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oralhygiene CONTENTS
ORAL HYGIENE Saving Lives… What’s in Your Toolkit?
8
Jo-Anne Jones, RDH
Oral Malodor: Innovative Strategies to Measure, Learn and Improve
14
Jo-Anne Jones, RDH
Making the Shift: Enhancing Our Impact Through Oral Systemic Links
28
8
Sara DeNino, RDH, RNCP
BUSINESS MANAGEMENT Embezzlement: What Every Brilliant Clinician Should Know
20
30
David Harris, CPA and Wendy Askins
PRACTICE MANAGEMENT The Critical Importance of Team Development & Dynamics in Your Practice
24
Mark Carbonelli
32
BOOK REVIEWS Dying From Dirty Teeth, Angie Stone, RDH, BS (review by Brian Chapnick, DDS)
30
Open Wide: The Ultimate Guide to Teeth, Susan Grigsby
32
DEPARTMENTS Editorial Global Dental Imaging Market Embracing Upsurge from CBCT
News Oral Hygiene, Nutritious Diet Directly Linked; Canadian Budget’s Health Care Funding Good News for Dentistry
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34 Dental Marketplace 37 New Products
May 2017
3
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2017-05-01 11:48 AM
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Smiles Ahead 2017-04-28 4:03 PM
EDITORIAL
Global Dental Imaging Market Embracing Upsurge from CBCT Cone-beam computed tomography…rolls off the tongue, doesn’t it? Well, if not now, it soon will. At the recent IDS in Cologne, Germany, CBCT was prominent. CBCT is one of the latest advancements in global dental imaging systems and is considered a prominent producttype segment in the global market for dental imaging equipment. The use of CBCT imaging equipment has increased in various aspects of dentistry and periodontal surgery. According to Future Market Insights (FMI), a global research and consulting firm, adoption of cone-beam computed tomography will continue to influence global dental imaging equipment market revenues. Dental professionals and radiologists are choosing CBCT over traditional dental imaging techniques as it helps reconstruct a 3-D image of the oral and maxillofacial region. As a product type segment, cone-based computed tomography currently accounts for more than 18 percent revenue share of the global dental imaging equipment market. This segment is anticipated to increase at a year-over-year growth rate of 5.3 percent in 2016 over 2015 and reach US$396 million in revenues. In its new report entitled “Dental Imaging Equipment Market,” FMI says implant dentistry and interventional radiology are some of the key clinical verticals that extensively use the CBCT imaging equipment. As a result, cone-beam computed tomography is emerging as an important and the most enhanced dental imaging system in private dental clinics,
hospitals and ambulatory surgical centres. “Moreover, the demand for CBCT scanners has increased in oral surgery, endodontics as well as orthodontics. Additionally, the rising number of cosmetic dental surgeries and complex dental procedures will continue to drive the growth in the demand for CBCT imaging equipment in the global market”. The risks of using CBCT technology are perceived as the main restraints challenging the growth of the segment in the global dental imaging equipment market. Unlike the conventional extraoral X-ray imaging, the radiation delivered by CBCT systems is higher, causing unanticipated damages on the health of the patient. The risk of radiation exposure through CBCT is higher among children and teens – a key demographic undergoing dental surgeries. Also, the higher threat towards cancer incidence has drastically plunged the demand for CBCT equipment in hospitals. Despite this, CBCT imaging products and devices are seen as the fastest-growing product type segment in the global market. Cone-beam computed tomography has gained prominence in North America, which is one of the leading regions in the global dental imaging equipment market. According to FMI, companies leading the charge to CBCT include Danaher Corp., Planmeca Oy, Carestream Health, and Dentsply Sirona. For more information, contact: http:// www.futuremarketinsights.com/reports/ sample/rep-gb-861
Catherine Wilson Editor
May 2017
5
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NEWS BRIEFS
Canadian Budget’s Health Care Funding Good News for Dentistry The Canadian Dental Hygienists Association (CDHA) supports the federal government’s enhanced investments in the Territorial Health Investment Fund, as outlined in Budget 2017. This funding will improve access to health services in the territories – including children’s oral health services – and will reduce reliance on medical transport outside the region for treatment. A total of $108 million will be added to the fund over four years, with $54 million allocated to Nunavut, $28.4 million to the Northwest Territories, and $25.6 million to Yukon. Dental hygienists are uniquely positioned to deliver preventive and therapeutic oral health services directly to individuals in northern communities. In recent years, the CDHA has partnered with the Government of Nunavut to provide onsite preventive and therapeutic dental hygiene services to children between the ages of 0 and 7 residing in 19 Nunavut communities. Preliminary data from the project show that the work of dental hygienists in the North is helping to alleviate the needless pain and suffering experienced by these children.
Good Oral Hygiene and Nutritious Diet are Directly Linked Dental hygienists see first-hand how poor diet and nutrition can affect a person’s oral and overall health. Foods high in sugar, such as candy, sweet baked goods, and carbonated drinks may contribute to tooth decay and periodontal disease, which in turn has been identified as a risk factor for more serious illnesses, such as diabetes, lung and heart disease, and stroke. Acidic foods like tomatoes, pickles, and citrus can lead to erosion of tooth enamel. For more information, visit www.dentalhygienecanada.ca.
PST on Insurance Premiums Could Limit Dental Care Access Dental hygienists raised concerns that adding the PST to health insurance premiums will reduce access to dental care in Saskatchewan at a meeting with MLAs in Regina on Monday. The Saskatchewan Dental Hygienists Association organized the meeting to enlighten MLAs on the rate of oral disease in the province. Association executive director Kellie Waston said the group was raising concerns about the provincial budget decision to apply the six percent PST to health insurance premiums. Insurance premiums will have the PST applied starting July 1st – adding $157.9 million to the treasury this year.
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oralhygiene A NEWCOM Business Media Publication
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OFFICE: Located at 80 Valleybrook Drive, Toronto ON M3B 2S9. Telephone 416-442-5600, Fax 416-510-5140. Oral Hygiene serves dental hygienists across Canada. The editorial environment speaks to hygienists as professionals, helping them build and develop clinical skills, master new products and technologies and increase their productivity and effectiveness as key members of the dental team. Articles focus on topics of interest to the hygienist, including education, communication, prevention and treatment modalities. Please address all submissions to: The Editor, Oral Hygiene, 80 Valleybrook Drive, Toronto, ON M3B 2S9.
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May 2017 www.oralhealthgroup.com
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ORAL HYGIENE
SAVING LIVES… What’s in Your Toolkit? Jo-Anne Jones
As a successful entrepreneur and international, award winning speaker, Jo-Anne has been selected as one of DPR’s Top 25 Women in Dentistry and is a returning 2017 Dentistry Today CE Leader for the 7th consecutive year. Jo-Anne is president of an educational and clinical training company and a sought after writer for leading dental journals and publications across the U.S., Canada, and the UK. Her frank and open style of lecturing complemented by the provision of clinical resources has earned many loyal followers. She may be contacted at jjones@ jo-annejones.com
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A
pril and Oral Cancer Awareness Month has just passed; a time when our attention once again turned to this insidious disease. Unfortunately due to over two-thirds of oral and oropharyngeal cancers being discovered in the later stages, only slightly more than half will be alive in 5 years.1 As a dental hygienist, it is not only our responsibility but a requirement of our standards of practice to perform a thorough visual and tactile extraoral and intraoral examination. There have been significant changes that have occurred in the landscape of oral and oropharyngeal cancer. There are two distinct etiologic pathways that exist; one the historical risk factors of smoking and alcohol and secondly, the more recent escalating viral transmission related to the Human papillomavirus (HPV). The Human papillomavirus is one of the most common sexually transmitted viruses. In fact, the CDC states that almost every sexually active adult will have a HPV infection in their lifetime. 2 The Special Topic feature of the 2016 Canadian Cancer Statistics was dedicated to HPV-associated cancers3 (Figure 1). The 2016 HPV topic feature was driven by a media release recognizing that HPV was not just a threat to women {i.e. cervical cancer} but that ‘mouth and throat cancers are rising sharply in men.’4 HPV-associated cancers of the mouth and throat are said to surpass the rate of cervical cancer in females. 5 Presently in Canada, 1 in 3 HPV-associated cancers are diagnosed in men with 4 out of 5 oral and oropharyngeal HPV-related cancers being diagnosed in men. Between 1992 and 2012, HPV-related oral and oropharyngeal cancers have experienced a dramatic increase; 56% in males and
17% in females.4 Eighty percent of HPV-related oropharyngeal cancers are diagnosed in men. 3 Many will not be aware that they have even been infected with the virus and will clear the infection within two years with no evident physical symptoms. This is the typical pathway for the vast majority if they possess a healthy functioning immune system. However for some who have contracted a high risk strain of the virus and have been plagued with persistent infection, the transformation to a malignancy is conceivable.
