Oral Hygiene May 2013 by Annex Business Media

oralhygiene May 2013

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1 M. Ward, W. Jenkins, K. Argosino, S. Souza, M. Nelson, J. Milleman, K.R. Milleman. Assessment of a Sonic Toothbrush on Plaque and Gingivitis. J Dent Res 92 (Spec IssA):3753, 2013. 2 Defenbaugh J, Liu T, Souza S, Ward M, Jenkins W, Colgan P. Comparison of Plaque Removal by Sonicare FlexCare Platinum and Oral-B Professional Care 5000 with Smart Guide. Data on file, 2013. Not yet verified by peer-reviewed research.

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oralhygiene CONTENTS

FEATURES Using an Antibiotic Rinse System as an Adjunct in the Treatment of Periodontal Disease

Anne Bosy, RDH, MEd, MSC

Tax Savings from Passing the Independent Contractor Test

David Chong Yen, CFP, CA

An Umbrella Policy for Sterility Assurance?

Leann Keefer, RDH, MSM

Using OptraGate Retraction Devices to Simplify Dental Procedures

Connie Lorich, RDH, BS

Professional Whitening: Speed, Comfort and Effective Results

Jo-Anne Jones, RDH

DEPARTMENTS Editorial News: O’Hehir University, Dental bib clips, Mouthguards Dental Marketplace

5 6

24 Editorial Board Members Lisa Philp | Jennifer de St. Georges Annick Ducharme | Beth Thompson

Cover & top image: thinkstockphotos.com

May 2013

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EDITORIAL

Who’s Your Daddy? Just came back from attending the ODA’s 146th Annual Spring Meeting (ASM) in Toronto, well, didn’t really ‘come back’ since I live in Toronto, but anyway, not the point. The ASM is typical of most dental shows/meetings/conventions/conferences: speakers speak, booths display, products entice. People mill about in the aisles wondering where the traffic is; people collect CE points; people wonder why there are no restaurants near the south building. Best quote overheard at the meeting? No one can tear a practice down faster than a hygienist and no one is more important. As the practice owner, the dentist may qualify as ‘more important’ but a dental practice is a finely tuned instrument, a welloiled machine, **cliché alert**, a team. A successful dental practice is not built on individual effort but rather on the cohesive performance of all members. Great dental care is delivered by a team and all members of the team contribute to the patient’s experience. Although collaboration is critical, the autonomy of each professional is essential. In an article by Howard M. Notgarnie, RDH, EdD, “The American Dental Hygienists’ Association (ADHA) noted that the traditional model of dental hygiene education as a short behavioral training process fosters a limited expectation of dental hygienists’ role as clinicians working for dentists and following dentists’ orders. Yet dental hygienists must distinguish their diagnoses and treatment plans from those of dentists. While dentists might provide a perio dontal diagnosis

and treatment plan comparable to one a dental hygienist provides, the dental hygiene diagnosis and plan should address more specific risks to a client’s periodontal health – those diagnostic elements for which a dental hygienist’s expertise is most applicable.” Whether we’re talking dentists, dental therapists, dental hygienists, dental assistants, receptionists or business staff, successful dental practices, not to mention practically every other profession, find success through skill sets in three areas: clinical skills, business skills, and relationship skills. “While any one of the three skill sets can be a dentist’s downfall, poor relationship skills typically reduce production and enjoyment levels the most,” according to Nate Booth, DDS. He says there are six keys to forming outstanding relationships with your team: 1. Be a person who attracts outstanding people 2. Have a practice that attracts outstanding people 3. Hire for attitude and work ethic, train for skill 4. Decide what’s important then talk about it again and again 5. Prune the prima donnas 6. Make office enjoyment a priority Do your teammates have your back? Do they have your support? I would add a few other keys to a great team: praise and appreciate; honor your word; care for each team member; take personal responsibility; listen, don’t talk. Do these things and you can answer the question, “Who’s Your Daddy?”

Catherine Wilson Editor

May 2013

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NEWS BRIEFS

Online University Introduces Oral Health Bachelor’s Degree O’Hehir University, an online education institution, has launched a program for hygienists with a certificate or associate’s degree to earn a Bachelor of Science degree in oral health. The curriculum follows a self-directed, project-based path to degree completion within six months with tuition of US$1,250. Registered dental hygienists (RDH) complete the necessary course work for a bachelor’s degree and have the equivalent of 150 contact credit hours, enough for a master’s degree. Each graduating class of five to eight students work together to fulfill the portfolio requirements of graduation. The aim of the university is to recognize the academic and clinical accomplishments of licensed or registered dental hygienists by providing a path to degree completion that enhances their success as clinicians, according to the school. For further details, visit the O’Hehir University website. www.ohehiruniversity.com

Dental Bib Clips Can Harbor Bacteria, Study Finds A study titled “Comprehensive Analysis of Aerobic and Anaerobic Bacteria Found on Dental Bib Clips at Hygiene Clinic” found harbored bacteria from the patient, dental clinician and the environment even after the dental bib clips had undergone standard disinfection procedures. Researchers at Tufts University of Dental Medicine and the Forsyth Institute found that 40 percent of the bib clips tested post-disinfection retained one or more

May 2013

A BUSINESS INFORMATION GROUP PUBLICATION Account Manager: Editorial Director: Tony Burgaretta / 416-510-6852 Catherine Wilson tburgaretta@oralhealthgroup.com 416-510-6785 cwilson@oralhealthgroup.com Classified Advertising: Editorial Assistant: Karen Shaw / 416-510-6770 Jillian Cecchini kshaw@oralhealthgroup.com 416-442-5600, ext. 3207 jcecchini@oralhealthgroup.com Dental Group Assistant: Kahaliah Richards Art Direction: 416-510-6777 Andrea M. Smith krichards@oralhealthgroup.com Production Manager: Associate Publisher: Phyllis Wright Hasina Ahmed / 416-510-6765 Circulation: hahmed@oralhealthgroup.com Cindi Holder Senior Publisher: Advertising Services: Melissa Summerfield Karen Samuels 416-510-6781 416-510-5190 msummerfield@oralhealthgroup.com karens@bizinfogroup.ca Vice President/Canadian Publishing: Consumer Ad Sales: Alex Papanou Barb Lebo President/Business Information Group: 905-709-2272 Bruce Creighton barblebo@rogers.com

aerobic bacteria, which can grow in oxygenated environments. They found that 70 percent tested post-disinfection retained one or more anaerobic bacteria, which do not live or grow in the company of oxygen. Microbiologists analyzed 20 clips on dental bib holders and used standard molecular identification techniques, as well as a one-of-a-kind technology that can detect 300 of the most common oral bacteria. “The results of our analysis show that there is indeed a risk of cross-contamination from dental bib clips,” said Dr. Bruce Paster, Chair of the Department of Microbiology at the Forsyth Institute. “It is important to the clinician and the patient that the dental environment be as sterile as possible; thus it’s concerning that we found bacteria on the clips after disinfection.” Paster further explained that “the situation can be avoided by thoroughly sterilizing the clips between each patient or by using disposable bib holders.” www.dentalbibclipbacteria.com.

Facial Protection Awareness By wearing a properly fitted mouthguard, 200,000 oral injuries are prevented each year. According to the American Association of Orthodontists, 33 percent of parents say their child has sustained an injury during an organized sport. Wearing an effective mouthguard minimizes the risk of injury to the face, jaw, teeth, and head. An effective mouthguard should cover the upper and lower teeth and the gums. Dental professionals can custom make a mouthguard by taking an impression of the person’s teeth and gums. Boil and bite mouthguards are available at pharmacies, as well as ready-to-wear mouthguards, but provide limited protection.

OFFICES Head Office: 80 Valleybrook Drive, Toronto ON M3B 2S9. Telephone 416-4425600, 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. Oral Hygiene (ISSN 0827-1305) will be published four times in 2013, 80 Valleybrook Drive, Toronto ON M3B 2S7.

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: 416-442-2191; E-mail: privacyofficer@ businessinformationgroup.ca; Mail to: Privacy Officer, Business Information Group, 80 Valleybrook Drive, Toronto ON M3B 2S7. Canada Post product agreement No. 40069240. Oral Hygiene 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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ORAL HYGIENE

Using an Antibiotic Rinse System An Adjunct in the Treatment of Periodontal Disease Anne Bosy, RDH, MEd, MSC

Creator of the Oravital System. Formerly a professor at George Brown College and Regency Dental Hygiene Academy, she is currently the senior vice-president and founding partner of Oravital Inc., a nonsurgical system for the treatment of periodontal disease. abosy@oravital.com

Dr. Gerald Pearson, B.Sc., D.D.S., Dip. Perio drgepearson@ bellnet.ca

Sherri Legere, RDH

sherri.legere@ rogers.com

8â&#x20AC;&#x192;

ABSTRACT

Research has now firmly established that dental plaque should be thought of as a biofilm and that perioÂdontitis is a biofilm associated disease. The loss of a healthy balance in the microflora of subgingival tissues appears an important determination in the development of periodontitis. The structure and behavior of biofilm is what makes treatment of these infections more difficult. It has been found that the minimal inhibitory concentration dose for antibiotics and antimicrobials for bacteria in biofilm may be 20 to 200 times higher than required for free floating or plankton bacteria. Successful management of periodontal disease requires knowledge of oral bacteria and their behavior within a biofilm. Combining full scaling and root planing with an antibiotic can result in considerable improvement consisting of an increase in normal or shallow periodontal pockets and a decrease in the number of deep periodontal pockets. Fourteen patients, eight men and six women, with refractory periodontitis were selected randomly from a periodontal practice. Microbiology samples were taken from the throat, tongue and all four quadrants. After sampling was completed, each patient had the teeth cleaned, then was given a preparation of metronidazole, nystatin and water and told to rinse three times a day for 30 seconds. They were to continue this routine for two weeks and then return to the office for a follow-up appointment. All the tests were repeated at the end of two weeks and the results compared to baseline measurements. Only 10 patients completed all the periodontal measurements and nine patients have a complete pre and post treatment microbiology report. The results provided strong evidence that an antibiotic mouth rinse containing metronidazole and nystatin is effective in the treatment of periodontitis. Gingival tissues were healthier, with fewer bleeding points and a decrease in periodontal pocket depth. This system fits within the guidelines of the American Academy of Periodontology. The results indicate that a rinse system provides a beneficial adjunct in the treatment of periodontal disease.

raditionally, periodontal diseases have been defined as plaque-induced and divided into two general categories; gingivitis, the inflammation of gingival tissues without attachment loss and periodontitis, an inflammatory response along with the pathological loss of collagen fibres from cementum and the junctional epithelium.1 Recurrent, chronic or refractory periodontitis refers to progression of disease and loss of attachment despite clinical treatment. 2 This progression is often related to aggressive or persistent subgingival pathogens and possibly to impaired host resistance. 3

