April 2011 ORAL HEALTH JOURNAL oralhealth
oralhealth April 2011
C Ath nANNIVERSARY A dA’ s L e A d i n gISSUE d e n tA L JournAL 100 2011
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100 Years of Excellence! Congratulations from 3M ESPE.
then
now
Collaborating to define the Future. 3M ESPE and Oral Health share a common goal. We’re both committed to improving dental care. More specifically, we’re both committed to finding and communicating healthier, safer and better solutions for the people we serve. New product developments will help, but this commitment isn’t just about products. New digital technologies will help, but this commitment isn’t just about technology either. This commitment requires the vision to transform the way dental work is done and to support that vision in all we do, from education to research to communication to participation in industry events to simply listening well.
We have high standards. Just like someone else we know. 3M ESPE is proud to congratulate Oral Health on its 100-year anniversary in promoting high standards that inspire confidence.
© 2011, 3M. All rights reserved. 3M and ESPE are trademarks of 3M or 3M ESPE AG. Used under license in Canada. 1108-02710 E
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YOU’VE GOT ONE SMILE TO LAST YOU A LIFETIME… WE’LL MAKE SURE IT DOES.
CONGRATULATIONS ON YOUR 100TH YEAR Through the pursuit of better dentistry, we enable dental professionals to deliver better quality care, which in turn, can enable their patients to lead healthier, happier lives. Whether it’s impressions and restorations, implants, prosthetics, endodontics, orthodontics, to overall oral hygiene, DENTSPLY’s dedicated to making it better.
For over 100 years and counting, we remain proud partners with dental professionals in providing innovative products that both advance the practice of dentistry and meet the oral health needs of patients.
www.dentsply.ca
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1.800.263.1437
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FEATURES 19 The
Successful Evolution of a Dental Journal
70 The
(Abridged) History of Orthodontics in Canada
James Kerr, DDS 26 Paediatric
Dentistry — 50 Years and Counting
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Keith Titley BDS, Dip Paedo, MScD, FRCD(C), David Farkouh BSc, DMD, MSc., FRCD(C) 28 A
History of Patient Comfort (Part 1): The First 24,850 Years Peter J. Nkansah, MSc., DDS, Dip. Anaes., FADSA, Spec. Dental Anaes. (ON)
32 You’ve
Come a Long Way, Baby
Janice Goodman, DDS
Dentistry: A Patient Driven Sub-Specialty
James L. Posluns, BSc, DDS, D. Ortho, M. Ed, FRCD(C) 76
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The Changing Face of Prosthodontics
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What’s in a Name?
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44 Raising
the Endodontic Bar for Success: Past, Present and the Future
Century of Radiology... What Hasn’t Changed?
Susanne Perschbacher, DDS, MSC, DIP ABOMR, FRCD(C) 52 The
Evolution of Oral and Maxillofacial Surgery
Bohdan Kryshtalskyj, BSc, DDS, DOMSA, MRCD(C), FACD, FICD, FADI, FACOMS, FPFA 56 Advertising
Trade Cards and Postcards
Bruce Pynn, MSc, DDS, FRCD(C), FICD
60 Better,
Faster, Easier
George Freedman, DDS, FAACD, FACD
66 Implant
Dentistry — Past, Present and Future Carl E. Misch, DDS, MDS
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100 th Anniversary Issue 2011
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Fay Goldstep, DDS, FACD, FADFE
The Plight of the Frail Elderly Aldo Boccia, DDS
Matter How Things Change, Do Things Stay the Same? Rollin Matsui, BSc, DDS, LL.B.
94 Dental
Technology: A Personal Reflection
Trevor R. Laingchild, RDT, A AACD 98 100
Years of Dental Education in Canada
David Mock, DDS, PhD, FRCD(C); Professor & Dean, Faculty of Dentistry, University of Toronto
Adam Grossman, DDS, FRCD(C), Gary Glassman, DDS, FRCD(C) 48 A
Bruce Glazer
90 No
Seeing With Esthetic Vision Elliot Mechanic, DDS
Peter Birek, DDS, MSc, Dip. Perio
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36 Cosmetic
Jordan Soll, DDS
One Hundred Years of Persuasion?
102
The History of Brokerage Timothy A. Brown with Roy Brown
104 The
Future is Now (Part 3) (It’s Time to Start Diagnosing) Steven R. Olmos, DDS
106 The
Evolution of Dental Office Design
Jean Akerman, ARIDO, IDC
110 A
Long way From Twigs and Urine
Bill Dorfman, DDS
112 The
‘No Tax’ System of 1911
David Chong Yen, CFP, CA
118 Things
Have Certainly Changed — Today’s Dentist / Lawyer Relationship John McMillan, LL.B.
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EDITORIAL DIRECTOR
Catherine Wilson • (416) 510-6785 cwilson@oralhealthjournal.com ART DIRECTORS
Andrea M. Smith, Anita Balgobin, Sandy MacIsaac PRINT PRODUCTION
FEATURES 120 Bridging
the Gap in the Next Century (Part 1)
Lisa Philp and Derek Hill
124 The
Evolution of Dental Imaging
David Gane, D.D.S., B.Sc. (Hons)
126 “Better
Dentistry” Pioneer, Teacher, Clinician, Father
Peter Jordan
130 The
Effects of New Technology on Dental Office Design
Brian S. Allen
132 A
‘C’ Change in Office Management
Lesson from the Past for Use in the Future
Paul L. Child Jr., DMD, CDT
140 Decades
of Innovations Advance Dentistry
Lisa Citton-Battel
142 Risk
Cindi Holder • (416) 442-5600, ext. 3544 cholder@bizinfogroup.ca PRODUCTION MANAGER
Karen Samuels • (416) 510-5190 karens@bizinfogroup.ca DENTAL MARKETPLACE – CLASSIFIED
Karen Shaw • (416) 510-6770 kshaw@oralhealthjournal.com Untitled-3 1
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DENTAL GROUP ASSISTANT
Kahaliah Richards • (416) 510-6777 krichards@oralhealthjournal.com SENIOR ACCOUNT MANAGER
Sandra Horton • (416) 510-6852 shorton@oralhealthjournal.com ASSOCIATE PUBLISHER
Cheryl Kanhai
136 A
Phyllis Wright
CIRCULATION
Management and Orthodontic Practice
Duncan Y. Brown, BSc, DDS, D. Ortho
CONGRATULATORY MESSAGES 25 The Rt. Hon. Stephen Harper, PC, MP 50 David Johnston, Governor General 82 Leona Aglukkaq, Minister of Health 147 Jamie Matera, RDT, President,
Dental Industry Assoc. of Canada
149 Ondian Love, CAE, Executive Dir.,
Canadian Dental Hygienists Association
151 Rob Ford, Mayor, City of Toronto 153 Raymond Gist, DDS, President,
American Dental Association
155 Birthday Card Ads 158 Author Biographies 161 Advertisers’ Index
Hasina Ahmed • (416) 510-6765 hahmed@oralhealthjournal.com SENIOR PUBLISHER
Melissa Summerfield • (416) 510-6781 msummerfield@oralhealthjournal.com VICE PRESIDENT, CANADIAN PUBLISHING
Alex Papanou
PRESIDENT, BUSINESS INFORMATION GROUP
Bruce Creighton
Oral Health, published by BIG Magazines LP, a div of Glacier BIG Holdings Company Ltd., is an independent, monthly professional journal, written and edited for the practicing dentist in Canada, and supervised by an Editorial Board of Consultants from both general practice and major specialties of the profession. The editorial content consists of clinical articles and abstracts from the world’s finest dental literature and monthly departments. The editorial purpose is to provide information on clinical advances in all phases of dentistry. Oral Health is not responsible for the quality of graphic images submitted by the authors. The Editorial Board of Oral Health does not necessarily agree with the claims made for any product advertised. Nor should it be construed that the appearance of any product advertisement in Oral Health implies that the Board either approves or accepts the product. Oral Health reserves the right to edit departmental submissions for content and length. The contents of this publication may not be reproduced either in part or in full without the written consent of the copyright owner. ISSN 0030-4204 Yearly subscription rates: Canada 1 year $60.95 + taxes, 2 years $99.95 + taxes (GST #809751274RT0001); U.S. $66.95; Foreign $99.95. Printed in Canada. All rights reserved. From time to time we make our subscription list available to select companies and organizations whose product or service may interest you. If you do not wish your contact information to be made available, please contact us via one of the following methods: Phone: 1-800-668-2374; Fax: 416-442-2191; E-mail: privacyofficer@businessinformationgroup.ca; Mail to: Privacy Officer, Business Information Group, 12 Concorde Place, Suite 800, Toronto, ON M3C 4J2. Oral Health, USPS 018-112 is published monthly. US office publication: 2424 Niagara Falls Blvd., Niagara Falls, NY 14304-0357. Periodicals Postage Paid at Niagara Falls, NY, USA. US postmaster: Send address corrections to Oral Health, P.O. Box 1118, Niagara Falls, NY 14304. CANADA POST Publications Mail Agreement No. 40069240. PAP Registration No. 11001. Changes of address notices, undelivered copies and orders for subscriptions are to be faxed to (416) 510-6875 or mailed to Circulation Department – Oral Health, 12 Concorde Place, Suite 800, Toronto, ON M3C 4J2. Return postage guaranteed.
We acknowledge the financial support of the Government of Canada through the Canada Periodical Fund (CPF) for our publishing activities.
www.oralhealthjournal.com
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100 th Anniversary Issue 2011
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April 2011 ORAL HEALTH JOURNAL oralhealth
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C Ath nANNIVERSARY A dA’ s L e A d i n gISSUE d e n tA L JournAL 100 2011
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April 2011
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1920s-1950s
1960s-2000s
Publications Mail Agreement No. 40069240
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100 th Anniversary Issue 2011
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YEARS
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OF DENTISTRY
Wallace Seccombe, DDS, FACD First Dean of the Faculty of Dentistry, University of Toronto, Founder and editor of Oral Health
Oral Health would like to thank the Dentistry Library, University of Toronto for access to its archives and for all assistance with this issue, in particular Jeff Comber with Media Services and Dr. Anne Dale with the Dental Museum.
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oralhe
The first issue of Oral Health appeared in early 1911 and was sent to 500 subscribers ($1 annually). It was an immediate success: advertisers and readers approved. Today, Oral Health is distributed to every practicing dentist in Canada, dental labs and 3rd and 4th year dental students.
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On our covers: (l-r above) Our futuristic 100th anniversary cover was designed by Anita Balgobin. A variety of past covers are also featured, from text to nature, sports to animals. The first cover of Oral Health from January, 1911 (left). “A journal devoted to the interests of the dental profession and oral hygiene.”
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EDITORIAL Dr. James M. Kerr Editor/Chairman Dr. Randy Lang Co-chairman/Orthodontics Dr. Gary Glassman Endodontics Dr. Bruce Pynn Oral and Maxillofacial Surgery Dr. Blake Nicolucci Implantology Dr. Peter Birek Periodontics Dr. Jordan Soll Cosmetics Dr. Elliot Mechanic Esthetics Dr. Bruce Glazer Prosthodontics
BOARD
MEMBERS
Dr. Kenneth S. Serota Director, Digital Content Dr. Janice Goodman General Dentistry Dr. Rollin M. Matsui Ethics & Jurisprudence Dr. Peter Nkansah Pharmacology/Anesthesiology Dr. George Freedman Dental Materials & Technology Dr. Fay Goldstep Preventive Dentistry/Healing Dr. Susanne Perschbacher Oral & Maxillofacial Radiology Dr. David Farkouh Paediatrics Dr. Aldo Boccia General Dentistry/Geriatrics
Contributing Consultants Dr. Frederick Barnett Endodontics Dr. Angelos Metaxas Orthodontics Dr. Yvan Poitras Implantology Dr. Bohdan Kryshtalskyj Oral & Maxillofacial Surgery Dr. Howard Holmes Oral & Maxilofacial Surgery Dr. Robert C. Margeas Esthetics
Dr. Reza Nouri Paediatrics Dr. Ross Anderson Paediatrics Dr. Richard Mounce Endodontics Dr. Dennis Marangos General Dentistry Dr. Edward Dwayne Karateew Prosthodontics Dr. Keith Titley Paediatrics
Dr. Simon Weinberg Oral & Maxilofacial Surgery Dr. Robert Lowe Esthetics Dr. Paresh Shah Esthetics Dr. Dmitri Svirsky Prosthodontics Dr. Mitra Sadrameli, DMD Oral & Maxilofacial Radiology
Dr. Luca Dalloca (Milan) Esthetics
www.oralhealthjournal.com
30/08/11 10:14 AM
Introducing new Sensodyne Rapid Relief ®
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To learn more visit www.dental-professional.ca. * When used as directed on pack. † With twice-daily brushing.2 1. Mason S, Hughes N, Sufi F, et al. J Clin Dent 2010;21(2):42–8. 2. Hughes N, Mason S, Jeffery P. J Clin Dent 2010;21(2):49–55. 3. Banfield N and Addy M. J Clin Periodontol 2004;31:325–335. 4. Parkinson C and Willson R. J Clin Dent 2011;22(1):6–10. TM /® or licensee GlaxoSmithKline Consumer Healthcare Inc. Mississauga, Ontario L5N 6L4
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CHAIRMAN’S MESSAGE
The Successful Evolution of a Dental Journal Untitled-3 1
A
s I look back on my 40-plus years as Chairman of Oral Health’s Editorial Advisory Board, it is fascinating to reflect on the many changes that have taken place, both in our profession and in the pages of our journal.
for Oral Health magazine.
For me personally, following many years of working in publishing, I could no longer suppress what I really wanted to do. I applied to the Faculty of Dentistry at the University of Toronto and at 29 years of age, I was accepted in the pre-dental years. Two years after graduation, in 1968, I was asked to join Oral Health as Chairman of the Editorial Board. The publication was basically a small size abstract journal (abstracting articles from other journals along with some news and obituaries).
The present Editorial Board are all specialists in their fields and their function is to provide editorial material in their specific area to our 18,000 plus readers. Each specialist on the Board, along with contributing editors and others, are responsible for the feature theme of their issue.
For a few years, our small Editorial Board continued with the same format. Fortunately in 1971, Southam Press Limited (the predecessor of today’s Business Information Group) purchased Oral Health and made it a regular size publication. They increased the publishing staff with a Managing Editor. As the publication expanded, so did the Editorial Board. The publication grew immediately with some original articles, some reprints but no abstracts. As of today, over 74 percent of our editorial materials are original, written exclusively www.oralhealthjournal.com
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What was really encouraging to us was to be an independent voice for Canadian dentistry. We did not have to answer to any group or Association.
It was the ’60s and ’70s that dictated changes in the delivery of Oral Health’s presentation for the profession. In the 1960s, lounge type dental chairs appeared and what could only follow was “4-Handed Dentistry.” The quality of this care had to start at the University level, and fortunately, in my final dental year, I was introduced to this by Dr. Donald Coburn. Dentists, with a chairside assistant, could now work faster and with less wear and tear on the patient, the practitioner and his or her staff. Dentistry changed rapidly from a exodontist repair profession to a disease controlled preventative practice. In other words, we were saving teeth.
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James Kerr, DDS Oral Health’s Editorial Board Chairman
The publication was basically a small size abstract journal (abstracting articles from other journals along with some news and obituaries)
In the ’60s, the “Fluoride Ion” was also introduced in many 100 th Anniversary Issue 2011
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countries’ drinking water. What a magnificent record shows up in the 70s and 80s; Dentists were, for the first time, seeing young patients with little or no caries. Dental materials over the last 40 years have changed radically and for the better. According to Dr. George Freedman, bonding to enamel and dentin was not only successful but introduced a cosmetic factor to modern Dentistry. Likely, the majority of all Dental Practices in North America have “Cosmetic and General Dentistry” on the front door of their practice. Two of our board members Dr. Jordan Soll of Toronto and Dr. Elliot Mechanic of Montreal, are exceptionally skilled practitioners in the ever evolving area of esthetic dentistry. Nitrous oxide, oxygen sedation was responsible, when introduced in the 70s, to bring in the anxious patients who would never see a Dentist. Dr. Peter Nkansah is responsible on our Editorial Board for sedation and anesthesia. Current root canal therapy is responsible for saving millions of teeth. Our endodontic specialist, Dr. Gary Glassman, lectures on this subject all over the world. In orthodontic dentistry, Dr. Randy Lang has taught orthodontics at the University of Toronto for more than 30 years. 20
100 th Anniversary Issue 2011
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His editorials are both humorous and very meaningful for the dental profession. Implants are the hot ticket currently in restorative dentistry. We have Dr. Blake Nicolucci on our board. He is the head of the Implant Association and lectures throughout the world. In addition, we have two other specialists: Oral Surgeon, Dr. Bruce Pynn and for Periodontics Dr. Peter Birek. Dr. Peter Birek is an Associate Professor at the University of Toronto and does unique periodontal surgery and also implants. Digital radiology and cone beam computed tomography (CBCT) are valuable tools in aiding diagnosis and treatment. The latter may someday take over most radiology. Dr. Susanne Perschbacher is our Oral and Maxillary Facial radiologist; she is also a Professor at the University of Toronto. We are also very grateful to: Dr. Janice Goodman and Dr. Aldo Boccia, our General Dentistry consultants; Dr. Rollin Matsui, our Ethics and Jurisprudence Consultant; Dr. David Farkouh, our Paediatrics consultants and Dr. Fay Goldstep, our Preventive Dentistry consultant. All the members of our Editorial Advisory Board, along with their Contributing Consultants and the dental colleagues,
are a vital part of the success and longevity of Oral Health. Most of our 18 Board Consultants travel a great deal, giving lectures and presentations on their specialty. This is not just in Canada or the U.S. These specialists do lectures in Europe, South America and other continents. This affords us a wonderful opportunity to obtain editorial material from their many contacts world-wide. The success of any independent journal is two-fold, you must have a good product but of equal importance are the publication staff. Catherine Wilson, our Editorial Director is the very best managing editor I have ever worked with in my 40 years as Chairman. Equally successful is our Senior Publisher Melissa Summerfield. They both are a treat to work with. They both do more travelling than the consultants, attending all our major conventions and special dental workshops, representing Oral Health around the world. With the current Editorial Board and Publication Staff working together for our 18,000+ dental readers, I believe Oral Health does an outstanding job of delivering the very best clinical content to all our readers. We look forward to continuing this tradition of excellence as we start our next 100 years! OH www.oralhealthjournal.com
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Keith Titley, BDS, Dip Paedo, MScD, FRCD(C) Oral Health’s contributing consultant for paediatrics
David Farkouh BSc, DMD, MSc., FRCD(C) Oral Health’s editorial board member for paediatrics
50 Years and Counting I
n the year 2010, the Gradu ate Program in Paediatric Dentistry at the University of Toronto celebrated its 50th anni versary. The program started as a two-year clinical program with the awarding of a diploma in the specialty of Paedodontics. Gradu ates then had the option to enrol in the School of Graduate Stud ies at the University, carry out a research project, write a thesis, orally defend it in front of an ex pert committee and if successful be awarded the degree of Mas ter of Science in Dentistry. A decade or so ago the University decided that it would no longer award diplomas and that gradu ate programs in clinical disci plines would be of three years in duration with the emphasis on research leading to the awarding of a Master of Science degree. One of the authors (Keith Titley) be gan his diploma program in 1967 and the other (David Farkouh) his MSc program in 2000. In 1967, Paediatric Dentistry was in its infancy both in Canada and the United States. There were several graduate programs in the United States and to the authors’ knowledge the only firmly estab lished program in Canada was at the University of Toronto. Over the intervening years the num ber of specialty Paediatric pro grams has increased in Canada with programs at the University of Montreal and the University of
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British Columbia and a plethora in the U.S. When Keith Titley be gan practicing the specialty, there were a few recognised paediatric specialists throughout the country although there were many tal ented general practitioners who were committed to treating chil dren and limited their practices to doing just this. At that time each province had its own regulations for licensing specialists. In On tario, for example, this was done by the presentation of credentials and in British Columbia by exami nation. Often specialty licensure by one province was not transfer able (i.e. portable) to another. This was also the case in many of the other professions and a cause of concern to the federal government. As a result, the Agreement on Internal Trade was introduced and to their credit the Canadian Dental Regulatory Authorities embraced the concept so that den tists and dental specialists can now practice in any Provide in Canada. General dental practi tioners must pass the examina tions set by the National Dental Examining Board and specialists, the National Dental Specialty Ex aminations administered by the Royal College of Dentists of Can ada. It should be noted that each regulatory authority may have other requirements such as bilin gualism in Quebec and a dental ethics examination in Ontario. The net result however, is that www.oralhealthjournal.com
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patients can be assured that all licensed dentists in Canada have met a national standard. Paediatric dentistry is a specialty that encompasses all of the clinical disciplines of dentistry but with a particular emphasis on growth and development of children and behaviour management. In other words, paediatric dentistry is the most comprehensive of all the dental specialties and encompasses all clinical disciplines of dentistry. Other niche areas for paediatric dentistry include craniofacial deformities, children with disabilities, children at risk and dental traumatology. This increased awareness that dental health is part and parcel of general bodily health has resulted in the inclusion of dentists in the general paediatric health care team. The concept of a ‘dental home’ for children was developed conjointly in the U.S. by paediatricians and paediatric dentists. It is encouraging that integrated health care with mutual recognition of the contribution of all providers seems to be finally taking place. There are still some areas in paediatric dentistry that are of concern. Early childhood caries continues to ravage the dentition of the very young despite public health efforts to educate parents of the inadvisability of the ‘night bottle.’ The disturbing factor of the disease is that it is www.oralhealthjournal.com
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not confined to any one socioeconomic group but encompasses all of them. Since treatment frequently has to be done under general anaesthesia, often times in hospital operating rooms it is expensive for both the patient’s family and the health care system. Another area of concern is the removal of fluoride from municipal water supplies. Recently a health committee in the City of Toronto examined a proposal to stop fluoridating the city’s water supply and if it hadn’t been for a well-informed chief medical officer and submission from the Paediatric Dental departments of the University of Toronto the Hospital for Sick Children it may well have passed. Apparently this is not an isolated incident and if this is a national trend it is disturbing.
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Early childhood caries continues to ravage the dentition of the very young despite public health efforts to educate parents of the inadvisability of the ’night bottle’
With the vibrant research being conducted in the area of paediatric dentistry in universities across Canada and around the world, we continue to grow as a speciality and find solutions to the problems plaguing our young patients. Over the past 50 years there has been a steady progression in the development of the specialty of paediatric dentistry and it only will continue in step with the rest of the progression. As it has, so ably, over the past 100 years Oral Health will continue to keep the profession informed of recent innovations and development. OH 100 th Anniversary Issue 2011
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A History of Patient Comfort (Part 1): Untitled-3 1
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Peter J. Nkansah, MSc., DDS, Dip. Anaes., FADSA, Spec. Dental Anaes. (ON) Oral Health’s editorial board member for dental pharmacology & anaesthesia.