WHAT ARE THE ‘TOOLKIT’ ESSENTIALS? The first essential in your ‘toolkit’ is an unwavering resolve to perform a thorough and effective visual and tactile extraoral and intraoral examination on every adult annually. Careful examination and palpation of the head and neck lymph nodes are critical aspects of the extraoral examination. A fixed, palpable, hard, non-tender node may be the first sign of an abnormal development that is not clinically visible or accessible by tactile examination. Typically and in the broadest terms, an infection-related node is most often tender, mobile and associated with a known or recent illness. “The incidence rate of thyroid cancer is the most rapidly increasing incidence rate among all major cancers not only in Canada but worldwide.”6 At the present time there is speculation to suggest that more frequent use of superior diagnostic capabilities of medical technology is allowing earlier stage, asymptomatic thyroid cancers to be diagnosed.7 Another suggested etiologic contributor to the escalation of thyroid cancer is the expo-
May 2017 www.oralhealthgroup.com
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ORAL HYGIENE sure to diagnostic ionizing radiation that has increased over time promoting the initiation of tumour development. 8 Iodine intake is also under investigation as a possible contributing factor however much debate makes the confirmation of this etiologic factor uncertain at this time.9 Observation and palpation of the thyroid gland may be done by instructing the client to swallow observing the superior movement. A glass of water may be required to assist the client in swallowing. Comparison of the two lobes may be accomplished by standing to the side of the client and “instructing the client to bend the neck forward and laterally toward the side being examined. Using manual palpation, place one hand on the side on the trachea, then with the other hand gently displace the thyroid tissue to that side of the neck and manually palpate the gland.”10 Repeat for the other side. The thyroid may also be examined with the client in a supine position allowing for protrusion of the thyroid anatomy. With the close proximity of the thyroid gland to the skin, the supine position affords a visual inspection of the neck area for both enlargement and/or asymmetry. All areas of the oral cavity need to be visually examined coupled with tactile palpation in a systematic order. The order may be as follows; the lips, labial and buccal mucosa, gingival tissues, tongue (dorsum, lateral borders and ventral surface), floor of the mouth, palatal tissues and oropharynx including uvula and tonsillar areas. The intraoral high risk anatomical areas include the palate, floor of the mouth, tongue and oropharyngeal areas. The palate must be visually examined and palpated. Bimanual palpation of the floor of the mouth is the only way an area of induration may be discovered (Figure 2). Visual examination is not sufficient to examine this very high risk anatomical area of the oral cavity. The tongue is a well-known potential lesion site and warrants careful examination as well. Visual and tactile palpation of the dorsum, lateral borders and the ventral sur-
FIGURE 1
face of the tongue are required (Figure 3). The v-shaped groove on the dorsum of the tongue referred to as the sulcus terminalus separates the oral cavity from the oropharyngeal region. To examine the oropharyngeal area it is recommended to place the mouth mirror (mirror side down) or tongue depressor on the midline of the dorsum of the tongue instructing the client to take a deep breath in and say ‘ah’. Visual access to a number of these high risk
FIGURE 2
FIGURE 3
areas has always presented its challenges. Once again, superior visual acuity with the use of magnification and headlights may make the difference between seeing something and missing it entirely (Figure 4). A new product to emerge is an all-in-one illuminated tongue depressor, Throat Scope™. The device enables illumination right at the site of examination whether it be viewing the floor of the mouth, retracting the tongue or depressing the tongue to gain visual access to the posterior regions of the oral cavity and oropharynx. Throat Scope™ also enables the client to perform a self-examination of the
May 2017
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ORAL HYGIENE
FIGURE 4
oral cavity illuminating many of the difficult areas to visually access (Figure 5). The second essential in your ‘toolkit’ is knowledge. As primary oral health care professionals, dental hygienists have the capability along with the responsibility to employ oral cancer screening examinations. A systematic, thorough and effective screening has a profoundly positively impact on the ability to discover oral cancer in its earliest stages. Current knowledge of palpation techniques as well as identifying risk factors, signs and symptoms related to both non-HPV and HPV-associated oral and oropharyngeal cancer is critical to meet the needs of today’s population. Symptoms of oral cancer to be aware of include however are not limited to; • Bleeding in the mouth or throat or sore that does not heal within 14 days including under a denture or appliance • Discoloration of the soft tissues; red, white, mixed or black • An indurated or hard area, lump or thickening detectable visually or through palpation of soft tissues • Continual lymphadenopathy; firm, fixed, non-tender and present for more than two weeks with no known etiology • Unexplained weight loss The more subtle symptoms that may accompany HPV-related oropharyngeal cancer include however are not limited to; • Recurrent sore throat or persistent infection that does not resolve completely within 2 weeks or respond to antibiotics • Hoarseness or change in speech; slurred speech • Tongue that tracks to 1 side when stuck out • A unilateral earache that persists • Continual lymphadenopathy; firm, fixed, non-tender and present for more than two weeks with no known etiology • A feeling like something is caught in the throat; continual cleaning of the throat
10
Our responsibility does not end in our chairside conversation and protocols. It is our mandate to translate knowledge to our dental hygiene clients. Does your practice have sufficient educational materials to empower your client to understand the importance of both the annual head and neck examination including the oral cancer screening as well as doing a periodic self-examination? The CDHA has developed a number of resources
FIGURE 5
for your practice as well as educational materials for your client. Links to downloadable materials both from the CDHA and others are listed at the end of the article. The Oral Cancer Foundation provides a number of marketing tools that inform your clients that your practice is dedicated to performing an oral cancer screening and making every attempt to discover oral cancer in its earliest stages (Figure 6). The Oral Cancer Foundation is a non-profit charitable organi-
FIGURE 6
zation dedicated to providing current scientific literature to the dental community, supporting oral cancer patients, their families, and contributing to funding ongoing research. The 3rd essential in your ‘toolkit’ is improving the oral cancer screening examination through the exploration of employing an adjunctive screening device to complement the white light examination. Adjunctive screening devices employing direct fluorescence visualization such as VELscope, OralID or Identafi enable the clinician to
May 2017 www.oralhealthgroup.com
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ORAL HYGIENE
FIGURE 7
and emailing as required through the use of a magnet attached iPod touch (Figure 7). Lastly, conduct your oral cancer screening as if a life depended on it. Your commitment to performing an effective and thorough extraoral and intraoral examination may save a life. There is no greater gift in this world that one human being can give to another.
view tissue changes beneath the surface where white light examination is unable to assist. With over two-thirds of oral cancers discovered in the later stages, it is clear that we need to utilize every capability possible to discover oral cancer in its earlier stages. The VELscope Vx system employs seamless smart technology capturing images, storing
Acknowledgements: The author would like to acknowledge and thank the Canadian Dental Hygienists Association for permission granted to use images from the online course “Oral Cancer Screening for Today’s Population” for educational purposes. Disclosure: The author serves in the capacity as an opinion leader/consultant for Orascoptic, LED Dental Inc. and in an advisory position for Throat Scope.
References:
Resources:
1. Oral Cancer Foundation. http://oralcancerfoundation.org/facts/ 2. Centers for Disease Control and Prevention. Human Papillomavirus (HPV) https://www.cdc. gov/std/hpv/stdfact-hpv.htm 3. Canadian Cancer Statistics 2016. Special Topic HPV-Associated Cancers 4. Canadian Cancer Society. HPV not just a threat to women: mouth and throat cancers rising sharply in men. Media Release October 19, 2016. https://www.cancer.ca/en/about-us/for-media/ media-releases/national/2016/canadian-cancerstatistics-2016/?region=bc 5. Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer in the United States. J Clin Oncol 29(32):4294-301, 2011. 6. Pellegriti G, Frasca F, Regalbuto C, Squatrito S, Vigneri R. Worldwide increasing incidence of thyroid cancer: update on epidemiology and risk factors. J Cancer Epidemiol. 2013;1–10. 7. Kent WD, Hall SF, Isotalo PA, Houlden RL, George RL, Groome PA. Increased incidence of differentiated thyroid carcinoma and detection of subclinical disease. CMAJ. 2007;177(11):1357–61. 8. How J, Tabah R. Explaining the increasing incidence of differentiated thyroid cancer. CMAJ. 2007;177(11):1383–4. 9. Zimmermann MB, Galetti V. Iodine intake as a risk factor for thyroid cancer: a comprehensive review of animal and human studies. Thyroid Research 20158:8 10. Dental Hygiene Theory and Practice. 2nd Edition. Darby ML, Walsh MM. Extraoral and Intraoral Clinical Assessment, Ch. 12.