Research has now firmly established that dental plaque should be thought of as a biofilm and that periodontitis should be considered a biofilm associated disease. The structure and behavior of biofilms is what makes treatment of these infections more difficult.4 As the tooth surface becomes colonized, a sticky extracellular substance consisting of polysaccharides, proteins, lipids, nucleic acids and other polymers is secreted to help these bacteria adhere to the surface, as well as to each other. It has been found that the minimal inhibitory concentration dose for antibiotics and antimicrobials for bacteria in

May 2013 www.oralhealthgroup.com

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ORAL HYGIENE

thinkstockphotos.com

Successful management of periodontal disease requires knowledge of oral bacteria and their behavior within a biofilm biofilms may be 20 to 200 times higher than required for free floating or plankton bacteria. This may be due to the difficulty in penetrating the sticky extracellular matrix. There is also a possibility that some of the bacteria found within the biofilm are less susceptible to antibiotics 4 and to antimicrobials. In many cases, gingivitis and periodontitis can be controlled with good oral hygiene and regular professional cleaning. Scaling, polishing, and curettage in a series of three to four visits are used to manage periodontal disease. For those patients that respond to debridement with clinical improvement, there is a reduction in the levels of bacteria but if the biofilm is not disrupted frequently, these bacteria return to the predebridement levels. 5 Some organisms such as Porphyromonas gingivalis may persist because the depth of the pocket does not allow thorough debridement. 5 Surgery may be necessary to allow access for deep cleaning of the root surface, removal of diseased tissue, and repositioning and shaping of the bones, gum, and tissues supporting the teeth. Surgical procedures vary depending on the individual diagnosis and needs of the patient. Successful management of periodontal disease requires knowledge of oral bacteria and their behavior within a biofilm. The loss of a healthy balance in the microflora of subgingival tissues appears an important determination in the development of periodontitis.6 Several complexes have been associated with periodontal disease. Prevotella intermedia, Fusobacterium nucleatum and other bacteria found in the orange complex are associated with periodontal disease.4 As the disease pro-

gresses, the periodontal pathogens of the red complex appear â&#x20AC;&#x201D; Porphyromonas gingivalis, Tannerella forsythia and Treponema denticola.4 The parasite Entamoeba gingivalis is commonly found in patients with periodontal disease and is often seen in a background of marked inflammation with abundÂa nt neutrophils.7 This parasite seems to be associated mainly with diseased gingival pocket sites. 8 An important feature of oral bacteria is the ability to interact by co-aggregation, a recognition that occurs between genetically distinct bacteria types and includes physical contact, metabolic and genetic material exchange and signal communication.9 As genetic exchange continues, the biofilm becomes less synergistic and more antagonistic with the most harmful and aggressive pathogens safe within the matrix. This change in the microflora of subgingival tissues is important in the development of periodontitis and can aid in future treatment decisions. Oral microbiology assessment can serve as a rapid diagnostic tool for detecting early stage periodontitis, as well as an aid in future treatment decisions.6

May 2013â&#x20AC;&#x192;

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ORAL HYGIENE

Oral microbiology assessment can serve as a rapid diagnostic tool for detecting early stage periodontitis The American Academy of Periodontology Parameter on ‘Refractory’ Periodontitis outlines the following steps for diagnosis and treatment; “Once the diagnosis of refractory periodontitis has been made, the following steps may be taken: 1. C ollection of subgingival microbial samples from selected sites for analyses, possibly including antibiotic-sensitivity testing. 2. Selection and administration of an appropriate antibiotic regimen. 3. I n conjunction with the administration of an antimicrobial regimen, conventional periodontal therapies may be used. 4. Reevaluation with microbiological testing as indicated. 2 The American Academy of Periodont ology recommends re-evaluation with micro biological testing at one to three months after antimicrobial therapy. The rationale is that it may be desirable to verify the elimination or marked suppression of the putative pathogens and to screen for possible superinfecting organisms including Gram-negative enteric rods, psuedomonads and yeasts. Micro biological analysis is most effective when performed in sites that have not had any instrumentation. It usually takes four to eight weeks for pathogens to repopulate to pretreatment levels. 2 Microbial diagnosis

Table 1: Comparison of bleeding points PRE TREATMENT

Bleeding Points Patient Maxillary Mandibular RC 53 53 JS 34 40 KW 21 29 GF 32 51 SY 55 50 PD 34 16 EP 21 16 KG 42 54 MT 23 32 SH 13 17 328 358 Difference 153 173 % change 46.64% 48.32%

POST TREATMENT

Bleeding Points Maxillary Mandibular 32 34 34 34 11 9 14 14 25 19 18 12 6 7 14 32 12 11 9 13 175 185

Comparison of bleeding points at baseline and after two weeks of rinsing with an antibiotic solution.

should be considered in early-onset perio dontitis or in subjects who respond poorly to conventional therapy. Microbial tests should then be applied to monitor the efficacy of mechanical treatment, as well as anti microbial chemotherapy and to determine the end-point of active treatment.10 The choice of treatment may be with an antibiotic such as metronidazole in conjunction with scaling and root planing and may result in statistically significant improvement in clinical attachment levels. 3 Metronidazole may be an effective choice as it shows activity against anaerobic cocci, gram-negative bacilli and gram-positive bacilli and its effectiveness has been demonstrated in severe adult and refractory periodontitis.11 The right choice of antimicrobial therapy is important and should be based on the pathogens present and linked with periodontal destruction.12 Combining full scaling and root planing with an antibiotic can result in consid erable improvement consisting of an increase in normal or shallow periodontal pockets and a decrease in the number of deep periodontal pockets.13 Antibiotic therapy can reinforce mechanical treatment and support host defenses in overcoming periodontal infections by killing subgingival pathogens that remain after periodontal instrumenta tion.4 Those pathogens that escape mechan ical debridement because of their ability to invade periodontal tissues are more acces sible with antibiotic therapy3 that is applied locally or administered systemically.4 The objective of this research project was to determine if an antibiotic rinse preparation of metronidazole and nystatin would have an effect on the periodontal disease status of chronic (refractory) periodontitis patients. The second objective was to determine if the antibiotic rinse would decrease the pathogens present in the oral biofilm.

Method Fourteen patients, eight men and six women, with refractory periodontitis were selected randomly from a periodontal practice. These

May 2013 www.oralhealthgroup.com

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ORAL HYGIENE

patients had been surgically treated and were now in the recare phase of treatment but continued to exhibit bleeding on probing and pocket depth > 4 mm. Each patient was examined for tissue changes, bleeding on probing and pocket depth using the six point evaluation (distal, centre, mesial) on both facial and lingual surfaces to establish a baseline. In addition, microbiology samples were taken from the throat, tongue and all four quadrants. Samples from the throat were taken using a flat mirror and placing the sample on a glass slide. The quadrants were sampled using a Soft-Pick for each sample and placing the tip deep into the pocket. The slides were sent to a microbiology lab for Gram-staining. The reports included both Gram-positive and Gram-negative bacteria, spirochetes, vibrio, yeast and the number of polymorphonuclear leukocytes and recorded as white blood cells (WBC). Separate slides were taken of the four quadrants and were stained with Geimsa staining and examined for amoeboid-like structures. After sampling was completed, each patient had the teeth cleaned. These patients were then given a preparation of metronidazole, nystatin and water and were told to rinse three times a day for 30 seconds. The patients were to swish vigorously for 20 seconds and gargle for 10 seconds then to floss immediately after rinsing at least once a day. They were to continue this routine for two weeks and then return to the office for a follow-up appointment. At this appointment, all the tests were repeated, including the microbiology samples, and the results compared to

Table 2: Decrease in Bleeding Points DECREASE IN BLEEDING POINTS RC JS KW GF SY PD EP KG MT SH

MAXILLARY ARCH 39.62% 0.00% 46.61% 56.25% 54.54% 47.05% 71.42% 66.66% 47.82% 30.76%

MANDIBULAR ARCH 35.84% 17.64% 68.96% 72.54% 62.00% 25.00% 56.25% 40.47% 65.62% 25.52%

Percent change in bleeding points for each patient.

Table 3: Paired T-Test Analysis DEGREES OF FREEDOM Maxillary BOP df = 8 Mandibular BOP df= 8 4 mm pockets df = 8 5 mm pockets df = 7 6 mm pockets df = 6 7 mm pockets df =1 8 mm pockets df = 3

P-VALUE

-5.050 -4.794 -3.681 -3.100 -3.194 -2 -2.210

P < 0.001 P < 0.001 P < 0.01 P < 0.05 P < 0.05 not significant P <0.10

Paired Samples T-Test analysis in SPSS (Laerd – online calculator). BOP=bleeding on probing.

baseline measurements. Only 10 patients completed all the periodontal measurements and nine patients have a complete pre and post treatment microbiology report. Seven of the 14 patients showed amoeboid-like structures in the pretreatment analysis, but only three of these completed the full study.

Results The comparison of total bleeding points at pre treatment and post treatment for maxil-

Table 4: Change in Number of Pockets Pre and Post Treatment RC JS KW GF SY PD EP KG MT SH Total Difference

8 mm 1 0 0 6 0 1 0 0 0 0 8 2 25.00%

POCKETS — PRE-TREATMENT 7 mm 6 mm 5 mm 0 8 18 1 3 5 1 3 9 0 7 3 0 0 0 0 1 7 0 1 11 1 1 4 0 3 4 0 0 2 3 27 63 0 24 38 0% 81.48% 60.31%

4 mm 28 13 14 13 3 16 12 11 6 3 119 52 43.69%

8 mm 1 0 0 5 0 0 0 0 0 0 6

POCKETS — POST-TREATMENT 7 mm 6 mm 5 mm 0 0 7 1 0 3 1 0 1 1 2 5 0 0 0 0 0 3 0 0 0 0 1 3 0 2 3 0 0 0 3 5 25

4 mm 15 5 8 14 0 4 8 8 2 3 67

Comparison of periodontal pocket depth at baseline and after two weeks of antibiotic rinsing.