T
he delivery of reliable anaesthesia stands as one of the greatest advances in healthcare. Battling pain has been a human endeavour for the entirety of our 40,000 years of existence. The word “comfortable” did not even enter common language until 1770, probably because before that it didn’t exist to any great extent. Bill Bryson’s wonderful book, At Home, notes that comfortable, modern living is a relatively recent phenomenon.1 We have been living in relative comfort for only about 150 years, thanks largely to the Industrial Revolution. Battling the pain of surgery has been a human endeavour for as long as surgery has existed, 28
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The First 24,850 Years which may be some 25,000 years. There is some evidence that CroMagnon man tried to address the issue of discomfort during disease or surgery by using grotesquely dressed medicine men who would fight off evil spirits through song and dance, and by placing the patient next to smoky fires that burned some “therapeutic agents.”2 Anaesthesia by partial asphyxiation; it’s not the last time that was tried (see: nitrous oxide). Before 1846, surgery was tolerated through human resolve. This resolve was supplemented by physical restraint and further supplemented by prayer or medicine men or magic or hemp or mandragora or opioids or alcohol or some combination therein. The incredibly popular laudanum was a drinkable cocktail of opium and alcohol plus the fashionable flavouring of the day. Even without the ability to provide reasonable patient comfort, the surgeries undertaken were not always simple. Ancient surgical procedures included amputations, caesarean sections, hernia treatments, haemorrhoid treatment and tooth extractions.3 Pain control for these interventions was a lovely but unattainable dream. The luckier surgical patients probably just passed out. Even today, dentistry is not associated with comfort despite our best efforts. But rest assured, it used to be a lot worse. Though the
details differ by source, St. Apollonia, the patron saint of dentistry, had her “beautiful” teeth either pulled out one by one or knocked out by an Alexandrian mob who wanted her to renounce her Christianity and publicly worship the Roman gods in 249 A.D. (Fig. 1).4-6 Now, in fairness, that mob probably didn’t want her to be numb for her procedure, but that point is moot since the option didn’t exist. Perhaps St. Apollonia should be the patroness of toothaches. Events that were known to cause pain like surgery or, oddly enough, torture have been addressed in many different ways throughout history. The King James Bible refers to criminals about to be punished drinking the “wine of the condemned” (Amos II:8), which was wine blended with hempseed.7,8 Around 450 B.C., Hippocrates mentions being able to produce perfect narcosis by having his patients inhale vapour of bangue (hemp).2 Hempseed, myrrh and vinegar may have been the drink offered to Christ at Calvary before his crucifixion.8 Hemp is mentioned again as a surgical anaesthetic by Hua Tuo, a Chinese physician, around 150 A.D. as an ingredient in his “Ma Fu Shuan” (or “mafeisan”) anaesthetic liquor.2,8,9 In addition to hemp, mandragora (mandrake or deadly nightshade) has been a popular ingredient in the search for pain relief. Ancient civilizations starting www.oralhealthjournal.com
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with the Babylonians around 2000 B.C. and including the Egyptians, Greeks, Assyrians, Hindus and Chinese have all used mandrake for pain relief.3 Mandrake has long been revered because of the plant’s resemblance to the form of man. Untitled-3 1
After a quiescent period, the pursuit of anaesthesia was rekindled by the spongia somnifera (“soporific sponge” or “sleeping ball”) in the Middle Ages. A number of recipes for inhalational anaesthesia were described between the 9th and 15th centuries, and most of them included one or all of opium, henbane (a historically popular psychoactive herb), mandragora (again), hemlock (poison at high doses, likely sedative at low doses) and solanum (a family of plants containing belladonna). This renewed interest in the ability to induce sleep even caught the attention of a number of authors of the day including Machiavelli, Marlowe and Shakespeare who included this concept in some of their writings.10 There are historic references specific to the control of dental pain. Around 2250 B.C., Mesopotamian physicians suggested a mixture of henbane seeds and gum mastic (a plant resin) that was to be pushed into a cavity.11 Scribonius Largus, in 47 A.D., recommended rubbing the patient’s nose “with brown sugar, ivy and green oil” then squeezing a stone between the teeth in order to express “the fluid which causes the pain” to flow from the mouth. After this the tooth is “no longer painful, and may easily be extracted”.2,12 In 165 A.D., the Greek physician Galen used the application of “pirethrin root and strong vinegar” to a tooth for an hour as an anaesthetic www.oralhealthjournal.com
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Ether Day painting by Robert C. Hinckley (1882-1893).
agent for extractions.2 From then through the eighteenth century, coca leaves, hemp, opioids and alcohol were the mainstays of pain control in dentistry. By the mid-1800s, speed was synonymous with skill in the worlds of medical and dental surgery. Hospitals were known as “houses of death” and many patients preferred to succumb to disease than be operated on.13 Parisian Dr. Alfred Velpeau, who was perhaps the most respected surgeon in the most respected surgical centre in the world at that time, authoritatively wrote in 1839 that, “Knife and pain, in surgery, are two words which never present themselves the one without the other in the minds of patients, and it is necessary for us surgeons to admit their association.”8,14 Then on October 16, 1846, Dr. William Thomas Green Morton, a dentist, provided anaesthesia for Gilbert Abbott, who was having a neck tumour removed by the eminent surgeon, Dr. John C. Warren at Massachusetts General Hospital in Boston. The tumour was removed, and Mr. Abbott did not flinch or “hallo”. Dr. Warren stepped back and announced, “Gentlemen, this is no humbug.”8,14 This was Ether Day
The Martyrdom of St. Apollonia painting by Jean Fouquet (1452-1460).
(Fig. 2), and the worlds of surgery, medical and dental, would never be the same as those first 24,850 years. The story continues... OH 1. B ryson, B. At Home: A Short History of Private Life. 2010. Doubleday Canada. 2. A rcher, WH. (1940) The History of Anesthesia. Proceedings of the Dental Centenary Celebration pp.334-363. 3. Keller, J. (2008) An Exploration of Anaesthesia through Antiquity. University of Western Ontario Medical Journal, 78(1): 49-52. 4. Catholic Saints website. http://www.catholic-saints. info/roman-catholic-saints-a-g/saint-apollonia.htm. Accessed May 19, 2011. 5. Donnelly, R. (2005) St. Apollonia: The Patron Saint of Dentistry. Journal of the History of Dentistry 53(3): 97-100. 6. W ikipedia website. http://en.wikipedia.org/wiki/ Saint_Apollonia. Accessed May 19, 2011. 7. B iblos website. http://bible.cc/amos/2-8.htm. Accessed May 27, 2011. 8. Woodward, GS. The Man Who Conquered Pain: A Biography of William Thomas Green Morton. 1962. SJ Reginald Saunders & Co., Ltd. 9. Wikipedia website. http://en.wikipedia.org/wiki/Hua_ Tuo. Accessed May 27, 2011. 10. Prioreschi, P. (2003) Medieval Anesthesia—the spongia somnifera. Medical Hypotheses 61(2): 213-219. 11. Kuhfeld, ER. The Bite of Pain. http://washuu.net/ Med-Lec/bitepain.htm. Accessed May 25, 2011. 12. Baldwin, B. (1992) The Career and Works of Scribonius Largus. Rheinisches Museum f¸r Philogie, 135, 74-82. 13. Jacobsohn, PH. (1995) Horace Wells: Discoverer of Anesthesia. Anesthesia Progress, 42: 73-75. 14. Fenster, JM. Ether Day: The Strange Tale of America’s Greatest Medical Discovery and the Haunted Men Who Made It. 2001. HarperCollins Publishers.
100 th Anniversary Issue 2011
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Be part of your community — join one of our Facebook groups just for dental professionals. www.sonicare.com/facebookDP 1. Milleman K, Milleman J, Putt M, et al. Comparison of gingivitis reduction and plaque removal by Sonicare DiamondClean and a manual toothbrush. Data on file, 2011. 2. Colgan P, DeLaurenti M, Johnson M, Jenkins W, Strate J. Evaluation of stain removal by Philips Sonicare DiamondClean power toothbrush and manual toothbrushes. Data on file, 2010. 3. Moore M, Putt M, Jain V, de Jager M. In vitro assessment of dentin wear resulting from the use of the Philips Sonicare DiamondClean power toothbrush. Data on file, 2010. In vitro study, results may vary with actual use. 4. Putt M, Milleman J, DeLaurenti M, Schmitt P. Plaque removal efficacy of two novel Philips Sonicare DiamondClean brush heads. Data on file, 2010.
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You’ve Come a Long Way Baby Untitled-3 1
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Janice Goodman, DDS Oral Health’s editorial board member for general dentistry
A personal look at the evolution of women in the dental profession spanning the past 100 years
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I
t’s hard to imagine that women got the right to vote in Canada only 82 years ago. Back then, a female who considered pursuing a profession in medicine or dentistry would have been ridiculed and outcast just for dreaming about it. It was a silly and absurd thought. Then, in 1967, just 44 years ago, a Royal Commission to report upon the status of women in Canada with the guidance of the Canadian Federation of University Women paved the way to open more opportunities to more women in such programs as dentistry, medicine and law. In 1970 when Dr. Myrna Halpenny entered McGill dental school she was one of three women in a class of 40. At University of Toronto in 1974, my class of 125 dental students, had fewer than 20 female classmates. The demographics of the sexes in the dental profession have done a complete somersault in the past century, going from women being an anomaly, to the majority, in most dental schools. The whole “feel” of dentistry has been influenced by the increased number of female practitioners with regards to both professional development and professional engagement. This is a North American phenomenon. Europe and other parts of the world do not mirror these statistics. Roughly half the dentists in Greece are female , one third in France, Denmark, Sweden, Norway and almost four fifths in Russia, Finland, Latvia and Lithuania. This article explores the feminizing of dentistry over the
past 100 years as well questions the impact this change in gender balance brings, for the profession, so far and in the future. The history of Canadian women in dentistry up to the present, has been well documented in an article in the Queens University library by Tracy Adams. I will attempt to condense some of it in point form here: 1. In the first 50 years (18681918) only 19 women became dentists. 2. Josephine Wells was the first and she went into dentistry after her dentist husband became ill and could not support the family. She graduated in 1894 andpracticed 36 years in Ontario. 3. D r. Emma Casgrain was awarded the first female dental license in Quebec in 1898. She was trained by her dentist husband who was 15 years her senior and practiced until 1920. 4. Abbey Walker was the second to graduate dental school, ten years after Wells, in 1904 5. There were 27 female dentists between 1921 and 1935. The surge in popularity was attributed to post WW1 and encouragement encouragement of the provincial government. I believe they had an average working life of 37 years and it was not unusual for them to work 40 plus years. 6. Increase in dental class size after WW1 to 804 in order to accommodate those applying when they came back from the www.oralhealthjournal.com
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ceptable society” attitude that made it a rare path to follow in those days. 11. Records show that most early female dentists were married and were able to handle both marriage and dental practice at a time when the balance of family care was a responsibility of the wife.
Josephine Wells, first woman in dentistry war lead to 6 women graduating in class of 1923, which virtually doubled the number of licensed female dentists in Canada to 12. 7. Female dentists accounted for 1.8% of the practicing dentists of Canada prior to the depression and then that number went down after the depression. Dentistry was considered a luxury at that time and there were fewer applications from both sexes. 8. In the earlier days, most female dentists either had a dentist relative when they started dental school or became and practiced with either a dentist or physician husband. It was more acceptable to work alongside your husband/family member than on your own or with a nonrelated male. Such dentists averaged over 25 years of practice. Female dentists without such relationships tended to leave practice sooner — on average after 13 years. 9. First year female dental students were called “freshettes” and they had a different “hazing” initiation than their male counterparts. 10. As far as the author could tell, females were not necessarily discouraged from entering the profession by the profession itself, but it was more “acwww.oralhealthjournal.com
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Let’s look at a few more recent statistics. A recent Ontario Dentist Journal article compared male and female dentists in Ontario in 2006. There were 7,560 dentists, 5,370 were male and 2,190 were female. On average the males worked 47.2 hours per week and the females 44.7. The average hours per week worked were 39.5 males and 35.6 females. Only 23% of the dentists were employees and the females dominated in the employee category. In addition the article stated that “the dentist population is outgrowing the general population and the increase in the number of women practicing dentistry may mitigate any impact this may have and may have an effect on the overall practice model.” In the same ODA article, it was stated that women dentists in Ontario currently make up close to one-third of the profession (in 2006), but they predict that in the youngest age cohorts, there will be equal amounts of male and female dentists. Current dental school statistics reported a 6040 female to male ratio. It was also stressed that this is happening very rapidly and the past ten years has seen the greatest change. Women should dominate the profession in a very short period of time, although the specialty programs are still largely owned by men. This means that women will likely have more in-
fluence in dental faculties, dental societies, industry and in private and public practices in the future. So, it might be worthwhile considering if male and female dentists are different in the way they practice dentistry and how one can expect these differences to influence the profession in the future. Untitled-3 1
I am afraid to name individuals who have been “the firsts” in dentistry, other than Josephine Wells, who in 1893 became the first Canadian female dentist. I have watched so many women be”firsts” in our profession, who I am proud to say that I knew many of them personally, and I would be afraid to neglect giving well deserved credit to someone. I do say “thank you” on behalf of us freeloaders for forging ahead and bringing women in the profession closer to being equals to our male counterparts. I am so lucky to have experienced the breakthrough of females in the profession over my 36 year tenure so far (school included). Timing has been everything. I am quite certain, that, on the whole the women who pioneered being the first registrar, the first president of a provincial organization, the first faculty member, dean, female in a specialty, etc. did not do it necessarily to be a first, but, rather out of sincere interest and caring for what they were doing, and the desire to devote their energy to improve something or serve someone. And there are still more “firsts” to come: it was a female dentist from Calgary who started Dentists Without Borders in Canada recently, bravo! OH The remainder of this article, including references, can be found in the Fall 2011 issue of Dental Practice Management. 100 th Anniversary Issue 2011
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Jordan Soll, DDS Oral Health’s editorial board member for cosmetic dentistry.
The simplest, least invasive and least expensive form of cosmetic dentistry is tooth-whitening...
Cosmetic Dentistry: A Patient-driven Sub-specialty R
ecently, the first baby boomers have reached the age of “social security,” as defined by most governments, yet this most vibrant generation in the history of mankind refuses to quietly accept their fate like the generations before them. In North America, personal cosmetic enhancements are a multi-billion dollar annual industry. Every inch of our bodies is fair game when it comes to rejuvenation and reincarnation. This phenomenon is quite evident with respect to our fixation to create the perfect white smile. Moreover, studies have suggested that dental appearance is significantly related to our perception of a pleasing overall look. A study published by J. Jenny and J. Proshek in 1986 titled, “Visibility and Prestige of Occupations and the Importance of Dental Appearance,” indicate that there is a significant relationship between prestige and dental appearance, as well as a strong relationship between visibility and dental appearance. This movement, as a society, to chase the perceived ideal of a beautiful white smile is no longer empirical. Clinical studies, combined with the overwhelming economic bonanza from dentist prescribed and over the counter whitening products, conclusively indicate the desire to enhance one’s appearance, specifically one’s smile. The evidence is further supported by a national study released by Crest Extra Whitening
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toothpaste, which noted that more than 90 percent of respondents rated photos of people with whiter teeth as healthier and more attractive than photos of the same people with duller, less white teeth. According to Gordon Christensen, “It seems that everybody in America wants whiter teeth to make them feel younger and provide beautiful smiles and accompanying increase in self-esteem.” The simplest, least invasive and least expensive form of cosmetic dentistry is tooth-whitening; or as it is more commonly known as, bleaching. The primary goal of this technique is through the application of various gels, all based on the same chemistry, which remove intrinsic stains within the teeth to reveal the inherent whiteness prior to the years of ingesting heavily stained foods and smoking. Though bleaching of teeth became popular in 1989, the dental profession has been attempting to lighten teeth since the 1800s. The earliest forms of bleaching involved the use of oxalic acid and even the application of chlorine to try and improve the appearance of the teeth. It is reported that the first use of hydrogen peroxide was in 1877, which serves as the basis of many of today’s whitening products. However, contemporary whitening has evolved to the placement of a weaker bleaching agent having intimate contact with the tooth surface over a prolonged period of time. The usual www.oralhealthjournal.com
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ingredient, and the most stable is various strengths of carbamide peroxide, placed within a custom fabricated tray, which is often referred to as “home whitening”. Additional professional whitening systems, that are employed chair side and are referred as “in-office whitening,” are based on techniques that were discovered as early as 1918 whereby high intensity light is used to cause a rapid rise in temperature of hydrogen peroxide to accelerate the bleaching process. Today, the in-office technique is used primarily as a convenience for people who do not want to fuss with wearing trays at home or who want a quick solution to brightening their smile. Whether the patient chooses home or in-office whitening, the goal is the same; to rejuvenate the smile by brightening their teeth. Consumer demand for an attractive smile is so strong that there has been an explosion in over the counter whitening products. These include tooth pastes, mouth washes and “whitening on the go” products sold from drug stores to grocery stores. These low investment products have varying degrees of success, yet their commercial viability is driven by mass marketing appeal. The Freedonia Group, a well known research company, stated that in 2005 whitening products accounted for four percent of total consumer dental products demand. This segment encompasses those products designed to lighten www.oralhealthjournal.com
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tooth shade, including strips, gels and liquids. In addition, Freedonia claims that demand for consumer whitening dental products is forecast to advance 10% per year to 250 million in 2011. These gains will be partially attributed to the aging baby boomers becoming aware of these over the counter products. Aggressive marketing strategies will portray these items as low cost alternatives to professional whitening, veneers or direct dental bonding. Freedonia also noted that, though there is a lower price structure, the over the counter (OTC) whitening agents are less effective than professional whitening products. Consequently, continued product developments will improve the efficacy of the OTC whitening products, while prices will remain the same or slightly decline to the increase in the number of players in the market place.
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If patients find that they are not pleased with their whitening result, regardless of their origin, they may choose to seek out more long term predictable solutions to their problem. These more predictable alternatives include freehand direct bonded or porcelain veneers. Regardless of the pathway, the motivation is the same; individuals are looking to improve the appearance of their teeth. Though the past may have focused on the rehabilitation of a deteriorated dentition, the future will focus on only techniques that rehabilitate from a cosmetic perspective. OH 100 th Anniversary Issue 2011
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CANADA’S APPRAISER AND BROKER
A Peek Into the Past… 1948 At the age of 18, Roy Brown stepped into a job that would define his life for the next 55 years. In 1948 he started with a co-operative known as the Associated Dentists Co-operative (ADC). Dentist shareholders numbered 900 from Ontario to British Columbia. They were mostly World War II veterans who were concerned with the investigation by our federal government into an alleged dental combine, fixing prices and limiting competition.
Roy Brown, 1954
He began as a salesman and worked his way to manager and finally became President in 1973. His achievements with this Company included introducing the high-speed handpieces, disposable needles, equipment leasing, and designing and manufacturing open concept cabinetry. It was through working with this company that Roy saw the need for the dentists of Canada to be given a value for their practices. In the past, a retiring dentist could not find a purchaser and was forced to store equipment and to hope that he/she could give patients a referral to another dentist.
1974
Roy & Joan, 1974
In 1974, ROI Management (later renamed ROI Corporation) was formed to offer the dental profession a reliable source to document practice value and to ensure confidential sales. Roy was the first in Canada to recognize the emerging market for dental practices and the first to obtain registration under the Real Estate and Business Brokers’ Act, specifically for dental practice brokerage. Other individuals then entered the business in the 1980’s thus building a market service, which has been to the benefit of all Canadian dentists nationwide. Roy is very proud that his family has been included in the business. His wife of 55 years, Joan, is seen here helping at ROI Corporation’s first ODA Convention in 1974.
1984 Timothy, the youngest of Roy and Joan’s children, completed his postsecondary education, and obtained his business broker’s licence in 1984.
Timothy A. Brown, 1984
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1994 In the 1990’s Roy decided to slow down and was appointed the honourable lifetime Chairman of the Board. In 1994 Timothy was elected Vice President and later President and C.E.O. Since then Timothy has written over 150 Practice Management columns and has spoken at hundreds of seminars and conventions about DentaGraphics™, his study of future trends in dental manpower, practice valuations and patient behaviour. He also introduced a formal Locum registry to Canada.
Roy & Joan, 1994
Roy & Timothy, 2004
Sandy Evans & Timothy A. Brown, 2004
2004 At the end of 2004 Roy will be retired and Timothy, his wife Sandy and the entire Canada wide ROI team, look forward to serving the dental industry for another 30 years.
Roy & Timothy, 2010
Roy, Timothy, Robert & David (Roy’s Two Grandsons) have now joined the family business
2008-2012 ROI trademarks “i-Dentist”™ and “Investor Dentist”™ which are the emerging trends in dental practice investing. Tim publishes his book “Profitable Practice” which has over 2,500 copies in circulation worldwide.
www.roicorp.com | 1-888-764-4145
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Seeing with Esthetic Vision Untitled-3 1
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Elliot Mechanic, DDS Oral Health’s editorial board member for esthetic dentistry
The face dictates the treatment
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any defining events happen in one’s lifetime. Some are happy and others traumatic. Birth, school, marriage, children, career, divorce, second marriage, sickness, death. In 1967, catastrophe struck in my young life. I needed glasses. Oh well, might as well make the best of it. After all some of my favourite heroes of the day wore specs. Denny McClain (Detroit Tigers) John Lennon (Beatles), John Sebastian (Lovin’ Spoonful) were all super cool and got the girls. So off I went with my mom to the optician, who happened to be my second cousin Irwin, all set for a groovy new look. I was horrified when to my surprise I was offered a selection of a mere three choices of frames that were not cool like John Lennon’s but rather made me look like a thirteen year old Buddy Holly. I was condemned to grade eight geekdom. I will never forget what cousin Irwin said to me when he saw how shocked and unhappy I was. “What do you need to look good for? You’re lucky you can see!” So much has changed since 1967. In 2011, people actually care about what they look like. When was the last time that a dental patient asked for “ugly teeth” and wanted to look like Austin Powers? Facially generated dental treatment planning is today’s standard. What were we missing for the past century?
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Going back in our time machine to 1895 we can learn from Dr. Alloway’s patient brochure (Fig. 1) that the goals of turn of the 20th century dentistry were 1) mastication; 2) digestion; 3) assimilation; 4) nutrition; 5) health; 6) life. Nowhere was esthetics even mentioned. Dentistry’s goal was to preserve teeth for as long as possible and having nice looking teeth was inconsequential to good dental health. A hundred years ago there were no root canals, orthodontics, white fillings, grafts or implants. Teeth were filled with amalgam following the principles of G.V Black and if they were unhealthy they were extracted. As the 20th century progressed the ABC (Amalgam, Blood, Chrome) dental philosophy continued. However things began to slowly change. Dr. Charles Pincus spoke of the Hollywood Smile (1923) and the concepts of bonding (Buonocore 1955), resins (Bowen 1960) and porcelain etching (Rochette 1972) were introduced opening up new possibilities in restorative dentistry. By the time I attended McGill dental school in the 1970s, dental esthetics finally appeared on the goals of dentistry hit parade albeit at number four following 1) stable oral health; 2) function; and 3) occlusal stability. In school we were taught to treat the disease first and then look at everything else. Often what we were left with was tissue levels and www.oralhealthjournal.com
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tooth positions that were far from ideal as treatment began and pro gressed with no vision of the final esthetic outcome. It was as if that looking good was viewed as an afterthought and was not part of the philosophy of “good dentistry.” However, winds of change were coming. Dr. Irwin Smigel, of New York City, founded the American Society for Dental Esthetics in 1976. This was the first organiza tion recognizing the importance and need for cosmetic dentistry. A small group of dentists jumped on Dr. Smigel’s bandwagon. Some members of the profession viewed them as charlatans having no place in dentistry. Throughout the 1980s developments in dental materials continued to give us better tools to work with; Porcel ain veneers (1983), Cerestore (1983) and Dicore (1985) crowns. Dentists began seeing things dif ferently, thinking “outside the box” using these new materials and creating techniques to offer their patient’s alternatives in their restorative treatment plan. By the 1990s the dental esthetic revolution was in full swing. The public demanded teeth that actu ally looked good as well as function and be healthy. Further advances in technology and philosophy ad dressed these demands. Periodon tal surgery was used not only to treat disease but to treat the tis sue levels as well, sometimes elec tively. Orthodontic treatment was undertaken not only to move teeth but also to modify tissue levels by intrusion and extrusion. Advances in materials continued to happen at a rapid pace; InCeram and Em www.oralhealthjournal.com
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press (1990), Dentin bonding (1991) Luxatemp (1992). We entered the 21st century with a multitude of tools to work with including a large variety of dental publications and continu ing education courses. The bar was raised significantly to what could be achieved and the stan dard of dental care. Dental lab technicians could now artistically create natural looking restora tions and we routinely utilized periodontics, orthodontics and im plants to place our restorations in esthetic dental harmony. Some of the dental catch phrases for the first decade of the century were “pink esthetics” and “the tissue is the issue.” These make reference to and recognize that the health and alignment of the gingival tis sue surrounding the teeth are just as important as the teeth them selves in achieving a lifelike healthy restoration. In 2011, the importance of es thetic dentistry has been univer sally recognized. Although den tistry treats the lower one third of the face, dentists now routinely look beyond the oral cavity in their esthetic vision. Facially generated treatment planning references the patient’s lips, skin, cheeks etc. and creates teeth to match. The face dictates the treatment! We must establish esthetics first and then design the appropriate tooth posi tion and occlusion. We reference the maxillary tooth position and gingival levels relative to the face and detemine if and how they must be changed. Instead of con sidering esthetics last, today we consider esthetics first!
