Dental Practice Management Fall 2011 by Annex Business Media

Dental Practice

CANADA’S CANADA’S LEADING LEADING BUSINESS BUSINESS & & LIFESTYLE LIFESTYLE MAGAZINE MAGAZINE FOR FOR DENTISTS DENTISTS

MANAGEMENT MANAGEMENT

FALL 2011

oralhealth achieves 100 years DPM Celebrates!

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In response to office demand, NEW complimentary materials are available to help incorporate the pink brushes into office fundraisers for breast cancer research. To share how your office is rising to the challenge, please send photos of your fundraising program to info@rdhu.ca. Your team will be featured on RDHU’s website! See the order form for details on how to participate. ™ Trademark of the Canadian Breast Cancer Foundation, used under licence.

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Last year, dental offices across Canada joined Crest® Oral-B® in supporting the Canadian Breast Cancer Foundation. We invite you to rise to the challenge once again with our pink brush promotion—when you buy 10 dozen, you get 2 dozen FREE! Simply call 1-800-543-2577 or fax a order form to our office.

Dental Practice

MANAGEMENT

Fall 2011

Features O R A L H E A L T H ’ S 1 0 0 TH ANNIVERSARY — Part II

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8 The Evolution of Dental Office Design Jean Akerman, ARIDO, IDC

10 Bridge the Gap in the Next Century Lisa Philp and Derek Hill

14 You’ve Come a Long Way Baby Janice Goodman, DDS

18 Raising the Endodontic Bar for Success: Past, Present and Future

Adam Grossman, DDS, FRCD(C) and Gary Glassman, DDS, FRCD(C)

21 No Matter How Things Change, Do Things Stay the Same? Rollin Matsui, BSc., DDS, LLB

26 The Evolution of Oral and Maxillofacial Surgery Bohdan Kryshtalskyj, BSc, DDS, MRCD(C), FADI, FICD, FACD and Michael Kryshtalskyj

Departments 5

Editorial O ral Health turns 100, DPM celebrates!

News Briefs Wasn’t that a Party?

Advertisers’ Index

olden Oldies from the Archives G Oral Health Archives

Dental Marketplace

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Fall 2011

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Editorial

Oral Health turns 100, DPM celebrates!

Catherine Wilson, Editor

The four covers included the very first from 1911; a diaper-wearing, thumb-sucking monkey; and an embossed glimpse into the future

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haven’t taken leave of my senses, well, not officially. Why then, you ask, is there a cover of Oral Health on the cover of Dental Practice Managment? We are celebrating Oral Health’s 100th anniversary year (2011) with a very special issue and it was so big in fact, we needed to spill some of the content into the pages of DPM. It’s not often that even the most venerable publications achieve 100 years let alone reach the milestone as healthily as OH has. Putting together the anniversary was a year-long project and a true labor of love. All of our editorial board members as well as some of our favorite contributors to DPM wrote original articles. The four covers included the very first from 1911; a diaper-wearing, thumb-sucking monkey; and an embossed glimpse into the future. Obviously, the dental industry embraced this project as well; some making editorial contributions and so many others supporting this venture through advertisements. We thank them all. The first issue of Oral Health appeared in early 1911 and was sent to 500 subscribers (cost: $1 annually). It was an immediate success: advertisers and readers approved. Today, the publication serves all of Canada’s 20,000 practicing dentists, dental labs and 3rd and 4th year dental students. The 100th anniversary issue is Oral Health’s biggest issue in its history (164-pages). On pages 12 and 13 of this issue of DPM you’ll find a few items from the OH archives we thought you’d get a kick out of: a practice for sale ‘for the right man’...‘she’s so bewildered’ because not

all denture powders are the same!...and my personal favorite, a plain-spoken article entitled, “The Susceptibility and Prevention of Dental Diseases in FeebleMinded Children,” which compares the plight of the ‘feeble-minded’ versus ‘normal’ people. Feeble-minded children can be broken into three subgroups: 1. The Idiot 2. The Imbecile 3. The Moron So many directions I could go, but won’t. The truly astounding thing is that while we celebrate our 100th anniversary we are anything but showing signs of old age. In fact, soon you will hold the next big thing we’re doing this year: the first issue of Oral Hygiene. As I wrote in the summer issue, the profession is a noble one but not without its issues. At the top of the list is the word GLUT. In Ontario alone there are 8,300+ registered dentists, close to 12,000 registered dental hygienists and the growth rate for hygienists is three times higher than that for dentists. Dental hygiene across Canada is a well-respected career with many opportunities. We look forward to serving this community as we add Oral Hygiene to our stable. Enjoy with us what’s left of this, our 100th anniversary year...and here’s to the year ahead! Oral Health would again like to thank the Dentistry Library, University of Toronto for access to its archives and for all assistance with this anniversary issue, in particular Jeff Comber with Media Services and Dr. Anne Dale with the Dental Museum. DPM

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News Briefs

A BUSINESS INFORMATION GROUP PUBLICATION Editorial Director: Catherine Wilson 416-510-6785 cwilson@oralhealthjournal.com

Scenes from Oral Health’s 100th Anniversary Party

Art Direction: Andrea M. Smith Production Manager: Phyllis Wright Circulation: Cindi Holder Advertising Services: Karen Samuels 416-510-5190 karens@bizinfogroup.ca Consumer Ad Sales: Barb Lebo 905-709-2272 barblebo@rogers.com

sident BIG pre hton, ig re Bruce C ang and Pat L dy Lang Dr. Ran

Classified Advertising: Karen Shaw 416-510-6770 kshaw@oralhealthjournal.com

Drs. Lang, Jim Ke rr and Blake Nicoluc ci

Dental Group Assistant: Kahaliah Richards 416-510-6777 krichards@oralhealthjournal.com Senior Account Manager Sandra Horton 416-510-6852 shorton@oralhealthjournal.com Associate Publisher: Hasina Ahmed 416-510-6765 hahmed@oralhealthjournal.com

U of T Dean David Mock, Dr. Simon Weinberg and Rose Weinberg

Senior Publisher: Melissa Summerfield 416-510-6781 msummerfield@oralhealthjournal.com Vice President/ Canadian Publishing: Alex Papanou President/ Business Information Group: Bruce Creighton

olucci Drs. Nic rr e K and Bruce Creighton and Dr. Sandra Nicolucci

Correction

The Summer 2011 of Dental Practice Management published the article titled “Individual Pension Plan: an RRSP on steroids” and credited by Lorne Dubros Senior Financial Consultant with Investors Group as the author, in error. It has been brought to our attention that the article was written by Adam Tenaschuk, MBA and Doug Leyland, C.A., MBA at yourCFO Wealth Management Inc. They provide dentists with unique tax minimization and estate maximization strategies. They can be reached at atenaschuk@ yourcfoinc.com and dleyland@yourcfoinc.com or (905) 331-2885. We apologize for this error. 6

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Ad Index ABELSoft Inc. . . . . . . . . . . . . . . . . . . 7 Crest Oral-B, P&G . . . . . . . . . . . . . IFC Discus Dental LLC . . . . . . . . . . . . OBC DOMACAN . . . . . . . . . . . . . . . . . . . 32 Hands on Training . . . . . . . . . . . . . 22 HealthSmart Financial Services . . . . 17 Henry Schein . . . . . . . . . . . . . . . . . 23 Maxim Software . . . . . . . . . . . . . . IBC Moneris Solutions . . . . . . . . . . 28, 30 ROI Corporation . . . . . . . . . . . . . . . 25 TD Canada Trust . . . . . . . . . . . . . . . 4

Photo credits: Andrea M. Smith

Dr. Fay G and OH oldstep a publish ssociate er Hasin a Ahme d

OFFICES Head Office: 80 Valleybrook Drive, Toronto, ON M3B 3J5. Telephone 416-442-5600, Fax 416-510-5140. Dental Practice Management is a quarterly publication designed to provide the entire dental team with business management information to make practices more successful. Articles dealing with investment planning, personal finances, scheduling and collection procedures, in addition to lifestyle issues, are geared to all practicing Canadian dentists, hygienists, dental assistants and office managers. Please address all submissions to: The Editor, Dental Practice Management, 80 Valleybrook Drive,Toronto, ON M3B 2S9. Dental Practice Management (ISSN 0827-1305) is published quarterly, 80 Valleybrook Drive, Toronto, ON M3B 2S9. Subscription rates: $10.00 single copy Canada. One year: ON & rest of Canada $26.70; QC $28.70; NB, NF, NS $28.69; U.S.A. US$27.95; Foreign US$45.95. Dental Guide $18.40 in ON, QC, NS, NB, NF; rest of Canada $17.12; US & Foreign US$16.00. Printed in Canada. All rights reserved. The contents of this publication may not be reproduced either in part or in full without the written consent of the copyright owner. From time to time we make our subscription list available to select companies and organizations whose product or service may interest you. If you do not wish your contact information to be made available, please contact us via one of the following methods: Phone: 1-800-668-2374; Fax: 416442-2191; E-mail: privacyofficer@businessinformationgroup. ca; Mail to: Privacy Officer, Business Information Group, 80 Valleybrook Drive, Toronto, ON M3B 2S9. Canada Post product agreement No. 40069240. Dental Practice Management is published quarterly by Business Information Group, a leading Canadian information campany with interests in daily and community newspapers and business-to-business information services. ISSN 0827-1305 (PRINT) ISSN 1923-3450 (ONLINE)

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OFFICE DESIGN

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Jean Akerman, ARIDO, IDC Award-winning interior designer specializing in healthcare

Good office design has evolved to the extent that it increases efficiency and productivity

Part 1 of Jean Ackerman’s article can be found in the 100 th Anniversary Issue of Oral Health Accessibility By the end of the 1990s, the needs of disabled patients and staff were addressed in law by new building codes. Mandatory compliance to accessibility requirements created new challenges for office design. The amount of necessary extra square footage to allow for critical clearances, minimum door sizes and swing direction, the mandatory inclusion of ramps to transition between elevation changes and elevator access for facilities above one storey-all impacted profoundly on plan configurations and space requisites. Generally, more space is necessary nowadays to accommodate accessibility needs within the office, but acknowledging the benefits to the community of these regulations has been a positive progression of office design. Sustainability Environmental concerns, such as water and energy consumption, indoor air quality, and waste management, have permeated into the professional consciousness and prompted a focus on sustainable and environmentally sensitive design. Current design practice promotes the use of natural, recycled

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or recyclable building and finishing materials and furnishings, energy efficient lighting, watersaving plumbing fixtures, efficient HVAC systems, and the sorting of recyclable waste. A growing trend, designing for the health of the environment also means designing for the health of the patients and staff that occupy the office interior. Relationship Building A major objective in dental practice in the last few decades has been the building of trusting and comfortable relationships between the dental professional and patient. Good office design today helps to address this issue by creating an environment that is relaxed and welcoming, and by reflecting a calm and contemporary atmosphere that encourages open communication. To accomplish this, modern design pays attention to effective and appropriate lighting solutions, the careful selection of interesting finishes, comfortable seating, details and focal points that often reference nature. Other design features also help put patients at ease: refreshment stations are a gesture of welcome, fireplaces or water features impart a sense of quietude, and high-end technology, like television, internet access, game stations, digital reading materials, earphones and virtual headsets, offer distraction for anxious patients. Private areas for conversation, like the consultation room, or the sit-down payment station, www.oralhealthgroup.com

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OFFICE DESIGN

are designed to nurture one-onone involvement & comfort between patient and staff. Spa Dentistry The notion of promoting a sense of well-being to enhance the dental experience became so relevant in the last couple of decades (especially with the emergence of cosmetic dentistry), that there has been a significant trend toward “spa dentistry.”

“Young girl having her teeth checked at the Dental Clinic, Hamilton, ca. 1930.” Courtesy of Archives of Ontario, Ministry of Health, Public health Nursing Records.

What’s Next? Good office design has evolved to the extent that it increases efficiency and productivity, value, safety, and well-being in dental facilities. It creates attractive, welcoming spaces that are pleasant for both patients and staff. So, what will affect dental office design in the future?

Looking forward, office design strategy must be responsive and proactive in meeting the needs of these transformations. It must support the personal relationships fostered in the office while accommodating the growing use of remote communication. Certainly, the design objective will be to seek innovative ways to satisfy the unchanging goals of today’s and future practices-providing a high quality of care, and safety for patients in a comfortable and pleasant environment. DPM

We have seen more change in dentistry in the last fifteen years than in the previous quarter century. It is therefore not unrealistic to think that change will occur at ever increasing rates. Demographics, rapid technological and scientific advances, and a more educated dental consumer will mean transformations in dental practice.

