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SCIENCE Volume 2 Number 4 August/September 2026 ISSN 3088-6775

EDITORIAL Deep caries management: summary of evidence

CLINICAL FEATURE Wisdom teeth: back to basics part 2 Laura O’Sullivan Katy Martin

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QUIZ RESEARCH Piloting the Modified Oral Status Survey Tool in a nursing home setting Darshini Ramasubbu Jonathan Lewney Brett Duane

CLINICAL TIPS Provisional shell crown technique in the contemporary management of amelogenesis imperfecta David McReynolds Alexander Lichtmannegger MDT Enrico Steger MDT

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NEW DENTAL SCIENCE Costello Award 2026 RESEARCHER PROFILE Looking at the life course Dr Vinay Sharma

ED I TORIAL

Deep caries management: summary of evidence Dr Cristiane da Mata BDS MFD (RCSI) Dip TLHE MPH Phd FFD RCSI

Honorary Editor

A new guideline provides evidence-based recommendations for the management of deep and extremely deep carious lesions in permanent teeth.

journaleditor@irishdentalassoc.ie

Deputy Editor Dr David McReynolds BA BDentSC MFDS RCSEd DChDent (Pros) FFD RCSI

Editorial Board Dr Meriem Abbas BDS (NUI) MFDS RCSEd PGDip TLHE

Una Farrell Dip Dental Hygiene Dr Catherine Gallagher MB BCh BAO BDS NUI FDS RCSEng FFD RCSI

Cariology has evolved over the last number of years from a surgical model, or a ‘drill and ﬁll’ approach, to a more preventive, biological, and minimally invasive science. The emphasis is no longer on aggressive tissue removal but on preserving the natural defence and repair mechanisms of the dental pulp. Thus, the recently published EFCD-ESE-ORCA S3 Clinical Practice Guideline for Deep Caries Management is a relevant and important article that clinicians should be aware of.1

Dr Geraldine McDermott BA BDentSc MFDS (RCSI) PGradDip ConSed (TCD) MSc Healthcare

Moving beyond complete caries removal

Leadership (RCSI)

The Guideline recommends selective caries removal (SE) or stepwise caries removal (SW) in preference to non-selective excavation (NSE) for deep carious lesions in permanent teeth with healthy pulps or signs of reversible pulpitis. The Guideline acknowledges ongoing uncertainty regarding extremely deep lesions, where radiographic evidence suggests little or no remaining dentine between the lesion and the pulp. In such cases, pulp exposure should be anticipated and appropriate management planned in advance.

Dr Clair Nolan BDS (NUI) MSc (Endo) U Lond Dr Adedeji Daniel Obikoya BChD MFDS (RCSI) MSc

Dr Judith Phelan BDS (NUI) MDS (NUI) MSc (U Lond) MRD (RCS Eng and Glas)

Dr Patrick Quinn BCL BDS LLM MDPH Dr Catherine Vaughan BDS (NUI) International Editorial Board Assoc. Prof. Lamyia Anweigi BDS MMedSc MFDS PhD (Qatar)

Dr Ana Cecilia Diniz Viana BDS MD PhD (Brazil)

Reconsidering the role of cavity liners

Dr John Macken BDS PGCertMEd PhD MFDS

The evidence reviewed by the group found no consistent beneﬁt for cavity liners in reducing treatment failure, postoperative sensitivity, secondary caries, or loss of pulp vitality. Consequently, the authors state that based on the evidence, routine use of cavity liners cannot be recommended in patients with deep caries in permanent teeth associated with no symptoms or symptoms indicative of reversible pulpitis. However, the authors recommend that “cavity ﬂoors in close relationship to the pulp (e.g., where the pulp may be visually detectable, shining through the dentine) should receive a liner”, even though evidence to support this approach is currently lacking.

RCSEng ACIEA FHEA (UK)

Prof. Leonardo Marchini DDS MSD PhD (USA)

Dr med dent Ramiar Karim BDS MSc Paed Dent (Germany)

Dr Elaine Smyth BA BDentSc DChDent (USA) Prof. Murali Srinivasan BDS MDS MBA MAS PD (Switzerland)

Prof. Sayaka Tada DDS PhD (Singapore) jida.scholasticahq.com Irish Dental Association Unit 2 Leopardstown Oﬃce Park, Sandyford, Dublin 18. T: +353 1 295 0072 F: +353 1 295 0092 www.dentist.ie Published on behalf of the IDA by Think Media, 537 NCR, Dublin 1.

Vital pulp therapy The guideline supports both direct pulp capping and pulpotomy (partial or full) as valid treatment options following carious pulp exposure in permanent teeth diagnosed with healthy pulps or reversible pulpitis, and the studies reviewed did not show a clear

advantage of one approach over the other. Perhaps even more importantly, the Guideline recognises the growing body of evidence supporting pulpotomy in teeth diagnosed with irreversible pulpitis. While root canal treatment remains a wellestablished standard of care, partial and full pulpotomy may offer similar clinical outcomes in selected cases. Therefore, clinicians are encouraged to assess whether enough healthy pulp tissue remains to heal aer removal of the inflamed coronal pulp. It is important to note that successful pulpotomies depend on following enhanced clinical protocols, including rubber dam isolation, use of antimicrobial irrigants, magnification, and careful restorative sealing.

Hydraulic calcium silicate cements For both direct pulp capping and pulpotomy, hydraulic calcium silicate cements (HCSCs), including mineral trioxide aggregate (MTA) and Biodentine, are recommended over calcium hydroxide. The main barriers to widespread adoption of these recommendations remain cost, handling characteristics, and concerns regarding tooth discolouration for some materials. Nevertheless, the evidence increasingly supports HCSCs as the contemporary gold standard for pulp preservation procedures.

Implications for clinical practice These recommendations reflect a shi towards more minimally invasive and biologically driven approaches. The Guideline also points out important implementation challenges. Many clinicians may still have limited experience performing pulpotomies in mature permanent teeth, and access to magnification tools, specialised materials, and advanced training can vary significantly. In addition, reimbursement models may continue to favour more invasive options.

Reference 1. Schwendicke F, Kosan E, Banerjee A, et al. Deep Caries Management: EFCD-ESE-ORCA S3-Level Clinical Practice Guideline. Int End J. 2026;59(7):1298-1315.

JIDA Science is an official publication of the Irish Dental Association. The opinions expressed in JIDA Science are, however, those of the authors and cannot be construed as reflecting the Association’s views. The editor reserves the right to edit all copy submitted to JIDA Science.

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Wisdom teeth: back to basics part 2 The second article in this series addresses complications of wisdom tooth surgery and management of common third molar problems.

Learning outcomes: n to understand the risks and complications associated with mandibular third molar (Md3M) and maxillary third molar (Mx3M) surgery; n to review alternative treatment modalities to Md3M removal; and, n to revise immediate management of complications associated with Mx3M removal.

Introduction Wisdom tooth removal is one of the most common surgical procedures carried out worldwide. General dental practitioners (GDPs) should not only be proﬁcient at examining and diagnosing third molar disease, but should also be familiar with the various treatment options available. The ﬁrst part of this series focused on wisdom tooth disease, assessment, and referral criteria for third molar surgery.1 This paper reviews the complications that can arise with wisdom tooth surgery, and outlines some alternative treatment options for management of third molars.

reasons for this finding.4 These functional and aesthetic limitations have been shown to peak at day one postoperatively, with a gradual improvement towards baseline pre-operative levels by day six.3,5 Pain is considered a reliable indicator of patient satisfaction,6 and may be influenced by factors such as patient anxiety, intra-operative bone removal, and operative duration.2,6 Studies have shown a peak in postoperative pain experience three to five hours following third molar surgery,6 which lends support to the deterioration in QoL observed during this period.

Complications of Md3M surgery Clinical relevance The GDP remains in a unique position to support early diagnosis and onward referral for assessment prior to third molar surgery. Where a dentist suspects that removal of third molars is indicated, counselling patients on the appropriate treatment options, alongside the risks and beneﬁts of intervention, is a central part of the consent process.

Objective The reader should gain an understanding of the risks of both Mx3M and Md3M surgery, and be able to counsel patients appropriately prior to undertaking third molar extraction, or arranging onward referral to oral surgery colleagues.

