the young dentist australia
TRANSCRIPT
COPING WITH STRESS AS A DENTIST Dentolegal Adviser Dr Annalene Weston looks at how to recognise the signs and manage your stress levels
CPD – RUNNINGBEFORE YOU CAN WALK Dr Nicole Stott offers guidance on choosing CPD courses
TAKE A BITE TO MAKE IT RIGHT Dr Mohit Tolani talks about work-life balance
INSIDE...
2017/18
DO NO HARM Dr Simra Azher looks at dental duty of care
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Essential advice once you’ve graduated, plus our tailored Young Dentist Conference
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“Dental Protection member” in Australia means a non-indemnity dental member of MPS. Dental Protection members may hold membership independently or in conjunction with membership of the Australian Dental Association (W.A. Branch) Inc. (“ADA WA”).
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* Free graduate membership applies if you join before 31 December of your final year of study** with the maximum limit of indemnity for any one claim under the policy not exceeding $20 million 23
25:1
0/20
17YD
/AD
FREEGRADUATE
MEMBERSHIP
MORE ADVICEFor Young DentistsFor new graduates, membership is FREE*. Givingyou access to expert guidance during the important early stages of your career.
JOIN TODAY or find out more atdentalprotection.org.au
1800 444 542
Colleague-to-colleague expertise, member focused events and resources
24/7 expert guidance in an emergency fromdedicated teams of specialist dentolegal advisers
Essential advice once you’ve graduated, plus our tailored Young Dentist Conference
MORE FOR MEMBERS
Access to professional indemnity insurance, including $40 million in the aggregate**
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Contact us Dental Protection Limited DPL Australia Pty Ltd Po Box 1013, Milton BC, QLD 4064 Email [email protected] Telephone +61 (07) 3831 6800 Facsimile +61 (07) 3831 7255 [email protected] dentalprotection.org
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Coping with stress as a dentist Dentolegal Adviser Dr Annalene Weston looks at how to recognise the signs and manage your stress levels
CPD – Running before you can walk Dr Nicole Stott offers guidance on choosing CPD courses
Do no harm Dr Simra Azher looks at dental duty of care
Take a bite to make it right Dr Mohit Tolani talks about work-life balance
12 Team working Dr Huyen Hoang looks at the importance of working as a team
Production Team Editors David Ford [email protected] Kara Stokes [email protected] Design Lucy Wilson Printer Panther Print (Brisbane)
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Dental practitioners are at increased risk of stress related illness. Dentolegal Adviser Dr Annalene Weston looks at how to recognise the signs and manage your stress levels
tress related illnesses take many familiar forms, with dental practitioners not only
demonstrating a higher than normal risk for back issues, but also gastrointestinal disorders and cardiovascular issues. They also often demonstrate higher levels of drug and alcohol dependency, mood disorders and even suicide.
CAUSES OF STRESS
In order to better manage our stress and protect our health, we first need to consider the contributing factors that make dental practitioners prone to its effects.
Isolation – While group practices and hospital settings have decreased the isolation of dental practice, this is still a recognised contributory factor to stress; especially for those practitioners who have experienced an adverse outcome or received a complaint. Many of us are lucky to work in supportive practices, or have a supportive network outside our practice, but not all of us have this luxury. When stress attacks, and the walls start closing in, those who cannot reach out to their support network will suffer greatly.
Confinement – We don’t get out much. Some of us don’t even have windows in our treatment rooms. Naturally, this flows
towards a diminished sense of wellbeing and happiness. This lack of ability to move around can impact on our wellness in other ways, as we can become unfit and sedentary, further increasing our risk for ill health.
Patient factors – Patient stress and anxiety is born from their fear of us, the treatment we are going to perform, and the news we are going to break to them about their dental health and needs. It is often compounded by the fact that patients are commonly attending under duress, making a ‘distress purchase’ due to pain or another problem. It is only natural that they will let this stress out on the person they feel most appropriate – that person is probably you.
Internal stress – We strive to provide our best work, at all times, and can become frustrated with ourselves if things don’t go to plan. This constant drive for perfection can only lead to bitter disappointment, as there are many factors outside our control that can negatively impact on the appearance, success and longevity of the work we do.
