Oral Hygiene May 2015 by Annex Business Media

oralhygiene May 2015

Therapeutic Fluoride Varnishes

Expanding

Hygiene's

Role in Healthcare

Nutrition

Counseling in the Office Setting

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Ultimate clean. Superior results. *

Philips Sonicare DiamondClean removes 7x more plaque than a manual brush1 and eliminates surface stains to whiten smiles in just one week.2 And with accessories like an innovative glass charger for home use and a portable charging case, itâ&#x20AC;&#x2122;s the jewel of our collection for good reason.

Call (800) 278-8282 or visit philipsoralhealthcare.com to order yours *Versus a manual toothbrush 1 Delaurenti M, et al. An Evaluation of Two Toothbrushes on Plaque and Gingivitis. Journal of Dental Research. 2012, 91(Special Issue B):522. 2 Data on file, 2010

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oralhygiene contents

Practice Management

Perform a “Probing” Analysis of Your Own System

Cathy Jameson, PhD

Oral Hygiene

Therapeutic Fluoride Varnishes: There has to be a better way!

Karen L. Comisi, RDA, FADAA

Topical Fluoride: Review of Current Recommendations

Kevin Donly, DDS, MS; Shahad Abudawood, BDS

Nutrition

Nutrition Counseling in the Office Setting

Warren B. Karp, PhD, DMD

Clinical

Is Periodontitis an Infectious or an Inflammatory Disease?

16 16

Jo-Anne Jones, RDH

Product Profile

Expanding Hygiene’s Role in Healthcare

Julie DiNardo, RDH

Editorial The Importance of Continuing Your Continuing Education

News Canada’s Favourite Hygienist The Listerine Challenge Dentists at Queen’s Park

New Products Dental Marketplace Editorial Board Members Lisa Philp | Kathleen Bokrosssy Debra Englehardt-Nash

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Cover: ©Erdosain/Getty Images/Thinkstock

Departments

May 2015

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One in five has it.

Many don’t know it.

They also may not know the oral health consequences.* They’re waiting for guidance.

Dry mouth is an oral health concern that patients are often unaware of. Patients who are on multiple medications are most at risk. So when you recognize the signs, have the conversation about dry mouth and how Biotène® can help.

www.biotene.ca

BIOTÈNE is a registered trademark of the GlaxoSmithKline group of companies. * Dry mouth can disrupt the oral health environment and lead to halitosis, demineralization, increased caries4,5. 1. Sreebny LM. A useful source for the drug-dry mouth relationship. J Dent Educ. 2004;68:6–7. 2. Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004;38:236–240. nd 3. Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth, 2 edition. Gerodontology. 1997;14:33–47. 4. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138:15S–20S. 5. Fox PC. J Clin Dent. 2006;17 (Spec Iss):27–28.

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editorial

The Importance of Continuing Your Continuing Education Taking a slice from the Ontario Dental Assistants Association homepage, as healthcare professionals, you can’t afford not to be current in thought and in practice. The health and well-being of your patients, not to mention your career, depends on it. Changes in government regulations, infection control and patient care, not to mention the incredible pace of change in technology, demand your constant continuing education. Not only are you constant learners, you are, of course, front-line educators and you and your opinions are sought out and respected. Case in point, albeit a US example, the American Dental Hygienists’ Association supports the new community water fluoridation recommendations issued by the US department of Health and Human Services. The ADHA is a supporter of community water fluoridation — the ADHA’s Policy Manual states that community water fluoridation is a “safe and effective method for reducing the incidence of dental caries.” In addition, the organization also promotes the “education of the public and other health professionals regarding the preventive and therapeutic benefits of fluoride.” “As dental hygienists, it’s important that we educate the public on the preventive benefits of community water fluoridation,” said ADHA President Kelli Swanson Jaecks, MA, RDH. “Community water fluoridation serves as an important measure that has been shown to lower the rate of dental caries. It is vital that we continue to utilize water fluoridation to help the public achieve their optimal oral health.” When measuring the value of continu-

ing education, I’d ask you to include the importance of learning as a team rather than learning in isolation. When you attend a CE course as a team you are hearing the same message and can discuss what you learned, what each team member took away, how you can implement what you learned in your own office, even how you can use what you learned to improve relationships with the dentist. And speaking of, does your dentist pay for you to attend CE courses or does he/she say “I’m not paying, what if they leave!” We know there is bad science out there. We know there is bad pharma. We know study sponsors get the results they want. We also know that patients need to arm themselves and take personal responsibility for their health and well-being. We know the proven links between dental health and overall health are piling up. And we know that a continually educated dental hygienist is a practice’s most valuable asset. The importance of ongoing education to hygienists’ roles as front line educators is recognized by entities such as the Oral Wellness Learning (OWL) Institute for Dentistry (www.owldentistry.org), launching this fall. OWL, led by Sara De Nino Paone, a career hygienist and dental education consultant, focuses on helping practices embrace a common philosophy, common system protocols, and a common commitment to achieving higher levels of patient engagement through education and awareness raising tools. By offering three full days of instruction OWL aims to offer a comprehensive alternative to hygienists and encourages multiple team members to participate.

Catherine Wilson

Editor

May 2015

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news briefs

Miele Launches Nationwide Competition to Name ‘Canada’s Favourite Hygienist’ Miele Professional, the brand’s commercial portfolio featuring dental, medical, commercial laundry and dishwashing products, is hosting a competition within the Canadian dental industry in search of Canada’s Favourite Hygienist. Hygienists have an opportunity to be nominated and voted for on the competition microsite for a chance to be named ‘Canada’s Favourite’. The winning hygienist will receive the Miele G7881 Dental Disinfector for their office as a reward for the entire team, plus the Miele G4925 dishwasher for themselves. One lucky voter will also win a Miele vacuum. Miele’s ‘Canada’s Favourite Hygienist’ competition will run until June 30th, 2015. Hygienists are nominated for entry and voted for based on participant profiles on the competition microsite. Complete details on the competition, including entry, voting, prizing, and full rules and regulations can be found at www. miele.ca/dentalcontest.

The Listerine Challenge The Canadian Dental Hygienists Association (CHDA) announced an exciting opportunity to help raise $10,000 for the Canadian Foundation for Dental Hygiene Research and Education (CFDHRE). This year, the CDHA partnered with the LISTERINE® Challenge, a campaign running until July 15th, that hopes to help Canadians reverse early gum disease. Participants are en-

May 2015

a newcom business media publication Senior Sales Manager: Tony Burgaretta 416-510-6852 Editorial Director: tburgaretta@oralhealthgroup.com Catherine Wilson Classified Advertising: 416-510-6785 Karen Shaw cwilson@oralhealthgroup.com 416-510-6770 kshaw@oralhealthgroup.com Assistant Editor: Jillian Cecchini Dental Group Assistant: 416-442-5600, ext. 3207 Kahaliah Richards jcecchini@oralhealthgroup.com 416-510-6777 krichards@oralhealthgroup.com Art Direction: Associate Publisher: Andrea M. Smith Hasina Ahmed Production Manager: 416-510-6765 Phyllis Wright hahmed@oralhealthgroup.com Circulation: Senior Publisher: Barbara Adelt Melissa Summerfield 416-442-5600, ext. 3546 416-510-6781 badelt@annexnewcom.ca msummerfield@oralhealthgroup.com Advertising Services: Vice-President: Joe Glionna Karen Samuels 416-510-5190 President: ksamuels@annexnewcom.ca Jim Glionna

couraged to swish twice-a-day to start a pattern of behaviour to help them get on the road to good oral health. www.listerinechallenge.ca

Ontario’s Dentists tell Government: We Can Help in the Fight Against Poverty Ontario dentists and the Wynne government agree that publicly funded dental services are proven tools in the fight against poverty. As frontline care providers, Ontario’s dentists know how important it is that Ontario’s low income families receive high-quality dental services. Dental services, including preventive care and treatment, reduce barriers to work and education. To this end, 50 Ontario Dental Association (ODA) member dentists gathered at Queen’s Park in April to make sure all parties know how important it is that the Wynne government deliver on promises to low-income Ontario children and youth. ODA President, Dr. Gerald Smith, asked Premier Wynne and Minister of Health and Long-term Care, Dr. Eric Hoskins, to work with his association to deliver high-quality public dental services to those most in need. Ontario spends the lowest amount per capita in Canada on public dental services – just $5.67 per person. The next lowest province, New Brunswick, spends more than twice that amount ($13.73 per capita). The Canadian average, at $19.54 per capita, is almost four times Ontario’s spending on public dental services. For more information, visit the Ontario Dental Association website at www.oda.on.ca. Offices Located at 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 2015, 80 Valleybrook Drive, Toronto ON M3B 2S7.

Subscription rates: Canada $25.00/1 year; $47.00/2 years; USA $46.95/1 year; Foreign $46.95/1 year; Single copies Canada & USA $10.00, Foreign $18.00. GST/HST #103862405RT0001.

Printed in Canada. All rights reserved. The contents of this publication may not be reproduced either in part or in full without the written consent of the copyright owner. From time to time we make our subscription list available to select companies and organizations whose product or service may interest you. If you do not wish your contact information to be made available, please contact us via one of the following methods: Phone: 1-800-668-2374; Fax: 416-442-2191; E-mail: privacyofficer@businessinformationgroup.ca; Mail to: Privacy Officer, Newcom Business Media Inc., 80 Valleybrook Drive, Toronto ON M3B 2S7. Canada Post product agreement No. 40069240. Oral Hygiene is published quarterly by Newcom Business Media Inc., a leading Canadian magazine publishing company. ISSN 0827-1305 (PRINT) ISSN 1923-3450 (ONLINE)

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CASE STUDY 6

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Beth Ryerse RDH, Professional Educator Beth Ryerse has not been compensated to appear in this ad.

Find out how our programs are paying off for other practices at

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We mean business.

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Practice Management

The Hygiene Department

Cathy Jameson, PhD

Founder of Jameson Management, Inc., an international dental consulting firm focusing on all marketing, hygiene and management systems that lead a dental practice to increased productivity and profitability while decreasing stress. Dr. Jameson and Dr. Linda Greenwall of the UK have recently released the book, “Success Strategies for the Aesthetic Dental Practice”, published by Quintessence. The book can be purchased by contacting quintpub.com, info@ jamesonmanagement. com or amazon.com.

Perform a “Probing” Analysis of Your Own System A

t Jameson Management, Inc., we call the hygiene department “The Lifeblood of the Practice.” Why? Because here you have the opportunity to help people get healthy and stay healthy; you provide both prophylactic and therapeutic treatments; you educate patients about the situation in their own mouth and the relationship of their oral health (or the lack thereof) to the overall health of their body; you re-evaluate, re-educate and hopefully, re-motivate a patient to move forward with any dentistry diagnosed but incomplete; and, certainly, you have a chance to educate patients about the new opportunities available in dentistry today.

So, yes — here is the lifeblood of your practice. Each person has a role in developing, nurturing and supporting this department, not just the hygienists. Let me present several “probing” questions regarding your hygiene department, so that you can evaluate the state of health (or need for improvement) in your own hygiene department. Always recognize and acknowledge things that are going well and continue doing those things. However, growth and development come when you identify even the tiniest of improvements that can be made. The combination of several small improvements can make a substantial difference in the department and/or the practice as a whole.

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Practice Management

There is nothing better than showing a person what is going on in their own mouth with photographs 1. Do you pre-appoint your hygiene patients? If so, what percentage of your patients are pre-appointing? Are you tracking that? 2. Do you have a comprehensive non-surgical periodontal therapy program in your practice? According to the Center for Disease Control (CDC) in the U.S., two thirds of American adults have periodontal disease. The statistics in Canada indicate similar statistics. So, what portion of the hygienic procedures that you are providing is periodontal in nature? 50 percent? 60 percent? 3. Do you have openings in the hygiene schedule on a regular basis? How many per day, per week, per month, per year? How many of those are filled? What is the average fee attached to a hygienic appointment? If you are not filling those voids, how much lost revenue is impacting the overall productivity of the practice? 4. W hat percentage of your active patient family is involved with hygiene? An appropriate goal is 85 to 90 percent. What is your percentage? Do you have a specific system for keeping patients actively involved with hygiene? What is it? Could it be improved? How? 5. Do your hygienists have cameras in their treatment room? Are they using those cameras on every patient? Since 83 percent of learning takes place visually, there is nothing better than showing a person what is going on in their own mouth with photographs of similar situations, both before and after treatment. Below are suggested situations where a cam-

era becomes valuable to patient education: a. Dentistry diagnosed but incomplete; b. New areas of concern since the last appointment; c. Periodontal concerns; d. O pportunities for improvement with advanced restorative care; e. O pportunities for aesthetic improvement. In most general practices, approximately 30 to 33 percent of the total production comes from the hygiene department (but there are exceptions). So, calculate your own data. In addition, approximately 40 to 60 percent of the doctor’s restorative or aesthetic dentistry should be coming directly out of hygiene. It is easy to see that the hygiene department provides not only excellent care for patients, but it is here that a practice can ultimately thrive. While it is imperative that a practice has an appropriate number of new patients every month, it is equally imperative that the following two things happen: (1) patients come to you and stay through the hygiene department, and (2) more patients say “yes” to the treatment that is being recommended by the doctor and supported through education by the hygienist. It is a total team effort. From the marketing and throughout the management of your practice, each and every person on the team is responsible for a valuable and critical role. Do your own “probing” of your systems, including your hygiene system to see if “therapy” and renewed health could be beneficial to your practice. n

May 2015

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nutrition Warren B. Karp, PhD, DMD

Professor Emeritus at Georgia Regents University in Augusta, GA. He has a PhD in nutritional biochemistry from The Ohio State University and a DMD from Georgia Regents University. He is an elected member of The American Institute of Nutrition, The American Society of Clinical Nutrition, and is past president of The Georgia Nutrition Council. He has served as the Director of the Nutrition Consult Service at the GRU College of Dental Medicine for over 20 years, appointed to the Governor’s Obesity Taskforce. Dr. Karp will be speaking at Winter Clinic on November 6th, 2015.