Morbidity of Md3M surgery Patients undergoing third molar surgery will routinely be informed about the common postoperative sequelae of pain, swelling and trismus (limitation of mouth opening less than 30mm).2 Despite ample discussion regarding these sequelae, patients can oen be surprised at the protracted morbidity associated with third molar surgery, with a deterioration in quality of life (QoL) reported for an average of five days postoperatively.3 The clinical findings of swelling and trismus appear to be the main contributors to this deterioration in QoL. The effects of swelling and trismus on a patient’s appearance and ability to masticate, respectively, have been reported as the

Laura O’Sullivan BDS FDS(OS) RCSEd DClinDent(OS) MFDS PDTLHE Specialist in Oral Surgery Cork University Dental School and Hospital University College Cork

Postoperative complications arise in up to 35% of cases of third molar surgery.7 The most common complication of any dental extraction, including third molar surgery, is alveolar osteitis (AO), more commonly referred to as dry socket. This is localised inflammation within a socket that may be partially or totally devoid of a blood clot, leading to persistent pain, malodour, and delayed wound healing.8 Factors such as smoking, female gender, poor dental hygiene, and concurrent oral contraceptive medication increase the likelihood of developing dry socket postoperatively.7,9 The use of antibiotics may reduce the risk by 38% but with a number needed to treat (NNT) of 38, the evidence supporting routine use of antibiotics is lacking.10 Nerve injury The posterior mandible is a high-risk site for dentoalveolar surgery, due in no small part to its complex anatomy. Specific to the lower third molar tooth is the close, and occasionally intimate, relationship with the lingual and inferior alveolar nerves. Iatrogenic trigeminal nerve injury is the most problematic complication of dentoalveolar surgery, with considerable medicolegal implications.11 Trigeminal nerve injuries can interfere with many day-to-day activities, such as speaking, eating, smiling, kissing, shaving, make-up application, toothbrushing, and drinking.11 The negative impact on QoL, social interaction, and general psychological well-being is well documented, with up to 70% of affected patients reporting long-term chronic pain and disability.12

Katy Martin BDS FDS OS RCSEd MOralSurg RCSEd MFDS RCSEd MA Dent Ed Specialist in Oral Surgery Dublin Dental University Hospital Lincoln Place Dublin

Corresponding author: Laura O’Sullivan E: laura.osullivan@ucc.ie

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The incidence of lingual nerve injury has remained more or less unchanged over the last 30 years, ranging from 0.4-1.5%.13 Third molar surgery remains the most common cause.13 Factors that increase the risk of lingual nerve injury include the depth of impaction, lingual flap retraction, vertical tooth sectioning, and operative duration.2,14 There is conflicting evidence to suggest that lingual nerve injuries are more likely to occur with an inexperienced operator and where surgery is performed under general anaesthesia;15 however, these speculations are not corroborated across the board. Recovery of lingual nerve injury within eight weeks is seen in 85-94% of cases,13 although spontaneous repair of sectioned lingual nerve axons is unlikely due to retraction and separation of nerve endings where there has been manipulation of the surrounding so tissues.16 Early referral to a specialist centre for investigation and prompt surgical intervention is therefore recommended, preferably within three months of injury. Third molar surgery accounts for up to 3.6% and 8% of permanent and temporary cases of inferior alveolar nerve (IAN) injury, respectively.17 Local anaesthetic administration, dental implant placement, and endodontic treatment are also major contributors to IAN injury.13 The intraosseous anatomical course of the IAN within the confines of the mandibular canal makes it less amenable to surgical repair than the lingual nerve.13 Recovery of sensation is unlikely beyond six months of the injury.13 IAN injuries are more common in females, and show a positive correlation with operator inexperience. The incidence of IAN neurosensory deficit is highest in cases of horizontal Md3M impaction,2 and lowest in vertical Md3M impactions.18 Mandible fracture Iatrogenic fracture of the mandible is a rare, but potentially very serious, complication of third molar surgery, with a reported incidence of 0.00330.0049%.19,20 Males are twice as likely to be affected as females, with mesioangular Md3Ms most commonly implicated.20 Mandible fracture secondary to third molar removal is more likely to occur in patients who are in their fih or sixth decade.21 This complication will significantly prolong recovery time for those affected.

Alternatives to Md3M removal For some patients, surgical removal of impacted Md3M may not be an appropriate first line of treatment. Reasons for alternative treatment modalities include significant medical comorbidities, increased risk of IAN injury, and patient choice. Alternative treatment modalities should be considered if the risk of delaying surgical removal of Md3M does not outweigh the benefit. Treatment options to consider include: n enameloplasty; n operculectomy; n coronectomy; and, n removal of opposing Mx3M. Enameloplasty In the case of overerupted Mx3M, enameloplasty is a minimally invasive treatment option for patients experiencing traumatic pericoronitis. Recontouring of prominent cusps of Mx3M can significantly reduce direct trauma to the so tissue operculum of the opposing Md3M. Enameloplasty is useful for the immediate management of acute pericoronitis, and can serve as a temporary measure to manage symptoms while awaiting Md3M intervention.

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FIGURE 1: Soft tissue operculum covering distal marginal ridge and distolingual cusp of mandibular molar (dotted line shows area of excision). A

FIGURE 2: (a) Section of pre-operative orthopantomogram showing impacted distoangular LL8 with radiolucent banding across apices; and, (b) section of postoperative orthopantomogram three months post coronectomy showing coronal migration of LL8 roots and the absence of pathology. Operculectomy Operculectomy involves removal of the so tissue flap overlying a partially erupted tooth (most commonly Md3M), and should only be performed by experienced clinicians trained in the procedure (Figure 1). Operculectomy should be reserved for select cases of so tissue impaction, and avoided in teeth affected by bony impaction. Some benefits of operculectomy include ease of oral hygiene, prevention of food trapping, and promotion of eruption of the affected tooth. Operculectomies are not without risk; operculum regrowth and lingual nerve injury are possible. It is therefore recommended that patients are reviewed clinically a few months aer completing this procedure. Coronectomy Coronectomy is an alternative surgical technique for management of high-risk Md3Ms, and involves removal of the crown of the tooth and deliberate retention of the roots (Figures 2a and 2b). Far from being a novel procedure, coronectomy was first described by Ecuyer and Debien22 in 1984, and the technique has gained popularity in recent years in an effort to mitigate the risk of iatrogenic trigeminal nerve injury. Coronectomy has been shown to reduce the risk of IAN injury in high-risk teeth by 84%.23

C L I NI C AL FE AT U R E

FIGURE 4: Right maxillary tuberosity fracture during routine extraction of UR7.

FIGURE 3: Left hemi-orthopantomogram showing grossly overerupted UL8. Failure is more likely to occur in horizontally impacted Md3Ms, lingually impacted Md3Ms, and in females with conical roots that narrow within the inferior alveolar canal.24 Risks of surgery include root migration, infection, and a need for future root retrieval. Contraindications include pulpal caries, periapical pathology, poorly controlled diabetes mellitus, steroid therapy, and immunosuppression, while coronectomy might be favoured in patients with a history of bisphosphonate use and/or radiotherapy to the head and neck region.25 Removal of opposing Mx3M Mechanical trauma from the opposing Mx3M can result from occlusion onto the operculum overlying the erupting Md3M, or onto the adjacent buccal mucosa (Figure 3). Extraction of the overerupted Mx3M is indicated in such instances to eliminate this so tissue trauma.

