research settings.2
In order to comprehend
the basics of COVID-19 diagnostics,
it is essential to know the structural
elements of SARS-CoV-2, as the
tests are based on the detection of
the anatomical components of the
organism. Similarly, to understand
the serological tests for the virus,
a clear comprehension of the host
antibody response is essential. These
are described first, followed by the
diagnostic tests that are in common use.
Anatomy of SARS-CoV-2
(Figure 1)
The overall structure of SARS-CoV-2
is similar to other viruses of the
Coronaviridae family. It has a protein
envelope with characteristic outward
projecting spikes (hence the Latin name
corona = crown), enclosing a single-
stranded, positive sense RNA genome
of approximately 30,000 nucleotides in
length (Figure 1). The genome is tightly
bound to a protein capsid, and both
together are called a nucleocapsid.
The nucleocapsid is protected by the
external protein envelope, which has
DentalUpdate 761
 COVID-19Commentary

a b

Figure 1. (a) Morphology of SARS-CoV-2. Transmission electron microscope image of SARS-CoV-2 spherical viral particles emerging from an infected epithe-
lial cell; (b) structural components of SARS-CoV-2. (Modified from the US Centres for Disease Control Image Library).

„ The envelope or E protein, which is

the smallest protein in the SARS-CoV-2
structure, plays a role in the production
and maturation of this virus.

Serological response
(Figure 2)
In simple terms, the host immune
response of the body to SARS-CoV-2 is
triggered through the stimulation of the
innate immune system cells via antigen
presenting cells (eg dendritic cells and
macrophages as frontline guardian cells
of the host). The antibodies produced
are mainly IgM and IgG (together with
some IgA), which have a unique profile
in response to the infection. The median
seroconversion time for IgM and IgG
Figure 2. A diagrammatic representation of antibody development after SARS-CoV-2 infection antibodies are 12 and 14 days after the
during the symptomatic period and thereafter (x axis), and the sensitivity for antibody tests (y axis); onset of symptoms, respectively, whilst
(RT PCR, real-time reverse transcription polymerase chain reaction; IgM, Immunoglobulin M; IgG they are detected only in less than 40%
Immunoglobulin G). (Note: Antigens can also be detected by RT PCR tests during the pre-symptomatic of the patients within the first week
period which is not shown in the figure).
(Figure 2). In some cases, serum IgG
could appear at the same time or even
earlier than IgM.
three major components, the spike (S) homotrimers protruding in the viral It is noteworthy that, in
glycoprotein, envelope (E) glycoprotein, surface, giving them the crown or addition to the antibody formation,
exposure to coronaviruses in general
membrane (M) glycoprotein, (plus several corona-like appearance. They facilitate
also induce CD4 T cells and CD8 memory
accessory proteins). Thus: binding of the virus to the host cells
cell development and maturation that
„ The nucleocapsid (N) protein cover by attaching to the angiotensin-
can last for up to 4 years. This bodes well
codes for 27 proteins, including an RNA- converting enzyme 2 (ACE2) receptors for the development of vaccines against
dependent RNA polymerase; expressed on epithelial and other cells; SARS-COV-2, as an encounter with the
„ The spike or S glycoprotein is a „ The membrane, or M protein, plays virus even after a few years is likely to
transmembrane protein in the outer a role in determining the shape of the protect the vaccinee, after the initial,
portion of the virus and forms, so called, virus envelope; successful vaccine procedure.
762 DentalUpdate October 2020
 COVID-19Commentary

Diagnostic tests for COVID-19

(Figure 3; Table 1)
COVID-19 diagnostics encompass either:
i) Detection of viral antigens which indicate
current infection; or
ii) The host immune response to the virus
(ie specific antibodies) that indicate past
infection or vaccination (Figure 3).
The following is a primer on the
currently prevalent antigen and antibody
tests for COVID-19, and their utility.
However, it should be noted that, due to the
Figure 3. A schematic diagram showing the principles guiding the diagnostic tests for COVID-19.

Type of Test Primary Clinical Specimen/s Required Turnaround Time* Properties

and Synonyms Use
I Viral test, Diagnosis of Nasal or throat swab May vary from 15 min Amplifies viral RNA; Highly sensitive
molecular test, current infection (most tests) to 8 hr depending on and specific in ideal settings.
nucleic acid Saliva (a few tests): the type of test, and (Results depend on the type and
amplification test respiratory tract laboratory workflow quality of the specimen and the
(NAAT), RT PCR specimens in hospitalized duration of illness at the time of
test, LAMP test patients testing).
Usually does not need to be
repeated.

II Antigen tests or Diagnosis of Nasopharyngeal or nasal Usually less than 60 Most probe for nucleocapsid (N)
rapid diagnostic current infection swabs min or spike (S) proteins, ie antigens
tests of SARS-CoV-2; generally less
sensitive, and more likely to miss
an active infection compared to
nucleic acid tests.

III Serology test, Diagnosis of Finger prick or Usually ranges from 15 Checks for IgG antibodies (mainly)
Serological test, prior infection venepuncture blood minutes to 2 hours to the S or the spike protein or
serology, blood or (in future) nucleocapsid, N or NC protein.
seroconversion Highly variable sensitivity and
after vaccination specificity, and hence results
should be interpreted with caution;
possible cross-reactivity with other
coronaviruses reported.