Nutrition Counseling in the Office Setting H

ave you ever felt that counseling a patient about nutrition and diet is an exercise in futility? Does it ever lead to any substantial behavioral changes in the patient? If not, why not? Is it that the patient doesn’t care? Or perhaps, you are simply an ineffective teacher. What is actually going on? It turns out that the journey from knowing something about nutrition, to actually doing something about it, is a long and complex trip. As Figure 1 represents, a patient not only has to KNOW, but the patient needs to UNDERSTAND the information. In addition, a patient must be able to APPLY the knowledge to his or her specific life and EVALUATE if this is being done in a satisfactory manner. The patient needs to BELIEVE that the information and change is important and applicable to their own life, and also must have the BEHAVIOURS and SKILLS to make the change. What a long journey. When you counsel a patient, where are you stopping? Unfortunately, most health professionals focus on patient “knowing” and perhaps, even move on to the “understanding” area, but usually go no further. It is rare that we continue the journey with a patient in order to help them integrate the information into their belief systems, their attitudes and feelings, or help them gain the behavioral skills necessary to carry out the changes. Is it any wonder that we, along with patients, of-

ten feel frustrated about the results of diet or nutrition counseling? Most health professionals must fit patient education into an already busy office schedule. In the usual office, it is the health professional who sets the time, the topic, and the place for educating the patient. Health professionals most often use a “teaching” model of patient education rather than a “learning” model. Health professionals most likely do this because it is the way most health professionals, themselves, are educated. It turns out that when it comes to nutrition, adult patients do not respond well to a “teaching” model. Instead, adults want to influence the place, time and type of learning that is about to take place. Adults learn about nutrition and diet most successfully when they are “active” in the learning process. Are you doing most of the talking and suggesting during a nutrition counseling session or is the patient? Adults learn best when they are approached as “adult learners”, rather than children learning mathematics or geography. As emphasized in Figure 2, adults have rich life experiences, and want and need to bring these experiences “to the nutrition counseling table” in order to influence their own learning. The most effective patient learning occurs when the patient learns what they want to learn, and when they are coached on how to discover the information for them-

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nutrition

Patients need to gain the skills to seek out evidenced-based sources of nutrition information to help them make their own knowledgeable decisions. selves. This type of learning turns the patient into the teacher and the health professional into the facilitator. In this educational approach, the patient doesn’t leave the nutritional counseling session with handouts, brochures and “information overload”. Instead, the patient “learns how to learn” about nutrition and learns how to evaluate if they have been successful in using the appropriate resources in meeting their own learning goals. This educational approach does not focus on “fund-of-knowledge” learning. In this approach, thinking about, evaluating and applying nutrition information is the goal. Stated another way, using facilitatory learning, the health professional helps the patient “learn how to learn” about nutrition. “Learning how to learn” is a critical step for a patient in becoming a lifelong learner about diet and nutrition. After all, new dietary guidelines will be published tomorrow, the day after, or next year, along with the appearance of thousands of new food products, TV shows and advertisements. How will a patient make informed nutrition decisions in the future without a health professional standing by? Patients need to gain the skills to seek out evidenced-based sources of nutrition information to help them make their own knowledgeable decisions. How does a health professional switch from a teaching model of nutrition counseling to a

learning model, especially in a busy office environment? For one thing, it requires that the health professional understands and accepts the role of a facilitator. Contrary to initial perceptions, the role of a facilitator is not a passive role. In fact, it is a very active role. Instead of being a teacher, the health professional assumes the role of a learning coach who probes a patient’s understanding of nutrition and diet. As a facilitator, a health professional actively “scaffolds” the nutrition

May 2015

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nutrition

counseling session, so it stays focused on the patient’s learning needs. A learning coach probes a patient’s understanding about a subject, encourages the patient to engage in thinking and discussing a subject, and models thinking and evaluation behavior for the patient. Another important job for a facilitatory health professional is knowing when to be quiet. It is important for health professionals to listen to patients and to “fade out” of the conversation, especially when the patient is thinking about and discussing productive and important nutrition concepts. It may be difficult for a health professional to stay quiet and listen to a patient. Usually, just the opposite occurs in a health professional setting. Facilitative health professionals are not protective of their own beliefs about diet and nutrition; they pay close attention to their patients’ attitudes and feelings about nutrition, not just what a patient knows, but how they feel about what they know. A facilitatory health professional is just as concerned about the relationship with a patient as about the content of what is being learned. Facilitative health professionals are open to feedback from a patient, both as a way of assessing

their own communication and counseling skills, as well as modeling behavior for the patient on ways of accepting constructive criticism. Facilitative health professionals are able to shift the responsibility and “work” of patient learning from their own shoulders onto the patient’s shoulders, where the responsibility truly belongs. As shown in Figure 3, the goal of facilitative learning is to help a patient evolve from seeing a fact about nutrition as an isolated bit of learning, to understanding how the information can be integrated into one’s behavior and culture. The information is learned not simply from the biological or clinical perspective. In addition, the patient learns how to critically self-evaluate nutrition information. For example, is the nutrition information from an evidenced-based scientific source or simply from “the web” or a friend or relative? One goal of learning in an office setting is helping the patient evolve from simply gaining information for short-term use to being able to see information in terms of lifelong value. Nutrition learning needs to evolve from individual learning to family learning, societal learning and cultural learning. Especially in the area of nutrition and diet, the best outcomes occur when a patient’s family and culture are integrated into the learning experience. Helping a patient gain the necessary skills to be better at self-evaluating their own knowledge and information about nutrition is critical to becoming a lifelong nutrition learner. A facilitative health professional probes a patient’s knowledge and understanding of a subject. To do this, certain phrases become helpful. For example, helpful probing questions might include: “What do you think that means?”, “What do you know for sure about that?”, “Do you think there is another possible explanation for what you observed?” and, “Is that something you can find out and where would you find it out?” As a practical approach, what are some things that you can do in a busy office to change the nutrition counseling model you

May 2015 www.oralhealthgroup.com

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nutrition

now use from a teaching model to a patient learning model? Figure 4 lists some suggested components of a facilitative nutrition counseling session. The session might begin by allowing the patient to change or alter the learning environment in some way, within the scope of what is possible. For example, it may be by simply offering the patient a cup of coffee or tea. or asking the patient if he or she would be more comfortable discussing nutrition in the office conference room, rather than in a clinical setting. In addition, nutrition counseling sessions should begin with a few minutes of “warm-up”. The warm-up component serves as a signal to the patient (and yourself) that a different type of education is about to occur. It also serves to include the patient’s culture and family into the conversation. For example, you might mention what movie you took your family to see a few nights ago and then ask the patient if he or she has seen a movie recently. Or “warmingup” might focus on a recent book, trip or pet. During the “warm-up” period of the nutrition counseling session, mention something more personal, not health-related. An important part of a nutrition learning

session is giving the patient permission to choose what is to be learned. A health professional’s role is to help frame and scaffold the patient’s choices, to ensure that the learning stays in an area important for the patient. For example, if you are with an overweight patient with diabetes and periodontal disease, the patient has many things to learn about all of these different areas. If, when you probe a patient about what the patient wants to learn, there is silence, then you might ask your patient if he or she is familiar with the relationship of diabetes with periodontal disease. Is this an area appropriate for learning and discussion today? Or perhaps, your patient would like to review and discuss the current nutrition recommendations for people with diabetes. Maybe your patient is unaware of the oral manifestations of diabetes and the management of these sequelae. Perhaps she or he wants to find out more about this. So, at the beginning of a nutrition counseling session, you can present a stymied patient with learning choices and let the patient decide what is to be learned. The patient may, in fact, bring their own learning issues about diabetes to the table and help YOU learn more about diabetes nutrition and diabetes care, especially from the patient’s point-of-view. Act as a facilitator throughout the nutritional counseling session. One guide to use is to listen to what is happening during the session. Is the patient actively talking and suggesting with you listening, agreeing, disagreeing, probing, and modeling behaviour? Or is the patient sitting quietly and respectfully, listening to you talk? If the latter happens, you can change direction during the session and, with skill and experience, switch the session from a teaching track, back onto a learning track. During a nutrition counseling session, you need to help the patient develop a learning issue. In a facilitative nutrition counseling session, there are no handouts, no brochures, no diets and no lists of “good foods and bad foods.” Rather, the health professional helps

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nutrition the patient develop one or two learning issues and further encourages the patient to choose the one learning issue which the patient would like to research prior to the next encounter. For example, you might say that the patient brought up many excellent questions about nutrition today. Which issue is the most interesting to the patient for discussion at the next session? You might further probe the patient about how they will gain information about their learning issue. If they are unsure, you might suggest ways that you, yourself, would go about finding out information and learning about the subject. This is important to help the patient differentiate between evidenced-based sources of nutrition information and non-evidenced-based sources. Before a patient leaves, you need to notate the learning issue in the patient record, so that you can ask the patient about it at the next patient encounter. One important aspect of facilitatory learning is “follow-up”. Every nutrition counseling session needs to have an evaluation component. Evaluation or feedback, as it is sometimes called, needs to focus on behaviours rather than personalities. And, ideally, the evaluation component during a counseling session, should begin with self-evaluation of your own behaviour during the session. This aids the patient in understanding what is expected when it comes to the patient’s turn at selfevaluation. Evaluation should be focused on “more or less” behaviours rather than on “right and wrong” behaviours. For example, you might give feedback to the patient that when they used an evidence-based source of information, that is an approach they might consider using more often, and when they relied on information from a television show, that is a source of nutrition information they might use less often. Feedback should be focused on sharing ideas, rather than giving advice. A successful feedback session is characterized by exploring alternative approaches to a problem, rather than on answers and solutions. Is facilitation always a role that a health

professional should assume? No. In clinical situations, such as during a procedure, a health professional will, and should, be directive and decisive. However, a skilled health professional is able to change paradigms when it comes to patient education and learning. An effective health professional is able to “switch hats” and become a facilitator of learning, rather than a nutrition teacher. It may be just the approach you are seeking to turn your nutrition counseling session from an exercise in futility, to a meaningful learning experience, for both you and your patient. n

Further Reading • Bloom BS (Ed.), Engelhart MD, Furst EJ, Hill WH, Krathwohl, DR (1956). Taxonomy of Educational Objectives, Handbook I, David McKay Co Inc., New York, 1956. • Karp WB, The Dentist’s Role in Promoting Health and Preventing Disease, Journal of the Greater Houston Dental Society, 63:34, 1991. • K nowles, MS, Holton, EF, Swanson, RA, The Adult Learner, 7th Edition, Taylor and Francis, New York, 2012. • L aird T, Karp N, Karp WB, Delivering nutrition education in a dental office. Journal of Nutrition Education, 21:32-34, 1989. • McKinney L, Karp NV, Karp WB, Practices and attitudes of dentists toward nutrition counseling, Massachusetts Dental Journal, 44:10-13, 1996. • Murphy M, Porter J, Yusuf H, Ntouva A, Newton T, Kolliakou A, Crawley H; Tsakos G, Pikhart H, Watt RG, Considerations and lessons learned from designing a motivational interviewing obesity intervention for young people attending dental practices: a study protocol paper. Contemporary Clinical Trials. 36:126-34, 2013. • Young S, Karp N, Karp W, Physicians’ and dentists’ attitudes on the role of the dental health care team in a cardiovascular risk factor reduction program. Journal of Public Health Dentistry, 50:38-41, 1990.

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clinical Jo-Anne Jones, RDH

President of RDH Connection Inc.; International Lecturer

Lorne M. Golub, DMD MSc, MD (Honorary)

SUNY Distinguished Professor; Department of Oral Biology and Pathology; Stony Brook School of Dental Medicine, SUNY

Ying Gu, DDS, PhD

Associate Professor; Department of General Dentistry; Stony Brook School of Dental Medicine

Maria Emanuel Ryan, DDS, PhD

Professor and Chair; Department of Oral Biology and Pathology; Stony Brook School of Dental Medicine

Denis Masse, RDH Program Director; International Dental Institute

Jacinthe Simard, RDH

In-office Consultant; International Dental Institute

Is Periodontitis an Infectious or an Inflammatory Disease? T

he cornerstone of the dental hygiene profession is the application of critical thinking. Critical thinking has been defined as “the use of self-correction and monitoring to judge the rationality of thinking. It is the ability to challenge one’s own thinking.”1 Consider the following question: are we treating periodontal disease as an infectious disease or as an inflammatory disease? If periodontitis is simply an infectious disease, one would assume that through the employment of judicious therapeutic measures to reduce the microbial burden at regular intervals, great inroads would have been made in the eradication of the disease. An infectious disease is defined by the World Health Org anization (WHO) as being ‘caused by pathogenic microorganisms, such as bacteria, viruses, parasites or fungi and may be spread, directly or indirectly, from one person to another. 2 As dental professionals, we realize this is simply not the case; a recent CDC report provides the following data related to prevalence of periodontitis in the U.S.: 47.2 percent of adults aged 30 years and older have some form of periodontal disease. Periodontal disease increases with age, 70.1 percent of adults 65 years and older have periodontal disease. 3 We now know that periodontal disease is one of the most prevalent, non-communicable, chronic diseases in our population, similar to cardiovascular disease and diabetes.4 We have treated dental caries as a bacterial infection and we are seeing a strong response to our therapeutic interventions. Conversely, are we achieving our therapeutic endpoints by

treating periodontal disease as an infection? Mechanical debridement, employment of anti-microbials and short-term systemic antibiotic regimens, have simply not sustained the desired therapeutic endpoints we had hoped for. A meta-analysis to study the efficacy of systemic antibiotics was conducted by CunhaCruz et al. 5 and published in 2008. Historically, systemic antibiotics have been recommended for the treatment of destructive periodontal disease. However, Cunha-Cruz found a lack of association between systemic antibiotics and tooth loss in adults, coupled with the growing concerns about antibiotic resistance, reinforcing the concern that prescription of antibiotics for chronic destructive periodontal diseases should only be made with extreme caution. 5 (Note in the same statistical study, sub-antimicrobial doxycycline, i.e. Periostat, was found to be associated with decreased tooth loss.) The late 80s began to delve into the aspect of a destructive host response as a causative etiologic factor in periodontal disease. A number of landmark studies began to draw the conclusion that periodontal disease was an inflammatory disease.6 These papers, and literally hundreds of related papers, brought to the forefront the realization that it was the inflammatory response, followed by the acquired immune response, that drove the pathogenesis of periodontal tissue destruction.7 Emerging data suggests that periodontal pathogens, that are more or less universally present in low numbers, use inflammation to provide an environment to foster their growth. The implication is that the pathologic biofilm “emerges” as a result of inflamma-