1. “ The History of Dentistry”, hosted by the Namibian Dental Association website (www.namibiadent.com) 2. “Dentistry/History” hosted by Wikipedia website (www. en.wikipedia.org) 3. “Dental Office Design: Evolution and Economics”, by Pat Carter, IIDA & Jeff Carter, DDS, hosted by Dentalcompare website (www.dentalcompare.com) 4. “History of Canadian Dentistry”, CDA, “The Canadian Dental Association, 1902-2002-A Century of Service”, by Dr. Ralph Crawford, hosted by www. cda-adc.ca 5. “Dentistry,” by J.A. Hargreaves, The Canadian Encyclopedia, hosted by www.thecanadianencyclo pedia.com.

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“Dentist at work at a travelling dental clinic, Manitoulin, 1931”. Courtesy of Archives of Ontario, Ministry of Health, Public Health Nursing Records.

Modern operatory.

All images are courtesy of Jean Akerman Design Inc.

What does this mean? A serene environment, scented candles, hot towelettes, warm blankets, and complimentary spring water come to mind. There may be a “patient concierge” to offer assistance, refreshments, and neck or hand massage. There are now dental chairs with built-in massage features, and some offices go so far as to incorporate non-dental spa services such as facial treatments, aromatherapy, reflexology, and more. Pick all or just a few of these options and you will have bought into the concept.

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Sterilization area.

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PRACTICE MANAGEMENT

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Lisa Philp President of Transitions Consulting Group

Derek Hill Broker for Hill Kindy Practice Sales & Realty Inc.

Part I of Lisa Philp & Derek Hill’s article can be found in the 100 th Anniversary Issue of Oral Health

n part one of our look at the four generations, we dealt with patients’ loyalty and marketing preferences. This segment will discuss each of the generations as employees and how they behave as team members; their work ethics, etc.

The generational segments are: 1. Traditionalists or Silent Generation (born 1922 to 1945); 2. The Baby Boomers or ME Generation (born 1946 to 1965); 3. The X Generation or Latch Key Kids (born 1966-1980); 10

4. The Y Generation or Millennial (born 1981-2000). Traditionalists, also known as the Silent Generation, Builders or Veterans. They experienced the Great Depression and World War II. They value financial security, team work, sacrifice, delayed gratification, and the government that got them through these ordeals. Traditionalists work in teams, committed to fulfilling the task at hand. They tend to be loyal and respect authority. They thrive in an environment that has clearly defined rules and protocols, which are enforced and followed. They would more often than not work best with a Traditionalist dentist because they would tend to understand each other’s work ethic. They are motivated by job security and a sense of connectedness beyond their immediate families. As long as the environment is steady and routine and devoid of a lot of change they will probably not “rock the boat.” If you need to dramatically change your environment or culture, they may be your biggest challenge if their experience is not respected and if the suggested changes are not supported with coaching related to the pragmatic rational of the change. Traditionalists don’t usually ask for rewards, bonuses and are generally happy to have a job that is secure. They don’t require regular feedback as they feel no news is good news on their performance and their own internal satisfaction motivates them to excel.

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Traditionalists are part of what is referred to as a second middle age. Healthcare science has given this generation a longer life span, yet they are not going to be elderly longer. These are vital, active people who are redefining the aging process. Women in this generation, in particular, are pioneering the way that aging people look. They have their teeth whitened, they have plastic surgery and liposuction, they dye their hair, take hormones and exercise. They require respect for their wisdom by addressing them as Mr. and Mrs. and they value formal mode of words and tone as opposed to acronyms and slang. They still check the regular mail and will open a letter addressed to them personally. They value a hand written personal letter with their accurate name, not a dear sir or madam. The deepest way to connect with them is to listen and validate the historical stories of their life challenges and experiences. i.e. “when I was your age, I walked five miles to school in bare feet.” Image and dress is important to them as they are known as the “suit and tie” generation and expect neat, pressed and conservative dress. Traditionalists trust that their dentist will make the best dental health care decisions for them. They want to hear it from the expert and although pleasant with the team, they don’t base their decision on the dental team opinion. Once the dentist has diagnosed and planned their care, they rarely need any further exwww.oralhealthgroup.com

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PRACTICE MANAGEMENT tensive consultation and will pay for the suggested treatment based on their word without a written financial agreement. Financially, this generation tends to be cash flow stable and upwardly mobile and holds most of this country’s wealth that they will spend regardless of their conservative behaviors. They are in a life stage in which they will also splurge on big-ticket items for themselves when they feel they have earned it, or deserve it. Traditionalists like to pay with cash as to not build up debt, when they have the money to do so, they do not like to use credit. They are accepting of the 5% accounting reduction offered for pre-payment as opposed to a senior citizen discount. If pre-payment is not an option, consider offering them a “layaway” approach. Their money mantra is “don’t buy it until you have the money to pay for it.” Baby Boomers, also known as the “ME” generation or sandwich generation, arrived to postwar affluence and the indulgence of parents who wanted them to have a better life than their own. They were aware of political and social issues and became more and more disillusioned with government, big business, traditional religion, and parental hardships Baby Boomers work for two things: Status — self fulfillment, and Salary — monetary success. They can be focused, hardworking, workaholics, loyal and respect the hierarchy on a less formal basis and will conform to the rules only if it is their best interests. They thrive on a team that has a consensus, interactive style of leadership and enjoy being asked to mentor or share their knowledge. Boomers can be open to change if they can see that the change www.oralhealthgroup.com

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will move them toward personal pleasure or if they get the right answer to their question of “what’s in this for me?” If the work culture doesn’t appeal to their needs they will hang in there longer then the next generations, however eventually they will exit with their experience and end loyalty with a high cost to the dental practice. They value a change in title or status among their colleagues and like to have annual performance reviews to be challenged and shown that they still matter. Boomers’ communication involves taking the time to provide an experience as opposed to an appointment. They want to be able to express their unique preferences and be heard with empathetic listening and want to feel that you have their best interests at heart. They respond well to deep interviewing of their goals, vision and the perception that you understand their dental objectives. They need to feel you are treating them as a person not just their disease state. The way they make decisions is 180 degrees different than the criteria used with Traditionalists. Baby Boomers won’t just do what they are told by the dentist and often ask multiple team members what their opinion is. They want to be shown why they should spend their money with you and why your recommended treatment is better than any other options and yes they want to know what the options are. They are great co-diagnosticians, in fact they demand to be part of the exam process as it’s completed and are much more apt to say yes when they see the treatment as a solution to a problem they own, not what you found. Boomers are key candidates to be exited to a treatment coordinator in a consult room for more in depth discussions outside of clinical area.

Boomers say yes to services they want and are most famous for driving dentistry’s cosmetic revolution of elective smile designs and appearance enhancing dentistry. They make their dental decisions based on how their teeth will help their status among peers and how dentistry will prevent them from getting sick, looking old and how it contributes to their health. Untitled-3 1

Boomers will spend money because they were raised in a time of economic prosperity. They live on credit, interest charges and monthly payments. For a procedure that costs $1,200, you will be more successful in gaining acceptance with a Baby Boomer if they see the procedure as a $100 a month service for 12 months rather than an upfront $1,200 fee. Ask any Boomer how much their mortgage payment is and they will know, ask them how much they will have paid for their house when all the mortgage payments have been made and they won’t have a clue. Generation X-age, also known as Latchkey kids, MTV Generation, Baby Busters. They grew up in a difficult time financially and socially with a struggling economy with an increase in single-parent households, which created many “latch-key kids” who came home from school and waited for working parents to arrive. Over 60% of Generation X attended college and their common belief is that there are no absolutes in life but that one must take care of one’s self. Generation X have no expectation of job security. Growing up watching their parents become workaholics to be downsized with restructuring has led them to see every job as a temporary stepping stone to something better. They Continued on page 31

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From the archives of oralhealth

These are just a few samples of materials featured in the early days of Oral Health.

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n of the FACD, first Dea o, , S D D , be m Wallace Secco tistry, University of Toront Faculty of Den editor of Oral Health. Founder and

2011 marked Oral Health magazine’s 100th anniversary. The first issue of Oral Health appeared in early 1911 and was sent to 500 subscribers (cost: $1 annually). It was an immediate success: advertisers and readers approved. Today, the publication serves all of Canada’s 20,000 practicing dentists, dental labs and 3rd and 4th year dental students. The 100 th anniversary issue is Oral Health’s biggest issue in its history. Oral Health and DPM thank the Dentistry Library, University of Toronto, for access to its archives and for all assistance with this special issue, in particular Jeff Comber with Media Services and Dr. Anne Dale with the Dental Museum. 12

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WOMEN IN DENTISTRY

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Part 1 of Janice Goodman’s article can be found in the 100 th Anniversary Issue of Oral Health

Janice Goodman, DDS Oral Health’s editorial board member for general dentistry

I We need to give credit to the fact that most hygienists, dental assistants and office managers are female...

t is not just the sheer number of females who have become dentists that are responsible for the feminizing of dentistry. This is the 100th anniversary issue of Oral Health and the past two Senior Publishers have been female: Erla Kay and Melissa Summerfield. Because of Melissa’s effort to integrate women onto the editorial board, I was invited as one of the first female dentist board members of Oral Health in 1999, and since then others have followed (Drs. Fay Goldstep and Susanne Perschbacher). Had I not been female, I would not have had the tremendous opportunity to be associated with this great publication. Both Melissa and our editorial director, Catherine Wilson basically control the publication of the journal and influence not just dentistry as a science, but also dentistry as a business and now with the newest addition Oral Hygiene, dental hygiene too. Credit goes to the women who work in the industry and are also becoming so dominant in influencing products made and procedural techniques. Oral Health was awarded an Award of Distinction, from the University of Toronto, for her work with and influence over the profession. Once unheard of, now women sit as CEO’s on many

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dental company boards and run many of the biggest dental research programs in North America. The dental company reps that visit our offices and influence how we practice are largely female and because of their success have paved the road for other women to have such opportunities. We need to give credit to the fact that most hygienists, dental assistants and office managers are female, which has had a huge influence on the feminization of the profession. The American Association of Women Dentists (AAWD), which has Canadian provincial chapters, is a unique organization which was formed to support and address the issues of female dentists. In 2010, I participated in an American Association of Women Dentists (AAWD) meeting in Chicago. What struck me was the difference in organization between the US and Canadian women dentists. They have a wellestablished membership with a home office, web site, sponsors and regular meetings. In Canada, there have been several WDA provincial organizations, which were affiliate chapters of the larger AAWD, but, most have petered out over time as the need for them seems to be less obvious as there are more female dentists in the profession. The Association of Women Dentists in Canada was quite strong in my earlier career years and I was president of our Ontario chapter for several years. It was a great networking group www.oralhealthgroup.com

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and we invited the female graduating dentists to join our events and tried to be mentors for them. I remember representing the Ontario AWD to arrange to sponsor lectures at an ODA meeting. I left the board meeting after being ridiculed that a women dentists’ organization should not have a place doing such a thing. There was a female dentist on that board, who had been a previous president of the AAWD who promptly called me afterwards to apologize for the conduct of a number of the male dentists who sat on that particular board. Males, who I admire, but, who lacked the vision of how our profession was moving back then, and might have responded differently in the present day. Dr. Lynn Carlyle (a male dentist), author of In a Spirit of Caring (which deals with dentist/patient relationships) has wondered how this female shift will alter both the traditional male-dominated analytical type of dental school teaching and the paradigm of dental practice. He has written a number of articles and explored these ideas. With regard to the question: “is there a difference in the way men and women practice dentistry?” his answer is definitely “yes, the differences are cultural, environmental, linguistic, biologic, neuroanatomical and neurochemical and they all influence how a female relates differently to colleagues, patients, team members and the practice of dentistry.” Dr. Carlyle asks a www.oralhealthgroup.com

