Australasian Dentist Issue 92

CATEGORY 68 AUSTRALASIAN DENTIST LINICAL recently changed with developments in Ultrasound (US) technology setting the new standard for care. Dentists lead the way Through the pioneering work of the Australasian Academy of Dento-Facial Aesthetics (AADFA), the provision of facial rejuvenation treatments has become an accepted part of the practice of dentistry over the past decade. Additionally, dentists are now recognised as among the very best practitioners to be offering these treatments to patients, with AADFA trained dentists at the forefront of the industry, even contributing to the education of specialist plastic surgeons and dermatologists. One of the main reasons for AADFA dentists being able to readily move into this new area of practice and set the gold- standard for patient care in this field, is because of the clear parallels between the knowledge, skills and logistics needed to successfully deliver facial rejuvenation procedures with those required for traditional dental practice. The approaches seen in dentistry, from high-level infection control and education, through to knowledge of material science and a focus on health-based responsible patient care, not cosmetic fads, have resulted in the bar being raised across the broader facial aesthetic community. That trend now continues with AADFA becoming the first training organisation to incorporate the concept of active imaging, using the latest portable, wireless, hand- held, point-of-use US technology into patient assessment and treatment protocols for all facial rejuvenation therapies able to be performed by dentists.The routine use of US has set the new standard for safety and efficacy when treating soft tissues, allowing dentists to visualise precisely where target tissues lie; which areas to avoid; and to be guided in their treatment delivery. This has not only set a new standard for patient care, providing comfort and reassurance to practitioners and patients alike, but it has set a new standard in the education of dentists. Practitioners now learning dento- facial procedures can do so confidently, utilising the latest technology with AADFA’s clear parameters and clinical structure to flatten the learning curve and accelerate proficiency, all while increasing safety. How is ultrasound used? Portable, point-of-use US technology utilises the same technology as all other ultrasound devices, with the advantage that it is low-cost, wireless, hand-held and can deliver real-time, high-quality diagnostic images direct to a tablet or smartphone, both quickly and painlessly, at chairside. The US device emits a high-frequency sound wave which can penetrate several centimetres below the surface of the skin, where it is reflected differently by the various tissues being examined. This produces a live image of different densities on a grey-scale – bone appears different to muscle, which looks different to fat, which is distinguishable from the dermis and so on. Additionally, special settings allow for the colourful visualisation of not only the location of blood vessels, but also their size and velocity of flow. Clinical research has demonstrated repeatedly that these unique imaging features allow practitioners to set new standards for safety and efficacy in three key ways: Pre-screening & diagnosis US can be used in much the same way as traditional dental x-rays are utilised in consultations to visualise individual anatomy, plan appropriate treatment, and identify areas of risk. US allows us to develop a clear understanding of the face we are working with, mapping out key structures in advance, to plan treatment delivery in a manner which achieves the best results while actively preventing adverse events. The position, orientation, size, and depth of features can all be noted in advance, allowing a plan to be developed to target specific tissue layers with the likes of threads; avoid critical blood vessels with dermal filler; inject only certain muscles strategically with Botox; and even measure exact skin thickness so micro- needles penetrate precisely into the desired level of the dermis for optimum collagen stimulation. Guided treatment delivery US enables the clinician to perform guided injections for treatments involving Botox, Dermal Filler, fat-dissolving injections, and even facial thread lifts. In real-time practitioners can visualise their needle penetrating through the different layers of tissue until the desired treatment area and depth is reached. They can watch as the treatment is administered deep within the face, all of which previously would have to be done blindly, by feel, while hoping for the best. Identification & management of complications US enables practitioners to closely examine areas treated previously that may have experienced complications, diagnose them properly and deliver the appropriate treatment. Prime examples of this are complications arising from the injection of dermal filler. US examination will quickly and easily reveal exactly where filler has been placed in the past and it is even possible to tell what type of product has been used from its unique echo signature. It would be possible to see if the filler is blocking a blood vessel and precisely where that blockage has occurred, which without active and accurate treatment, may lead to skin necrosis. Thankfully, the best modern day dermal filler products consist of a Hyaluronic Acid gel and are therefore dissolvable with hyaluronidase enzymes. This allows the emergency treatment of dermal filler complications by dissolving the gel deposit and can be applied to resolve areas of lumpiness, irregularity or overfill, or importantly, to dissolve areas of filler that are causing a blockage of blood flow to the skin. However, the reversal agent is not without its problems, as it does not discriminate between natural hyaluronic acid in the skin (which forms a vital component adding hydration, elasticity, and integrity), and the filler product injected by the practitioner. The problem is that previously, flying blind, practitioners had no way of knowing exactly where a blood vessel was blocked or precisely where an irregularity was positioned within the tissues. This meant that, in order to dissolve dermal filler to treat a complication, the only option Fig.2: Hand-held, chairside ultrasound allows practitioners to visualise vital structures in real-time, improving treatment safety and efficacy.