Data from various sources including References 1 and 5; COVID-19: coronavirus disease 2019; RT PCR: real-time reverse transcription
polymerase chain reaction; IgG: immunoglobulin G; loop-mediated amplification: LAMP.
*Turnaround time is influenced by the test used and laboratory workflow.
Note: the sensitivity and specificity of any diagnostic test depend upon the quality of the sample, and various other technical factors.
(Note: Antigens can also be detected by RT PCR tests during the pre-symptomatic period which is not shown in the figure)
Antigen tests colour coded in green and antibody tests in red.
Table 1. Diagnostic tests for COVID-19 and their properties.

764 DentalUpdate October 2020


dynamic nature of the subject, the viral
testing procedures are in a state of flux.
In general, COVID-19
diagnostic tests can be broadly
classified as:
I. Tests for viral nucleic acid (so called
nucleic acid amplification tests or
NAATs);
II. Tests for viral antigen tests;
III. Antibody tests for seroconversion.
(Note: A continuously updated
infographic on COVID diagnostic tests
can be found at https://csb.mgh.
harvard.edu/covid)
I. Tests for viral nucleic acid (RNA)
Real-time reverse transcription
polymerase chain reaction (RT PCR)
test is the gold standard for diagnosis
of current infection with COVID-19.
It amplifies the viral RNA (Figure 1)
to detectable levels; hence the term
nucleic acid amplification tests (NAAT).3
This method, which is quantitative,
and highly sensitive and specific,
is also the commonest technique
currently used to detect SARS-CoV-2
RNA from respiratory samples. The test
is used increasingly on automated
platforms, and may take several hours
to complete (Table 1).
II. Tests for viral antigens
The antigen tests probe for the
structural components, such as
the nucleocapsid (N) or spike (S)
proteins of SARS-CoV-2 (Figure 1)
via lateral flow or ELISA (enzyme-
linked immunosorbent assay) tests,
and can be performed with only
nasopharyngeal swabs. As these tests
take less than an hour to complete,
and yield faster results than some
NAATs, they are used for point of care
(POC) testing (eg airports for arrivals
and departures).
However, the broad
consensus is that the viral antigen tests
are less sensitive than NAATs, described
in Table 1, and often yield false-
negative results. Hence, a negative
antigen test does not necessarily
rule out SARS-CoV-2 infection, and
should be confirmed using a sensitive
NAAT if the clinical suspicion is
high. Nevertheless, antigen tests are
October 2020
valuable for detecting those in the early
stages of infection, when virus replication
is at its highest.
III. Serological tests
In general, serological tests are useful
to determine prior viral exposure of
an individual and seroconversion after
a course of vaccination (eg akin to
seroconversion after Hepatitis B infection
or vaccination). They could also be
used for retrospective assessment of
the efficacy of infection control and
lockdown measures, as well as for
ascertaining the extent of COVID-19
in the community through en masse
evaluation.
As soon as any virus infects
a person, he/she will start developing
antibodies, and the first such antibody
type is IgM immediately followed by IgG.
The former is rather transient compared
to IgG, which could last for several
months or years, depending on various
factors. This is also the case with SARS-
CoV-2 infection as, in many studies, IgM
and IgG seroconversion occurred in all
patients between the third and fourth
week. Thereafter IgM began to wane,
and virtually disappeared by week 7,
although IgG levels persisted beyond 7
weeks.4
As seen above, SARS-CoV-2
possesses various antigenic structural
components (Figure 2), and a substantial
antibody response is directed against
the nucleocapsid (N or NC) protein.
Hence, tests that detect antibodies to
NC are the most sensitive, though they
may be lacking in specificity. However,
antibodies to the S or the spike protein
are much more specific than that for the
NC protein. Additionally, antibodies to
the S protein are considered to neutralize
the viral infectivity much more than
the other antibodies. The long-term
persistence of protection conferred by
the neutralizing antibodies is unknown,
as yet.
Finally, serological tests for
SARS-CoV-2 should be specific and must
differentiate past infections from those
caused by other human coronavirus
infections (eg SARS-CoV, HKU1). There
are also many confounding factors that
interfere with laboratory testing for
COVID-19Commentary
COVID-19, including sample collection,
transportation and so on, that are not
described here, and are beyond the remit of
this article.
Future perspectives and
conclusions
Several simple, reliable and rapid COVID-
19 diagnostic tests, which could be used
at community level and obviate sample
referral to a centralized laboratory and
consequent prolonged turnaround time, are
currently under development. They include
loop-mediated amplification (LAMP),
recombinase polymerase amplification
(RPA) and nicking enzyme-assisted reaction
(NEAR) technologies that yield results
within 15 to 30 minutes. It is hoped that,
in the fullness of time, such miniaturized
tests, akin to ‘pregnancy tests’, could be
used and interpreted by ordinary citizens
at home. These rapid diagnostic tests hold
much promise and would be a valuable and
welcome addition to curb the pandemic,
particularly in resource-poor settings in
the developing world where its rabid and
rampant spread has created unprecedented
suffering, misery and privation.
References
1. Lee RWH, Ko J, Mikael J, Pittet MJ.
COVID-19 diagnostics in context.
Sci Transl Med 2020; 12: eabc1931 doi:
10.1126/scitranslmed.abc1931.
2. COVID-19 diagnostic tests. https://csb.
mgh.harvard.edu/covid
3. Li CX, Zhao C, Bao J, Tang B, Wang Y, Gu
B. Laboratory diagnosis of coronavirus
disease-2019 (COVID-19). Clin Chim
Acta 2020; 510: 35−46.
4. Sethuraman N, Sundararj SJ, Ryo