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Research has shown that periodontal disease is associated with several other diseases. For a long time it was thought that bacteria was the factor that linked periodontal disease to other diseases in the body; however, more recent research demonstrates that inflammation may be responsible for the association. Therefore, treating inflammation may not only help manage periodontal diseases but may also help with the management of other chronic inflammatory conditions. Source: www.perio.org/consumer/other-diseases tion.7 Traditional means of identifying active disease have relied upon the measurement of pocket depths, which are often indicators of past disease, and not necessarily current ac tive disease. Therefore, the focus should be on inflammatory biomarkers in addition to longitudinal measures of CAL. The transition from infectious disease to inflammatory disease was redefined by the American Academy of Periodontology (AAP) in 2008. Today, the AAP refers to periodontitis as an inflammatory disease with far reaching destructive effects on sys temic health. “For a long time, it was thought that bacteria was the factor that linked perio dontal disease to other disease in the body; however, more recent research demonstrates that inflammation may be responsible for the association. Therefore, treating inflamma tion (and the resultant increase in host-de rived, tissue-destructive enzymes, e.g., colla genase plus other MMPs) may not only help manage periodontal diseases, but may also help with the management of other chronic inflammatory conditions.” 8

Tissue Destruction Mediated by Inflammation

An article published in TIME magazine, ti tled ‘The Secret Killer’, positions the acute inflammatory response as a lifesaver that ini tially enables our bodies to fend off bacteri al, viral and parasitic invasions.9 The very moment any one of these intruders enter, a well-functioning immune system will react and engulf foreign invaders, aiding in con trol of the inflammatory response. Under

normal conditions, the process subsequently subsides and our bodies are then given the chance to heal. However, when in the pres ence of a variety of inflammatory diseases associated with periodontitis (e.g. Crohns disease, rheumatoid arthritis, CVD), this process is not “resolved”, then prolongation of the inflammation leads to destruction of the host tissues. One of the most widely studied topics of medical research today is the destruction caused by the inflammatory pathway when a transient infection becomes chronic. The very thing that will perform well with a tran sient infection can literally turn the body against itself when the inflammation becomes chronic. Today’s population is subjected to the attributes of a Western lifestyle, such as a diet high in sugars and saturated fats, accom panied by little or no exercise, making it far easier to sustain chronic inflammation.9 The role of chronic inflammation and its association with today’s most prevalent dis eases, such as cardiovascular disease, Alz heimers, cancers, diabetes and autoimmune disorders, are well documented.10 Coronary Artery Disease (CAD) remains the number one cause of death in the world. While tradi tional risk factors partially account for the development of CAD, chronic inflammation has been postulated to play a role in the development and propagation of this dis ease. A systematic review was carried out by Roifman et al. and published in the Cana dian Journal of Cardiology. The purpose of this systematic review was to determine if patients with chronic inflammatory diseases

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The longer the inflammation persists, the higher the risk of associated carcinogen esis.15 The chronic inflammatory states asso ciated with infection and irritation may lead to environments that foster genomic lesions and tumor initiation.16

Treating Periodontal Disease as an Inflammatory Disease Figure 1. Chronic Inflammatory Process. (Acknowledgment Dr. LM Golub)

Figure 2. Sub-antimicrobial Dose Doxycycline.

have higher rates of cardiovascular disease. The results indicated that patients with chronic inflammatory conditions are at ele vated risk for the development of CAD.11 Chronic inflammation is now accepted as playing a potentially important role in the promotion of atherosclerosis, a main cause of CAD.12 In this regard, chronic periodontitis is a very common chronic inflammatory disease, which is increasingly being recognized as hav ing an association with, and a potential causal relationship to, coronary artery disease.13,14 A substantial body of evidence supports the conclusion that chronic inflammation can predispose an individual to certain types of cancer, as demonstrated by the association between chronic inflammatory bowel diseas es and the increased risk of colon carcinoma.

Do we really understand the far reaching de struction of inflammation on the entire body? If so, are we treating periodontal disease as it has been defined by leading authorities as an inflammatory disease? The foundational characteristics of all inflammatory diseases is the up-regulation of cytokines, prostaglandins, MMPs (i.e. hostderived, tissue-destructive matrix metallo proteinases), reactive oxygen species, etc. The only apparent difference between an inflammatory response in these diseases, such as rheumatoid arthritis, atherosclerosis, Crohn’s and periodontal disease, is the ana tomical location. Periodontal disease is a chronic inflamma tory disease resulting in alveolar bone loss. The release of excessive MMP-8 or collage nase (as well as other less prominent MMPs, i.e. MMP-13, MMP-12, plus other proteinas es) is a key event in the pathogenesis of peri odontal disease. Collagen forms 60 percent of the gingival tissues and the periodontal ligament. Moreover, 90 percent of the organ ic matrix (living part) of bone is collagen; cal cium phosphate crystals are imbedded within this collagenous matrix to provide the min eral (hard) part of this tissue. The destruc tion of collagen in all the periodontal tissues is largely mediated by elevated MMP levels attacking the living organic matrix. A major event in the link between local periodontitis and relevant systemic/medical conditions is the release, from the inflamed periodontal tissues of inflammatory media tors into the bloodstream, which subsequent ly travel to the liver. The following cascade of events illustrates how chronic inflammation plays a strong etiologic role in the exacerba

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E H T T H L I L N A G F S YOUR PATIENTS O MAY TAKE TO BED

THEIR DENTURES SHOULDN’T BE ONE OF THEM. 1-5

Though your patients may take comfort in keeping their dentures in at night, the consequences can be severe, from increased odour to fungal infections to increased caries.1–5 Guiding your patients through the best nighttime routine could be one of the most important conversations you have with them. That means removal and gentle, antibacterial cleaning with Polident®.6 1. Jeganathan S, Payne JA, Thean HP. Denture stomatitis in an elderly edentulous Asian population. J Oral Rehabil. 1997;24(6):468–472. 2. Emami E, de Grandmont P, Rompré PH, et al. Favoring trauma as an etiological factor in denture stomatitis. J Dent Res.2008;87(5):440–444. 3. Barbeau J, Seguin J, Goulet JP, et al. Reassessing the presence of Candida albicans in denture-related stomatitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(1):51–59. 4. Arendorf TM, Walker DM. Oral candidal populations in health and disease. Br Dent J. 1979;147(10):267–272. 5. Compagnoni Ma, Souza RF, Marra J, et al. Relationship between Candida and nocturnal denture wear: quantitative study. J Oral Rehabil. 2007;34(8):600–605. 6. GSK data on file, 2011.

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clinical tion of a stroke or a myocardial infarction. Once inflammatory mediators are present in the blood (i.e. derived from the inflamed gingiva), the liver is stimulated to produce acute phase proteins, which are diagnostic markers and mediators of inflammatory disease; one being C-reactive protein or CRP (Figure 1). To add insult to injury, LDL (low density lipoprotein) cholesterol, when oxidized by the inflammatory response, then forms a chemical reaction with CRP. The end result is a complex of oxidized LDL combined with CRP, which is taken up by macrophages in the atheroma. These macrophages differentiate into foam cells, which is characteristic of this lipid-laden plaque in the arteries. They are an indication of plaque build-up in atherosclerosis, which is commonly associated with increased risk of heart attack and stroke. The foam cells, in turn, release MMP’s, such as MMP-8, also known as collagenase. Collagenase’s primary function is to breakdown collagen. The collagen rich protective cap, which encapsulates the atherosclerotic plaque, is now in great danger. The protective cap destroyed by collagenase results in rupture, thrombosis, followed by stroke or a myocardial infarction (heart attack).

A Call to Action We can no longer afford to ignore the impact of the most common chronic inflammatory disease known to mankind; periodontitis. The consequence of relentless ongoing periodontal inflammation makes healing impossible and systemic disease more likely. The human body is continually destroying old collagen, followed by a renewal process of normal turnover. In chronic inflammatory disease, collagenases, particularly MMP-8, become excessive. The repair process is halted. Until the cessation of inflammatory response, we are at a standstill in our treatment progress, resulting in further destruction and unpredictable outcomes. What if we could slow down the breakdown of collagen or somehow inhibit the production of collagenase to an acceptable level? In research conducted at Stony Brook on collagen-destruction mechanisms and perio

incidence (%) of adverse reactions in periostat clinicals trials Headache Common Cold Flu Symptoms Tooth Ache Periodontal Abscess Tooth Disorder Nausea Sinusitis Injury Dyspepsia Sore Throat Joint Pain Diarrhea Sinus Congestion Coughing Sinus Headache Rash Back Pain Back Ache Menstrul Cramps Acid Indigestion Pain Infection Gingival Pain Bronchitis Muscle Pain

periostat 20 MG bid (N=213)

Placebo (N=215)

55 (26%) 47 (22%) 24 (11%) 14 (7%) 8 (4%) 13 (6%) 17 (8%) 7 (3%) 11 (5%) 13 (6%) 11 (5%) 12 (6%) 12 (6%) 11 (5%) 9 (4%) 8 (4%) 8 (4%) 7 (3%) 4 (2%) 9 (4%) 8 (4%) 8 (4%) 4 (2%) 1 (≤1%) 7 (3%) 2 (1%)

56 (26%) 46 (21%) 40 (19%) 28 (13%) 21 (10%) 19 (9%) 12 (6%) 18 (8%) 18 (8%) 5 (2%) 13 (6%) 8 (4%) 8 (4%) 11 (5%) 11 (5%) 8 (4%) 6 (3%) 8 (4%) 9 (4%) 5 (2%) 7 (3%) 5 (2%) 6 (3%) 6 (3%) 5 (2%) 6 (3%)

Table 1. Periostat Product Monograph Incidence (%) of Adverse Reactions.

dontal disease, Golub and his colleagues made an unexpected discovery; namely, that tetracyclines, a class of drugs that had been recognized only as antibiotics, were unexpectedly found to block collagenase in mammals.6 This exciting discovery led to further research to develop a formulation of doxycycline that would inhibit collagenase (MMP8) and other MMPs at a blood level so low that it would NOT perform as an antibiotic (Figure 2). The sub-antimicrobial level would eliminate the typical antibiotic side effects (Table 1). The drug today is known as, and prescribed under the trade name, of Periostat® (Figure 3). Over 10 million prescriptions have been written in the U.S.

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Figure 3.

alone, and it is the most widely prescribed drug for treating periodontal disease in the world. The American Dental Association (ADA) Council on Scientific Affairs published the following statement; “Periostat® has been shown to help stop the progression of periodontitis when used as directed as an adjunct to scaling and root planing, in a conscientiously applied program of oral hygiene and regular professional care.” [Note: scientifically, Perio stat® is described as SDD or sub-antimicrobialdose doxycycline.] The science found in the following doubleblind clinical studies on patients with periodontitis, and published in leading journals, is both extensive and compelling comparing SRP + SDD versus SRP + placebo; • Significantly more effective than SRP + placebo with no antibiotic side-effects.17-20 • 75 percent fewer teeth lost than patients treated with SRP + placebo. 21 • 8 0-90 percent reduction of “active” pockets21–27; “active” pockets are defined as those which get deeper with time. • No “rebound” effect.17,28 • 50-60 percent reduction of biologic mediators of tissue breakdown and bone resorption (i.e., MMP-8/collagenase, MMP-9, IL1ß).17,29 • I n rapidly progressing periodontitis, adjunctive SDD (versus adjunctive placebo) produced a 73 percent reduction in “active” pockets; combined with two to three times greater mean attachment gain (i.e. 2.2 mm. vs. 0.8 mm); and significant reduction of BOP.18,24,25

Who Would Benefit from SDD?

With the large baby-boomer cohort aging, our dental hygiene client population is expe-

riencing a rapid increase in diabetes, cardiovascular disease and other prevalent diseases, all with a common denominator; the inflammatory pathway. The success of low dose or subantimicrobial dose doxycycline (SDD), as the first-ever systemically administered collagenase inhibitor drug approved by the U.S. FDA and by Health Canada for periodontal disease, has also made a resounding impact on other inflammatory mediated diseases. As expected, this has gained significant attention from the medical community.

