The Irish dentistry landscape

The modern dental practice has changed out of all recognition since they were places that struck terror into the hearts of many patients. Gone are the days when the main tools were drills and forceps. Indeed, such have been the advances in modern dentistry that extractions have become a rarity.

“Taking teeth out is almost a thing of the past,” says Dr Sarah Flannery of the Azure dental and aesthetics practice in Blackrock, Co Dublin. “Sometimes it’s unavoidable, but early in my career I was extracting teeth every day, now it’s a once a month if that. Minimally invasive dentistry is the order of the day now. We take that approach with everything we do. We try to retain teeth as much as we can.”

While the new technologies available to dentists are playing a significant role in reduced extraction rates, Flannery attributes much of it to the fluoridation of water. “Dentistry has changed so much since that began in 1964,” she says. “The rate of tooth decay has slowed dramatically since then. People born before then have far more fillings and extractions. Fluoride strengthens teeth and reduces the depth of the crevices in them and helps prevent decay. The main impact is in childhood. Improved dental and oral hygiene have also helped. Young people tend not to have the problems with their teeth as previous generations.”

That minimally invasive approach extents to tooth repair. “We add on instead of taking part of the surface of the tooth away. In the past we often cut the tooth to put a crown on it. Today’s approach is to retain and add composite. The catchphrase is biomimetics. We are copying nature both anatomically and through materials we use. The materials are as similar to nature as possible.”

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Technology helps. “We now have CAD CAM (computer aided design – computer aided manufacturing) technology which scans the tooth and the area under treatment. The digital file goes directly to the lab and where the crowns and bridges and so on are manufactured precisely to fit teeth perfectly like a jigsaw piece. Old style silver fillings are held in place mechanically rather than chemically. That puts pressure on the tooth which often cracks over time. These modern much more accurate techniques and materials eliminate that problem.”

That degree of precision is also important in aesthetic dentistry. “People who are unhappy with the way their teeth look can use invisible aligners to adjust them,” says Flannery. “There are no train tracks. We use the scanner and the file goes to the Invisalign lab which manufacturers the aligners to fit the teeth. Treatment can take between seven weeks and a year, and the patient receives a new slightly altered aligner each week. It’s a much more modern and pleasant way to move teeth. Also patients can take out the aligners when they go out for a meal if they wish.”

New technologies have also been transformative for patients who require replacement teeth, according to Dr Mohamed Shirin, founder of Truly Dental which has seven branches in Dublin and Leinster. “Advances in technology means we can now deliver same-day brand new teeth. Before this if you wanted new teeth you had to have implants in place for three to six months before getting new teeth. We now know that if we have the right implant and insert it at high torque we can put the tooth in immediately.”

The other element is the manufacture of new teeth. “That process has changed massively. It used to be done by hand. Now it’s done by CNC (computer numeric controlled) milling which is extremely accurate and delivers very high-quality results. New materials like zirconia also speed up the process. The old materials had to be heated at very high temperatures for up to 14 hours to harden them. The new materials don’t require that long. With a well planned out workflow we can get a patient in the morning and have their new teeth for them in the afternoon. This is a game-changer. We now routinely have the teeth on the same day or the morning after for patients.”

Much of this is enabled by the availability of scanning technologies. “The cone beam CT scanner is one of the key components of this,” says Shirin. “It shows us a patient’s skull in 3D. We can see how much bone they have as well as their blood vessels and muscles. We can take that scan and use it for virtual surgery. Virtual surgical planning can assist surgery and let us know exactly what implants to use and the depth to drill. That makes surgery much more predictable and speeds it up.

“We can also use it to manufacture surgical guides to indicate exactly where to drill. These scanners used to only be available in hospitals and were cost prohibitive for dental practices. We now have small-scale scanners in all our practices.”

They are not cheap, however, with each scanner coming it at around €50,000 or more.

“Zygomatic and pterygoid implants can allow people with poor bone or even no bone to have implants,” Shirin adds. “The latest innovations mean that implants can engage with different bones. Assuming people are fit for surgery, we can provide implants for almost anyone.”

Professor Albert Leung, past dean of the RCSI faculty of dentistry, points to another benefit of digital dentistry. “It has been a major advance, particularly during Covid when saliva was a key source of infection. A traditional impression creates a lot of saliva. With digital dentistry you put a scanner in the patient’s mouth for a relatively short period of time, generating much less saliva and resulting in far better infection control. You can also make 3D printed models from the scans. Students can use these exact replicas to learn about interesting patient cases.”

He says dentists are also involved in the treatment of sleep apnoea. “Sleep apnoea can be partly due to the relative position of the upper and lower jaws which differs when a person is lying down. Dentists can make appliances for patients to allow the jaw to move into a more stable position during the night. Digital dentistry makes that easier.”