Sunday, 27 March 2016

Tubules on Tour: G-Aenial Composite Course

Last week, the Dentinal Tubules Study Club Directors headed over to Leuven in Belgium for the GC G-Aenial Composite course. 

The course which lasted 2 days was fantastic value and ran very smoothly (thanks to the reps Debbie and Patrick). We caught an early Eurostar over to Brussels where it was a short taxi ride over to Leuven and GC's European HQ. And when we weren't perfecting our composite skills, we were sampling the Belgian beers in this quaint university town! 

But what did I learn...?

Anterior Composites

As you can see from the picture above, we restored a class IV restoration on a central incisor - one of the toughest aesthetic challenges. We used the G-Aenial anterior composite

We used a putty stent to help build up the shape (which in practice you can ask your lab for a wax up, see a previous post about this here), but as well as shape, making sure you have the correct SHADE is important! This includes the use of dentine and enamel shades. But how do you do this?
  • Select the enamel shade e.g. junior, adult, senior + special characteristics e.g. incisal or translucent enamel
  • Select the tone from the middle 1/3 of the tooth e.g. yellow, red
  • Select the chroma/saturation from the cervical 1/3 of the tooth e.g. A2, A3
When you are restoring a class IV, build up each layer in order to create a natural looking restoration:
  1. Palatal shell in enamel shade
  2. Dentine opaque shade to disguise the margin so you will not see where the restoration meets the tooth
  3. Dentine shade leaving areas that can mimic mammelons
  4. Add in any stains if you require at this stage e.g. to create an enamel halo
  5. Final layer of enamel shade
Once built up, correct any gross shape discrepancies with SoftFlex/Shofu discs and smooth with an abrasive rubber cone. Then use your preferred polishing protocol finishing with diamond paste to create a shine. You can use pencils to copy characteristics from the adjacent tooth to guide you in you finishing protocol. 


I've been on a few composite courses before, so the restoration of a class IV isn't that new to me. What was new and changed how I thought I can produce a really natural looking restoration is the use of GLAZES

These are different to stains which you place between the dentine and final enamel layer - glazes have a high ceramic content so are highly resistant to wear. This means that you can paint them on top of your final composite layer so add certain characteristics to teeth. 

You cannot apply glazes to highly polished surfaces, so they need to be applied after any gross finishing and the composite surface should be sand-blasted. You can then do your high polish finish after their application. You also need to add a composite primer to bond the glaze to the resin. 

Characteristics you can add include:
  • Translucency with grey colour
  • Tetracycline like banding with lilac colour
  • Fluorosis, white spots and demineralisation with white colour
  • Micro-cracks and smoking stains with the brown colour
  • Enamel halo with blue colour
Each colour can be diluted with the clear colour and the longer you expose the glaze to the light, the more intense the colour becomes. After painting on each characteristic with a fine paintbrush you cure the glaze and it leaves a high shine. It's amazing what you can achieve with these glazes! 

Resin tooth before and after application of characteristics with Optiglaze.

Posterior Composites

And finally, we briefly worked on a class I restoration using the G-Aenial Universal Flo which despite it's flowableness (is that a word?) has a reasonably high filler content (69%) so can be used for class Is. 

The advantage of using this over conventional composite is that building up each individual cusp is easy using the flowable tip and overall I found it's a much quicker technique! You can still build up each layer as it is available in enamel and dentine shades. I would be wary of using on patients you know to be bruxists however. 

Thanks to GC for making this course so informative and enjoyable and all the fantastic Tubules Team! Having the opportunity to meet and get to know some inspirational individuals in dentistry was incredible...bring on the next #TubulesOnTour!

Tuesday, 22 March 2016

Audit vs Research...What's the difference?

Some of you may have read one of my old posts about Audit (see here) in preparation for DCT interviews or just for curiosity! But how is audit different to research?

What is Audit?

  • Is a means for quality assurance and analysis of the quality of dental care provided by a practice or service
  • Uses standards set by research and guidelines e.g. FGDP, RCS, society guidelines
  • No ethical approval is needed
  • Undergoes cycles of data collection and compares these rounds
  • Is a pillar of Clinical Governance
  • You set a GOLD STANDARD which is your target

What is Research?