May 2013 www.oralhealthgroup.com

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ORAL HYGIENE

lary and mandibular bleeding points showed a change of 46.64% on the maxillary arch and 48.32% on the mandibular arch (Table 1). Every participant had a positive change but the changes varied with each individual (Table 2). A paired T-Test was performed to ascertain whether the antibiotic rinsing was effective (Table 3). There is evidence that there was a substantial decrease in bleeding on probing and that it was statistically significant at a p < 0.001. When the periodontal pocket measurements were compared, there were overall changes in the number of pockets for each category of measurements except for 7 mm pockets. These changes were as follows; 8 mm pockets had a 25% change; 81.48% change for 6mm pockets; 60.41 % change for 5 mm pockets and a 43.69% change for 4mm pockets (Table 4). Post treatment examination showed that patient GF, with six 8 mm pockets, now had five 8mm pockets and one 7 mm pocket. Patient PD had one 8 mm pocket pretreatment and the pocket measured 5 mm post treatment. Two patients (JS & KW) had no change in their 7 mm pockets but for patient KD, the 7 mm pocket decreased to 6 mm (Table 4). When the paired T-Test was calculated, the change in 7 mm pockets was not significant (Table 3). The decrease in 8 mm pockets had a low significance with a p-value >0.10. However, the other changes were significant: 6 mm (p>0.05); 5 mm (p>0.05) and 4 mm (p>0.01). To determine if there was a decrease in microorganisms after treatment, post treatment reports were compared with the baseline and all increases, decreases and lack of change were noted. To calculate the change in the Gram-negative and Gram-positive cocci and bacilli, for each of the areas that were sampled, (tongue base, tongue dorsum and the four quadrants) decreases were calculated as a percent of the total. For example, three out of the nine patients showed a decrease in Gram-positive cocci in the tongue base sample and this was recorded as one third of the test population showing a decrease or 33.33% (Table 5). Since the results could not be stated quantitatively, these results show a trend rather than a numerical decline. Fusiforms, spirochetes, vibrio (strains of curved Gram-negative rods such as some Wollinella sp. or Capnocytophaga species14) and

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ORAL HYGIENE

Table 5: Percent Decrease in Microorganisms Post Treatment PERCENT OF PATIENTS WITH POST TREATMENT RESULTS SHOWING DECREASE IN MICROORGANISMS Based on 9 patients Tongue Base Tongue Dorsum Quad 1 Quad 2 Quad 3 Quad 4 Gr+ Cocci 33.37% 44.44% 22.22% 11.11% 25.00% 44.44% Gr + Bacilli 66.67% 66.67% 55.56% 77.78% 50.00% 66.67% Gr - Cocci 44.44% 33.37% 33.33% 22.22% 37.50% 16.67% Gr- Bacilli 55.56% 66.67% 66.67% 88.89% 62.50% 55.55%

Average 30.01% 63.89% 31.26% 65.97%

Percent of post treatment results that show a decrease in the samples taken from the tongue base, tongue dorsum and quadrants. Quad= Quadrant; Gr+ =Gram-positive; Gr- = Gram negative.

yeast were present in some of the patients and these had the greatest decrease post treatment (Table 6). For those patients with amoeboid-like structures present in the biofilm, there was a decrease in numbers with the use of the antibiotic rinse (Table 7).

Discussion The results provided strong evidence that an antibiotic mouth rinse containing metronidazole and nystatin is effective in the treatment of periodontitis as indicated by the tissue and biofilm changes. Gingival tissues were healthier, with fewer bleeding points and a decrease in periodontal pocket depth. These changes are brought about through decrease and in some cases elimination of many of the perio dontal pathogens, such as oral spirochetes, implicated in periodontal disease5 were not present in the second sample. Spirochetes have unique characteristics of locomotion that may enable them to penetrate and invade tissues15 and have been widely recognized as important in the pathogenesis of periodontal disease.15 Examinations of biofilm samples have been used in the detection of spirochetes which were then used for diagnosis and monitoring the need for periodontal treatment.16 The use of systemic metronidazole in the treatment of periodontal disease has been associated with significant reduction in the proportion and levels of spirochetes.16 When used along with scaling and root planing, metronidazole has decreased periodontal pockets and significantly improved the outcome compared to scaling and root planing alone17 and it is often the preferred anti biotic in the treatment of periodontal disease.18 Further, it is well documented that metronidazole decreases periodontal pathogens, especially the fusospirochaetal complex.19 It is also associated with rapid clinical improvement19 and a gain in clinical attachment, indicating less need for surgery. 20 Once periodontal infection has been

even partially resolved, it is important to place the patient on an individualized maintenance protocol with optimal biofilm control. 21 Combating periodontal infections is best accomplished when the choice of anti biotic is restricted to one that least is likely to develop resistance, such as metronidazole. 21,22 The use of this antibiotic as a rinse where it is not ingested further decreases the

Table 6: Pre and Post Treatment Comparisons CHANGES IN MICROORGANISMS WITH ANTIBIOTIC RINSE TREATMENT TB TD Q1 Q2 Q3 FUSIFORMS 7 (9) 5 (9) 8 (9) 7 (9) 7 (9) eliminated 5 3 4 3 3 decreased 1 2 2 2 2 no change 1 1 1 1 increased 1 1 SPIRO 4 (9) 4 (9) 5 (9) 5 (9) 3 (9) eliminated 4 3 3 5 2 decreased 1 1 no change 1 increased 1 VIBRIO 6 (9) 2 (9) 7 (9) 7 (9) 5 (9) eliminated 6 2 5 7 1 decreased 2 no change increased 2 2 YEAST 5 (9) 4 (9) 2 (9) 3 (9) 3 (9) eliminated 4 3 2 2 2 decreased no change increased 1 1 1 1

Q4 9 (9) 4 2 3 4 (9) 2 1 1 4 (9) 2 1 1 4 (9) 3

TB=tongue base; TD=tongue dorsum; Q=quadrant. Spiro=spirochetes. Numbers inside the brackets are the patients assessed and the number beside the bracket is the number of microorganisms found in that group.

Table 7: Amoeboid Structures

GF KG MT

NUMBER OF AMOEBOID STRUCTURES Quadrant 1 Quadrant 2 Quadrant 3 Quadrant 4 Pre Post Pre Post Pre Post Pre Post 30 8 14 0 20 8 20 0 0 0 10 0 0 0 2 0 50 0 22 0 1 0 0 0

Changes in amoeboid-like structures post treatment. Pre=Pretreatment; Post=Post treatment

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ORAL HYGIENE

Microbial diagnosis in the early-onset of disease is a recommended procedure to determine the status of disease risk of systemic interaction and the develop ment of microbial resistance. The American Academy of Periodont ology states that antibiotics may be pre scribed on the basis of the clinical need for further treatment, the findings of micro biological testing and the medical status and current medications of the patient. 5 Diag nostic microbiology and the use of antibiotics should be considered as available tools in periodontal therapy as their combined use offers the clinician a high degree of efficacy and few or mild adverse effects. Microbial diagnosis in the early-onset of disease is a recommended procedure23 to determine the status of disease. Microbial tests should then be applied to monitor the efficacy of mechan ical treatment as well as antimicrobial che motherapy and to determine the end-point of active treatment. 23 This system fits within the guidelines of the American Academy of Periodontology. The results indicate that a rinse system provides a beneficial adjunct in the treatment of periodontal disease. n

REFERENCES

May 2013

1. Position Paper: Diagnosis of Periodontal Diseases. J. Periodontol. 2003;74:1237-1247. 2. American Academy of Periodontology. Parameter on “refractory” periodontitis. J Periodontol. May 2000;71:859-860. 3. Position Paper:Systemic Antibiotics in Periodontics. J Periodontol. 2004;75:1553-1565. 4. Berezow AB and Darveau RP. Microbial shift and periodontitis. Periodontol 2000. 2011 February; 55(1):36-47. 5. Loesche WJ and Grossman NS. Periodontal disease as a specific, albeit chronic, infection: Diagnosis and treatment. Clinical Microbiology Reviews. 2001; 14(4): 727-752. 6. Lee HJ et al. Quantification of subgingival bacteria pathogens at different stages of periodontal disease. Curr. Microbiol published online April 2012. DOI10.1007/ 500284-012-0121-8. 7. Bhaijee F. and Bell D. Case Report – Entamoeba gingivalis in acute osteomyelitis of the mandible. Hindawi Publishing Corporation, Case Reports in Medicine. V 2011; Article ID 3570301- 3 pages. 8. Trim RD et al. Use of PCR to detect Entamoeba gingivalis in diseased gingival pockets and demon strate its absence in healthy tissues. Parasitol Res published online 12 March 2011. 9. Kolenbrander PE et al. Bacterial interactions and

successions during plaque development. Periodon tology 2000. 2006; V42:47-79. 10. Baehni PC and Guggenheim B. Potential of Diag nostic Microbiology for Treatment and Prognosis of Dental Caries and Periodontal Diseases. Crit. Rev. Oral Biol. Med. 1996; 7(3): 259-277. 11. Mariotti A. and Monroe PJ. Pharmacologic man agement of periodontal disease using systemically administered agents. Advances in Periodontics, Part I Dental Clinics of North America, April 1998; 42(2):245-262. 12. Maestre JR et al. Odontogenic bacteria in periodon tal disease and resistance patterns to common anti biotics used as treatment and prophylaxis in odon tology in Spain. Rev Esp Quimioterap. March 2007;20(1):61-67. 13. Baltacioglu E et al. Analysis of clinical results of sys temic antimicrobials combined with nonsurgical peri odontal treatment for generalized aggressive periodon titis: A pilot study. J Can Dent Assoc 2011; 77:b97. 14. Tanner ACR et al. Wo Zinella gen. nov., WoZinella succinogenes (Vibriosuccinogenes Wolin et al.) comb. nov., and Description of Bacteroides gracilis sp. nov., Wolinella recta sp. nov.,Campylobacter concisus sp. nov., and Eikenella corrodens from hu mans with periodontal disease. International Jour nal of Systemic Bacteriology. 1981;3(4):432-445. 15. Hong L et al. Gene inactivation in the oral spiro chete Treponema denticola; construction of an flgE mutant. Journal of Bacteriology. 1996; 178(12):3664-3667. 16. Loesche WJ et al. The utility of the BANA test for monitoring anaerobic infections due to Spirochetes (Treponema denticol) in periodontal disease. Microscopic J Dent Res 1990; 69(10):1696-1702. 17. Feres M. et al. Metronidazole alone or with amoxicil lin as adjuncts to non-surgical treatment of chronic periodontitis: a 1-year double blinded, placebo-con trolled, randomized clinical trial. J Clin Periodontol 2012; 00: 000–000. doi: 10.1111/jcpe.12004 18. Ghayoumi N. The use of Metronidazole in the treat ment of periodontal diseases. J West Soc Periodontol. 2001;49(2):37-40. 19. Oral Microbiology 5th ed. Editors Marsh PD and Martin MV. Churchill Livingston Elsevier 2009. 20. Loesche et al. Metronidazole in Periodontitis: re duced need for surgery. J Clin Periodontol. 1992;1 9:103-112. 21. Slots J. Selection of antimicrobial agents in peri odontal therapy. J Periodont Res 2002; 37:389-398. 22. Mombelli A and Samaranayake LP. Topical and systemic antibiotics in the management of periodon tal disease. Int Dent J. 2004; 54(1):3-14. 23. Walter C et al. Critical assessment of microbiologi cal diagnostics in periodontal disease with special focus on Porphyromonas gingivalis. Schweiz Monat tsschr Zahnmed. 2005;5(5):415-424.