CDHA Video – What to expect from an oral cancer screening examination http://www.dentalhygienecanada.ca/DHCanada/Your%20Oral%20Health/ Oral_Cancer_Awareness/DHCanada/Information/ Oral_Cancer.aspx CDHA Fact Sheet and Quick Quiz http://www. dentalhygienecanada.ca/pdfs/education/OCS_ FactSheet_2015.pdf CDHA Oral Cancer Early Detection Flyer http://www.dentalhygienecanada.ca/DHCanada/ Your%20Oral%20Health/Oral_Cancer_Awareness/ DHCanada/Information/Oral_Cancer.aspx CDHA Oral Cancer Screening for Today’s Population booklet - http://files.cdha.ca/Education/Courses/Oral-Cancer-4page-booklet.pdf CDHA Oral Cancer Screening for Today’s Population (2015) – Online self-study http://www.cdha.ca/ cdha/Education/Online_Courses/Oral_Cancer_ Screening_for_Today_s_Population/CDHA/Education/Courses/Oral_Cancer_Screening.aspx Oral Cancer Foundation Information Resource http://oralcancerfoundation.org/wp-content/uploads/2017/03/Oral-Cancer-and-HPV-Facts-2017. pdf Health Canada ‘SMILE’ booklet – To obtain printed copies of the document (limit of 50 copies per order), contact publications@hc-sc.gc.ca Lexi-Comp Reference Library “Oral Soft Tissue Diseases” www.lexi.com/dentistry (Promo code: RDHC01) Oral Cancer Foundation professional products http://www.ocfstore.org/Professional_ Products_s/2.htm http://www.velscope.com/education/downloadscenter/
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ORAL HYGIENE
ORAL MALODOR:
Innovative Strategies to Measure, Learn and Improve Jo-Anne Jones
14
How Is My Breath? The immense concern of the general population towards halitosis or oral malodor is very real. This is reflected in the North American multi-billion dollar cosmetic fresh breath product portfolio aimed to help the consumer treat the condition. “Up to 50% of the U.S. {general} population reports that their own ‘bad breath’ has concerned them during some point in the course of their lifetime. Half of this group is indeed likely to have an ongoing sporadic or a chronic breath malodor problem.”1, 2 The public often make numerous daily, yet ineffective attempts to cover up this social problem with excessive brushing, mouth rinsing, use of mints and flavored chewing gum. The social stigma that oral malodor presents is a key opportunity for the dental hygienist to engage in dialogue with the dental hygiene client beginning with communication pertaining to possible etiologic pathways. The etiologic factors are quite diverse and represent a wide gamut spanning from poor or ineffective daily oral self-care measures to systemic disease. Both intrinsic and extrinsic pathways have been identified that contribute to oral malodor. These include the oral cavity, oropharynx, nasopharyngeal areas, respiratory tract, gastrointestinal diseases and disorders, xerostomia and odor causing foods, fluids and medications. “Historically education has focused on systemicbased malodor conditions. However, 80% to 90% of malodor originates from oral cavity.”3 “The source of 90% of cases is the oral cavity such as poor oral hygiene, periodontal disease, tongue coat, food impaction, unclean dentures, faulty restorations, oral carcinomas, and throat infections.”4 The tongue is a prominent anatomical site accounting for the majority of oral malodor. Determining the etiologic factors will help
direct the management pathway. For example, the dental hygienist has a prime opportunity to inform a client of the relationship with oral malodor if the client is taking one or more of the over 400 prescription drugs that induce xerostomia. Counselling and product recommendation to combat the effects of xerostomia and the potential environment for subsequent malodor would be indicated. This dialogue can occur during the medical history and may provide a more natural segue into a meaningful conversation rather than trying to initiate the conversation on its own. The principle components of oral malodor are volatile sulfide compounds (VSC) being mainly hydrogen sulfide, methyl mercaptan and dimethyl sulfide. Both hydrogen sulfide and methyl mercaptan account for about 90% of the volatile sulfur compounds found in oral malodor. These compounds result from the proteolytic degradation by predominantly anaerobic Gram-negative oral microorganisms of various sulfur-containing substrates in food debris, saliva, blood, and epithelial cells. 5 Research validates the cause of the oral malodor is directly related to the metabolic activities and breakdown of gramnegative anaerobic bacteria. Microorganisms specifically identified with both gingivitis and periodontitis are connected with the production of large amounts of VSC. “The presence of B. forsythus, P. gingivalis and P. intermedia influenced the production of VSC. Specifically, the presence of B. forsythus in subjects with periodontitis was strongly correlated to the concentration of VSC in mouth air.”6 Research has also brought to light the role oral malodor plays in the progression of periodontal infections;7 the point being that both oral malodor and periodontal disease are interconnected.
May 2017 www.oralhealthgroup.com
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ORAL HYGIENE
FIGURE 2
HISTORICAL ANALYSIS OF ORAL MALODOR
One of the most reliable methods of detecting oral malodor is our ‘sense of smell’. Using this method for evaluative purposes presents its obvious discomfort for both the clinician and the client. The ability to develop a device with the accuracy and sensitivity of the human nose has been a challenge to the research community. 8 The Halimeter ® is an internationally recognized instrument for measuring oral malodor (Figure 1). The Halimeter was traditionally used as a measuring device in dental research studies to assess VSC levels however FIGURE 1
is now used by over 3,000 dentists in private practice.9 Noteworthy contributions include leaders in our dental hygiene community such as Anne Bosy, RDH, BSc, MS, Med, recognized internationally as a scientist, researcher and inventor who dedicated 15 years of practice to the Fresh Breath Clinic which operated in Toronto, Canada. Continual product innovations are emerging on the consumer markets; however, are they simply masking the problem and not encouraging healthy oral hygiene habits that are going to effectively address the issue? The multi-faceted complex nature of halitosis coupled with the hesitancy for the dental hygienist to approach the subject has resulted in a distinct lack of integration of fresh breath protocols both chairside and for self-care.
MEASURE, LEARN AND IMPROVE Philips Oral Healthcare, a prominent leader in innovative oral health solutions, diligently went to work on addressing this global issue of public concern over breath quality. The impetus behind this was fueled by the knowledge that the type of bacteria responsible for oral malodor is also associated with other
oral health problems. It is a global concern that goes far beyond the social stigma of ‘bad breath’. “How is my breath?” Now we have an opportunity to provide an accurate response to this question. Philips has recently launched the Philips Sonicare Breath Care system being the first digitally connected complete breath management system utilizing Breathometer™ sensor technology. The ‘smart’ Bluetooth® technology integrates with the free Philips Sonicare app to analyze breath in 30 seconds with professional accuracy displaying real time breath measurements of VSC syncing data to track breath quality and oral care habits over time. How does it work? The sensor inside the breath analyzer employs professional detection technology to detect hydrogen sulfide, methyl mercaptan, and dimethyl sulfide VSCs and reports results in parts per billion (0-500PPB). It is calibrated to replicate professional breath quality measurement devices used in laboratories and dental offices. Data tracking then has the ability to provide tailored tips and personalized insights to educate our clients as to how to manage their overall oral care routines to maximize outcomes. The Philips Sonicare Breath care system includes the Philips Sonicare Breath analyzer which works with the Philips Sonicare app experience with coaching and education designed by dental professionals, and the Philips Sonicare TongueCare+ tongue brush head and spray (Figure 2). The TongueCare+ tongue brush head is a soft silicone brush containing 240 microbristles optimally designed to remove bacterial biofilm from the tongue’s complex surface. The brush head conveniently transforms the Sonicare toothbrush handle into a sonic-powered tongue cleaner employing the Sonicare technology of 31,000 strokes per minute. The Breath Rx tongue spray is an alcohol free spray containing 0.09% CPC (cetylpyridinium chloride) and, Zytex. Zytex is a proprietary formula of antibacterial eucalyptus, thymol oils and odor-neutralizing zinc gluconate. The com-
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ORAL HYGIENE
FIGURE 3
illustrate how oral care habits influence one of the leading social concerns being oral malodor, we have now opened the door to internal motivation and change behavior. How is my breath? Empower your dental hygiene client to measure, learn and improve being confident in the management of oral malodor and the attainment of fresh breath.
FIGURE 4
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bined use of both the mechanical properties of the tongue care brush head and the chemical action of Breath Rx tongue spray effectively removes debris and kills 99% of oral malodor bacteria* resulting in the neutralizing of VSC gases. A clinical study was conducted to investigate the effectiveness of TongueCare+ (TC) coupled with a sonic powered toothbrush handle in combination with an antibacterial tongue spray (BreathRx) containing 0.09% cetylpyridinium chloride and 0.7% zinc gluconate.10 Inclusion criteria for study participants in this cross-over clinical investigation were the identification of oral malodor exceeding normal thresholds. The study methods consisted of four treatment arms with a one week period in between. Malodor levels and bacterial density were monitored up to 6 hours. The results of this clinical investigation demonstrated that the combined use of a the sonic-powered tongue cleaning brush head used in conjunction with the antibacterial tongue spray resulted in the ability to deliver six hours of fresh breath following a single-use (Figure 3). In conclusion, we literally have an opportunity now to revolutionize behavioral modification (Figure 4). If we are able to tangibly
References: 1. Lee SS, Zhang W, Li Y. Halitosis update: a review of causes, diagnoses, and treatments. J Calif Dent Assoc. 2007; 35(4):258-60, 262, 264-8. 2. Nachnani S. Oral malodor: Causes, assessment, and treatment. (26-28, 30-21 ;). Compend Contin Educ Dent. 2011; 32:22–24. 3. Bernie, KM. Contributing author to Mosby’s Dental Hygiene Concepts, Cases and Competencies. Oral Malodor Diagnosis and Management. Mosby’s Dental Hygiene, 2nd Edition. Chapter 38; p.720-734. Mosby Elsevier. 2008. 4. Aylikci BU, Colak H. Halitosis: From diagnosis to management. J Nat Sci Biol Med. 2013 Jan-Jun; 4(1): 14-23. 5. CortelliI JR, Dourado M, BarbosaII S, et al. Halitosis: a review of associated factors and therapeutic approach. Oral Res. vol.22: supl.1 São Paulo Aug. 2008. 6 . Awano S, Gohara K, Kurihara E, Ansai T, Takehara T. The relationship between the presence of periodontopathogenic bacteria in saliva and halitosis. Int Dent J. 2002; 52 Suppl 3:212-6. 7. Morita M, Wang HL: Association between oral malodor and adult periodontitis: a review, J Clin Periodontol 28:813-819, 2001. 8. Eli I et al: Self-perception of breath odor, J Am Dent Assoc 132:621-626, 2001. 9. https://www.halimeter.com/the-halimeter-measure-bad-breath-scientifically/ 10. Saad S, Gomez-Pereira P, Hewett K, et al. Daily reduction of oral malodor with the use of a sonic tongue brush combined with an antibacterial tongue spray in a randomized cross-over clinical investigation. J Breath Res. 2016 Feb 12; 10(1):016013
*In a lab study Disclosure: Jo-Anne Jones works in the capacity of a Key Opinion Leader with Philips Oral Healthcare.