  • You need to follow research governance framework
  • Need for ethical approval and compliance with legal and regulatory standards
  • May involve greater risk, burden or intrusion
  • Is a service evaluation conducted to define or judge a current service
  • Intervention where no change is standard is being delivered e.g. randomisation in groups of patients
  • Data is anonymous
  • Not possible to identify participants from a report
  • Use of data will not cause substantial damage and distress

Still not sure what's the difference..?

What is the intention of each?

RESEARCH - derives new knowledge and finds out what should be you be doing

AUDIT -  measure a current standard of care i.e. are you doing a planned activity and assess if it's working

What treatment/service is provided in each?

RESEARCH - may use intervention with little or no support

AUDIT -  does not use intervention without a firm basis of support in clinical/health community

How is allocation done in each?

RESEARCH - allocation by protocol

AUDIT -  no allocation by protocol, joint decision by clinical and patient

Is randomisation used?


AUDIT -  no

A great resource to find out more is the Department of Health Research Framework and Governance, see here

I hope this helps to clear things up if you were a bit confused! If you have any questions please leave them in the comments below!

Wednesday, 16 March 2016

The Secret to Whitening your Teeth...

What's the secret to getting results like the one below?

Note that the pictures above HAVE NOT been edited apart from cropping i.e. the exposure is exactly the same, taken with the same camera in the same condition but have been taken 2 weeks apart.

I will tell you the secret to results like those above...

2 weeks at home whitening at night time PRESCRIBED BY A DENTIST!

The above patient was a chap I saw who was unhappy with the gradual darkening of his teeth (he was in his late 40s). I prescribed him 16% Carbamide Peroxide for 2 weeks to be worn in his custom made whitening trays (I used the PolaNight system is anyone is interested). 

This compound can only be prescribed by a dentist or dental professional e.g. therapist according to the law GDC vs. Jamous, therefore it is illegal for anyone else to provide tooth whitening which uses more than 0.1% hydrogen peroxide (by the way, for those of you who aren't dentists, carbamide peroxide breaks down into hydrogen peroxide).

But don't beauticians and hairdressers do whitening?

I'm sure many of you have walked past salons advertising tooth whitening and some of you may have even had the treatment... if it's illegal for people other than dental professionals to provide whitening how can these places offer it?

Well there are a small number who may be practising it illegally, but more commonly these salons are using non-peroxide whitening gels (ingredients vary). These products are not clinically effective. So why do people report some great results with this sort of whitening...?

That is because most of these systems are 'light activated'. This involves having the gel on your teeth being exposed to a blue light for 15-30 mins or so. In this time your teeth dry out...and dehydrated teeth look LIGHTER! After a day or two of rehydration, your teeth will look exactly the same as before! And of course there is always the placebo effect. 

Any other 'whitening' product such as toothpastes or gels are not bleaching agents, they have abrasive particles to scrub away stains. They do not whiten the underlying teeth but aim to remove any external staining on your teeth commonly from coffee or tobacco for example. 

So how does tooth whitening work? Does it harm my teeth?

The bleach contains active oxygen that penetrates your enamel and binds with the the internal stains that build up in your teeth over time. 

This sounds scary right? It sounds like the bleach eats away at your teeth? But there is no evidence that bleaching is harmful for you teeth - especially since whitening is something that is designed to be done over short periods of time! 

You can get some side-effects from tooth whitening, most commonly sensitivity to hot and cold food/drinks. This however is temporary and will cessate once you finish bleaching. A lot of bleaching gels have ingredients in them to help counteract this sensitivity, or your dentist may recommend a specific toothpaste for you to use during treatment. Other side-effects are usually the results of the strong whitening gel accidentally spreading onto your gums which can cause irritation and burns. 

