• Bonded restorations (either ceramic or composite) can be BIOMIMETIC i.e. they can mimic the natural appearance of the tooth tissues
• According to some studies, the 10-15 year survival rate of these restorations is similar to that of conventional full coverage restorations
• The difference is not the lifespan, but what happens when the restoration fails. 
• Very few failures with bonded restorations are catastrophic failure compared with conventional prepared restorations as you are preserving more of the tooth tissue 
• You can produce a more aesthetic outcome, not only because the restoration is tooth-coloured, but you are also preserving more of the natural tooth
• The key pillars of tooth preparation are:

This Maryland bridge that I provided for a patient recently was a definitive restoration

• Maryland bridges or even conventional bridgework can be used in interim periods, especially when providing implant work
• The material used can be heat-cured acrylic for short term replacements, or longer term composite bonded to metal work could be used
• There is also the option of using the extracted tooth for the pontic as long as the tooth is intact enough (usually more useful for periodontally involved teeth)
• If using the patient's own tooth, you can have the metal work made in the lab and then bond it to the tooth using Panavia after you have performed a rudimentary root canal treatment in the coronal portion to prevent discolouration
• To make decementation easier, you should use a smaller bonding area on the tooth and create a bevel coronally on the metal wing so that you have an application point for the chisel on removal
• Cement with permanent cement e.g. Panavia and due to the bevel you will have a greater cement lute than normal which you may need to remove with an ultrasonic prior to applying the chisel
• Remember to sharpen the chisel every time you use it as the autoclave will blunt the surface
• There is no need to cement the Maryland under Rubber Dam as this is it a provisional restoration
• Other options for adhesive bridge provisionals include Rochette bridges or using GIC as the cement 
• Always use a floss tie when attempting decementation as a safety measure
• Top tip to remove excess cement on the abutments is to use a fluted Tungsten Carbide bur carefully. Do not press hard as this will remove enamel
• Another way to remove excess cement is with an ultrasonic which can be safer but takes longer
• If removing cement from the bridge over the sink, remember to put the plug in the sink!
• To remove residue and get a cleaner impression, use a cotton wool pledget soaked in chlorhexidine 
• For a more stable bite record use Beauty Wax reinforced with metal foil which prevents distortion n transit to the lab
• When removing conventional cantilever bridges, try to remove with a Towel Clip and if that doesn't work use a Bridge remover with smaller and then bigger taps to break the cement
• When designing the occlusion for the bridgework, try to create a static single contact on the abutment and none on the pontic
• Bond failures with Marylands can either be due to poor treatment planning or poor execution in cementation
• If the debond occurs and there is no cement on the bridge, that means that the metal wing was not prepared enough i.e. sandblasted prior to cementation
• If the debond occurs and there in no cement on the tooth, that means that there was a moisture contamination on cementation
• For a good aesthetic result, ask the lab for an ovate pontic and for 0.5mm gingival relief on the cast itself

• CBCT can be used in both implant dentistry and oral surgery to help both with diagnosis and treatment planning
• 2D images such as DPTs can be misleading sometimes as it only gives a flattened view of a 3D object
• You can use CBCT to scan patients as well as prostheses to treatment plan cases - placing gutta percha in points in the denture can help locate the prosthesis. 
• Ideally you need around 4-5mm of sound bone to place an implant - CBCT can help you determine the amount and quality of the bone present
• If you don't have enough bone to place an implant, you can consider angled implants, zygomatic implants or extensive bone grafts or sinus lifts
• The UK guidelines of CBCT are containing in the HA-CREC-010 document
• When considering performing or referring for these images, you need to adhere to the IRR (99) and the IRMER (2000) guidelines 
• Usually in order to be a CBCT practitioner, you will need at least 11 hours of training 
• When taking a CBCT you must justify the reason why you need to take one and specify which area you need to see
• Record the justification and the report on the image fully in your notes. Dictated notes have been deemed contemporaneous
• You must also perform a quality assessment if you take CBCT. At least 95% need to be of an acceptable standard. 
• Unlike conventional dental radiographs, the quality assessment is only broken down into acceptable and unacceptable (< 5%), due to the scattering effect of metallic restorations
• A small Field of Vision (FOV) CBCT usually amounts to around 2-4 times a DPT, whereas a large FOV amounts to 6-7 times. 
• Doses keep decreasing with the newer machines 
• Typical background radiations is 7-8 mSv a day, so a CBCT usually amounts to a couple of days worth of background radiation, although not all machines are the same
• Uses of CBCT in oral surgery include: assessment of ID nerve position in impacted wisdom tooth extractions, position of impacted teeth in relation to adjacent teeth to assess potential to damage, assessment of periapical pathology prior to surgical endodontics
• Uses of CBCT in implant dentistry include: assessment of bone volume and quality, proximity to vital structures e.g. ID nerve, mental foramen, sinuses, sinus assessment e.g. spicules, membrane thickness
• The software you can use with your CBCT scan can be integrated e.g. Galaxis, Carestream, Icat Vision, or a third party software e.g. Nobel Clinician, Simplant, Osirix
• You can use CBCT with digitial scanning system e.g. CEREC (please see the previous #Tubuleslive post to read about this) in order to plan the ideal position of the implants and create a drilling guide
• With proper planning you can avoid complications such as a sublingual artery bleed as a result of lingual wall perforation