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FINANCE

Tax Savings from Passing the Independent Contractor Test S

ome hygienists choose to operate their own hygiene business in their own premises. Others choose to work with dentists in an employee capacity, or as a self-employed individual. This article will address the tax issues relating to those who choose to work with dentists. Working as self-employed rather than the employee of a particular dental practice has several tax advantages, since self-employed persons can sometimes deduct expenses not available for employees, such as travel costs or the cost of a telephone. Selfemployed persons also are not required to pay Employment Insurance (EI) premiums although they can choose to do so under special rules tailored to the self-employed. However, self-employed persons must pay the full annual Canada Pension Plan (CPP) premium (2013–$4,712.40), whereas for employees, the employer bears half this cost. Self-employed persons also have the option of operating through a corporation, which has significant tax advantages. However, the important issue is not whether you consider yourself self-employed, but whether the Canada Revenue Agency (CRA) would, given the facts of your situation. It is very important to have a written contract, indicating clearly that the person is an independent contractor and not an employee. However, simply calling yourself an independent contractor in the written contract is not enough in itself to make you one. The CRA uses four basic tests to determine if your facts fit within their definition of “self-employed.” • Is the person required to provide his/her

own tools and equipment to do the job? • Is the person in a position to make a profit if he/she operates successfully, but have to bear a loss if he/she doesn’t? • Does the person fit into an authority structure in the work place, or is he/she autonomous? • Is the person responsible for a defined project, or does he/she take up duties as assigned? Employees are typically given the tools they require to do their work by the employer, and are not expected to provide them for themselves. But self-employed persons generally use their own tools and instruments, including specialized equipment in some cases. The CRA looks at whether the person is responsible for buying their own equipment, and is more likely to consider a person to be selfemployed if he/she has to buy his/her own equipment. As a result, if a hygienist provides at least some equipment at his/her own expense, such as loupes or handpieces, this is an indicator of a self-employment relation ship. It is a good idea to include a term in the self- employment contract which requires the hygienist to provide some of the equipment needed to do the job. Employees do not directly bear any economic risk since they are paid by the employer regardless of whether what they are doing turns a profit or not. But truly self-employed persons are taking a risk, and they can either make a profit, or bear a loss, depending on how the assignment turns out. The more that a person fits into a workpla-

David Chong Yen, CFP, CA

Tax specialist advising dentists for decades. Additional information can be obtained by e-mail david@dcy.ca. Please visit our website at www.dcy.ca. This article is intended to present tax saving and planning ideas, and is not intended to replace professional advice.

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FINANCE

ce authority structure, the more likely it is that he/she would be considered an employee by the CRA. However, an employee has ongoing duties and relationships in the work place, and takes direction as to when and where to work. Sometimes the distinction is made between a “staff” function and a “line” function. Staff functions could include, for example, an outside management consultant engaged to review operations. Line functions would include anyone, from the president down, who fits into the work place organizational structure. Hygienists who work on a regular basis in a practice, who must attend staff meetings, and who work on whichever patients are assigned to them, are more likely to be seen by the CRA as employees. Where a person has assumed a defined task, and leaves the organization when it is completed, this person could be viewed by

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the CRA as an independent contractor. Hygienists are not hired to do a single task, but to provide hygiene services to patients as they come into the office. For this reason, hygienists are more likely to be viewed as employed by the CRA. Self-employed persons typically have many contracts, rather than working for just one organization. Persons who work in only one workplace are more likely to be consider ed employees, so many self-employed persons are careful to ensure they are working in more than one place at the same time. Hygienists who want to be viewed by the CRA as self-employed persons should ensure that they are working for numerous dentists during a given period (i.e. the period of a given week); it is not necessary that you work the same amount for each dentist, but you should have multiple contracts at a given time. The dentist who is paying a hygienist as self-employed should pay the hygienist with out any deductions, and if the hygienist is incorporated, then the cheque should be payable to the hygienist’s corporation. This issue has been considered by the courts, and in the Bernice Bradford (1988) case, and sev eral informal rulings since, it has been held that the hygienist was self-employed. There were several factors which were considered in reaching this conclusion, and which should therefore be considered if you want to be taxed as a self-employed contractor: • T he hygienist worked in several offices, travelling up to 100 km between them; • She sometimes arrived at an office to find no patients, and on those days, did not get her fee; • She had a say in which patients she accepted, and determined her own availability for work; • She took her own equipment, such as brushes, minor tools, and polish; • She paid for her own professional liability insurance; • She invoiced the office for her services. While self-employed status offers significant tax advantages to hygienists, it is import ant to meet or pass the CRA’s tests so that the CRA will view your status as self-employed, rather than an employee. If you get this wrong and are later reassessed by the CRA, there can be expensive tax consequences. n

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ORAL HYGIENE

An Umbrella Policy for Sterility Assurance? I

Leann Keefer, RDH, MSM

Is general manager and Director of Education, Crosstex International. leannk@crosstex.com

n the world of insurance, an umbrella policy provides liability coverage over and above standard insurance. It offers protection against large and potentially devastating liability claims — it “kicks in” when regular coverage hits the ceiling. The goal of this article is to illustrate how the combination of progressive steps in sterilization monitoring can shield the practice and its patients for greater sterility assurance.

INTRODUCTION Recently, world news highlighted a disturbing story in Oklahoma where thousands of dental patients were allegedly exposed to bloodborne pathogens. It was reportedly major breaches of instrument processing and failures in sterilization protocol that caused the potential subsequent cross-contamination. The goal of a dental infection control program is to reduce the risk of disease transmission and to provide a safe environment for everyone who works in or visits a dental office. Sterilization is a process designed to inactivate all forms of microbial life and is carried out in health-care facilities by physical or chemical methods. The most predominant sterilization method used in dentistry is steam (autoclave) sterilization. Effective sterilization is critical to safety and optimal patient care; it is estimated that sterilization failure can occur about 1% of the time for steam autoclaves. A comprehensive sterility assurance program requires compliance with recognized recommendations and standards. Clinicians rely on professional guidelines in setting policies for sterilization process monitoring. In the United States, the Centers for Disease Control and Prevention (CDC) developed the Guidelines for Infection Control in Dental Health-Care Settings (2003) which recommends that all heat tolerant

items be sterilized. Likewise in Canada, professional dental associations, including provincial licensing authorities, have advocated the adoption of published Canadian recommendations and guidelines for infection control in the dental office. Four levels of monitors for sterility assurance are available: — Administrative (policies and procedures) — Physical (gauges, LEDs, and printouts) — Chemical (six classifications) — Biological (in-house and mail-in) When combined and used as directed, these monitors evaluate both the sterilizing conditions and the procedure’s effectiveness.

STERILIZATION PACKAGING Classified as a medical device, there are stringent criteria for the manufacturing of sterilization packaging materials. There are a number of factors to consider when selecting packaging materials such as pouches or wraps. Packaging materials must be compatible with the type of sterilizer used (i.e. steam autoclave, dry heat, unsaturated chemical vapor). It should be noted, all packaging types and materials are not compatible with all sterilization methods. The use of incorrect materials may prevent or reduce penetration of the sterilizing agent. Quality sterilization pouches, usually constructed of paper and plastic, are a key component of any sterility assurance protocol. ISO standards for performance and infection control guidelines make it clear — the only way to be sure an item has been sterilized is to expose it to all three sterilization variables — time, temperature, and steam. Yet, many traditional sterilization pouches have either an external or internal process indicator that measures only temperature (Figure 1). Advanced technology is now available with both internal and external multi-variable indi-

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ORAL HYGIENE Figure 1

Figure 2

cators (ISO-11140-1 Class 4) featured in one patented pouch design. The internal/external indicators will ONLY change color when all three criteria for sterilization (time, temperature, steam) have been met. Additionally, this dual indicator pouch also saves time and money by eliminating the extra step of placing a separate multi-variable indicator inside each pouch as recommended in the guidelines. The use of this multi-variable pouch, in combination with weekly biological monitoring, provides a trusted level of sterility assurance.

Biological Monitoring Biological monitoring (BI) is an indispensable tool for the proper validation of the sterilization process. In accordance with the CDC guidelines, dental practices in the United States should conduct biological monitoring at least weekly to remain compliant. Consideration should be given for more frequent testing if the sterilizer is used multiple times each day or with use of a variation of sterilization cycles. In Canada, the Alberta Dental Association & College was the first provincial dental organization to establish the requirement of physical, chemical and biological monitoring processes. As a benchmark, other provinces have used these guidelines to establish their requirements; Saskatchewan guidelines mandate weekly testing while Quebec’s require monthly. Alberta mandates daily testing, while Ontario recommends daily testing. As of 2012, British Columbia practices now require testing on a daily basis. In 1999, the Journal of the Canadian Dental Association published the results of a comprehensive study of dentists’ compliance recommendations along with infection control procedures. Questionnaires were mailed to a random sample of all dentists licensed to practice in Canada (n=6,537). More than 95% of the respondents reported using heat sterilizers; of the twelve provinces responding, the

Figure 3

average for routine use of biological monitoring was 71% (high of 91% in Alberta and low of 50% in the Yukon Territory). Statistically significant predictors of excellent compliance with recommended infection control procedures included dentists attending more than six hours of continuing education on infection control in the past two years (Figure 2). Spore testing (biological monitoring) is the use of highly resistant bacterial spores to challenge the use and function of sterilizers. Spores are more resistant than other micro organisms, thus it stands to reason when spores are killed during the sterilization cycle less resistant microbes on equipment should have also been killed. Biological indicators (BIs) are considered the gold standard of biological testing. Appropriate types (i.e. dual-species) of BIs can be used with steam (autoclave), dry heat, chemical vapor, and ethylene oxide units. Regular biological monitoring and accurate documentation of test results are key elements of a sterility assurance program. Three options are available for monitoring sterility assurance in the dental office: mailin sterilization monitoring services to a third party testing laboratory (i.e. private companies or dental schools), in-office 24-hour and 48-hour monitoring systems and a recently released in-office 10-hour monitoring system. While some offices prefer the use of a professional lab for testing and third party documentation of results, others appreciate the convenience in-office processing provides with a direct turnaround time and without the hassle of mailing and waiting for results. Users should follow the manufacturer’s directions concerning the appropriate placement of the biological indicators within the sterilizer. Sterilant (i.e. steam, heat, or chemical) penetration is best monitored by placing the BIs in the hardest-to-reach areas of the sterilizer (where steam is least likely to reach). It should be noted, in-office monitoring

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ORAL HYGIENE

Table 1: Chemical Indicator Classifications CLASSIFICATION

TYPE

PROCESS

Process indicator

Attached or printed device placed externally on pouches or packs to visually distinguish between processed and unprocessed.

Indicator tape, labels, and load cards.

Class 2

Indicators for use in specific test

Daily test used to evaluate proper air removal of dynamic air removal steam sterilizers.

Bowie-Dick test pack.

Class 3

Single parameter indicator

Reacts to one of the critical variables (i.e. heat, steam, time) during the sterilization cycle. For use as an internal chemical indicator.

Temperature tube which contains a chemical pellet that melts at a specific temperature.