A. Interpreting diagnostic tests for
SARS-CoV-2. J Am Med Assoc 2020;
323: 2249−2251. doi:10.1001/
jama.2020.8259.
5. Cheng MP, Papenburg J, Desjardins
M et al. Diagnostic testing for severe
acute respiratory syndrome-related
coronavirus 2: a narrative review. Ann
Intern Med 2020; 172: 726−734.
See review of SDCEP document ’Breaking
News: COVID-19 and Dentistry‘ at the
end of the Letters to The Editor on page
769.
DentalUpdate 765
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Letters to the Editor
COVID-19 mitigation is a
barrier to meeting population
oral health needs
The COVID-19 pandemic has caused
substantial disruptions to dental services
globally. In the United Kingdom, National
Health Service (NHS) dentistry was
reduced to telephone consultations
with Urgent Dental Care Centres
established to deliver emergency
dentistry, when deemed necessary,
based on a national triaging system.
Following lifting of lockdown restrictions,
numerous countries released guidance
for re-opening and re-structuring
dental services to mitigate the risk of
SARS-CoV-2 transmission.1 Such risks
are of concern in dental clinics due
to the high volume of patients, close
physical proximity of dental professionals
to patients, and aerosol generating
procedures (AGPs).
SARS-CoV-2 has high affinity
to angiotensin-converting enzyme 2,
distributed throughout the respiratory
tract and present in the oral mucosa.
The virus has been isolated in saliva
and in the pharynx,2 hence dental AGPs
are stratified as high-risk procedures.
The current evidence shows that SARS-
CoV-2 can remain viable in an aerosol
for up to three hours.3 Therefore, a
‘fallow’ period is required for the aerosol
to settle after an AGP, and is necessary
to prevent infection transmission, but
limits the number of patients that can
be seen. However, there is considerable
heterogeneity in the interpretation of the
limited available evidence with respect
to risk mitigation strategies (eg the use
of rubber dam, high volume aspiration,
room ventilation, etc), with countries
issuing guidance of different fallow times
(ranging from 2−180 minutes)1 to their
dental workforce. There are substantial
challenges in meeting population oral
health needs if dental services are limited
by a fallow period and, in many instances,
dental clinics may become financially
unviable to maintain. The risk of live
SARS-CoV-2 remaining suspended in
the air should not be underestimated.
Nevertheless, evidence-based consensus
October 2020
is required on ventilation parameters
and the most effective risk reduction
strategies to enable safe resumption of
dental care.
Ideally, a rapid SARS-CoV-2
test would provide reassurances for
dental professionals to reduce their
fallow period and adopt routine
personal protective equipment (PPE).
This can increase patient capacity and
reduce the burden of limited PPE, but
would involve testing every patient
before each appointment. Multi-faceted
infection prevention and control
interventions, including hand hygiene
and the right level of PPE, remain the
most effective methods to prevent
infection transmission.
The COVID-19 mitigation
policies of time restrictions between
patients and enhanced PPE, with their
surplus costs, strongly suggests that the
current commissioning of NHS dentistry
requires major reforms to prevent
collapse of an integral component of
population healthcare. It is expected
that rapid SARS-CoV-2 testing will be
available in the future, however until
then, prolonged disruptions to dental
services is likely to have a detrimental
effect on patient health. A pragmatic
and balanced approach to dental public
health reforms is needed, as is urgent
research on risk reduction strategies for
SARS-CoV-2 in aerosols.
Declaration of interests
All authors declare no competing
interests.
References
1. Clarkson JE, Ramsay C, Aceves M,
Brazzelli M, Dave M, Glenny AM
et al. Recommendations for the
re-opening of dental services:
a rapid review of international
sources. 2020. Cochrane Oral Health
(Accessed 25 August 2020]. https://
oralhealth.cochrane.org/news/
recommendations-re-opening-
dental-services-rapid-review-
international-sources
Letters
2. To KK, Tsang OT, Leung WS, Tam
AR, Wu TC, Lung DC et al. Temporal
profiles of viral load in posterior
oropharyngeal saliva samples
and serum antibody responses
during infection by sars-cov-2: an
observational cohort study. Lancet
Infect Dis 2020; 20: 565−574.
3. van Doremalen N, Bushmaker T,
Morris DH, Holbrook MG, Gamble
A, Williamson BN et al. Aerosol and
surface stability of sars-cov-2 as
compared with sars-cov-1. N Engl J
Med 2020; 382: 1564−1567.
Manas Dave, NIHR Academic Clinical
Fellow in Oral and Maxillofacial
Pathology, University of Manchester
Noha Seoudi, Senior Clinical Lecturer
in Oral Microbiology, Queen Mary
University, London
Paul Coulthard, Dean for Dentistry
and Institute Director, Queen Mary
University, London
The Effect of COVID-19 on
dental foundation training
applications
COVID-19 in dental school
The COVID-19 pandemic has altered
several features in the practice of
dentistry globally, including dental
education. Most UK-based dental schools
have been closed for at least 6 months
and will be operating at a lower capacity
once they re-open. Dental schools have
been working diligently to establish
protocols to ensure that the dental team
and patients are in a safe environment.
This includes wearing robust PPE,
limiting the number of attending
patients and one-way walking systems.
Students will also be fit-tested for masks
before performing aerosol producing
procedures. Furthermore, there is likely
to be an increase in simulation teaching,
such as phantom head work and using
virtual reality technology.
Dental foundation training application
alterations
In June, it was announced that, in light of
COVID-19, the dental foundation training
DentalUpdate 767
 Letters
(DFT) application process would be
altered. Whilst previously the ranking
for DFT placements was based on face-