Satisfaction and Dissatisfaction

Why do some people complain and others don't?

• The person's personality and assertiveness
• If the patient is busy as it takes time and effort to complain
• If it is easy for them to complain and whether they are obstacles in their way
• If they have the view that it won't make a difference
• Some people prefer to tell people they know rather than complain
• It can depend on what went wrong and what factors are at work

What people are looking for when they complain?

What makes some people want to take things further?

• How much they like you
• Whether they think you like them
• Whether or not they think you care about them
• Whether they trust you
• How important or valued you make them feel

Danger signs

1. Pain
2. Money - 'why should I pay, it's all your fault!'
3. A sense of violation - 'I trusted you and you let me down'
4. Interpersonal problems - falling out of some sort
5. Dignity - dentist perceived to be arrogant or dismissive
6. Consequences - 'I had a wedding to attend'

Ingredients of an effective in-house complaints system

Organisational culture and leadership

Management, systems and processes

Top Tips for Complaints Handlers

DO NOT:

• Blame the patient - this will escalate the patient's dissatisfaction
• Pick a fight - resolving a complaint is not the same as winning an argument
• Ignore complaints - they will not go away and patients will view this as a sign of disrespect

A CEREC designed and milled Emax crown on the lower first molar.

• CAD/CAM has many applications in patient care: from CBCT scanning to the production of surgical guides and provisional restorations as well the final definitive restoration
• CEREC can be used conventionally to manufacture restorative extra-coronal restorations such as inlays, onlays and full coverage crowns. 
• These restorations are made on the same day, which means that there is no need for a provisional restoration and there is only one visit for the patient - this often increases patient satisfaction as they can watch the milling of their restoration sitting in the waiting room
• CEREC alongside CBCT scanning can be used in the diagnosis and planning of treatments and can be useful to help explain to patients their situation as a 3D image of their teeth and their surrounding anatomy can be generated.
• This 3D image gives a better diagnosis than conventional 2D imaging as you can accurately diagnose fractures, qualities of root fillings, periapical areas, the amount and quality of the surrounding bone and proximity to vital structures e.g. ID canal
• All the team can be involved in the diagnosis and planning stages of a patient's visit - appropriately qualified nurses and technicians can take the scans and place implants in the correct place on the scan. This can lead to more efficient use of a clinician's time
• Provisional restorations can be milled from composite blocks based on these planning stages to help plan the emergence profile of the restorations, shape the soft tissues as well as help the patient understand what the final restoration may look like
• CEREC can then be used to scan preps or the implant (either at the same stage as the surgery or delayed) so there is no need for impression taking
• Definite materials for implant crowns include Zirconia and Emax. Emax crowns can be milled in 12-13 minutes!
• If there are any issues with the provisional or definitive restorations, data has been stored electronically so re-milling is easy and there is no loss of information which can happen with an analogue system. 
• In order to introduce a CEREC or CBCT system into practice, you will have to invest quite a lot of money both in the equipment but also in yourself in terms of training. 
• These systems, despite the high initial outlay can help increase your turnover as you are not only providing a better quality of care for your patients, you can actually save a lot of clinical time so you can ultimately see more patients!

Why can a business struggle?

You'd think there is plenty of business and money in dentistry, but the market is becoming increasingly challenging and there is more of a drive towards an entrepreneurial dentist recently.

Usually, stuggles come about due to break of the processes of a business: investment, marketing, answering customers and serving them. Either that or there isn't a constant flow through the processes.

This leads to a waste of resources (which is automatic), instead of profit (which is intentional).

What does a Complete Business Model look like?