Maxillary third molar surgery While the primary focus of this series has been the Md3M, the removal of upper wisdom teeth can oen be carried out without complication by GDPs. In addition to the general risks associated with exodontia, consideration should be given to those risks speciﬁc to the removal of the Mx3M. Judicious clinical and radiographic assessment are essential to reduce the risk of the following complications: n tuberosity fracture; and, n oro-antral communication (OAC). Tuberosity fracture The risk of maxillary tuberosity fracture during removal of Mx3M increases with age, by 3.1% per year.26 Risk factors for tuberosity fracture include divergent or bulbous root morphology, tooth ankylosis, lone-standing maxillary molars, ectopic Mx3M, increasing patient age, and unsupported extraction technique.26,27 Signs of impending tuberosity fracture include soft tissue blanching, tearing of the palatal mucosa, excessive bleeding, mobility of the alveolar segment including adjacent teeth, and distinctive cracking sounds that may be

FIGURE 5: Breach of antral floor at palatal aspect of socket following routine extraction of UL6 in a healthy 23-year-old patient.

indicative of a bony fracture (Figure 4). Immediate management options depend on the size of fracture and communication with the maxillary sinus, as well as clinical expertise, and include clinical monitoring, dissection of the alveolar segment from soft tissue, and splinting.27 Large tuberosity fractures or those resulting in an OAC may require immediate rigid fragment stabilisation, analgesia, and onward referral to an oral surgeon for assessment and surgical repair. Oro-antral communication OAC can arise in isolation during an otherwise routine extraction of a maxillary permanent molar (Figure 5), or in combination with a fractured tuberosity. ‘Beware the lone-standing molar’ is a phrase with which many dentists will be familiar, and not without reason. The complications of tuberosity fracture and OAC are most commonly associated with the lone-standing maxillary molar, due to the dual processes of alveolar resorption and pneumatisation of the neighbouring maxillary sinus. Complex root morphology, low-lying maxillary sinus ﬂoor, hypercementosis, excessive force, and unsupported extraction technique increase the risk of developing an OAC. However, it can arise in the most experienced of hands and during the most routine of extractions. At the time of surgery, an OAC can be

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FIGURE 6: (a) Intra-operative view of large oro-antral communication at the site of a recent UR7 extraction; and, (b) closure of the defect using a combination of buccal fat pad and buccal advancement flap. identified by a clear discontinuity of the socket apex (Figures 5 and 6), observation of ‘bubbling’ at the base of the extraction socket, or visualisation of movement of the antral lining during patient respiration. Clinicians may also note bony fragments indicative of a tuberosity fracture or concave bone attached to the roots of the extracted Mx3M.28 Small communications of <5mm are likely to close spontaneously and require conservative management only (Table 1). For defects of >5mm, immediate surgical repair by an oral surgeon is advised.29 Early repair of OACs using the buccal advancement flap with/without the buccal fat pad is the technique of choice for surgical management (Figure 6). In rare cases of failed buccal advancement flap repair, consideration can be given to closure of the defect using a palatal rotational flap if the affected site is accessible. This technique should be reserved for select cases only, due to the increased discomfort experienced by patients during the healing process. In cases of late surgical repair, OACs will typically have undergone epithelialisation and matured into an oro-antral fistula (OAF). The fistula will require careful complete excision prior to closure using buccal advancement flap with/without buccal fat pad advancement or autogenous bone graing.28,29

Table 1: Conservative management of OAC. n Haemostatic agent (communications <5mm only) and suture of site; n antibiotics and decongestant to prevent onset of sinusitis; n avoid Valsalva manoeuvre (nose-blowing, sneeze suppression, ear popping); n regular warm salt water mouthrinses to promote healing; and, n steam inhalations twice daily to maintain sinus patency.

Conclusion GDPs should have an understanding of their essential role in the assessment and diagnosis of third molar pathology. Awareness of the risks and beneﬁts of third molar surgery will help patients during the decision-making process. By recognising and knowing how to effectively manage complications associated with molar extractions, the GDP should be well equipped to select cases appropriate for management in primary care and know when to refer for intervention.

References 1. O’Sullivan L, Martin K. Wisdom teeth: back to basics part 1. J Ir Dent Assoc Science. 2026;2(3): 44-48. 2. Hill CM, Mostafa P, Thomas DW, Newcombe RG, Walker RV. Nerve morbidity

5. Duarte-Rodrigues L, Miranda EFP, Souza TO, de Paiva HN, Falci SGM, Galvão EL. Third molar removal and its impact on quality of life: systematic review and metaanalysis. Qual Life Res. 2018;27(10):2477-2489.

following wisdom tooth removal under local and general anaesthesia. Br J Oral

6. Coulthard P. Post-operative oral surgery pain: a review. Oral Surg. 2009;1(4):167-177.

Maxillofac Surg. 2001;39(6):419-422.

7. Anjrini AA, Kruger E, Tennant M. International benchmarking of hospitalisations for

3. McGrath C, Comfort MB, Lo EC, Luo Y. Changes in life quality following third molar surgery – the immediate postoperative period. Br Dent J. 2003;194(5):265-268.

impacted teeth: a 10-year retrospective study from the United Kingdom, France, and Australia. Br Dent J. 2014;216(7):E16.

4. Savin J, Ogden GR. Third molar surgery – a preliminary report on aspects aﬀecting

8. Daly BJM, Sharif MO, Jones K, Worthington HV, Beattie A. Local interventions for the

quality of life in the early postoperative period. Br J Oral Maxillofac Surg.

management of alveolar osteitis (dry socket). Cochrane Database Syst Rev.

1997;35(4):246-253.

2022;9(9):CD006968.

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9. Jerjes W, Upile T, El-Maaytah M, et al. Experience in third molar surgery: a prospective study. Br J Oral Maxillofac Surg. 2009;47(7):e11. 10. Lodi G, Figini L, Sardella A, Carrassi A, Del Fabbro M, Furness S. Antibiotics to prevent complications following tooth extractions. Cochrane Database Syst Rev. 2012;11:CD003811. Update in: Cochrane Database Syst Rev. 2021;2(2):CD003811. 11. Renton T. Prevention of iatrogenic inferior alveolar nerve injuries in relation to dental procedures. Dent Update. 2010;37(6):350-363. 12. Renton T. Risk assessment of M3Ms and decisions on ordering a CBCT and prescribing a coronectomy. Dent Update. 2017;44(10):957-976. 13. Renton T. Oral surgery: part 4. Minimising and managing nerve injuries and other complications. Br Dent J. 2013;215(8):393-399.

removal of impacted third molars: an analysis of 130 cases. Br Dent J. 2012;212(4):179184. 21. Krimmel M, Reinert S. Mandibular fracture aer third molar removal. J Oral Maxillofac Surg. 2000;58(10):1110-1112. 22. Ecuyer J, Debien J. Déductions opératoires [Surgical deductions]. Actual Odontostomatol (Paris). 1984;38(148):695-702. 23. Pitros P, O’Connor N, Tryfonos A, Lopes V. A systematic review of the complications of high-risk third molar removal and coronectomy: development of a decision tree model and preliminary health economic analysis to assist in treatment planning. Br J Oral Maxillofac Surg. 2020;58(9):e16-e24. 24. Renton T, Hankins M, Sproate C, McGurk M. A randomised controlled clinical trial

14. Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C. Lingual nerve damage aer

to compare the incidence of injury to the inferior alveolar nerve as a result of

third lower molar surgical extraction. Oral Surg Oral Med Oral Pathol Oral Radiol

coronectomy and removal of mandibular third molars. Br J Oral Maxillofac Surg.

Endod. 2000;90(5):567-573.

2005;43(1):7-12.

15. Brann CR, Brickley MR, Shepherd JP. Factors inﬂuencing nerve damage during lower third molar surgery. Br Dent J. 1999;186(10):514-516. 16. Loescher AR, Smith KG, Robinson PP. Nerve damage and third molar removal. Dent Update. 2003;30(7):375-382.

25. Dhanrajani P, Smith M. Coronectomy: a recognised procedure? Oral Surg. 2018;11(4):273-281. 26. Shmuly T, Winocur-Arias O, Kahn A, Findler M, Adam I. Maxillary tuberosity fractures following third molar extraction, prevalence, and risk factors. J Craniofac Surg.

17. Renton T. Notes on coronectomy. Br Dent J. 2012;212(7):323-326. 18. Smith WP. The relative risk of neurosensory deﬁcit following removal of mandibular third molar teeth: the inﬂuence of radiography and surgical technique. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;115(1):18-24. 19. Libersa P, Roze D, Cachart T, Libersa JC. Immediate and late mandibular fractures aer third molar removal. J Oral Maxillofac Surg. 2002;60(2):163-166. 20. Ethunandan M, Shanahan D, Patel M. Iatrogenic mandibular fractures following

2022;33(7):e708-e712. 27. O’Sullivan L. Management of the fractured maxillary tuberosity. JIDA. 2024;70(4): 189-190. 28. Renton, T, Durham, J, Hill, C. Oral surgery II: Part 2. The maxillary sinus (antrum) and oral surgery. Br Dent J. 2017;223:483-493. 29. Visscher SH, van Minnen B, Bos RRM. Closure of oroantral communications: a review of the literature. J Oral Maxillofac Surg. 2010;68(6):1384-1391.