to-face assessment centre interviews
and a situational judgement test (SJT),
it will now be based solely on the SJT
in order to reduce social contact during
interviews. Naturally, applicants are
under an increased amount of pressure,
given that they will no longer have an
interview to support their application or
an outlet to present their personalities
and enthusiasm to potential trainers.
Expectation for the future
Despite the efforts made by universities
to continue teaching during the
pandemic, students will be graduating
having partaken in less clinical time at
university. Furthermore, in the event of
a second wave of the virus, there are
likely to be further disruptions. Due to
the lack of clinical time, it is probable
that newly qualified dentists will require
more support from their dental trainers.
In addition, with video and phone
consultations becoming more routine,
learning to conduct these effectively
may become essential to training. With
diligent planning and preparation, there
is hope that the next cohort of dental
foundation trainees will also have a
constructive training experience and
ultimately be able to provide optimal
care to their patients.
Ayla Mahmud, Biomedical Science
BSc(Hons)
BDS5 Student at King’s College
London
COVID-19 educational
resource
COVID has had an unsettling impact
on dental education. The team at
revisedental.com have produced an
evidence-based educational resource,
providing the student and young
professional with a ‘go to’, reliable
platform that helps guide self-directed
learning. Moreover, the site donates
all its contributions, supporting: the
BDA Benevolent Fund and the Motor
Neurone Disease Association.
The site has attracted a vast
amount of specialist help, supporting
the growth of the premium content;
768 DentalUpdate
advancing student learning. This area
continues to expand and, if you wish to
help and support, please don’t hesitate to
contact the team. The impact of the site
so far has received wonderful feedback,
with numerous students already visiting
and interacting with the content.
The site also offers student
collaborations, through interprofessional
teamwork, which is essential during
these times more than ever. The team has
brought together medics, pharmacists
and other dental professionals. This
has been on both a national and an
international scale (eg Australia), boosting
the quality of the lesson content.
In addition to the charitable
donations and the site itself, the team’s
efficiency, motivation and dedication to
producing the wonderful content has
been incredible. Each member brings his/
her unique attributes, all with the aim
to help colleagues, both during these
strange times, and for the future.
We hope you enjoy visiting
www.revisedental.com Now is the time
to pull together and support our own
education, going forward, to adapt for
the new normal.
Mike Daldry, Sumeet Sandhu,
Leah Webb and Jaimi Shah
Time to rethink, reconsider
and reinvite case reports!
We, as clinicians come across interesting,
or challenging clinical cases in our
everyday practice. Few of these cases
stand apart, as they may be combined
with an interesting observation, a rare
clinical sign, unexplored association
of various clinical manifestations, etc.1
Unfortunately, case reports are not being
accepted by many reputed journals
and are tagged as the lowest level of
research.2 Many journals flatly refuse to
accept case reports and consider them
as beyond the scope of publishing. Sadly,
some journals, which do accept them,
quote exorbitant article processing
charges, which demotivates the authors
further. Most indexed journals do
not support publishing case reports,
which has paved the way for predatory
and dubious journals to fill this void,
publishing case reports while charging
the fees. This is one of the known barriers,
preventing competent clinicians from
sharing their experiences in the form of
case reports and series.
The current medical literature
primarily focuses on evidence-based
practice which has led to the notable
decline in the publishing of clinical case
reports,2 possibly due to the inability of
scrutinizing the originality of the case, with
an inherent risk of fraudulent information
being incorporated to make it more
appealing. Furthermore, the lesser number
of citations received for case reports
compared to original research, meta-
analysis and reviews, which indirectly
hampers the overall journal performance
assessment and impact factor, further
discourages the publishing of case
reports.3
Case reports can still serve as
a useful platform to share our unique and
interesting experiences and to reinforce
certain overlooked clinical diagnostic
clues. They serve as teaching aids for
educating healthcare students.4 Moreover,
the novel management strategies or
follow-up protocols adopted in specific
disorders, and its response, could help us
to think beyond the traditional options
and seed research ideas. Thus, case reports
contribute to a modest but significant role
in knowledge dissemination.
To ensure completeness and
transparency of published case reports, a
consensus-based clinical case reporting
guideline, termed ‘CARE’ (CAse REport)
has been formulated.1 A CARE guidelines
checklist helps the author to document
the clinical case reports accurately and
this checklist has become an integral part
of the manuscript submission platform
in recognized journals. On the other
hand, PROCESS (Preferred Reporting
Of CasE Series in Surgery) guidelines
are recommended while documenting
surgical case reports, and this has
improved reporting transparency of case
series across several surgical specialties.5
It is time to realize that case
reports contain a small but significant
piece of disrupted information, unlike
original research articles, which may have
technical and processing errors inherent to
the study design. However, shouldn’t we
reconsider and reinvite case reports and
October 2020