1. The generation of new processes occurs (within 24 hours)
2. A process to capture details and build relationships with potential customers is present
3. A process is present which converts interest into sales
4. You deliver on your promises and exceed expectations i.e. the WOW factor
5. A second sale and repeated purchases happen as a result of the wow factor 
6. There is a process to emotionally impact a patient so they refer their family and friends to your services 

Common mistakes that are made:

• Phone conversation blackhole - patients show interest but this is never followed up
• A list is not built based on who has shown interest
• One step marketing i.e. a large percentage of people will not want treatment at this precise moment in time but may do in the future. They are often ignored by some businesses

5 Mistakes that are made that lose you Orthodontic Patients

Why most marketing doesn't work

• No tracking on the website
• No calls to action
• No opt-ins on the website
• No phone call tracking
• No email follow ups
• No Facebook engagement
• No thank you page

How to become a Provider

1. People who want to straighten their teeth now
2. People who want straight teeth, but not right now
3. People who want straight teeth and didn't realise it could be done as cheaply or as quickly as some systems offer
4. People who want to improve their health and understand that crooked teeth can have negative impacts on their oral health
5. People who do not want to straighten their teeth

For more information please see Click Convert Sell's website or Facebook page.

And if you're interested in some orthodontic systems, check out my overview of the BDIA showcase where I summarise the system In-Line.

The lateral window technique for sinus augmentation prior to implant placement.

• Sinus lifts are one of the most common pre-prosthetic surgical procedures carried out in the UK
• The maxillary sinus (or antrum) is one of the 4 paranasal sinuses which enlarges with age and growth can be rapid following the loss of posterior teeth
• Paranasal sinuses are all connected which means that infection originating in one sinus can spread to the others. 
• The maxillary sinus is a quadrangular pyramid in shape and can vary in size significantly, even extending as anterior as the distal of the lateral incisor
• Some vital structures associated with the maxillary sinus include the facial artery and nerve, internal maxillary artery and the sub-orbital nerve
• Maxillary sinuses sometimes contain septa, which although they look like spikes on DPTs, are actually walls running that divide the sinus
• The sinus membrane is very elastic and thin (although this can vary), and can thicken on response to chronic irritation e.g. sinusitis, chronic periapical infection of maxillary molars
• Pathology of the maxillary sinuses include tumours e.g. ameloblastoma, or more commonly sinusitis
• Sinusitis is caused by a chronic irritant and can be viral, bacterial or fungal in origin.
• Contra-indications to sinus augmentation include: radiotherapy patients, drug addicts, smokers, presence of an oral-antral fistula, complex medical histories
• Patient suitability must be assessed in several ways:

What are MJDF and MFDS?

Why should I sit them?

What's the difference between the Colleges?

How much do they cost?

What are the exams like?

When can I take the exams?

What is Dentinal Tubules?

Why should I join?

What's coming up in 2015?

Lots of prestigious speakers are coming to #Tubuleslive this year. Not only this, but the Tubules Team has some new members, including new presenters and others behind the scenes.

The first event of 2015 is this coming Thursday 29th with Dr Alan Sidi speaking about sinus augmentation for dental implants - and there are lots more events coming up.

Take at look at the Dentinal Tubules website for the full list of events.

Take a look at my presenter profile below!

What constitutes balance?

According to Dr Singh, balance is measured with the 5 F's:

1. Faith
2. Family
3. Finances
4. Fitness
5. Fun

Wheel of life

Source: Harry Singh Dental Property Club.

• Where are the gaps in your wheel? 
• Which areas do you spend too much or too little time? 
• What is the ideal situation for you?

Action Plan

1. Sensitivity

2. Fractured amalgam restorations

3. Fractured or lost post crowns

4. Tori

An example of a palatal torus

5. Silver GIC

6. Tooth wear

Literally SO many people have tooth wear and most of the time it's multi-factorial. The most common causes include brushing too hard (leading to abrasion lesions), grinding their teeth at night time (leading to pictures like below, attrition) or drinking too many fizzy drinks or fruit juices (erosion).

I have seen a couple of interesting erosion cases, one being a bulimic patient who was also a bruxist (nightmare combo) and another guy who upon questioning, revealed he liked to drink cider vinegar!

The difficulty I find is knowing when to intervene and provide treatment for these patients. For a lot of them, this will be the first they've ever heard of suffering from tooth wear and some aren't very receptive to the idea of a mouthguard to wear at night or get defensive when you ask about their diet habits.

In this attrition case below I managed the wear with composite build ups that I had used a putty matrix made from a lab wax up in order to help me create a stable occlusion and a good aesthetic result the patient was very happy with.

Before and after snaps of a tooth wear case (please forgive the after photo which was taken with my phone as I forgot my camera that day!)

7. Stained Composites

8. Dodgy implants/bridge designs

9. Scalloped tongues

10. Caries