Class 4

Multivariable indicator

Multivariable indicators react to two or more sterilization parameters. For use as an internal chemical indicator.

Paper strips printed with indicator ink that changes color when parameters are met.

Class 5

Integrating indicator

Reacts to all sterilization parameters over a range of cycles; performance mimics but does not replace biological indicators. For use as an internal chemical indicator. Specified by AAMI for use with critical devices, i.e. implants and immediate-use steam sterilization (flash) cycles.

Indicator pellet that migrates across the strip to a safe area when exposed to all sterilization parameters.

Class 6

Emulating indicator

Cycle specific; reacts to all critical parameters for a specified sterilization cycle. For use as an internal chemical indicator.

Indicator strip that changes color when exposed to all sterilization parameters.

systems can only be used with steam (autoclave) sterilizers; the mail-in monitoring services can provide results for steam, dry heat, chemical vapor, and EtO (ethylene oxide). In addition to conducting routine biolog ical monitoring, dental practices should perform biological monitoring for the following occurrences: • W henever a new type of packaging material or tray is used. • A fter training new sterilization personnel. • A fter repairing a sterilizer. • A fter any change in the sterilizer loading procedures.

Chemical Monitoring Chemical indicators are critical to the monitoring process, as they provide immediate feedback on the sterilization cycle upon their removal. Chemical monitoring is the use of physico-sensitive chemicals to assess the physical conditions (i.e. time, temperature and presence of sterilant) during the sterilization process. Chemical indicators (CIs) are available as paper strips, labels, and steam pattern cards. Used in load release decisions, CIs measure only the physical parameter of the sterilization cycle for which they are used. While CIs do not prove that lethality has

EXAMPLE

Class 1

Indicator pellet that migrates across the strip to a safe area when exposed to all sterilization parameters.

been achieved, they do allow detection of certain equipment malfunctions and can help identify procedural errors. External chemical indicators can verify that a sterilization pouch or package has been exposed to the sterilization process. Process indi cator tape (i.e. “autoclave tape”) routinely used to effectively seal tubing, autoclave bags, and CSR wraps are examples of external indicators. The ‘hash mark’ color change to black indicates specific temperature has been achieved during the sterilization cycle; however, this color change does not guarantee sterilization of the package contents. Note, process indicator tape may show the diagonal lines with temperatures as low as 200° and well before 20 minutes of exposure has occurred. Again, the role of an external indicator is to provide simple visual identification that a pack has or has not been processed, but is not reflective of sterilization. Internal chemical indicators are used to ensure that the sterilizing agent has penetrated the packaging material and actually reached the instruments. They show that some sterilizing conditions were met, but do not indicate whether the contents within the sterilizer are sterilized. False negative results can be influenced by the location of the

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Classification of Chemical Indicators Six classes of chemical indicators (Table 1) are recognized by the International Organization for Standards (ISO); three of these are commonly used in dentistry. CIs are classified by their intended use and provides performance requirement for each class; the classification has no hierarchical significance meaning a Class 5 is not better than a Class 4 but they have different performance characteristics and intended uses. As covered in the Association for the Advancement of Medical Instrumentation (AAMI) manufacturer standard for chemical indicators (ANSI/AAMI/ISO 11140-1:2005) Table 1 defines the classes of indicators and performance requirements and/or test methods for CIs. * Note: Recommended practices state that Class 4 and Class 5 CIs provide more information than Class 3 CIs. “If the interpretation of the CI suggests inadequate steam process, the contents of the package should not be used (AAMI ST79 Section 10.5.2.2.2).

CLASS 5 Integrating Indicator A Class 5 indicator mimics that of a biological indicator at three different times and temperatures without requiring incubation. They can detect certain types of sterilization process failures, such as air-steam mixtures and inadequate air removal which may not be detected by physical monitors or other types of chemical indicators. These integrating indicators provide the convenience of a chemical indicator. AAMI steam sterilization standard for health care facilities (ANSI/AAMI ST79) states, “Biological monitoring provides the only direct measure of the lethality of a sterilization cycle.” Therefore, it must be acknowledged that a Class 5 integrator does not contain spores and therefore, does not directly measure the lethality of a sterilization process. Class 5 integrating indicators used daily, or even with every load, could be a means of improving patient safety and reduce the cost and disruption of potential recalls when a BI fails. Like an umbrella policy, a Class 5 inte-

ORAL HYGIENE

indicator within the sterilizer, the types of packaging materials used and operator error. Gross malfunctions as indicated by a positive result, such as overloading of the sterilizer, can be quickly addressed.

grating indicator can become the primary policy “on the risk” while waiting for the results of a biological spore test. Technical Design of Class 5: The base is made of aluminum foil with a temperature and steam-sensitive chemical placed in the cavity embossed in the foil. When subjected to a heated steam environment, the chemical ‘melts’ and moves sequentially across the visual gauge. Proper sterilization is indicated when the dark bar enters the SAFE zone as indicated on the strip (Figure 3). One distinctive benefit of using a Class 5 indicator is for the release of sterilizer loads versus quarantined until the BI result is reported as negative. Remember, biological indicators remain the gold standard to ensure a sterilization process had sufficient lethality to produce the desired sterility assurance level (SAL). Can you go without a Class 5 integrator according to guidelines? You can, but is it worth it? It costs less than $1 per indicator strip and yet, it can provide you with enhanced confidence of the sterilization load.

Summary Is there such a thing as ‘too much’ insurance, or as it were, too much sterility assurance? Have you considered an umbrella of safety to cover any gaps in underlying sterilization practices? When it comes to sterility assurance, it is always better to be safe than sorry. You’ve spent your career building infection prevention into the safety of your practice and for the patients you treat; the last thing you want is a breach in sterility assurance due to uninformed choices or complacency. Dedication to ensure the highest possible level of sterilization assurance for instruments which come into contact with patients is the added confidence in providing better protection for patients and healthcare workers. n

REFERENCES 1. Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infectin Control in Dental Health-care Settings – 2003. MMWR Recomm Rep. 2003. Available at http:// www.cdc.gov/mmwr/preview/mmwrhtml/ rr5217a1.htm. Accessed March 15, 2013. 2. Molinari JA, Harte JA; Cottone’s Practical Infection Control in Dentistry 3rd edition. Lippincott Williams & Wilkins 2010.

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ORAL HYGIENE

OptraGate Retraction Devices Using them to simplify dental procedures Connie Lorich, RDH, BS

Has over 16 years of clinical dental hygiene experience, and seven years in dental pharmaceutical marketing, education, and sales; as well as research and education at the University at Buffalo School of Dental Medicine. Currently she is employed as Associate Manager Professional Services at Ivoclar Vivadent. To see the Optra Gate Retraction Device video, please click here. http://www. oralhealthgroup.com/ videos/play/?plid=1 002378009

Introduction Dental procedures performed in the posterior section of the oral cavity are often difficult, time-consuming, and not ideal. Access and visualization of the treatment field can be compromised by the patient’s lips, tongue and cheeks. Unfortunately, traditional retraction techniques and instruments are largely responsible for the musculoskeletal pain experienced by dental professionals due to their poor ergonomics, and the sprain and strain they cause accounts for countless occu pational injuries.1 Many dentists still use traditional retraction techniques and dental instruments which, though effective, present unnecessary complications. According to the Bureau of Labor Statistics, chronic musculoskeletal disorders account for 60 percent of occupational disease. 2

Traditional Retraction Techniques Dental mirrors are a traditional retraction instrument that act as a visual aid and simultaneously retract tissues to achieve better visualization of the teeth, particularly within the posterior regions of the oral cavity. However, dental mirrors can be difficult to use, since concave mirrors produce an enlarged and distorted image of the tooth, while plane mirrors produce a ghost or double image. 3 Another problematic factor caused by traditional retractors is added strain on the retraction hand during time-consuming dental procedures. Since great force is necessary to move the lips, cheeks, and tongue out of the way, dental professionals must exert

prolonged force for an unmitigated time frame, which puts further stress and strain on their fingers, arm, and hand, causing pain or fatigue.1 Research demonstrates that dental hygienists are more predisposed to repetitive strain injury in the hands and wrists, while dentists are more prone to neck and shoulder strain.4 This occurs when dentists do not have a proper fulcrum or rest, and are forced to rely on their muscles and tendons to work in the correct position within the patient’s mouth. 5 The amount of force that can be applied is contingent upon the practitioner’s posture. Research shows that when the hand is extended, flexed, or ulnarly or radially deviated, the power grip force is at 65 percent, which is a little more than half of what can be generated when the hand is in the neutral posture. Other injuries, such as static loading, can occur when the body is in a deviated and unnatural position for an extended period. Upper musculoskeletal pain can also develop from the chronic use of repetitive, forceful, and unnatural movements or postures.6 Therefore, dental professionals are at risk for carpel tunnel syndrome and/or injuries to the hand, fingers, wrist, and forearm.7 Additionally, small diameter mirror handles can increase fatigue in the operator’s hand. Contemporary retraction devices eliminate many of these complications and save considerable chair time and man power. A solution to counteract many of the aforementioned complications has been available for the past 145 years: the rubber dam. 8 Rubber

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ORAL HYGIENE dams can be used for the majority of dental procedures.9 Over the years, the methods for using rubber dams have been perfected, taught worldwide, and recommended by professional organizations, although they are not often utilized. Unsubstantiated reasons for lack of use include worries over patient acceptance, time required for application, cost of equipment and materials, and insufficient training.10 Though underutilized, rubber dams provide excellent isolation for gingival tissue11 and can be used during cavity preparation and restorative procedures to prevent contamination that can lead to postoperative symptoms and restoration failure.12 Other uses for rubber dams include facilitating better access and visibility of treatment fields, providing adequate dry field isolation, and enlarging working areas.13 Additionally, some dental dams do the work of the assistant or dental hygienist by retracting the tongue, cheeks, and lips and decreasing the amount of dental instruments needed within the patient’s mouth. Today’s retraction devices are compatible with the majority of patients and dental procedures. One retraction system claims to replace the rubber dam with a mouthpiece and is available in five sizes (e.g. pediatric, small,

medium, medium deep vestibule, and large). This system distributes bright, shadowless illumination throughout the oral cavity via an LED light source and continuously aspirates fluids and oral debris. Although this system provides access to the patient’s mouth, its large size and expense may be a deterrent to use (i.e. average price of $1,500); eventually with wear and time, parts will need to be replaced. Additionally, dental teams must learn proper use and maintenance of the device. A cost-effective and user-friendly retraction device is OptraDam® Plus (Ivoclar Vivadent, Amherst, NY), which features a flexible three-dimensional anatomical design for optimum adaptation to the oral cavity. The latex material can be stretched to ensure the dam stays in place, without needing metal clamps. Patients are comfortable during long procedures, and dentists experience easier access to, and full visibility of, the treatment field. The OptraDam® Plus is indicated for use in therapeutic dental procedures requiring a dry and isolated working field, such as adhesive cementation, direct composite restorations, and root canal treatments.14 OptraGate® Extra Soft is a latex-free lip and cheek retractor that complements the OptraDam® Plus. This retractor provides a snug yet gentle fit in the upper and lower lip

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frenulum, minimizing intraoral pressure and facilitating moisture control. The flexibility and elasticity of the OptraGate® Extra Soft allows unimpeded jaw movements during procedures, aiding patients in keeping their mouth open. Furthermore, procedures are simpler and more effective, since only one person is needed to insert and remove the retractor; supplementary instruments are not required.14 OptraGate® Extra Soft can also be used for children and is suitable for diagnostic, preventive, and therapeutic dental procedures, including restorative procedures, cavity preparation, professional tooth cleaning, impression making, tooth whitening, and scaling and root planing. Another product within the OptraGate family of retraction devices is OptraGate® Junior, made specifically for children. Although beneficial, these devices have specific indications. For example, OptraDam® Plus is contraindicated for patients with a latex allergy, and OptraGate Extra Soft is not recommended for oral surgical implantological procedures. All of the OptraGate retraction devices are cost-effective and can be purchased in assortment packs. Optimal ergonomics is achieved because practitioners are relieved from sitting or standing in unnatural positions for long periods, and repetitive hand and wrist movements are reduced, preventing the stress and strain that cause injuries.