May 2017 www.oralhealthgroup.com
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SYMPOSIUM IMPLANT COMPLICATIONS & INNOVATIONS
JUNE 2-3, 2017
REGISTER NOW! LOCATION: BMO Institute for Learning 3550 Pharmacy Ave. Toronto, ON Friday & Saturday Sign in : 8:00–8:30 am Lectures: 8:30 am–5:00 pm
DAY ONE SCHEDULE Doctors Session 8:00-8:30 am 8:30- 9:00 am 9:00-9:45 am 9:45-10:30 am 10:30-11:15 am 11:15- 12:00 pm 12:00-1:30 pm 1:30-2:15 pm 2:15-2:45 pm 2:45-3:15 pm 3:15-4:15 pm 4:15-5:00 pm
9:45-10:30 am 10:30-11:15 am 11:15- 12:00 pm 12:00-1:30 pm 1:30-2:15 pm 2:15-3:00 pm 3:00-4:15 pm 4:15-5:00 pm
+ HST
195
$
+ HST
Dr. Mark Lin Dr. Mark Lin Dr. Lesley David Dr. David Chvartszai Dr. Joseph Fava Dr. Izchak Barzilay Dr. Izchak Barzilay Dr. Romeo Paculanan Multiple Experts Multiple Experts
To register contact Gina Mazza at 416.825.3500 / 1-844-440-8433 / gina@tideinc.ca
WORKSHOP 2: Peter Barry $195 Powerful Treatment Consultation Inspire Your Patients – Empower Their Lives WORKSHOP 3: Dr Mark Lin and Dr Romeo Paculanan $495 Immediate Anterior and Posterior Implant Dentistry with Anterior Provisionalization WORKSHOP 4: Dr Mark Lin and Dr Romeo Paculanan $495 Teeth In a Day Treatment Concept, Treatment Planning, Surgical Parameters and Prosthetics
per team member.
Registration/Breakfast Welcome & Introduction A Team Centered Approach to Implant Dentistry – It Takes a Team to Grow the Dream! Tooth Replacements Modalities Advantages/Disadvantages Who’s to Blame? Effective Methods for Predicable Results Patient treatment flow from beginning to end/steps involved for successful outcomes in patient management Lunch/Corporate Exhibits/Presentations Implant health, maintenance, and biologic complications A Team Approach to Dental mplants: The Art of Successfull Implant Treatment Planning and Long-Term Implant Maintenance Sterile Technique & Sterilization Implementation and Integration/Strategic remarks
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WORKSHOP 1: Dr. Goth Siu $495 Implant Prosthetics
per doctor.
Registration/Breakfast Welcome & Introduction Treatment Planning Complications in Implant Dentistry/Innovations Surgical Implant Complications/Innovations Implant success, failure and removal Aesthetic Implant Complications/Innovations Lunch/Corporate Exhibits/Presentations Prosthetic Implant Complications/Innovations Prosthetic Screw Complications/Innovations “Don’t trust what you see, sugar” even salt looks like Expert Panel on “Peri-Implantitis”; aetiologies and management options Expert Panel on “Risk Management In Implant Dentistry”
Team Members 8:00-8:30 am 8:30- 9:00 am 9:00-9:45 am
895
$
DAY TWO
Gina Mazza Peter Barry Dr. Joseph Fava Dr. Romeo Paculanan Dr. Lesley David
Dr. David Chvartszaid Dr. Tina Kokosis
WORKSHOP 5: Dr. Joseph Fava $495 Surgical Implant Precision Utilizing Dynamic Guided Concept WORKSHOP 6: Dr. Jon Suzuki $995 Crown Lengthening and Periodontal and Flap Surgery (hands-on)
Vavi Bohbot Peter Barry
TORONTO INSTITUTE FOR DENTAL EXCELLENCE
2017-04-28 4:03 PM
BUSINESS MANAGEMENT
EMBEZZLEMENT – What Every Brilliant Clinician Should Know David Harris
is the CEO of Prosperident and the world’s foremost expert on financial crimes committed against dentists. David is a CPA, private investigator, and is “dual certified” in fraud examination, being both a Certified Fraud Examiner and Certified in Financial Forensics.
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ou believe you have been blessed with the dream employee! This person has stood closely beside you for years, fighting for the success of your practice, arriving early and staying late and refusing to take vacations because the practice simply could not function without them. This person displays all the traits of an ideal employee. Imagine how you would feel upon discovering that your dream was really a nightmare. While you focused on building the perfect office by freely giving trust, praising positive performance, and giving financial rewards, your dream employee had devised a complicated embezzlement scheme and had robbed you of hundreds of thousands of dollars. There are many practice owners who no longer need to imagine this scenario because embezzlement became their reality. Beliefs that they were immune from embezzlement because “my team would NEVER steal from me”, “my CPA audits my books for embezzlement”, and “if someone were stealing from me I WOULD KNOW IT” have been harshly extinguished. They have joined the 60% of practice owners who are embezzled during their careers. “Illusory Superiority” is a basic human characteristic where we overestimate our capabilities relative to those of others. It is tempting to believe that your extra years of education and probably superior intellect provide an advantage over a would-be embezzler. However, your adversary is more adaptive, cunning, and committed to their personal well-being than you realize. They are burdened by their personal demons, have constructed a self-serving rationalization,
and now see your practice as their personal cookie jar.
EMBEZZLEMENT BASICS Prosperident is the world’s largest dental embezzlement investigation firm. We are consulted on hundreds of embezzlement matters annually, and this work provides insight into embezzlement unavailable to anyone else. Embezzlement is rampant in dentistry; published statistics suggest that 60% of dentists will eventually be victims1. Our own files suggest that, on average, embezzlement goes undetected for almost two years and that the amount stolen until discovery averages $109,000. Prevention of embezzlement is a myth and the ideas that one is immune or that certain dentists are more prone to embezzlement than others are dangerous. For example, many small-town practitioners mistakenly believe embezzlement is an urban issue. Dentists with long-term staff or those who pay their staff above the local going rate often also have misplaced comfort.
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HOW EMBEZZLERS THINK Premeditated crimes have three preconditions – motive, rationalization, and opportunity. An embezzler’s motivation is obviously outside the practice owner’s control. Some thieves are in desperate financial situations and steal to meet family needs. Others steal believing that you (and probably society) have failed to reward their talents properly, and a third group gets pleasure from successful risk-taking. Rationalizing embezzlement is never difficult, and the perceived income disparity between doctor and staff is frequently seized as justification for embezzlement. Others determine that the doctor is fleecing patients or insurance companies, and this makes their own crimes appropriate. Of the three pre-conditions, “opportunity” is misunderstood most frequently by casual observers. Intuitively, reduced opportunity should result in less embezzlement. In fact, opportunity works differently. It is a binary factor and either exists or does not. As long as at least some opportunity remains, so does the
potential for embezzlement. We believe that there is no reasonable way to eliminate opportunity, and accordingly, it exists in every practice. Drawing a correlation between opportunity and probability of victimization overlooks a basic difference between embezzlement and other crimes. Criminals in most economically motivated crimes can choose their victims. Therefore, a reduction in opportunity (for example, an alarm system) causes criminals to divert to a less-defended victim. However, alarm systems do not prevent crime (i.e. convert thieves to honest people); they simply redirect crime to different victims. In contrast, embezzlement normally has a pre-ordained victim – you. A reduction in opportunity will not typically cause a wouldbe embezzler to leave your employ and wait a year or more to acquire sufficient knowledge and trust to steal from their new employer. With opportunity always present, the true determinants of vulnerability are motivation and rationalization, which are almost completely out of practice owner’s control.
BUT WE HAVE A STRONG SYSTEM OF CONTROLS, AND OUR CPA LOOKS AT OUR BOOKS!
BUSINESS MANAGEMENT
Our experience indicates that embezzlement occurs at the same rate for well-organized, procedure-laden practices as for a solo practitioner who has not reviewed bank statements in years. The misconceptions flow from a flawed understanding of criminal thinking.
Wendy Askins
is the Supervising Examiner of Prosperident’s Orthodontic Department. In addition to her MBA and undergraduate studies in psychology and criminology, she has an encyclopedic knowledge of orthodontic practices after more than 25 years of experience. Wendy is a Certified Fraud Examiner.
Now we are back to discussing “Illusory Superiority”. The skills utilized to master your clinical craft can cause you to overestimate positive qualities and underestimate weaknesses. You may be an excellent clinician and business owner, but never forget that you have an adaptive opponent who is able to perceive (and counter) your strategy. Every embezzler performs the same exercise – they survey their environment, observe the controls in place, and design an embezzlement that overcomes or bypasses those controls. Whether you practice solo or own a multi-site group practice, thieves have more embezzlement pathways than you could ever hope to block. The impact of implementing more or different controls is simply to prompt adaptation by the embezzler, and every new rule or procedure you implement carries a financial or productivity cost. With respect to the involvement of your
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BUSINESS MANAGEMENT
accountants, they normally are hired to perform a “Notice to Reader” engagement. This involves the transmogrification of your information for third parties (e.g. your bank or Canada Revenue Agency), with no analytical review, and certainly no search for embezzlement. And even if you select a higher level of accountant involvement (a “Review Engagement” or an Audit), these are neither designed nor oriented to catch embezzlement. Research from the ACFE suggests that only about 3.8% of all embezzlement is detected by external accountants2 , so clearly accountants do not play a major role in embezzlement control.