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I am no longer self conscious about wearing glasses as there are thousands of frames from which to choose from the world’s top design ers. Eyewear is a fashion state ment and so is a beautiful healthy smile. So what has changed over the past hundred years? People are still people.However our abil ity to see things differently allows us to create and be different. Only now we are able to see through a multitude of frames allowing us to have esthetic vision. OH 100 th Anniversary Issue 2011
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composites have proven to be a good choice for natural looking, long lasting restorations. In addition to being radiopaque, they exhibit superior esthetics and eliminate shrinkage. N’Durance also has zero solubility, ensuring my patients long lasting restorations.”
- Dr. Ross Nash, DDS, Nash Institute for Dental Learning . . . . .
Post-op x-ray showing clear results of N’Durance radiopacity**
NOW YOU CAN HAVE IT ALL • With Proven Science* • Extremely Low Shrinkage • Outstanding Monomer Conversion • Superior Esthetics • Highest Radiopacity
*Proven ongoing study, Catholic University of Leuven, School of Dentistry, Loma Linda University, School of Dentistry, California USA. 3+ yrs - anterior/posterior **Photo courtesy of Dr. Louis Charles Passauer Jr. D.D.S.
Some lead... others follow. 800.872.8305 | www.septodont.com
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26/08/11 9:00 AM
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Racegel is a new hemostatic agent that controls bleeding and absorbs crevicular fluid prior to and during impression taking and crown placement. Due to its thermodynamic characteristics, the material’s viscosity increases upon contact with the tissue (95°) providing access to the gingival margin. Racegel contains 25% Aluminum Chloride which is clinically proven for its astringent properties. The bright orange color makes it easy to dispense, place and rinse. Racegel rinses away quickly, leaving no residual material, discoloration or irritation of the surrounding tissue. To learn more, contact your dealer sales representative.
Leonard A. Hess DDS Private Practice Monroe, NC Associate Faculty Dawson Academy
“ Racegel provides exceptional hemostasis and also acts as a retraction aid. Whether used alone or in conjunction with a cord, Racegel is a permanent part of our crown and bridge armamentarium.”
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800.872.8305 | www.septodont.com
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ENDODONTICS
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Adam Grossman, DDS, FRCD(C)
Gary Glassman, DDS, FRCD(C) Oral Health’s editorial board member for endodontics
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Raising the Endodontic Bar for Success: Past, Present and the Future V
The objective of endodontic treatment has remained to be a constant since root canal treatment was first performed; the prevention or treatment of apical periodontitis such that there is complete healing and an absence of infection,1 while the overall long-term goal is the placement of a definitive, clinically successful restoration and preservation of the tooth.
Dental Operating Microscope First, superior vision became attainable with the integration of the dental operating microscope (DOM) (Fig. 1). Diagnostically, the operating microscope is an indispensable aid in locating cracks and tracking vertically fractured teeth.2,4 It allows a more detailed view of root canal intricacies enabling the operator to more efficiently examine, clean, and shape complex anatomy.5 It provides a superior resolution thereby aiding the removal or bypassing of separated instrument.6 A microscope provides an improved surgical technique allowing for smaller osteotomies, shallower bevels, and the location of isthmi and other canal irregularities,7 thereby allowing unprecedented success rates of up to 96.8%.8 A DOM has significantly shown to improve the probability of locating a second mesial buccal canal in maxillary molars. Baldassari-Cruz et. al9 showed that the MB-2 canal was located in 90% of maxillary molars with the operating microscope but only 52% with unaided vision.
From about 1985 to 1995 there was more change in clinical endodontics than in perhaps the previous 100 years combined. In these ten years, clinical endodontics changed forever with the emergence and development of four technologies.2,3
Sonics Second, piezoelectric ultrasonic energy, in conjunction with the DOM, drove microsonic (sonic and ultrasonic) instrumentation techniques that are minimally invasive, efficient, and precise2(Figs. 2 & 3). Refinement of access open-
ince Lombardi so eloquently stated “Practice does not make perfect. Only perfect practice makes perfect.” In other words we can perform a procedure repeatedly over and over again and not obtain the expected outcome for success. We must continually advance in all disciplines of dentistry in order to provide our patients with the most predictable treatment regimens possible, understanding the greatest variable that stands in our way is the human variable. Elevating the standards of endodontic care is inexorably tied to an important dynamic in our armamentaria.48
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ings in a controlled and predictable manner, locating calcified canals with a reduced risk of perforation, removal of attached pulp stones, removal intracanal obstructions (separated instruments, silver points, and posts) and removal of the smear layer, biofilm and and remaining debris are just some of the many uses that microsonics are capable of doing.2,10,11 In surgical endodontics, specially design retro tips are used ultrasonically for superior root-end cavity preparation. This allows minimal removal of root structure down the long access of the root canal without the creation of a bevel for surgical access. This subsequently reduces the number of exposed dentinal tubules and minimizes apical leakage.10 Nickel Titanium Instruments Third, canal preparation procedures became more predictably successful with the emergence of Nickel Titanium files (NiTi) files.2 This super elastic alloy has shape memory allowing for better maintenance of the original canal anatomy. They produce less extrusion of debris, allow greater cutting efficiency and reduce the time for canal shaping compared to stainless steel files. They are biocompatible, anticorrosive, and do not weaken following sterilization.12,13 Mineral Trioxide Aggregate (MTA) Finally, this decade of extraordinary change concluded with the introduction of mineral trioxide aggregate (MTA).2 This remarkable and biocompatible restorative material has become the stanwww.oralhealthjournal.com
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dard for pulp capping and has salvaged countless teeth that previously had been considered hopeless.2 In vital pulp therapy when MTA is used as a direct pulp cap to maintain pulp vitality studies have shown that these areas were free of inflammation, and all of them had calcified bridge formation after five months.49 MTA has proved to be the ideal pulpotomy agent in terms of dentin bridge formation and preserving normal pulpal architecture.49 MTA produces favorable results when it is used as a root-end filling material in terms of lack of inflammation, presence of cementum and hard tissue formation.49 It is used to repair both furcal and lateral perforations with a relatively high degree of success and to seal both internal and external resorptive defect from an orthograde and retrograde approach.49 The treatment of teeth with open apices and necrotic pulps has always been a challenge for the dental practitioner. MTA can effectively be used as an apical barrier in teeth with necrotic pulps and open apices.49
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FIGURE 1—The Dental Operating Microscope (DOM) (Global Microscopes, St. Louis, Mo) allows improved visualization of the operating field and provides a more ergonomic physiologically compatible operator position.
FIGURE 2—The EndoActivator System (Dentsply Tulsa Dental Specialties; Tulsa, Oklahoma) may be utilized to perform a variety of endodontic procedures easier, safer, and more effectively.
The future of endodontics holds incredible promise to increase predictable success for patients in order to help satisfy the main objective in dentistry which is to prevent oral disease and the preserve the natural dentition.14 OH The remainder of this article, including references, can be found in the Fall 2011 issue of Dental Practice Management.
FIGURE 3—The Mini Endo Ultrasonic Unit (SybronEndo; Orange, California).
100 th Anniversary Issue 2011
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The daily activities in a dentistry practice produce infectious matter which consists of bacteria, viruses and spores that contaminate your environment. Washing, disinfection and sterilization are the processes required for infection control in order to reduce the risk of cross-contamination to you and your patients. SciCan provides a full spectrum product line as well as training, consultation and service to support your every need. SciCan protects you every step of the way.
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OH 100th p046-47 SciCan DPS AD.indd 46
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29/08/11 9:36 AM
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RADIOLOGY
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Susanne Perschbacher, DDS, MSC, DIP ABOMR, FRCD(C) Oral Health’s editorial board member for oral & maxillofacial radiology
It remains apparent that we do not see what we do not know and more information will not always equate to greater diagnostic ability if we do not know how to use the information
A Century of Radiology... What Hasn’t Changed? O
ver the last 100 years, it would be an understatement to say the field of radiology has seen a few changes. Since the discovery of x-rays in 1895 and their first application in imaging the teeth and jaws very shortly after, radiography has become an essential tool in our diagnostic tool kit. It would be hard to imagine diagnosing periodontal disease, planning an extraction or investigating jaw pain without the aid of radiographs today. Today you would also have many choices about the technology you would use to produce the images you require. You may choose film or digital sensors, intraoral or panoramic views or, perhaps, advanced imaging modalities, such as cone beam computed tomography or magnetic resonance imaging, would be indicated. Technology in radiography has seen growth and development at a remarkably rapid pace. This is exciting for practitioners who are eager to provide optimal patient care but can be confusing when the options overwhelm. In this time of rapidly progressing change, it is interesting to reflect on the aspects of the field of radiology that have remained constant. These include our concern for patient exposure to ionizing radiation and our need to develop the skills required to interpret the images we acquire. The potential dangers of x-radi-
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ation were not always recognized, or if they were, they have not always been respected. Shortly after the discovery of x-rays it became fashionable to dream up new uses for this mysterious entity. When it was discovered that x-rays could cause hair loss, entrepreneurial people began offering x-ray hair removal services. This practice continued even after it was banned because vanity trumped the intangible risk. It was not so long ago that you could also shop for shoes and check how they fit by viewing your foot inside the shoe using a “Pedoscope”. Today we have a better understanding of the nature of x-radiation and its ability to damage DNA, leading to carcinogenesis, the most serious potential outcome at low doses. Fortunately, with vast improvements in the technology of x-ray generators and the detectors used to capture images, the exposure of patients necessary to produce diagnostic radiographs has decreased drastically. Images which took minutes to expose are now acquired in a small fraction of a second. Nonetheless, radiography is not a zero-risk procedure. Each exposure carries with it a chance, though considered minimal, that an undesirable cellular event will take place. For this reason, it remains our responsibility to our patients to only expose them when necessary. Determining what is www.oralhealthjournal.com
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necessary requires a risk vs. benefit assessment; the benefit the patient receives from having the radiograph must outweigh the potential risks of the examination. Benefits may include obtaining an accurate diagnosis or determining optimal treatment. Radiographs should be used as a test performed to confirm or rule out a diagnostic question that arises based on the patient history or exam. Imaging may also help improve treatment outcomes by providing information unavailable by examination alone. The risks are small and when radiographs are prescribed appropriately, patients are expected to benefit overall. When we expose patients with no specific purpose (i.e. “just to look”, “in case something is lurking”) this potential benefit is lost. Appropriate prescription also involves selecting the best modality for the diagnostic task. With the development of new technologies comes the requirement for practitioners to be informed of the advantages and disadvantages of each option in order to understand where it fits into their practice. Until we can image patients and obtain the information we need with non-ionizing, no-risk, methods (perhaps in the next 100 years?), our responsibility to consider patient safety will not change. Patients can only benefit from www.oralhealthjournal.com
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the radiographic examinations we order if we know how to interpret the results. The skill of reading the images obtained remains a fundamental necessity in the appropriate use of this test. Over the years, attempts have been made to make diagnosis easier; digital radiographic software systems use algorithms to adjust the images to try to make caries more detectable; computer programs have been developed which attempt to automatically detect disease. However, none of these gimmicks has been able to replace the complex decision-making process that occurs in the skilled professional’s brain. The interpretation of diagnostic images still requires an understanding of the physics involved in producing the image; the normal anatomy and its variants; the potential diseases that may affect this anatomy and the characteristic ways these diseases present. Advances in technology may make the images we acquire clearer and even make more information available. For instance, cone beam computed tomography allows visualization of anatomy in multiple planes and without the superimpositions which sometimes limit the effectiveness of conventional radiographs. Magnetic resonance imaging allows superior visualization of differences between soft tissues.
21/07/11 1:40 PM
However, without the knowledge of the anatomy and how it appears in each modality and each different plane viewed, it is not possible to identify when the structures are altered or abnormal. Without knowledge of the pathology that can be present and the mechanisms in which each type affects the anatomy, our brains cannot ascribe significance to the shapes and shadows that our eyes detect. Decades of study into the process of visual perception and learning in radiology have left us without definitive answers as to why we see, or fail to see, the features present on diagnostic images. However, it remains apparent that we do not see what we do not know and more information will not always equate to greater diagnostic ability if we do not know how to use the information. One hundred years is a long time and radiology, as much or perhaps more than some other parts of dentistry, has undergone significant developments that have had positive impacts on the provision of oral health care. It is also certain that future advancements will continue to change the way we perform radiologic diagnosis. But as long as x-rays are our primary source of image generation and computers cannot replicate and replace our critical thought processes, some things will remain unchanged. OH 100 th Anniversary Issue 2011
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OH 100th p050 GovGeneralletter.indd 50
26/08/11 11:33 AM
oh
What a Milestone!
.
.
C
ongratulations to our friends at Oral Health as you celebrate 100 years of bringing award-winning content and insightful editorial direction to the dental profession across Canada. Like Oral Health, we are proud to be a Canadian company and proud of our history of teaching better dentistry. We’ve seen a lot of changes over the years but have always remained committed to only providing clinically-proven solutions that make a true difference in the way our customers practice dentistry. This is a wonderful time to be a dentist with new and innovative procedures increasing the opportunity to grow your practice in ways not imaginable 100 years ago. Bring on the future! Peter Jordan, President
1-800-265-3444 w w w.clinicalresearchdental.com
Dr. Ronald Jordan
C O R D L E S S
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ORAL & MAXILLOFACIAL SURGERY
The Evolution of Oral and Maxillofacial Surgery Untitled-3 1
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Bohdan Kryshtalskyj, BSc, DDS, MRCD(C), FADI, FICD, FACD Oral Health’s contributing consultant for oral and maxillofacial surgery.
Michael Kryshtalskyj A grade 11 student at Royal St. Georges College in Toronto.
M
any advancements have occurred in oral and maxillofacial surgery over the last 100 years. This has been due to the enormous strides in technological, medical, radiologic imaging, and research initiatives that have been proposed by various investigators and have been built and augmented with time by each successive generation of surgeons. The many “firsts” have resulted in better patient care, reduced morbidity and operating time, and has increased the quality of life for our patients. The practice of oral and maxillofacial surgery is forever changing at an accelerated pace. By the time this article comes to print, many other advancements will have been documented. It is impossible to mention every single discovery in this specialty over the past 100 years given the space provided. We have gathered historical advances that we believe have influenced significantly the modern practice as it is known today. The lists are not definite by any means. This paper will outline the advances in surgery of the temporomandibular joint, orthognathic surgery, pre-prosthetic/dental implant surgery and sialoadenoscopy.
TEMPOROMANDIBULAR JOINT SURGERY
Meniscectomy In 1909, Lanz described to the first meniscectomy. It was the dominant procedure in the first three decades of the 20th century. It then appeared to fade from the 52
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literature. After World War II it was performed with increasing frequency throughout the 1950s and 60s. This procedure was used where the patient presented with a displaced, damaged and deformed disc that may act as a joint irritant producing pain dysfunction and joint instability. Other surgeons have contributed to the body of knowledge of success rates for meniscectomy surgery: Dingman and Moorman (1951), Brown (1980), Carlson et al (1981) Westesson and Erickson (1985), Silver (1984) and others. Meniscectomy with Interpositional Implants In the early 1980s, interpositional implants post meniscectomy such as Proplast Teflon and Silastic were used to prevent bony ankylosis and degenerative joint disease. Because of the high incidence of destructive foreign body reactions associated with their use, they were removed from the market in 1988 and 1993 respectively. Surgeons now however continue to use a variety of autogenous material such as auricular cartilage, dermis, and temporalis muscle and fascia to replace the disc after its removal. Moreover fat has been used most recently to prevent ankylosis. Not all patients require an interpositional autogenous graft after meniscectomy as most do well without one. Disc Repositioning Surgery In 1887, Annandale performed www.oralhealthjournal.com
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and reported the first reconstructive arthroplasty using a disc repositioning procedure through the preauricular approach. In 1918, Behan described another repositioning technique. He felt to be more in harmony with the mandibular condyle. In 1974 Toller described a capsular rearrangement operation in which there would be an increasing freedom of movement of the meniscus due to the release of its lateral attachment to the temporomandibular ligament; he also sectioned the sensory nerve supply to the joint providing analgesia. McCarty and Farrar in 1979 developed an operation that involves partial excision of the posterior attachment, meniscal placation, and high condylectomy for the correction of internal derangement without significantly modifying the patient’s existing occlusion. The meniscus after partial excision was sutured to the remainder of the posterior attachment. The surgery was done only after a clinical and arthrographic confirmation of disc displacement. Others have described variations of the plication procedures: Dolwick and Sanders 1985, plication of the superior lamina of the posterior attachment tissue without violation of joint space by Hall (1994), meniscorhaphy (1984) Weinberg, and other modifications of the operation by Leopard (1984), Weinberg and Cousens (1996), Nespeca (1987), and the concept of disc preservation surgery in which the intracapsular disc surgery is performed using a microscope Piper (1992). www.oralhealthjournal.com
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Condylotomy This procedure was described by Ward et al. in 1957 and 1961. It is an oblique osteotomy of the condylar process starting at the level of the sigmoid notch and ending high on the ramus. The rationale for this approach was that some patients had suffered condylar fractures and who had previously experienced temporomandibular joint clicking and locking, had lessening or disappearance of the temporomandibular joint symptoms following treatment and rehabilitation of the fractured condyle. Studies showed an 84% clinical improvement by this surgery. The technique was modified towards the late 80s as an intraoral vertical ramus osteotomy done with fiberoptics which also revealed a similar high success rate of approximately 93%. This is known as the modified condylotomy which is currently used today. Arthroscopic surgery In 1975, the first arthroscopy of the human temporomandibular joint was described and performed by Ohnishi. Most of the knowledge came from the previous arthroscopic procedures done by orthopaedic surgeons and the orthopaedic literature. The level of technological sophistication and success that has been obtained with arthroscopic surgery as applied to small joint surgery was directed towards the temporomandibular joint. This procedure became paramount in the accurate diagnosis of systemic temporomandibular joint intracapsu-
lar disorders by providing direct visualization and the use of minimally invasive surgical techniques in order to relieve most causes of pain, closed lock and inflammation related to temporomandibular joint dysfunction. Gunther and Holmlund in 1994 found a high correlation between arthroscopic diagnosis and histologic interpretation of synovitis. Various classifications were created along with classifications of chondromalacia, and adhesion formation. Arthroscopy provides a three-dimensional view of the superior joint space. The arthroscope itself is about 2.3 mm in greatest diameter and has been created as small as 1 mm in diameter for inferior joint space arthroscopy which has been done at the research level. Surgical arthroscopy procedures have included: lateral capsular release, anterior discal release, cautery of the posterior attachment tissue, adhesiolysis of superior joint space adhesions, synovectomy procedures, and abrasion arthroplasty (done with small shavers), eminoplasty, disc suturing procedures, and sub-synovial steroid injections all under direct arthroscopic guidance. All have evolved in the late 80s through the 90s and in the past decade. In the past 3 years, smaller flexible arthroscopic equipment was created for diagnostic arthroscopy to be performed in the office. Once such counsel was introduced by the Walter Lorenz Company. OH Untitled-3 1
The remainder of this article can be found in the Fall 2011 issue of Dental Practice Management. 100 th Anniversary Issue 2011
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Advertising Trade Cards and Post Cards Untitled-3 1
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Ben Z. Swanson, DDS, MPhil Past-President, American Academy of Dental History
Ted P. Croll, DDS Practices pediatric dentistry in Doylestown, Pennsylvania
Bruce Pynn, MSc, DDS, FRCD(C), FICD Oral Health’s editorial board member for oral surgery
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T
he industrial revolution spawned a vast array of new consumer products and services. This, coupled with rapid population growth and crosscountry distribution of products by rail, brought about an unprecedented need and opportunity for advertising on a large scale. There was no radio or television and newspapers and periodicals were most conservative in what they would permit in a print advertisement. The stage was set for a new type of advertising.1-4 In the first half of the 1800s, engraving was replaced by lithography as the chief commercial printing medium. Developments and improvements in the chromolithographic process followed and a veritable print advertising boom came about in North America, in the last third of the century. Manufacturers, individual retailers and anyone who had even a modest advertising budget, could afford to print small give-away cards, known in the time as ‘chromos’, that featured advertising messages. Advertising trade cards of the 19th century were printed on light to medium paper. Most were about 3x5 inches, although some were much smaller, and some had height and width dimensions as large as 10 inches. Other advertising cards were die-cut and had unusual shapes. Trade cards usually had a colorful, eye-catching front surface (obverse) with a
printed message on the back (reverse side). However, many had blank backs — the entire message was portrayed on the front. The cards were sent through the mail, given out at retail shops, or given to children or jobbers to pass out to prospective customers on the street. Advertisers found that the more colorful and unusual the cards were, the more the public enjoyed gathering and collecting them. Cards depicted babies, beautiful women, humorous scenes, puzzles and sometimes involved newsworthy topics of the day or clever verse. The cards were bringing attention to the products and services — dollars allocated for advertising were paying off! This, of course, resulted in production of even more cards. The trade card form of advertising had been used in Europe and the United States to some degree in the late 1700s and early in the 1800s.1 Earlier cards, without color reproduction, being somewhat bland and less attractive, were often not saved. Examples of these are rare and highly prized by today’s collectors. Cards from the 1870s to about 1900 were so appealing that family members collected them as a hobby pasting them into scrapbooks that were proudly displayed in the home.2,3 Dentistry and oral health products were well represented in the advertising trade card genre. Breath fresheners, dentifrices, toothache cures, tooth polishers www.oralhealthjournal.com
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and other cleaning devices, teething cures, dental parlors and individual dental practices all were subjects on cards. Trade cards with a dentistry motif were used not only by dental practitioners and by producers of dental products but also to promote services and products unrelated to the field of dentistry. Many dentists, dental parlors and large dental office operations (ie. Albany Dentists, Buffalo Dental Association, Philadelphia Dental Association) used colorful, pleasant images of nature, beautiful young women, and sweet babies and children, to highlight their advertising “chromos.” However, others seemed to promote a horrible image of dentistry such as seen on the 1905 example for MacDonald’s teeth. The poor patient is depicted tied to the chair while the dentist pried the tooth out. Makers of dental products rarely used extraction scenes to promote their merchandise. Oral hygiene product manufacturers www.oralhealthjournal.com
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also preferred the images of pretty women or young children on their cards. An artist-drawn postcard advertisement for Dentifrices Alba-Dentina shows a patient seated in a 1920s dental chair having a tooth extracted with a dental key by a dentist having only his arms visible. As the dentist applies a twist to the key, the patient frantically and probably belatedly reaches with one arm toward the heavens where two hands offer him either a flagon of the Alba-Dentina elixir or a tin of the Alba-Dentina powder. Then there is a surprising category of extraction scene images used to sell products or services completely unrelated to dentistry. Many of the oral surgery trade cards and postcards were animals in anthropomorphic poses. Because there were no regulations concerning the veracity of claims made for products and services advertised on Victorian Era trade cards, advertisers were unrestrained in their exaggerations
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and not necessarily influenced by science or the truth.5 Claims for remedies for diseases and bodily ailments, were particularly imaginative and laughable by today’s scientific standards. However, the patent medicine phenomenon was as lucrative as it was outrageous, so it had a large presence in society leading up to the Pure Food and Drug act of 1906 and eventual founding of the Food and Drug Administration. Besides preserving individual cards, collecting them has another benefit. Each card gives today’s observer a small picture of what dentistry and oral health care were like during that time in history when the card was produced and passed around. Each card serves as a memory of our profession in years gone by — a colorful emissary from the past, sharing with us what was happening in dentistry and consumer oral health care, over 100 years ago. As collectors, we consider ourselves privileged to be caretakers of those memories. OH 1. J ay R: The Trade Card in Nineteenth-Century America. Columbia, Missouri, University of Missouri Press. 1987, pp. 1-3, 34-60, 99-103. 2. Croll TP: Memories of 19th century dentistry: the advertising trade card. Part I. Dentists and dental parlors. Quintessence International, 19(2):161-166, 1988 3. Croll TP: Memories of 19th century dentistry: the advertising trade card. Part II. Potions, lotions, and a felt tooth polisher. Quintessence International, 19(3):233-238, 1988. 4. Croll TP, Swanson,BZ. Victorian Era and Restorative Dentistry: An Advertising Trade Card Gallery. J Esthet Restor Dent 18(5):235-255, 2006. 5. Swanson BZ, Hamann CP. Hog bristles, hucksters & radioactive paste. Phoenix (AZ): SmartPractice; 2005.