Diabetes Consider the diabetic patient; more than one in four Canadians lives with diabetes or prediabetes. This will rise to more than one in three by 2020. 30 Chronic periodontitis is prevalent and more severe in the diabetic patient. A six-month, multicenter, randomized clinical trial was conducted on participants who had type two diabetes. All were taking stable doses of medications, HbA1c levels between seven percent and nine percent (i.e. poorly controlled hyperglycemia) and untreated chronic periodontitis. Five hundred and fourteen participants were enrolled with the treatment group (n=257) receiving SRP plus chlorhexidine oral rinse at baseline and supportive periodontal therapy at three and six months. The control group (n=257) received no treatment for six months. Enrollment was stopped early because of futility. At six months, mean HbA1c levels in the periodontal therapy group increased 0.17 percent compared with 0.11 percent in the control group, with no significant difference between groups. The study concluded that nonsurgical periodontal therapy did not improve glycemic control in patients with type two diabetes and moderate to advanced chronic periodontitis. These findings do not support the use of nonsurgical periodontal treatment in patients with diabetes for the purpose of lowering levels of HbA1c. 31 However, drastically different results were seen in a separate three-month, randomized placebo-controlled pilot clinical trial, which

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clinical included 45 patients with long-standing type two diabetes and untreated chronic periodontitis. These subjects received conventional nonsurgical periodontal therapy combined with either: (a) a three-month regimen of sub-antimicrobial-dose doxycycline (SDD), or (b) a two week regimen of antibiotic therapy, or (c) placebo. Note that all subjects were taking stable doses of oral hypoglycemic medications and/or insulin. Treatment response was assessed by measuring hemoglobin A1c (HbA1c), plasma glucose, and clinical periodontal disease measures. At one-month and three-month follow-ups, clinical measures of periodontitis were decreased in all groups. At threemonths, mean HbA1c levels in the SDD group were reduced from 7.2 percent units±2.2 (±SD), to 6.3 percent units±1.1, which represents a 12.5 percent improvement. In contrast, there was no significant improvement in HbA1c in the antibiotic (7.5%±2.0 to 7.8%±2.1) or placebo (8.5%±2.0 to 8.5%±2.6) groups. The results of this pilot study suggest that the treatment of periodontitis with sub-gingival debridement and three-months of daily sub-antimicrobialdose doxycycline may decrease HbA1c in patients with type two diabetes taking normally prescribed hypog lycemic agents. 32

Cardiovascular Disease The effect of subantimicrobial-dose-doxycycline (SDD) has been widely studied for its potential to reduce serum biomarkers of systemic inflammation. CRP (C-reactive protein, an acute-phase protein produced by the liver and an important biomarker in the circulation of systemic inflammation) along with several other serum biomarkers, are widely studied risk factors for coronary artery disease (CAD). These patients show elevated CRP in their blood samples, indicating patients at elevated risk for future cardiac events, such as a heart attack. One of

the groups who are particularly at risk for CAD are post-menopausal women. 33,34 A randomized, double-masked, placebo-controlled clinical trial, conducted by Payne et al. and published in JADA in March 2011, randomly assigned 128 eligible post-menopausal women with chronic periodontitis to a twice-daily regimen of subantimicrobialdose-doxycycline (SDD), or placebo tablets, for two years as an adjunct to periodontal maintenance therapy. Following the twoyear regimen, SDD significantly reduced the serum inflammatory biomarkers (CRP and MMP’s) and among women, more than five years post-menopausal, increased the HDL (high density lipoprotein) “good” cholesterol, which is correlated with reduced risk of atherosclerosis). 35 As discussed earlier, chronic inflammation, whereby macrophages secrete excessive MMPs, eventually degrade the collagen rich, fibrous protective cap. This destabilizes the atherosclerotic plaques, leading to plaque rupture, thrombosis, and heart attack (MI). It was hypothesized that if MMP activity could be inhibited or suppressed, there may be less risk of rupture of the protective cap. A randomized, double-blind, placebo-controlled pilot study of six months of SDD, or placebo treatment, to reduce inflammation and prevent rupture events was conducted. A total of 50 patients all diagnosed with severe CAD (i.e. acute coronary syndromes or ACS) were enrolled; 24 randomized to placebo and 26 to SDD (30 patients completed the six month study; 17 SDD and 13 placebo). In the SDD-treated patients, C-reactive protein (CRP) in the circulation was reduced by 46 percent, whereas CRP was not significantly reduced in placebo patients. Interleukin (IL)-6 was decreased in SDD-treated patients but did not decrease significantly in placebotreated patients. MMP-9 (also known as type IV collagenase) was also reduced 50 percent by SDD therapy, whereas it was unchanged by placebo treatment. [It should be recognized that these reductions in CAD biomarkers in the patient’s blood samples are recog-

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nized as indicators of reduced risk for cardiac events, including reduced risk for heart attack]. The study concluded that SDD appears to exert potentially beneficial effects on inflammation that could promote plaque stability, preventing plaque rupture events. 36

Osteopenia/Osteoporosis

The medical condition of osteoporosis, a dis ease characterized by low bone mass and deterioration of bone tissue, leads to in creased bone fragility and risk of fracture, and in many cases, fatality. Twenty-eight per cent of women and 37 percent of men who suffer a hip fracture will die within the fol lowing year. 37 A preliminary study by Payne et al. had previously demonstrated that sub antimicrobial-dose-doxycycline (SDD) treat ment of post-menopausal women with perio dontitis and osteopenia (reduced bone mass of lesser severity than osteoporosis) reduced periodontal disease progression, including decreased alveolar bone loss, biomarkers of collagen destruction, and bone resorption locally in periodontal pockets, in a doubleblind placebo-controlled clinical trial. 38 An earlier study by Golub et al. (1999), us ing a rat model of post-menopausal osteopo rosis, clearly demonstrated that oral admin istration of a NON-antimicrobial doxycycline not only reduced the severity of systemic bone loss in skeletal tissue (femur), but also reduced local bone loss in the periodontium, which was associated with reduced collage nase in adjacent gingival tissues. 39 The National Institutes of Health (NIH) funded study screened 600 women of which 128 were selected. Participants had to be post-menopausal, have osteopenia, radio graphic evidence of alveolar bone loss and not be taking bisphosphonates or other medi cations that would impact osteoporosis. The 128 post-menopausal women with chronic periodontitis and osteopenia randomly re ceived SDD or placebo tablets daily for two years, adjunctive to periodontal maintenance therapy every three to four months. Blood was collected at baseline and at one and two-

year appointments, and sera were analyzed for bone resorption and bone formation/ turnover biomarkers. In conclusion, the twoyear regimen of SDD therapy not only re duced the clinical, radiologic and biochemi cal markers of periodontal disease in post-menopausal women, but also reduced the risk of conversion of mild systemic bone loss (osteopenia) into a severe form of bone disease (osteoporosis).40

Rheumatoid Arthritis (RA) Historically rheumatoid arthritis and peri odontitis have been linked. Is it the lack of manual dexterity and ineffective biofilm re moval that was the accepted explanation sev eral decades ago? We now understand that the link exists through vascular transport into the circulation. The inflammatory medi ators (cytokines, prostaglandin, MMPs) pres ent with oral inflammation, flow into the blood bi-directionally from the gingiva into the circulation, resulting in systemic inflam mation. The profiling of elevated inflamma tory markers is similar for both periodontitis and rheumatoid arthritis. A clinical study was conducted to compare the efficacy of doxycycline plus methotrexate (MTX) versus MTX alone in the treatment of early seropositive rheumatoid arthritis (RA), and to attempt to differentiate the antibacte rial and anti-metalloproteinase (SDD) effects of doxycycline. Sixty-six patients with sero positive RA of <one year’s duration who had not been previously treated with disease-mod ifying anti-rheumatic drugs, were randomized to receive 100 mg of doxycycline twice daily with MTX (high, antibiotic-dose doxycycline group), 20 mg (low, NON-antibiotic-dose, i.e. SDD) doxycycline twice daily with MTX (SDD), or placebo with MTX (placebo group), in a two-year double-blind study. The study concluded that in patients with early seroposi tive RA, initial therapy with MTX plus doxycy cline was superior to treatment with MTX plus placebo. The therapeutic responses to low-dose and high-dose doxycycline were essentially the same, except that the high-dose doxycycline

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clinical group exhibited greater side effects, while SDD was similar to the placebo group. This study demonstrated that the SDD effects on host response were responsible for the beneficial effects on RA, rather than the antibacterial effect of the high-dose doxycycline.41

Conclusion The overwhelming amount of science speaks for itself. Robert Burton, an english scholar at Oxford University in the 17th century, made the following profound statement regarding health: “Restore a man to his health, his purse lies open to thee.” There is no greater wealth or richness in life than good health. Our CDHA professional statement represents our professional mandate very clearly. “I am a dental hygienist. I educate and empower Canadians to embrace their oral health for better overall health and well-being.” It’s time to put our words into action and recognize our role in reducing inflammation, and sustaining overall health for our dental hygiene clients. n

Acknowledgements: The first author would like to acknowledge Dr. Lorne Golub, Dr. Ying Gu, and Dr. Maria Ryan for their assistance in preparing this manuscript.

Disclaimer: The authors received no compensation for the writing of this article.

References:

All sites accessed March 2015. 1. Brookfield S. Developing Critical Thinkers: Challenging Adults to Explore Alternative Ways of Thinking and Acting. San Francisco: Jossey-Bass: 1987. 2. http://www.who.int/topics/infectious_diseases/en/ 3. C DC: Periodontal Disease http://www.cdc. gov/oralhealth/periodontal_disease/ 4. CDC survey finds ‘high burden’ of disease among adults August 30, 2012 http://www.ada. org/en/publications/ada-news/2012-archive/ august/prevalence-of-periodontitis

5. Cunha-Cruz J, Hujoel PP, Maupome G, Saver B. Systemic Antibiotics and Tooth Loss in Periodontal Disease. J Dent Res. 2008 Sep; 87(9): 871-876. 6. Golub LM, Lee HM, Ryan ME et al. Tetracyclines inhibit connective tissue breakdown by multiple non-antimicrobial mechanisms. Adv Dent Res 1998;12:12-26. 7. Van Dyke, TE. Periodontitis is characterized by an immune-inflammatory host-mediated destruction of bone and connective tissues that support the teeth. J Periodontol. April 2014. 8. www.perio.org/consumer/other-diseases 9. http://www.inflammationresearchfoundation. org/inflammation-science/inflammation-details/time-cellular-inflammation-article/ 10. Willerson JT, Ridker PM. Inflammation as a Cardiovascular Risk Factor. Circ Journ 2004; 109: II-2-II-10. 11. Roifman I, Beck PL, Anderson TJ et al. Chronic inflammatory diseases and cardiovascular risk: a systematic review. Can J Cardiol. 2011 Mar-Apr;27(2):174-82. 12. Wilson, PW. Evidence of systemic inflammation and estimation of coronary artery disease risk: a population perspective. Am J Med. 2008 Oct;121(10 Suppl 1):S15-20. 13. C raig RG, Yip JK, So MK, et al. Relationship of destructive periodontal disease to the acute-phase response. J Periodontol. 2003; 74(7): 1007–1016. 14. Friedewald VE, Kornman KS, Beck JD, et al. The American Journal of Cardiology and Journal of Periodontology Editors’ Consensus: periodontitis and atherosclerotic cardiovascular disease. Am J Cardiol. 2009;104(1): 59-68. 15. Shacter E, Weitzman A. Chronic Inflammation and Cancer. Colorectal Cancer, Oncol Journ. January 31, 2002. 16. Rakoff-Nahoum S. Why Cancer and Inflammation? Yale J Biol Med. 2006 Dec; 79(3-4): 123–130. 17. C aton J, Ryan ME. Clinical studies on the management of periodontal diseases utilizing subantimicrobial dose doxycycline (SDD). Pharmacol Res. 2011 Feb;63(2):114-20. 18. A shley RA. Clinical trials of a matrix metalloproteinase inhibitor in human periodontal disease. SDD Clinical Research Team. Ann N Y Acad Sci. 1999 Jun 30;878:335-46. 19. Preshaw PM. Host response modulation in periodontics. Periodontol 2000. 2008;48:92-110. 20. Gu Y, Walker C, Ryan ME, Payne JB, Golub LM. Non-antibacterial tetracycline formulations: clinical applications in dentistry and medicine. J Oral Microbiol. 2012;4: doi: 10.3402/jom.v4i0.19227. 21. C aton JG, Ciancio SG, Blieden TM, et al.