Conclusion Finding the best solution and retraction aid for patients is contingent upon a variety of factors. These include the procedure being performed and what works best for the dentist. While all retraction devices seek to essentially accomplish the same thing—provide optimal retraction and isolation to simplify procedures—each device presents different features that are more appealing to some dentists than others. Ultimately, this determines which retraction device dentists utilize within their practices. The OptraGate line from Ivoclar Vivadent provides a variety of functional, cost-effective, and easy-to-use methods to choose from. n

REFERENCES 1. Putz-Anderson V, ed. Cumulative Trau-

ma Disorders: A Manual for Musculoskeletal Disorders of the Upper Limbs. Philadelphia: Taylor & Francis; 1988. 2. Piligian G, Herbert R, Hearns M, et al. Evaluation and management of chronic work related musculoskeletal disorders of the distal upper extremity. Am J Ind Med. 2000 Jan;37(1):75-93. 3. Summit BJ, Robbins W, Schwartz SR. Fundamentals of Operative Dentistry: A Contemporary Approach. 2nd edition. Carol Stream, Illinois, Quintessence Publishing Co, Inc.; 2001. 4. Rundcrantz BL, Johnsson B, Moritz U. Cervical pain and discomfort among dentists. Epidemiological, clinical, and therapeutic aspects. Part 1. A survey of pain and discomfort. Swed Dent J. 1990; 14(2):71-80. 5. Gupta S. Ergonomic applications to dental practice. Indian J Dent Res. 2011; 22:816-22. 6. Strong DR, Lennartz FH. Carpal tunnel syndrome. J Calif Dent Assoc. 1992 Apr; 20(4): 27-30, 32-3, 35-6 passim. 7. Ugbolue UC, Nicol AC. A wrist tendon travel assessment of hand movements associated with industrial repetitive activities. Work. 2012;42(3):311-20. 8. Karaouzas L, Kim YE, Boynton JR Jr. Rubber dam isolation in pediatric patients: a review. J Mich Dent Assoc. 2012 Jan; 94(1):34-7. 9. Gilbert GH, Litaker MS, Pihlstrom DJ, et al. Rubber dam use during routine operative dentistry procedures: findings from the Dental PBRN. Oper Dent. 2010 SepOct; 35(5):491-9. 10. Ahmad IA. Rubber dam usage for endodontic treatment: a review. Int Endod J. 2009. Nov;42(11):963-72. 11. Psaltis GL, Kupietzky A. A simplified isolation technique for preparation and placement of resin composite strip crowns. Pediatr Dent. 2008. Sep-Oct;30(5):436-8. 12. Owens BM. Alternative rubber dam isolation technique for the restoration of Class V cervical lesions. Oper Dent. 2006. Mar-Apr; 31(2):277-80. 13. Small BW. Rubber dam--the easy way. Gen Dent. 1999 Jan-Feb;47(1):30-3. 14. Ivoclar Vivadent. Optra Innovative Accessories. Amherst, NY: Ivoclar Vivadent; 2010: 1-10.

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Helping shine a light on your Acid Erosion patient.

Acid ErosioN idENTiFiEr

The new ProActTM tool from ProNamel® is based on the published index of BEWE (Basic Erosive Wear Examination) to help dental professionals across Canada identify acid erosion and erosive wear, and counsel patients on acidic dietary challenges and oral hygiene while helping to manage patients over time – all in an effort to help you shine a little more light on your acid erosion patients.1 www.ProNamel.ca/dentalprofessional TM /® or licensee GlaxoSmithKline Consumer Healthcare Inc. Mississauga, Ontario L5N 6L4 © 2012 GlaxoSmithKline

OHY May2013 p27 GSK English AD.indd 27

1. Bartlett D, et al. Clin Oral Invest. 2008;12(Suppl 1):S65–S68.

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ORAL HYGIENE Jo-Anne Jones, RDH

A recognized international speaker, consultant, author and President of RDH Connection Inc. Jo-Anne has been appointed to serve on the advisory board for Dentistry Today and invited to join Dentistry Today’s 2013 CE Leaders for the 4th consecutive year. Nominated for a 2012 Dental Excellence Award for the Most Effective Dental Hygiene Educator by her peers and is PennWell’s award recipient for writing “The Most Important Dental Story Published in 2012.” Jo-Anne may be reached at jjones@ rdhconnection.com

Professional Whitening Speed, Comfort and Effective Results

ccording to a recent survey conducted by the American Academy of Cosmetic Dentistry, a smile is deemed to be an important social asset. Three-quarters of the adults surveyed feel an unattractive smile can hinder a person’s chances for career success. Respondents were asked, “What would you most like to improve about your smile?” The most common response was whiter and brighter teeth. There also appears to be a gender difference with 65% of patients receiving whitening treatments being female compared to 35% of our male counterparts enhancing their smile. Whitening has become a multi-million dollar industry. The two most documented stumbling blocks to achieving the ultimate end result are sensitivity and lack of compliance with completing the suggested whitening regimen. This is where it is essential to not only seek the advice of a dental professional to determine the cause of discoloration, but also to evaluate the suitability of the client for whitening. The second stumbling block is related to the demands of societal change. Most people tend to want fast and effective results today whether it be enhancing their smile or improving their golf swing!

Client Assessment In order to recommend an appropriate whit-

ening system it is imperative to do a comprehensive client assessment and a proper dental examination. The determination of the origin and cause of discoloration is essential. Extrinsic staining located in the tooth pellicle can be the result of repetitive consumption of staining foods and beverages (Figure 1). This film can be removed by proper and effective self-care regimens, complemented by regular dental hygiene visits. It is wise to perform a thorough debridement and stain removal prior to commencing professional whitening in order to obtain an accurate baseline shade. Intrinsic staining conversely lies beneath the enamel surface. Over time, chromagenic materials slowly diffuse into the enamel creating discoloration. This is often further magnified with physiological changes, creating a thinner enamel structure which reveals more of the darker dentin that lies below. Other lifestyle habits such as smoking or use of smokeless tobacco products can contribute to further discoloration of the enamel. Nicotine-stained teeth may take one to three months of nightly whitening with 10% CP.1 Medications can also play a role in discoloration of the dentition. Intrinsic gray discoloration is commonly seen in exposure to different types of medications. The most widely known is the antibiotic, tetracycline. We of-

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ORAL HYGIENE Figure 1

Figure 3

ten think of tetracycline as being a culprit during the formative years of the dentition; however, several reports have been noted related to adult teeth being stained by tetracycline. Minocycline, which is the number one drug prescribed for treatment of acne, will create a gray discoloration of the teeth over time. Minocycline may be deposited in secondary dentin, and also secreted in saliva and absorbed externally. Tetracycline stained teeth may have limited response and require two to six months (or more) of professionally supervised nightly treatment. It is documented that those with more of a yellowish hue have greater response to whitening than those who have more gray or brown. Ten percent carbamide peroxide and a custom-fitted soft tray for nighttime use have demonstrated long-term efficacy for the removal of brown stains. 3 Diagnosis of the cause(s) of tooth discoloration, followed by an explanation of the projected treatment time, benefits and risks are important considerations to address patient concerns and set reasonable expectations.

Evaluating and Addressing Sensitivity Once the etiology of the discoloration is known, the next step is the evaluation of the sensitivity of the dentition. This may be accom-

Figure 2

Figure 4

plished by simply utilizing a quick blast of air along the buccal aspects of the dentition, noting any mild, moderate, or frank sensitivity. Gingival sensitivity is often related to higher concentrations of peroxide, tray imperfections, incorrect isolation prior to in-office procedures, excess material and inherent client sensitivity. In regards to custom tray whitening, instructions to the client prior to whitening, as to not overloading the tray and following the dosage markings on the syringe with the whitening agent will normally eliminate the risk of gingival irritation. Research found that bleaching agents readily penetrate tooth enamel and dentin into the pulp chamber and may cause sensitivity in the form of reversible pulpitis. Short term pulpal response varies from client to client and even tooth to tooth. Smaller teeth such as mandibular anteriors are more susceptible due to anatomical features and sizing. A client with known sensitivity should be treated pro-actively before commencing professional whitening in order to eliminate or minimize sensitivity. Pro-active desensitization may be accomplished by the application of a fluoride varnish in site specific areas in conjunction with the daily use of a remineralization toothpaste containing ACP (amorphous calcium phosphate) prior to, during

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and following professional whitening. Pre-brushing for two weeks with a potassium nitrate containing tooth paste will also reduce sensitivity.4 Relief ACP, which accompanies the ZOOM WhiteSpeed system, contains a proprietary formula combining the speed of chemical sensitivity relief from potassium nitrate with the long-term relief of amorphous calcium phosphate (ACP) and fluoride, which precipitates hydroxyapatite and fluorapatite. The combination of compounds successfully occludes the dentin tubules (Figure 2). During the whitening process, the patient is instructed to place the Relief ACP gel into each tooth compartment where sensitivity is felt. Normal wear time is 30 minutes twice daily, with instructions to not eat or drink for 30 minutes after the application. The gel may also be placed on the lingual surfaces during the light activated whitening procedure inoffice and immediately following in the whitening trays for 15 minutes.