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Better, Faster, Easier T Untitled-3 1
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2011
he past hundred years have witnessed the coming of age of dentistry. The full scope and magnitude of the advances would take many volumes to document, but they can be reflected in a series of images documenting the
rapid advance of the technologies and materials available to the dental profession during this century. These extraordinary developments are catalogued below in 10 areas of specific interest to patients and practitioners.
1961
1991
1.
2011
1911
LOCAL ANESTHETICS were used rarely or not at all in 1911. The “fortunate” few suffered a very large gauge needle injection without topical, and ran grave risks of cross infection from reusable syringes and contaminated containers. Fifty years ago, both the
carpule and the needle were conveniently disposable, but the process was still painful and frightening to many patients. Today, topicals, automated injection rate control, and totally disposable components make dental anesthesia safe, fast, and comfortable.
1961 1978 George Freedman, DDS, FAACD, FACD Oral Health’s editorial board member for dental materials and technology
2011 1911
2.
BURS were already highly developed a century ago, byproducts of small gauge industrial tooling. Some incremental advances, stainless steel to carbide to diamond to tungsten-carbide, were introduced over the years to accommodate high speed 60
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handpieces and newer, faster, and more precise preparation techniques. The recent introduction of polymer burs that selectively eliminate carious tissues while preserving healthy ones represents the next evolutionary step of cutting instruments. www.oralhealthjournal.com
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3.
CROWNS have been part of the dental armamentarium for millennia. In the early 1900s, lost-wax cast metal techniques were capable of delivering accurately fitting and functioning restorations. By the mid 20th century, acrylic and ceramic coverage offered an esthetic component to long-term dental treatment. The introduction of bondable ceramic and adhesive resin cement in the 2000s allow the practitioner to deliver true-to-life restorations that are often esthetically superior to natural dentition.
1911
1961
1981
2011
1911
4.
DENTAL PHOTOGRAPHY was very primitive a hundred years ago: no close-up lenses, no skinsafe f lashes, and unpredictable film and print quality. By the 1980s, the first dedicated dental photographic systems had been introduced. The lens, f lash, and
camera were coupled to provide good results most of the time, with confirmation after development within a week or so. In 2011, dental digital photo systems are virtually foolproof and offer instant image gratification. These cameras are an integral part of most dental practices.
2011
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make possible the 6. HANDPIECES modern practice of dentistry.
Most clinical procedures depend on the ability to focus rotational forces at the tooth surface. In Oral Health’s inaugural year, many dental drills were foot-powered, slow and cumbersome. A half century later, electrically-powered, cable driven drills delivered more power with less physical effort on the dentist’s part. The high speed handpiece revolutionized dentistry, making restorative treatment clinically and financially practical. Ultrafast, fiberoptic, air and water spray, pushbutton high speed handpieces are today’s clinical standard. 1911
1911
2011 1991
5.
DIAGNOSTIC TOOLS were more prized for their elegance than their accuracy in 1911. The explorer and mirror (along with the practitioner’s eyes, hands, and experience) remained the singular analytic devices available until www.oralhealthjournal.com
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recently. Just 20 years ago, the first fluorescence measuring devices were introduced to assist in diagnosing decay. Today, measuring the variances in tooth conductivity can assess the level of decay and pinpoint its exact location.
2011
100 th Anniversary Issue 2011
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10.
1991
2011 2001
7.
LASERS were not even a twinkle in dentists’ eyes 100 ago. When first introduced in 1991, the units were large, limited in scope, and expensive, but extremely popular with patients. Laser therapy expanded rapidly to hard as well as soft tissues, but in 2001, lasers
were still beyond the financial reach of most practices. Innovative design and manufacturing has expanded the utility of diode lasers while simultaneously reducing the unit costs to that of a handpiece. This permits practices to place a diode laser in every operatory.
1961
8.
X-RAYS were brand new to dentistry in 1911, having been discovered a scant 15 years earlier. For the most part, they were still experimental. By 1961, manufacturers had addressed many safety and quality issues in the equipment. Radiography required a darkroom and manual processing of films, with highly variable clinical results. Digital radiography eliminated the messy chemistry and reduced patient exposure by 80% or more. In 2011, highly accurate technology provides radiographs, tomog raphs, and greater analytical detail, more quickly, than ever before. Untitled-3 1
2011
1911
MAGNIFICATION was of minimal concern to the profession until recently. Jewelers’ loupes fit the bill in the early 1900s. By the 1960s, optically challenged and ageing dentists had jury-rigged devices attached to their glasses. Recent clinical procedures and increased patient
awareness demand much greater attention to detail, and magnification today is a part of dental school training. The addition of ultra light illumination to the magnifying loupes, and more recently, a confocal video camera, literally change the practitioner’s perspective.
1911
2011 1961 2011 1911
9.
STERILIZATION in 1911, in retrospect, was quite primitive. Instruments were wiped with alcohol in between patients (in the more progressive practices). By 1961, ultrasonic cleaning was in common use and sterilizers were beginning to appear, but gloves were rarely
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used. In 2011, every non-disposable instrument is washed, dried, and autoclaved, preferably with an integrated sterilization system, according to very strict protocols. Autoclaves are continuously monitored for contamination. Gloves for the dentist and the staff are standard.
Oral Health has heralded all these developments, and many more. It has served tens of thousands of Canadian dentists as the trusted source of education and information over the span of five generations. OH 100 th Anniversary Issue 2011
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alcohol formulation that kills the germs that cause plaque, gingivitis & bad breath No other alcohol-free mouthrinse is better at helping to kill bad breath bacteria.*1 Keep out of reach of children. Do not swallow. Not to be used by children under 12 years of age. In case of accidental ingestion, contact a Poison Control Centre or doctor immediately.
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Listerine Ad Oral Health FINAL.indd 1 OH 100th p064 J&J AD.indd 64
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ince .S .. l a t n e on D
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1877
Patterson Dental is proud to celebrate the 100th anniversary of Oral Health. Congratulations for the dedicated journalistic service offered to Canadian dentistry throughout the century! Patterson Dental remains your most trusted dental partner for the very latest technology, digital products, dental operatory equipment, sundries, office supplies, technical service and office design.
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Implant Dentistry — Past, Present and Future Untitled-3 1
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Carl E. Misch, DDS, MDS Clinical Professor and Director Oral Implantology Temple University, PA, and head of Misch International Implant Institute, Beverly Hills, MI and Toronto, Canada
The Past Implantology is the second oldest discipline in dentistry. Oral surgery is the oldest branch, with dental extractions helping to invent the forceps (pliers) used to pull spear and arrow heads from the body and to remove teeth. Implants were used to replace missing teeth more than 4,000 years ago, when the Chinese used stakelike pieces of bamboo pounded into tooth sockets to replace a missing tooth. The Mayan Indians used a similar technique in 600 AD with pieces of sea shells shaped like a stake driven into sockets to replace anterior teeth.1 One of the earliest two-stage implant insertions (an implant body and crown connection) was developed by Greenfield of Kansas, USA in 1912.2 A trephine bur was used to insert a one-stage implant body of iridioplatinum which was permitted to heal prior to attaching a crown. Al Strock of Massachusetts, USA first described a desired “ankylosis” of an implant to bone and developed a two-stage cylinder and screw implant body of cobalt-chrome in 1938.3 An implant inserted by Strock at this time was still in function more than 40 years later. A few years later, Bothe observed titanium was a “miracle metal” and would bond directly to bone.4 Titanium is still the most popular implant material used today. Leonard Linkow of New York,
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USA is often considered the “father of modern implantology.”5 He developed a screw shaped implant in the late 1950 era, a narrow “blade” implant in 1965 and was an early developer of the subperiosteal implant during this time frame (which was originally invented by Gustof Dahl of Sweden in 1949). Linkow shepherded the field of implantology to the general dentist around the world and even today, continues to share his wide and broad aspects of implant dentistry. P.I. Branemark led the development of a surgical protocol for a titanium shaped implant to obtain a predictable bone-implant interface in 1965.6 By 1981, Adell et al published a 15 year report of the Branemark implant to restore completely edentulous maxillae and mandibles.7 In these early years, Zarb of Toronto, Canada was instrumental in developing a prosthetic protocol for these clinical applications.8 The Present Over the last decade there has been a revolution in dentistry related to implantology. From 1975 to 1985, all implant products sold to North America dentists was less than 1 to 2 million dollars each year, and less than 500 scientific articles (total) were published on implant dentistry in English. From 1985 to 1995, the total number of articles increased to 3,000 and the total sales of implant products sold to dentists increased to www.oralhealthjournal.com
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more than 100 million dollars each year. From 1995 to 2005, there were more than 5,000 articles in this time span and the implant related product sales were more than 1 billion dollars each year. Implant dentistry has evolved into the primary method to return a patient to original contour, comfort, function, esthetics, speech and health, often regardless of the previous oral disease, bone or soft tissue atrophy or physical trauma. In the history of dentistry, no other discipline has modified and shaped the field of dentistry to such an extreme. The last decade now accepts implants as a primary option to replace missing teeth in both partial and complete edentulous patients. Every interfacing specialty must teach implant dentistry to be accredited. The surgical process of placing implants into existing bone volume has not been modified to any extend over the last 20 years and an undisturbed healing development can result with success rates over 99 percent. Today, the majority of complications occur to the implant prosthesis rather than the implant body. Porcelain fracture, uncemented restorations and abutment screw loosening occur more frequently than the failure of initial integration with the bone. Surface conditions of implant bodies have evolved to obtain a more predictable integration in softer bone. These improved surface condition concepts may now extend to the region of the soft tissue around the implants, permitting a physical connective tissue attachment, rather than a hemidesmosomal approximation. CT scanning machines, digital www.oralhealthjournal.com
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dentistry and bone augmentation materials have also largely developed within the confines of implant dentistry. The improved esthetic demands of dentistry have also included dental implant restorations. Recently, soft tissue contours around restorations and emergence profiles permit an implant crown to blend into the landscape of the surrounding dentition. These concepts are more often controlled by the skill of the clinician, rather than determined by a particular implant product. The Future The biologic aspects of bone, tooth and soft tissue development is now emerging in dentistry. Implant dentistry is helping to lead this aspect, since bone regeneration is vital to the restoration of many patients and it is also a major interest in orthopedics and other medical disciplines. Bone morphogenetic proteins, cytokines, amino acid sequences and other genetic engineering processes are beyond the initial development period. It is logical in the future, to “turn on the genes” for tooth development to replace teeth. After all, sharks grow teeth their whole lives and salamanders even replace limbs. OH
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It is logical in the future, to “turn on the genes” for tooth development to replace teeth. After all, sharks grow teeth their whole lives and salamanders even replace limbs.
1. A njard R Mayan dental wonders. Oral Implant. 9:423, 1981. 2. Greenfield EJ. Implantation of artificial crowns and bride abutments. Dent Cosmos. 55: 364-430, 1913. 3. Strock AE. Experimental work in dental Implantation in the alveolus. Am J Orthod Oral Surg. 25: 9, 1939. 4. Both RT, Beaton LE, Davenport HA. Reaction of bone to multiple metallic implants. Surg Gynecol Obstet. 71: 598-602, 1940. 5. Lindow LI. Endosseous oral implantology: A 7-year progress report. Dent Clin North Am. 14: 185-199, 1970. 6. Branemark PI, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10 year period. Scand J Plast Recontruc Surg Suppl. 16: 1-132, 1977. 7. Adell R, Lekholm U, Rockler B. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 10: 387-416, 1981. 8. Branemark PI, Zarb GA, Albrektsson J, editors, Tissue-integrated Prostheses, Quintessence, Chicago, IL. 1985.
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James L. Posluns, BSc, DDS, D. Ortho, M.Ed, FRCD(C) Director of the graduate orthodontic clinic at the University of California San Francisco
As long as there have been happy kids with bad habits and crooked teeth, there have been frustrated adults trying to straighten them out (the teeth, not the kids; or maybe not)
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The (Abridged) History of Orthodontics in Canada “W
hen am I getting my braces off? You said it would be two years. It’s been two years. I want my braces off.” “Well, you missed a number of appointments, and when you did show up I ended up re-bonding broken brackets most of the time.” “What’s taking so long?” “Well, it takes time for the periodontal ligament to respond to the forces and...” “No! Not for my braces. This appointment! How much longer do I have to sit here with my mouth wide open, tasting stuff that tastes like....” “Maybe if you didn’t break so many brackets....” “Maybe if you knew what you were doing. Hey! Those braces look nasty.” “They are what they are.” “Hey! That hurts!” “Well, maybe if I knew what I was doing.....”
The above exchange is pure fiction; a day in the life, of the typical Canadian orthodontist and his or her charge. Actually it’s more of a montage, based on the priceless exchange in the movie Bridesmaids between the protagonist and an adolescent customer across the counter of a jewelry store. For those of us who practice orthodontics, we’ve all been there. We can all relate.Whenever a young patient spouts off about
how rough he or she has it when it comes to orthodontic treatment, I think of the oh-too-familiar things my parents and grandparents would say when placed in similar situations. “When I was a kid, we had to walk fifteen miles in the snow to school barefoot. And when we got there, we had to light the fire and make our teacher lunch.” A hint of exaggeration no doubt, but point made. When viewed through the vantage point of progress, the past always appears significantly more of a struggle. This is true for so many aspects of life, but when it comes to orthodontics, it’s legit. Step back in time, into the offices of Drs. Hume (Fig. 1) and Kennedy (Fig. 2) Professor and Associate Professor of orthodontia respectively at the University of Toronto. There were no bonded brackets. There was no light cured cement. Bands didn’t come out of a box, they were formed by hand one-by-one out of a ribbon of stainless steel that came on a roll. Back in the day, orthodontists didn’t spend all day looking at a screen; heck no! They sweated it out in the trenches, separating teeth, making impressions and then heading downstairs to the ‘lab’ where they would pull out their www.oralhealthjournal.com
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FIGURE 1—Plaque commemorating Dr. Guy Hume, Professor of Orthodontics, Faculty of Dentistry, University of Toronto.
soldering guns and their welding torches. It’s easy to imagine a scene straight out of Dickens, where from dark and dungy basements masterpieces of appliance design would routinely spring forth (Fig. 3). As complex as the appliances of yore were to make and to fit, they were beautiful to behold. Convoluted contraptions made of gold and silver solder they seemed more at home on the boiler of an ancient locomotive than in the mouth of babes (Fig. 4). But into the mouths they went, and they didn’t come out until the orthodontist said it was time to come out. The orthodontists liked it. They loved it. And they were happy. Not surprisingly, there isn’t that much new under the sun. Expanders, no matter how robust, are still expanders, with form-fitting bands around the buccal segment teeth and cross-arch screw mechanisms providing the force (Fig. 5). In the absence of flexible materials with extended range of activation, ingenuity becomes the mother of invention. When all you’ve got is a hammer, everything becomes a nail. The use of expansion screws to alleviate anterior crossbite may be taboo today, but when a screw www.oralhealthjournal.com
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FIGURE 2—Plaque commemorating Dr. C. Angus Kennedy, Professor of Orthodontics, Faculty of Dentistry, University of Toronto.
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FIGURE 3—Atypical lab bench made up of numerous dental armamentaria.
provides the most effective, predictable and stable result possible, one makes use of it wherever he or she can (Fig. 6). Fixed functional appliances roared back onto the scene a few years back to take their wellearned place in everyday ortho dontic armamentarium. It takes a bit of time to measure and insert one of these devices. There are little pins, rods and springs, but in less than thirty minutes, they are in place and the patient is moving his or her jaw in every direction possible to test the limit of tolerance of both the appliance and the practitioner. There are a lot of parts, but the box is well organized and clearly marked. Check out how fixed functional appliances used to arrive (Figs. 7 & 8). Making sense of this mish-mash of Meccano could not have been easy, with the instructions being in Gaelic and all. Construction must have meant an all-day reservation in the dental chair. Bring out the ‘Regulator’ and watch the children scatter like leaves! One of the more marketable features of the ever-popular selfligating bracket is the ability to efficiently open the latch mechanism, remove the present arch-
FIGURE 4—Early fixed appliance.
FIGURE 5—Early expansion appliance spanning the maxillary lateral incisors and bicsupids.
FIGURE 6—Expansion appliance from maxillary bicuspid to contralateral cuspid. 100 th Anniversary Issue 2011
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FIGURE 7—Box containing pieces of a Regu lator used for mandibular protrusion.
FIGURE 8—Simple bite-jumping appliance.
FIGURE 9—Twin wire two-by-four.
FIGURE 10—Fixed appliance with passivated heavy labial bow.
FIGURE 11—Ivory teething ring. www.oralhealthjournal.com
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wire, replace said archwire with a new archwire and close the latch mechanism. According to the manufacturers, one can use the time one saves by not having to manually untie and retie archwires for whatever one wants; surfing the internet, reviewing one’s stocks or the piece-de-resistance, spending more time with one’s family. It’s too bad one cannot store up saved time like airmiles to be used for whatever one wants when the time is right. One look at the bracket and archwire set up from the turn of the century and it’s easy to surmise that time was probably pretty tight. Each band around each tooth was pinched, soldered, welded to an attachment and then cemented into place (Fig. 9). Once all the bands were cemented, one or two gold archwires were passivated and then attached to the pin mechanism for total tooth control in at least two directions. It’s probably pretty safe to say that a number of orthodontists’ kids in the early part of the twenty century were raised by wolves, seeing how their parents never got out of the office before midnight on any given day. Nickel titanium; you can’t beat it for aligning teeth. To coin a phrase, ‘it’s better than sliced bread.’ There are a number of permutations; classic, super elastic, braided coaxial, all delivering low levels of biocompatical force that were at one time both unimaginable and unattainable. Orthodontists today throw these wires around with nary a thought. ‘Got a crooked tooth? No problem. Insert a nickel titanium archwire, take two aspirin and call me in eight to ten weeks.’ Tooth alignment wasn’t always so straightforward (pun intended).
Large dimension passive stabilizing archwires were fabricated (Fig. 10) for anchorage with ties to banded teeth to pull and rotate the numerous young offenders back into line. The movement was inefficient, time consuming and painful. Thanks to the folks at NASA, the development of nickel titanium was ‘one small step for orthodontists, one giant leap for orthodontics.’ Untitled-3 1
As long as there have been happy kids with bad habits and crooked teeth there have been frustrated adults trying to straighten them out (the teeth, not the kids; or maybe not.) And they started ‘em young. Teething rings were made out of ivory from the tusks of elephants, decorated with caps of lead and bells attached to the ring with loops of wire (Fig. 11). Nice and secure. Sure the kid’s life was in jeopardy, but by golly, he or she would be SEEN AND NOT HEARD! It kind of makes you wonder how any of us survived. If your teething ring didn’t kill you, then cruising down the 401 in the back of a ’68 Oldsmobile convertible with the top down and Sonny and Cher on the 8-track sans seatbelt with your parents flicking cigarette butts rearward while you fought with your brother and sister might just do the trick. Like teething rings, pacifiers have been around for ages. Did you ever wonder exactly what makes an ‘orthodontic’ pacifier ‘orthodontic’? Anything stuck in a kiddy’s mouth, wedged in between his or her teeth while the little darling goes at it like a house on fire has got to do some damage, regardless of what Madison Avenue wants us to believe. But generations of offspring continue 100 th Anniversary Issue 2011
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to love the soft rubber of the pacifier, whether or not it’s covered in dirt. It couldn’t have been much fun having an old-school device as a soother. Made of wire and ribbon, this appliance was more of a habit-breaker than the habit-makers of today (Fig. 12). Maybe that’s why kids run wild these days. Parents of today: Control your progeny! I hereby make a motion to bring back the wire pacifier. Who’s with me? Anybody? Anyone?
HAVE YOU JOINED?
21/07/11 1:40 PM
Despite of all these alleged advances, in this wondrous age of digital models, Clincheck® and Suresmile®, have we made any real progress (Fig. 13)? It’s hard to say. Do teeth move any faster? Most likely. Are the procedures less invasive? Definitely. Does one spend less time bent over the chair? Undeniably. But even with the advent of all this technology, one question remains. “When am I getting my braces off ?” To which there is only one answer, “Well, back when I was a kid....” OH
FIGURE 12—Wire and ribbon pacifier.
Sincere personal thanks to Dr. Anne Dale, Curator of the University of Toronto, Faculty of Dentistry Museum and to Dr. Jack Dale for simply being himself.
FIGURE 13—Typical model box of pre and post treatment records.