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number of open-ended questions regarding the gender change in dentistry. He says that “the vast majority of research, opinions, and surveys on what makes an outstanding dentist were done by white males on white males. Does this research apply to women? What applies and what does not? Will the feminine replace the masculine? Dr. Carlyle expresses his concerns that female dentists are following the male dentistry model instead of adapting it to their feminine differences. I am not sure that I fully agree with this as from what I have experienced, female and male practices have slightly different “feels” to them and I believe that most patients can sense the differences which may or may not seem more obvious as time goes on. What he says is, “I cannot leave this series without expressing my concern that this generation of women dentists has not balanced the masculine paradigm that has dominated health care from the early 1900s to the present with the feminine. As yet, they have not made their practice of dentistry their own by integrating the feminine with the masculine. They have adopted the masculine paradigm of dentist.” Professor Deborah Tanner PhD students studied linguistic differences between the sexes at Georgetown University. She states that “our ways of talking are in-

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fluenced by every aspect of our communities...understanding the patterns of influence on our styles is crucial to understanding what happens to us in conversations and our lives.” These ideas were incorporated into the popular book, Men Are From Mars and Women Are From Venus by John Gray. Women appear to have a better natural ability to build relationships than men. She states “that we are different with a cultural, environmental, linguistic, biologic, neuro-anatomic and neuro-chemical” basis. Communication has a lot to do with the dentist/patient relationships and it has been suggested that such relationships will differ on several levels due to gender differences. Louann Brizendine also points out that we are unique physio logically, neuro-anatomically and psychologically from men in her book The Female Brain. She says that a woman’s chemistry and hormones affect her and have influence over her values, desires and priorities. Some of her conclusions are: “Scientists have documented an astonishing array of structural, chemical, genetic, hormonal and functional brain differences between men and women.” • “ The female brain has tremendous unique aptitudes-outstanding verbal agility, the ability to connect deeply in friendship, a nearly psychic capacity to read faces and tone of voice for emotions and states of mind, and

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WOMEN IN DENTISTRY

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the ability to defuse conflict.” • “ That their styles (boys and girls) of communication and interaction are completely different is probably a result of these brain variations.” • “Girls who expect their boyfriend to chat with them the way their girlfriends do are in for a big surprise.” • “Motherhood changes you because it literally alters a woman’s brain — structurally, functionally and in many ways, irreversibly.” • “Most mothers on some level, feel torn between the pleasures, responsibilities and pressures of children and their own need for financial or emotional resources.” 21/07/11 1:40 PM

One of the things that I get out of this information is that both male and female dentists may say that “family comes first” to them. But, in practical terms it may have different connotations to each of the sexes. It may mean that the female dentist is more likely to alter her practice of dentistry to accommodate what the family needs than a man and this might impact the nature of the profession over time, once the gender balance becomes more static. I have been the first woman dentist on several all-male advisory boards, and a participant on all women dentist advisory boards for companies in the dental industry. The all women advisory boards are a new phenomenon, especially over the past 5-6 years. Kerr is one company that is a pioneer at this, 16

thanks to the enlightened vision of Kirsten Edwards and Sue Seaman and open-minded men of Kerr who allowed them to proceed and make their visions a reality. I really am not sure what the advantage of an all-female advisory board is, but having participated in both mixed and all female advisory boards, I believe that the companies do get a slightly different slant with the all female ones. I assume that it must be worthwhile since more companies now are investing money and buying into the concept that females will influence the dental industry’s direction in the future. All-women dental CE meetings are also being sponsored by journals and equipment companies in destination locations and have proven to be profitable and a great way for an office to enjoy some special bonding time and get rewarded for their office contributions. The women attendees enjoy their exclusively female status for the meetings and the atmosphere is about enjoying and letting loose. The meetings are more about the social aspect of connecting, than they are about the material presented. Multiple internet web sites have sprung up catering exclusively to the female dentist. Besides the AAWD web site, Pinktooth.com was another attempt to cater to females in the dental profession. While they were trendy for awhile, I believe that female dentists do have their own issues that are unique because of their sex and position in society, but, on a whole women are now so integrated into

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the profession that this type of support is less important than when we were a minority and had more hurdles to jump. I would like to take the opportunity to show appreciation to the myriad of female dentists that have been the pioneers, the leaders and the mentors, who have paved the path for future generations to follow. Women who enter the profession now, can take for granted what others struggled to achieve, not that long ago. My daughters and a niece are in the process of entering the dental profession now. For them, being female is not as much a hurdle to get through dental school as it used to be, other than perhaps, occasionally butting heads with dinosaur males of the old guard. I acknowledge and show gratitude to the males of the profession who, as a whole have been very welcoming to us gals, and helped us transition into becoming part of the wonderful profession of dentistry over the past 100 years. Male or female, dentistry is, more than ever, the best profession in the world. DPM 1. H ealth Professions-Dentistry Washington University, School of Medicine, 2004;1. 2. Ontario Dentist, June 2011, Demographics, pages 39-42. 3. Dr. Myrna Halpenny, The Bridge Magazine, Feature Article Women In Dentistry: Growing in Number and in Accomplishments. The Last Word Nov/Dec 2009, BC. 4. Dr. Myrna Halpenny, The Bridge Magazine The Last Word, From Activists to Feminists...to Dentists Nov/ Dec 2009. 5. AMA library excerps and stats. 6. The Gender Shift, the demographics of women in dentistry. What impact will it have? 7. ADA, Survey Center, Lynn D Carlisle DDS. 8. Tracy L Adams; A Real Girl and a Real Dentist: Ontario Women Dental Graduates of the 1920’s. Historical Studies in Education; Fall 2004; library @ Queens U with special credit to Dr. Ann Dale for contributing historical facts.

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ENDODONTICS

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Adam Grossman, DDS, FRCD(C)

Gary Glassman, DDS, FRCD(C) Oral Health’s editorial board member for endodontics

Part 1 of Adam Grossman & Gary Glassman’s article can be found in the 100 th Anniversary Issue of Oral Health Irrigants and Irrigant Delivery Systems Perhaps the greatest international attention in recent years has focused on methods to improve endodontic disinfection in the root canal system.2 The desired attributes of a root canal irrigant include the ability to dissolve necrotic and pulpal tissue, bacterial decontamination with a broad antimicrobial spectrum, the ability 18

Raising the Endodontic Bar for Success: Past, Present and the Future to enter deep into the dentinal tubules, biocompatibility and lack of toxicity, the ability to dissolve inorganic material and remove the smear layer, ease of use, and moderate cost. The combination of sodium hypochlorite and EDTA has been used worldwide for antisepsis of root canal systems.15 Sodium hypochlorite has the unique ability to dissolve necrotic tissue and the organic components of the smear layer.16-18 It also kills sessile endodontic pathogens organized in a biofilm.19,20 There is no other root canal irrigant that can meet all these requirements, even with the use of methods such as increasing the temperature,21-25 or adding surfactants to increase the wetting efficacy of the irrigant.26,27 Demineralizing agents such as EDTA have therefore been recommended as adjuvants in root canal therapy in combination with sodium hypochlorite.20,28 EDTA dissolves inorganic dentin particles and aids in the removal of the smear layer during instrumentation.29 It is very important to note that while sodium hypochlorite has unique properties that satisfy most requirements for a root canal irrigant, it also exhibits tissue toxicity that can result in damage to the adjacent tissues, including nerve damage should sodium hypochlorite incidents occur during canal irrigation.15 It is therefore very important that irrigant delivery devices are used that not only allow voluminous

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exchange right to the apex but also to deliver them in a safe and effective manner without apical extrusion. Root canal irrigation systems can be divided into two categories: manual agitation techniques and machine-assisted agitation techniques.11 Manual irrigation includes positive pressure irrigation, which is commonly performed with a syringe and a sidevented needle. Machine-assisted irrigation techniques include sonics and ultrasonics, as well as newer systems such as the EndoVac® (Discus Dental, Culver City, CA) (Fig. 6), which delivers apical negative pressure (ANP) irrigation,30 the plastic rotary F® File (Plastic Endo, Lincolnshire, IL),31,32 the Vibringe® (Vibringe BV, Amsterdam, The Netherlands),33 the RinsEndo® (Air Techniques Inc., NY),9 and the Endo-Activator® (Dentsply Tulsa Dental Specialties, Tulsa, OK). Of all the techniques listed above, only the Endo Vac has repeatedly shown to break the apical vapour lock (the column of gas that is formed at the apical 3mm of the root canal formed by the hydrolysis of organic tissue by sodium hypochlorite), produce a current of irrigant, remove debris and deliver voluminous amounts of irrigant to the apex WITHOUT the risk of apical extrusion.15 Digital Radiography Digital radiography has significantly reduced treatment time for endodontic procedures with far www.oralhealthgroup.com

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ENDODONTICS FIGURE 4—TF NiTi files (SybronEndo; Orange, California) are made of a superelastic alloy that has shape memory and exceptional cutting ability.

less exposure compared to conventional film. Highresolution digital images are instantaneously generated and easily manipulated for enhanced diagnostic performance. Digital storage of images is simple allowing quick transfer and communication.34,35 Cone-Beam Computed Tomography (CBCT) What digital radiography has provided us for imaging in the present, CBCT (cone-beam computed tomography) (Fig. 7) will carry us into the future. CBCT technology has been around since the1980s, however only recently has it become a viable option for the endodontic office.36 Cone-beam technology uses a cone-shaped beam of radiation to acquire a volume in a single 360-degree rotation, similar to panoramic radiography.36 It has advantages over conventional medical CT including increased accuracy, higher resolution, scan-time reduction, and dose reduction.36 Endodontic uses include but are not limited to diagnosis of odontogenic and non-odontogenic cysts, cysts vs granulomas,37 location of untreated canals and the diagnosis of certain root fractures. The extent of internal, external and cervical resorption can be accurately mapped and the presurgical evaluation of anatomic landmarks can be precisely surveyed.36 Regenerative Endodontics Regenerative endodontics has become an exciting possibility allowing stem cells found in the dental www.oralhealthgroup.com

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patients were able to maintain their occlusion and health in those functional areas that were missing teeth. Unfortunately implants are also being used to replace viable teeth.41 If a tooth is sound from both a restorative and periodontal aspect then endodontic therapy should be the treatment of choice. However, if a tooth is compromised from a restorative or periodontal perspective then an implant may be considered.42 Both root canal therapy and orthograde retreatment as a first and second line of intervention are more cost-effective compared to implant therapy. Current cost structures indicate that implants are limited to a third line of intervention.43 Confidence and embracing the advances in the science and art of endodontics is imperative if we are to continue to achieve and improve the successes that we have. There are numerous studies that support the excellent clinical results of endodontic treatment.44 Kim and Iqbal, conducted a review of the relative success rates of endodontic treatment and implants. The literature review found equal survival rates of singletooth implants and restored endodontically-treated teeth. Both therapies had overall survival rates of 94 percent, thus providing predictable outcomes.45,46 However, implants have a longer mean and median time to function, and have a higher frequency of post-operative complications requiring additional treatment intervention.47 Untitled-3 1

FIGURE 5—Mineral Trioxide Aggregate (MTA) (Clinical Research Dental, London, Ontario, Canada) is a biologically compatible material that has a variety of uses in endodontics.

pulp to regenerate and replace diseased tissue with healthy tissue and revitalize a tooth.38 The vasularization of necrotic teeth with immature apices can be a significant challenge to the clinician. Apexification procedures in the past have allowed root length to continue but the walls of the roots remained thin carrying with it the high risk and probability of fracture. Revascularization techniques provides such a tooth the ability to not only continue linear root growth but also to allow increased thickness of dentin on the root canal walls which will ultimately allow retention of the natural tooth, obviating the need for extraction and implant replacement.39 The technique is not complicated and easy to learn. Through the use of a specialized tri-antibiotic mixture, blood clot inducement and its coronal sealing with MTA, many necrotic and immaturely developed teeth that would otherwise be extracted, can now be retained.40 Endodontics vs. Implants With the advent of implants,

The Future Science and research will elevate the specialty of endodontics to its rightful pinnacle.48 The cornerstone to our specialty’s integrity and relevance must be built on a strong foundation of randomized clinical trials and evidencedbase endodontics.48 The future of

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FIGURE 6—The Endo Vac Irrigation System (Discus Dental, Culver City, California) allows voluminous exchange of irrigants right to the apex without the risk of extrusion when use according to manufacturers recommendations.