External stress – There are many factors impinging on our lives that will create more stress. Money is certainly at the crux of much practitioner stress, as we struggle to support ourselves and our loved ones whilst
simultaneously paying off hefty HECS and other debts. We are often at the stage of our most rapid career development, while at the same time building a family of our own, which no doubt comes with financial and emotional burdens. The burdens do not outweigh the joys of family life, but financial and familial issues have been responsible for many sleepless nights for generations of dental practitioners.
Running late – This could easily have sat under any of the headings above, but such a significant stressor deserves a heading of its own. We run late for a wide variety of reasons, from squeezing in emergencies to human error. We do not run late because we want to, or because we enjoy it, and no matter how you look at it, running late causes us stress.
Facebook fibbing – The societal tendency to hide our flaws and failures, and promote only our strengths, is played out daily in a narcissistic fashion in the public arena of social media. Not only does this skew one’s view of what is good and what is right, but it can cause many practitioners to reflect on their own work with shame for not being ‘good enough’. Read the posts with interest, take the key learning points and do not dwell. Truly great practitioners share their failures, as well as their successes, with others to help them grow.
COPING WITH STRESS AS A DENTIST
Read this article to
Recognise the causes of stress in professional practice
Increase your awareness of stressful situations in work
Learn ways to manage and reduce your stress
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YOUNG DENTIST | 2017/18 | dentalprotection.org.au
SOLUTIONS FOR MANAGING STRESSNetworking for a better ‘everything’ – Mentors and study groups help us to talk through the challenges of practice and exchange ideas about treatment modalities. Collective treatment planning and timely constructive feedback will enable us to grow confidently as practitioners, through every stage of our career, and naturally we are able to provide much better treatments to patients.
Networking outside the surgery will also reap rewards. Having a solid group of people you can trust to talk through your failures with is incredibly empowering, as a problem shared is truly a problem halved.
Closing the surgery door and engaging in some hobbies and relaxation will make a more balanced you, and give you friends who don’t want to talk about teeth.
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Don’t sweat the small stuff –Regretfully, the very nature of dental practice means that things can and will go wrong. It’s OK.
A calm approach in the face of adversity will lead to a better outcome for both you and the patient. And once the crisis is over, talk about it. There is no shame in struggling with an extraction, or a root canal treatment, or any dental procedure. Talking about what went wrong will help you to recognise the warning signs in the future and avoid adverse outcomes of a similar nature.Also, talk to your staff. If you are struggling because of time pressures, they need to give you a bit more time. If they are not prepared to do that, then this may well not be the best practice for you.
HALT – Dental Protection review the complaints and adverse outcomes reported to us, and one thing we have identified is that you (and the patient) are more at risk of something going wrong if you are Hungry, Angry, Late or Tired (HALT). Sometimes, time spent having a quick break will save heartache for all. Don’t be scared to take a break between patients to clear your head if needed.
Patient factors – Accept that you don’t see the best side of people when they come to you frightened and in pain. Accept that people say silly things, that they come to you because they DO like and trust you, and don’t take negative comments personally.
Try to work with patients, within their time and financial constraints, to provide the best treatment you can. If you are unable to produce quality treatment with the constraints they place on you, then consider referring the patient to another practitioner who may be a better fit for them.
Recognise dependency – The path to dependency is short and easily followed, but the road to recovery takes a lifetime. Be honest with yourself about what you drink and consume. There is no place for drug dependency for those who choose to become a dental practitioner, and use of both legal drugs and illicit drugs will lead to the loss of your registration. Alcohol may be legal, but it too is open to abuse. Please reach out if this section has in any way made you feel uncomfortable because it is relevant to your life right now.
Bringing it all together – The key to health is multifaceted and complex, but we can start on the right path by caring for ourselves, mentally, physically and emotionally, by stepping away from the surgery to develop some perspective.
Eating right, exercising, enjoying some fresh air and finding a work-life balance all feed into this, but we can start by being kinder to ourselves and others, to set the tone for a less stressful life.
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YOUNG DENTIST | 2017/18 | dentalprotection.org.au
D entists have a mandated responsibility to ensure their skills are up-to-date and to undertake
continuing professional development. However, this can present the new graduate dentist with an unusual dilemma in their first few years of practice. On one hand, they feel relatively up-to-date with their knowledge and basic scientific principles, due to their rigorous studies through their degrees. At the same time, it can be difficult for young and recent dental graduates to concentrate their professional development on useful and high quality development activities.