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Treatment with subantimicrobial dose doxycycline improves the efficacy of scaling and root planing in patients with adult periodontitis. J Periodontol 2000:71:521-32. 22. L ee JY, Lee YM, Shin SY, Seol YJ, Ku Y, Rhyu IC, Chung CP, Han SB. Effect of subantimicrobial dose doxycycline as an effective adjunct to scaling and root planing. J Periodontol. 2004 Nov;75(11):1500-8. 23. P reshaw PM, Hefti AF, Bradshaw MH. Adjunctive subantimicrobial dose doxycycline in smokers and non-smokers with chronic periodontitis. J Clin Periodontol. 2005 Jun;32(6): 610-6. 24. Novak MJ, Johns LP, Miller RC, et al. Adjunctive benefits of subantimicrobial dose doxycycline in the management of severe, generalized, chronic periodontitis. J Periodontol 2002:72:762-9. 25. Mohammad AR, Preshaw PM, Bradshaw MH, Hefti AF, Powala CV, Romanowicz M.Adjunctive subantimicrobial dose doxycycline in the management of institutionalised geriatric patients with chronic periodontitis. Gerontology. 2005 Mar;22(1):37-43. 26. Novak MJ, Dawson DR 3rd, Magnusson I, Karpinia K, Polson A, Polson A, Ryan ME, Ciancio S, Drisko CH, Kinane D, Powala C, Bradshaw M. Combining host modulation and topical antimicrobial therapy in the management of moderate to severe periodontitis: a randomized multicenter trial. J Periodontol. 2008 Jan;79(1):33-41. 27. P reshaw PM, Hefti AF, Novak MJ, Michalowicz BS, Pihlstrom BL, Schoor R, Trummel CL, Dean J, Van Dyke TE, Walker CB, Bradshaw MH. Subantimicrobial dose doxycycline enhances the efficacy of scaling and root planing in chronic periodontitis: a multicenter trial. J Periodontol. 2004 Aug;75(8):1068-76. 28. C aton JG, Ciancio SG, Blieden TM, Bradshaw M, Crout RJ, Hefti AF, Massaro JM, Polson AM, Thomas J, Walker C. Subantimicrobial dose doxycycline as an adjunct to scaling and root planing: post-treatment effects. J Clin Periodontol. 2001 Aug;28(8):782-9. 29. Golub LM, Lee HM, Stoner JA, et al. Subantimicrobial dose doxycycline modulates gingival crevicular fluid biomarkers of periodontitis in postmenopausal osteopenic women. J Periodontol 2008:79:1409-18. 30. Diabetes: Canada at the Tipping Point. Canadian Diabetes Association. http://www.diabetes.ca/CDA/media/documents/publicationsand-newsletters/advocacy-reports/canada-atthe-tipping-point-english.pdf Engebretson SP, Hyman LG, Michalowicz 31. BS, Schoenfeld ER, Gelato MC, Hou W, Seaquist ER, Reddy MS, Lewis CE, Oates

TW, Tripathy D, Katancik JA, Orlander PR, Paquette DW, Hanson NQ, Tsai MY. The effect of nonsurgical periodontal therapy on hemoglobin A1c levels in persons with type 2 diabetes and chronic periodontitis: a randomized clinical trial. JAMA. 2013 Dec 18; 310(23): 2523-32. 32. Engebretson SP, Hey-Hadavi J. Sub-antimicrobial doxycycline for periodontitis reduces hemoglobin A1c in subjects with type 2 diabetes: a pilot study. Pharmacol Res. 2011 Dec; 64(6): 624-9. 33. R idker PM, Hennekens CH, Buring JE, et al. Creactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med. 2000;342(12): 836–843. 34. R idker PM, Rifai N, Rose L, et al. Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med. 2002;347(20):1557–1565. 35. Payne JB, Golub LM, Stoner JA, Lee HM, Reinhardt RA, Sorsa T, Slepian MJ. The effect of subantimicrobial-dose-doxycycline periodontal therapy on serum biomarkers of systemic inflammation: a randomized, double-masked, placebo-controlled clinical trial. J Am Dent Assoc. 2011 Mar;142(3):262-73. 36. Brown DL, Desai KK, Vakili BA, Nouneh C, Lee HM, Golub LM. Clinical and biochemical results of the metalloproteinase inhibition with subantimicrobial doses of doxycycline to prevent acute coronary syndromes (MIDAS) pilot trial. Arterioscler Thromb Vasc Biol. 2004 Apr;24(4):733-8. 37. http://www.osteoporosis.ca/osteoporosis-andyou/osteoporosis-facts-and-statistics/ 38. Payne JB, Golub LM. Using tetracyclines to treat osteoporotic/osteopenic bone loss: From the basic science laboratory to the clinic. Pharmacological Res. 63 (2), pp 121-129, 2011. 39. Golub L.M., Ramamurthy N.S., Llavaneras A., Ryan M.E., Lee H.M., Liu Y., Bain S. and Sorsa T.: A chemically modified nonantimicrobial tetracycline (CMT-8) inhibits gingival matrix metalloproteinases, periodontal breakdown, and extra-oral bone loss in ovariectomized rats. Ann. N.Y. Acad. Sci., 878: 290-310, 1999. 40. Golub LM, Lee HM, Stoner JA, Reinhardt RA, Sorsa T, Goren AD, Payne JB. Doxycycline effects on serum bone biomarkers in post-menopausal women. J Dent Res. 2010 Jun; 89(6):644-9. 41. O’Dell JR, Elliot JR, Mallek JA, Mikuls TR, Weaver CA, Glickstein S, et al. Treatment of early seropositive rheumatoid arthritis: doxycycline plus methotrexate alone. Arthritis Rheum. 2006;54:621-7.

May 2015 www.oralhealthgroup.com

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Improved oral health for an elderly stroke survivor

Julie DiNardo, RDH

Has been practicing as an independent dental hygienist since 2008 and registered since 1987. Julie owns Gleam Smile Centre in Hamilton, Ontario. She can be reached at gleamsmilecentre@ gmail.com.

Expanding Hygiene’s Role in Healthcare A

s our communities age, so grows the need and opportunity for delivering preventive dental care to a higher-risk population with limited insurance and on fixed incomes. This article outlines a new topical hygiene procedure, which significantly improved the oral health of an elderly stroke survivor. It then considers the broader implications of this case study for expanding hygiene’s importance in Canadian healthcare.

Case Study

In October 2013, a 90-year-old male, who had a stroke paralyzing his right side, visited my clinic suffering from extremely poor oral health. In particular, his gums were severely inflamed and infected with loss of connective tissue and alveolar bone (Figure 1). He also had many exposed root surfaces and a history of caries. The initial treatent plan involved periodontal scaling and root planing, a prophylaxis of the teeth, and homecare instruction. His homecare was, however, constrained by his stroke and by the burden for his overall care on his wife. In May 2014, I presented to the patient and his wife the option of more aggressive preventive care conducted in my practice; specifically, I recommended Prevora (DIN

02046245) to prevent more caries. The patient was agreeable and the caregiver was enthusiastic. The Prevora coating contains 10 percent chlorhexidine in a sustained release formulation. It offers a unique base of evidence from two randomized controlled trials of community-dwelling adults. The College of Dental Hygienists of Ontario has recently permitted hygienists to use Prevora without a prescribing order from the dentist. Prevora was applied four times over eight weeks on the full dentition, up to and including the gingival margin (Figure 2). A fifth single application of Prevora was applied in February 2015, or approximately six months from the last of application. The coating was administered with a mini-brush in a visit lasting less than half-hour. There were no side effects during these treatments, including no tooth staining. The patient was compliant in following the treatment plan. At the six-month recall appointment for Prevora, the patient showed no development of caries but surprisingly also showed significantly reduced inflammation of the gums (Figure 3). This was unexpected in that Prevora was not administered to the soft tissues.

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product profile Figure 1. Soft tissue inflammation of the stroke victim at baseline. Figure 2. Topical application of Prevora up to the gingival margin in a healthy control. Figure 3. Soft tissue of the stroke survivor at six months in the Prevora treatment plan .

Protecting the teeth can mean protecting the gums

The growing number of stroke survivors in our community

Commonly, dental professionals separate the hard tissues from the soft tissues in developing treatment plans. To an extent, this is justified because the biofilm above and below the gum line differs in composition. But the gingival margin is the transition between these distinct biofilms. Metaphorically, it is an estuary of oxygen and nutrition where microorganisms, causing both caries and periodontal disease, are found. Studies show, for example, that the facultative anaerobe Streptococcus mutans, the primary cause of dental caries, populates the gum line, as do spirochetes, which are indicated in periodontal disease. The role of the gingival microbes, in both caries and periodontal disease, may explain the improvement in periodontal health of this stroke victim after the topical application of a high-strength chlorhexidine coating to gum line. Chlorhexidine is a broad spectrum antimicrobial, which disrupts complex biofilms and, in turn, adjusts their mix of microbes. In the case of caries, Prevora reduces the levels of Streptococcus mutans for long periods. In this stroke victim, it evidently reduced pathogens for periodontitis.

As the boomer generation passes from middle age to its senior years, the prevalence of stroke grows from about two percent to six percent.1 There are now more stroke patients in Canada than people who call London, Ontario their home. 2 Many of these patients have limited access to dental services because of their mobility and a limited household budget, and also because of physical limitations, many cannot maintain good oral hygiene. In short, this growing segment of the Canadian adult population is a strong candidate for expanded hygiene services.

The connection between poor gums, poor teeth and stroke There is mounting evidence that periodontal disease is an independent risk factor for stroke. In 2004, Grau et al. reported that patients with severe periodontal disease (such as this patient in Figure 1) had more than four times the risk of stroke than patients with mild or no periodontal disease. 3 More recently, Yu et al. reported that women with incident periodontal disease had 41 percent more chance of a stroke.4 Lafon et al. reported that Continued on page 38

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oral hygiene Karen L. Comisi, RDA, FADAA

Karen is the Practice Administrator and CFO for Dental Care with a Difference®, PC. She is one of the first licensed, registered Restorative Function Dental Assistants in New York state and is a founding member of the Southern Tier Dental Assistants Society. She has been appointed to the NY State Board for Dentistry and is a member of the ADAA, AADOM, OSAP, AADB, and an affiliate member of the AGD).

Therapeutic Fluoride Varnishes: There has to be a better way!

ental professionals who apply fluoride varnish are often using products that produce an unpleasant, gritty sensation after the varnish interacts with saliva. We often hear patients say, “I came in to have my teeth cleaned and now I’m leaving with them feeling more fuzzy than they were when I walked in.” It seems that the benefits of fluoride varnish are diminished in the mind of the patients because of this “fuzzy” feeling from our conventional varnishes. The thick, gritty consistency of traditional varnishes leaves a displeasing coating on the teeth that patients simply do not like. Clinicians can see that the varnish is not a uniform, well-mixed consistency. Upon opening the varnish packet, one often observes a brownish film floating on top of a thicker, white paste. The brown liquid is the resin and solvent components of the varnish, and the white paste-like material is the fluoride and other ingredients. To use the varnishes correctly, you must first mix the separated components together into a uniform mixture, with an even distribution of fluoride. This is like shaking up oil and vinegar in a cruet before pouring it on your salad. If it’s not mixed well, it tastes funny. The same thing happens with these types of fluoride varnishes – if they are not mixed well, they won’t work properly. To get a uniform dose, the

clinician should mix the varnish with the handle of the brush before dipping the brush into the varnish; otherwise, the brush will become saturated with resin and leave behind the fluoride. Consequently, the patient will not get the proper dose or the full benefit of the fluoride application. How much fluoride is released? Can it be released effectively to really be therapeutic? Ideally, fluoride release from varnish should occur between three to four hours after treatment. This is a reasonable amount of time to expect the varnish to remain in contact with the teeth, considering the nature of the material and patient behavior. However, independent studies have shown that many fluoride

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varnishes release very little fluoride.1 In addition to fluoride, calcium and phosphate release is known to be important in the remineralization process. Many varnishes available today do not contain or release a significant amount of the favorable ions during the anticipated treatment period; however,

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References 1. Yapp R, Powers JM. Fluoride Ion Release from Several Fluoride Varnishes. Dent Advis Res Rpt 45:1, March 2012.

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Chlorhexidine is a broad spectrum antimicrobial, which disrupts complex biofilms and, in turns, adjusts their mix of microbes Continued from page 33

bleeding on probing and bone loss were significant independent risk factors for stroke5 and using meta-analysis, Sfyroeras et al. reported that prospective studies indicate a 47 percent increased risk for stroke for patients with periodontal disease.6 It’s possbile that this patient had periodontal disease before his stroke, just as he has this condition after his stroke.

Conclusion The treatment of this stroke survivor with Prevora resulted in improved health of the periodontal tissues. This may be explained by changes to the biofilm at the gingival margin after the application of this highstrength chlorhexidine coating. Improved periodontal health is important to stroke victims. With Prevora, hygienists have a useful tool to help the growing numbers of stroke victims. n

References 1. Mozaffarian D et al. 2015. Executive summary: heart disease and stoke statistics, 2015 update – a report from the American Heart Association. Circulation. 131 (4): 434-441. 2. Wilson M. 2004. Microbial Inhabitants of Humans. Cambridge: Cambridge University Press, Chapter 8. 3. Grau AJ et al. 2004. Periodontal disease as a risk factor for ischemic stroke. Stroke. 35 (2): 496-501. 4. Van der Reijden et al. 2001. Mutans strep-

tococci in subgingival plaque of treated and untreated patients with periodontitis. J Clin Periodontol, 28: 686-91 and Loesche W et al. 1985. Bacterial profiles of subgingival plaques in periodontitis. J Periodontol, 56: 447-456. 5. Yu YH et al. 2015. Cardiovascular risks associated with incident and prevalent periodontal disease. J Clin Periodontol. 41 (1): 21-28. 5. Lafon A et al. 2014. Association between periodontal disease and non-fatal ischemic stroke: a case control study. Acta Odontol Scand. 72 (8): 687-693. 6. Visser MB, Ellen RP. 2011. New insights into the emerging role of oral spirochetes in periodontal disease. Clin Microbiol Infect., 17 (4): 502-512 7. Mozaffarian D et al. 2015. Executive summary: heart disease and stoke statistics, 2015 update – a report from the American Heart Association. Circulation. 131 (4): 434-441. 9. Grau AJ et al. 2004. Periodontal disease as a risk factor for ischemic stroke. Stroke. 35 (2): 496-501. 10. Yu YH et al. 2015. Cardiovascular risks associated with incident and prevalent periodontal disease. J Clin Periodontol. 41 (1): 21-28. 11. L afon A et al. 2014. Association between periodontal disease and non-fatal ischemic stroke: a case control study. Acta Odontol Scand. 72 (8): 687-693. 12. Sfyroeras GS et al. 2012. Association between periodontal disease and stroke. J Vascular Surg. 55 (4): 1178-1184.

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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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Topical Fluoride:

Shahad Abudawood, BDS

Shahad is currently a second-year resident in Pediatric Dentistry at The University of Texas Health Science Center at San Antonio. She is a member of the AAPD and the ADA.