FIGURE 7—The I-CAT cone-beam computed tomography (Imaging Sciences International, LLC, Hatfield, PA).

endodontics is bright as we continue to develop new techniques and technologies that will allow us to perform endodontic treatment painlessly and predictably and continue to satisfy one of the main objectives in dentistry, that being to retain the natural dentition. DPM 1. O rstavik D, Pittford T. Essential endodontology: prevention and treatment of apical periodontitis. 2nd ed. Ames, IA: Blackwell Munksgaard Ltd; 2008:1. 2. Ruddle CJ. Endodontic Advancements: Game Changing Technologies. Oral Health, May 2011, Volume 101, Number 5, pages 40-44.

3. R uddle CJ: New directions in endodontics, Dentistry Today 21:2, pp. 74-81, February 2002. 4. Koch K. The microscope: its effect on your practice. Dent Clin North Am. 1997;41:619-626. 5. Saunders WP, Saunders EM. Conventional endodontics and the operating microscope. Dent Clin North Am. 1997;41:415-428. 6. Mines P, Loushine RJ, West LA, Liewehr FR, Zadinsky JR. Use of the microscope in endodontics: a report based on a questionnaire. J Endod. 1999;25:755-758. 7. Kim S. Modern endodontic practice: instruments and techniques. Dent Clin North Am. 2004;48:1-9 8. Rubinstein RA, Kim S. Short-term observation of the results of endodontic surgery with the use of a surgical operation microscope and super-EBA as root-end filling material. J Endod. 1999;25:43-48. 9. Baldassari-Cruz LA, Lilly JP, Rivera EM. The influence of dental operating microscope in locating the mesiolingual canal orifice. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93:190-194. 10. Plotino G, Pameijer CH, Maria Grande N, Somma F. Ultrasonics in endodontics: a review of the literature. J Endod. 2007;33:81-95. 11. Gu LS, Kim JR, Ling J, Choi KK, Pashley DH, Tay FR.Review of contemporary irrigant agitation techniques and devices. J Endod. 2009;35(6):791-804. 12. Himel V.T., McSpadden J.T. & Goodis, H.E. Pathways of The Pulp, 9th Edition; Chpter 8. Mosby, 2006. 13. Ahlhelm F, Kaufmann R, Ahlhelm D, Ong MF, Roth C, Reith W Carotid artery stenting using a novel self-expanding braided nickel-titanium stent: feasibility and safety porcine trial. Cardiovasc Intervent Radiol.2009 Sep;32(5):1019-27. E pub 2009 Jun 16. 14. DeVan MM. The nature of the partial denture foundation (suggestions for its preservation). J Prosthet Dent. 1952;2:210-218. 15. Glassman G, Safety and Efficacy Considerations in Endodontic Irrigation, ineedce.com, Penwell Corp, January, 2011, Pages 1-15. 16. Paragliola F, Franco V, Fabiani C, et al. Final rinse optimization: Influence of different agitation protocols. J Endod. 2010;36(2):282-5. 17. Naenni N, Thoma K, Zehnder M. Soft tissue dissolution capacity of currently used and potential endodontic irrigants. J Endod. 2004;30:785-7. 18. Haikel Y, Gorce F, Allemann C, et al. In vitro efficiency of endodontic irrigation solutions on protein desorption. Int Endod J. 1994;27:16-20. 19. Spratt DA, Pratten J, Wilson M, et al. An in vitro evaluation of the antimicrobial efficacy of irrigants on biofilms of root canal isolates. Int Endod J. 2001;34:300-7. 20. Clegg MS, Vertucci FJ, Walker C, Belanger M, Britto LR. The effect of exposure to irrigant solutions on apical dentin biofilms in vitro. J Endod. 2006;32(5):434-7. 21. Sirtes G, Waltimo T, Schaetzle M, Zehnder M. The effects of temperature on sodium hypochlorite shortterm stability, pulp dissolution capacity, and antimicrobial efficacy. J Endod. 2005;31:669-71. 22. Abou-Rass M, Oglesby SW. The effects of temperature, concentration, and tissue type on the solvent ability of sodium hypochlorite. J Endod. 1981;7:376-7. 23. Cunningham WT, Joseph SW. Effect of temperature on the bactericidal action of sodium hypochlorite endodontic irrigant. Oral Surg Oral Med Oral Pathol. 1980;50:569-71. 24. Cunningham WT, Balekjian AY. Effect of temperature on collagen-dissolving ability of sodium hypochlorite endodontic irrigant. Oral Surg Oral Med Oral Pathol. 1980;49:175-7. 25. Kamburis JJ, Barker TH, Barfield RD, Eleazer PD. Removal of organic debris from bovine dentin shavings. J Endod. 2003;29:559-61. 26. Lui JN, Kuah HG, Chen NN. Effect of EDTA with and without surfactants or ultrasonics on removal of smear layer. J Endod. 2007;33:472-5. 27. Giardino L, Ambu E, Becce C, Rimondini L, Morra

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M. Surface tension comparison of four common root canal irrigants and two new irrigants containing antibiotic. J Endod. 2006;32:1091-3. 28. Nygaard Östby B. Chelation in root canal therapy. Odontol Tidskr. 1957;65:3-11. 29. Lester KS, Boyde A. Scanning electron microscopy of nstrumented, irrigated and filled root canals. Br Dent J. 977;143:359-67. 30. Nielsen BA, Baumgartner JC. Comparison of the endovac system to needle irrigation of root canals. J Endod.2007;33:611-5. 31. Bahcall J, Olsen FK. Clinical introduction of a plastic rotatory endodontic finishing file. Endo Prac. 2007;10:17-20. 32. Chopra S, Murray PE, Namerow KN. A scanning electron microscopic evaluation of the effectiveness of the F-file versus ultrasonic activation of a K-file to remove smear layer. J Endod. 2008;34:1243-5. 33. Rödig T, Bozkurt M, Konietschke F, Hülsmann M. Comparison of the Vibringe System with syringe and passive ultrasonic irrigation in removing debris from simulated root canal irregularities. J Endod. 2010;36(8):1410-3. 34. Wenzel A, Grondahl HG. Direct digital radiography in the dental office. Int Dent J. 1995;45:27-34. 35. Naoum HJ, Chandler NP, Love RM. Conventional versus storage phosphor-plate digital images to visualize the root canal system contrasted with a radiopaque medium. J Endod. 2003;29:349-352. 36. Taylor P. Cotton, Todd M. Geisler, David T. Holden, Scott A. Schwartz, & William G. Schindler. Endodontic Applications of Cone-Beam Volumetric Tomography. J Endod 2007;33.9:1121-1132. 37. James H.S. Simon, Reyes Enciso, Jose-Maria Malfaz, Ramon Roges, Michelle Bailey-Perry, & Anish Patel. Differential Diagnosis of Large Periapical Lesions Using Cone-Beam Computed Tomography Measurements and Biopsy . J Endod 2006;32.9:833-837. 38. Spatafore CM, Evidenc, Biology, Research-Themes for the Future. J Endod 2011; 37; 1: 115. 39. Joseph A. Petrino, Kendra K. Boda, Sandra Shambarger, Walter R. Bowles, & Scott B. McClanahan. Challenges in Regenerative Endodontics: A Case Series. J Endod 2009:1-6. 40. Francisco Banchs, & Martin Trope. Revascularization of Immature Permanent Teeth With Apical Periodontitis: New Treatment Protocol? J Endod 2004; 30.4:196-200. 41. Rossman LE. Implant Your Opoinion With Confi dence. J Endod 2008; 24;8: 1025. 42. Michael F. Morris, Timothy C. Kirkpatrick, Richard E. Rutledge & William G. Schindler. Comparison of Nonsurgical Root Canal Treatment and Single-tooth Implants. J Endod 2009; 35.10:325-1330. 43. M. W. Pennington, C. R. Vernazza, P. Shackley, N. T. Armstrong, J. M. Whitworth & J. G. Steele. Evaluation of the cost-effectiveness of root canal treatment using conventional approaches versus replacement with an implant. International Endodontic Journal 2009,42: 874-883. 44. Salehrabi R, Rotstein I: Endodontic tredatment outcomes in a large patient population in the USA: an epidemiological study. J Endo 2004;30;846-850. 45. Goldstein SS. Implants. J Endo 2007; 33; 6: 761. 46. Iqbal M, KimS: single-tooth iimplant versus root canal treatment and restoration for compromised teeth: a meta analysis. International Journal of Oral and Maxillofacial Implants, 21:96-116, 2007. 47. Scott L. Doyle, James S. Hodges, Igor J. Pesun, Alan S. Law & Walter R. Bowles. Retrospective Cross Sectional Comparison of Initial Nonsurgical Endodontic Treatment and Single-Tooth Implants. J Endod 2006; 32.9:822-827. 48. Balson M. How High Have You Raised Your Bar? J Endod 2006;32;1;73. 49. Masoud Parirokh, Mahmoud Torabinejad. Mineral Trioxide Aggregate: A Comprehensive Literature ReviewPart III: Clinical Applications, Drawbacks, and Mechanism of Action. J Endod. 2010;36.3:410-413.

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brief review of some of the topics in the first volume of Oral Health reveals some of the issues and concerns of dentists in private practice. It appears that a primary focus of dentists at that time reflected economic concerns of the profession. The economic viability of the practice of dentistry from the dentist’s perspective was a pressing worry. In 1911, although there was a general sense of respect, dignity and honour associated with being a dentist, dentists were not the financially stable, well-established entrepreneurs and professionals that they are typically seen to be today. Instead, they were known to be hard working, underpaid oral physicians who struggled to support their families and worked longer hours than their professional peers.18

Articles addressed the handling of competition from incompetent / illegal practitioners (eg. the Henry case, part 1 of my article), what constituted reasonable fees dentists should receive for services rendered, what advertising for the acquisition of new patients was appropriate and what the obligations www.oralhealthgroup.com

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DENTAL JURISPRUDENCE

No Matter How Things Change, Do Things Stay the Same? Part 1 of Rollin Matsui’s article can be found in the 100 th Anniversary Issue of Oral Health

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of the dentist were to the public with regard to prevention and education. The attitude of the day was evident in articles entitled “Demoralization of Inferior Work”19 and “The Conduct of a Dental Practice From the Business Standpoint.”20 Emphasis was also placed on the importance of honesty to the public, prevention of disease and education of dentists. However, in terms of education, it is most interesting to find that, as a result of the harsh economic realities and self-interest at the time, the belief in the value of sharing professional knowledge was not a high priority and secrecy kept communication and goodwill among dentists at a minimum.21 It can be argued that the dentists of the day had forgotten (never learned?) about the exemplary attitude of Dr. Pierre Fauchard, the eighteenth century Parisian dentist commonly regarded as the father of modern dentistry. In the days when Dr. Fauchard practiced, it was common for dentists to tightly protect their trade secrets, clinical skills and knowledge and only convey this information to carefully selected apprentices, creating great obstacles to the dissemination of proper knowledge among dentists. It was to the credit of this legendary dentist that he chose to write a textbook on dentistry and encourage the sharing of knowledge among fellow dentists. “What he

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Rollin Matsui, BSc,DDS,LLB Oral Health’s editorial board member for ethics and jurisprudence

did to knock down the barriers seems today to be so transparently simple as to be hardly worthy of comment, but in his time, it was revolutionary.”22 Insofar as the secrecy of dental information is concerned, the stark contrast of the situation at the end of the nineteenth century with that in the twenty-first century is indeed dramatic and most reassuring. Today, of course, the importance of continuing dental education is well appreciated and the sharing of professional knowledge among dentists is widespread. These concepts are endorsed not only by dentists and organized dentistry, but also by dental regulators. Continuing education is typically a requirement in order to maintain a certificate of registration / licence to practice dentistry. Therefore, with this context in mind, it is perhaps inspiring that the legislature chose to revise the Dentistry Act as it did in 1911. The aspirations of the day were expressed by Dr. Seccombe in his position as the Chairman of the Dis-

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DENTAL JURISPRUDENCE cipline Committee of the Royal College of Dental Surgeons of Ontario:

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“The effect is to state clearly and explicitly in the new Act what the courts have declared the old Act to contain, and in addition to provide the necessary machinery for giving the disciplinary sections better effect. This machinery embraces a Discipline Committee, power to take evidence under oath, to subpoena witnesses, and order the production of books or other documents. 21/07/11 1:40 PM

Under the new Act the public will be more amply protected, and indeed, if henceforth the Ontario public is not entirely protected from the dental shark and charlatan, the Provincial Board will be open to most severe censure.