Recent graduates face an endless bombardment of up-skill courses – weekend implant courses, two-day Invisalign training, and two-hour sleep apnoea seminars, all of which might make you the master of MAS, but will likely leave you with no free time. Sometimes, it is important to stop and take a breath, and find out where to best spend your time and money.
Firstly, concentrate time and energy on focusing on some of your weaker areas in dentistry – we will all have at least one area of dentistry not completely mastered in our first year out. Perhaps you didn’t do too much molar endo during uni – so maybe this is a good place to start. Or perhaps you have found yourself in a practice that does a lot of fixed pros. Maybe it’s a good idea to review some of the basics prior to diving into complex treatment on your patients. So here is a guide on how to choose appropriate CPD for your level:
1. Reflect on areas that you feel need improving or focus on mastering areas that you seem to be doing a lot of in practice. It is difficult to choose CPD when you have no idea what you should focus on.
2. Choose courses that are tailored to your level. It is no good choosing an implant placement course when you haven’t restored an implant before. Perhaps look at courses that review basics or are targeted towards those who are just starting out. The YDC+ is specifically tailored for recently trained graduates and is a great starting point. It will be held on 12 May 2018. This means you will have a few months to save up leave if you need to travel an extra day and, as it’s held on the weekend, it’s much easier to plan for.
3. Listen to good quality speakers. Not all outstanding clinicians and speakers are affiliated with a university or an association, but these can be good places to start. Over time, you will get to know some of the big names in the areas you choose to focus on. Young up-and-comers in specialty fields are also great for recent grad training, because they have a good understanding of where you might be at with your education.
4. Plan ahead. Most of the large events will give you plenty of notice and advertise heavily. But some of the hands-on courses that are smaller in numbers may be difficult to get into, and may not advertise heavily because their popularity is due to word-of-mouth.
5. Try to engage in various different delivery modalities – there are plenty of face-to-face conferences that may require travelling, but don’t forget online webinars and courses can count as CPD as well. The beauty of online learning is that you can do it at your own pace and in a comfortable environment. Also, look around your local area for study groups, which may contribute to your learning.
CPD courses are not accredited, and, as they can turn a significant profit for those who run them, you should carefully review the content to ensure that you are choosing a high quality course. Keeping a log of your activities is a must, as the Dental Board conducts audits to ensure compliance with their CPD standard. You will also need the log to evidence that you have completed a minimum of 60 hours of CPD activity over a three-year cycle.
CPD – RUNNING BEFORE YOU CAN WALKDr Nicole Stott offers guidance on choosing CPD courses
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BIOGRAPHY Dr Simra Azher is a Doctor of Dental Surgery graduate from the University of Melbourne having previously completed a Bachelor of Biomedicine degree. She is currently enjoying working as a general dentist at Goulburn Valley Dental Group in Shepparton, Victoria. ©
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YOUNG DENTIST | 2017/18 | dentalprotection.org.au
isk management is an essential core aspect of dental care. It is among the earliest topics taught
during dental training, in close association with ethics, and is reinforced throughout our professional careers. I recall my Law and Ethics lecturer emphasising the term ‘do no harm’ as he introduced us to the concept of informed consent. This ethical foundation shaped my initial understanding of risk management. I learned that risk management begins when informed consent is gained from the patient with full disclosure of the perceived risks of treatment. It is continued throughout the treatment procedure, where steps may be taken to reduce the likelihood of adverse outcomes arising. Furthermore, it is the ethical management of any adverse consequences when they do arise.
To ‘do no harm’ towards patients was my basic understanding of risk management when I first began practice. To always act in the patient’s best interest is a strong belief shared among many recent graduates. Unfortunately, in the current employment climate it can be very challenging for young dentists to uphold this belief. Jobs are difficult to find, with multiple graduates competing for limited positions. Graduates are forced to apply for positions with lack of mentorship, where financial gain is the main focus for the practice.
This has left recent graduates vulnerable to hazardous dental practice. Increasingly, job interviews entail questions regarding a graduate’s ability to independently perform complex treatment, such as molar endodontics as well as crown and bridge prosthodontic treatment. Safely undertaking such complex patient management may be beyond the capability of many new dentists; however, this may not be disclosed for fear of not finding employment. I have heard from colleagues of cases where practices will have a ‘no referral policy’ and employers will hold
regular meetings to assess the financial output of graduates. This competitive climate can lead new graduates to undertake risky treatment in an effort to impress their bosses and stay employed. Treatment risks may not be explained to the patient for the fear of losing them to another practice. Moreover, if the treatment undertaken has an adverse outcome, there may be unethical management of the case, with lack of support available to young dentists employed in positions where mentorship is not provided.