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Peter Birek, DDS, MSc, Dip. Perio Oral Health’s editorial board member for Periodontology
...most, if not all, well-conducted studies raise more questions than they answer. This, by the way, drives progress and is “raison d’être” of science. I share the opinion of many that in fact science should raise more questions than it can answer
One Hundred Years of Persuasion? B
eing under the influence of my favorite CBC radio program “The Age of Persuasion” I sat down to write this short note about the Oral Health Journal (OHJ) on the occasion of its 100-year birthday. In this program, the award-winning journalist Terry O’Reilly muses about the advertising industry and how ad men “persuade” consumers to do one thing or another. Often, the ads are based upon “spinning” the truth rather than presenting hard-core realities based on which consumers can make a choice. For a moment, I felt uneasy about my association with OHJ that goes back more years than I care to admit. The dark recesses of my uncontrollable mind conjured that “peer-reviewed” journals present facts (i.e. science), while the “non-peered” ones, such as OHJ, would be the “spinners” in the business of persuasion of the dentists at large about how to do their work. I felt a moral pang deep in my stomach and had nightmares about it before I sorted out my thoughts and finally recovered. Science — basic or clinical — is based on testing hypotheses by posing questions of practical interest for those who dispense health care. Scientists conduct these tests according to well-
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established standards of study design, rigorous testing and precise analysis of the data. The results are then disseminated to the “consumers” via publications. Only those papers that pass the test of rigorous peer reviews of fellow scientists see the light of the print. Publishing in itself is not the ultimate proof though. True validation comes only after replication of the studies by fellow scientists often at opposite edge of the global village. As unfortunate as it is understandable, not all questions are asked and researched. Some just don’t come up on the radar of scientists; other cannot be tested for various reasons related to constraints of our societal standards and habits and scarcity of research funds. Moreover, most, if not all, well-conducted studies raise more questions than they answer. This, by the way, drives progress and is “raison d’être” of science. I share the opinion of many that in fact science should raise more questions that it can answer. A good reflection of the role and contribution of OHJ and other non-peer reviewed publications is the example of a book printed in 1950, when the OHJ was barely 50 years of age. The author of the book entitled “Practical Periodontia,” set out to www.oralhealthjournal.com
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Cover page of Practical Periodontia, complements of the faculty of Dentistry Library, University of Toronto. Untitled-3 1
many breakthroughs in our field. True to Dr. Robb’s tradition, OHJ continued to “bring to the general practitioner...” valuable information that could be used to solve every day issues in our practices. Attempts to provide the best “...bring to the general practitioner an easy-to-read account of Periodontia and to outline the practical applications of the research being done at the University of Toronto by Dr. H. K. Box” with special thanks to Dr. P. G. Anderson’s contribution, a prominent Toronto dentist and educator of his time. In the preamble, the author, H. Murray Robb, acknowledges the permission of OHJ for the reprint of a series of 37 published articles from the journal as the basis for his work. Now, that is a significant contribution of OHJ achieved in 1950 — for those who are not up on “ancient history” this is the year when the Korean War started, the first organ transplant was done and the first “Peanuts” cartoon was published giving birth to Charlie Brown. Over the next 50 years OHJpublished over a hundred papers about various aspects of periodontics as we witnessed www.oralhealthjournal.com
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possible answers to questions unanswered by science, and pose questions that science may try to answer is what OHJ does best! Looking at it this way I no longer question my meager contribution to OHJ and I sure won’t have nightmares for the next 100 years... OH
Thanks
to Oral Health for 100 years of service to the dental industry and profession.
Dr. Rita Kilislian D.M.D. CERT.ENDO. 425 Water St.,Suite 200. Peterborough, ON. Tel: 705.750.0700 Toll Free: 877.313.7066 www.kawarthaendo.com
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Bruce Glazer Oral Health’s editorial board member for prosthodontics
Not only are prosthodontists needed as teachers at a general level, but also they are needed as facilitators in a multi-disciplined approach to complex treatment planning
S
ince 1918, when a group of dedicated dentists met in Chicago to create the National Society of Denture Prosthetists, prosthodontics has continually redefined itself. Today it is at the teaching forefront of dentistry. Prosthodontics was one of the first specialties recognized in dentistry, but its’ development lagged behind its’ American cousin. It was not until Dr. George Zarb, one of the first prosthodontic editors of Oral Health, began his academic career at the University of Toronto, that prosthodontics as a specialty within Canada began to take shape. Working alongside Drs. Douglas Chaytor and Donald Kepron, the Association of Prosthodontist of Canada (APC) was created in Ottawa on September 1971.1 APC was a departure from the separation concept of the specialty into fixed and removable components towards a more blended graduate educational based approach to the specialty. Prosthodontics was refocused towards orofacial rehabilitation. The creation of APC and its’ eventual recognition by the Canadian Dental Association to Section status for prosthodontics in 1976 was facilitated through the cooperation of the two separate disciplines of prosthodontics represented by CARD (Canadian Academy of Restorative Dentistry) and CAP (Canadian Academy of Prosthodontics). Prosthodontics today might be
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defined as a marriage of bioengineering and architecture. It encompasses the management of our patient’s teeth and supporting tissue as defined by age, overall systemic health and socioeconomic status. It is the interplay of these factors that makes prosthodontics one of the most complex and demanding specialties in dentistry.2 The significance of prosthodontics as a specialty in dentistry has increased as the prevalence of a dentate and a partly dentate population has developed. Previously, our Canadian elders were subjected to edentulism due to the high rate of caries and periodontal disease. Today, and into the future we can expect an older tooth bearing cohort seeking more complex dental services.3 This will create an increasing demand for general dental services, which today translates into an increasing role for not only general dentists, but dental assistants, dental hygienists, denturists, and dental laboratory technologists. In order to train and manage these expanded dental providers we will need qualified teachers and the demand for well trained general practitioners will place more burden on the specialty; as only educational excellence delivered by prosthodontists will translate into the very best of patient care.1 Since 1965, when prosthodontics was recognized as a specialty in Canada, there www.oralhealthjournal.com
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has been a constant movement away from a discipline of builders towards a more science based intraoral architectural approach. In order to achieve this demand, we must address the paucity of graduate programs and dental educators in Canada. In particular, this dearth of educators must change for the positive if our Canadian universities are to be able to educate future dentists in a problem-based learning environment. Not only are prosthodontists needed as teachers at a general level, but also they are needed as facilitators in a multidisciplined approach to complex treatment planning.
ing advantage of the principals of implantology, tissue engineering, stem cell biology, neuroscience, material sciences, and last but not least, genetics and genomics.” “Working research tools including computer-assisted designed manufacturing and modern imaging, promise rapid transformation of new knowledge into applications for the patients. The future of prosthodontics is bright only if we address the meager government funding allocated for clinical education necessary to train future specialists.”5
Many times there needs to be a coordinated team effort between an orthodontist, endodontist, periodontist, oral radiologist, and an oral and maxillofacial surgeon. The prosthodontist then would function as the intraoral architect responsible for developing and eventually finalizing the reconstructive dentistry.
Figures 1 and 2 not only reflect the title of this article but they represent a tribute to the specialty. They highlight the spectacular results possible when a prostho dontist leads a multidiscipline team approach to reconstructive dentistry. A special thank you to my teacher, Dr. George Zarb, who enabled me to turn this caterpillar into a beautiful butterfly. OH
No discussion of prosthodontic’s changing face would be complete without acknowledging the role of osseointegration. In North America, the watershed event was the Toronto Conference of 1982.4 Here under the direction of Dr. George Zarb, the Branemark Osseointegration Era began. As mentioned previously, “prosthodontics is well positioned to meet the expectations of an aging population, tak-
1. T aylor James. APC web site URL: http://www.pros thodontics.ca/index_eng.html 2. Interview with Dr. George Zarb. JCDA 2005; 71 (5). 3. MacEntee Michael. A Look at the (Near) Future Based on the (Recent) Past - How Our Patients Have Changed and How They Will Change. JCDA, 2005; 71 (5). 4. Chaytor Douglas. Prosthodontics 1966-2042: Changes in Prosthodontic Education, Past and Future. JCDA 2005; 71(5). 5. Stohler Christian, Prosthodontics Research: Break ing Traditional Barriers. JCDA 2005; 71(5). 6. Hobkirk John A. Prosthodontics: A Past with a Future? JCDA 2005; 71 (5):326. 7. Carlsson Gunnar. Changes in the Prosthodontic Literature, 1966 to 2042. JCDA 2005; 71(5) . 8. Worthington Philip. The Changing Relations between the Allied Disciplines. JCDA 2005; 71 (5):330.
www.oralhealthjournal.com
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PREVENTIVE DENTISTRY & HEALING
What’s in a Name?... F
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Fay Goldstep, DDS, FACD, FADFE Oral Health’s editorial board member for preventive dentistry and healing
“...the thought that the modern dentist is not merely a dental surgeon, but also a dental physician who practices preventive dentistry”
ar be it from me to contradict Shakespeare, but here I go. A name is very important for the function and reputation of an institution or organization. Its selection is key to the philosophy, vision and core values of the group. One hundred years ago, the first editorial of Oral Health Journal spoke of the need to “emblazon.... the thought that the modern dentist is not merely a dental surgeon, but also a dental physician....a dental physician who practices preventive dentistry.” This was the vision of the journal. Simply and clearly, it was named Oral Health. One hundred years ago ‘preventive dentistry’ was in its infancy; W. D. Miller published his revolutionary work called: Microorganisms of the Human Mouth, in 1890. His thesis proposed that when carbohydrates are fermented by bacteria in the mouth, the acids produced decalcify and weaken teeth, creating the downward spiral of decay. This process, that we take for granted today, was previously unknown. This revolutionary concept led to the birth of preventive dentistry. No longer would dentists watch powerlessly as decay ravaged their patients’ teeth; they were now armed with an understanding of the cause of decay and the means to control it. Research focused on more effective dentifrices and mouth rinses. Patients were educated to brush their teeth. This was also the beginning of modern dentistry, founded on scientific research and principles.
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G.V. Black was the most influential dentist in the transition to modern dentistry. Black standardized scientifically-based preparation designs for the restoration of decayed teeth to proper function. He coined the term “extension for prevention,” a counter-intuitive concept in preparation design that was necessary due to the inadequacies of the restorative materials of the time. In an address to some of his students, Black prophesized that “the day is surely coming...when we will be engaged in practicing preventive rather than reparative dentistry; when we will so understand the etiology and pathology of dental caries, that we will be able to combat its destructive effects by systemic means.” This was the environment in which Oral Health Journal was conceived. The editors held the forward looking objective of science-based clinical knowledge for the improvement of oral health. The future would make all this possible. Preventive dentistry was front and centre! Fast forward 100 years to 2011; so much has happened, so much of the original promise of preventive dentistry has been fulfilled. We are no longer chasing caries and periodontal disease and forever playing catch-up. We now understand the disease process and are able to proactively intervene to slow and even stop its progress. We have arrived at the era of “proactive intervention dentistry.” We have the tools needed to properly diagnose, assess risk www.oralhealthjournal.com
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PREVENTIVE DENTISTRY & HEALING and then armed with this essential information, treat our patients. Demineralization and early caries are no longer invisible. We have the means to detect the initial effects of demineralization on all tooth surfaces and to quickly intervene with a remineralization regimen. Several instruments have made this possible. One of the most promising was developed in Canada, and released just this year: The Canary System by Quantum Dental Technologies. The Canary System is a laserbased device that uses heat and light to directly examine the crystal structure of teeth and map areas of demineralization. Not only is the decayed surface noted but the actual footprint of caries is demarcated. What would G.V. Black say now? Armed with this map, the dentist can use very effective remineralization protocols for treatment. A wide range of products have been developed. The dentist and hygienist must keep up with a potpourri of ingredients: Sodium Fluoride, Stannous Fluoride, Novamin, Recaldent, ACP, Tri-Calcium Phosphate, glass ionomers, giomers and many more. Patients can participate in the process and monitor their own progress in a way that was not possible in early preventive dentistry. Over 100 years ago when dentists were shown that bacteria were involved in the caries process, they were not aware that microorganisms were also implicated in periodontal disease. This was to come later. Today, DNA testing can plot the specific, or group of specific, bacteria that are involved in a patient’s periodontal condition. The patient can then be treated with rinses, tray-borne www.oralhealthjournal.com
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solutions, locally applied antimicrobials, photoacti vated disinfection, lasers and anti-collagenase pro tocols before resorting to periodontal surgery. Screening of the patient’s oral mucosa for early detec tion of diseases such as dysplasia and cancer is the dentist’s responsibility. Today’s practitioner has tools available to facilitate the discovery of mucosal abnormalities before they become visible under ordinary light. One such tool, developed in Canada, is VELscope. It is a handheld device that detects the differential fluorescent properties of healthy and abnormal tissues at a very early Proactive Intervention stage. This is where we are today. We are able to diagnose, assess and treat pathology in hard and soft oral tissues and mucosa. We have come far on the path envisioned by the founders of Oral Health. What does the future hold? The oral systemic health link is the preventive dentistry of the future! Until recently dentists and physicians have paid attention only to their own narrow fields. However, recent scientific research strongly suggests a bidirectional association between periodontal inflammation and systemic conditions such as cardiovascular disease, type 2 diabetes and osteoporosis. By tackling periodontal disease, the dentist becomes a vital partner to the physician in enhancing general health. A recently launched product, also developed in Canada, will help strengthen this dentist-physician partnership. UFIT by Bio-
VELscope by LED Dental. Untitled-3 1
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The Canary System by Quantum Dental Technologies.
sign Dental has created a simple, web-based, on-going, trackable system to monitor blood pressure and pulse. This information is vital for many dental procedures. Also, hypertension is a frequently undiagnosed condition. Due to the regularity of dental visits, the dentist can become an important link in the monitoring of the patient’s cardiac health. We have come a long way since 1911. We have a greater understanding of oral health; we have a partial understanding of how it affects our patients’ general health. Oral health... It is what our profession strives for. It is so essential to the well-being of our patients. Oral Health Journal... there is so much in a name... OH 100 th Anniversary Issue 2011
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GERIATRICS
The Plight of the Frail Elderly Untitled-3 1
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Aldo Boccia, DDS Current member of Oral Health‘s editorial board
I
n a 1985 text book, Clinical Geriatric Dentistry,1 Dr. Ronald Ettinger suggests “Geriatric dentistry should be defined as the provision of dental care for adult persons with one or more chronic, debilitating physical or mental illness and/or psychosocial problems” and then went on to note that “Our definition of a “geriatric” person is a biologically compromised individual who may or may not be older than 65. However, the majority of “geriatric” patients are older than 65 and can be divided into two groups: the frail elderly and the functionally dependent elderly.” Dr. Ettinger closed his comments on definition with his usual sage advice: “Obviously, the treatment of frail and functionally dependent older patients can be complicated, and requires an additional array of skills not usually possessed by most general practitioners.” Another book of the same era, Geriatric Dentistry2 (1986), bears within its Preface the statement, “In the individualized world the new generations of elderly will be better educated and more demanding of social and health services 88
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than past generations. Many will retain their natural teeth; only a minority will wear complete dentures. These changes in health status, in attitude and behaviour, will have a significant impact on oral health needs, creating new challenges for the dental profession.” It is interesting to look over the 25 years since those profound statements were made and note how prophetic they were. The elderly are better educated with many retaining their natural teeth, and the treatment of frail and functionally older patients will be complicated. And there are new challenges for the dental profession — with the challenges affected mainly by demographics, technology and expectations (i.e., cosmetic dentistry). We are all familiar with the term Baby Boomer3 — those born between the years of 1947 and 1966. During that time there were about 28 births on average per 1,000 people in Canada. Since the year 2,000 the birth rate has been hovering around 11 births per 1,000 Canadians. By the year 2020 the boomers will be 60 to 75 years old and by 2030 the early Boomers will be in their 80s. Sources from Statistics Canada tell the graphic story of our growing population of seniors (see Table). It is estimated that there are about nine million Boomers in Canada today and reflecting back over past years it is generally agreed that their dental health care —
and dental health of all Canadians — has improved. Evidence of this is revealed by a Statistics Canada report4 on edentulism. In 1990, 16 percent of Canadians were edentate whereas just 13 years later, only nine percent reported having no natural teeth. The same improvement in oral health is evidenced in the elderly. Close to half (48 percent) of those aged 65 or older were edentate in 1990 whereas in 2003 it was 30 percent and in the coming years we can expect even more dramatic decreases. The American 3rd National Health and Nutrition Examination Survey in 1996 estimates that by 2024 only 10 per cent of those between 65 and 74 will be edentulous. Much of the improvement in oral health, particularly amongst the Boomers, can be attributed to the introduction of the fluoride in water supplies and toothpaste, the overall emphasis on personal oral hygiene and employee dental plans that encourage the six-month check-up. Accompanying these oral health benefits are the technological advancements in filling materials, crown and bridge technology and dental implants. Nor can we overlook the whole concept of cosmetic dentistry where that “perfect smile” is part of life and is being emphasized more and more in dental advancements and within practices across the country. It is encouraging to look at the improvements in health care and the drop in edentulism but this “Senior Tsunami” of the aging www.oralhealthjournal.com
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GERIATRICS Boomers is definitely going to increase the treatment requirements of the elderly in the coming years — particularly as we recall Ron Ettinger’s reference to the frail and functionally dependent older patients where the treatment can be complicated and requires an additional array of skills not usually possessed by most general practitioners. Also, as shown in their article The Aged Mouth: An Insight,5 Raina and Patil outline many of the “aged” problems not often seen in the average “normal” dental patient. Among their numerous observations are: • complexity in performing oral hygiene procedures coupled with delayed sugar elimination time as a result of poor general health and hyposalivation has a powerful effect on the development of caries; • g ingival recession and loss of periodontal attachment and alveolar bone are in real fact universal findings of the old; • the usage of numerous drugs concomitant with underlying systemic disorders makes the aged particularly prone to oral dryness; • the aged are considered to be at greater risk for developing opportunistic oral infections. In his October 28, 2010 report on the state of public health, David Butler-Jones, Canada’s chief public health officer, revealed recent statistics on the well-being of seniors that certainly will have some effect on their aging oral environments and requirement for treatment: • an estimated 20 per cent of seniors living on their own and 80 to 90 per cent of those living in institutions have mental health issues or illness. At the same time, dementia affects about 400,000 Canadian Seniors; • one in four of those aged 65 to www.oralhealthjournal.com
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Portion of Canadian Population 65 years and over 1900
1950
1990
2010
2030
5%
8%
12%
14%
20%
79 and one in three of those 80plus have at least four chronic conditions; • available research suggests that four to 10 per cent of Canadian seniors experience physical, psychological or financial abuse or neglect; Considering then the growing numbers of elderly — by the year 2030 at least 20 per cent of the population will be over 65 with more than 14,000 over the age of 100 —how well will Canadian dentists be prepared to treat those who are frail and functionally dependent. If we are to put credence in a recent article by Dr. Ron Ettinger,6 the dental profession is not well prepared. It is his opinion that even though each of our Canadian dental schools has a required course in geriatric dentistry, that one didactic course without supporting clinical experience is insufficient at the pre-doctoral level. From a U.S. Department of Health and Human services report Ettinger extrapolates and estimates that Canada will need at least 600 fully trained geriatric dentists and 200 minimally trained dentists to care for its aging population by the year 2020. Upon review of the growing numbers of aged seniors with physical and mental problems influencing their over-all oral health — requiring literally hundreds of trained geriatric dentists — what can the profession do to bring some enhancement to the quality of life of an entire segment of our population. Unless the complete issue is addressed it
is obvious that the need, the problem, is only going to become more critical. Like many health issues there are no quick and easy answers and ignoring the problem will only make matters worse. Untitled-3 1
Federal and provincial health departments have a responsibility to address all the health need of the elderly. Health Canada is to be applauded for the November 2009 bulletin The Effects of Oral Health on Overall Health but at the same time should address specifically the plight of the geriatric’s oral health. Dental faculties must be encouraged to actively support the teaching and specialization of geriatric dentistry and assure that dental graduates have an adequate basic knowledge in treating the frail and compromised patient. Dental associations and societies across the land have an obligation to promote and persuade within their membership the importance of treating aging seniors. This can be accomplished with appropriate and timely lectures and seminars, pamphlets and public promotion. And most important of all, individual dentists, hygienists — all dental health workers throughout the land — must do everything possible to increase and enhance their individual knowledge and skills in treating the elderly. OH 1. C hauncy HH, Epstein S Rose CL, Hefferen JJ, Clinical Geriatric Dentistry (Chicago, Ill ADA, 1985) 194-5. 2. Holm-Pederson P, Loë H, Geriatric Dentistry, (Copenhagen, 1986). 3. Fortin P, UQAM, July 17, 2006. 4. Miller WJ, Locker D, Health Reports, Vol. 17, No. 1, November 2005. 5. Raina A, Patil K, Internet Journal of Geriatrics and Gerontology. 2010 Volume 5 Number 2. 6. Ettinger RL, The Development of Geriatric Dental Education Programs in Canada. J Can Dent Assoc 2010;76(I)45-48.
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DENTAL JURISPRUDENCE
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Rollin Matsui, BSc,DDS,LLB Oral Health’s editorial board member for ethics and jurisprudence
The small number of dental practitioners with formal dental training and scientific experience faced stiff competition from the tramp dentists and, as a result, reputable dentists were hard put to make a living
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No Matter How Things Change, Do Things Stay the Same? I
n the 1911 March issue of Oral Health, it was reported that the Ontario Dental Board ruled against Mr. Henry, a non-licentiate proprietor of the Toronto Painless Dental Parlour. His business was terminated and he was required to pay fines for a direct breach of the New Dentistry Act for practicing dentistry without a license in Ontario.1 The Act had been recently passed by the Ontario Legislature and was the latest revision to the Dentistry Act of 1868, in response to concerns raised about shortcomings of the statute.
flim-flam artists, the lineal descendants of “Le Grand Thomas”.” They travelled from town to town, staying a few days in each place and seldom returning to the same place twice. Known collectively as “tramp dentists,” they had little knowledge of dental science. They practiced sloppy dentistry, worked for low fees and were very hard to find when problems arose.”3
WHAT WAS IT LIKE TO PRACTICE DENTISTRY AT THAT TIME?