TEN GREAT IDEAS If the series of controls you have implemented and the involvement of your accountants are unlikely to stop embezzlement, is stealing therefore inevitable? What can be done to mitigate this problem? We can tell you that there is virtually nothing that will deter an embezzler from committing their first criminal act. A realistic goal is to catch embezzlement quickly to reduce financial damage. The challenge is the breathtaking variety of embezzlement methodologies that exist; we have observed hundreds of variations, and we keep seeing new twists. Here are ten things that take very little time and will minimize your risk: DAILY: 1. Print computer reports yourself. This prevents “selective reporting”. 2. Review and initial day-end reports. Retain for three years or more. For many embezzlement patterns, comparing these “original” reports to ones printed later helps us piece the puzzle together.
MONTHLY: 3. Review alarm system logs to see if employees are visiting at unusual times. 4. Review receivables listing and compare with the previous month (to ensure that amounts are aging properly). A frequent symptom of embezzlement is high receivables. 5. Review the modified transactions report (its exact name depends on your software). 6. Have bank and credit card statements sent to your house. 7. Use Prosperident’s Monthly Monitoring Spreadsheet to ensure that all receipts are deposited. AS NEEDED: 8. Prosperident’s Embezzlement Risk Assessment Questionnaire (see discussion below). 9. Mandatory vacations and cross training for all staff. 10. Skepticism when hiring (53% of resumes have some amount of untruth 3).
CONCLUSION We would like to leave you with a simple thought – research suggests that, regardless of how someone embezzles, behavior when stealing is predictable. The ACFE reports that 91% of embezzlers display at least one “embezzlement behavior” and 57% display two or more indicators. The best way to spot embezzlement is therefore to monitor employee behavior. A great tool is our affordably-priced Embezzlement Risk Assessment Questionnaire, which provides a systematic way to evaluate your risk. It is available on our website. So take some simple and time-efficient steps, and let’s hope that you never have to deal with that awful feeling of being victimized by a trusted, long-term employee.
1 See, for example “Dental Embezzlement: “It Can’t Happen to Me!”, 2 The Association of Certified Fraud Examiners 2016 Report to the Nations http://www.acfe.com/rttn2016
retrieved Feb 16, 2017
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3 http://www.statisticbrain.com/resume-falsification-statistics/ retrieved Feb 16, 2017 4 ibid
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PRACTICE MANAGEMENT
THE CRITICAL IMPORTANCE OF TEAM DEVELOPMENT & DYNAMICS IN YOUR PRACTICE Mark Carbonelli
Chief Human Resources Officer of dentalcorp. dentalcorp is focused on acquiring and partnering with leading, growth-oriented general and specialist dental practices across Canada. The unique value proposition allows dentist Partners to retain their clinical and operating autonomy while dentalcorp, as their business partner, provides comprehensive strategic expertise and tactical resources to support their growth. This enables partners to focus their energy on delivering optimal patient care.
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eveloping an effective team can be one of the most crucial aspects of success in a practice. It takes time, as each member brings unique personality traits, preferences, styles and experiences to the team. It is a worthy investment, because once things gel, a team that works together effectively will benefit your practice operations and improve the overall experience for your patients. It is important to remember that word of mouth remains the largest driver of new patient flow. Your patients are very observant to their surroundings and will be more comfortable if they feel they are being treated within a positive environment. I remain an advocate of Bruce W. Tuckman’s model of team development. Tuckman was an authority on group dynamics. He passed away last March, but his four-stage model – Forming, Storming, Norming and Performing – remains a mainstay.
Tuckman’s Stages of Group Development FORMING This is where individuals come together for the first time, with the objective of working towards a common goal. Since it is the first phase of team development, most members are initially engaged, polite and positive. In a practice, this stage may involve team members avoiding conflict and controversy because they are more concerned with gaining the acceptance of their fellow members rather than achieving the team’s goal. It is critical at this time that team members get to know one another in order to remove barriers and
learn about each other’s strengths and build trust. Building trust can include anything from team meetings, training, lunches and celebrating wins as a team. Trust leads to open communication between members, which is tremendously important for the next stage.
STORMING This stage is characterized by testing boundaries as members attempt to establish their preferred roles. This is when conflict can first arise, stemming from different personalities, opinions and values between members which can manifest as power struggles. This is the most delicate stage of the team development process – where teams are most susceptible to failure or dissolution. That’s why a foundation of trust is so important. If members feel they can express their ideas without fear of judgment, they will be more likely to identify where their interests lie. When respect is established and ideas can flow freely, differences of opinion or disagreements can be resolved in ways that benefit everyone and contributes to the team’s collective success.
NORMING This stage marks the development of the team’s mission, values and goals. By establishing these agreed-upon norms, teams are able to set guidelines for appropriate and inappropriate behaviour. They also provide a sense of identity for the team, allowing members to feel aligned and connected to the goals of the group. This can be the time when teams begin to socialize together beyond their specific responsibilities, in attempt to
May 2017 www.oralhealthgroup.com
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PRACTICE MANAGEMENT
get to know one another even better. As a result, order, cohesion, team unity and commitment tend to be very strong during this stage of development.
PERFORMING The performing stage is the most valuable to team success in a practice. At this stage, teams are ideally producing great results, working cohesively and optimizing each memberâ&#x20AC;&#x2122;s strengths. They are able to produce quality work without significant friction. Emphasis is strong toward accomplishment of team goals and members being focused on what is best for the team. Aspiring to reach this stage and remain at it for as long as possible must be a top priority. Maintaining peak performance can be challenging if members join or leave the practice. Such changes in the makeup of a team, including the introduction of new, strong personalities, can bring a team back to the Forming stage. If thereâ&#x20AC;&#x2122;s one single factor which goes the furthest toward a team being effective, all
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members must feel safe from being vulnerable. In other words, they must feel that they are able to express their opinions or feelings without fear of judgment or disrespect. When this is the case, members are able to contribute ideas, brainstorm freely, and develop innovative and creative solutions to challenges facing the practice. Healthy conflict can be a good thing. Differences of opinion can spur thought-provoking and challenging conversations. Respectful disagreement can also increase the ability of team members to be open-minded and considerate of other thoughts and ideas. All of the topics laid out here contribute in equally important ways to the ultimate success and productivity of a team. Once you have determined which stage of team development your practice team is at, reflect on the characteristics outlined above to determine which items you may need to help foster team growth. By striving to develop these values, you are taking essential steps toward having an efficient, high-performing practice team.
May 2017 www.oralhealthgroup.com
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ORAL HYGIENE
MAKING THE SHIFT: Enhancing our Impact Through Oral Systemic Links Sara DeNino Paone, RDH, RNCP
President of Smart Dental Practices, a company dedicated to working with dental teams to advance patients’ oral and overall wellness. Sara’s 20 years experience as a dental hygienist, including the last 10 as a holistic nutritionist, has helped her develop a view that an integrated, whole-person centred approach best serves our patients. Sara is a member of the AAOSH, IONC, ODHA, CDHA, CHHO, as well as the Complete Oral Health Movement. She can be reached at www.smartdental practices.net
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n March 29, the Oral Wellness Learning Institute for Dentistry (OWL) where I serve as the educational director, had the privilege to assemble an amazing group of dental and medical practitioners and advocates. Our guests included representatives from Diabetes Canada, the CDHA, Sleep Disorders Dentistry, as well as naturopathic doctors, researchers, dentists, and dental hygienists. Sunstar, a trusted partner of OWL, graciously served as our host. I was so grateful that such an esteemed group was ready for the message that there is a new horizon for many of our dental practices to consider embracing. A horizon made possible by embracing the science related to oral systemic links. At OWL, we advance a perspective that an understanding of oral systemic links can serve as solid foundation by which you serve your patients. We base our approach on two simple, but critical, insights: 1. That there is a direct relationship between our oral and overall health 2. That an understanding and integration of these oral systemic links has the power to transform our practices and our patients’ perspectives towards their care and health I have practiced with these insights in mind for over two decades. As I said to the group on March 29, I can feel a shift happening in dentistry. I can see with my patients, my consulting clients, and OWL attendees, an openness to the opportunity they have to advance
overall health through dental health. I know that my patients understand the value of their dental care to their overall health by the compelling results they have experienced and their eagerness to pursue care that is beneficial to their health. I have seen dentists and entire practices inspired by the idea that they can serve as preventative healthcare hubs for their patients in ways that benefit their patients and their practices. I have seen the power of this perspective among attendees at OWL who have achieved a complete new understanding of what they can achieve as healthcare providers. And I have even seen medical practitioners enlivened to what dentistry can bring to their patients. But today my focus is on you. I wonder how many readers of Oral Hygiene magazine and their practices are aware that in May 2000, the US Surgeon General stated that “oral health and general health should not be interpreted as separate entities. Oral health is integral to general health.” I wonder how many readers realize that cardiovascular disease is the second leading cause of death in Canada, with costs to our healthcare system in the hundreds of millions, and that Level A evidence exists that periodontal disease is independently associated with arterial disease. I wonder how many appreciate that diabetes, which costs billions to our healthcare system annually and great distress for our patients, is also correlated with periodontal disease. For example, if 26% of a patient’s pockets are 5mm deep or greater or there are 4 or more missing teeth, patients have a higher likelihood
May 2017 www.oralhealthgroup.com
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ORAL HYGIENE
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of developing diabetes. I meet hundreds of dental professionals through my work every year. I know that if they understood that the way they practice has the power to transform peoples’ lives, even more so that they already do, that they would leap at the opportunity. That’s why we created OWL – to empower our attendees to step even more fully into their power and responsibility to benefit people’s lives. We teach approaches to communicate and educate our patients about the links between their oral and overall health. We outline and demonstrate the technology and diagnostic tools we use to raise awareness of oral systemic links. We provide a Preventative Oral Wellness Program to guide our patients to prevent the negative correlations that poor oral health can bring to their overall health. And we stress that the way we collaborate with allied medical professionals bears directly on our patients’ overall health. And that’s why I’m writing to you today. Our healthcare system, our patients, our colleagues in dentistry and our allied medical professional colleagues need our preventative healthcare leadership – they need your leadership. I’m asking you to join with the group we assembled on March 29 to make the decision to expand our collective impact on society. I know from my own experience that both the journey and the destination offer tremendous rewards and gratification. If you would like to learn more about OWL please visit our website at www.owldentistry. org or email us at contact@owldentistry.org.