Furthermore, the business of dentistry has also created an atmosphere where colleagues may not be as supportive or forgiving of others’ mistakes. It is easy to pick faults in the treatment performed by other dentists, in an effort to secure the patient for one’s own practice. This can make the process of risk management extremely difficult for dentists where treatment has resulted in an adverse outcome.
I am very fortunate to be working at a clinic where ethical practice is encouraged, both towards patients and to colleagues. I had an experience recently where a patient presented with a broken rotary nickel titanium file during root canal treatment that was performed by another dentist. Understandably the patient was upset and wanted to have the remainder of the root canal treatment completed with another dentist (me in this case). Through an open discussion with the patient I was able to ascertain that they had been warned regarding the potential risk of file fracture during root canal treatment at the beginning of the procedure. The complication had been confirmed with a radiograph and the treating dentist had maintained open disclosure to the patient when it occurred. The patient had also been warned of the foreseeable problems with completion of the root canal treatment as a consequence of the file fracture and the
possible need for specialist referral. This affirmed to me that the treating dentist had gained consent before the procedure, recognised the issue when it occurred and informed the patient accordingly. Therefore, the problem had been managed ethically on the treating dentist’s part, and I felt it was my professional responsibility to inform the patient of this rather than focus on the negative aspects of the situation. On the other hand, if the treating dentist had not managed this situation ethically, then it would have been my professional responsibility to inform the patient accordingly, for the management and advice provided should always be in the patient’s best interests.
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DO NO HARMDr Simra Azher’s award-winning article on the dental duty of care
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The patient also wanted to know why this complication could have occurred. This question placed me in a difficult position as my response could very easily have portrayed the treating dentist in an unfavourable light. Where it can be shown that an instrument was incorrectly used or that the technique deviated from the manufacturer’s instructions, it is possible that a particular instrument fracture event could be considered negligent on the dentist’s behalf.
However, I had no confirmed knowledge of how the adverse outcome had occurred, so I had to be guarded with my response to the patient and not imply that the treating dentist had been negligent. Accusing a colleague of malpractice is a serious implication that may lead to a potential legal case. If patients are interested in pursuing legal action there are accredited professional bodies they can contact, who will conduct a thorough investigation into such matters, before implicating the treating dentist.
The other challenging aspect to this situation was the fact that the patient wanted me to complete the remaining root canal treatment for the tooth in question. I knew as a new graduate that I didn’t have the skills required to assess, plan and execute the retrieval of broken endodontic files.
Furthermore, I did not want to expose the patient to any further risk, such as pushing the file through the apex or causing root fracture. After consulting with my mentors, we decided it was best to encourage the patient to return to their treating dentist for either completion of the root canal treatment or a specialist referral for its completion. The patient was receptive to this suggestion, as they had been reassured that although a mishap had occurred, the treating dentist had managed the situation correctly and ethically.
In the current financially driven climate faced by dentistry as a profession, there is a risk to forgo ethical practice towards patients and colleagues. It is extremely important for employers to not place pressures on new graduates to undertake treatments that may expose patients to avoidable risks. New graduates must seek help from supportive mentors, as well as professional bodies such as the ADA and their indemnity insurance, if they find themselves in difficult risk management situations.
I left dental school knowing that I must do everything in my power to ‘do no harm’ towards patients and this includes informing patients when they have received unethical care. However, this perspective has grown to include ‘do no harm’ towards honest colleagues in difficult risk management situations, by providing a fair appraisal of their case rather than a critical review, which may potentially expose them to the risk of litigation. This is how the profession will remain ethical within itself in all aspects of patient care.
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YOUNG DENTIST | 2017/18 | dentalprotection.org.au
The significance of work-life balance is imperative in maintaining optimum physical, mental and environmental health. Dentistry is one such profession that demands adequate focus, constructive inter-personal relationships and, above all, sustenance of motivation to succeed in the profession. When the equation to having a sustainable career is infiltrated by high-end expectations, superlative competition and associated pressures, the thread of a new dental graduate’s career gets outstretched and thinned.