recognize their duly deserved position in
the medical literature? In the mad rush
to compete with journal ratings, citations
and impact factors, etc, are we ignoring
the reader’s choices?
References
1. Gagnier JJ, Kienle G, Altman DG,
Moher D, Sox H, Riley D, CARE Group.
The CARE guidelines: consensus-
based clinical case reporting
guideline development. J Med Case
Rep 2013; 7: 223.
Breaking News: COVID-19
and Dentistry
Mitigation of Aerosol Generating
Procedures in Dentistry – A Rapid
Review by the Scottish Dental Clinical
Effectiveness Programme (SDCEP): An
Appraisal
It had the makings of a perfect storm!
A vicious virus infecting through
aerosol transmission, and a livelihood
necessitating aerosol generating
procedures (AGPs). This epitomizes the
predicament of returning to dental
practice in the Coronavirus Disease 2019
(COVID-19) pandemic era. Eight months
into the pandemic, various bodies have
issued multiple recommendations on
how best to mitigate AGPs in routine
dentistry,1 but most are not evidence-
based and are unsubstantiated, probably
due to the dearth of data on SARS-CoV-2
and its spread.
Hence, it is gratifying to note
the arrival of a brand new document
from the Scottish Dental Clinical
Effectiveness Programme (SDCEP)
entitled Mitigation of Aerosol Generating
Procedures in Dentistry – A Rapid Review,2
sponsored by NHS Education, Scotland.
Chaired by Professor Jeremy Bagg,
and an erudite group of academics,
clinicians and a member of the public
have produced this timely document
(46 pages) identifying and appraising
the extant evidence on a number of key
questions related to AGPs in dentistry,
and recommending mitigation measures.
In the preamble, the authors
categorically state that the review and
the conclusions do not have the status
October 2020
2. Pimlott N. Two cheers for case
reports. Can Fam Physician 2014;
60: 966–967. Available from: http://
www.cfp.ca/content/60/11/966.
long
3. Kidd MR, Saltman DC. Case reports
at the vanguard of 21st century
medicine. J Med Case Rep 2012; 6:
156.
4. Yitschaky O, Yitschaky M, Zadik Y.
Case report on trial: Do you, Doctor,
swear to tell the truth, the whole
truth and nothing but the truth?
J Med Case Rep 2011; 5: 179.
of guidance, and should primarily be
used to inform policy-making, and
developing clinical guidance relevant to
dental care delivery during the COVID-
19 pandemic. This is a sensible stance as
the data on SARS CoV-2 and the spread
of infection are constantly emerging.
The document focuses on
three main areas, ie AGPs, procedural
mitigation and environmental
mitigation. These are then subdivided
as, categorization of AGPs, high
volume suction, rubber dam
isolation, preprocedural mouthrinses,
antimicrobial coolants, ventilation
and air-cleaners. Then, each of the
sub-sections are further discussed in
terms of: i) evidence summary and
appraisal; ii) considered judgement
and agreed position; and iii) agreed
position statement. Thus, in total there
are well argued and articulated, six
position statements for the foregoing
subcategories. The document ends
with a succinct section on implications
for clinical practice, and research
considerations.
On the whole, the clarity of
the document must be commended.
Some of the traditionally recommended
infection control measures, such as the
preprocedural antiseptic mouthwashes,
are discouraged, and I fully concur with
this view of a ritualistic practice that
has a flimsy evidence base, in terms of
combating infection transmission in
the clinical environment. I also believe
the categorization of AGPs into three
groups, according to the uses of high (a)
and low (b) powered instrumentation,
Letters
5. Agha RA, Borrelli MR, Farwana R,
Koshy K, Fowler AJ, Orgill DP, et al. The
PROCESS 2018 statement : Updating
Consensus Preferred Reporting Of CasE
Series in Surgery (PROCESS) guidelines.
Int J Surg 2019; 60: 279–282.
Mathangi Kumar
Shruthi Acharya
Ravindranath Vineetha
Department of Oral Medicine and
Radiology, Manipal College of Dental
Sciences, Manipal Academy of Higher
Education, Manipal 576104,
Karnataka, India
and (c) no powered instrumentation, is
sensible, simple and practical, as dentists
can formulate the mitigation measures
accordingly. One statement that I personally
do not concur with is the division of fallow
periods into five different time periods of
5 min intervals, as dictated by the use of
AGPs. I wonder whether this is a practical
proposition.
The latter, however, is a minor
blemish in an otherwise insightful and
instructive review on AGPs in dental
practice. Professor Bagg and his team
should be applauded for producing such
an important, comprehensive and a timely
commentary when the pandemic is waning
in most countries, and return to routine
clinical dentistry is a feasible proposition.
I have no hesitation in commending this
freely available review as essential reading
to all practitioners.
Note: Any further discussion of
the review will appear in the November
2020 issue of Dental Update.
References
1. Jamal M, Shah M, Almarzooqi SH,
Samaranayake LP et al. Overview of
transnational recommendations for
COVID‐19 transmission control in
dental care settings. Oral Dis 2020.
Available at: https://doi.org/10.1111/
odi.13431
2. https://www.sdcep.org.uk/
wp-content/uploads/2020/09/
SDCEP-Mitigation-of-AGPS-in-
Dentistry-Rapid-Review.pdf
Lakshman Samaranayake
Professor Emeritus, University of
Hong Kong
DentalUpdate 769
 ClinicalExperiencesofReaders