Review of Current Recommendations Abstract

This paper reviews current information for fluoride regimens based on patients caries risk assessment and presents the expert panel, commissioned by the American Dental Associationâ&#x20AC;&#x2122;s (ADA) Council on Scientific Affairs (CSA), evidence-based clinical recommendations for professionally applied topical fluoride. The focus will be on fluoride varnish, gel and foam. The fluoride varnish is the best choice for pre-school aged children zero to five and/or with children with special needs. Fluoride varnish, gel or foam can be used for children six to 18 years. In addition, this paper also supports the ADA and American Academy of Pediatric Dentistry (AAPD) recommendations of the initiation of tooth brushing with dentifrice, as early as the first tooth erupts into the oral cavity, and discusses the recommended amount of fluoridated dentifrice based on age. Finally, the use of fluoride mouth rinses will be addressed.

40â&#x20AC;&#x192;

opical fluoride has contributed to the reduction in the incidence of dental caries in the past half century. There is clear evidence that exposure to fluoride results in a reduction of dental caries in children. Despite efforts to reduce caries and emphasize preventive dentistry, dental caries remains a major oral health problem in most industrialized countries, affecting 60 to 90 percent of schoolchildren world-wide.1 Recent data reported by the National Center for Health Statistics (NCHS) indicates that the overall prevalence of dental caries in primary teeth increased from 40 percent (1988-1994) to 42 percent (1999-2004). 2 Dental caries is a chronic, infectious disease causing dissolution of enamel inorganic substances by acids produced by a biofilm of cariogenic bacteria that metabolize dietary fermentable carbohydrates. It is a dynamic process of demineralization and remineralization. Early enamel caries and demineral-

ization are reversible/arrested by protective interventions, such as the application of fluoride. The availability of low levels of fluoride enhances the reprecipitation process. In fact, arrested lesions are generally considered more resistant to subsequent cariogenic attacks compared to sound enamel. 3 To prevent caries, good oral hygiene, including brushing twice daily with a fluoridated dentifrice, diet modification/nutritional counseling to reduce the frequency of ingesting high fermentable carbohydrates and high sugar content soft drinks, and optimal exposure to fluoride are essential. Sealant application has proven to be an effective way of preventing occlusal dental caries in newly erupted teeth.1,4 Currently, it is recommended by the ADA and AAPD that all children brush twice-aday using fluoridated dentifrice with an appropriate amount of toothpaste based on the childâ&#x20AC;&#x2122;s age. The American Dental Associa-

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oral hygiene

Dental caries remains a major oral health problem in most industrialized countries, affecting 60 to 90 percent of schoolchildren world-wide tion’s (ADA) Council on Scientific Affairs (CSA) recently updated its guidelines, based on scientific evidence supporting the long standing recommendation by AAPD, that caregivers should start brushing their children’s teeth with a smear layer of fluoridated dentifrice as soon as the first tooth erupts, and continue to do so for infants two years of age and younger. Children three to six years of age should use dentifrice, not exceeding a pea-size. 5 According to the recommendation of the AAPD and the American Academy of Pediatrics (AAP), the first dental home visit should be when the first tooth erupts in the oral cavity, but not later than the child’s first birthday. This recommendation aims to reduce caries incidence by providing ongoing comprehensive oral health care. 5

Caries Risk Assessment / Categories Preventive dental regimens should be patient specific according to their caries risk category. It is important to note that an individual’s caries risk may change over time, as the risk factors change and it should be reassessed periodically. Caries risk factors that puts the patient at a higher level of risk includes, but is not limited to poor oral hygiene, developmental enamel defects, low socioeconomic status, irregular dental visits, frequent cariogenic diet, prolonged nursing, taking the bottle to bed, physical and/or mental disability, orthodontic appliances, suboptimal fluoride exposure, xerostomia, radiotherapy and chemotherapy.6

An expert panel established by the American Dental Association (ADA) Council on Scientific Affairs (CSA) recommended the system below to categorize patients with either low, moderate, or high caries risk. This system helps providers make clinical decisions, as well as identify and target high caries risk patients, to apply appropriate preventive measures. In addition to this system, the clinician should use professional clinical judgment of caries risk assessment and the patient’s previous caries experience in determining those children at higher risk for caries who will benefit from topical fluoride application.

Kevin J. Donly, DDS, MS

Kevin Donly is a professor and chair in the Department of Developmental Dentistry and Professor in the Department of Pediatrics at the University of Texas Health Science Center in San Antonio. He is a Diplomat of the American Board of Pediatric Dentistry.

Low caries risk: Individuals with no incipient or cavitated lesions during the last three years, no caries risk factors and optimal fluoride exposure. Moderate caries risk: • Younger than six years: No incipient or cavitated carious lesions during the last three years but the presence of at least one risk factor. • Older than six years, either: One to two incipient or cavitated carious lesions during the last three years. No incipient or cavitated carious lesions during the last three years but the presence of at least one risk factor. High caries risk: • Younger than six years: Incipient or cavitated carious lesions dur-

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For moderate and high caries risk patients, additional preventive measures should be considered ing the last three years, the presence of multiple risk factors, low socioeconomic status, suboptimal fluoride exposure and xerostomia. â&#x20AC;˘ Older than six years, either: Three or more incipient or cavitated carious lesions during the last three years, the presence of multiple risk factors, suboptimal fluoride exposure and xerostomia.

Recommendations for Professionally Applied Topical Fluoride: Low caries risk: May not receive professional topical fluoride. Application of topical fluoride varnish should be based on practitioner professional experience and taking into consideration patientâ&#x20AC;&#x2122;s/parents preference. Moderate caries risk: Will benefit from topical fluoride application every six months. Fluoride varnishes should be considered for children younger than six years of age. Children older than six years of age may receive varnish, gel or foam. High caries risk: Will benefit from topical fluoride application every three to six months. Fluoride varnishes should be considered for children younger than six years of age. Children older than six years of age may receive varnish, gel or foam. For moderate and high caries risk patients, additional preventive measures should be considered, including regular dental visits, pit and fissure sealants, diet counseling and modification, and the use of additional fluoride products at home.

Options Available for Professionally Applied Fluoride:

42â&#x20AC;&#x192;

Multiple forms of professionally applied topical fluoride are available, including gel, foam and varnish. It is important to note that silver

diamine fluoride received FDA approval for caries control in children this past year. Fluoride varnish: Fluoride-containing varnishes typically have a high fluoride content containing five percent sodium fluoride, which is equal to 2.26 percent or 22,600 ppm fluoride ion. Fluoride varnishes have been shown to be as effective as fluoride gel in preventing proximal caries in the primary and permanent dentition.7 Varnishes should particularly be considered for use in children younger than six years and for children with special health needs, where the swallowing reflex has not developed sufficiently. 8 One of the main advantages of fluoride varnish is that it adheres to enamel, extending the fluoride exposure time, and sets rapidly after application, thereby reducing the risk of fluoride ingestion.9 According to Hawkins et al., the fluoride varnish application process was found to be less time consuming, a lower cost, achieved greater patient acceptability and exhibited less patient discomfort and gagging, compared to fluoride gel, especially in preschoolaged children.9 Some patients reported to be unhappy with the temporary yellowish discoloration caused by the application of varnish.10 To overcome this issue, white varnishes are available from some companies, which are virtually invisible when applied. Prior to varnish application, teeth should preferably receive a toothbrush or rubber cup prophylaxis. Teeth should then be dried and varnish can be applied to all teeth using a small brush. Recommend to patients to avoid eating and drinking for at least 30 minutes, skip brushing the day of the application and have a soft diet for at least 12 hours.11 Safety: Regarding safety, fluoride varnish has been proven to be safe for use in young

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Post fluoride application instructions include avoiding eating or drinking for the next 30 minutes children. Measurements of the fluoride level

in the blood plasma and urinary output in children after treatment with professionally applied topical fluoride varnish are far below the toxic level.12 Fluoride gels: Acidulated phosphate fluoride (APF) is the most common gel used by professionals. It contains 1.23 percent or 12,300 parts per million (ppm) fluoride ion. Sodium fluoride gels are recommended over APF for patients that have porcelain crowns because APF has been found to etch the porcelain surface. Stannous fluoride gel is also available for professionally applied topical application. The eight percent stannous fluoride contains 19,440 ppm fluoride ion. Improvement in flavour and shelf life has increased the use of stannous fluoride. All three of the fluoride gels mentioned have been shown to be effective caries preventive agents and the practitioner may decide which system is their preference. APF gel is an acidic agent with a pH in the range of 3-4 pka. It is a potent gastric irritant, which might cause side effects including nausea and/or vomiting during or after application.13 To prevent this side effect, the use of a suction evacuation system while applying the topical fluoride with a tray system is recommended.

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Fluoride foam: A new APF product delivered as foam was introduced into the market in the 1990s, with the intention to improve patient safety and maximize acceptance by minimizing fluoride ingestion. The product has the same fluoride concentration and pH, as the APF gel exposes the patients to only 22 percent as much fluoride, when compared to APF gel. Whitford et al. found significantly less fluoride was applied to the teeth when the APF foam was used, compared to conventional

APF gel products, however, enamel fluoride uptake from foam was as effective as enamel fluoride uptake from gel. It was concluded that the two products are equivalent with respect to enamel fluoride uptake, with less material required of the foam products to cover all the teeth, which significantly reduces the patientâ&#x20AC;&#x2122;s fluoride exposure.13 Sodium fluoride foam is also available for application. Application technique: Upper and lower stock trays should be filled to about one-third to one-half of their depth to cover all teeth without excess fluoride flowing into the vestibules. Visual inspection after placement of the trays on the teeth and the use of low suction to remove excess foam from the vestibule will prevent swallowing of too much fluoride. Post fluoride application instructions include avoiding eating or drinking for the next 30 minutes. As previously noted, silver diamine fluoride has gained FDA approval as a professionally applied topical fluoride. This fluoride agent has been recommended to inhibit or even arrest active caries.14 There has been a slow acceptance for use of this fluoride regimen in the United States, due to teeth discoloring secondary to the uptake of the silver ion into tooth structure. Foundations that may demonstrate less tooth discoloration and the known effectiveness of silver diamine fluoride should allow the integration of this product into our prevention armamentarium. Fluoride containing mouth rinses: The use of over the counter 0.05 percent sodium fluoride solution daily or high dose 0.2 percent sodium fluoride prescription weekly has been found effective as a means of reducing dental caries incidence, especially in high caries risk individuals. On the other hand, low caries risk patients may not receive additional benefits.14 The use of mouthwashes in children less than six years of age and/or chil-

May 2015 www.oralhealthgroup.com

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oral hygiene

The use of professionally applied topical varnishes fluoride gels or foams are recommended for patients categorized as moderate or high risk for caries dren with poor swallowing reflexes is discouraged, due to their inability to rinse and expectorate without ingesting some of the fluoride product. Alcohol free fluoride rinse products are the best choice for children age six to twelve with high caries risk.15

Summary In summary, the recommendations today include the initiation of brushing with a fluoridated dentifrice upon the eruption of the first primary tooth. The use of professionally applied topical varnishes fluoride gels or foams are recommended for patients categorized as moderate or high risk for caries. The addition of daily 0.05 percent sodium fluoride rinse, or weekly 0.2 percent sodium fluoride rinse, can be beneficial to patients at high caries risk but should not be considered for children less than six years of age. n

References:

1. World Health Organization. The World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva: World Health Organization, 2002. 2. National Center for Health Statistics. Health, United States, 2009 with Special Features on Medical Technology. Hyattsville, MD: 2010. 3. Z ero DT. Dental caries process. Dental Clinics of North America. 1999; 43: 635664. 4. Feigal R, Donly K. The use of pit and fissure sealants. Pediatr Dent 2006; 28: 143150. 5. A merican Academy of Pediatric Dentistry. Infant oral health. Pediatr Dent 2000; 22:47– 48. 6. P rofessionally Applied Topical Fluoride: Executive Summary of Evidence-Based

Clinical Recommendations, The ADA Council on Scientific Affairs, May 2006. 7. Seppa L, Leppänen T, Hausen H. Fluoride varnish versus acidulated phosphate fluoride gel: A 3-year clinical trial. Caries Res 1995; 29:327-330. 8. Blinkhorn A, Davies R. Using fluoride varnish in the practice. Br Dent J 1998; 185:280-281. 9. Hawkins R, Noble J, Locker D, Wiebe D, Murray H, Wiebe P, Frosina C, Clarke M. A comparison of the costs and patient acceptability of professionally applied topical fluoride foam and varnish. J Public Health Dent 2004; 64:106–110. 10. Warren DP, Henson HA, Chan JT. Dental hygienist and patient comparisons of fluoride varnishes to fluoride gels. J Dent Hyg 2000; 74:94-101. 11. M iller EK, Vann WF. The use of fluoride varnish in children: A critical review with treatment recommendations. J Clin Pediatr Dent 2008; 32: 259-264. 12. Ekstrand J, Koch G, Petersson LG. Plasma fluoride concentration and urinary fluoride excretion in children following application of fluoride-containing varnish Duraphat. Caries Res 1980; 14:185189. 13. W hitford GM, Adair SM, Hanes CM, Perdue EC, Russell CM. Enamel uptake and patient exposure to fluoride: Comparison of APF gel and foam. Pediatr Dent; 1995; 17:199-203. 14. Yee R, Holmgreen C, Mulder J, Lama D, Walker D, van Palestein Helderman W. Efficacy of silver diamine fluoride for arresting caries treatment. J Dent Res 2009; 88:644-647. 15. Adair S. The role of fluoride mouth rinses in the control of dental caries a brief review. Pediatr Dent 1998; 20: 101-104.

May 2015 www.oralhealthgroup.com

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SALUS™ – Hygiene Sterility Maintenance Container The SALUS hygiene sterility maintenance container eliminates the costly and timeconsuming use of sterilization paper and pouches. SALUS is a reusable container intended to enclose hygiene instruments and is designed to withstand washing and steam sterilization. Instruments can be easily transported chair-side in the rack and sleeve with no extra carrying container. The see-through container allows instant identification of instruments inside.