The small number of dental practitioners with formal dental training and scientific experience faced stiff competition from the tramp dentists and, as a result, reputable dentists were hard put to make a living.4
Put another way, the “flamboyant” category of practitioner essentially “comprised of quacks, charlatans, itinerants and assorted
The case against Mr. Henry reflected the attitude of dental professionals with credible training and academic degrees against the non-licensed “dental mechanic” and the charlatan licenced dentist. The public’s attitude about dentists appeared to be driven by the fear of painful and expensive dental care and this directly impacted those dentists who were trying to elevate the professionalism of the dental practitioner. “Cheap dentists” represented a majority of the practitioners during this time and they were advertising their services to the unsuspecting public.5 Rural populations often debated whether or not it was more beneficial to make the long drive to
In the mid to late nineteenth century in Canada, there were four types of persons who practiced dentistry: (1) medical practitioners who performed some dental emergency services, (2) medical practitioners who had taken apprenticeship training and confined their services to the practice of dentistry, (3) the flamboyant type of dental practitioner who had arrived in urban centres preceded by extravagantly advertised claims, and (4) practitioners who had served an apprenticeship of varying length with a dentist.2
www.oralhealthjournal.com
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DENTAL JURISPRUDENCE
the dentist in town with his ‘cruel’ forceps or to just go down the road to the local farmer who seemed equally capable of extracting an aching tooth with his turnkey.6 Leading pioneers at the time were attempting to establish dentistry as a true profession and not merely a trade; they frowned heavily upon advertising and considered it to be unprofessional. One of these pioneers, Dr. George Beers, stated succinctly “If we consider dentistry a mere trade, then let us agree to work for little over cost as the shoemaker who makes our shoes; but if a profession, let us charge for our brains.”7 Many efforts were made to legitimize the profession in an attempt to change the current state of mind of the public, who at the time had little appreciation for dental services.8 Dental schools were established with University affiliation across the nation and a new form of formal education was created that could provide students with the ability to be recognized as “Doctors” rather than just having the recognition of a Licentiate of Dental Surgery (L.D.S.).9 Despite these efforts, advertising still remained the bane of the profession and a serious impairment that prevented its elevation.10 By 1887, 8x12 foot boards with the names and addresses of dentists who emphasized nothing more than cheapness stood at every public road entrance to the city of Toronto and the public suffered the consequences as these offenders continued to conduct their ‘quackish’ practices via these ‘claptrap’ ads and ‘Cheap John’ performances.11 As early as 1871, documented evidence existed where the Ontario Dental Society cancelled the license of S.J. Sovereign who was www.oralhealthjournal.com
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considered a notorious advertiser, but the action was withdrawn upon receiving further legal advice.12 To make matters worse there was competition between dentists and dental laboratories. The usual situation at the time was for the laboratory to be physically located within the dental office since it was an essential component of dental practice. However, dental supply houses saw an economic opportunity and set up separate dental laboratories outside of dental offices and performed dental procedures for their clients without a license.13 Although the dental board tried to close down these illegal practices, they were widespread and very difficult, if not impossible, to police and regulate. By the beginning of the twentieth century, a more serious attempt to stop such unprofessional behaviour gathered steam due to amendments in dental laws and reform movements initiated within dental organizations to finally bring advertising under control.14 It should create a sense of pride for present-day dentists to realize that early leaders of the profession were concerned that dentists be made aware of dental jurisprudence issues. One such prominent leader was Dr. Walter Seccombe. Dr. Seccombe was a “force for progress” in dentistry, filling numerous positions with zest and action. By 1908 he was a member of the Ontario Board, and in 1912 he was appointed superintendent of the Toronto school in recognition of his administrative ability. In 1923, he was appointed by the Ontario Board...as dean of the school. His main interests were in dental education, dental research,
and dental public health, to all of which he made great contributions. In addition, he established a dental journal, Oral Health, in 1911 and served as both editor and publisher as long as he lived. He was a remarkable leader, a forward-looking educator for his time with an intense pride in his profession.”15 Untitled-3 1
With regard to the dental journal Oral Health, this was “the first dental publication to promote the concept of preventive dentistry. In his mission statement, Seccombe said it was to be “a monthly journal devoted to the interest of the dental profession, to the furtherance of Public Health, and to the education of the public in relation to oral hygiene; published in the hope that it may reach those with an open mind, a willing heart and a ready hand to serve. A second purpose, unstated in the mission but executed nonetheless, was that the journal would serve as a convenient platform for Seccombe to blast less visionary practitioners.”16 It could be said that Dr. Seccombe had the foresight to create a publication for dentists that presented the views and issues of the dental profession and brought ethical (and other practical and scientific) issues to the attention of dentists of the day. The introduction of Oral Health was a significant addition to dental journalism in Canada.17 The fact that Oral Health is celebrating its one hundredth (100th) anniversary this year is truly a testament to Dr. Seccombe’s foresight and concern for the best interests of the dental profession. OH The remainder of this article, including references, can be found in the Fall 2011 issue of Dental Practice Management. 100 th Anniversary Issue 2011
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30/08/11 10:11 AM
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DENTAL LABORATORIES
Dental Technology: A Personal Reflection Untitled-3 1
21/07/11 1:40 PM
Trevor R. Laingchild RDT, A AACD President, dentalstudios Yorkville/Burlington, ON
T
he driving force behind the development and advancement of dental technology has always been advances in material sciences along with the educators who have provided continuous advancement in protocols for the fabrication and techniques for the placement of the various types of dental prostheses. As these sciences developed, special skills in fabricating prosthetic devices were needed, the demand from the dentist to send out for the necessary fabricating services began and the dental lab, as we know it, was born. According to the National Association of Dental Laboratories in the US, the first dental lab was established in Boston in 1887 and thus the dental lab technician became an integral part of everyday dentistry. My own personal recollections of dental technology bring back fond memories of my grandfather and father fabricating removable appliances and prostheses. I need to thank them for their inspiration which guided me into a truly inspirational profession. 94
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I think it can be said that only with a commercial financial return, dental material companies increased their research and development as market demand grew. Nevertheless, they were the pioneers of some of today’s techniques and education. Working conÂditions were not always ideal and remuneration for services not always at an appropriate level. Many factors were responsible for this, primarily the lack of credentialing and education. Apprentices learning the skill sets within the dental lab often spent a lifetime learning and perfecting their skills without obtaining an official Certificate or Diploma. In many cases that is still the situation today. The importance of credentialing, in any form, cannot be underestimated. As the techniques, procedures and the responsibility of the laboratory technician increased, both to the dentist and the patient, more jurisdictions introduced different forms of credentialing and subsequently, licenses to practice. There are varying forms of licenses and credentials to be found, throughout different jurisdictions, with some authorities within governments and schools, developing professional standards with professional accountability and including Bachelor of Science Degrees in Dental Technology. It is paramount for dental technicians to become educated and credentialed. Unfortunately not all juris-
dictions pursue the development of these credentialing standards; standards which nurture the advancement of professional excellence, which benefit the patient. As with many different industries and technologies, the cost of implementing new and expensive procedures has seen the fees required to maintain these standards rise. As recently as 20 years ago the startup and implementation of technologies within a dental laboratory was reasonably affordable within a financial business plan and one which a skilled technician may have decided to undertake. In recent years the explosion of more advanced techniques, which require more financial commitment, have created a more challenging environment not only to start and develop a new business, but also to maintain. Within dentistry, the dental laboratory has evolved into a business that requires significant financial capital and in some instances even surpassing that level. It is not uncommon for dental laboratories to spend between 50k-300k for fabricating systems and there is need to have several systems on site. This does not include the cost of training, research and development, and differing staffing levels and education. The overall cost increases, along with a shortage of highly skilled technicians, has led to the modern business model of outsourcing. Within dental technology there is ample discussion on the causes and effects of this modern phewww.oralhealthjournal.com
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DENTAL LABORATORIES nomenon. As in other industries, the pursuit of maximizing profit has led to a situation where the location of fabrication plays an important part with the costs of labor. Having prosthetic appliances fabricated in an unregulated environment also raises arguments over standards met or not, simultaneously with the erosion of a skilled labor force, along with their earning power. If professionalism and salary levels are allowed to slide it will become increasingly difficult to cultivate a highly skilled and renewable body of dental technicians. Since the last century when the dental laboratory industry began, prosthetic appliances were fabricated outside of the dental office, interestingly now, more fabricating is being undertaken within the modern dental office. Modern CAD/CAM technologies allow a selection of materials utilized for this purpose. Does this jeopardize the dental technicians future? As in the industrial revolution, machinery and automation are becoming more prevalent, which in return reduces the number of employed technicians. Larger laboratories have more financial power and leverage to engage with the varying business dynamics, whereas smaller laboratories have the ability to compete with a more personalized service often offering a boutique service, often in close proximity to their clients and patients. I feel both will survive and flourish, but a vigilance to new technologies whilst maintaining an increased level of professionalism, will be necessary. The outsourcing discussion will continue; whether it is for a reduction in labor costs or the ability of a laboratory to utilize www.oralhealthjournal.com
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services of another laboratory with a specialized technique. The increase in the use of dental implants for the foreseeable future requires considerable investment in education for the lab. Clinical and esthetic challenges are ever changing and this I feel, is an ever expanding scope of practice. Digital technologies are the future and they are becoming more commonplace but sometimes they come with a price. Startup costs can be high and the additional costs of fabrication for the laboratory need to be considered. Fabricating the prosthesis on expensive equipment may be more efficient, but the overall cost of the equipment needs to be considered within the laboratory business plan. Digital technologies will also expend the range of prosthesis available to be fabricated within the dental office, thus giving the patient options for faster completion of dental treatment. However, complex machines have limitations when endeavoring to create bespoke and characterized restorations, there will always be a demand for aesthetic modifications to a milled restoration, otherwise all restorations will be of similar quality and esthetics. Creativity will always be in demand, therefore the future requires that dental technicians enjoy and embrace the new technologies but with an esthetic eye to enhance milled products. Without this eye, there will be no difference amongst dental labs and their products. In order to promote excellence, any set standardization should always be surpassed. In conclusion, as we find ourselves in an ever-changing world,
FIGURES 1A&B—Pre-op & post-op of maxillary restorations with natural and implant abutments. Materials: IPS e.max V3 Ingot. Dentistry, courtesy of Dr. Bruce Glazer, Toronto, Ontario. Ceramics, courtesy of dentalstudios Yorkville. Burlington, ON. Untitled-3 1
FIGURES 2A,B & 3—Pre-op & post-op of maxillary incisors on natural preparations. Materials: IPS e.max HT BL 2 Ingot. Dentistry, courtesy of Dr. Karen Morris, North Bay, ON. Ceramics, courtesy of dentalstudios Yorkville. Burlington, ON.
the need to keep a strong business sense is important, especially when deciding what opportunities are available to purchase, amongst many available technologies. Whatever techniques are to being used for fabrication in the future, the patients’ welfare is paramount, for non-compromised, functional and aesthetic results. OH 100 th Anniversary Issue 2011
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the toronto academy of dentistry - Who We are: As early as 1890 Toronto dentists had formed as a group called the Toronto Dental Society. This organization would reinvent themselves in 1906 to “form a society on a basis more suited to the demands of a profession of busy men and women in the most progressive city in a progressive country”. This group continued to thrive over the years and would subsequently become the Toronto Academy of Dentistry on May 8, 1922. They shared office space and staff with the RCDS and the annual fee for membership was $5.00. What was once called Clinic Night was formally changed to Winter Clinic for the meeting on December 8, 1937. The Academy had in fact been holding spring and winter clinics for many years before this, attracting several hundred dentists to each meeting. As an ODA member who practices in Toronto and belongs to North Toronto Dental Society, Toronto East Dental Society, Toronto Central Dental Society, or West Toronto Dental Society you are AUTOMATICALLY a member of The Toronto Academy of Dentistry and part of this long heritage.
Programme at a glance
ToronTo aCaDemy of DenTiSTry 74th Annual Winter Clinic Programme
friDay, november 4, 2011
• Capsule Clinics on the Exhibit Floor by AboutFace • An Introduction to Diode Laser - A Hands on Workshop • Building the Network: Professional Learning and Social Media • Contemporary Ultrasonic Instrumentation A Visual Presentation • What Patients Really Want • Removable Appliances in the Mixed Dentition
• Why dental Teams Fail • Enamel Therapy • Update on Restorative ToronTo CenTral DenTal SoCieTy Materials ToronTo eaST DenTal SoCieTy norTh ToronTo DenTal SoCieTy • INVISALIGN 1 and 2 WeST ToronTo DenTal SoCieTy • Splint Therapy in the Adult Dentition ome and ake • ITRANS & CDAnet - At work for you dvantage of any • Advanced Laser Usage in Dentistry inter linic Pecials • Preventing Traumatic Head Injuries on a mount guard clinic on the exhibit floor
a W
c
t
m c s the eXhiBit floor
• Humanitarian Operations and Disaster Relief Involvement • Double Jeopardy - Managing Personal and Professional Financial Risks • Evidence-based Treatment of Traumatic Dental Injuries - How big is the chance for healing? • Current Concepts in Caries Management Diagnostic, Treatment and Ethical/Medico - Legal Considerations • Making Sense of Dental Technology - How much stuff do we really need? • Needle Free Anesthesia for Non-Surgical Periodontal Therapy
• New Science - Oral Health and Whole Body Health • Dental Practice 2011 and Beyond What Every Dentist Must Know • University of Toronto Faculty of Dentistry Update in Dentistry • Natural & Artificial Sweeteners - A Sweet Spot
metro toronto convention centre, south Building Programs will be mailed to all dentists in Ontario and posted on the Toronto Academy of Dentistry website in September www.tordent.com For more information contact:
The Toronto Academy of Dentistry Tel: 416.967.5649 Fax: 416.967.5081 Email: admin@tordent.com
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David Mock, DDS, PhD, FRCD(C Professor & Dean, Faculty of Dentistry, University of Toronto.
Canadian schools all pay equal heed to art and science, producing graduates who are oral health practitioners as opposed to dental mechanics
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100 Years of Dental Education in Canada P
rior to 1840 dentistry was as much a trade as a profession. Practitioners varied considerably in quality: Some trained as physicians, some served an apprenticeship or preceptorship with a practicing dentist, some were self-taught. Apprenticeship was the most common route. Where the preceptor took his teaching responsibilities seriously, apprenticeship worked well. Unfortunately, some practitioners used students primarily as a means of expanding clientele. Apprenticeship of this type is more akin to indentureship. Major change began after 1840, when the first dental school in the world was established in Baltimore, Maryland. Canada followed suit, as the more conscientious practitioners became interested in establishing a Canadian dental school. After two failed attempts in Toronto, the Ontario Dental Society, led by a number of visionary practitioners, including Barnabus Day, created the School of Dentistry, also in Toronto, in 1875. Operating under the authority of the Royal College of Dental Surgeons of Ontario, the School had two teachers and six clinical instructors. Only universities were allowed to issue degrees, so in 1889, the School formally affiliated with the Uni-
versity of Toronto. J.B. Willmott was appointed the first Dean in 1893. In 1925, the School of Dentistry became the Faculty of Dentistry, University of Toronto under the leadership of its first Dean, Wallace Seccombe, who was also the originator of the journal Oral Health. This historical pattern was duplicated in other provinces. The Dental College of the Province of Quebec was established in 1892 and became the Faculty of Dentistry, University of Bishop’s College in 1896. This was superseded in 1905 by the Department of Dentistry of the Faculty of Medicine at McGill University. The Faculté de chirurgie dentaire at the Université de Montréal was established in 1905: the Maritime Dental College (1908) became the Faculty of Dentistry at Dalhousie University in 1912. The Faculties of Dentistry at the Universities of Alberta (1923), Manitoba (1958), British Columbia (1964), Western Ontario (1966), Saskatchewan (1968) and Université Laval (1971) were started either as faculties on their own or departments within medical schools de novo.
WEDDING ART AND SCIENCE
The move from independent dental schools to faculties or departments in universities had a dewww.oralhealthjournal.com
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cisive effect on the profession. Dental training became dental education; the technical side of dentistry was linked to medicine to create a science of dentistry. D.W. Gullett, in acknowledging the addition of another medical doctor, W. Theophilis Stuart, to the Toronto faculty, noted that “the need for a basic scientific emphasis is recognized today but the school was strongly criticized on the point for many years.”1 Now, of course, this approach is universal. Canadian schools all pay equal heed to art and science, producing graduates who are oral health practitioners as opposed to dental mechanics. Over time, training lengthened as well as deepened. Dental programs grew from a few months of apprenticeship to four years of study, with clinical training as a vital component. By 1927, all the Canadian programs had added some form of pre-professional training as a requirement.2 The acceptance of the importance of a sound background of basic biomedical and biomechanical principles has been crucial to the advancement of dental education. In the early model of dental education, the basic, didactic learning was relegated to the first few years of the dental curriculum while the later years concentrated on clinical practice. www.oralhealthjournal.com
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It soon became apparent that this created an artificial distinction between knowledge and practice. Many schools have moved to “problem-based learning” in varying degrees. Others have produced hybrid curricula where there is still an initial period of didactic teaching with further introduction of the sciences at the clinical level. Regardless of the techniques employed, all Canadian dental programs now have a strong science or evidence basis. In order to meet the demands of these new curricula, dental schools have had to change the nature of their faculty to place greater stress on research. Research — be it basic science, clinical science or translational — is the source of evidence-based training. Students are now exposed to critical thinking and taught the appropriate skills to evaluate and interpret research. Schools have recognized that it is not adequate to graduate with state-of-the-art knowledge and skills without the ability to adapt to new knowledge and new skills. As B.F. Skinner put it, “Education is what survives when what has been learned has been forgotten.”3
COLLABORATING TO SERVE THE WHOLE PATIENT
Interprofessional collaboration
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has also become an important part of dental education, as it has in all the health sciences. The interrelationship between oral health and general health has an increased presence in the minds of both health professions and the general public. Dental health is known to be linked strongly to such areas as cardiovascular disease, diabetes, premature birth and low-birth-weight infants. Practicing dentists can no longer isolate themselves from their colleagues in the other health professions. Dental students, accordingly, are no longer educated in isolation from these health professions. Although other health professionals have always been involved to some degree in dental education, the relationship is now reciprocal, as dental educators are now teaching in other health curricula. This extends beyond sharing a classroom. The interprofessional pain curriculum at the University of Toronto is a good example of integrated practice, and we are sure to see more such programs in the future.
TECHNOLOGY OF TEACHING
Dental schools have also moved into the digital era by adopting available technology to facilitate education. In the 1960s we started to move away from the recurring scene of a group of 100 th Anniversary Issue 2011
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students huddled around a clinical instructor, each trying to get a glimpse into the mouth of a patient. First with film, then with analogue video tape, and finally with digital recording and live broadcasting, students have been able to sit comfortably and observe the practice of their profession close-up. At one time computers were locked in inaccessible back rooms. Now they stand beside each dental chair in our clinics and throughout our libraries. Students access clinical information and library material throughout our buildings on laptop computers via wireless networks. Online courses are offered and lectures are available to students for review 24/7 using lecture capture technology. As computerized simulation is perfected, it will replace the old “phantom head” that is so familiar to most dental graduates. The physical plant in which dentistry is taught has also evolved from rows of dental chairs with patients and students bumping elbows to closer simulation of a modern dental operatory. Equipment and materials are constantly being updated and replaced as new technologies are developed and scientifically validated.
MODERN DAY APPRENTICESHIP
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the clinicians who give so generously of their time and skills to help shape the dentists of the future. One of the most noticeable changes over the years has been the evolution of an improved student/clinical instructor relationship. Dental schools have come to understand that teaching by intimidation does not make better learners whereas a collegial student/teacher interaction does. The introduction of “standardized patients,” actors portraying patients, has noticeably improved our students’ abilities in diagnosis and patient relations.
COMMUNITY SERVICE
The modernization of dental education has not, however, eliminated devotion to the health of our patients and the population as a whole. Dental school clinics across Canada provide oral health care for vast numbers of patients, most from otherwise underserviced populations. Increasingly, the dental schools have created outreach programs to further deliver this care where it is most needed, nationally and internationally.
PARTNERSHIP AND PROGRESS
Canadians can certainly be proud of our dental schools and their contribution to our nation, not only through the education of dental professionals, but also in the advancement of our profession through research and development. All this, of course, is not without challenges. The cost of dental education has dramatically in-
creased since the founding of Canada’s first dental school in 1889. While tuition and fees currently cover only one half to one third of the actual cost of dental education, tuition is still as high as $50,000 per year. Combined with bachelor’s degree loans, the resulting loan burden on graduation often tops $200,000, even more for those who pursue specialty training. For the dental faculties, the increasing cost of dental education is exacerbated by diminishing public funding, to varying degrees depending on where the schools are located. This combination of increasing cost and diminishing funding has led to an important change in dental education: increasing reliance on philanthropy to fund student financial aid, program enhancements, research, facility improvements and other needs. Untitled-3 1
The future of dental education in Canada will most definitely include an increasing role for philanthropy, and the financial support of alumni and friends to keep faculties of dentistry strong and accountable to our mission, a mission of the utmost importance to the people of Canada. A past CDA president, Dr. George Sweetnam, summarized it well when he wrote: “No professors, OH no profession.”4 1. G ullett, D.W. A history of dentistry in Canada, University of Toronto Press, page 64, 1971. 2. Bagnall, S, Dental Education in Canada, JCDA 18:320-314 1952. 3. B F Skinner, New Scientist 22:483-4, 1964. 4. Dr. George Sweetnam, President’s Column, Journal of the Canadian Dental Association, February, 2002 .
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Timothy A. Brown with Roy Brown Timothy A. Brown is President & C.E.O. of ROI Corporation
Truly, brokers have allowed many dentists to retire with dignity
The History of Brokerage A
s Roy Brown walks down the aisles showcasing the latest in dental equipment, supplies and technology at the 2011 ODA Annual Spring Meeting, a smile comes to his face. An old friend and colleague greets him and a warm welcome and handshake are exchanged. This is his 62nd ODA Convention and while he still meets many old acquaintances, he laments that there are not nearly as many as in earlier years. When he started in the dental supply business 62 years ago, there was no resale market for dental practices and no need for brokers. When a dentist retired, his equipment ended up in a basement or dump as it was not saleable and his patients moved on to another dentist. All this changed in the 1960s when the brokerage business was born. The change stimulated by the “baby boom” initially came in the form of partnerships and group practices in dentistry. While this development was short lived, it created a need for a qualified opinion of what dental assets were worth; either for dentists to start a group practice or to form a partnership. Roy saw this need and the first “brokering” came into to play. Initially, Roy faced obstacles.
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He was not recognized as a professional in the same way lawyers, accountants and bankers were. His philosophy that there was value in the ëgoodwill’ of a practice was not readily accepted. His opinion was underestimated and the ëgoodwill’ aspect of selling a dental practice was deemed to be worth only $1. When the ratio of dentists to patients increased, patient flow became a concern. Young dentists with bills and loans to pay, as well as retiring dentists started to advertise to keep new patient flow steady. Roy recalls that Oral Health Journal was the preferred venue for dentists to advertise their practices for sale. The number of pages with ROI listings grew significantly, year after year. If there was a problem or question, Marg Whittaker, at Oral Health, was for years the person to talk to. Roy chuckles as he recalls Marg calling and saying, tongue firmly in cheek, “It’s that time of the month again, Roy — get those ads in!” By the end of the 1970s practices with solid financials and a large patient base had become valuable commodities. Roy fondly recalls when he and www.oralhealthjournal.com
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his wife, Joan, worked for thirteen years out of their house in a fledgling but slowly prospering dental practice sales business. Soon his eldest daughter, Lanee, joined the company and they opened an office together. Over the following 15 years, they established the foundations of a successful company based on good business practices. The company became synonymous with the appraisal and sale of dental practices. For the last 25 years, Roy’s son, Timothy, after having bought the business, has taken ROI Corporation to new heights of success. The company is truly a family owned and operated endeavour, with Tim’s wife Sandy and Roy’s grandsons, Robert and David actively involved.
with the law. He points out that he has an obligation to the buyer to be honest and forthright. Brokers have done much to make Canadian dentists financially secure when they must sell their practice because of illness or a desire to retire. Many practices today receive multiple offers and sell for well over a million dollars. Compare today’s prices with that of the first known dental practice sale, by Roy Brown in 1974 — for $28,000!
He recommends that graduating dentists spend three to fiveyears as an Associate in order to perfect their skills and learn practice management skills. Then he suggests they buy an existing practice and run their own show.
Roy maintains that success in his business is based on ensuring the confidentiality of the listing and representing the seller exclusively. Canadian Agency Law allows for no equivocation in this matter and Roy firmly agrees
Back at the ASM, Roy stops, recognizes and then reacquaints with another old pal and more memories are shared. It is easy to see that Roy still relishes his long relationship with the ODA and Oral Health Journal. OH
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Today, practice “goodwill” constitutes to about 1/2 of the value of the practice
Roy relates many of the changes he has witnessed, especially with regard to the new technologies and procedures. He is encouraged by the large percentage of female dentists that have graduated in recent years.
Today in Canada, brokers are licensed by the province (with the exception of BritishColumbia). The Broker Act ensures that they are qualified in communications, real estate law and sound business fundamentals.