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BOOK REVIEW
DYING FROM DIRTY TEETH Reviewed by Brian Chapnick, DDS
I
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have been a member of a committee tasked with the re-development of a geriatric dental cclinic at Baycrest Hospital in Toronto. Recognising the need , Bayr crest approached the Alpha Omega c Dental Fraternity in Toronto for D our professional expertise with this project. After 4 years of planning, the clinic is in the final stages of development and construction is soon to commence, funded initially with a $500,000 donation from the Toronto Chapter of Alpha Omega Dental Fraternity, additional donations now approaching $500,000 $500 000 and tremendous support from Henry Schein. The real work is just beginning. Part of the process in the development of this clinic has been an examination of the literature to support the need for the clinic. Recently, while attending a programme on geriatric dentistry at the Chicago Mid Winter Meeting, a book â&#x20AC;&#x2DC;Dying from Dirty Teethâ&#x20AC;Ś.. Why the Lack of Proper Oral Care is Killing Nursing Home Residents and How to Prevent Itâ&#x20AC;&#x2122; was suggested as recommended reading. Written by Angie Stone, RDH , published by Indie: Books International, the book is a passionate plea to the medical/dental profession describing how the dentition of individuals can quickly deteriorate due to the inability to maintain adequate oral care in this aged , medically compromised, disabled and cognitively impaired population and emphasized the need for continued vigilant monitoring and care once our patients are no longer able to come to our traditional dental office. The book is not a scientific expose nor a definitive text on geriatric dentistry. Writ-
ten in lay terms, it describes the experiences of the author and provides a goal to strive for. Many of us will some day be members of this rapidly increasing in numbers age group. We may have parents and friends , brothers and sisters, aunts and uncles, even our children and grandchildren who are or will be in this stage of life. Gone are the days when nursing home facilities are filled with residents without teeth and with dentures. Modern science has allowed people to retain many of their own teeth for a lifetime. People have spent 10s of thousands of dollars in a lifetime maintaining their dentitions and have diligently cared for them until they are no longer able to do so. Geriatric care facilities are admitting people who have undergone complex dental treatment, who need our expertise to be able to live their final years in comfort and health. The need is great and becoming greater. The lack of care in senior care facilities leads to rapidly deteriorating dentitions, uncontrolled proliferation of bacteria, and biofilms leading to not only infection and pain in the oral cavity and all its sequelae, but also aspirational pneumonia and other infections that place a severe burden on the patient and health care system. Although the book is thinly referenced as it is not intended as a scientific document, the literature does substantiate much of what the author has described and is a valuable resource. This 88 page book can be purchased from many online sellers in both print and digital format. It is recommended for the entire medical/dental community, hospital administrators, care givers, hospital staff, educators and family members. Find out what you need to know and help solve what is described as an impending crisis.
May 2017 www.oralhealthgroup.com
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Controls plaque, prevents gingivitis and provides relief from sensitivity? Cheers to that!
When you recommend Sensodyne® Complete Protection to your patients, you’ll take comfort knowing you’re helping them with dentin hypersensitivity relief, while providing other gum health benefits, such as plaque removal and reduced gingivitis.
GlaxoSmithKline Consumer Healthcare Inc. Mississauga, Ontario L5N 6L4 ©2017 GSK group of companies or its licensor. All rights reserved.
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BOOK REVIEW
OPEN WIDE:
THE ULTIMATE GUIDE TO TEETH iscover a world of mystery, history, and lore inside your mouth. Yes, we’re talking about teeth! In Open Wide, you’ll find out everything you need to know about your teeth. No matter what you call them, pearly whites, chompers, canines, or tooth fairy bait, teeth play a vital part in your life and have an interesting past. In Open Wide, you’ll find out everything you need to know about your teeth from what ancient civilizations believed about teeth and how scientists use teeth to learn about past societies and solve investigations in the present. With helpful diagrams and tips, you’ll learn how to keep your smile happy and healthy and how to keep your pet’s teeth clean and pristine. What’s in store for our teeth in the future? Read Open Wide to find out.
D
OPEN WIDE: Th Ulti The Ultimate t Guide to Teeth Susan Grigsby Seagrass Press 9781633221239 Pub Date: 5/1/17 $16.95/$21.95 Can. Hardcover 48 Pages 220 Photos Ages 6 to 8, Grades 1 to 3
32
ABOUT THE AUTHOR Susan Grigsby lives in St. Louis, MO. Her children’s books have received awards from groups including The American Farm Bureau, The American Horticultural Society, and the Macy’s Reading is Fundamental – STEAM booklist. A teaching artist, she integrates poetry with social studies, science and the arts in schools, gardens, and museums.
May 2017 www.oralhealthgroup.com
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“…and I lied about flossing.” The truth is, people often lie about how often they floss. For your patients who don’t like to floss, there’s the Waterpik® Water Flosser. It’s easy and recent clinical studies show that the Water Flosser is the most effective way to floss; more effective than string floss, air floss and interdental brushes. Go to Waterpik.com to see clinical research abstracts. Help your patients end the lie by recommending the Waterpik® Water Flosser!
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PRODUCT PROFILE
Crest Pro Health Crest Pro Health isn’t a new toothpaste, but it’s results are something to be reminded of. Stannous fluoride strengthens enamel while forming a protective layer that keeps teeth strong and healthy. Make sure your patients know what they’re looking for when they buy their toothpaste. They need an oral hygiene product that will not just clean, but strengthen their teeth. They need Crest Pro Health. www.crest.com
White Towel Services Take the simplicity of individually packaged towels, heat or cool them, and add your own branding to the package. That’s the opportunity being offered from White Towel Service. Coming in five different scents, including Unscented, these towels are a great tool to have around with your logo and name on them. www.wtowel.com
Plaque HD
Waterpik WaterFlosser
As the first professional plaque-identifying toothpaste, the Plaque HD toothpaste will be a staple part of every oral hygiene routine. With patented Targetol Technology, an all natural agent that will discolour any found plaque. This easy-touse technology will change the way you and your patients brush their teeth every morning, giving them a look at what is in their mouth. 1-888-442-7070
Fight gum disease with Waterpik’s new WaterFlosser, designed to make the seemingly difficult task of flossing a breeze. There are 5 unique tips available for the WaterFlosser, allowing it to be a one-stop-shop item for better oral hygiene. Floss with water, a small pick, or one of the other tips designed for any oral health situation. www.waterpik.com AD INDEX
34
AMD Medicom . . . . . . . . . . . . . . . . . . . . . . . 4, 15, 27
Premier Dental Products . . . . . . . . . . . . . . . . . . . . . 12
Clinical Research Dental . . . . . . . . . . . . . . . . . . . . . 16
SciCan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Crest Oral-B, P&G . . . . . . . . . . . . . . . . . . . . . . . . 7, 23
TIDE – Toronto Institute for Dental Excellence . . . . 19
GSK – GlaxoSmithKline . . . . . . . . . . . . . . . 31, 35, IBC
VOCO Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . OBC
McCaughey Consumer Products Management . . . 29
Waterpik . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Philips Oral Health Care . . . . . . . . . . . . . . . . . . . . IFC
Xlear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Mayy 2017 www.oralhealthgroup.com
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One in four has it.
1
Many don’t know it.
2
They also may not know the oral health consequences.* They’re waiting for your guidance.
Dry Mouth is an oral health concern that affects people on multiple medications the most.3 Yet some people aren’t aware that it’s a problem.2 Talk to your patients about Dry Mouth and how Biotene can help provide relief.† ®
www.biotene.ca
GlaxoSmithKline Consumer Healthcare Inc., Mississauga, Ontario L5N 6L4 © 2017 GSK group of companies or its licensor. All rights reserved. * Dry mouth can disrupt the oral health environment and lead to halitosis, demineralization, and increased caries.4,5 † Mouthwash, Gel and Spray. ‡ As measured in a 28-day clinical study.6 1. GSK data on file. Biotène dry mouth growth opportunity (with Canadian U&A data). July 16, 2014. 2. Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004;38:236–240. 3. Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth, 2nd edition. Gerodontology. 1997;14:33–47. 4. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138:15S–20S. 5. Fox PC. J Clin Dent. 2006;17(Spec Iss):27–28. 6. GSK data on file 2014, RH01986.