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Oral-B Black 7000 The Oral-B Black 7000 features 40,000 pulsations and 8,800 oscillations per minute and provides a tooth-by-tooth clean. It offers six different cleaning modes, including a new Tongue Cleaner mode for fresh breath, and is compatible with a range of Oral-B brush heads. The Oral-B Black 7000 also interacts with Oral-B’s SmartGuide technology, a wireless display that acts like a dental professional in your bathroom. It provides feedback as you brush to help guide a thorough, yet gentle, two-minute brushing experience as recommended by dentists.

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doctorsEyes™ Ultrabright Photo Mirrors doctorseyes™ Ultrabright Photo Mirrors offer nearly 100% reflectivity for crisp, accurate intraoral photos. While high-grade rhodium and titanium mirrors can only offer an approximately 75 percent reflectivity, a proprietary coating on German-made Ultrabright Mirrors brings an even greater detail and truer colour to intraoral photos. Removable silicone handles improve gripping ability and operator comfort. Available in six popular sizes, these single-sided front-surface mirrors are fully autoclavable to 390°.

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No-Splash A-W Syringe Tips No-Splash A-W Syringe Tips feature a transparent infection control shield that reduces splash-back and contamination. The shield quickly adjusts forward or backward for optimum performance under varying water pressures and working positions. It aids in cheek retraction and does not interfere with working field or block visibility. No-Splash Tips are precision-molded to deliver powerful dry air, water, and mist functions without leaking.

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Oral Health Group

With four leading publications and a dynamic website, Oral Health Group delivers complete, comprehensive coverage for the dental profession. Our publications serve all members of the dental team: dentists, hygienists, dental lab owners and technicians, dental students and members of the dental industry. Proud to be serving Canadian dentists for over 100 years, Oral Health is the voice of Canadian dentistry!

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May 2015 www.oralhealthgroup.com

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dental marketplace

Hygienists

practices & offices

PRINCE ALBERT, SK

VICTORIA, BC

The Prince Albert, Sask. office of Dr. Jerry Janzen and associate Dr. Jenna Gogolinski are looking for 2 full-time hygiensts. One position would begin May 1, 2015 and one position would begin Oct. 1, 2015. Please submit resume via email: janzen.jerry@gmail.com or by fax to (306)763-7227. If you have any questions, please contact the office at (306)763-7841.

• Dental Clinic Cost Sharing Opportunity in warm and sunny Victoria, BC. • Patient Centered Professional Team Approx. 2200 Sq.Ft. available. • Approx. 1500 Current active Charts with room to Expand to 7 Ops. • Currently 5 Ops. Active. Expected growth to 2500 Active Patients. E-mail: brenda@victoriasmile.com or tel: 250-590-1059.

practices & offices STATE OF THE ART CLINIC FOR SALE — NORTH EASTERN ALBERTA

Large General Practice, 3000+ sqft, 8 ops. Fully updated Adec equipment, 3D conebeam, digital x-rays. Strong Hygiene Program. High grossing. Loyal patient base with many new patients every month. Great location with lots of new development in the area. Significant growth potential, clinic can accommodate 2-3 dentists simultaneously. DentalClinicSale@gmail.com

GREAT LANDLORD INCENTIVES

For lease, unit built by professional dental designers. 3 ops plumbed & wired, led walls, panoramic x-ray, lab, reception area, Dr. office and more. Fast growing town 30 min. north of Mississauga. Call Ralph 1-519-939-2454 email: rrutledge@trebnet.com

BARRIE, ON

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

BRANTFORD, ON Associate needed for very busy family practice in Brantford. We are looking for long term relationship — 2–3 days to start. Please e-mail your resume to apply4@rogers.com

LONDON, ON Looking for a part time associate to work in a modern, busy office for 2 days a week including Saturdays. Please send resume to m_atiya@hotmail.com or fax # 519-649-7714

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MONTREAL, PQ Orthodontist Wanted ASAP

Orthodontist needed for partnership buyin. Highly successful senior practice with an excellent income. Experienced staff will stay. Equipment includes 7 dental chairs, CBCT, state of the art sterilization center, office is fully computerized and paperless. Appraisal done and available upon request. Reason for sale: Owner would desire a smooth transition to retirement. Contact office manager: tonyamugford2015@gmail.com

MIDTOWN TORONTO, ON

Available new retail space on busy Mapleview Dr. West. Ideal for Professional Dental Office. Attractive lease rates. Surrounded by residential. National brands in plaza. Contact Michael Pearlman at (416) 567-5101 or pearlmanmichael@gmail.com

FOR RENT DENTAL OFFICE with 4 dental chairs, equipped with Digital X-rays. Excellent opportunity for a dentist willing to use it for few years. Located Midtown Toronto. Direct Contact: 416-805-3059.

TORONTO, ON

CENTRAL VANCOUVER ISLAND, BC

Small Toronto practice with great potential for sale. Ability to speak Spanish a plus. E-mail: Practicesale@minnaar.ca

TORONTO, ON

Fully equipped dental office, Toronto east end for sale. In an established storefront location (over 40 years). On the Danforth, just steps to a subway stop. Current dentist set to retire. Email to inquire: dental-practice@outlook.com

associateships

www.oralhealthgroup.com

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

Busy, established practice for sale. 3 fully equipped operatories. Digital XRays, digital charts, Pan, excellent gross. High new patient flow, good parking. Reply: options246@hotmail.com

MAPLE, ON

PRACTICE: well lit, clean 3 op established practice on 2nd floor in large plaza. 1500 patients with good hygiene programme. Dentist could transition if desired. E-mail wjurczak1223@msn.com

YONGE-EGLINTON — TORONTO, ON FOR SALE

ORANGEVILLE, ON Established Orangeville office seeking a full-time associate. Canadian experience an asset. Email resume: Progressivedental16@hotmail.com

MULTIPLE LOCATIONS IN ONTARIO

Seeking a Certified Orthodontist and Endodontist to join a well established dental corporation. E-mail: yourdentaldream@gmail.com

THOMPSON, MB

Westwood dental clinic in Thompson, MB team looking for experienced dentist full time or part time. Decent income plus accommodation . E-mail: westwooddental@hotmail.com

New Office Space. (1291 + 973 Sq. Ft.) Best Use Dental or Clinical. For more info please call Majid Torkashvand, Trust Realty Point 647-290-1342

associateships ORILLIA, ON

Part time associate required 1-2 days per week for busy general family practice. Please forward resume to dental_2010@live.ca CORNWALL AND/OR HAWKESBURY(ALFRED), ON AND/OR VALLEYFIELD, PQ

Very busy family dental practices looking for a part time/full time associate. E-mail: lucleboeuf291@hotmail.com

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dental marketplace

associateships NORTH SCARBOROUGH, ON Busy Dental Office in north Scarborough is looking for a FT/PT Dental Associate. Saturdays and weekdays available. Canadian graduate is preferred, Chinese speaking a must. E-mail: dentistassociates@gmail.com BRAMPTON, ON

Associate needed part time for busy, established, family oriented Brampton Office. Graduates of North American Dental programs preferred with a 1 year GPR experience. Please send cover letter and CV to solidassociate@gmail.com

SCARBOROUGH & BRAMPTON, ON ASSOCIATE OPPORTUNITY

Experienced associates and pedodontist required to work in supportive and progressive practice in Scarborough and Brampton on weekdays and weekends. Candidates should enjoy every aspect of dentistry. Fax resume to 416-443-9090 or e-mail: rose-2010@live.ca

VICTORIA, BC PART-TIME associate required for ever growing practice in the beautiful Westshore of Victoria. Position could become full time as required. Please email dawn@westshoredental.com

MISSISSAUGA, SCARBOROUGH, BARRIE, BRANTFORD, ORILLIA, ON Exciting associate positions available for full and part time opportunities. E-mail: yourdentaldream@gmail.com

CRANBROOK, BC Full-time Associate needed immediately. Live and work in a year round recreational paradise, Cranbrook, BC. Rather than plan vacations you can plan your evenings and weekends. Our recent associate laments leaving the area and a full patient base. Our digital office is strong on team dynamics, continuing education and patient care. Enjoy available hospital privileges, a cooperative dental community, city amenities and a small town lifestyle. Future buy-in possible. New Grads welcome!

52â&#x20AC;&#x192;

ARE YOU READY?

Focus on the dentistry without the admin burden. Looking for a dynamic, experienced practitioner for a well established, busy practice in Regina. ReginaDentalOffice@gmail.com

LONDON, ON (and surrounding area) Dove Dental Centres is looking for full time associates for their progressive, modern, multi-location group of dental practices in London, Ontario and surrounding area. Interested candidates should forward resume and cover letter to: dovedental@ody.ca

PICKERING, ON

Please respond to Dr.Harris@shaw.ca

Associate needed for a busy family practice in Pickering. Must have minimum two years Canadian experience. Must be professional with great bed side manner and a team player. Days are M 12-8, W 12-8, F 9-5. E-mail: ashkevari.drhaleh@gmail.com

GRANDE PRAIRIE, AB

TORONTO, ON SPECIALIST REQUIRED

Full time associate dentist required for busy family practice. Looking for highly motivated associate. Our practice includes the latest in technology (IOC camera, digital x-rays, paperless etc.). Large existing patient base. Current associate moving, team in place to help. Please send resume to pmdcgp@telus.net 780-538-2992.

May 2015

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KITCHENER, ON

A busy family practice in Kitchener is searching for a competent and friendly dentist to work 4-5 days a week including some evenings and Saturday. Please email resume to Kaylashiru@gmail.com

RED DEER, AB

SASKATOON, SK Associate required for modern, very busy practice with strong new patient flow. Great opportunity in a University setting. E-mail: associatedentist@ymail.com Fax CV: 888-880-4024.

NEWMARKET, ON

Part time associate needed for our busy, well established dental practice in the heart of Newmarket. Looking for someone who is committed and has excellent chair side manner and motivated to join our team. Please email resumes to drbriancroppo@rogers.com

Established office, a large loyal client base with multiple locations, is seeking a Periodontist, and an Oral Surgeon who is passionate about Dentistry to join our team that thrives on patient experience and excellence. This ideal candidate must be enthusiastic, dynamic and conscientious. Come join our family and help us create a new frontier in Dentistry. E-mail: audrey@sterlingdental.com

Situated in between Edmonton and Calgary, Red Deer is a bustling city with great opportunities. We are in need of an associate for our established, friendly, prosperous and growing family practice offering all modes of high quality/contemporary dentistry. Our successful candidate will have at least 3 years experience and should be comfortable with most disciplines of dentistry including pediatrics. Experience with conscious sedation preferred. Great opportunity to buy in and become part of this lucrative practice!!! E-mail resumes to: bianca@practicesmadeperfect.ca

WHITBY, ON

State-of-the-art new office in Whitby looking for part time associate. 3+ years experience preferred and good people skills a must. Please email resume to dentaljobs1801@gmail.com

BARRIE, ON

Part-time associate required for GP office. 2 days/week, and 1 Saturday/month. Candidate must have a minimum of 3 years experience and comfortable with all aspects of dentistry. Email your resume to gpdentist@outlook.com

LETHBRIDGE, AB ASSOCIATE WANTED Maternity leave coverage to be extended in to a part/time Associate position upon maternity leave return. Position to commence Aug 1, 2015. Office is equipped to provide all aspects of dentistry, including root canal therapy, crown and bridge, Botox therapy and general family dentistry. Inquiries can be made in confidence to shari@abledentalgroup.com or 403-715-5069 or visit our website www.abledentalgroup.com

www.oralhealthgroup.com

15-05-01 9:07 AM

We are looking for a motivated pediatric dentist and a general dentist who enjoys all aspects of dentistry. Come work in a busy, state of the art facility with new technologies. We have an excellent and very friendly team and looking for the right fit to join our practice. Please email us at ryounes@sympatico.ca

KINGSTON AND/OR TRENTON, ON We are looking for a PT and/or FT DDS to join our team at King’s Town Dental and/or Mike the Molar Dental Centre, both well-established dental offices and member of Teeth First Dental Group. This is a great opportunity for professionals that prefer to practice dentistry with flexibility and without administrative responsibilities. If you are interested please call Heather: 613-453-6985.

SAULT STE. MARIE, ON Dental Anesthesiologist and Orthodontist Wanted

Amazing opportunity in our well-established, rapidly growing family practice in beautiful Sault Ste. Marie, ON. Highly skilled support team and a newly expanded, 7500 square foot facility. Be as busy as you want to be. To learn more, visit saultdds.com

KITCHENER/WATERLOO, ON Associate needed 3 days leading to full time, for busy group practice in the K-W area. We offer an amazing opportunity to join an existing office with long standing staff, large new patient flow and no evenings or weekends. Must be dynamic, have leadership skills and enjoy all aspects of dentistry. Reply to: dentistsreply@yahoo.ca

EDMONTON, AB Great opportunity for a motivated associate with some experience. $80,000-$100,000 per month, in a beautiful office with new equipment and a great team. Current associate is moving to another province. Potential of earning up to 45% and longterm buy-in for the right candidate. Experience is an asset but not required. Please email: EdmontonDentalCareer@gmail.com

YELLOWKNIFE, NT

A Full-Time Associate Dentist is needed for Great Slave Dental Clinic in downtown Yellowknife. The current Associate dentist will be taking maternity leave in July 2015; and will be working part-time upon her return. The successful applicant will cover the maternity leave and then continue on as a full-time Associate dentist. Mentorship is available. To send resumes, and for more information please contact: Dr. Roger Armstrong Phone: 867-873-2450 Office Phone: 867-445-8687 Cell Fax: 867-873-5032 Office E-mail: DrRogerArmstrong@gsdental.ca

www.oralhealthgroup.com

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dental marketplace

RED DEER, AB ASSOCIATE REQUIRED

TRENTON, ON

Here is the opportunity! We are looking for a PERSONABLE, PATIENTORIENTED individual to join Red Deer’s fastest growing new dental office. Schedule will be busy from day one as office has a very high volume of new patient flow. Please email resume/CV to drnar@clearviewmarketdental.ca. Talk to you soon!