Quiz Submitted by Dr Caitriona Kieran BA BDentSc MFDS MSc(Aes Med) PGDipDerm Rae Clinic President Elect, Irish College Aesthetic Medicine 1. Can you name the muscle highlighted in the photograph? A. Procerus B. Frontalis C. Depressor anguli oris D. Levator labii superioris alaeque nasi

2. By injecting this muscle with botulinum toxin, your patient will have: A. Fewer horizontal lines B. Fewer vertical lines

3. What eﬀect will this have on the patient’s brows? A. It will raise their brows B. It will drop their brows

Answers on page 78

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RESEARCH

Piloting the Modified Oral Status Survey Tool in a nursing home setting Précis: This pilot study trialled the Modified Oral Status Survey Tool in nursing home residents. While the tool was easy to use, consent was a barrier to participation.

Abstract Introduction Little is known about the oral health of older adults in nursing homes in Ireland. This study explored the use of the Modified Oral Status Survey Tool (MOSST) in examining the oral health of this population. Objectives 1. Trial the use of the MOSST by a dentist in the nursing home population in Ireland. 2. Provide initial data on the oral health status of participants. 3. Provide initial data on dental service use and oral health-related quality of life (OHRQOL). Methods Training and calibration in the MOSST and its accompanying questionnaire were completed and ethical approval gained. Convenience sampling from private nursing homes in Leinster was undertaken. Patients aged 65+ who were able to provide informed consent were eligible for inclusion. Results Five nursing homes were visited, which housed 366 residents. Of these, 78 people were willing to be examined and able to consent to examination. No participants were identified as having urgent dental needs. Despite the variety in numbers of functional units, natural teeth and visibly cavitated teeth, the majority of participants did not report pain or difficulty chewing, and were happy with their smile.

Darshini Ramasubbu Division of Public and Child Dental Health, School of Dental Science, Dublin Dental University Hospital,

Conclusion The low number of participants illustrates the difficulty of research in the nursing home population. Large numbers of people were not able to provide informed consent, largely due to barriers such as dementia. However, the MOSST was easy to use in the population able to consent, and beneficial in that it can be used by both dentists and non-dentists following training. Journal of the Irish Dental Association Science 2026;2(4):68-74

Lincoln Place, Dublin 2 Jonathan Lewney Specialist in Dental Public Health (UK GDC) and independent researcher Paris, France Brett Duane Division of Public and Child Dental Health, School of Dental Science, Dublin Dental University Hospital, Lincoln Place, Dublin 2

Corresponding author: Dr Darshini Ramasubbu E: ramasubd@tcd.ie

Introduction Little is known about the oral health of older adults in nursing homes in Ireland. The Irish Longitudinal Study on Ageing (TILDA) is a large, national study that aims to determine current health status and health needs of older people who reside in the community, their social and economic needs, and what the biological and environmental effects of successful ageing are.1 There are limited prior data available regarding the oral health of older adults in Ireland, as the last national survey of the oral health of this population was conducted over 20 years ago.2 However, Wave 3 of TILDA included a dental assessment of adults over 50 who live in the community.3 Action 33 of Smile Agus Sláinte, Ireland’s oral health policy, specified the development of a nationally agreed set of core criteria to assess the oral health of patients at each World Health Organization (WHO) indicative age, including those aged 65 and older.4 TILDA has helped to provide more information on older adults in the community. However, there is a paucity of information regarding adults of a similar age in residential settings. Action 34 aims to develop a programme for pathfinder studies that will initially focus on residential centres and vulnerable people.3,4 In Ireland, approximately 20% of nursing homes are publicly funded Health Service Executive (HSE) facilities, approximately 3.7% are run by not-for-profit organisations, and the remaining 77% are run by private providers.5 The Dental Treatment Services Scheme (DTSS) in Ireland currently entitles eligible adult medical card holders to an annual examination, teeth cleaning, extractions, and two fillings per year. Additional treatments such as dentures and periodontal treatment are available to some patients.6 Austerity measures introduced in 2010 resulted in funding for this Scheme being cut from €62m to €10m from 2010 to 2015, causing severe restrictions in restorative and preventive dentistry, which are still largely in place today.7 A subsequent exodus of dentists from the DTSS has created access issues nationally for patients, and

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RESEARCH

FIGURE 1 : The Modified Oral Status Survey Tool (MOSST). further pressure on the HSE dental services.8 For those in residential care, this may cause further barriers to accessing dental care. Additionally, there may be variation in their oral health needs, their ability to manage their own oral health, and in support and training in this area from staﬀ.9 The Modiﬁed Oral Status Survey Tool (MOSST) was developed by Trinity College Dublin, the Trinity Centre for Ageing and the Life Course in Intellectual Disability (TCAID), and Dublin Dental University Hospital, in partnership with adults with intellectual disabilities (ID) for use on the Intellectual Disability Supplement of the TILDA study (IDS-TILDA).10 The MOSST covers seven concepts that indicate oral status and oral function. It was developed to be quick, acceptable, robust and administered by non-dental professionals (such as nurses and healthcare assistants), as well as by dental professionals, without the use of an assistant or scribe.10,11 The aim of the MOSST is to collect data based on the following concepts: number of functional tooth units; aesthetics (presence of the front 12 teeth); denture wear; number of teeth in each arch; cavitated teeth; gum condition; and, oral cleanliness. The MOSST-Self Report Supplement (SRS) aims to collect data on selected aspects of oral healthcare utilisation, oral health behaviours (home care), and oral health-related quality of life (OHRQOL).10,11 The MOSST can be used for research, or to inform service planning and policy, but is not designed to be used to assess the dental needs of individuals or to replace appointments with a dental professional.10,11 It was hypothesised that the MOSST could be used by dentists to determine the oral health status of people who reside in nursing homes in Ireland. The aim of this pilot study is to assess the use of the MOSST in private nursing homes in Leinster (Dublin, Kildare, Wicklow, Carlow, Kilkenny, Laois, Longford, Meath, Westmeath, and Wexford). The objectives of this pilot study are to: 1. Trial the use of the MOSST by a dentist in the nursing home population in Ireland to determine its appropriateness and identify challenges with dental research in this population. 2. Provide initial data on the oral health status of participants based on an intraoral exam. 3. Provide initial data on dental service use and OHRQOL based on a questionnaire.

Methods The examiner was a dentist with experience of working with vulnerable adults. Training and calibration of the dentist on the MOSST and MOSST-SRS were completed in March 2024, with a combination of online and in-person sessions facilitated by Dr Caoimhin Mac Giolla Phadraig and Katrina Byrne (Trinity College Dublin). The dentist achieved an inter-rater agreement Kappa statistic result of 1.00, and therefore a very good strength of agreement with the gold standard examiner. Ethical approval for the study was granted by Trinity College Dublin’s Faculty of Health Sciences Research Ethics Committee in December 2024. This included a data protection impact assessment. Convenience sampling from private nursing homes in Leinster was undertaken. Each of the facilities was contacted by email or phone call, and an accompanying letter. Gatekeepers for each facility who did not provide direct clinical care to nursing home residents were identified. Adults were targeted via their nursing homes, and consent forms and participant information leaflets were given to each person selected for inclusion. Patients aged 65 and older living in nursing homes in Leinster were included in this study. The study was explained by the gatekeeper, and anyone who expressed interest, or was able to express interest, in participation was then met by the dentist, who went through the participant information leaflet and consent form. The dentist who undertook the examination determined if informed consent could be taken on the day, and some participants were excluded on the day as they could not provide consent in any form (for example, some patients were bed bound and non-verbal, and could not indicate whether they understood the study). Many potential participants were excluded by gatekeepers and nursing staff due to conditions such as advanced dementia. A gatekeeper was required by the Faculty of Health Science, Trinity College Dublin to be “someone in an administrative role, not directly responsible for clinical care”. In order to participate, informed consent was required. Those who could not provide consent were not included. Data collection was undertaken by an Irish Dental Council-registered dentist, using a dental mirror, head torch, and personal protective equipment (PPE). The MOSST and the MOSST-SRS were used to gather data for all participants who could provide consent (Figure 1). Every participant was given a verbal summary

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30 27

Number of participants

25 20 15 12 10 10 7 4

0 0

Number of functional units FIGURE 2: Number of pairs of functional tooth units present per participant.