The fine for practicing without a licence has been changed from $20 to not more than $50 for the first offence, and not more than $100 for the second offence.”23 Dr. Seccombe appeared to be satisfied that the new legislation increased the fines for the illegal practice of dentistry. He did not comment on the adequacy of the requirements needed to obtain a licence to practice dentistry. He did not express whether or not he was satisfied with the provisions of the Act regarding the prevention of unprofessional conduct (eg. advertising by charlatan dentists) by licenced dentists.

ILLEGAL PRACTICE OF DENTISTRY

The revised Dentistry Act of 1911 stated that if the Board was sat-

isfied by examination that the candidate was duly qualified to practice dentistry and that the candidate possessed integrity and good moral character, then it shall grant the candidate a certificate of license.24 Apparently there were no requirements as to education or other qualifications. One can see that without any academic requirements the barriers to obtaining a license were quite low; one can only imagine what the skill level would have been for those illegal dental practitioners unable to meet even such minimal requirements. Today an applicant for a certificate of registration to practice dentistry in Ontario must present evidence of satisfactory completion of a formal university dental education before he or she

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DENTAL JURISPRUDENCE is permitted to take the licensing examination. Thus the law has changed considerably and is far more demanding than in the past. As previously noted in the 1911 revised Dentistry Act, the penalty for the illegal practice of dentistry was not to exceed $50.00 for the first offence and not to exceed $100.00 for every subsequent offence.25 However today, if a person practices dentistry without a valid certificate of registration, the person is guilty of an offence and on conviction is liable for a first offence, to a fine of not more than $25,000 or to imprisonment for a term of not more than one year or both; and for a second or subsequent offence, to a fine of not more than $50,000, or to im-

prisonment for a term of not more than one year or both.26 I have not often encountered the issue of the illegal practice of dentistry through my law practice and so I cannot offer any firsthand comment on how prevalent it is. However, it appears that it is not a major concern to practicing dentists, certainly not to the level or extent that it was about a hundred years ago. On the other hand, the media have recently brought public attention to the issue in Ontario. An article in a major Toronto newspaper in 2010 entitled “Bogus ‘dentists’ preying on immigrants” revealed the results of an undercover investigation which reported on the prevalence of illegally practicing “dentists” in the

City of Toronto27 and suggested that this issue is far from dead, at least from the media’s perspective. The comments of the investigators are worth noting as they eerily echo sentiments from the distant past: “Offering cut-rate prices for inferior dental care, these bogus dentists attract patients, overwhelmingly new immigrants, who share the same culture. Vulnerable, ill-informed and desperate to save money, they have low expectations for care.” I would think Dr. Seccombe would be alarmed to read that even 100 years later, the public media reports “The dental profession’s watchdog is struggling to thwart this underground enterprise with a seven-year, $1 million crackdown that has netted 42 imposters. But where one practice is Untitled-3 1

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DENTAL JURISPRUDENCE knocked down another pops up.” As in 1911, the provincial regulator today continues to expend efforts to curtail the illegal practice of dentistry and it remains to be seen if this issue rises to the levels perceived a hundred years ago. Untitled-3 1

To complicate the issue further, there have been legislative initiatives designed to increase the access of appropriately qualified foreign trained dentists to practice dentistry in Ontario. It is beyond the scope of this article to comment on the underlying reasons for such direction, but it is worthwhile to consider how the dental profession may respond to this development. If more foreign trained dentists are legally able to practise dentistry, will this reduce the number of illegal dental practitioners servicing the public? Perhaps it could be argued that things are different now, the illegal practice of dentistry is less a concern to the profession and no longer poses a threat to the economic livelihood of dentists 100 years later. 21/07/11 1:40 PM

In my view, even if things have changed and there is verifiable proof that there are fewer illegal dental practitioners and charlatan dentists to contend with, the experiences I have had through my law practice indicate to me that the underlying economic concerns facing dentists are as prevalent today as they appeared to have been a 100 years ago. The competition for patients due to the larger numbers of dentists in the marketplace, the high costs related to running a dental practice combined with the desire for dentists to live a lifestyle commensurate with their professional status has continued to affect the underlying motives of dentists in the practice of dentistry. A casual observing of dental courses available to dentists today suggests that courses focusing on 24

the “business of dentistry” are readily available much like they were to dentists back in 1911 as evidenced in the pages of the first issues of Oral Health. While researching this article, I could not help but notice with amazement the concerns that the dental profession had with the role of dental laboratories and dental staff back in 1911. I wonder what dentists from that time would think of the current regulatory scheme now in place in Ontario with dental technologists self-regulated and both denturists and self-initiating dental hygienists having the right to practice their own scopes of practice without the presence, supervision or control of a dentist. Would they be mortified to learn that the laws in Ontario have now been loosened allowing certain traditional dental procedures such as polishing and whitening of teeth to be performed by literally anyone, even without any formal dental education or training? Could they argue that the risk posed by “tramp dentists” to the economic viability of dentists has now been either replaced, or added to, by the creation of legal “non-dentist” health practitioners? Would they see these developments as not being in the public interest and / or more a matter of unwanted competition to the dental profession? Clearly things have changed but have the underlying issues remained the same?

UNPROFESSIONAL CONDUCT BY A DENTIST

The revised Dentistry Act of 1911 stated that the Board could suspend or cancel a certificate of licence of a member of the College who has been convicted of an indictable offence or where the member has been guilty of infamous, disgraceful or improper conduct in a professional respect.28

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If this 1911 Act was intended to curtail inappropriate advertising by “charlatan” dentists who were already licenced, it is unlikely that the Act made this very easy to accomplish. In the absence of any particular provisions outlining what was considered to be unprofessional advertising, it is likely that successfully prosecuting members for alleged unprofessional advertising may well have been difficult. Furthermore, if there were already a high percentage of dentists who were charlatans, it would not be surprising if the net effect of the legislation was not felt. “Advertising by dentists seemed to reach a crescendo by the turn of the century; after that it diminished, slowly and over several decades. Amendments to dental laws and reform movements initiated within dental organizations finally brought advertising under control...” 29 It is arguable that advertising is “under control” today but based on personal experience through my law practice, I have commonly heard clients comment on the relative rigidity of the advertising regulations currently in place in Ontario. In contrast to the 1911 Act, the professional misconduct regulations set out in considerable detail the law relating to dental advertising for dentists in Ontario:

PROFESSIONAL MISCONDUCT

60. P ublishing, displaying, distributing, or using or causing or permitting, directly or indirectly, the publication, display, distribution or use of any advertisement, announcement or information related to a member’s practice, which, i. a s a result of its content or method or frequency of dissemination, may be reasonably www.oralhealthgroup.com

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DENTAL JURISPRUDENCE regarded by members as likely to demean the integrity or dig nity of the profession or bring the profession into disrepute, ii. includes information that, A. is false, misleading, fraud ulent, deceptive, ambigu ous or confusing or likely to mislead or deceive the public because, in context, it makes only partial dis closure of relevant facts, B. is not relevant to the public’s ability to make an informed choice, or C. i s not verifiable by facts or can only be verified by a person’s personal feel ings, beliefs, opinions or interpretations, iii. m akes comparisons with an other practice or member or would be reasonably regarded

as suggestive of uniqueness or superiority over another practice or member, or iv. is likely to create expecta tions of favourable results or to appeal to the public’s fears. 61. Publishing, displaying, distrib uting, or using or causing or permitting, directly or indi rectly, the publication, display, distribution or use of any ad vertisement, announcement or information related to a mem ber’s practice, which makes ref erence to any area of practice, dental procedure or treatment unless the advertisement, an nouncement or information dis closes whether the member is a specialist or a general practitio ner and, if a specialist, in what particular specialty.30

I would think most dentists will agree that advertising by a “char latan” dentist as perceived both by the public and profession in 1911 is virtually extinct today. Clearly, the dental laws in Ontario have changed over the last hundred years in this regard consistent with the goals as set out by the early leaders of the dental profession. Untitled-3 1

I suspect that a professionally minded ethical dentist from 1911 practising today would welcome these current advertising regula tions insofar as how the practice of dentistry ought to be practised either in 1911 or 2011. However, it remains to be seen if the charlatan dentist of the past returns as a “wolf in sheep’s cloth Continued on page 32

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ORAL & MAXILLOFACIAL SURGERY

The Evolution of Oral and Maxillofacial Surgery Untitled-3 1

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Bohdan Kryshtalskyj, BSc, DDS, MRCD(C), FADI, FICD, FACD Oral Health’s contributing consultant for oral and maxillofacial surgery

Michael Kryshtalskyj A grade 11 student at Royal St. Georges College in Toronto

Part 1 of Bohdan & Michael Kryshtalskyj’s article can be found in the 100 th Anniversary Issue of Oral Health Arthrocentesis In 1994 and 1997, Nitzan and Murakami (1995) found that closed lock of the mandible can be managed by arthrocentesis. This is a procedure whereby fluid (usually lactated Ringer’s) was injected into the superior joint space and then aspirated. A therapeutic substance is then injected into the joint, usually a steroid. Various other techniques have introduced an outflow portal such that when fluid is injected, it usually goes as an outflow through an 18-gauge needle. It has been shown that 300-400 cc of lactated Ringer’s would be the optimum lavage. This procedure is usually effective after sudden occurring closed lock. In situations where the closed lock has exceeded 3 months, arthroscopy is then the procedure of choice. Laser arthroscopy The pulsed mid-infrared laser based on the element holmium has been developed that operates at a wavelength of 2.1 millimicrons (1990). Its output can be transmitted through cord fibres and it may be used in an environment of saline or lactated Ringer solution. The laser radiation is well absorbed by most biological tissues which permits precise tis-

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sue removal. In a publication by Hendler et al. (1992) the use of the holmium-yag laser, which was used on 27 patients with temporomandibular joint arthroscopic surgery showed that, when compared to mechanical instrumentation, the laser markedly improved the ability to remove and sculpt diseased tissue. The ability to manipulate the small diameter fiber-optic handpiece allowed easy access to all recesses of the temporomandibular joint and reduced operating time. Direct percutaneous puncture with the optical fiber eliminated the need for a working cannula and simplified triangulation. Tissues were easily sculpted to a smooth surface by the laser beam, adhesions and further lesions were quickly vaporized in the non-contact mode and owing to the inherent coagulation effect of the laser, hemostasis was generally unnecessary. Postoperatively all patients appeared to have less pain and a quicker return to function including the ability to initiate jaw exercises immediately after surgery. Viscosurgery and Visco-Supplementation In 1983, Balazs introduced this surgery to be indicated in surgical procedures in which biologically inert, viscoelastic sub stances are used to protect tissues and facilitate their manipulation. Arthroscopy inflicts certain damage to joint surfaces and disrupts delicate synovial membrane linings. Joint lavage with saline or lactated Ringer www.oralhealthgroup.com

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ORAL & MAXILLOFACIAL SURGERY solution during surgery removes protective hyaluronan covering from the joint surfaces causing further loss of proteoglycans. This may result in synovial inflammation and scuffing of articular surfaces. The end results may become apparent as degenerative arthritic change. Similar mechanical problems in ophthalmic surgery were eliminated by the application of biologically inert viscoelastic devices such as hyaluronan. The bio-compatibility of this tissue and its unique properties may be the ideal choice for viscosurgery. Injury is best minimized by creating or maintaining tissue spaces within which the surgeon can safely operate. The properties of this material reduces the mechanical trauma of instruments to cells and tissue surfaces. Joint hemostasis was maintained by ensuring separation and lubrication of normally non-adherent tissue surfaces and by preventing the movement and activities of sensitive cells. Moreover visco-supplementation may be performed instead of a steroid injection by injecting three doses of Synvisc (hyaluronan) one month apart for three consecutive months into the arthritic symptomatic temporomandibular joint. This, like steroids, eliminates pain and dysfunction, inflammation, and locking in most patients. However because the cost of this material is so high and studies have shown the response to treatment is similar to those patients that have had steroid injections, the latter is almost always used. Continuous Passive Motion Research in the use of continuous passive motion (CPM) to be used immediately after temporomandibular joint surgery has shown that CPM stimulates the regeneration of articular tissue, eliminates and reduces adhesions, joint www.oralhealthgroup.com