From my perspective, dentistry is an amalgamation of science, medicine, hand work and communication. It is an interwoven network of health, artwork and research; outcomes for which are driven by the patient and the treating dentist. It is with this notion that I pursued a career in dentistry. From the day I got the offer to begin dental school, the uninvited guests of expectations became part of the rather mystifying journey. The first expectation that I faced was that I have, or would later have, a lot of money as a dentist. This was subsequently followed by family and friends expecting me to be the smartest and the best with hand work. Throughout dental school, there was an expectation to be ‘perfect’ and know everything about anything in dentistry.
As a final year student, I saw the dental career journey as tumultuous. Being bombarded with information such as the increasing number of dental graduates, and limited availability of jobs post-graduation, had become a regular occurrence at any seminar or conference that I attended. A few of my colleagues saw this as confidence crushing and became downhearted. The fear of not having a job instilled competition amongst fellow
peers. The trend had become to attend the best and new continuing professional development (CPD) courses to stand out from the rest during the final two years of dental school.
Unsure of what the actual dental working world entails, a few of my colleagues sailed a voyage not knowing whether it is even applicable. Undertaking courses requiring complex thinking and application, clinically bolstered confidence in some to undertake procedures requiring further practice and clinical growth. Amidst the slapdash nature of competition, I stayed baffled. The ferocious nature of competition evoked secrecy in some and sowed the seeds of distrust amongst others. It was always reiterated to us as dental students that we are in the same boat and part of one dental fraternity. However, from the group of colleagues around me, I could see this concept fading away.
It became evident that competition had increased and started to affect individuals emotionally. A few of my colleagues started regular catch-up groups at university, where interested final year dental students would meet to openly discuss their concerns and queries, and assist each other in relation to applying for jobs. Certainly, this didn’t guarantee a job; however, it reduced the shared burden of an uncertain future and provided constructive ideas for maximising one’s strengths. Professionally, this was seen as a novel confidence-building mechanism amongst fellow future peers and invited shared learning.
One of the key challenges for a new graduate is the sustenance of inter-professional relationships within the workplace. During my interview, I was asked how I would like to work with dental
assistants who could be seen as overruling my clinical judgement and perceived to be interfering. At the time, I discussed this scenario in two parts; one being acknowledging the assistant’s point of view and second, requesting the assistant to provide her viewpoint, should she wish to, following the patient’s departure. In this way, professional respect is maintained and the potential for conflicts is reduced.
Working in a public facility with senior dental assistants who have significant experience can be challenging and affect confidence. Professionally, I employed the aforementioned strategy as discussed in my interview and it has been exceptionally effective in my workplace. Not only has this enhanced team work and appreciation of one another’s views, but it also sustained respect. Additionally, I have tried to seek opinions and varying perspectives on certain cases or techniques from other professionals in the workplace, such as senior dentists and oral health therapists. This has valorised the concept of inter-connectedness amongst professionals in the workplace and enhanced my clinical learning experience.
In conclusion, it has been evidently said that “if it doesn’t challenge you, it doesn’t change you”. Undeniably, this holds true in my situation and foregrounds the idea that despite the challenges that have surfaced during my transition from dental school to workplace, engaging constructively with them will outgrow underlying uncertainties. Striking the right balance by understanding one’s own expectations and challenge resolution plan, and engaging in constructive workplace inter-professional relationships, will bolster growth both personally and prolifically as a new graduate.
TAKE A BITE TO MAKE IT RIGHTDr Mohit Tolani gives his take on work-life balance
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T eamwork can be described as a “co-operative or co-ordinated effort” of a group of people
working together “in the interests of a common cause” (Random House Dictionary 1987).
Through reflecting upon my years in dental school and beyond, in which I have graduated and commenced work in private practice, I would like to share my personal experiences, and how they have shaped my outlook on professional relationships and what it means to work as part of a team.
TEAMWORK WITH YOUR DENTAL ASSISTANT
In my third year of dental school, I was fortunate enough to have been given the opportunity to work as a dental assistant (DA) in a busy private dental practice. This was my first real taste of what life beyond university might look like, and it was both unexpected and overwhelming. Working as a DA allowed me to learn how to work closely and efficiently with another person, with the shared goal of managing a patient, ensuring their comfort during their visit, and meeting their dental needs. During my time assisting, I quickly realised that DAs are invaluable to the dentist and dental practice.