Number of lower teeth per participant

Number of upper teeth per participant 25

Number of participants

25 20 15 10 5

20 15 10 5

0 0

Number of teeth

FIGURE 3: Number of teeth per arch. of ﬁndings, including discussion of care options, and a written letter similar to that used in the TILDA study recommending urgent, soon or routine care need. Need for dental care was also discussed with their care team in the nursing home. The MOSST-SRS was used to investigate speciﬁcally selected aspects of oral healthcare utilisation, oral health behaviours, and OHRQOL for each participant via multiple choice questions.

Results Five nursing homes were visited, which in total housed 366 residents. Gatekeepers for each nursing home aided in identifying residents interested in participating and who were able to provide informed consent. While 86 people were presented for examination, the ﬁnal sample for the oral examination totalled 78 (21.3%) people, as seven could not provide informed consent and one declined to participate. Of the 78 people who participated in the MOSST, 26 were male and 52 were female. The mean participant age was 80.6 years. All participants were given feedback on their oral health needs and advised whether they should see their dentist routinely, soon or urgently. No participants were identiﬁed as having urgent dental needs, such as acute infection or suspicious lesions.

70 | Volume 2 Number 4 | August/September 2026

The 21.3% of the total population who were able to participate likely represent those more capable of personal oral healthcare. Therefore, while these results may be an underestimate of need, the initial ﬁndings were as follows. The ﬁrst part of the MOSST assessed the number of functional units of each participant, which may consist of natural or prosthetic teeth. A molar pair counts as two functional units, while a pre-molar pair is one. There was a lot of variation in numbers of functional units between participants (Figure 2). The next part of the MOSST focused on aesthetics, looking at whether each participant had 12 front teeth present, either natural or prosthetic. From this sample, 56 people out of 78 had 12 front teeth present, which is over 70% (71.8%). Participants were then investigated for denture use, and recorded as wearing an upper or lower denture only if they were wearing one at the time of examination. Over 35% (n=28) of residents were wearing an upper denture and 23.1% (n=18) were wearing a lower denture. Dentures were then removed and the number of teeth per arch recorded. The mean number of teeth per participant in the upper arch was 6.86, and for the lower arch it was 7.81 (Figure 3). In terms of cavitated teeth present, over 60% (64.1%) had no visibly cavitated teeth present, although 19% of participants had three or more cavitated teeth.

RESEARCH

Which of the following best describes your oral health service use? 12

I/[He/She] go to the dentist at least once every two years

I/[He/She] go to the dentist at least once every year I/[He/She] go to the dentist less oen than once every two years

9 6

I/[He/She] never go to the dentist I/[He/She] only go to the dentist if there is a problem (e.g., a tooth hurts)

25 7

Not answered 0

Number of participants FIGURE 4: Oral health service use. When you need a routine dental visit, who do you visit? 26

A MEDICAL CARD dentist or dental hygienist

A PRIVATE dentist or dental hygienist Not answered

3 5

Other* (please specify) 0

Number of participants FIGURE 5: Attendance for routine dental care. What best describes the help you get from someone else to clean your teeth? 52

I/[He/She] clean(s) teeth without help (can include prompting, reminding, supporting) I/[He/She] clean(s) teeth with a little help (e.g., physical guidance, shared brushing)

I/[He/She] do [does] not have any teeth to clean

9 3

I/[He/She] do [does] not clean my/their teeth Not answered

I/[He/She] clean(s) teeth with a lot of help (e.g., all brushing by carer)

2 0

Number of participants FIGURE 6: Help for routine oral hygiene. Over 70% of the sample (n=60) had healthy gums, and 59% (n=46) had clean mouths/dentures. Participation in the questionnaire was more varied, as some participants did not answer certain questions. Four participants required some assistance to answer questions. When asked about their oral health service use, there was a lot of variation in terms of regularity of attendance, with over 30% of participants only going to see the dentist if they have a dental problem (Figure 4). The majority of participants (56.4%, n=44) stated that when they need a routine dental visit, they attend a private dentist or hygienist, and 26 participants (33.3%) stated that they attend a medical card dentist (Figure 5). When asked if they needed additional measures for routine dental treatment such as restorations, 17 participants did not answer this question, but the majority (75.6%, n=59) answered that they only needed local anaesthesia. In response to being asked about barriers to accessing dental care, 65 participants

reported no difficulty in accessing dental treatment. Three people stated that there was a long waiting list to see their dentist, one participant reported difficulty accessing dental treatment, and one person responded that their dentist did not have the facilities to treat them. The majority of patients (84.6%) found it easy or very easy to get a dental appointment. Most participants (75.6%, n=59) reported that they were happy or very happy with their smile. Over 90% of patients (91.0%, n=71) reported no oral pain in the last week. The majority of participants (75.6%) reported no difficulty chewing, though 16.7% of participants (n=13) reported difficulty chewing with some types of food and 6.4% (n=5) with all types of food. In terms of oral health behaviour, most participants reported brushing their teeth at least once a day (76.9%, n=60), and the majority of participants (66.7%, n=52) reported that they could clean their teeth without assistance, while 7.8% (n=10) reported needing a little help (Figure 6). Most participants did not have a

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How many times a day do you eat sweet foods or drink sweet drinks? 9

Not answered 2

Four times a day Three times a day

1 10

Twice a day Once a day

39 17

Never 0

Number of participants FIGURE 7: Frequency of consumption of sugary foods or drinks.

Number of participants

n Fewer than 3 functional units 17

n More than 3 functional units 10 3

Yes, with some types of food

4 1 Yes, with all types of food

Not answered

FIGURE 8: Comparison between functional units and difficulty chewing. mouthcare plan (93.6%, n=73). Over 60% of participants (n=52) consumed sugary sweets or drinks at least once a day (Figure 7). The majority of participants (n=59) reported no difficulty chewing, despite over 20% (21.8%) having fewer than three functional units present (Figure 8). Having 10 tooth contacts (20 occluding teeth) is considered to be a minimally functional dentition.3

Discussion This pilot study illustrates the difficulties of research in the nursing home population. Large numbers of people were not able to provide informed consent and participate in the MOSST. It is important to note that the profile of the population sample was included simply to give initial pilot data on the oral health of care home residents able to participate. This may inform methods in future, larger studies. However, due to the limitations outlined, such as the limited number of the target population who could provide informed consent, this cannot be seen to be representative of the general population of care home residents in Ireland. The results relating to oral health status are reflective only of those in private nursing homes who could provide informed consent and were willing to participate in this study, and are therefore highly likely to be an underestimate of need. The gatekeepers identified barriers, such as advanced dementia, to

72 | Volume 2 Number 4 | August/September 2026

providing informed consent. Less than 25% (21.3%) of potential participants could provide informed consent and were willing to participate. In the pilot, the examination was conducted by a dentist with extensive experience of providing dental care for vulnerable adults. Non-dental professionals report low confidence and a lack of training in dealing with the oral cavity in this population.12,13 This has important implications for further epidemiological research in this area. It would also be useful to include some data around the use of services by people in care homes in Ireland, to provide more context for the dental needs of this population. Although not currently suitable for providing reliable and valid data at the population level, for those able to consent, the MOSST was easy to use in this population and beneficial in that it can be used by dentists and non-dentists aer the completion of training. It provided a good overview of the oral health status of this consenting population, with functional units, cavitation, denture use, and number of natural teeth included. Number of teeth or functional units has previously been reported as being directly related to chewing.14,15 This relationship was not observed here, and 42% of participants had no difficulty with chewing, despite 20% having fewer than three functional units present. Additionally, the majority of participants (75.6%) felt happy about their smile. This may be attributable to the disability paradox, whereby patients’ perceptions of personal health, well-being and life satisfaction are oen discordant with their objective health status and disability.16 A similar

RESEARCH

lack of correlation was found with the number of cavitated teeth and reported pain. This may be due to natural changes to tooth structure associated with ageing, but may also illustrate a diﬀerence between expected need and dental service use. As this is pilot study data, this could again be explored further with a properly powered sample. It should also be highlighted that nursing homes may want to have emergency protocols in place for the management of pain and infection, and may want to work with individuals and families to ensure that residents have appropriate oral care plans on ﬁle, which would necessitate a dental consultation.

a brief cognitive screening tool, such as the Mini-Cog, prior to the MOSST-SRS could help to ensure the reliability of the results.17

Conclusions n This pilot study trialled the MOSST and MOSST-SRS in the private nursing home population of Leinster, and found that the MOSST was relatively easy to use for those who could consent. However, the small proportion of the population who were willing and able to be examined restricts the validity and generalisability of the results across the population as a whole. n The MOSST-SRS would beneﬁt from being tailored to this population more speciﬁcally, through PPI.