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stiffness, reduces pain and is well tolerated by patients. Some of the beneficial effects of CPM may be related to the transportation of synovial fluid stimulated by joint movement. While there are several CPM devices available for the temporomandibular joint, not all physical therapists are in favour of their use, because joint movement is limited to only the sagittal plane. Postoperatively, however, tongue depressors are a cheap and effective way for patient’s to improve their outcome. Total Prosthetic Joint Replacement For patients who have failed multiple TMJ procedures secondarily due to Proplast-Teflon implants, silicone implants; severe facial trauma involving loss or necrosis of the segment of the mandible (condylar head, neck and ramus) and other autogenous grafting techniques, Rheumatoid arthritis and other arthritides, ankylosis secondary to failed conservative surgery, severe degenerative joint disease, neoplasms, and gross dentofacial deformity (acquired and genetic) and idiopathic condylar resorption; this treatment may be indicated to re-establish the normal skeletal proportions and temporomandibular joint function. The history of fossa implants may be traced back to 1934 when Risdon placed gold foil into the glenoid fossa to prevent re-ankylosis. In 1960, Robinson used a stainless steel cup-like glenoid fossa implant for correction of ankylosis. In 1963 Christensen used a chrome cobalt fossa secured with 5 screws to the zygomatic arch. Morgan in 1973 reported the use of a chrome cobalt fossa with a silicone rubber insert other surgeons continued to use silicone rubber implants in reports from

the 1960s and 1970s. The history of condylar prostheses goes back to the 1920s when gold castings were used and attached to condylar stumps in ankylosis surgery. Since then the literature has abounded with descriptions of condylar prostheses using gold, stainless steel, chrome cobalt, Vitallium, and titanium. There have been studies on polyacetyl homopolymer polyoxymethylene (DELRIN) with the total prosthetic Delrin condyle attached to a titanium mesh. In the past there were a number of commercially available condylar prostheses that were in general use which were: The Vitek-Kent Prosthesis (1980s), A-O stainless steel, A-O titanium, Ti-mesh with titanium head and delrin head, Howmedica (vitallium stem polished vitallium head), Wurtzburg titanium, Techmedica titanium mesh. The procedures above are sometimes performed with orthognathic surgery. Untitled-3 1

Several new prostheses have been developed and approved by the FDA as well as Health Canada. The primary prostheses is the TMJ Concepts/Techmedica which is available in a fossa and mandibular component. The fossa is made on a wrought titanium shell with commercial titanium. The articular surface is a dense ultrahigh molecular weight polyethylene. The mandibular component shaft is a wrought titanium alloy mainly. Prior to using this prosthesis one has to order a preoperative three-dimensional CAT scan of the maxilla and mandible. A plastic model is then duplicated from the three-dimensional CAT scan using stereolithographic technology which has been developed in the last decade. The surgery is done on the plastic model first and then duplicated on the patient. A custom-made total joint prosthesis conforming to the pa-

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tient’s specific anatomical morphology is then fabricated on the plastic model by TMJ Concepts and it is then ready for insertion during the patient’s surgery. Recently in the last three years Walter Lorenz has also developed a total joint prosthesis with the polyethylene fossa piece and a cobalt chromium -molebdenum mandibular condyle prosthesis. 21/07/11 1:40 PM

Orthognathic Surgery The first orthognathic surgery procedure was performed in 1849 by Hullihen. He was the first to surgically correct an open bite. It was later known as “the anterior mandibular sub-apical osteotomy” and has been since modified by Trauner, Hofer (1942) and Kole (1965). The procedure

was done without any anesthesia whatsoever. Other procedures to correct open bite were based on sub-condylar surgery of the mandible. The osteotomy of the mandibular body for prognathism correction was done in 1897 by a general surgeon Vilray Blair. He presented the first classification of jaw deformities that is still used in orthognathic surgery today. He described mandibular prognathism, mandibular retrognathism, dentoalveolar, mandibular and maxillary protrusion as well as open bite. He realized and was the first to stress the importance of orthodontics in surgical management. In 1897 Berger described a condylar osteotomy for prognathism correction.

Subcondylar osteotomy with the Gigli saw for prognathism correction was described by Kostecka in 1929. This was a blind operation. The techniques of trauma surgery after World War I and World War II were carried over to modern orthognathic surgery at that time. In the 1950s Caldwell and Lederman developed a vertical ramus osteotomy minimizing trauma to the inferior alveolar neurovascular bundle. This was used instead of the body ostectomy. Babcock popularized a horizontal ramus osteotomy. Other procedures were all variations of the open oblique osteotomy introduced by Limberg in 1925. Trauner and Obwegeser in 1957 introduced the intraoral bi-

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ORAL & MAXILLOFACIAL SURGERY lateral sagittal split ramus osteotomy of the mandible with an “inverted L” modification. Schuchardt described it in 1942. Modifications by Dal Pont (1961), Hunsuck (1968), Epker (1977) followed. This procedure was a “sliding osteotomy” so no bone graft was required. The very first operation on the maxilla to correct open bite deformity was the anterior maxillary osteotomy pioneered by CohnStock in 1921. It was then modified by German surgeons Wassmund (1927), Wunderer (1963) and Cupar (1955). The operations centered mainly on the anterior maxilla and most early procedures were not fixated with wires. In 1955 Schuchardt described a posterior maxillary osteotomy to produce intrusion of teeth followed by Kufner (1971). René LeFort, in his experimental work on cadaver skulls, induced blunt force trauma on them in 1901 by doing so identified the sites at which fractures in the mid-face occurred. His studies were then used to describe the various trauma fractures and osteotomies of the midface: LeFort I, LeFort II, and LeFort III fractures and surgeries with concurrent modifications. In 1868, David Cheever of Boston performed the first LeFort I osteotomy down fracture on a patient to expose and remove a large nasopharyngeal polyp. His published account was 31 years before the LeFort classification. In 1960, Obwegeser performed maxillary surgery and described a large series of LeFort osteotomies in 1969. Prior to the mid 60s almost all ortthognathic surgery procedures centered on the www.oralhealthgroup.com

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mandible only. With his studies he demonstrated that the maxilla could now be moved in all three planes of space. Furthermore animal perfusion studies done by Bell allowed the preservation of a wide intact pedicle attached to osteotomized segments providing good blood supply to them. Variations on the LeFort I osteotomy techniques were subsequently introduced by Tessier, Epker, Wolford, West and others. With the evolution of general anesthesia it became possible to correct the dentofacial deformities with safety, predictability, and efficiency. Technology itself has led to significant improvement in that the older cases of the 1800s no fixation was used then direct arch bars and wire fixation including suspension wires were used to minimize relapse. With the advance of titanium plates and rigid internal fixation intermaxillary fixation was shortened and or eliminated along with skeletal relapse and recovery/healing time. A more predictable outcome and reduced morbidity and complications became the gold standard. With the introduction of modern anesthetic techniques in 1959 Kole performed the first bimaxillary surgery. The first total bimaxillary jaw surgery was performed by Obwegeser in 1970. Modern anaesthetic concepts of hypotensive anaesthesia to reduce blood loss was incorporated as well as advanced nasal-nasofibreoptic intubation techniques to aid the oral and maxillofacial surgeon. Further advancements in instrumentation as well as innovative saws and biodegradable plates and screws followed in the late 90s and early 2000s. Diagnostic imaging with 3D CAT scanning has aided in the soft tissue prediction

tracings in orthognathic surgery. Distraction osteogenesis of the maxilla and mandible represents the newest surgical treatment for patients with dentoalveolar skeletal deformities. It has evolved over the last decade in oral and maxillofacial surgery. McCarthy lengthened the mandible in 1992 using an extraoral apparatus that was fixed to the mandible and after osteotomies applied traction gaining mandibular length during healing. More recently orthognathic surgery has been performed through endoscopes. This technique allowed minimally invasive Le Fort I osteotomies as well as mandibular osteotomies. Cleft lip and palate surgery followed with innovations in bone grafting techniques and soft tissue plastic surgical reconstruction. Modern oral and maxillofacial surgery currently is focusing on cosmetic soft tissue repair in the form of facelift surgeries, blephoroplasties, brow lifts and collagen injection techniques. Many advancements in allogeneic bone grafting materials, collagen membranes, as well as dermal tissue products has resulted in an ever expanding subspecialty of oral and maxillofacial surgery used to treat extraoral and intraoral defects and deficiencies. Botox over the last decade has been used in the cosmetic (wrinkle reduction) management as well as temporomandibular joint dysfunction. Untitled-3 1

Pre-Prosthetic and Dental Implant Surgery Prior to dental implantology, procedures were devised to increase denture stability and retention. After the dentaoalveolar ridges have resorbed in patients post dental extraction, procedures in the 1950s and 60s that were devised where: sulcoplasty,

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ORAL & MAXILLOFACIAL SURGERY vestibuloplasty with mucosal advancement, sub-mucous vestibuloplasty (devised in 1963), vestibuloplasty by secondary epithelialisation and with epithelial grafts.

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Many attempts at implant sur gery have been evident in the past. Many materials have been implanted into jaws to recreate a functional dentition and occlusion. Historically in the ancient times the Myans and Egyptians used seashells. Other materials included ceramics, and a variety of metals. Dr. Leonard Linkow in 1952 placed his first dental implant. The implants that he used were subperiosteal and blade implants. Also in 1952 Dr. P.I. Branemark (through his 21/07/11 1:40 PM

research), found that titanium bonded with bone directly and became integrated with it. He found this while he was doing rabbit tibia experiments. He then pioneered the first endosseous dental implant of which the first was inserted in a human in 1965. Thus titanium dental implants were born and many modifications of them have since been developed. Sialoadenoscopy This procedure was pioneered by Dr. Francis Marchal in Geneva in the early 90s through his research. It was actually introduced to the world in 1995. This procedure involves the use of miniature endoscopes measuring 1-3mm in greatest diameter. The endoscopes were used to en-

ter the small ducts of the major salivary glands in search of sialoliths, adhesions, ductal pathology, growths and stenosis. Various procedures were developed to correct the above and this has spared the removal of the major salivary glands in many patients. This subspecialty is still continuing to evolve. Much more information is available regarding the progress in oral and maxillofacial surgery and this summary has tried to demonstrate most of the more important advancements. We can be sure that within the next 100 years, more modern innovations and standards will be introduced for the continuing benefit of our DPM patients.

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see work with a something “we have to do in life” attitude. They work for two reasons: work-life balance and status. They are independent and self-reliant and have a solid work ethic when working in a job they believe in and that challenges them. Their leadership style is one that says everyone is the same and understands that constant training is a requirement to retain interest. X’er’s will question the rules and must know the context of the “why” before they will comply or adapt to change. They thrive on a team that allows them their autonomy and freedom to do it their way while seeing their individuality. They don’t want to spend a lot of time talking about things and have meetings, they want to get in, do the work and move to next thing. They crave time with their bosses and can never get enough feedback in which they will ask for at any time in any way and expect it back directly and immediately. Generation X was raised in the ‘don’t speak to strangers’ era and as a result unless they know you they won’t listen to you, let alone accept your treatment. They must see the information about their oral health as useful and trusting while feeling like you have involved them the entire way. They’ll value you for involving them with their own outcomes but will reject you just as fast as they if they find you’ve misrepresented anything. The case presentation must be in lay terms, simple, and must connect with their lives. They shy away from complex words and technical jargon and judge you on how efficiently you give them their treatment plans. They won’t likely want to return for a lengthy consultation and may pressure you to tell them, get in and do it now and move to next thing. www.oralhealthgroup.com

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Once they see the value of dentistry, believe in you and say yes, it will be on their terms of what is most convenient based on time before money. This generation relies heavily on female authority as this generation was raised with mothers having careers and women are perceived as intelligent individuals with knowledge and are delegated to make the majority of family decisions about healthcare. Financially, Xer’s were raised in difficult economic times but have all the desires the boomers have. They often don’t have the credit status and live beyond their means. Gen X loves to buy online. They’ve made eBay what it is today and are willing to accept the risks that buying online entails. Generation Y, also known as the “Net” generation or Millennial. They are the technology savvy: accomplished multi taskers who watch TV while seated at their computers listening to MP3, burning CD’s, Instant messaging their friends and pretending to do homework. They value education and fun and find all mega corporations irrelevant to them and their future. One in four teens live in a single parent household, they all know someone who is gay and have been exposed to drugs, pornography and anything else via the internet, face book and instant messaging. Generation Y are starting to enter the workforce and is the fastest growing segment. They bring with them a childhood of participating in team sports and play groups who value teamwork and are the “no-person-left-behind” generation. Generation Y’s work motivation is seen as a means to a flexible lifestyle and will trade high pay for fewer billable hours, flex-