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AC Distributors Ltd. Office: 604.278.7442 Axel Kraft International Office: 905.841.6840 Purity Life Health Products Office: 1.800.265.2615
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HYGIENISTS
SAULT STE. MARIE, ON HYGIENIST WANTED
Love your career at Northern Dental Care! Full time position available. Send CV to ashlee@ northerndentalcare.com
DENTAL MARKETPLACE
Contact: Karen Shaw • tel: 416-510-6770 • fax: 416-510-5140 • e-mail: karen@newcom.ca Toll free: CDA 1-800-268-7742, ext 6770 • Toll free: USA 1-800-387-0273, ext. 6770
PRACTICES & OFFICES
MISSISSAUGA, ON
OAKVILLE, ON
FULL TIME Dental Hygienist wanted immediately for a large busy dental practice in Central Mississauga. Minimum 2 years experience preferred. Apply in confidence to ddsmississauga@yahoo.com
Dental office space available. Prime Oakville location. Newly constructed plaza. Great opportunity. Call 416-995-0159 for more details.
ASSOCIATESHIPS
ON THE SHORES OF LAKE HURON, ON
SASKATCHEWAN Are you tired of competition? Are you looking for a busy schedule from day one? Do you want to be welcomed in a community that desperately need your services? Do you want the chance to perform all aspects of dentistry and have the support of a winning team that want to see you successful? Are you flexible and willing to live away from busy city life? If you answered YES to any of the above, drop us a line and let us connect you with the perfect opportunity for you. E-mail: westspiritdental@gmail.com
Fantastic career and lifestyle opportunity! Established Dental Office is seeking a long term associate relationship with a friendly caring GP who possesses exceptional people skills and a strong grasp of clinical dentistry. You will enjoy an excellent team with strong new patient flow. If you love dentistry and enjoy people come interview us for an exciting opportunity to join our team and help us move to the next level. Located in a beautiful rural community on the shores of Lake Huron. Close to a large city with all amenities. Achieve your personal and professional goals. Call today and leave a detailed message at 519-955-4063 or 519-441-1140.
THOMPSON, MB
REGINA, SK
ASSOCIATE – NEEDED IMMEDIATELY!!
Our pediatric dental clinic is currently seeking a highly-motivated associate to join our dental clinic. The ideal candidate would have the opportunity to deal with a variety of kids’ dental cases with the potential for future opportunities to work in an operating room setting. General Practitioners are also welcome to apply. Please send your resume to: sharly@cdwregina.com
Full-time, energetic, detail oriented associate needed immediately for established, busy family practice with high income potential per month. Enjoy a fully booked schedule and ability to reach your goals as a dental professional. Experience preferred. Excellent opportunity. New grads welcome. Living accommodations provided. E-mail cv: thompsondent@gmail.com P: 204-939-0083.
NEWMARKET, ON
WHITBY/OSHAWA, ON
We are seeking an associate for Monday and Wednesdays, Monday 10-6 and Wednesdays 2-8. We are a busy practice in the Heart of Newmarket located on Davis Drive. Please email resume attention of Dr. Croppo – drcroppooffice@rogers.com
The Airport Dental Centre is looking for its next 2 associates. General Dentist and Paedodontist. Work in a multidisciplinary clinic. Experienced and new graduates welcomed. Commute from GTA against traffic to our location. Contact: Dr. Viet Nguyen, Clinic Admin. (airportdentalcentre@rogers.com)
BARRIE, ON
BRAMPTON, ON – Highway 7/Airport Rd
GP WHO DOES ENDO NEEDED IN BARRIE. Looking for a GP who has a lot of experience doing endo and retreatments for an office in Barrie once or twice a month. If interested please email resume to bbashi@yahoo.com
www.oralhealthgroup.com
OHY May17 Complete.indd 37
General Dentist required to perform routine periodontal procedures ie: gingival grafts (from palate preferred), pocket elimination, crown lengthening and gingivectomy. Must be proficient in these periodontal procedures. Please email resume to: 1drbrightsmiles@gmail.com
CALGARY, MEDICINE HAT, AB AND GTA-TORONTO, ON Seeking Full Time General Dentists and Dental Specialists seeking work/ life balance for locations in Calgary, Medicine Hat – Alberta and GTA – Toronto, ON Multi Dentist practice(s) seeking self driven, motivated dentists with great communication and clinical skills. Positions available in great locations in Alberta and GTA – Toronto, ON. Progressive clinics with strong new patient along with existing patient base and excellent support structure. Optional 4 days on, 4 days off allow the right individual an opportunity to enjoy life and also be very productive. All clinics open 6 days for 12 hours per day so multiple options available with respect to schedule. Remuneration to be greater of guaranteed income, or percent collections. Experience with kids, surgery, endo and sedation an asset. Mentorship and buy-in opportunities available to right candidates. Email resume to dentaldocs051@gmail.com
TORONTO, ON Full time dental associate needed immediately for busy group practice in downtown Toronto. Seeking dentist who is comfortable with a fast paced environment. Excellent earning potential. Please forward your resume to: dentistrywithcare15@gmail.com
May 2017
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2017-04-28 4:03 PM
DENTAL MARKETPLACE
ASSOCIATESHIPS
CALGARY, AB CRANBROOK, BC Wanted Associate for long established recently up-dated and thriving general family practice in beautiful East Kootenay Valley, Cranbrook, BC. Applicants must be motivated and comfortable with all aspects of dentistry, part-time to begin with is okay. Please call: 250-426-3422 or email: jwnesbitt@shaw.ca
GRANDE PRAIRIE, ALBERTA A Full time Associate needed for Grande Prairie Family Dental Centre starting middle of April 2017. Also need a Full time Associate for Roy & Kali Family Dental Centre starting July 2017. Both offices are busy and offer all aspects of dentistry. If you are trustworthy, friendly and committed to excellence please contact Dr. Roy at 780-539-6883 or drroy04@telus.net
Established Calgary office currently seeking to expand our practice with a licensed Endodontist 1-2 days per week. We are a busy, growth focused practice, with an energetic and motivated team who focus on living our culture, by providing exceptional service and care to our patients and each other. Please contact: tracey@dimensiondentistry.com
COBOURG, ON Busy practice seeking Licensed Endodontist Established family practice with three locations currently seeking to expand our practice with a licensed Endodontist. This position will be based in our Cobourg location 2 Fridays per month to start. Our team is dedicated to providing an exceptional patient experience at every visit. Please contact louise@familydentalcentre.com
NEWMARKET, ON
D/T TORONTO, ON
Associate opportunity in Newmarket. Applicant must have a minimum of 3 years experience, a team player, can build a rapport with patients quickly and is amazing with children. Please email your resume and a preference of location to: mightymolars@live.ca & bbashi@yahoo.com
Downtown Dental Clinic seeking Spanish speaking Dentist and Dental Specialists for Toronto clientele. Reply to Oral Hygiene Box 47 – e-mail karen@newcom.ca – indicate box no.
STOUFFVILLE, ON DR. BOB BOADWAY requires an experienced Part time Dental Associate to join his practice at the PARK DRIVE DENTAL CENTRE INC. in Stouffville ,Ontario. www.parkdrivedental.com Please email resume to drbobboadway@gmail.com
THOMPSON, MB Looking for an energetic dentist with experience to join our team full time at Westwood dental clinic. Very good income can be made. Office with all modern equipment making it feasible to practice all aspects of dentistry. Specialist welcome. To apply email: westwooddental @hotmail.com
BRANTFORD, ON
NANAIMO, BC
Part-time Associate needed in Brantford, Ontario.
General dental practice in Nanaimo seeking a part-time associate. Busy, well established, modern, digital, Cad-Cam enabled practice. Great team environment. 1-3 days per week. Please forward inquiries to Cedar Valley Dental Centre: cvdc@shaw.ca
We are an established family practice looking for a committed associate who is interested in 1-2 days/week plus 1 Saturday/month. Willing to pay above the average remuneration. Please email: brantdentistry@yahoo.com
TORONTO, ON Busy Toronto Clinic seeks best associates out there! We are selectively seeking out clinicians that deliver beautiful work and results, who have a great rapport with patients and go above and beyond. Opportunity to associate short term, long term and more. Reply to Oral Hygiene Box 48 – e-mail karen@newcom.ca – indicate box no.
KENORA, ON F/T associate to replace current female associate at the end of contract. Established practice with regular hygiene recall and two principal dentists. Accommodation close by and arranged. A friendly, experienced dentist with skills in endo, oral surgery and pedo preferred. Contact: kenoradent@hotmail.com
RED DEER, AB Busy dental office in Red Deer is looking for an enthusiastic and motivated associate to join our practice. Associate must be confident in all aspects of dentistry with a desire to learn new techniques and technology. Our office has excellent new patient flow and current associate has great production numbers. Current associate is moving back to Ontario. Please contact us at drnar@clearviewmarketdental.ca
BRAMPTON, ON Family dental practice looking for part time associate to work Thursdays and Saturdays. Must have good communications skills. Please email resume: Bramptondentaloffice305@gmail.com
RED DEER, AB We are seeking a highly motivated enthusiastic dentist to join our practices in the city of Red Deer. We have a well trained support team in place to ensure growth and stability. We are looking for a long term team member to grow with our practice. We offer flexibility in scheduling and are fully paperless. Please forward resumes to: brad@practicesmadeperfect.ca
OTTAWA DENTIST Busy dental practice in Ottawa seeking a full time Associate to join our experienced team of Dental Professionals and Mentors. E-mail: 7dentalresponse@gmail.com
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May 2017
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www.oralhealthgroup.com www.oralhealthgroup.com
2017-04-28 4:03 PM
SHE KNOWS THAT STRAWBERRIES HAVE A HIGH ANTIOXIDANT CAPACITY. WHAT ELSE WOULD SHE WANT TO KNOW? Young people today are staying informed to stay healthy.1 But do they know that healthy foods including fruit, juices and sports drinks are highly acidic and can put their enamel at risk?2-5 Exercise your influence as their trusted dental professional. Help educate every young patient about the effects of acid erosion. Because the investment in their enamel should start today.