Addressing the Demand for Fast Results

Clinical studies have shown that when a light source is added to the whitening process, the results are enhanced. 5 Some studies actually show an additional two shade improvement when a light is used versus no use of a light. As reported in the Journal of the American Dental Association, “Peroxide and light treatment significantly lightened the color of teeth to a greater extent than did peroxide or light alone.”6 In-office teeth whitening systems that are not light activated can achieve the same end result of whiter, brighter teeth, but usually with a higher strength of peroxide or more office visits. The CDA has published the following statement; “The effects of tooth bleaching can be expected to last up to two years, depending on lifestyle choices such as smoking and consumption of staining foods and beverages. The degree to which teeth appear whiter, the evenness of shading and the speed at which the change occurs depend largely on the concentration of the bleaching chemicals and the mechanism of delivery (mouthguard

tray, strip delivery or paint-on method). The current literature does not indicate that power- or light-assisted (laser) bleaching produces whiter teeth, although the bleaching process occurs more quickly with these methods.” 7 The general consensus is that light activation does accelerate or activate the whitening process however the end result versus nonlight activated is relatively similar over time. To this point, a comparative in vivo study to assess the whitening effect of two professional bleaching regimens (Philips Zoom White Speed LED Accelerator vs. Ultradent Opalescence Boost PF) was conducted by Y Li et al at Loma Linda University producing some compelling results. 8 Immediate post bleaching resulted in over 100% difference in whitening results of Zoom vs. Boost and seven day difference of 55% (6.34 vs. 4.08). A second study comprised of a randomized, parallel-design clinical trial was conducted to assess tooth bleaching efficacy and safety of light versus non-light activated chairside whitening. The objectives of the study were to characterize the extent to which the safety and efficacy profile of Philips ZOOM WhiteSpeed (25% HP) and Ultradent Opalescence Boost PF (40%HP) cosmetic whitening regimens differ immediately following and at seven and thirty days post bleaching application. Median ΔE values for instrumental color change immediately post-whitening were 5.12 for Zoom and 2.55 for Boost (p<0.0001). At Day 7, ΔE outcomes were 6.34 for Zoom and 4.08 for Boost (p=0.0059). At Day 30, ΔE outcomes were 6.03 for Zoom and 3.44 for Boost (p=0.0019). The difference between treatments at each time point was statistically significant. The percentage of subjects who reported ‘no sensitivity’ immediately post whitening was 98.5% for ZOOM and 98.6% for Boost. At day seven, subject-reported values for ‘no sensitivity’ were 82.1% for ZOOM and 79.4% for Boost9 (Figure 3). An in vivo study to assess the color change of vital teeth exposed to bleaching performed with and without supplementary light resulted in the following conclusions;

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ORAL HYGIENE • Treatment with supplementary light showed significant greater changes in color compared to treatment without light when assessing using instrumental methods. The same was determined for the visual method10 (Figure 4).

Conclusion The evidence based decision making model takes into consideration scientific evidence, clinical/patient circumstances, patient preferences or values, our own experience and judgment. A comprehensive client assessment must always be conducted prior to selecting an appropriate whitening product and protocol. Each recommendation must be client specific in order to maximize the outcome of the treatment. With advancements in innovative product design, there are a number of options that deliver fast, comfortable and effective results. Be educated, be informed and make the best choice for your dental hygiene client! n Disclosure Statement: Jo-Anne Jones serves as a Key Opinion Leader for Philips Oral Healthcare.

REFERENCES 1. Haywood, VB. Tooth Whitening: Indications and outcomes of Nightguard Vital Bleaching. 2007 2. Tooth Whitening/Bleaching: Treatment Considerations for Dentists and Their Patients. ADA Council on Scientific Affairs. Revised November 2010 3. Leonard RD Jr. Haywood et al. Nightguard vital bleaching of tetracycline stained teeth; J Esthet Restor Dent. 2003; 15(3):142-152 4. Browning WD. Haywood VB. Hughes N, Cordero R. Prebrushing with a Potassium Nitrate Dentifrice to Reduce Tooth Sensitivity During Bleaching Evaluated in a Practice-Based Setting. Compendium 2010; 31(3):220-225. 5. Ontiveros JC, Paravina R, Ward MT. Clinical Evaluation of a Chairside Whitening Lamp and Bleaching Efficacy. Journal of Dental Research 87 (Special Issue

A): 1081, 2008. 6. Tavares M, Stultz J, Newman M et al. Light augments tooth whitening with peroxide. JADA, Vol. 134, February 2003, p167-175. 7. CDA Position on Tooth Bleaching and Whitening. November 2007. http://www. cda-adc.ca/_files/position_ statements/ toothBleachingAndWhitening.pdf (Accessed March 2013) 8. A comparative study to assess the whitening effect of two professional bleaching regimens. (Loma Linda University Li Y, et al) (Philips Zoom WhiteSpeed LED Accelerator vs. Ultradent Opalescence Boost PF). 9. A Randomized, Parallel-Design Clinical Trial to Assess Tooth Bleaching Efficacy and Safety of Light versus non-Light Activated Chairside Whitening in vivo study Li Y, Lee S, Kwon S.R., Arambula M, Yang H, Li J, Delaurenti M, Jenkins W, Nelson M, Souza S, Ward M. Data on file, 2012. 10. O ntiveros JC, Paravina RD. Color Change of Vital Teeth Exposed to Bleaching Performed With and Without Supplementary Light. Journal of Dentistry 2009;37:840-847.

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DENTAL MARKETPLACE

Contact: Karen Shaw • tel: 416-510-6770 • fax: 416-510-5140 • e-mail: kshaw@oralhealthgroup.com Toll free: CDA 1-800-268-7742, ext 6770 • Toll free: USA 1-800-387-0273, ext. 6770

PROFESSIONAL SERVICES

Alglobe • • • • • •

Construction Company

20 years construction experience Dental office construction and design + cabinet making. Provide turn key operation to dental office. Reliable construction timing, Good following up service after construction. Call: Stanley New dental location and lease negotiation. Tel: (416) 321-3313 Save time, save money. www.alglobe.com

ONTER CONSTRUCTION • Specialized in dental office design & construction. • In-house architect and interior designer. • We are qualified code consultants to review all drawings and make your building permit application easy. • Own millwork facilities for best quality of custom built cabinets and time control of your project.

Tel: (905) 793-2344

www.onterconstruction.com

PRACTICES & OFFICES INDEPENDENT DENTAL HYGIENE CLINIC FOR SALE

11 year old well established practice located near Victoria, BC, on Vancouver Island. Successful 2 op, beautiful office in picturesque sea side community. One of the first stand alone clinics in Canada. This office is perfect for Hygienists as well as Dentists. Planmeca equipment. Financing options available. Contact: 250 888-2378 E-mail: vihygdent@gmail.com

INGLESIDE, ON

(about 1 hr. from Ottawa/Montreal) 1200 square foot space available for sale or lease. Terms are flexible. Great demand for dentist in the community. Privy to other opportunities in community if current location deemed unsuitable. Please call Bryan (Pharmacy Owner) at 613-537-2477 or email me at inglesidepharmacy@hotmail.com for more information.

BUILD YOUR NEXT DENTAL OFFICE WITH ME

Locations include GTA, Timmins, Cobourg and more. From immediate to 3 yrs. 647-339-6859 Michael Comartin

ONTARIO, CANADA

Oral & Maxillofacial Surgery full scope practice.

This high grossing practice is very profitable. Turn-key office with professional staff and a strong referral base. Principal has full staff privileges and elective operating room time at regional hospital. Asking price is well below appraised value. Principal relocating for family reasons. Please contact George Osterbauer at 416 312-6166.

TORONTO, ON

Two Great locations for a Dental clinic. For information please call 416-839-2542 or Email @ seifadam@yahoo.com

May 2013

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SCARBOROUGH, ON

Dental practice for sale. Located close to large residential area on the main floor of a medical center with street exposure in Scarborough. 3 new dental operatories + 1 plumbed room ready to expand. 800 patients + lots of room for growth. Selling price at fair market value. Contact: scarborough.dental.clinic@gmail.com

DARTMOUTH, NOVA SCOTIA Well established general practice for sale. 1400+Active patients. Beautifully appointed clinic. Store front in high traffic area. Free Parking. Excellent hygiene program and growth potential as current owner refers many procedures and good new patient flow. Owner retiring. Contact: HRMpractice4sale@gmail.com

CENTRAL ALBERTA

Central Alberta Dental Hygiene Mobile Service FOR SALE!!! Small but growing. Selling assets and corporation with approx. 100 active patients. Ideal for RDH wanting an Indep. Practice. Contact lisa@mydazzlingwhites.com

BRAMPTON, ON

Practice for Sale, $1 million. Share sale. Gross in excess of $850,000. Cash flow: $380,000. Contact: practicesale@minnaar.ca

CAREERS OAKRIDGE MALL — VANCOUVER, BC

Looking To Get Paid What You Are Worth? Be Fully Supported, Continue Your Education, Work With A Skilled TEAM, While Earning Performance Bonuses & Incentives… Is This YOUR New “Dental Home”? www.DentalDreamTeam.ca/assistant

Increase revenue in your dental practice. Experienced Certified Orthodontist available to treat patients in your office. BC and Alberta license. Email: tolusast@hotmail.com

ASSOCIATESHIPS KAMLOOPS, BC

Well established, progressive practice in the beautiful Thompson Valley seeking a F/T Associate. Office is newly renovated with well trained, long term staff. Ideal candidate should be motivated, compassionate, and have strong communication and clinical skills . Please forward resume to admin@ aberdeendentalarts.ca

LONDON, ON.

Part-time associate required to work in two busy centrally located family practices. Experienced dentists are preferred. Candidates must be people oriented, and have strong clinical and communication skills. Excellent opportunity for the right individual. Please Email resume to: dfavell@rogers.com

WOODSTOCK, ON Just 30 minutes from London or Kitchener, a great opportunity for associate position and/or buy into a prosperous family practice offering all modes of dentistry. Approaching our 7th year in this modern and beautiful facility, we are having difficulty keeping up with the demand for quality dentistry and our tremendous growth rate. Please send your resumes to woodstockdental@yahoo.com or contact Bianca at 416-244-5544. A seasoned practitioner who is comfortable treating children as well as adults, is preferred — endodontic and orthodontic experience would be an asset, however, all candidates will be considered.

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BARRIE, ON

Needed asap in Barrie. DDS part time leading to full time. Send resume to barriedentist@gmail.com

EAST OF GTA — ASSOCIATE

EAST OTTAWA, ON

Full time associate dentist needed for state of the art practice in a growing bedroom community in East Ottawa, ON. New graduates welcome. Opportunities to buy in. E-mail: lisa-hawkins@hotmail.com

DOVE DENTAL CENTRES

Peterborough 1.5 hours from Toronto. Digital X-rays, Paperless Chart. Contact at Dr. Alex at alexrheedds@gmail.com or 905-706-7665.