Limitations and suggestions for further study The MOSST was originally validated for adults with intellectual disabilities as part of the IDS-TILDA supplement, comparing favourably with dentist-performed examinations.10,11 In this pilot, the MOSST was completed by a dentist to explore its feasibility and acceptability in a nursing home population. Because this setting differs from the original validation population in terms of age, cognitive status, and oral health needs, further work is warranted to examine whether the MOSST can be reliably and accurately used by non-dentists, such as nurses or carers, to identify residents requiring dental referral. A subsequent validation phase could therefore compare MOSST assessments conducted by trained non-dentist staff with independent dentist examinations using standard clinical indices, and estimate inter- and intra-rater reliability for use in long-term care settings. As the MOSST-SRS was designed for people with intellectual disabilities, some of the questions may not be necessary for this population and others could be added or modified to be more appropriate for the nursing home population.10,11 This could be done by using Public and Patient Involvement (PPI) prior to future research.10 Examples of questions that could be considered for inclusion are ‘When did you last see a dentist?’ and ‘How long have you been in this nursing home?’. This could be important for this population, as their engagement with or use of dental services may have changed dramatically when transitioning from living at home to a nursing home. Question 4 regarding barriers could be modified to include issues faced by nursing home residents. Oral health service use question 3 on whether adjuncts to local anaesthetic are needed prior to a restorative treatment could be considered for omission as it may be more geared towards people with intellectual disabilities. There may be other pertinent questions identified for potential inclusion, and further research, perhaps using service use data, may be needed to identify more suitable and relevant questions for this population. The prevalence of dementia in the population examined was unknown and could have impacted the ability of participants to accurately selfreport during the MOSST-SRS, potentially influencing the results. Incorporating

n This was a convenience sample, and only reﬂects those in private nursing homes in one province of Ireland, who were able to provide informed, valid consent (21.3% of the targeted population). n The majority of this sample population (75.6%) were happy with their appearance and function despite huge variations in functional units and numbers of natural teeth. n It is important for nursing homes and their staﬀ to know of emergency dental protocols and accessible practices, and more research may be needed to investigate these knowledge levels in the community.

Funding The authors have no funding sources to declare.

Data availability statement The data supporting the ﬁndings of this study are available from the corresponding author upon reasonable request.

Author contributions Conceptualisation of the project: Darshini Ramasubbu, Brett Duane Data collection: Darshini Ramasubbu Data interpretation: Darshini Ramasubbu, Jonathan Lewney Writing of the original dra: Darshini Ramasubbu, Jonathan Lewney, Brett Duane Final approval of the dra and agreement for accountability: Darshini Ramasubbu, Jonathan Lewney, Brett Duane

Ethical approval Ethical approval for the study was granted by Trinity College Dublin’s Faculty of Health Sciences Research Ethics Committee in December 2024 (ref. 240610). This included a data protection impact assessment.

References 1. Trinity College Dublin. The Irish Longitudinal Study on Ageing (TILDA). 2026. https://tilda.tcd.ie/. Accessed January 20, 2025.

Dublin: Department of Health and Children; 2007.

of community-dwelling adults aged 50 years and over in Ireland. A cross-sectional analysis of the Wave 3 TILDA cohort. HRB Open Res. 2022;1:26. Ireland.

Smile

5. Seanad Éireann debate. Private nursing home sector: Statements. 2022. https://www.oireachtas.ie/en/debates/debate/seanad/2022-11-16/9/.

3. Naseer A, McLoughlin J, Donoghue OA, Kenny RA, O’Connell B. Dental health status

Accessed

December 19, 2024.

2. Whelton H, Crowley E, O’Mullane D, et al. Oral Health of Irish Adults 2000-2002.

4. Government

https://assets.gov.ie/9614/d1be290ee99743f8ba4c0ef9ac4cb401.pdf.

Agus

Accessed

March 7, 2025. 6. Citizens Information. Dental Services. 2026. https://www.citizensinformation.ie/ en/health/health-services/dental-aural-and-optical-services/dental-services/

Sláinte.

2019.

Accessed May 20, 2026.

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7. McAuliﬀe Ú, Whelton H, Harding M, Burke S. ‘Toothless’ – the absence of political priority for oral health: a case study of Ireland 1994-2021. BMC Oral Health. 2022;22(1):95.

Hobbelen DJSM. Barriers and facilitators of oral health care experienced by nursing home staﬀ. Geriatr Nurs. 2021;42(4):799-805. 13. Pombo-Lopes J, Rodrigues I, Costa J, Gomes AC, Fonseca J, Grillo-Evangelista J.

8. Irish Dental Association. Improving Access to Dental Care for Medical Card Patients.

Health professionals’ perceptions, barriers and knowledge towards oral health care

2022. https://dentist.ie/app/uploads/2026/02/DTSS-Report-v9-Final.pdf. Accessed

of dependent people in nursing homes: a systematic review. Front Public Health.

January 20, 2025.

2025;12:1504542.

9. Albrecht M, Kupfer R, Reissmann DR, Mühlhauser I, Köpke S. Oral health educational

14. Naka O, Anastassiadou V, Pissiotis A. Association between functional tooth units

interventions for nursing home staﬀ and residents. Cochrane Database Syst Rev.

and chewing ability in older adults: a systematic review. Gerodontology.

2016;9(9):CD010535.

2014;31(3):166-177.

10. Mac Giolla Phadraig C, Ishak NS, van Harten M, et al. The Oral Status Survey Tool:

15. Hildebrandt GH, Dominguez BL, Schork MA, Loesche WJ. Functional units, chewing,

construction, validity, reliability and feasibility among people with mild and

swallowing, and food avoidance among the elderly. J Prosthet Dent. 1997;77(6):588-

moderate intellectual disabilities. J Intellect Disabil Res. 2021;65(5):437-451.

595.

11. Byrne K, Hisamuddin NS, Moynihan J, et al. Oral health. In: McCarron M, Haigh M, Dann G, McCallion P (eds). Longitudinal Dynamics in the Ageing of People with an Intellectual Disability. Dublin: Trinity Centre for Ageing and Intellectual Disability; 2023:135.

Soc Sci Med. 1999;48(8):977-988. 17. Health

Service

Executive.

Instructions

for

the

Mini-Cog

test.

https://www.hse.ie/eng/dementia-pathways/ﬁles/mini-cog-assessment-tool.pdf.

12. Weening-Verbree LF, Schuller DAA, Cheung SL, Zuidema PDSU, Schans PDCPV,

CPD questions

16. Albrecht GL, Devlieger PJ. The disability paradox: high quality of life against all odds.

The Modiﬁed Oral Status Survey Tool (MOSST) can only be used by dentists.

To claim CPD points, go to the MEMBERS’ SECTION of www.dentist.ie l A. True and answer the following questions: l

Accessed August 16, 2025.

2. The MOSST-Self Report Supplement (SRS) questionnaire includes questions on:

l A. Oral health-related quality of life

l A. True l B. False

B. False l B. Oral health-related quality of life and oral health behaviour l C. Oral health-related quality of life, oral health behaviour and dental service use

CPD

74 | Volume 2 Number 4 | August/September 2026

Informed consent is a major barrier to investigating the oral health of people in nursing homes.

CL I N I CA L T I P S

Provisional shell crown technique in the contemporary management of amelogenesis imperfecta Maximising efficiency and clinical control in crown preparation and provisionalisation.

Introduction The tooth preparation and provisionalisation stage in a complex ﬁxed dental reconstruction treatment plan is inherently stressful for both the patient and the clinician.1 However, when multiple adjacent tooth preparations are deemed clinically indicated, all stakeholders tend to remain satisﬁed when the outcome of provisional treatment is biomechanically stable and aesthetically pleasing.2 Digital design and meticulous implementation of the plan can ensure that provisional restoration contours closely match the patient-approved predetermined smile design. Similarly, a careful approach during interim restoration with segmental splinted provisional crowns can lead to a stable restorative outcome, with retention security.2 This clinical tips article will exemplify the splinted provisional shell crown technique, with a focus on the maxillary labial segment dentition.