There are 2 ways that dentists provide whitening:

1. In-surgery whitening

  • You get a faster result
  • The dentist controls exactly where the bleach goes
  • This is the more expensive option
  • You can't control the final colour of the teeth 
  • You often need a top up at home

2. At home whitening

  • This is the slower option taking on average 2-4 weeks depending on the situation
  • You can control the final result of the teeth more and sensitivity side-effects
  • You place the bleach in custom made trays to wear at night time
  • This is generally the cheaper option

Please bare in mind, whitening is not permanent....whichever option you go for, you will need it topped up after 18-24 months depending on your diet/whether you smoke and the gel will not whiten any fillings, crowns, veneers, bridges or dentures you may have. 

I hope this has answered some of your questions! I don't mean this as an attack on other professionals trying to earn a living, but to make everyone aware of the legislation surrounding tooth whitening. The General Dental Council have prosecuted several beauticians/hairdressers for providing whitening illegally! If you're worried about any of this, please see the GDC's website.

If you have any questions or comments, please leave them in the comments below!

Monday, 7 March 2016

Top Tips to Prepare you for your DCT1 Interview

So those of you who have read my previous post about why I chose DCT (see here) may have submitted your own application - but what are the interviews like and how should you prepare? Here are my top tips!

Personal Specification

If you've checked your application on Oriel, you should notice that there is a Personal Specification to help guide you with what they want a successful applicant to be like. If you haven't checked it yet, here's a brief summary:
  1. Clinical skills: To be aware of own limitations/have insight into their deficiencies, be competent to work without clinical supervision, show knowledge of evidence-informed practice and demonstrates it use in practice.
  2. Organisation, planning and management: Prioritise clinical need, organise yourself and your work, be able to work in multi-professional teams, understanding of clinical governance and audit
  3. Academia/research: Understanding of research, evidence of presentation and professional qualifications
  4. Career progression: Understanding of value, purpose and structure of DCT

The interview itself is made up for 3 x 10 minute stations and this year they will be introducing a SJT (oh no!), the stations are as follows:

1. Personal Skills/Portfolio Station

This station focuses mainly on your portfolio or ePDP and they ask you questions around this and your professional development. Example questions include:

  • What have you done during your DFT?
  • How useful have you found ePDP?
  • Why do you want to do DCT?
  • What makes a good tutorial?
  • How would you make your tutorials better?
  • Are you a good dentist?
  • What is your career plan? (read about careers here)

2. Management and Leadership/Clinical Station

This station was one where you were given 2 clinical scenarios and asked how you might manage them. Most of them were testing your leadership skills rather than just your clinical knowledge and there was often a complication added into the mix e.g. capacity, safeguarding, consent. Some examples include:

  • Management of a patient with post-op pain after XLA 
  • Management of an OAC during XLA
  • Management of post-op bleeding 
  • Management of a patient with a numb lip post XLA
  • Management of a patient who cannot close mouth post XLA
  • Management of child with avulsed tooth
  • Management of Ludwig's Angina
  • Management of patient with facial pain
  • Management of patient with complex MH e.g. bisphosphonates, anti-coagulants

3. Clinical Governance Station

This station is based on the pillars of clinical governance where you discuss clinical effectiveness, risk management and patient focus. Example questions include:

  • What's the difference between research and audit
  • Talk about an audit you have performed in practice (read about audit here)
  • Why is it important to use evidence base in practice?
  • Talk about CPD/courses you have been on
  • What difficulties could you foresee when trying to conduct research?
  • What are the different types of evidence? (read about EBD here)
  • Give an example of where evidence has changed your practice
  • How would you perform a risk assessment in practice?
  • What is professional propriety? 
  • How would you manage a member of staff working outside of their remit/arriving drunk 
  • What is Duty of Candour?

The pilot SJT that I took last year was pretty similar to the DFT SJT but instead of being a foundation dentist, you were acting as a junior doctor in hospital. Just remember the hieracrhy of staff in a hospital:
(Junior Doctor - Clinical fellow - Registrar - Consultant - Clinical Director - Medical Director).

Some extra things to read to help you prepare for the interview:
  • GDC standards (see here)
  • Francis Report 
  • Steele Report
  • The White Report
  • Darzi Report
  • CQC report of the practice you work in
  • CPD requirements of dental professionals 

I hope that helps everyone! The interview for DCT are coming up in April so keep an eye out on Oriel! Good luck!

If you have any questions, please add them to the comments section below!

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