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Future of Dentistry (Part 3) THE FUTURE IS NOW (IT’S TIME TO START DIAGNOSING)
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Steven R. Olmos, DDS Adjunct Professor, University of Tennessee, Memphis College of Dentistry
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e need to evaluate our system of treatment. A patient presents with worn denti tion or complaints of muscle soreness. The dentist produces a nightguard without further investigation. The result is that the treatment helps the symptom of muscle soreness, makes it worse or has no effect. The dentist is unclear what to do. Facial muscles are sore because of central nervous system stimulation. Jaw joints break down the result of continued nocturnal parafunctional activity. We bite harder at night due the result of proprioception ascending to the cerebellum and basal ganglia instead of the cortex where we recognize how hard we are biting. In the daytime proprioception ascends to the cortex where we are quite aware of how hard we are biting. Stress is often thought to be the most important factor in bruxism. The University of Pittsburgh School of Dental Medicine 104
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conducted a study on one hundred adult bruxers and their relationship to stress and anticipatory stress measured by EMG. They found: “No overall relationship was established between electromyographic measures and the personality variables nor between electromyographic measures and self-reported stress.”1 Drs. Gilles Lavigne (Dean of the Dental School at the University of Montreal) and Barry Sessle (Professor and Canada Research Chair in the Faculties of Dentistry and Medicine, Editor of the Journal of Orofacial Pain) have collaborated in their book, Sleep and Pain to explain the relationship between chronic pain, sleep disorders and bruxism. They make this recommendation: “Evidence of bruxism should always prompt the clinician to test for abnormal breathing during sleep.” Is it hard for us to understand the relationship between Obstructive Sleep Apnea (OSA) and the anaerobic result of mouth breathing that results in periodontal disease. It was found that between 77-79% of patients with OSA have periodontal disease.2 So if all non-caries pathology has a relationship to chronic pain and sleep disordered breathing then why aren’t we evaluating it? Which patients should we suspect have airway and chronic pain: Patients with mandibular opening less than 40mm and less than 5mm laterally, worn dentition, and scalloping of lateral sur-
face of tongue (70% predictive for OSA,3 and fractured teeth or restorations. Questions of sleep and pain should be asked. Questions of sleep would be: Can you get to sleep? Do you wake throughout the night? Do you wake rested? The leading cause of insomnia is chronic pain.4 So questions of headaches and chronic pain should be asked. We should see that the patients who seek dental care are the ones who suffer from chronic central nervous system stimulation. A recent study from two general dental practices demonstrated that 67% of the men and 28% of the women were identified as having a high risk for sleep apnea.5 We need to stop treating and start diagnosing. How many sleep studies have you prescribed? The future can be now. Dentist’s need to know whether they are treating primary idiopathic bruxism or iatrogenic secondary bruxism. A recently published article in the Journal of Oral Health from the Department of Clinical Neurophysiology and Center for Sleep-Wake Disorders, Slotervaart Medical Center, Amsterdam, The Netherlands, demonstrated an increase in apneic events in 50% of patients treated with nightguards who had OSA (Obstructive sleep apnea). OH Part 1 appeared in March 2011 and Part 2 appeared in August 2011 Oral Health. References for this article are available upon request. www.oralhealthjournal.com
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Jean Akerman, ARIDO, IDC Award-winning interior designer specializing in healthcare.
From the original one-room wonder and questionable sterilization techniques of early days, changes in dental practice have driven the progression of dental office design to accommodate ever-evolving technologies, philosophies, and standards of care
S
everal years ago, while visiting the outdoor market in Marrakesh, Morocco, I came across a tooth vendor selling a variety of teeth he had recently pulled from some poor wretches’ mouths. Feeling as if I had crossed a time warp, I stood in awe at the primitiveness of the display and considered the suffering of those who, throughout human history, and even today, had no recourse to proper, let alone modern, dentistry. Never having given much thought to this idea, I suddenly realized that, in attempts to combat pain, infection, and even death in primeval times, people would have had to subject themselves to terrifying, barbaric “treatments” that often produced more anguish than relief.
In fact, dental disease and remedial efforts are described in ancient Egyptian documents dating back over five millennia; evidence of tooth restoration has even been found in Egyptian mummies. Other early civilizations, like the Hebrews, Chinese, Greeks, and Romans, also recorded attempts at primitive dentistry. Even thousands of years later, during the Middle Ages, then the Renaissance, “dentistry” remained a brutal ordeal, consisting primarily of extraction, performed by merchants or barber-surgeons in open marketplaces or shops. The dawn of true dentistry came
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in the 18th Century, an era when medical surgeons at last made significant strides in the study and practice of dentistry. By the turn of that century, dentistry emerged as a discipline independent of medicine, though the practice of it still took place in a merchant setting. With the construction in 1790 of the first known “dental foot engine” to rotate a drill (an adaptation of a foot treadle spinning wheel), and the first “dental chair” (made by attaching a headrest and arm extension for instruments to a wooden chair), dental practice began to demand a distinct place of its own. The creation in the 1800s of The Royal College of Dental Surgeons of Ontario, the first dental college in Canada, marked the point when dentistry became a recognized profession in this country. With the establishment and growth of the dental profession in the 20th century, and the development of specialization, the evolution of dental office design began. How far we’ve come since then! From the original one-room wonder and questionable sterilization techniques of early days, changes in dental practice have driven the progression of dental office design to accommodate ever-evolving technologies, philosophies, and standards of care. So what has impacted the design and planning of dental facilities in recent history? www.oralhealthjournal.com
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OFFICE DESIGN Science & Technology Scientific research over the last one hundred years resulted in the development of safe and effective local anaesthesia, the use of x-ray in diagnostics, high-speed instrumentation, lasers, new dental materials and implants. The expanding knowledge base and advanced techniques which became available created a gradual shift from reactive, to proactive dentistryfrom merely solving problems, to preventing problems. As an example, whereas at the beginning of the last half century, the dentist provided treatment and cleaning of teeth in a twoop practice, more recently, offices have typically been planned to accommodate not only operatories for treatment, but also dedicated hygiene rooms, with the goal of providing both better oral hygiene and patient education. Technology has been one of the most influential factors. Computers have revolutionized equipment, radiography, treatment and record keeping, and now are an integral consideration in office design. Increasingly, computers are getting smaller, and offices are becoming “paperless,” with patient records and business information being stored electronically. This means that less room and storage space is required for equipment and charts. The advent of digital imaging means every modern operatory has a computer, and it is just a matter of time before the dark room and daylight loader go the way of the dinosaur. New technology has also inf luenced operatory size. For www.oralhealthjournal.com
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“Le Dentiste” (ca. 1670) by Adrienensz Berckheyde, State Museum, Keulen, image from Namibia Dental Association website (www.nambiadent.com/history/HistoricPictures.html)
many years, the typical operatory was a standard 9’-6” x 10’ room. Now, the increased size of dental chairs, the streamlining of dental equipment and delivery systems, and more complex procedures that require supporting technology, all demand a different design solution. The optimal size of an operatory, and its access, is now determined according to these criteria. Health & Safety Recognition of the need for public, patient, and team health and safety has also influenced design. Recent infection control guidelines and regulations mandate appropriate disposal of biohazardous materials, protective eyewear, gloves and dress for dental staff, and strict compliance with sterilization processes, which are constantly being updated by the RCDS. Placement of a sharps receptacles in each op & sterilization area is one contemporary response to concern about contamination. Increasingly, we are seeing handsfree faucets, soap and towel dis-
pensers, and hand dryers. Hand sanitizers are routinely and strategically located in offices, air purifiers to remove airborne microbial contaminants and pollutants are becoming more commonplace, and even eye wash stations are being accommodated in today’s sterilization areas. The sterilization centre itself, at one time isolated because of the unappealing visibility of dirty trays and contamination concerns, has become an important and thoughtfully conceived element in office design, often being located within clear view of patients. Most cutting-edge offices emphasize the careful attention to asepsis, since current techniques, the efficient design of storage cabinetry, and configuration of washers and sterilizers have resulted in the elimination of unsightly clutter, providing assurance of effective safeguards for everyone’s well-being. OH The remainder of this article, including references, can be found in the Fall 2011 issue of Dental 100 th Anniversary Issue 2011
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Bill Dorfman, DDS Dr. Dorfman is responsible for creating dazzling smiles for some of Hollywood’s biggest stars
Most patients are aware of dietary causes of discoloration; however, many do not realize that their tooth coloring is sometimes indicative of more serious health risks
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hat do twigs, urine and peroxide have in common? Probably more than you think. Throughout the course of history, each one of these items has served as a material used in teeth whitening. From “chew sticks” made from twigs dating back to 3000 B.C. and the ancient Romans’ discovery that ammonia in urine could serve as a bleaching agent to today’s use of various forms of peroxide to safely whiten teeth, the quest for “pearly whites” threads throughout the history of oral health.1 In the 1800s, the discovery of fluoride’s teeth protecting capabilities allowed for new oral hygiene opportunities. And, in the 1980s, modern teeth-whitening methods were introduced, using a new formula that included peroxide and came in various forms, most notably in wearable trays that were filled with whitening gels.2 Since then, whitening options have evolved to include the toothpastes and whitening strips that sit on Aisle 3 at the supermarket to lightactivated whitening that you’ll find in the dentist’s chair. With the evolution of teethwhitening agents, it is clear that whiter teeth have been associated with success and attractiveness for thousands of years. Today, studies have found women associate white teeth with a warm personality, while men consider a white smile to indicate success in
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life. Still, more than one-third of the population is concerned about the look of their teeth.3
WHAT DOES THIS MEAN FOR DENTISTS?
According to the Academy of General Dentistry (AGD), teeth-whitening is a $600 million industry that continues to grow at a rate of 15-20 percent each year.4 In-office whitening procedures can have measurable effects on the bottom line of a dental practice and, in a time where white teeth are an accessory to Hollywood stars and successful CEOs, patients are increasingly receptive to learning about treatment options. With a multitude of studies confirming the social importance of white teeth, patients expect a lot from their smile. And, dental professionals feel a strong responsibility to get it right when recommending whitening options to patients. Dentists and hygienists are tasked with staying up-to-date on the latest whitening treatments, as well as recognizing previously existing conditions that might cause discoloration or affect the results of whitening. The importance of patients involving their dentist or hygienist in conversations about whitening is often underestimated, as over-the-counter products grow in popularity and become increasingly common within the market. www.oralhealthjournal.com
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As dental professionals know, the causes of teeth discoloration can range from eating habits, such as heavy coffee consumption, to more serious conditions like cavities, gum disease and systemic infections. Most patients are aware of dietary causes of discoloration; however, many do not realize that their tooth coloring is sometimes indicative of more serious health risks.5 In a study by the British Academy of Cosmetic Dentistry, more than half of the representative sample visited their dentist regularly. This represented a five percent increase from the previous year and is expected to continue growing.6 With more people recognizing the importance of involving their dentist or hygienist in their overall oral hygiene, opportunities to discuss color and whitening options are growing.
WHAT CAN I DO?
Dentists and hygienists understand the importance of meeting patient expectations when treating or making recommendations for any condition, particularly when it comes to whitening. Patients are increasingly interested in methods that offer instant gratification and noticeable results, often providing an opportunity to discuss in-office treatments with quick results, like Zoom!, and take-home whitening trays. Dental professionals may miss an opportunity to talk with patients about professional whitwww.oralhealthjournal.com
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ening options because they are concerned about offending the patient by bringing up the subject. In this lost opportunity, patients all too often leave the office uneducated and seek overthe-counter treatments at their nearby drug stores. Sometimes the conversation is as simple as including questions in your initial conversations with a patient on each visit like, “Are you concerned about the color of your teeth?” or “Have you noticed any changes in the coloring of your teeth?” Often, their answer is “yes” and offers an opportunity to for dentists and hygienists to share recommendations and professional treatments that can be administered in-office. When considering teeth-whitening treatments, patients will often ask about whether the procedure will cause sensitivity in their teeth after the treatment and for how long. The fact is that most professional teeth-whitening techniques will create some sensitivity; however, there are a variety of ways for professionals to help patients to reduce their sensitivity through the use of desensitizing gels, fluorides, toothpastes and rinses. An important component of every conversation about whitening is a discussion about patient lifestyle and how the whitening fits into a patient’s current routine. Those who smoke or have a poor diet, for example,
might need to whiten their teeth more often than others. Patients should also be aware of other professional maintenance products that can extend the benefits of whitening over longer periods of time, such as toothpastes, rinses and between treatment, at-home whitening kits. Untitled-3 1
Today, there are a multitude of professional teeth-whitening treatments available, including light-activated and take-home options that meet the needs and lifestyle requirements of patients. The improved safety, speed and comfort of today’s products reflect centuries of research and development to create brighter, whiter smiles. And, dentists and hygienists are now able to look much deeper into the dental health of their patient to meet expectations, while also managing and improving their oral hygiene. We have come a long way from twigs and urine. OH 1,2. S parks, Lisa Vernon. “A history of tooth-whitening.” The Seattle Times 15 Nov. 2010. The Seattle Times Online. Web. 13 July 2011. <http://seattletimes.nwsource.com/html/health/2013419604_ teeth16.html>. 3. British Academy of Cosmetic Dentists. Quick Facts and Highlights from the BACD survey. November 2007. Web. https://www.bacd.com/media/statistics. html. 4. Harvard Medical School. “Cosmetic Dentistry.” AARP.org. Review Date: 2007-04-01. http://www. aarp.org/health/conditions/articles/harvard__dentalhealth-for-adults-a-guide-to-protecting-your-teethand-gums_11.html. 5. Kerr, A Ross, DDS. “Tooth Discoloration Clinical Presentation.” Medscape Reference. Ed. Dirk M Elston, MD. Medscape Reference. Web. 13 July 2011. <http://emedicine.medscape.com/article/1076389clinical>. 6. British Academy of Cosmetic Dentists. Quick Facts and Highlights from the BACD survey. November 2007. Web. https://www.bacd.com/media/statistics.html.
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David Chong Yen, CFP, CA DCY Professional Corporation Chartered Accountants, is a tax specialist and has been advising dentists for decades
Undoubtedly, most would prefer to have the modern conveniences of the dental profession with the no-tax system of 1911
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The ‘No Tax’ System of 1911 D
uring the past 100 years, accounting evolved from a double entry manual bookkeeping system, to a manual one write system. In these early manual days, bookkeeping was typically recorded using one or more ledger books, with pages containing several columns to facilitate the recording of journal entries. With the advent of mini/micro computers, the manual one-write system developed into a computerized one-write system and evolution of accounting software as we know it today. Computerization simplified many bookkeeping tasks since accounting and bookkeeping software became increasingly userfriendly. The ease of use encouraged better recordkeeping and bookkeeping by the dentist since the software user typically did not have to understand accounting techniques, but instead merely needed to input information. The Canadian income tax system has also seen some dramatic changes over the last 100 years. As incredible as it may seem, any form of income earned by Canadians (personal, corporate or otherwise) up to and including 1911 was NOT subject to any kind of income tax. Income tax returns simply did not exist at this time. However, in 1917, the Federal government, needing funds to participate in World War I, decided to introduce income
tax as a “temporary measure.” As we all know, this new Canadian tax system became anything but “temporary.” For many years, dentists were subject to very high tax rates on their professional incomes. In fact, most dentists today, who have been rushing to incorporate in order to avoid the high top personal tax rate, would likely be surprised with the tax rates faced by earlier generations of dentists. For example, in 1972, once your personal taxable income reached $60,000, you would already be subject to the top personal tax rate of almost 70%. Today, in Ontario the maximum personal rate is about 46%, and applies once your taxable income reaches $128,800. As you can see, personal tax rates have been gradually lowered over the last 40 years, but at the same time, taxes are being applied to a much broader base. Prior to 1972, there were no income taxes on capital gains in Canada. Any capital gains realized prior to this time were taxfree. Since 1972, capital gains have been included in taxable income, albeit at a reduced rate. Today, 50% of capital gains are added to a taxpayer’s income and taxed at his/her marginal tax rate. Since 1972, the “income inclusion rate” for capital gains has actually ranged from today’s curwww.oralhealthjournal.com
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rent rate of 50% up to as high as 75% at one point. During this high tax rate period, dentists, as well as most other higher income professionals, would participate in any legal way to defer the payment of income taxes as much as possible. As a result, most dentists chose to report their proprietorships or partnerships using a January 31 fiscal year-end. This generally allowed them to not pay any income taxes during their first year of earning dental income, as the payment of this tax was legally deferred to the second year, with the second year’s tax bill being moved to the third year, and so on. However, the tax rules were changed back in 1995 putting an end to this “tax deferral maneuver.” From a tax perspective, the documentation required to support a particular expense has changed with technology from original paper receipts to electronic copies. Instead of filing and storing original documents/receipts which require file folders, filing cabinets and costly storage space, not to mention the time involved to properly organize a proper filing system which can permit fast and efficient retrieval of such documents when needed, original documents today can be scanned into an electronic format. With the very fast and efficient search capabilities of modern software programs, these electronic files can be located very quickly, easily and efficiently. Storage space is no longer an issue, since the average computer hard drive can store literally millions of invoices/receipts. Some dental offices today are now converting their dental charts to a paperless system. www.oralhealthjournal.com
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Prior to 2001 in Ontario, dentists were not permitted to practice their profession or earn any dental related income, as opposed to hygiene or technical services income, through any kind of corporation. All dentists had no choice back then but to operate as either a sole proprietor or through a partnership (if he/ she worked together with other dentists). This put dentists at a tax disadvantage compared to other types of businesses which were generally allowed to operate through a corporate entity in order to benefit from the lower corporate tax rates. Prior to this time, many dentists used corporations as a means of shifting the technical or hygiene component of their income into a corporation. Prior to 1991, it was common for a dentist to setup a management corporation, which typically would pay for all the office expenses and charge the dental practice a “management fee,” usually based on a 15% markup from actual expenses. This allowed the dentist to shift some of his/her income to the corporation and eventually to lower income family members. With the introduction of Goods and Services Tax (GST) in 1991, the management company was no longer very effective, as it introduced a new tax to the dentist which unfortunately could not be completely recovered. Since then, hygiene or technical service corporations became popular as these allowed the hygiene or technical profits from the practice to be legally recognized by a separate corporation. With the advent of professional corporations (PC) in 2001, dentists were finally able to benefit from the lower corporate tax rates
on all of his/her practice income, not just the hygiene/technical portion. This also facilitated greater accumulation of net profits after a low corporate tax within the PC. Currently, a PC pays a tax rate of only 15.5% on its first $500,000 of taxable income per year in Ontario. The accumulation of profits inside a PC allowed dentists to expand their practices at a faster pace and served as a catalyst for the concept of “investor dentists.” This situation gave rise to clinical duties being performed by other dentists who may not own the practice. However, notwithstanding this major concession to allow PCs for dentists, initially there were still restrictions on who could be the shareholder of a dentistry PC. When PCs were first permitted, the shareholder had to be a qualified dentist. Untitled-3 1
In Ontario, starting in 2006, the PC rules were broadened so that a dentistry PC could be owned by the dentist and any qualifying “family member”, which included only the spouse, parents and children of the dentist. Although this did not provide the same degree of tax planning flexibility permitted to most other types of businesses, this provided a window of opportunity for significant tax savings as income could be dispersed among family members. A case in point is a child (18 or older), spouse or parent who receives a dividend of $35,000 and has no other income during the year pays no more than $600 of personal taxes in Ontario. The ability to setup PCs for dentists along with the hot market for dental practices in some parts of Ontario has created an excellent opportunity to benefit 100 th Anniversary Issue 2011
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125 years Dentaurum – worldwide unique.
We congratulate Oral Health in celebrating their 100th anniversary. We welcome this great publication to the very exclusive club of companies with over 100 years in the dental industry, an achievement very few share.
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from a tax incentive first introduced back in the mid 1980s: the tax free capital gains exemption (CGE). As mentioned above, although capital gains started to be taxed in Canada in 1972, the CGE allowed the possibility to earn capital gains totally free of income tax. However, there were, and still are, several restrictions and limits to claiming the CGE. The benefit for dentists started to become very meaningful in 2001 when PCs were first allowed. At this point, the dentist was able to transfer his/her dental practice into a PC, and in some cases then virtually immediately sell his/her PC shares to take advantage of the CGE, which at that time was limited to $500,000 in lifetime
capital gains. The CGE was later increased in 2009 to $750,000 of life time capital gains. Until recently, it was very common for dentists with a PC to receive only enough salary/bonus from his/her PC in order to maximize RRSP limits and avoid the high corporate tax rates, and if additional funds were needed, the PC would pay dividends to lower income family member shareholders. Today, some dentists no longer believe that maximizing their RRSPs is the best way to achieve their retirement goals. These individuals are now considering little, or possibly no salaries at all from their PC, and opting instead to go the “dividend only”
route when they draw funds for their personal needs. If there are further declines in corporate tax rates in the future, this alternative form of remuneration may possibly have some merit. Undoubtedly most would prefer to have the modern conveniences of the dental profession with the no-tax system of 1911. The past 100 years has produced many changes to bookkeeping, accounting and tax. Along the way dentists have been subjected to increasing and decreasing tax rates, thereby promoting more interest and involvement and encouraging better tax planning and ownership structure of the dental practice. OH Untitled-3 1
Toronto Integration for Dental Excellence Inc. ac a d e m y o f i n t e g r at i v e i m p l a n t d e n t i s t ry Top 10 Reasons to Participate in the AIID Implant Mini-Residency Program
Dr. Mark Lin B.Sc., D.D.S., M.Sc., Dip (Prosthodontics), F.R.C.D. (C)
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phone: 416-827-4901 online: www.tideinc.ca
• Clinical Procedures Performed by Course Participants on Patients (Treatment Planning and Surgical Implant Placement) • Comprehensive and Focused 13 Days of Training for ONLY $9950 • Scientific Foundation for Clinical Implant Practice. Comprehensive Training Manual, Training DVD’s and Case Series CD’s included. • Multidisciplinary Specialist Guest Speakers (Prosthodontist, Periodontist, Oral Surgeon, Dental Anesthesiologist). Live Patient Demonstrations Performed by Specialists • Treatment Planning Module with Customized Model Based Exercises • Pig Mandible and Foot Soft Tissue Simulation Exercises • Human Cadaver Head 2- Day Hands-on Exercises • Implant Prosthodontics, Occlusion and Pharmacology Education • Option to Participate in Individual Modules (Module 5 Excepted. Completion of Modules 1-4 Mandatory Prerequisite for Module 5) • Exclusive Study Club for continued support for 1 year upon completion of full program • AGD Nationally Approved (Earn up to 78 CE Points)
The Ontario Academy of General Dentistry (Approval # 219289) Academy of General Dentistry Approved PACE Program Provider. FAGD/MAGD Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 01/01/2010 - 12/31/2014.
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100 th Anniversary Issue 2011
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John McMillan, LL.B. A Toronto business lawyer serving dental professionals
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here was a time when practicing dentistry was just that — practicing dentistry. Now it also involves managing a complex business with a myriad of business, legal and tax considerations. Much of the increased complexity can be attributed to a number of major changes in the landscape, among those being: • T he recognition that dental practices are marketable assets; • Legislative changes permitting dentists to incorporate (and in some provinces permitting nondentists to participate in share ownership); • Increased complexity in employer/employee relationship; • Greater number of regulatory compliance requirements. Evolving common law in relation to restraint of trade and restrictive covenants. 118
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Things Have Certainly Changed — Today’s Dentist/Lawyer Relationship Until a few decades ago, most retiring dentists simply closed their practices and referred their patients to colleagues (with no expectation of compensation). It was through the 1970s and ’80s that the dental community recognized that their practices had a viable market value and through that period of time, private enterprise responded to and nurtured that realization, with the result today being a number of established appraisers and brokers dedicated exclusively to serving the dental community. Today there is an active dental practice sale market and the assumption (or hope) of most owner/ operators is that the sale of their practice is imminent. That being the case, it logically follows that the value of the practice should be built, maintained and defended. Your practice is now a significant asset, which makes it more important than ever to obtain legal and accounting advice early and throughout your career.
INCORPORATION
In the past decade, dentists in most provinces have begun to enjoy (to some degree) the same benefits of incorporation as any other incorporated business owner, including tax deferrals, income splitting (in most provinces) and a capital gains exemption on the sale of the shares of the professional corpora-
tion. The caveat here is that proper setup and structuring is critical. Missteps in the initial set-up or ongoing maintenance of your professional corporation can result in the loss (or reversal) of tax benefits, so it is critical that your accountant and lawyer be consulted prior to incorporation and that the corporation be properly maintained.