(PlaneSystem®, Zirkonzahn Srl, Gais, Italy) on Zirkonzahn.Modiﬁer soware (Zirkonzahn Srl, Gais, Italy). A full mouth digital wax-up and patient-approved snap-on smile type mock-up was fabricated, forming the foundation on which treatment is prescribed. n Facially driven and digitally guided surgical crown lengthening was performed to correct for an uneven gingival display in this speciﬁc case, which was detected at the planning stage.4 n Digitally guided reduction of anticipated interferences was performed prior to tooth preparations for crowns (Figure 1).5 n At this stage, the mouth is suitably prepared to proceed to provisional crowns on the prescribed teeth.

Clinical tips n At the dental laboratory, provisional shell crowns may be milled in a ﬂexible

Mouth preparation for ﬁxed prosthodontics n As previously described,3-5 at the dental laboratory, a three-dimensional (3D)

virtual patient was created through the merging of an intra-oral scan (3Shape TRIOS, Copenhagen, Denmark), a facial triangulation scan (Face Hunter 3D facial scanner, Zirkonzahn Srl, Gais, Italy), and patient-speciﬁc occlusal data A

polycarbonate resin (Temp Premium Flexible, Zirkonzahn Srl, Gais, Italy) according to the contours of the patient-approved mock-up. The shells should be splinted in predetermined segments, which in turn deﬁne the implementation strategy of the treatment plan (Figure 2).2

FIGURE 1: The pre-tooth-preparation situation at the maxillary labial segment following all preliminary mouth preparation steps, including digital diagnostic design, digitally guided crown-lengthening surgery, and removal of anticipated interferences with digital tooth reduction guides. A

FIGURE 2: Prior to any intra-oral tooth preparation for crowns, splinted provisional shell crowns are milled at the dental laboratory on the basis of the contours determined in the digital planning steps. David McReynolds BA BDentSc MFDS RCSEd DChDent (Pros) FFD RCSI (Pros) Academic Prosthodontist Dublin Dental University Hospital Trinity College Dublin ORCID: https://orcid.org/0000-0003-4427-1788

Alexander Lichtmannegger MDT Steger Dental Laboratory Zirkonzahn Srl Brunico, Italy

Corresponding author: David McReynolds, Department of Restorative Dentistry and Periodontology, Division II, Dublin Dental University Hospital, Lincoln Place, Dublin 2 E: david.mcreynolds@dental.tcd.ie

Enrico Steger MDT CEO, Zirkonzahn Srl Gais, Italy

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FIGURE 3: A diagnostic mock-up in bis-acryl is placed onto the treatment segment with a polyvinyl siloxane preparation index, the purpose of which is to indicate to the clinician the final contours of the proposed definitive restorations and to inform tooth reduction space requirements.

FIGURE 4: The clinician prepares standard depth cuts for all-ceramic crowns into the diagnostic mock-up to determine how much tooth preparation depth is required to achieve the desired restorative space.

FIGURE 5: Upon removal of the depth cut mock-up, it can be seen that minimal tooth preparation is required in this specific case, as the majority of the restorative space may be derived from an additive approach to the contours of the existing dentition. Only a removal of circumferential undercuts and formation of a conservative finish line are indicated in this case.

n Based on classic techniques, the clinician transfers the diagnostic wax-up

into the mouth in bis-acryl (Protemp™, 3M, St Paul, MN, USA) using a standard preparation index to form a mock-up, the purpose of which is to permit matrix-based tooth reduction (Figure 3).6 n Depth cuts are made into the mocked-up teeth to the predetermined restorative space requirements. In this situation, a 1.5-2mm incisal edge space, 0.8mm-1mm facial space, and 0.3mm finish line depth were desired (Figure 4). n Upon removal of the cut mock-up, it can be seen in this specific case that minimal further tooth reduction is required beyond elimination of undercuts and the creation of a circumferential finish line of 0.3mm depth (Figure 5). n Tooth preparations for minimal-thickness all-ceramic crowns are completed at the selected treatment segment. Importantly, for the splinted

76 | Volume 2 Number 4 | August/September 2026

provisional shell crown technique to work successfully, all tooth preparations should be made to a common path of insertion. In general, for the labial segment dentition, a path of insertion that is parallel to the facial midline and perpendicular to the inter-pupillary line tends to result in the best outcomes, in this author’s experience (Figure 6). n The provisional shells are seated onto the treatment segment, ideally with an indexing device, to ensure that the contours of the provisionals remain harmonious in the context of the facial landmarks and the treatment plan. The shells may be relined with a chairside polymethylmethacrylate (PMMA) (Jet™ acrylic, Lang Dental Manufacturing Co., Inc., Wheeling, IL, USA) (Figure 7A). The excess acrylic is trimmed prior to cementation (Figure 7B), and the quality of marginal fit and finish of the provisionals will become apparent in the stability of the periodontal health at subsequent review (Figure 7C).7

CL I N I CA L T I P S

FIGURE 6: Appearance of the tooth preparations following formation of a circumferential finish line of approximately 0.3mm depth. Note that all tooth preparations must have a common path of insertion to permit successful implementation of the splinted provisional shell crown technique.

FIGURE 7: The aforementioned provisional shells are seated, and relined with PMMA, ensuring positional accuracy with respect to the patient’s facial midline and interpupillary line (7A). The appearance of the shells on the day of tooth preparation is presented in 7B and, following two weeks of gingival healing, a satisfying provisional restoration conducive to periodontal health is illustrated in 7C.

FIGURE 8: Initially, the custom, pre-formed provisional crowns are eggshell thick (8A). Upon relining intra-orally, the shells become over contoured, specifically at their gingival embrasures (8B). Considerable time and attention must be paid towards achieving marginal fit and opening of the gingival embrasures, particularly interproximally, to ensure that control over the periodontium is maintained with this technique (8C).

n When working with the shell crown technique, specific care needs to be

Conclusion

taken to ensure that the shells are treated gently prior to their chairside reline, owing to their thin section and low mechanical strength at this stage (Figure 8A). Following reline, excess acrylic naturally splays out beyond the finish line, which is not conducive to periodontal health (Figure 8B). Therefore, considerable time and attention must be paid towards removing over-contoured acrylic at the finish line, and gingival and interproximal embrasures (Figure 8C), prior to cementation of the provisional crowns using standard acrylic trimmers and finishing discs.7 n With the application of the provisional shell crown technique, the clinician and patient can proceed through all planned segments of interim treatment with relative comfort, control, retention security and efficiency (Figure 9).2

The splinted provisional shell crown technique offers a pragmatic method to transfer a precisely planned restorative outcome in interim form to the clinical situation, in a phased approach, that can remain within the comfort zone of the patient and clinician. With this strategy, treatment stages can be broken down into smaller steps where due time and attention may be applied to achieving optimal outcomes, such that the clinician remains in control of the treatment plan.

CRediT author statement David McReynolds: conceptualisation, clinical procedures, visualisation, original dra preparation, writing – review and editing. Alexander Lichtmannegger: conceptualisation, laboratory procedures,

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FIGURE 9: The pre-operative situation (9A-9C) compared to the chairside provisional restoration (9D-9F) illustrates the efficient and controlled full mouth transfer of the intended outcome of treatment to the clinical situation.

visualisation, original dra preparation, writing – review and editing. Enrico Steger: conceptualisation, supervision, writing – review and editing, funding, resources.

Conﬂict of interest: funding was generously provided for the laboratory steps illustrated in this clinical technique guide by Zirkonzahn Srl, Gais, Bolzano, South Tyrol, Italy.

References 1. Ibbetson RJ, Setchell DJ. Treatment of the worn dentition. 1. Dent Update. 1989;16(6):247-253. 2. Mizrahi B. Temporary restorations: the key to success. Br Dent J. 2019;226(10):761768. 3. McReynolds D, Lichtmannegger A, Steger E. Digital planning in the contemporary management of amelogenesis imperfecta. J Ir Dent Assoc. 2025;71(2):81-84. 4. McReynolds D, Polyzois I, Lichtmannegger A, Steger E. Facially driven and digitally guided surgical crown lengthening in the contemporary management of

amelogenesis imperfecta. J Ir Dent Assoc Sci. 2025;1(2):12-14. 5. McReynolds D, Lichtmannegger A, Steger E. Digitally guided tooth reduction in the contemporary management of amelogenesis imperfecta. J Ir Dent Assoc Sci. 2026;2(1):14-16. 6. Fareed K, Solaihim A. Making a ﬁxed restoration contour guide. J Prosthet Dent. 1989;61(1):112-114. 7. Ferencz JL. Maintaining and enhancing gingival architecture in ﬁxed prosthodontics. J Prosthet Dent. 1991;65(5):650-657.