'I learnt about Dentistry from that'

Readers are encouraged to submit clinical experiences, good and bad, in a culture of open reporting, so that other clinicians will learn from
these experiences. Unlike articles in Dental Update, in which published articles are peer reviewed by two experts in the field of the article,
this page is not subjected to review other than by the Editorial Director.

When I was a newly qualified dentist, an older gentleman attended for his 6-monthly routine dental check-up. He had no complaints.
He lay back in the chair and I began the check-up. He had an upper denture in place and asked if I would like him to remove this.
‘Yes please’, I replied. Out the denture came. I began to examine him again and was immediately worried. On the buccal aspect of the
maxillary alveolar ridge was a poorly defined patch of erythema with several white speckles overlying it, which had previously been
hidden by his denture. Thinking back to my oral medicine lectures, I knew that a white and red patch, in an older patient, who also
smoked, was bad news. I asked the patient if he was aware of the patch or it had given him any symptoms; ‘I didn’t know there was
anything there at all’, he replied. ‘Painless’ I thought – another bad sign. I called a (very busy) senior associate dentist to come and
have a look. When he arrived (mid-extraction with his own patient), I tried to convey my concern to him in ‘dental code’ and with my
worried facial expression. He sat down and looked at the patch. He then wiped it clean off with a glove, revealing totally normal mucosa
beneath. He examined the red debris that had come away on his glove. ‘That’s a bit of old mouldy cherry tomato skin that’s been sitting
beneath the denture’, he explained. The patient then recalled the last time he ate cherry tomatoes (a full week ago) and, needless to say,
I went the colour of the cherry tomato.

I learnt always ‘to get stuck in’ when examining mucosal abnormalities, something which is now the bread and butter of my job in oral
medicine. Don’t be scared by a mucosal abnormality – touch it, feel it, see if it rubs off! These are all essential for a provisional diagnosis!

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DentalUpdate
1 18/06/2020 16:55
October 2020