TORONTO, ON ASSOCIATE REQUIRED

Established office, a large loyal client base with multiple locations, is seeking an Associate who is passionate about Dentistry to join our team that thrives on patient experience and excellence. This ideal candidate must be enthusiastic, dynamic and conscientious. Polish speaking would be an asset. Come join our family and help us create a new frontier in Dentistry. E-mail: audrey@sterlingdental.com

ABUNDANT OPPORTUNITIES IN THE SOUTH GENERAL PRACTITIONERS AND ALL DENTAL SPECIALTIES Able Dental Group Jump start your career with us… Associate or Buy-In Opportunities for the Right Candidate Exciting career opportunities are awaiting you in sunny southern Alberta. We are looking for motivated individuals to join our team of dental professionals who use “big city technology”, yet serving the needs of our community and surrounding areas. The Group has always been one step ahead of the rest to take advantage of new technology and “looking outside of the box” attitude and ideas. We share this enthusiasm with our Associates and Staff, and we pride our company’s success on teamwork and providing a team environment. Visit our website to get an insight on who we are… www.abledentalgroup.com Please contact our office to arrange on-site meeting and viewing Shari Mead, Office Manager 403-327-7227 shari@abledentalgroup.com

May 2015

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dental marketplace

SCARBOROUGH AND OSHAWA, ON

FORT MCMURRAY, AB

Well established practice with outstanding earning potential in Fort McMurray AB, with good patient base and new patient flow. Looking to fill a full-time associate with the opportunity for buy-in. Committed, energetic & flexible experienced with excellent communication skills. Please call Dawn at 780-743-3570 or email mcdg@shaw.ca

TORONTO, ON

Looking for a part-time associate for a very busy office in Toronto at Bayview & Sheppard Office. Mondays 8-6. (With an option to extend to longer hours/days in different offices). Experience an asset but new grads welcome. Email: laserdent@rogers.com

Looking forward to adding a Full Time associate to our 2 practices located in Scarborough and Oshawa. The Scarborough practice is well established and has been in operation for well over 25 years. Ideal candidate must be family oriented, team player and friendly towards patients and staff, confident but well grounded, good communications skill and willing to make a long term commitment to our clinics. Future partnership could be considered for the right associate. E-mail: drvkarlin@hotmail.ca att’n Nikki.

NORTH YORK, ON

Modern digital office treating multiple nationalities requires KOREAN speaking dentist part time ASAP. E-mail: andyc@coradixgta.com

equipment LETHBRIDGE, AB EQUIPMENT FOR SALE Sirona Cerec Bluecam MCXL (2009). Maintained with service contract through Patterson Dental. Comes with milling machine, 168 Cerec blocks, extra oil and filter. All inclusive $50,000. Also available older red cam Cerec (Great if you already have this system and would like an extra scanner for other operatory. $4000 OBO. Inquiries can be made in confidence to shari@abledentalgroup.com or 403-715-5069.

BURLINGTON, ON

Seeking Gently Used Intra Oral Camera Dental office seeking a gently used Kodak 1000 Intra Oral camera, with all components, for little cost. Please contact claire@altondental.com should you have one.

www. oralhealthgroup. com

VICTORIA, BC

Full time associate required to join our dynamic team. Our busy well established restorative, preventative practice is located in the beautiful Westshore of Victoria. Experience, skill, and a pleasant personality a definite asset, as well as knowledge of the Cerec. Please send all replies and resumes to dawn@westshoredental.com

WESTLOCK, AB

Large established Group Practice in Rural Alberta (one hour north of Edmonton) requires a Part-time associate for three (3) full days per week. The principal dentist has a full-time Implant practice (mentoring available). The office is equipped with a CBCT Scanner, Implant equipment and supplies, soft tissue laser, Digital cameras, E4D CAD/CAM Scanner & Crown Milling Machine and computer monitors in every operatory. Experience in molar endo, surgical extractions and sedation an asset. Join our highly trained, terrific, friendly team, with an opportunity for a long-term full-time associateship. Please email your resume to: anitalgh@gmail.com or Phone: 1-888-877-0737 and ask for Corie. HIGH PRAIRIE, AB Full-time associate dentist needed for our wellestablished family practice in High Prairie, AB. Position available immediately. Very busy practice with above average remuneration. Accommodations provided. Please email: drroy04@telus.net if interested.

Advertiser Page Aseptico. . . . . . . . . . . . . . . . . . . . . . . . . 50 Clinical Research Dental. . . . . . . . . . 27 Crest Oral-B, P&G. . . . . . . . . . . . . . 7, 23

DENTAL MARKETPLACE HELP

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HE KNOWS JUST HOW LONG HE NEEDS TO RUN TO BURN 8OO CALORIES. WHAT ELSE WOULD HE WANT TO KNOW? Young people today are staying informed to stay healthy.1 But do they know that healthy foods including fruit, juices and sports drinks are highly acidic and can put their enamel at risk?2-5 Exercise your influence as their trusted dental professional. Help educate every young patient about the effects of acid erosion. Because the investment in their enamel should start today.

For your acid erosion candidate. 1. GSK data on file, 2013. 2. Lussi A. Erosive tooth wear – a multifactorial condition. In: Lussi A, editor. Dental Erosion – from Diagnosis to Therapy. Karger, Basel, 2006. 3. Lussi A. Eur J Oral Sci. 1996;104:191–198. 4. Hara AT, et al. Caries Research. 2009;43:57–63. 5. Lussi A, et al. Caries Research. 2004;38(suppl 1):34–44.

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Propreté ultime. Des résultats supérieurs. *

Philips Sonicare DiamondClean élimine 7 fois plus de plaque qu’une brosse à dents manuelle et élimine les taches de surface pour blanchir les dents en une semaine seulement. De plus, les accessoires tels que le verre chargeur innovant pour l’utilisation à la maison et aussi la trousse de voyage avec chargeur USB, en font le joyau de notre collection.

Composez le (800) 278-8282 ou visitez philipsoralhealthcare.com pour commander le votre *Par rapport à une brosse à dents manuelle 1 Delaurenti M, et al. An Evaluation of Two Toothbrushes on Plaque and Gingivitis. Journal of Dental Research. 2012, 91(Special Issue B):522. 2 Données de dossier

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Sign and initial:

15-05-01 ok as is ok with edits needs edits

7:43 AM

Une personne sur cinq en souffre . 1

Plusieurs l’ignorent . 2

Ils peuvent aussi en ignorer les conséquences sur leur santé buccodentaire*. Ils attendent vos conseils.

La bouche sèche est un risque pour la santé buccodentaire que bien des patients ignorent . Les patients prenant plusieurs médicaments sont le plus à risque . Par conséquent, lorsque vous en reconnaissez les signes, abordez la question de la bouche sèche et de l’aide que peut apporter Biotène®. 2

www.biotene.ca

BIOTÈNE est une marque déposée du groupe d’entreprises GlaxoSmithKline. * La bouche sèche peut perturber l’environnement de santé buccodentaire et causer la mauvaise haleine, la déminéralisation, l’augmentation des caries4,5. | 1. Sreebny LM. A useful source for the drug-dry mouth relationship. J Dent Educ. 2004;68:6–7. 2. Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004;38:236–240. 3. Sreebny LM, Schwartz SS. e A reference guide to drugs and dry mouth, 2 édition. Gerodontology. 1997;14:33–47. 4. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138:15S–20S. 5. Fox PC. J Clin Dent. 2006;17 (numéro spécial):27–28.

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VOS PATIENTS PEUVENT DORMIR AVEC

E S T R D O E S C S H E O T S U E O S T

MAIS LA PROTHÈSE DENTAIRE EN EST UNE DE TROP . 1-5

Vos patients peuvent trouver réconfortant de garder leur prothèse pendant la nuit, mais les conséquences peuvent être graves et englobent la mauvaise haleine, les infections fongiques et les caries plus nombreuses1-5. Guider vos patients à adopter de bonnes habitudes avant de se coucher pourrait être une des plus importantes conversations que vous aurez avec eux. Ces habitudes consistent dans le retrait de la prothèse et un nettoyage doux et antibactérien grâce à Polident®6. 1. Jeganathan S, Payne JA, Thean HP. Denture stomatitis in an elderly edentulous Asian population. J Oral Rehabil. 1997;24(6):468–472. 2. Emami E, de Grandmont P, Rompré PH, et al. Favoring trauma as an etiological factor in denture stomatitis. J Dent Res. 2008;87(5):440–444. 3. Barbeau J, Seguin J, Goulet JP, et al. Reassessing the presence of Candida albicans in denture-related stomatitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Endod. 2003;95(1):51–59. 4. Arendorf TM, Walker DM. Oral candidal populations in health and disease. Br Dent J J. 1979;147(10):267–272. 5. Compagnoni Ma, Souza RF, Marra J, et al al. Relationship between Candida and nocturnal denture wear: quantitative study. J Oral Rehabil. 2007;34(8):600–605. 6. Données internes de GSK, 2011.

/ ou sous licence GlaxoSmithKline Soins de santé aux consommateurs Inc. Mississauga, Ontario L5N 6L4 MC

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Les hygiénistes dentaires du Canada méritent ce qu’il y a de mieux. Miele Professional souhaite reconnaître la « meilleure hygiéniste dentaire au Canada ». Vous pourriez gagner un laveur-désinfecteur Miele Professional G7881 SST (d’une valeur de 13 000 $) pour votre clinique dentaire ainsi qu’un lave-vaisselle Miele G4925 SCUss (d’une valeur de 1 649 $) pour la « meilleure hygiéniste dentaire au Canada ». Elles profiteront ainsi de ce qu’il y a de mieux à la maison comme au travail. Miele. Fabriqué en Allemagne.

Proposer aujourd’hui!

miele.ca/concoursdentaire

Vous trouverez tous les détails sur le site miele.ca/concoursdentaire.

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Un blanchiment aussi unique

que vos patients

Il n’a jamais été aussi facile de trouver le système de blanchiment parfait pour chaque patient. Philips Zoom DayWhite et NiteWhite ont les mêmes formules supérieures que vous connaissez et que vous aimez. Nous les avons repensées pour répondre aux besoins particuliers de vos patients. Il n’est pas surprenant que Philips Zoom soit la marque numéro 1 de blanchiment professionnel demandée par le patient.*

DayWhite

Blanchiment maximal

NiteWhite

Blanchiment maximal

NiteWhite

Rapide, en trois jours

DayWhite

Doux

DayWhite

Retouches

Pour en savoir davantage, composez le (800) 278-8282

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Sensodyne Répare et Protège ®

Activé par NovaMin

Sensodyne Répare et Protège est le premier dentifrice au fluorure à exploiter la technologie du calcium et du phosphate NovaMin brevetée pour faire plus que traiter la douleur liée à l’hypersensibilité dentinaire. ®

• Répare la dentine exposée* : Crée une solide couche semblable à l’hydroxylapatite sur la dentine exposée et dans les tubules dentinaires . 1–5

• Protège les patients de la douleur liée à la sensibilité future* : La couche semblable à l’hydroxylapatite est jusqu’à 50 % plus dure que la dentine sous-jacente et elle résiste aux attaques mécaniques et chimiques quotidiennes . 6

1,6–8

* Avec un brossage deux fois par jour.

Pensez au-delà du soulagement de la douleur et recommandez Sensodyne Répare et Protège.

1. Burwell A, et al. J Clin Dent. 2010;21 (numéro spécial):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 (numéro spécial):82-89. 4. Earl J, et al. J Clin Dent. 2011;22 (numéro spécial):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 (numéro spécial):74-81. 7. Earl J, et al. J Clin Dent. 2011;22 (numéro spécial):68-73. 8. Wang Z, et al. J Dent. 2010;38:400−410.

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PLUS RAPIDE, PLUS FAÇILE, PLUS DOUCE…

BeautiSealant Un systeme de scellant pour puits et fissures a liberation de fluorure

Dites adieu aux gels de mordoncage et rincez les étapes pour toujours � Aucun acide phosphorique etch et rinçage requis � Superior bond force en seulement 30 secondes � Radio-opaques/cariostatic matériau de remplissage � Lisse, livraison sans des bulles � Sans BPA et HEMA

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Scan ici pour plus d’informations sur la technologie Giomer Regardez la neutralisation acide vidéo

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Shofu Dental Corporation • San Marcos, CA

15-05-01 8:49 AM

IL CONNAÎT LA DISTANCE À COURIR POUR BRÛLER 800 CALORIES. QUE VOUDRAIT-IL SAVOIR DE PLUS? De nos jours, les jeunes se tiennent au courant pour vivre sainement1. Mais savent-ils que les aliments sains, comme les fruits, le jus ou les boissons pour sportifs, sont très acides et qu’ils peuvent mettre leur émail à risque2-5? Usez de votre influence en tant que professionnel dentaire de confiance. Informez chaque jeune patient des effets de l’érosion par acide. Puisqu’ils doivent investir dans leur émail dès aujourd’hui.

Pour vos patients prédisposés à l’érosion par acide 1. Données internes de GSK, 2013. 2. Lussi A. Erosive tooth wear – a multifactorial condition. Dans : Lussi A, rédacteur. Dental Erosion – from Diagnosis to Therapy. Karger, Basel, 2006. 3. Lussi A. Eur J Oral Sci. 1996;104:191– 198. 4. Hara AT, et al. Caries Research. 2009;43:57–63. 5. Lussi A, et al. Caries Research. 2004;38(suppl 1):34–44.

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