Quiz answers 1. B – Frontalis The frontalis elevates the eyebrows and creates horizontal forehead lines. n Origin: Epicranial aponeurosis n Insertion: Dermis of the brows (interdigitates with orbicularis oculi and

3. B – It will drop their brows The frontalis is the primary brow elevator. Over-treatment, low placement, or treating a weak frontalis can lead to brow ptosis. Above the line of convergence the frontalis does act as a depressor muscle, which, when injected correctly, can increase brow elevation.

corrugator) n Innervation: Temporal branch of the facial nerve

2. A – Fewer horizontal lines Relaxation of the frontalis reduces dynamic horizontal forehead lines and, over time, can soen static lines.

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Questions on page 67

N E W DE N TA L S C I E N C E

Costello Award 2026 Students from Cork University Dental School and Hospital and the Dublin Dental University Hospital competed at the IDA Annual Conference 2026 for consideration for the Costello Award.

The winners of this year’s Award were Cork students Ava Grant and Elaine Murphy.

What is the impact of human factors on oral surgery? Ava Grant, Elaine Murphy, Dr Laura O’Sullivan

interventions were shown to reduce clinician stress and burnout. A quasiexperimental study demonstrated that digital checklists improve compliance and reduce wrong-site extractions.

Background

Conclusion

The discipline of human factors is widely regarded as a bridge between the humanistic aspects of healthcare and the system-based components involved in delivering patient-centred care. In recent years, the importance of human factors has become even more apparent. The Health Service Executive (HSE) has paid over €1.4bn in claims over the past four years, highlighting the significant impact of medical negligence and the need to address the human and systemic factors that contribute to errors in healthcare. Dentists are key stakeholders in the provision of high-quality, patient-centred care across primary and secondary care. As such, understanding the influence of human factors on performance and teamwork is highly relevant to dentistry.

Non-technical factors are key to improving patient safety and clinical outcomes in dentistry. Strategies such as effective communication and shared responsibility enhance team performance. Surgical safety checklists increase reliability, reduce stress, lower adverse outcomes, and improve staff satisfaction. Mindfulness-based interventions may further reduce clinician stress. Overall, the hypothesis is supported: human factors interventions are associated with improved safety and reduced adverse surgical outcomes.

Aims 1. To understand whether pre-operative safety measures improve patient outcomes and reduce the frequency of human errors. 2. To identify procedural systems currently in use to help identify areas that could compromise patient safety and reduce the occurrence of human errors. 3. To explore the role that human factors play in oral surgery.

Methods An online search of the PubMed database was performed using a predefined PICO framework: Population (P): oral surgery departments, dental practitioners, and primary care clinical staff Intervention (I): human factors-related safety training Comparison (C) Outcome (O): reduction in negative surgical safety incidents.

“Elements that affect our individual performance at work and how we interact with colleagues, teams, and technology.”1

Reference 1. Brennan PA, Oeppen RS. The role of human factors in improving patient safety. Trends Urol Men’s Health. 2022;13(3):30-33.

“Engage with that checklist as if your own life, limb or tooth depends on it.” Prof. Peter Brennan OBE, April 2026. Scan the QR code to listen to an interview with Prof. Peter Brennan on the impact of human factors in oral surgery.

The literature search was restricted to studies published during the last 10 years, to coincide with the development of the National Advisory Board for Human Factors in Dentistry in the UK. Single case reports and studies without documented safety incidents were excluded.

Results From 804 identified studies, eight were included in the review after screening. A randomised controlled trial showed that surgical safety checklists improve workflow, reduce stress, and enhance safety outcomes. Narrative and systematic reviews highlighted the importance of non-technical skills – particularly communication, teamwork, and decision-making – in improving clinical outcomes, although dentistry-specific evidence remains limited. Retrospective data identified poor communication and inadequate consent as key contributors to adverse outcomes and litigation. Mindfulness-based

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RESEARCH ER PRO FILE

Looking at the life course Dr Vinay Sharma is a post-doctoral researcher at Dublin Dental University Hospital (DDUH).

Tell us about your background, what led you to dentistry, and to dental research. I like dentistry because it combines clinical skills with direct patient impact. You don’t just treat disease; you help someone regain their function, aesthetics, and confidence. I worked for six years as a general dentist in my own private practice in India. Over time, I found myself drawn to the ‘why’ behind what I was seeing in the chair: why certain populations had different disease patterns, why some had access to preventive care. That’s why I came to UCD to do my master’s in public health. Aer that, I was fortunate to get a PhD position in DDUH. Can you share the primary focus of your recent research and what inspired you to pursue this topic? In my post-doctoral research, we are examining fluoride exposure from community water fluoridation (CWF) and its effect on neurodevelopmental and dental health outcomes in children, adolescents, and adults. We are analysing two nationally representative cohort studies: Growing Up in Ireland (GUI) and The Irish Longitudinal Study on Ageing (TILDA). Recent scientific debate on CWF safety has centred on the potential impact of fluoride on neurodevelopment. Currently, with TILDA, we are focusing on the effect of fluoride on cognitive health and any potential association between fluoride exposure and brain structure in older Irish adults. Using GUI data, we’ll examine the relationship between fluoride exposure and various neurodevelopmental and behavioural outcomes in Irish children and adolescents. The point is to bring rigorous lifecourse epidemiological methods to the question of community water fluoridation safety and effectiveness, especially in an Irish context.

Are there any misconceptions in the field that your research helps to clarify or correct? I had this misconception that when someone didn’t have good teeth, it’s their responsibility. During my research, we looked at why some people have worse oral health than others. While behaviours do play a role, there are other factors, like material and societal factors. It’s not just individual responsibility; it’s the social structure. Another misconception is that fluoridation policy is uniformly implemented. We collected data from the last five decades of public water fluoridation, and found that compliance and data completeness have varied over time and across counties. Which emerging technologies or methods do you believe will most significantly shape the future of dental research? Data linking. We have data everywhere: geospatial, administrative, health, social data. If we can link these longitudinal surveys with different datasets, we can enrich the datasets and make more informed decisions. Also, I think if we could implement geographic information system (GIS) tools for spatial epidemiology in an Irish context, it would be great. How important is interdisciplinary collaboration in your work, and can you give an example where it made a key difference? It’s very important. My research is an intersection of public health, epidemiology, environmental science, nutrition, medicine, neurophysiology, and data science. We have collaborators from institutions across Ireland, and international collaborators in Canada and Singapore. So, it’s not just dental public health. If you don’t collaborate, there is a risk of misinterpreting findings and making naive decisions.

What challenges have you encountered during your research, and how have you overcome them? Secondary data analysis saves time and resources, but there are challenges. The ﬁrst is data discovery: the ability to ﬁnd relevant data for a research project. It can be challenging in large-scale cohort surveys because these studies are under-documented and have varied data structures and labelling conventions. Another important challenge is about integrating and linking information from multiple datasets. To overcome these, we have collaborated with data scientists and domain experts.

What advice would you give to young dental researchers just starting out in the ﬁeld? Invest early in data literacy and methodological skills, even if it feels tangential to clinical dentistry. Dental research is increasingly a data science discipline as much as a clinical one, and the earlier you build that toolkit, the more ambitious your questions can be. Seek interdisciplinary collaborations deliberately, at the start of a project. Get comfortable with peer review – it’s a dialogue. Build your skills early, collaborate widely, and let precision, not persuasion, guide you.

How do you see your research contributing to clinical practice or patient outcomes in dentistry? Our research team has developed tools to harmonise and visualise national child oral health data – infrastructure that makes evidence more trustworthy and usable for clinicians and policymakers. Most recently, our focus has been on developing a rigorous evidence base for the safety and eﬀectiveness of CWF.

Outside of your research, how do you maintain balance and well-being in such a demanding ﬁeld? I’m from the Jammu and Kashmir region in India – a land of mountains, lakes, and rivers. So, I have a connection with nature, and whenever I’m free, my ﬁrst thought is to go for a long walk or a hike. I love cooking, reading, and spending time with my family and friends. That’s how I make the work–life balance work.

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