Technique Tips
The Role of Fibre-reinforced Composite Posts in Children
This technique tip highlights the role of
fibre-reinforced composite (FRC) posts in
managing fractured teeth, as well as their
specific application in children, with a case-
based discussion and exploration of their
advantages and disadvantages.
Dentists are frequently exposed to
the management of fractured anterior teeth
in children. Restoring extensively fractured
permanent teeth in a child to maintain
function and aesthetics can pose a significant
clinical challenge. Conventional techniques
to support coronal restorations of teeth with
little supragingival tooth structure in children
may not always be practicable. They may not
conform to immature canal anatomy or may
require an indirect restoration with laboratory
input, which may necessitate multiple
appointments.
In a growing child, FRC may
provide a useful alternative to address the
shortcomings of more traditional restorative
techniques in restoring an extensively
fractured anterior tooth. The everStick®
POST (GC Europe NV, Leuven, Belgium)
(Figures 1−3), a silanated E-glass fibre
impregnated with a bis-GMA matrix and
Polymethylmethacrylate (PMMA) polymer,1,2
is an example of such an alternative. It is
an adaptable, soft and flexible post with
a diameter of approximately 1.5 mm and
similar composition to composite. The term
‘E-glass’ refers to fibres which are a variant of
a FRC which has been found to have superior
strength properties in varying conditions,
good chemical resistance and sufficient
imperviousness to moisture.3,4 Whilst we are
focusing on its use as a post in a fractured
anterior permanent central incisor, other uses
of variants of everStick® POST (GC Europe
NV, Leuven, Belgium) include a splinting
material for periodontally compromised teeth
or a minimally invasive composite bridge,
which are discussed in greater detail in other
literature.5,6
In using this type of post, it
Amardeep Singh Dhadwal, BDS, MFDS RCPS(Glasg), Academic DCT, (email: amardeepsingh.dhadwal@nhs.net), Sarah J McKaig,
BChD, FDS RCS(Ed), MPaedDent(Glasg), FDS(PaedDent) RCS(Ed), Consultant in Paediatric Dentistry and Abdullah Casaus, BDS, MJDF
RCS(Eng), MPaedDent RCS(Eng), FDS(PaedDent) RCS(Eng), Consultant in Paediatric Dentistry, Birmingham Dental Hospital and School
of Dentistry, Birmingham Community Healthcare NHS Foundation Trust, Birmingham, UK.
October 2020
TechniqueTips
allows for less invasive canal preparation,
helping to maintain dentine and reduce
the likelihood of iatrogenic damage to the
tooth, such as perforations. In paediatric
patients, traumatized teeth can require
operative treatment at an early age and
may require further treatment in the
future. This proved to be a useful choice
for re-restoring a heavily fractured tooth
with a guarded clinical prognosis. A low
viscosity cement helps to ensure that the Figure 1. everStick® POST (GC Europe NV, Leuven,
post can reach the full anatomy of the root Belgium) packet.
canal, preventing voids and unpolymerized
areas for leakage and a poor overall seal.7
Further advantages and disadvantages are
summarized in Table 1.
The use of everStick® POST (GC
Europe NV, Leuven, Belgium), as a post to
aid in the restoration of an UR1 in a child
which had a history of a complicated crown
fracture and previous failed root canal
treatment with post, core and crown is
Figure 2. everStick® POST (GC Europe NV, Leuven,
highlighted.
Belgium) encased within silicone, where it can be
cut to the appropriate length.
Case report
A nine-year-old boy was seen in the
Paediatric Dental Department at
Birmingham Dental Hospital for assessment
of his UR1, which was causing him pain. On
presentation, the UR1 had a buccal sinus
and mobile indirect crown. The UR1 had
previously sustained a complicated crown
fracture, which had been treated with root
canal treatment and a metal post, core and
crown. A pre-operative radiograph was
taken of the UR1 revealing an open apex,
suboptimal RCT and poorly fitting post, core Figure 3. Handling of everStick® POST (GC
Europe NV, Leuven, Belgium) with tweezers, for
and crown (Figure 4).
placement into root canal. Multiple posts can be
On removal of the restoration
used, if necessary, depending on morphology.
under dry dam and local anaesthetic, it
was noted that there was a lack of coronal
supragingival tooth structure. Following
removal of GP using Hedstrom files, the UR1 hydroxide and temporized with composite.
underwent re-root canal treatment Four weeks later, symptoms improved and
(Figure 5) and was dressed with calcium the patient returned for removal of the
DentalUpdate 771
 TechniqueTips
Advantages
Improved aesthetics and shade to tooth
colour
Good flexibility, facilitating negotiation
around curved canals, immature canal
anatomy and larger canals
Chairside fabrication and adjustments: can
be adjusted for size through cutting and/or
adding more posts to the canal based on
anatomy and size
Ability to bond directly to composite
Similar modulus of elasticity to dentine8
Table 1. A table to summarize the advantages and disadvantages of FRC posts in paediatric patients.
Figure 4. Pre-operative periapical radiograph
of UR1 highlighting a suboptimal root canal
treatment with extrusion of GP, poorly fitting
post, core and crown and associated apical area.
temporary restoration and obturation with
Mineral Trioxide Aggregate (MTA). Due to
the lack of remaining supragingival tooth
structure remaining (Figure 6), retraction
cord with astringent was used to isolate
the margins and a FRC post everStick®
POST (GC Europe NV, Leuven, Belgium)
was used (Figures 7 and 8), which was
cemented using a low-viscosity dual curing
resin cement (GRADIA®, GC). Finally, the
772 DentalUpdate
Disadvantages
Canal preparation and dentine removal still
required
Radiolucent and reduced visibility on
radiographs
Technique sensitive − clinicians may find
them difficult to handle and manipulate
with tweezers
Figure 6. Labial view of UR1 after re-root canal
treatment had been undertaken showing a lack
Still reliant on the child’s co-operation and of supragingival tooth structure labially.
the ability of the child to tolerate root canal
treatment and tooth isolation
Figure 7. UR1 with FRC post in situ, rubber dam
and OpalDam (Ultradent Products Inc, South
Jordan, USA) used for moisture control.
Figure 5. Mid-treatment radiograph, highlighting Figure 8. Close-up image of UR1 with FRC post
re-established working length following canal in situ, rubber dam andOpalDam (Ultradent
re-preparation. Products Inc, South Jordan, USA) used for
moisture control.
permanent teeth in children due to
tooth was restored using direct composite.
insufficient supragingival tooth structure
Occlusion was checked prior to completion
and large root canal anatomy. The use
(Figure 9). A post-operative radiograph
of FRC posts can provide an alternative,
revealed a well-condensed post, following
chairside solution to restore a child’s dental
the patient’s root canal anatomy (Figure 10).
function and aesthetics in these cases.
Conclusion Conflict of interest
Dentists may encounter difficulties in The authors declare that they have no
restoring severely fractured anterior conflict of interest or any support from the
October 2020
 TechniqueTips