Full time associates needed for progressive, modern, multi-location group dental practice in London, Ontario and surrounding area. Interested candidates should forward resume and cover letter to: dovedental@ody.ca

EAR FALLS, ON

ORANGEVILLE, ON

Associate/Locum dentist needed for mature practice with fully booked office 1-2 weeks per month, accomodation provided, pristine wilderness, in NW Ontario 400km from Winnipeg, 45% of gross billings. Send resume to Dr. Matthew Walkiewicz at e-mail: mattjw@kmts.ca

URGENTLY NEEDED: PEDODONTIST

City of Guelph, population 100,000 has only one Pedodontist and needs one more. 1700 sq. feet available in a facility with lots of parking zoned for Dental. Full General Anaesthesia available. Please call Dr. Cooperband (519)767-2886. CAMBRIDGE, STRATFORD, ORANGEVILLE, ON

Cambridge, ON (right off the 401) Stratford, ON (between Kitchener and London) Orangeville, ON (just north of Brampton) Full time or part time. Busy and established offices. Fully paperless/digital, new equipment and leading edge technologies (cerec, lasers, implants, ortho...). Restorative hygienist available. Potential for buyout or partnership for the right person. Email resume to: dentalgroupswo@gmail.com

ASSOCIATE REQUIRED

Full time associate required for busy and growing modern general practice. E-mail: dent.associate@gmail.com

ASSOCIATES FOR HAMILTON & WATERLOO, ON

Associates required, for TWO VERY busy and modern practices with VERY strong new patient flow. E-mail: associatedentist@ymail.com Fax CV: 888-880-4024

LONDON AREA, ON F.T./P.T ASSOCIATE DDS Associate needed for modern clinic, with 3 days hygiene and growing. Present Associate of 2 years leaving province July 1st. Submit resume to info@gbdentalhealth.com or call Dr.B.Hough at (519)238-3384.

ORILLIA, ON

Part time associate required 1-2 days per week for busy general family practice. Please forward resume to dental_2010@live.ca KITCHENER, ON Part time associate dentist needed to join our busy, modern general practice. Seeking a friendly, professional dentist who is comfortable performing general dentistry. Please forward resumes to smilereaction@gmail.com

EDMONTON, AB Looking for an associate (part/full time) to join our group of multidisciplinary practices which are focused on the highest quality of patient care and using the latest technology available. We are looking for a self-motivated, high-energy, clinically strong candidate who is interested in learning and continuing education. This is a great opportunity for the right candidate to grow with our expanding group and to work in a great environment. Buy-in opportunities are also available for the long-term associates. If you are interested, please email your CV in confidence to edmontondentalcareer@gmail.com

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DENTAL MARKETPLACE

ASSOCIATESHIPS OTTAWA, ON

Full-Time Associate Needed. Outstanding opportunity for a dynamic, dedicated team-oriented individual to join a large, well-established group practice in Kanata, (Ottawa) Ontario. Please submit CV by email: hazeldeandental@gmail.com

KITCHENER-WATERLOO AREA Full Time Associate — leading to partnership, neeeded asap. We are a busy small town group of practices with current equipment, long standing staff and great hours. Please reply to dentistsreply@yahoo.ca

CALGARY, AB

Full time associate needed for a new dental office in the Calgary northwest. Please submit your resume to: DrRichardKolen@hotmail.com or fax your resume to 403-638-3604.

CALGARY, AB ASSOCIATE WANTED

New dental office in a great family friendly neighbourhood in southwest area of Calgary. Position for F/T or P/T dentist with hours and days are negotiable. Interest in paediatric and cosmetic dentistry preferred however will consider all interested dentists. Interested individuals should reply in confidence to: drpicard@telus.net

NORTHERN BRITISH COLUMBIA

Full-time or part-time associate needed immediately for established, busy family practice in Burns Lake with high income potential. The clinic features high quality full time hygienists, dental assistants, Cerec and friendly, hard working staff. Contact David: drdwy45@gmail.com or 435-767-8375.

NIAGARA FALLS, ON

McLeod Dental Care invites you to consider this exciting career opportunity. We are interested in a full time associate, who is focused on a long term, exclusive involvement, with our group. We have a long established history of exceptional remuneration. In fact, McLeod Dental Care is the longest standing, original group practice in North America! Our team’s continued success is focused on our patient centered philosophy with an extraordinary staff, and a clear operational process / management platform. Please visit us on our website www.mcleoddentalcare.com, and email our office at nancymcleoddentalcare@gmail.com, to arrange the next steps.

May 2013

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DENTAL MARKETPLACE

ARE YOU A DENTAL ASSOCIATE LOOKING FOR A FULL SCHEDULE?

Newly Renovated, State of The Art Equipment, 10 Operatories, Skilled TEAM, Performance Bonuses & Incentives… Is This YOUR New “Dental Home”? www.DentalDreamTeam.ca/Dentist

PART TIME ASSOCIATESHIP IN AURORA, ON

To take over exisiting patient base, Wed 10-8, Fri 9-4 and alt Sat’s 9-2. Strong surgical skills an asset. Fully digital, oral sedation permit and equipment. Send info to drtalsky@rogers.com

MISSISSAUGA, ON

Growing Mississauga, Practice is looking for a part time ENDODONTIST to work 1-2 days per month. We are currently referring out of our office. Please contact Bonnie: bonnie.rockwooddental@bellnet.ca Tel: 905 624 8917.

BRAMPTON, ON

Friendly and experienced associate needed for busy Brampton office – for Thursdays, Fridays, and every second Saturday. Please contact Patricia @ 905-495-1155 between 5-8pm or email resumes to welcome@fcdo.com

DOWNTOWN TORONTO

Associate dentist needed for a modern dental office located downtown Toronto in the financial district. This is a part-time position (1/day) with possibility of more. Please forward resume at: appts@simcoedentalgroup.com

NIAGARA FALLS, ON

Long term permanent part-time associate needed for progressive general practice. Should be comfortable performing all aspects of general dentistry. Schedule includes days, some nights and alternating Saturdays. Resumes may be faxed to 905-358-6877 or e-mail to info@smileniagara.ca

OTTAWA, ON

Full time associate required for general practice in Ottawa. Please contact: colleen@greatsmile.com

GET PAID UP TO 50% IN CALGARY, AB

An excellent associate opportunity awaits for a motivated dentist 30 minutes east of Calgary, in a rapidly growing practice which provides you with the best to thrive as a dentist; new grads are welcome. Please email resume to: strathmoreassociatedentist@gmail.com

May 2013

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TABER, AB

Full-time dental associate required for a busy, well established dental practice. Future opportunity to buy in. New grads welcome. No evenings or weekends Please respond by e-mail to griziffin@hotmail.com

AJAX, ON Brand new dental practice opening in Ajax for May 2013. We are looking for an experienced Pediatric Dentist who must be open to working evenings and Saturdays. Please send a copy of your cover letter/resume to our Office Manager Samantha at samanthainajax@gmail.com.

FULL TIME ASSOCIATE DENTIST REQUIRED High River, Alberta (30 min. south of Calgary) Busy general practice looking for a highly motivated associate. This is an opportunity to practice in a modern, 7 operatory practice with a team oriented group and established patient load. Excellent production for a highly motivated candidate. Please reply with resume to: highriverdentaladmin@telus.net

NEWMARKET, ON

Associate dentist needed for a modern family oriented dental practice with opportunity for rapid growth. Dentist is required for one – two days including evening during the week and Saturdays. Full time easily attainable. Must be self-motivated, caring individual proficient in all aspects of dentistry and team oriented. Experience is an asset. Please forward your resume to bwinfodental@gmail.com

NORTH SCARBOROUGH, ON

Busy Dental Office in north Scarborough is looking for a FULL TIME Dental Associate. Mon to Sat, Canadian graduate is preferred, Chinese speaking a must. Fax to (416) 492-1800 e-mail: dentistassociates@gmail.com

ONTARIO, CANADA

Associate Buy In Opportunity! Oral & Maxillofacial Surgery full scope practice. Excellent opportunity to be mentored in a very successful practice. This high grossing practice is very profitable. Turn-key office with professional staff and a strong referral base. Principal has full staff privileges and elective operating room time at regional hospital. Asking price is well below appraised value. Principal relocating for family reasons. Please contact George Osterbauer at 416 312-6166.

FULL TIME ASSOCIATE WANTED — NORTHERN ONTARIO (TIMMINS AREA) Bright, busy, modern well established practice. Superior Compensation Package $20K-$25K per month range. Cheerful, professional& efficient staff. Vibrant and active community in pristine setting. Graduates and Experienced Dentists welcome. Please e-mail resumes to firstline_dental@hotmail.ca

MEDICINE HAT, AB

Associate position available in a progressive, busy and collegial practice. The city of Medicine Hat, the clinic and the remuneration are exceptional. Please e-mail CV to cindy@broadwaydental.ca

EASTERN ONTARIO

Sandhu Dental Group is looking for a full time associate starting June 1. Cornwall: Monday to Thursday and 1 Saturday replacing existing full time associate. Minimum 2 year commitment required. Please email your resume to rsandhu@sandhudental.ca and visit our website www.sandhudental.ca

KLEINBURG, ON

Looking for a part-time associate and orthodontist to join our team, which is focused on the highest quality of patient care and using the latest technology available. Located in the Village of Kleinburg. We are looking for a self motivated, high energy and clinically strong candidate. We have a successful clinic that is a great place to practice dentistry!! If you are interested, please e-mail us at: greenappledentistry@gmail.com

ETOBICOKE, ON We’re looking for that unique dentist to compliment our well established practice. Located in a busy Etobicoke area. Two to three days per week leading to a full time position. Please contact Pat Grant via email to pat.grant@rogers.com

EQUIPMENT OTTAWA, ON FOR SALE Dental Equipment: Adec/Belmont Dental and Hygiene Chairs and Sterilization Unit. Purchased 2011 used only for 9 months, almost brand new. Contact: ttwccnt@gmail.com

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1. Burwell A, et al. J Clin Dent. 2010;21(Spec Iss):66–71. 2. LaTorre G, et al. J Clin Dent. 2010;21(3):72–76. 3. West NX, et al. J Clin Dent. 2011;22(Spec Iss):82–89. 4. Earl J, et al. J Clin Dent. 2011;22(Spec Iss):62–67. 5. Efflant SE, et al. J Mater Sci Mater Med. 2002;26(6):557–565. 6. Parkinson C, et al. J Clin Dent. 2011;22 (Spec Iss):74–81. 7. Earl J, et al. J Clin Dent. 2011;22(Spec Iss):68–73. 8. Wang Z, et al. J Dent. 2010;38:400−410.

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Le nouvel outil ProActif de Pro-Émail se base sur l’indice publié de BEWE (examen de base de l’usure par érosion) afin d’aider les professionnels des soins dentaires du Canada à identifier l’érosion par acide et l’usure par érosion, à prendre les patients en charge au fil du temps et à les conseiller quant aux défis que représentent les aliments acides et l’hygiène buccale. Tout cela dans le but de vous aider à mettre davantage en lumière vos patients atteints d’érosion par acide1. MC

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1. Bartlett D, et al. Clin Oral Invest. 2008;12(Suppl 1):S65–S68.

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