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PRACTICE MANAGEMENT

ible schedules and a better work/ life balance. They don’t have a great deal of respect for authority or bureaucracy and will question the rules to see if they should be rewritten and respond to competency not position or title. Untitled-3 1

Gen Yers want information now and will judge or ‘uncover’ poor organization and lack of sophistication if you don’t have a speedy communication channel and a website for them to visit. Gen Yers have a take charge attitude about their appearance and health. They welcome education that enhances their well being. Gen Y does not want to be instructed on what to do, but steered through the decision-making process. As they begin taking ownership of their health, provide them with enough information to make educated decisions. As far as spending they represent a large disposable income controlled by today’s child who grew up in economic prosperity with a new tool of the internet for immediate gratification. They account for 21% of all online apparel purchases and are the greatest influence on auto purchases in their homes. They spend an estimated $20 billion in online purchases alone each year and their biggest influencers in buying from you is peer recommendations. In conclusion, to be successful in today’s cultural environment you need to understand all generations that you serve and what makes each generation “tick.” Start with generating an age breakdown of your active patients report and assess your generations segment of the practice and then create systems and protocols to match your situation. DPM

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ing.” Advertising of “cheap and cut-rate” dental care may be a thing of the past but in today’s multi-media world of communication, understanding how to comply with the advertising regulations becomes the issue. The concern now may be with frank or potentially misleading and deceptive advertisements being made by otherwise competent and qualified dentists. Through my law practice, issues relating to overtreatment, unnecessary and excessive dentistry and overcharging by dentists are often raised and represent a potential dark side of advertising in dentistry. Furthermore, these issues are closely interconnected with the level of transparency and forthrightness during dentist-patient communications, standards of practice and the obtaining of 21/07/11 1:40 PM

informed consent before commencing treatment. In my opinion, advocates both for and against advertising in dentistry would be prudent and wise in looking at the issue objectively keeping the ethics of the profession foremost in mind. Given a recent poll indicating the public’s trust in dentists is a concern, we could learn a valuable lesson from the pioneers of dentistry a century ago and remember to never take the public trust for granted and earn it every time we treat our patients. Certainly many things have changed over the past 100 years; but as far as dental jurisprudence is concerned, it seems to me that the underlying issues have truly remained the same. For the dental profession, self-interest must

Dental Office Managers and Administrators Communicating, Achieving, Networking

I conclude with the following quote from the foreword written by Dr. Seccombe in the inaugural first issue of Oral Health in 1911: “As a profession, we must go forward to the task of public enlightenment on dental matters, fearlessly, energetically and persistently, that we may emblazon in the public mind the thought that the modern dentist is not merely a dental surgeon, but a dental physician. Let every dentist also keep that ideal in mind. A dental physician who practices preventive dentistry.” DPM Complete references available upon request.

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I am an experienced Dentist who has placed and restored more than I will place Desante - 1/4 pg - 3 3/8" x 4 7/8" - Oral Health500+ Ad -Implants. September 14_11 dental implants for your Patients and guide you in the prosthetic steps. B.C.

We have a client operating a very successful and profitable corporation in the Vancouver area. Our client is interested in selling this business to a purchaser or purchasers who have knowledge in the field of dentistry. This business is not a dental practice but would be of interest to dental practitioners. The business has been generating profits in excess of $500,000 per annum with tremendous opportunities for growth. The new owner would be involved in an administrative capacity. No actual “hands on” dentistry would be required. Existing owner is prepared to assist purchaser during a transitional period. If you are interested please contact Larry Himmelfarb C.A. at 416-630-1370 extension 236 or by e-mail at larry@marrfoster.ca

For information regarding classified ads contact: Karen Shaw, Tel: 416-510-6770, Fax: 416-510-5140 E-mail: kshaw@oralhealthjournal.com Toll free: CDA 1-800-268-7742, ext 6770 Toll free: USA 1-800-387-0273, ext. 6770

Fall 2011 Dental Practice Management

DPMFall2011 p33-38 Classifieds.indd 34

Keep Dental Implants in House and Increase Your revenue!

Call me today: Dr. Mazahreh 647-444-1336 ontarioimplantdentist@gmail.com

PERIODONTIST AVAILABLE — TORONTO

Certified periodontist, UWO graduate, available for periodontics and implantology in a general practice or specialty setting. Email torontoperio@gmail.com or call Dr. Gebrael at 416-617-0520 for complete resume.

FREDERICTON, NB LOCUM position available: Busy, modern practice in Fredericton, NB seeking a 4-6 week replacement for the Jan-Mar 2012 period. Please reply to: drjohn.steeves@nb.aibn.com.

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03/10/11 11:02 AM

Practices & Offices SPACE AVAILABLE

Dental Clinic / Medical Space available for lease in Medical Building. 740 sq. ft. & 1480 sq. ft. in Toronto Downtown (Spadina & Dundas) — $10/sq.ft.+TMI 485 to 1702 sq.ft. in Brampton Downtown (population 500K+) — Gross $27/sq.ft. Contact: mortgage55@hotmail.com 905-454-4400.

I CAN HELP YOU REDUCE YOUR OVERHEAD! Sure fire methods to reduce your office expenses. Free initial consultation 416-371-3384.

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Dental office for sale or lease. Used as an orthodontist office. Fully plumbed, wired, partitioned etc on a busy main street in Hamilton. Low cost startup or satellite office. Phone 905-692-5245 or e-mail: ult.ext@sympatico.ca

DEAR DENTISTS:

I am looking for a $1+ million grossing practice to buy privately or brokered. Save up to 10% commission. Areas: up to 1-1.5hr distance surrounding toronto in all directions. Please respond to loki.trader@gmail.com in strict confidence.

PRACTICE FOR SALE! NORTH OF BRAMPTON, ON Part time practice. 23 yrs old. Contact: egartner123@gmail.com

LESS OFFICE RESPONSIBILITY — EXCEPTIONAL OPPORTUNITY

We are a progressive office in mid-town Toronto that is able to accommodate your existing practice 2-4 days per week. All 050323 SPRING 09of practice management looked after. 080908 APRIL 10 aspects This is an ideal opportunity for someone facing lease termination due to sale and demolition, or simply wants to practice without additional stress. Our practice offers comprehensive care with a strong preventive Is looking for full-time/part-time d model and on-site periodontist. Dreaming of an easier 9-5? Consider joining our high profile practice that is quality centered. in one A full-time associate position is available Practices are located in very busy retail Serious Only: of Canada’s most successful DentalInquiries Implant Paperless Offices. If you are energet info@aestheticsindentistry.com

DENTAL IMPLANT SURGERY & TEACHING CENTER ALBERTA, WESTLOCK

want to grow professionally, please co Centers in early Spring 2009. Our state-ofthe-art, computerized facility with CT-scan Dr. Raja Sandhu, BDS, D DOWNTOWN TORONTO CEO - SANDHU DENTAL G CALGARY, ALBERTA is located 45 minutes north of Edmonton in a Renovated practice, near subway, across from E-mail: rsandhu@sandhude Well Established High Tech GP practice Faculty of Dentistry. Looking for GP to share beautiful Ranching Community ideal for familocated SE, 4 Op’s – 1 additionalFax: plumbed. 613.258.5276 www.sand space. Relationship negotiable. Days/hours lies. Patients come from across Canada to thison 3 days a week. High Production flexible. Periodontist available. NEW GRADUATES WELC buyour condo or lease. Fax: 416-597-0412 or unique Dental Facility. Become aOption parttoof E-Mail: practicesale@live.ca e-mail: edwarddental123@gmail.com ongoing, fun and highly qualified young Dental Team. Assume a very busy A s s full-service o c i a t e s h i pgeneral, s 090336 SPRING 09 cosmetic dental practice with extremely high ASSOCIATE OPPORTUNIT FULL and TIMEaASSOCIATE earnings 50% split. Be mentored by the REQUIRED ASSOCIATE — COMOX VALLEY ON VANCOUVE DENTIST REQUIRED OKOTOKS, AB Senior Dentist whose practice is limited excluWe are looking for an associate dentis KAWARTHA LAKES, ON Busy family practice seeking F/T a permanent, full-time position, 3-4 da sively to Implantology. A well established, patient oriented full associate to start immediately in a an established patie Our office has scope family dental in LindPlease reply practice by faxing CV or resume to: well-established practice of over 15 being serviced by ju patients currently say, Ontario (1 hourImplant outside the GTA)Center, years. We have a highly The Smile have aorganized brand new facility with all new offers a rewarding, fully booked posiand dedicated teamx-rays and a and stateelectronic of charting. Our 1-780-349-2626 tion allowing the practice of any(Attn: facet Anita), the or art facility. Ourbased, practice envi- comprehensive care offering of dentistry desired. Earning potential ronment is friendly and focuses on email to drleigh@telus.net. ventive model. easily exceeds 20k+ monthly NET. We patient care and comfort. We areValley is the recreation The Comox Phone inquiries: 1-888-877-0737 (toll free). located 15 minutes south ofoffering Calgary.a mild climate and affo seek a candidate committed to quality Websites: www.albertadentalimplants.com Non-assignment. F/T or P/T inquirieswww.riverwaydental.c dentistry, with strong communication welcome. skills. New&graduates are welcome to www.implantsmilecenter.com www.discovercomoxvalle apply. Fax resumes to (705) 324-3863 or e-mail drjameskimdds@yahoo.ca

Associateships BURLINGTON, ON Full time associate wanted for a busy Burlington office. No weekends,only one evening.Experience preferred, ideally should be comfortable with endo and surgery.Ongoing CE support for the right candidate. Please send your resumes to assoc.wanted@gmail.com

HAMILTON AREA, ON

Current opportunity in our Hamilton area practice beginning October through April 2012 with the potential for a permanent 3 day position. Our dedicated team and proven systems will support you with your treatment plans. Please forward your resume in confidence to: Veronica at opportunitiesindentistry@gmail.com

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DPMFall2011 p33-38 Classifieds.indd 35

OTTAWA ARE

ASSOCIATE – EAST TORONTO

Associate wanted for a busy, progressive, well-established 060327 JULY 09mall practice in East Toronto. Experience preCALGARY, ALBERTA ferred, 2-3 days including Saturdays. Associate required for progressive, Fax resume to 416-447-4401

dynamic dental practice located in beautiful Calgary, Alberta. Please e-mail CV to DOWNTOWN TORONTO, ON horkoffp@telus.net Toronto general practice, p/t or fax resume to 403-276-3664 Periodontist and Oral Surgeon needed. resume: 09 051029 E-mail WINTER dentalspecialist2004-hr@yahoo.ca

ASSOCIATE REQUIRED NORTH OF TORONTO

Please call Sherry @ Please send CV to: riverwayden (403) 995-9544 or email resume to manager@okotoksfamilydental.com

090335

FEB 2011

FT/PT ASSOCIATES

FT/PT Associates required for very busy offices in Mississauga, Barrie and Scarborough. Please email: Dentaldreams@live.com. Please specify which location you are applying for.

CERTIFIED P/T PERIODONTIST WANTED BURLINGTON/OAKVILLE AREA

090325 JULY 09Busy Family Periodontist wanted for a Practice in the Burlington/Oakville area. OTTAWA, ON Please fax resume to 905-637-0868

Denture clinic seeking dentist to or email: drmgc@rogers.com assume workload from current dentist transitioning outON of practice. HAMILTON, Clinic beenrequired in business for over Full timehas associate immediately. Pro25 years inGreat the location Ottawa area. Hamilton Great gressive office. on central mountain. Bookedtoschedule and goodpatients insurance opportunity start taking plans. Great team patients. welcome. One evening right away. Newand graduates and occassional Saturday. Email resume to: Call 613-749-4055 hamilton.associate.dentist@gmail.com, ortoe-mail: samlima10@aol.com or fax (905) 387-2615.