3. Zhang M, Matinlinna JP. E-glass fiber

Figure 9. Post-operative labial view of UR1 post
finishing and placement of final composite
restoration.
manufacturers of any items discussed.
References
1. Özcan M, Kumbuloglu O. Fracture
strength of fiber-reinforced surface-
retained anterior cantilever restorations.
Int J Prosthodont 2008; 21: 228−232.
2. Vallittu PK, Sevelius C. Resin-bonded,
4.
5.
6.
7.
Figure 10. Post-operative radiograph,
highlighting a well-condensed post and a good
apical and coronal seal.
8.
glass fiber-reinforced composite fixed
partial dentures: a clinical study.
J Prosthet Dent 2000; 84: 413−418.
reinforced composites in dental
applications. Silicon 2012; 4: 73−78.
Nayar S, Ganesh R, Santhosh S. Fiber
reinforced composites in prosthodontics
− a systematic review. J Pharm Bioallied Sci
2015; 7(Suppl 1): S220−S222.
Van Rensburg J. Fibre-reinforced
composite (FRC) bridge − a minimally
destructive approach. Dent Update 2015;
42: 360−366.
Van Rensburg J. Fibre-reinforced
composite splint − step-by-step
instructions. Dent Update 2019; 46:
380−387.
Aksornmuang J, Nakajima M, Tagami
J. Effect of viscosity of dual-cure luting
resin composite core materials on bond
strength to fiber posts with various surface
treatments. J Dent Sci 2014; 9: 320−327.
Plotino G, Grande NM, Bedini R, Pameijer
CH, Somma F. Flexural properties of
endodontic posts and human root dentin.
Dent Mat J 2007; 23: 1129−1135.

Healthy habits for

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range of clinical information and patient resources to help you care
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October 2020 DentalUpdate 773

TePe_IDB_Pro_W2_180x125_2647_20.indd 1 28/07/2020 10:59
 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 AYUB, KHAN AND KELLEHER 47: 706–712 Q6 MEADE 47: 729–738

Regarding dens evaginatus (DE): Regarding supernumerary teeth:

A. There is only one classification for this.
B. Pulp tissue is never found within the tubercle associated with
this.
C. This is never associated with shovel-shaped incisors with
prominent marginal ridges.
D. This occurs more frequently in the mandible than the maxilla.
A. Their aetiology is well understood.
B. Prevalence has been reported to be greater among African
Americans.
C. Males appear to be less likely than females to present with a
supernumerary in the permanent dentition.
D. These never need to be removed.

Q2 AYUB, KHAN AND KELLEHER 47: 706–712

Q7 MEADE 47: 729–738
Regarding prevalence of DE:
Regarding clinical characteristics of supernumerary teeth:
A. This never occurs bilaterally.
A. Dentigerous cyst formation is never a complication associated
B. It is seen more frequently in Asian patients.
with a supernumerary tooth.
C. Upper incisors are more frequently affected than premolars.
B. Delayed eruption of associated teeth has been reported in up
D. Patients with SturgeWeber syndrome are at a lower risk of
to 60% of Caucasians with supernumerary teeth.
having DE.
C. These never cause failure of eruption of a permanent maxillary
incisor.
Q3 OWEN ET AL 47: 714–718 D. Migration of the supernumerary into the nasal cavity is
common.
Regarding coronectomy:
A: Re-operation rates are 15%.
B: Case selection is limited to vital teeth with a high risk of Q8 NOORANI ET AL 47: 747–754
IANI. Regarding RCT access cavity preparation:
C: CBCT is of no help in cases requiring coronectomy. A. The least important tooth structure responsible for long-term survival is
D: Piezosurgery is of no value in coronectomy cases. considered to be the pericervical dentine.
B. Complete removal of caries is not necessary.
C. An important reason to eliminate undermined and unsupported tooth
Q4 O’LEARY AND GUNDERMAN 47: 719−727 structure is to evaluate whether the tooth is restorable or not.
D. There is very good evidence to suggest that conservative or ultra-
Regarding chairside digitization:
conservative access cavity design can help retain endodontically treated
A. There are no challenges when trying to obtain accurate cross-arch
teeth for longer.
dental prostheses.
B. The potential for gag-reflex activation is increased by using this.
C. The main advantage is improved patient comfort. Q9 GREWAL AND HEATH 47: 755–760
D. Set-up costs are low and therefore not a barrier. A ‘clinically significant’ exposure is considered to be:
A. Any over exposure/unintended dose that results in an additional risk to

Q5 O’LEARY AND GUNDERMAN 47: 719−727

the patient of more than 1 in 10.
B. Any over exposure/unintended dose that results in an additional risk to
Regarding gag reflex: the patient of more than 1 in 500.
A. Patients with a severe gag reflex never vomit during impression- C. Any over exposure/unintended dose that results in an additional risk to
taking. the patient of more than 1 in 1000.
B. Jackson and Jones produced an index for its severity. D. Any over exposure/unintended dose that results in an additional risk to
C. Using intra-oral scanners rather than conventional impressioning the patient of more than 1 in 10,000.
may reduce the potential for gag-reflex activation.
D. Gagging is always caused by a mental trigger.
Q10 GREWAL AND HEATH 47: 755–760
DEADLINE FOR SUBMISSION: 14 DECEMBER 2020 Revisions to IRMER 2018:
A. Incorporate voluminous amendments.
10 QUESTIONS REPRESENT 4 HOURS OF CPD B. Include the text ‘… written instructions and information are provided to
the patient and the individual concerned is informed in advance about the
ANSWERS FOR JULY/AUGUST CPD ON PAGE 746 risks of the exposure’.
C. Quality assurance programmes and audit to record exposure dosages are
CPD in Dental Update in partnership with no longer needed.
D. Regular maintenance of equipment to enhance performance is not
needed.

774 DentalUpdate October 2020

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