For your acid erosion candidate. 1. GSK data on file, 2013. 2. Lussi A. Erosive tooth wear – a multifactorial condition. In: Lussi A, editor. Dental Erosion – from Diagnosis to Therapy. Karger, Basel, 2006. 3. Lussi A. Eur J Oral Sci. 1996;104:191–198. 4. Hara AT, et al. Caries Research. 2009;43:57–63. 5. Lussi A, et al. Caries Research. 2004;38(suppl 1):34–44.
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TM/® or licensed GlaxoSmithKline Consumer Healthcare Inc. Mississauga, Ontario L5N 6L4 ©2017 The GSK group of companies. All rights reserved.
2017-04-28 4:03 PM
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Call 1-888-658-2584 VOCO Canada · toll-free 1-888-658-2584 · Fax 905-824-2788 · infousa@voco.com · www.voco.com
OHY May17 Complete.indd 40
2017-04-28 4:03 PM
Pour vous,
cela représente une bouche saine. Pour vos patients,
cela représente la confiance totale. De la part des spécialistes en hygiène buccale de Sonicare, Philips Zoom peut dévoiler un sourire sain qui renforce la confiance de vos patients. • Efficacité en clinique – blanchit jusqu’à 8 teintes en 45 minutes1 • Des résultats à domicile – les formules les plus avancées en matière de blanchiment à la maison Faites connaître à vos patients le traitement de blanchiment sain et fiable de Philips Zoom.
Philips Zoom WhiteSpeed
La marque de blanchiment
la plus utilisée par les professionnels en soins dentaires
OHY May17 Complete.indd 2
Philips Zoom DayWhite Doux
Philips Zoom Stylo de blanchiment
Appelez dès maintenant pour obtenir votre essai gratuit au (800) 278-8282 ou consultez le site www.philips.com/ZoomPortfolio 1 Avec Philips Zoom WhiteSpeed. N’inclut pas le temps de préparation.
2017-04-24 9:53 AM
Duraflor Halo ®
Vernis blanc à 5 % fluorure de sodium
Votre rendezvous de 16h...
Le vernis de l’heure
Vous avez besoin d’un vernis blanc efficace qui s’applique sans effort. Duraflor Halo simplifie les matinées et les après-midis depuis des années. Sa consistance lisse et soyeuse ne forme pas de grumeaux, de sorte que son application est toujours sans effort. Édulcoré avec Xylitol, ce vernis prend une couleur blanche naturelle à l’état sec. À la fin de votre journée, Duraflor Halo est si lisse, qu’il surpasse toute concurrence… un sourire blanc à la fois ! Visitez medicom.com dès aujourd’hui pour votre échantillon gratuit !
OHY May17 Complete.indd 4
Un sourire à la fois 2017-04-26 11:31 AM
VOICI POURQUOI ELLE EST RONDE Brossette ronde CrossAction unique
Système de suivi de la pression du brossage
Contrairement aux brossettes rectangulaires, la brossette ronde ORAL-B® inspirée des outils prophylactiques procure un nettoyage sur trois côtés afin d’atteindre toutes les surfaces de chaque dent.
Seul Oral-B® offre un système de contrôle de la pression triple afin de détecter un brossage excessif et procure au patient une alerte visuelle de l’anneau intelligent 360°.
La brosse à dents Oral-B® GENIUS™ CrossAction nettoie mieux que la brosse à dents Sonicare DiamondClean*
Innovation : Détection de la position
L’action de pulsation oscillo-rotative de
L’application pour téléphone intelligent aide le patient à améliorer sa technique de brossage en lui montrant les surfaces qu’il néglige.
Oral-B® Pro CrossAction
Mouvements latéraux de
Sonicare DiamondClean
Parlez de Oral-B® GENIUS™ à vos patients afin qu’ils ne négligent aucune surface.
* Selon des études cliniques portant sur plusieurs semaines. Sonicare est une marque déposée de Koninklijke Philips N.V.
© 2016, P&G
OHY May17 Complete.indd 7
ORAL-20485
2017-04-28 12:53 PM
L’ADVERSAIRE DE L’ACIDE. Crest® Pro-Santé Avancé contient du fluorure stanneux pour des dents plus saines et plus fortes.
1. Le fluorure stanneux reminéralise l’émail affaibli.
2. Le fluorure stanneux forme une micro pellicule de protection pour prévenir l’érosion causée par l’acidité et soigner la sensibilité dentaire.
3. Le fluorure stanneux freine de façon importante la production d’acides liés aux bactéries responsables de la plaque.
avec SHMP
Fluorure stanneux stabilisé Non traité
SANS BILLES DE POLYÉTHYLÈNE NE TACHE PAS
© P&G, 2016
ORAL-20443
un soin continu après votre visite chez le dentiste PRO-SANTÉ
OHY May17 Complete.indd 23
2017-04-27 1:54 PM
Contrôle la plaque, prévient la gingivite et procure un soulagement de la sensibilité? À votre santé!
Lorsque vous recommandez Sensodyne® Protection complète à vos patients, vous serez rassuré de savoir que vous les aidez à soulager l’hypersensibilité dentinaire, et que vous recommandez un produit procurant d’autres bienfaits pour la santé des gencives, comme l’élimination de la plaque et la réduction de la gingivite.
GlaxoSmithKline Soins de santé aux consommateurs Inc. Mississauga, Ontario L5N 6L4 ©2017 Le groupe d’entreprises GSK ou son concédant. Tous droits réservés.
OHY May17 Complete.indd 29
2017-04-24 4:05 PM
1
Une personne sur quatre en souffre . 2
Plusieurs l’ignorent . Elles peuvent aussi en ignorer les conséquences sur leur santé buccodentaire*. Elles attendent vos conseils.
La bouche sèche est un problème de santé buccodentaire qui affecte surtout les personnes prenant plusieurs médicaments3. Pourtant, certaines personnes qui souffrent de bouche sèche ne savent pas qu’il s’agit d’un problème courant2. Parlez à vos patients de la bouche sèche et du soulagement que Biotène peut aider à procurer†. ®
www.biotene.ca
GlaxoSmithKline Soins de santé aux consommateurs Inc. Mississauga, Ontario L5N 6L4 © 2017 Le groupe d’entreprises GSK ou son concédant. Tous droits réservés. * La bouche sèche peut perturber l’environnement de santé buccodentaire et causer la mauvaise haleine, la déminéralisation et l’augmentation de la carie4,5. † Rince-bouche, gel et vaporisateur. ‡ Tel que mesuré dans le cadre d’une étude clinique de 28 jours6. 1. Données internes de GSK. Occasion de croissance de Biotène pour la bouche sèche (incluant les données U&A canadiennes). 16 juillet 2014. 2. Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004;38:236-240. 3. Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth, 2e édition. Gerodontology. 1997;14:33–47. 4. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138:15S–20S. 5. Fox PC. J Clin Dent. 2006;17 (numéro spécial):27-28. 6. Données internes de GSK 2014, RH01986.
OHY May17 Complete.indd 35
2017-04-28 4:01 PM
ELLE SAIT QUE LES FRAISES COMPORTENT D’EXCELLENTES PROPRIÉTÉS ANTIOXYDANTES. QUE DEVRAIT-ELLE SAVOIR DE PLUS? De nos jours, les jeunes se tiennent au courant pour vivre sainement1. Mais savent-ils que les aliments sains, comme les fruits, le jus et les boissons pour sportifs, sont très acides et qu’ils peuvent mettre leur émail à risque2-5? Usez de votre influence en tant que professionnel dentaire de confiance. Informez chaque jeune patient des effets de l’érosion par acide. Ils doivent investir dans leur émail dès aujourd’hui.
Pour vos patients prédisposés à l’érosion par acide. 1. Données internes de GSK, 2013. 2. Lussi A. Erosive tooth wear – a multifactorial condition. Dans : Lussi A, directeur. Dental Erosion – from Diagnosis to Therapy. Karger, Basel, 2006. 3. Lussi A. Eur J Oral Sci. 1996;104:191-198. 4. Hara AT et al. Caries Research. 2009;43:57-63. 5. Lussi A, et al. Caries Research. 2004;38(suppl. 1):34-44.
OHY May17 Complete.indd 39
MC/® ou sous licence GlaxoSmithKline Soins de santé aux consommateurs Inc. Mississauga, Ontario L5N 6L4 ©2017 Le groupe d’entreprises GSK. Tous droits réservés.
2017-04-26 11:29 AM
Quelle réaction voulez-vous?
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lus ez en p Découvr andez votre m et com
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2017-04-24 9:51 AM