LLOYDMINSTER, AB Excellent part-time associate Full-time, quality minded, detail and patientop portunity available immedioriented Associate required for busy practice. ately for a busy, well established, State-of-the-art – digital, offering implants and re spected family practice. Unique ortho. Well established, growing practice. Paid oppor tunity for self-motivated, on PRODUCTION! Newa grads welcome. caring individual who performs all Please email: azhrdental@gmail.com. aspects of dentistry. Conveniently located 45 minutes north of Toronto. Please reply in confidence to Dental Practice Management Fall 2011 35 fax: (905) 722-8271 or e-mail: drrbross@bellnet.ca

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03/10/11 11:03 AM

ASSOC

BRITISH COLUMBIA — FORT ST. JOHN

Full-time associates needed immediately for established, busy family practices in beautiful clinics with high income potential. These clinics provide full time CDAs, hygienists, high tech equipment, Cerec and friendly, hard working staff. Locations provide some of the most exquisite outdoor recreation areas in BC. Contact Curtis at: (810) 376-9876 or email:cklmanagement@gmail.com.

GRANDE PRAIRIE, ALBERTA A full time associate needed for our busy, well established family practice. Our practice offers all aspects of family dentistry including I-V sedation, oral sedation and implants. We will be moving into a brand new office soon in a high traffic area. If you are trustworthy, friendly and committed to excellence please contact Christa at 780-539-6883 or email resume to drroy04@telus.net

CALGARY, AB

Full time associate required for a busy, well established dental practice. Excellent opportunity in a modern, pleasant, digital office. Current associate moving abroad. Fax: 403-293-8852 or e-mail: ne.dent@gmail.com

DOVE DENTAL CENTRES Full-time associate required for one of their dental centres in London ON. Any inquiries, please e-mail to: dovedental@ody.ca

DRUMHELLER, AB

Full-time Associate Position available in a newly renovated, technologically advanced, busy practice in Drumheller. Excellent opportunity for new graduate or experienced dentist wanting to live in a great family community close to Calgary. Hospital privileges available. Also open to practice partnership to the right candidate. Please call (403) 823-7755 or e-mail jcaravan@magtech.ca TORONTO, ON

Dental Associates required in my downtown Toronto office: General dentists, periodontist/implantologist, oral surgeon/ implantologist, orthodontist, endodontist, denturist, and anaesthesiologist. E-mail resume to tooth32@295.ca

WILLIAMS LAKE, BRITISH COLUMBIA FULL TIME ASSOCIATE

EDMONTON ALBERTA

Excellent opportunity for Highly motivated and confident practitioner dedicated to providing the best quality dentistry in a progressive family clinic with a great dental team. Email resume to aponiadental@gmail.com or call Krista at 780-944-1999 visit us at aponiadental.ca

www.broadwaydental.ca

BROADWAY DENTAL ASSOCIATES • Experience the Medicine Hat advantage. • Protect your career from gridlock. • You are interested in predictable community living. • How do you value family time? • Lowest tax and utility rates in the province. • Children walk to nearby schools. • Highest grossing private practice in Southeastern Alberta. • Enjoy all the technological advances in today’s dentistry. • Achieving excellence with our experienced team is assured. • You are interested in above average compensation. • Check out our website, contact Dr. Greg Bradley. • Home of the Medicine Hat Tigers, the team has won two Memorial Cups, five WHL Championships and seven Division Titles. 101 - 7 Strachan Bay S.E. • Medicine Hat, Alberta • T1B 4Y2 Ph: (403) 548-7000 Fax (403) 548-7111 Toll Free 1-888-607-6453 www.broadwaydental.ca

DPMFall2011 p33-38 Classifieds.indd 36

Full Time Associate dentist position available in our modern large family dental practice with a 35 year proven track record. This is a great opportunity for a new graduate to gain excellent clinical experience and earn a SIX figure income while enjoying this outdoor recreation hotspot. Mountain biking, hiking, fishing, skiing, golf and kayaking all at our doorstep. Position is available July 2012. Call Perry Collect 250-398-7161 (daytime); 250-398-9085 (evening); 250-398-8633 (fax) or vitoratos@shaw.ca or visit www.cariboodentalclinic.com

STEINBACH, MB ASSOCIATE REQUIRED Associate required for busy, progressive, fast paced Steinbach dental practice two evenings a week, Fridays and Saturdays. The ideal candidate will have 3-5 years of general dentistry experience, aspire to continually provide patients with high standards of dental care and a potential to earn 30,000 thousand a month. Our full range of dentistry includes: endodontics, orthodontics, full mouth rehabilitation as well as implant placement. Conveniently located in our brand new location at the Clearspring mall, Hanover Dental is an established clinic with excellent patient flow. We provide state of the art technology including digital xrays, clean air filtration system, a wonderful staff and exciting environment. All enquiries will be held in strict confidence. Please send resumes to marie@hanoverdentalclinic.ca For more info please visit our website at hanoverdentalclinic.ca

03/10/11 11:04 AM

THUNDER BAY, ON

Full Time Associate Needed Scott Family Dental seeks full time associate for their busy general practice, open since 1980. Our clinic includes 5 computerized operatories, digital intraoral as well as pan radiography, and an enthusiastic and efficient staff. An option to purchase the practice and building may be available to an interested individual. Resumes may be faxed to (807) 345-8581. Any questions may be answered by calling Dr. Brian Scott at (807) 345-6331.

ASSOCIATE REQUIRED BURLINGTON/OAKVILLE AREA Associate required for well established busy family practice. Applicant should be a positive easy going individual able to practice all aspects of dentistry. Part time to start with transition to full time for the right candidate within 12 – 18 months. Serious candidates prepared to make this committment only please. Please e-mail to drmgc@rogers.com

Full time associate required in a busy family practice in London ,Ontario. Ideal for a prosthodontist or a general dentist with strong interest in prosthodontics. Current associate is leaving. We are seeking and energetic individual with desire and ability to provide advanced reconstructive dentistry. For more information regarding this exciting opportunity please contact Cosmo Dental Centre, Dr. Anwar Dean by calling (519) 636-8447 or email anwar.dean@bellnet.ca

SCARBOROUGH AND/ OR HALIBURTON COUNTY ASSOCIATESHIP

Both Offices are newly renovated with modern equipment. The staff is fantastic and this is a great opportunity to be part of two growing and progressive general dentistry practices. Part time and Full time possibilities available. A minimum of 2 years’ experience preferred. Please email resume to bill_kerr@sympatico.ca

FORWARD CV TO ASSOCIATES@STEINBERGDENTAL.COM

www.oralhealthgroup.com

DPMFall2011 p33-38 Classifieds.indd 37

EDSON, AB

FULL TIME ASSOCIATE LONDON, ON

Full time associate required for busy family practice. Work in a well established clinic where one can enjoy all aspects of dentistry. Edson, a vibrant town of 8000 people, is situated half way between Edmonton and Jasper, making it ideal for sharing the amenities of the city and those of the vast outdoors. If you are a proficient clinician who’s committed and caring, please contact Dr. ShariJean Robinson at srobin11@telus.net or call 780-723-5221.

ORTHODONTIST ASSOCIATE/PARTNER WANTED IN VANCOUVER AREA Certified specialist in orthodontics wanted to join a growing and profitable orthodontist office as an associate with opportunity to buy in as a working partner in beautiful Vancouver, BC. Please reply by email in confidence to bcorthodontist@gmail.com with resume and orthodontic background.

WWW.STEINBERGDENTAL.COM/ASSOCIATES

Dental Practice Management Fall 2011

03/10/11 11:04 AM

EDMONTON, AB

Full time associate sought for busy north Edmonton dental practice. You will have the opportunity to practice in a brand new clinic with digital equipment. This practice has OUTSTANDING new patient flow along with a fantastic support team. This makes for a great place to enjoy dentistry. Seeking a motivated team-oriented dentist with great communication skills. Must be available to work some Saturdays and one evening per week. Please email resume to g.mandrusiak@yahoo.ca or fax resume to 780-473-2550 attention Gina.

THE SMILE CLINICS Is looking for GP Associates. All DDS with minimum of two years of experience who are driven , self motivated and want to make a great income are welcome to apply for this rare opportunity. Bonus systems and partnership are available to the right candidate.

KITCHENER, ONTARIO

MEDICINE HAT, ALBERTA Well-established, busy Family Dental Practice requires a full-time Associate. We have a friendly team providing comprehensive and progressive treatment to a very large patient base. CE Subsidized. New grads are welcome to apply. Please submit resumes by email to medhatdental@gmail.com

WATERLOO, ONTARIO We are looking for a part time associate for a busy general practice. Candidate must have great interpersonal skills, be great with children, have at least 2 yrs experience and be interested in building a long term business relationship with the practice. Our clinic offers leading edge technologies. Our Staff is well educated and has learned to produce truly amazing results. Please apply with confidence to qualityassociate@gmail.com

Dentist required to join our well-established, busy practice. Self-motivated, caring individual with the highest quality of all aspects with family dentistry in mind. Busy from the start. Please email resume to resumedental@live.ca

ST. JOHN’S, NL ASSOCIATE POSITION Cowan Heights Dental Centre is providing an excellent opportunity for a highly motivated dentist to join a well established and growing practice using the latest in dental technology. Please e-mail Joanie Trainor at: cowanheightsdental@nl.aibn.com or phone 709-364-2654.

KITCHENER,ON.

Associate needed for a busy and well established family practice. Looking for friendly, people oriented, proficient and quality minded individual. Part-time with possiblity of full-time. Candidate must be committed to providing exceptional and gentle care. Email: highland.dental@rogers.com Fax: 1-866-874-1329.

WEST END, VANCOUVER, BC.

Full time associate position available. A rare opportunity to live and work in the most sought after location in BC. This is BC’s answer to Manhattan, NY. Strong clinical and interpersonal skills will assist to assume and grow patient load. Please contact us at mercuryfree12@gmail.com

OTTAWA, ONTARIO

Do you want to be an Associate with the opportunity of becoming a partner? If so, we are a busy, progressive practice looking for a people oriented dentist seeking to associate with the opportunity of becoming a partner. Please fax resume to 613-523-5318.

45% NET

Long-term Associate position available for an Experienced Dentist. Must be proficient in Endo Therapy and all aspects of General Dentistry. We are an established state of the art SW Calgary clinic with a commitment to the highest level of patient care and comfort. No evenings or weekends. Email resume in confidence to: dentalops@shaw.ca ASSOCIATE REQUIRED WOODBRIDGE, ON

PT associate required leading to FT leading to purchase. Very busy growing family practice. Owner is focusing on specialty areas. Send CV to: vellorewoodsdentistry@bellnet.ca.

Fall 2011 Dental Practice Management

DPMFall2011 p33-38 Classifieds.indd 38

We are looking for a strong clinical dentist with good leadership skills and an ambition to succeed within a growth focused environment. Future buy-in opportunity for the right person. High producing newly expanded facility with a strong patient flow located in a beautiful growing North Ontario community. Great recreation-hunting, fishing, golfing, snowmobiling, hiking and boating are all at your doorstep. Suitable candidate must be a passionate, self driven, confident, caring person who loves & connects well with people. Day time practice hours. Technology in place. Highly skilled team. Above average remuneration. Beautiful accommodation provided. Achieve your professional & career goals. Come interview us … Voice Mail reply at … 1-416-619-0318.

UPPER OTTAWA VALLEY ASSOCIATE POSTION AVAILABLE

Please send your resume to thesmileclinics@gmail.com

Associate wanted, part-time or full-time for busy Kitchener family practice. Great location in a busy plaza. Position is replacing an existing associate who is relocating out of the province. Please fax resumes to 519-744-7354 or e-mail to mbensky@rogers.com

FANTASTIC CAREER & LIFESTYLE OPPORTUNITY? RED LAKE, ON

BRAMPTON, ON

Caring part-time associate required for busy dental office in Brampton. Experience an asset but not essential. Call 905-456-0827 or fax resume to 905-456-8869 or e-mail: annasimas@bellnet.ca Equipment FOR SALE • Intra-oral camera system (HD Doc port) – 3 yrs old • Belmont PAN (good working condition) – 20 yrs old • 2 Belmont Chairman Traversing chairs (newly reupholstered) – 15 yrs old • Tuttnauer Sterilizer (fully functional) – 12 yrs old Please e-mail: tntdds1@hotmail.com

FOR SALE Pan by Instrumentarium Model OP 200 — new — manufactured in 2006 Covertable to pan-ceph Delivered and installed and guaranteed for 3 months $10,500.00. Contact fletchersmeadows@gmail.com if interested.

www.oralhealthgroup.com

03/10/11 11:05 AM

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