They are heavily relied upon to set up before each appointment, to have a broad knowledge and understanding of many procedures performed in the dental practice in order to have the necessary equipment and materials prepared, to changeover efficiently after each patient, and overall to ensure that each appointment runs smoothly. This is a lot of responsibility, which can sometimes leave the DA potentially feeling unappreciated and overworked, especially if they feel as though their efforts are going unnoticed. A good relationship, built on mutual respect, is essential in ensuring you and your DA work well as a team.
TEAMWORK WITH DENTAL COLLEAGUES
While my short time in the dental industry has been an overall positive experience, I am aware that there is a certain degree of competitiveness and rivalry amongst dental professionals. This is expected because, when you think about it, getting into dental school is very tough and competitive, with most dental students dedicating their Year 12 (if not entire high school experience) solely to achieving a score high enough to allow them to be accepted into dental school. Although I have yet to be negatively affected, I am aware of instances where dentists have been disrespectful to other dentists. To me this is unprofessional, and undermines the dental profession as a whole.
While it is our duty to deliver a high standard of care to our patients, I strongly believe we can do this whilst remaining professional and supportive of our colleagues. In particular, I have noted occasions where more experienced dentists may look down on younger graduates. This kind of behaviour helps no-one and fosters an unfriendly, unsupportive environment that is not conducive to teambuilding and teamwork. While recent graduates have a long way to go and could gain a lot from drawing on and learning from their more experienced colleagues, older dentists could also learn from recent graduates who may arguably be more up-to-date with the ever-changing face of dentistry. Ultimately, no matter what stage in our career we are at, we are all continually learning and we should endeavour to support each other in the journey towards becoming better dental professionals.
TEAM WORKINGDr Huyen Hoang talks about the importance of working as a team in practice
© Robert [email protected]
YOUNG DENTIST | 2017/18 | dentalprotection.org.au
TEAMWORK BETWEEN YOU AND YOUR PATIENT
While the relationship between your DA and other dentists/health professionals is critical, it is the relationship between you and the patient that has a direct impact on their oral health. Any dentist can perform the most thorough scale and clean, or provide the best restorative care, but ultimately the state of the patient’s mouth also depends on their compliance.
Improving someone’s oral condition is a collaborative effort between you and your patient, where teamwork is necessary for improvement. Building a good relationship with your patient is a stepping stone towards working together as a team to improve their oral health. While the literature often alludes to ‘patient-centred care’, Beach et al introduced the concept of “relationship-centred care” (2006, pp. 3-8), which places additional emphasis upon the nature and quality of relationships, recognising that teamwork and relationships are central to achieving desired health outcomes (Beach et al. 2006). Relationship-centred care champions authenticity and empathy, which is essential in developing trust, but it can still be challenging to get patients to modify their behaviour (for example, to increase brushing or start flossing regularly), even if considerable time is spent educating them.
I find that once a patient realises that you genuinely care for them, they are more accepting of your recommendations and are more likely to work with you to improve their oral health.
Ultimately, providing quality dental care is a team effort. Teamwork is essential in all aspects of dentistry – whether it involves working well with your dental assistant, collaborating with other dentists and other dental professionals/specialists, or empowering your patient to achieve their oral health goals.
REFERENCES
1. Beach MC & Inui T & the Relationship-Centred Care
Research Network 2006, ‘Relationship-centred Care
A Constructive Reframing’, Journal of General Internal
Medicine vol. 21, pp. 3-8.
2. Walsh, LJ & Brostek, AM 2013, ‘Minimum intervention
dentistry principles and objectives’, Australian Dental
Journal, vol. 58, pp. 3-16.
© Robert [email protected]
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ContactsYou can contact Dental Protection via the website dentalprotection.org.au or by using the contacts below
For membership enquires
DPL Australia Pty Ltd Po Box 1013, Milton BC, QLD 4064
Email [email protected]
Telephone +61 (07) 3831 6800
Facsimile +61 (07) 3831 7255
Freecall 1800 444 542
Kara Stokes, Business Development Executive [email protected]
Michael Pears, Membership Manager [email protected]
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Opinions expressed by any named external authors herein remain those of the author and do not necessarily represent the views of Dental Protection. Pictures should not be relied upon as accurate representations of clinical situations.