YOUR PREMISES LEASE
Your premises lease provides critical underpinning to the value of your practice. Your lease (and security of tenure) is also a critical requirement for lenders when financing a practice purchase. That being the case, there are certain threats contained in many leases that your layer would watch for, including (but not limited to): • Demolition clauses — The right of the landlord to terminate the lease if they wish to demolish (or remodel) the building; • Relocation clauses — The right of the landlord to relocate your premises (often with insufficient compensation); • Recapture clauses — The right of the landlord to terminate the lease in the event of a request for an assignment (to a purchaser for example); • Additional Rent provisions — Buried costs can be significant and variable. You should also be looking to secure certain provisions for www.oralhealthjournal.com
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your benefit: • Exclusivity (where applicable); • Tenant inducements; • Options to renew; •A ssignment and subletting rights.
GROUP PRACTICE ARRANGEMENTS
It is not uncommon for two or more dentists to practice in the same location, as there are many economic and clinical benefits in doing so. However, how that group practice arrangement is structured can have vastly different implications. The term “partnership” is often used to describe these types of arrangements and was the norm for many decades, but such an arrangement can have adverse tax, liability and marketability implications and there are other arrangements (such as “cost sharing”) that can achieve all of the economic benefits of group practices without the disadvantages of partnerships. It is important that you consult with you accountant and lawyer to ensure that you set up an optimal structure.
RESTRICTIVE COVENANTS
As a significant portion of your practice value is reliant upon patient retention, it is important that you have properly drafted, reasonable and enforceable restrictive covenants executed by all associate dentists (and dental hygienists, particularly in provinces where they can operate independently). The case law in relation to restrictive covenants has undergone significant change in recent years and the courts continue to add to that body of law, so you should consult with legal counsel.
EMPLOYER / EMPLOYEE MATTERS
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value stemming from employees. Contrasted to past decades, there is an increased risk of employer liability for dentists, due in part to the free flow of information (and rights savvy employees), increased regulatory burdens, contingency-based litigation, more generous judgments in favour of employees and the perception of the “deep-pocketed” dentist. Gone are the days of “shut your doors lay off staff.” Your general goal is maximizing the potential sale value of the practice. To that end, your approach should be to ensure you are not needlessly sacrificing that value to employees and that you are not exposing yourself (and your successors) to significant employee liabilities. Seek the advice of an employment lawyer to transition your staff now to proper contracts and a Workplace Policy Manual. If you wait until your retirement, the effectiveness of this strategy would likely be diminished. If you have a “problem” employee, consult an employment lawyer and deal with the issue immediately.
THE INDEPENDENT DENTAL HYGIENIST
Certain provinces permit hygienists to offer independent services to the public. This trend opens up the possibility for the relationship between dentists and dental hygienists to be governed under a contract versus an employment arrangement. While there can be benefits to both parties (such as no source deductions, tax deductions for the hygienist, the nonapplication of employment law to name a few) it is important to ensure (with the assistance of your employment lawyer) that the
test for independent contractor is satisfied, having regard to the following main factors: (1) Degree of control and super vision; (2) Ownership of tools and equipment; (3) Chance of profit; and (4) Risk of loss. Untitled-3 1
Regardless of how the relationship is characterized, it is also important to have a clear understanding (in writing) as to the ownership and proprietary interests in the patient charts and that there be clear and enforceable restrictive covenants in place.
LEGISLATIVE COMPLIANCE
Unlike previous generations, dentists today also need to be aware of many new laws affecting them, recent examples being the Personal Health Information Protection Act — Ontario (also in certain other provinces) and the Personal Information Protection and Electronic Documents Act (Canada). Additionally, the evolution of environmental, human rights and accessibility laws will continue to give rise to additional compliance requirements. The reality is that the business success of the dentist today is a product of much more than costs and billings — it is also the product of minimizing threats and exploiting opportunities (with the help of your professional advisors). Issues that used to often “go away” on retirement can now survive the sale of your practice and are therefore subject to scrutiny by would-be buyers. Your careful attention to these issues throughout your career will be well rewarded. OH 100 th Anniversary Issue 2011
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Bridge the Gap in the Next Century (Part 1) Untitled-3 1
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Lisa Philp President of Transitions Consulting Group
Derek Hill Broker for Hill Kindy Practice Sales & Realty Inc.
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oday, there are all four generational segments impacting dentistry, as they see, think, feel and behave very differently as an employee, patient and how they say YES to dental treatment. Traditionalist born 1946-1964 and also known as the Silent Generation, Builders or Veterans. They experienced the Great Depression and World War II. They value financial security, teamwork, sacrifice, delayed gratification. The Silent Generation customers are savvy travelers, loving grandparents, budding entrepreneurs, affluent retirees and lifelong learners. Traditionalists can be long term and loyal to a fault. They normally don’t change dentists as easy as the other generations. Their marketing must relate to them as people who are in the prime of their lives. For example, a generic new patient post card direct mail offer to them that highlights a senior discount or age defying bleaching will be discarded or ignored. They respond favorably to words like “mature and seasoned” citizens or referring to their “life stages.” They are major readers (hard copy) of books, magazines and newspapers and moved to action personal testimonials from other patients and expert endorsements. They don’t like being rushed or pressed (e.g., “Last chance to act”). They have a deep respect of the opinions of experts and want to see
the dentist, who they respect and will listen to about their dental solutions. Baby Boomers born 19461964 also known as the “ME” generation or sandwich generation arrived to postwar affluence and the indulgence of parents who wanted them to have a better life than their own. They launched the sexual revolution and shaped their morals to be more conducive to individualism, and material wealth. Boomers see the world as their oyster and believe in challenging the status quo and changing the world. 2011 marks the year the first Boomers, turn 65 and will find the money to buy what they want. As patients, Boomers’ loyalty is centered about how you make them feel and having a “dental experience” with a relationship in which you understand their needs. They want to know why yours is better than the rest and will be looking for exceptional customer service. In their eyes you will only be as good as your “last at bat” and they will change dentists easily if they feel any indifference or lack of your understanding their customized needs. Generation X-age: 1966-1980also known as Latchkey kids, MTV Generation, Baby Busters. They grew up in a difficult time financially and socially with a struggling economy with an increase in single-parent housewww.oralhealthjournal.com
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holds, created many “latch-key kids.” Over 60% of Generation X attended college and their common belief that there are no absolutes in life but that one must take care of one’s self. Generation X is the first generation raised where consumption is a way of life. X’ers won’t waste their valuable time reading a lot of propaganda advertising that appears to “sell them.” They want to know the reason WHY (if they can believe it) and how the service can help them. Gen-Xers are cynic’s and anything that looks like playing on Gen-X stereotypes will be poorly received (like this article). Their loyalty is based on service and enjoy carefully evaluating their experience with you based on truth, credibility. They are watching you during the ENTIRE diagnostic and treatment planning stages and have been known to still look for comparisons, shop around and like things that stand out from the rest and are not ‘more of the same.’ To appeal to Gen-Xers loyalty you must understand and acknowledge their independence of doing it their way. Generation Y-age: 1981-2000 also known as the “net” generation or Millennial. They are the technology savvy: accomplished multi taskers who watch TV while seated at their computers listening to MP3, burning CDs, Instant messaging their friends and pretending to do homework. They have lived a life of instant gratifiwww.oralhealthjournal.com
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cation and are sometimes referred to as the “entitlement era” who expects to be handed what they want when they want it wih the click of a button.” The marketing to attract them needs to be socially conscious, fun and trendy. They are remarkably diverse and have been exposed to slick ad’s and commercial messages. They don’t trust advertising and 89% would switch service providers for one who gives back to the less fortunate or support charitable community initiatives. They thrive on contests and promotions as they are unbelievably excited about webstie coupons. They will drive your “refer a friend” programs as 50% of Generation Y share information about services with their friends and family as they happen in real time. Giving them a reminder to add a positive blog or post about your experience at your dental practice on the internet or sending them an email with a link to you and asking they check the LIKE button on your practice face book page works for them. They are plugged-in 24 hours a day, seven days a week. Forty five (45) percent having Internet on their mobile devices with. They assume technology in their dentistry and will speak up if they don’t see evidence that the dental practice is “state-of-the-art.” OH
In their (Boomer) eyes you will only be as good as your “last at bat” and they will change dentists easily if they feel any indifference or lack of your understanding their customized needs Untitled-3 1
Part II of this article can be found in the Fall 2011 issue of Dental Practice Management. 100 th Anniversary Issue 2011
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Wash Away
Gingivitis
With the Power of
© 2008, 3M. All rights reserved. 3M and ESPE are trademarks of 3M or 3M ESPE AG. Peridex is a registered trademark of 3M or 3M ESPE AG. Used under license in Canada. 0807-2674 E
Peridex
®
Oral Rinse
Contact your certified 3M ESPE Distributor for details.
Kills Germs for More Than 12 Hours. Your patients deserve the best, that’s why you choose the proven staying power of Peridex® Oral Rinse. Since Peridex® is indicated for gingival bleeding, gingival inflammation, as well as gingivitis, you can be sure that no matter how mild or severe their case may be, your patients are getting the best care in your chair.
Give Your Patients the Power of Peridex . ®
Peridex
®
Peridex Oral Rinse is indicated for use between dental visits as part of a professional program for the treatment of gingivitis. ®
Call 1-877-262-3368 or visit www.3MESPE.ca
OH 100th p122-123 ANB DPS AD.indd 122
Chlorhexidine Gluconate 0.12% Oral Rinse DIN 02237452
26/08/11 9:36 AM
r for details.
ate
PRODUCT MONOGRAPH Pr PERIDEX® CHLORHEXIDINE GLUCONATE 0.12% ORAL RINSE
The suggested initial course of therapy is three months, at which time patients should be recalled for evaluation. At the time of the recall visit, the dental professional should: • Evaluate progress, remove any stain, and reinforce proper home care techniques. • If gingival inflammation and bleeding is controlled, discontinue Peridex therapy and recall the patient in three months to assess gingival health. • If gingival inflammation and bleeding persist, continue Peridex therapy for an additional three months and schedule a three-month recall for evaluation.
Anti-Gingivitis Oral Rinse
These results support that Peridex usage does not result in significant changes in plaque bacterial resistance and does not cause significant changes in the plaque flora.
• Evaluate for evidence of epithelial irritation, desquamation and parotitis. The following generally accepted grading scheme may be of use in evaluating the severity of gingivitis.
ACTIONS, CLINICAL PHARMACOLOGY: Peridex Chlorhexidine Gluconate 0.12% Oral Rinse or Peridex provides antimicrobial activity during oral rinsing, which is maintained between rinsings. Microbiologic sampling of plaque has shown a general reduction of both aerobic and anaerobic bacterial counts ranging from 54-97% through six months’ clinical use. Rinsing with Peridex inhibits the buildup and maturation of plaque by reducing certain microbes regarded as gingival pathogens, thereby reducing gingivitis1,4,5. Peridex provided antimicrobial activity during rinsing and for several hours thereafter. No significant changes in bacterial sensitivity, overgrowth of potentially opportunistic organisms or other adverse changes in the oral microbial flora were observed following the use of Peridex for six months. Three months after Peridex use was discontinued, the number of bacteria in plaque had returned to pre-treatment levels and sensitivity of plaque bacteria to chlorhexidine gluconate remained unchanged. Studies conducted with human subjects and animals demonstrate that any ingested chlorhexidine gluconate is poorly absorbed from the gastrointestinal tract. Excretion of chlorhexidine gluconate occurred primarily through the feces (approximately 90%). Less than 1% of the chlorhexidine gluconate ingested by these subjects was excreted in the urine.
INDICATIONS AND CLINICAL USE: Peridex chlorhexidine gluconate 0.12% is indicated for use as part of a professional program for the treatment of moderate to severe gingivitis, and for management of associated gingival bleeding and inflammation between dental visits. For patients having coexisting gingivitis and periodontitis, see PRECAUTIONS.
GINGIVAL INDEX (GI) Description
1
Normal gingival, no inflammation, no discolouration, no bleeding.
2
Mild inflammation, slight colour change, mild alteration of gingival surface. No bleeding.
3
Moderate inflammation, erythema, swelling, bleeding on probing or when pressure applied.
4
Severe inflammation, severe erythema and swelling, tendency toward spontaneous haemorrhage, some ulceration.
The effect of duration and frequency of rinsing on plaque formation and tooth and tongue discolouration was examined in another 88 day study. The data demonstrated that shorted, more frequent rinsing (i.e., 2 x 30 sec.) provided optimal efficacy as compared to longer, less frequent rinsing (i.e., 1 x 60 sec.).
Pharmacokinetics 1. Oral Retention/Desorption
An occasional missed dose can be ignored if the patient is generally compliant with the prescribed regimen.
PHARMACEUTICAL INFORMATION DRUG SUBSTANCE: Proper Name: Clorhexidine gluconate (U.S.A.N.) Chemical Name: 1,1’-hexamethylene bis [5- (p-chlorophenol) bi-guanide] di-D-gluconate Structure:
2. Ingestion/Absorption/Excretion
Peridex chlorhexidine gluconate 0.12% should not be used by persons who are known to be hypersensitive to chlorhexidine gluconate or other formula ingredients.
Molecular Weight: 897.8 Description: Chlorhexidine has basic character and exists in the di-cationic form at physiologic pH. The two
USE IN PREGNANCY: Reproduction and fertility studies with chlorhexidine gluconate have been conducted. No evidence of impaired fertility was observed in male and female rats at doses up to 100 mg/kg/day, and no evidence of harm to the fetus was observed in rats and rabbits at doses up to 300 mg/kg/day and 40 mg/kg/day, respectively. These doses are approximately 100, 300, and 40 times that which would result from a person ingesting 30 mL (2 capfuls) of Peridex chlorhexidine gluconate 0.12% per day. Since controlled studies in pregnant women have not been conducted, the benefits of use of the drug in pregnant women should be weighed against possible risk to the fetus.
BREASTFEEDING MOTHERS: It is not known whether this drug is excreted in human milk. In parturition and lactation studies with rats, no evidence of impaired parturition or of toxic effects to suckling pups was observed when chlorhexidine gluconate was administered to dams at doses that were over 100 times greater than the dose which would result if a person ingested the entire recommended dose of Peridex chlorhexidine gluconate 0.12% on a daily basis.
protonic positive charges become somewhat localized on the bi-guanide portion of the molecule. Both pKa’s are reported 6 as 10.78 ± 0.06. The gluconate salt is soluble in excess of 70% (w/v) in water at 20°C. At 19-21% w/v chlorhexidine gluconate solution is colourless to pale straw-coloured and is odourless to almost odourless (British Pharmacopoeia).
COMPOSITION: Peridex contains chlorhexidine gluconate 0.12% in a base containing water, alcohol, glycerine, PEG-40 sorbitan di-isostearate, flavour, saccharin sodium and FD&C Blue #1 Dye.
STABILITY AND STORAGE: Store above freezing (0°C).
INCOMPATIBILITIES: Peridex is not to be mixed/diluted with any other product.
USE IN CHILDREN: Since the safety and efficacy of Peridex in children has not yet been fully established, the benefits of its use should be weighed against the possible risks.
Approximately 30% of the chlorhexidine present in the mouth rinse is retained in the oral cavity after rinsing. The amount retained was directly related to drug concentration, with an average of 6.3 and 2.7 mg (mean) of chlorhexidine being retained orally after a single use of a mouth rinse containing 0.12% and 0.06% chlorhexidine gluconate, respectively. The release rate of chlorhexidine from oral surfaces was similar for both treatments. Based on morning/evening rinses, previous exposure to a chlorhexidine-containing mouth rinse was observed to have little effect on subsequent retention of chlorhexidine. Peridex chlorhexidine gluconate 0.12% is to be used topically as an oral rinse, not to be ingested. Studies were conducted to study its metabolic pathway in the event of oral ingestion.
CONTRAINDICATIONS:
WARNINGS:
Pharmacodynamics Two clinical studies examined dose-response relationships and confirmed earlier animal studies. One short term study demonstrated equal efficacy, as measured by plaque reduction, for 0.10% and 0.20% chlorhexidine gluconate solutions, while a 0.05% chlorhexidine gluconate solution was less effective. In a three month study, anti-gingivitis efficacy was equal for 0.12% and 0.20% chlorhexidine gluconate mouth rinses. However, tooth and tongue discolouration increases with chlorhexidine concentration in both studies. Therefore, the chlorhexidine gluconate concentration for Peridex was set at 0.12% to optimize efficacy while minimizing side effects.
Loe and Silness Grade
Another study was conducted to investigate whether changes occurred in resistance to chlorhexidine which might limit efficacy of the mouth rinse, and if such changes occurred, whether they dissipated or disappeared after cessation of use of the mouth rinse. Minimum Inhibitory Concentrations (MICs) for chlorhexidine were determined on isolates of streptococci and actinomyces obtained from patients during six months’ use of the mouth rinse and three months after cessation of use of the mouth rinse5. Changes in bacterial sensitivity due to exposure to chlorhexidine were slight, sporadic and had returned to pre-treatment values three months after product usage was discontinued.
Human studies using radiological markers indicated that chlorhexidine gluconate is poorly absorbed from the gastrointestinal tract. This is in agreement with the findings from animal studies. Among five normal male volunteers, GI transit time was 31 to 53 hours as indicated by radiopaque markers. The primary route for the excretion of chlorhexidine was through the feces (approximately 90%). The mean peak plasma level of chlorhexidine was 0.206 μg/g, reached 30 minutes after ingestion of a 300 mg dose of the drug. Chlorhexidine was not detectable in plasma 12 hours after ingestion. Urine samples contained 0.5 to 1% of the 14 C-chlorhexidine gluconate administered to the study subjects.
TOXICOLOGY: • Acute Toxicity Studies The oral LD50 of chlorhexidine gluconate was estimated as 1.476 g/kg in rats and 0.1122 g/kg in rabbits. The oral LD50 of the mouth rinse formulation was estimated at >20 g/kg in rats. • Chronic and Subchronic Toxicity Studies The only consistently observed finding in eight subchronic and chronic toxicity studies was the accumulation of foamy macrophages in the mesenteric lymph nodes of rats. Representative samples of these lesions were evaluated by two independent pathologists. They concluded that the lesions did not represent a significant toxic effect. This conclusion is supported by the following facts: 1) The macrophages do not contain bacteria, indicating that a significant change in the intestinal flora has not occurred. 2) The reaction is not associated with increased morbidity or mortality. 3) The reaction does not become progressively more severe with continued exposure to chlorhexidine. 4) The reaction is reversible after administration of chlorhexidine is discontinued.
SPECIAL INSTRUCTIONS:
Reproduction and Teratology
None.
No adverse reproductive or teratologic effects on rats or rabbits were observed in studies with the mouth rinse formulation.
PRECAUTIONS:
AVAILABILITY OF DOSAGE FORM:
1. For patients having coexisting gingivitis and periodontitis, the absence of gingival inflammation following treatment with Peridex chlorhexidine gluconate 0.12% may not be indicative of the absence of underlying periodontitis. Appropriate treatment of periodontitis is therefore indicated.
Peridex Chlorhexidine Gluconate 0.12% Oral Rinse is supplied as a blue liquid in 475 mL amber plastic bottles with child-resistant dispensing closures.
2. Peridex may cause staining of oral surfaces such as the film on tooth surfaces, restorations, and the dorsum of the tongue. Stain will be more pronounced in patients who have heavier accumulations of un-removed plaque. Stain resulting from use of Peridex does not adversely affect the health of gingivae or other oral tissue. Stain can be removed from most tooth surfaces by conventional professional prophylactic techniques. Additional time may be required to complete the prophylaxis. Discretion should be used when treating patients with exposed root surfaces or anterior facial restorations with rough surfaces or margins. If natural stains cannot be removed from these surfaces by a dental prophylaxis, patients should be excluded from Peridex treatment if the risk of permanent discolouration is unacceptable. Stains in these areas may be difficult to remove by dental prophylaxis and on rare occasions may necessitate replacement of these restorations.
INFORMATION FOR THE CONSUMER:
Carcinogenicity
(Proposed patient insert or bottle label.)
No evidence of carcinogenicity was reported in two rat studies in which chlorhexidine was administered in their drinking water. The studies were two years in duration and delivered chlorhexidine at dose levels of up to 200 mg/kg/day.
Store above freezing (0°C).
3. A few patients may experience an alteration in taste perception while undergoing treatment with Peridex. Most of these patients accommodate to this effect with continued use of Peridex. Rare instances of permanent taste alteration following Peridex use have been reported via post-marketing product surveillance.
“WHAT TO EXPECT WHEN USING PERIDEX” Your dentist has prescribed Peridex Chlorhexidine Gluconate 0.12% Oral Rinse to treat your gingivitis – to help reduce the redness and swelling of your gums, and also to help you control any gum bleeding. Use Peridex regularly, as directed by your dentist, in addition to daily brushing and flossing. Do not swallow Peridex. Peridex may cause some tooth discolouration or increases in tartar (calculus) formation, particularly in areas where plaque is more difficult to remove with normal brushing alone. It is important to do a thorough job of cleaning your teeth and to see your dentist at least every six months, or more frequently if your dentist advises. • Both stain and tartar can be removed by your dentist or hygienist. Peridex may cause permanent discolouration of some front-tooth fillings. To minimize discolouration, you should brush and floss daily, emphasizing areas which begin to discolour. In some cases discolouration may be permanent.
4. For maximum effectiveness the patient should avoid rinsing their mouth (with water or other mouthwashes), brushing their teeth, eating or drinking for about 30 minutes after using Peridex.
No serious systemic reactions associated with use of Peridex chlorhexidine gluconate 0.12% were observed in clinical testing. However, some adverse reactions have been reported in studies with Peridex or other chlorhexidine-containing mouth rinses. The most common side effects associated with chlorhexidine gluconate oral rinse are (1) an increase in staining of oral surfaces, (2) an increase in supra-gingival tartar (3) an alteration in taste perception to which most patients accommodate (see PRECAUTIONS). Epithelial irritation and superficial desquamation of the oral mucosa have been noted in studies of children using chlorhexidine gluconate 0.12% which were reversible upon discontinuation. There have been rare cases of parotid gland swelling and inflammation of the salivary glands, in patients using Peridex. Oral irritation and local allergy-type symptoms have been spontaneously reported as side effects associated with use of chlorhexidine gluconate rinse. The following oral mucosal side effects were reported during placebo-controlled adult clinical trials: aphthous ulcer, grossly obvious gingivitis, trauma, ulcerations, erythema, desquamation, coated tongue, keratinization, geographic tongue, mucocele, and short frenum. Each occurred at a frequency of less than 1.0%. Among post-marketing reports, the most frequently reported oral mucosal symptoms associated with Peridex are stomatitis, gingivitis, glossitis, ulcer, dry mouth, hypesthesia, glossal edema, and paresthesia.
SYMPTOMS AND TREATMENT OF OVERDOSAGE: Ingestion of 30 or 60 mL of Peridex chlorhexidine gluconate 0.12% by a small child (10 kg or less body weight) might result in gastric distress, including nausea, or signs of alcohol intoxication. Medical attention should be sought if more than 120 mL of Peridex is ingested by a small child or signs of alcohol intoxication develop.
• Peridex may taste bitter to some patients and may affect the taste of foods and beverages. This will become less noticeable in most cases with continued use of Peridex. To avoid taste interference, rinse with Peridex after meals. Do not rinse with water or other mouth rinses immediately after rinsing with Peridex.
Other Studies
• For maximum effectiveness avoid rinsing your mouth, brushing your teeth, eating or drinking for about 30 minutes after using Peridex.
The emetic dose, irritation potential, and sensitization potential have also been determined for Peridex chlorhexidine gluconate 0.12%. Peridex has an emetic ED50 of approximately 13.4 mL/kg (tested in dogs using the oral route of administration), is only slightly irritating to the eye (tested in rabbits), and was not irritating to the oral mucosa (tested in dogs). In addition, the mouth rinse does not induce delayed contact sensitization.
If you have any questions or comments about Peridex, contact your dentist or pharmacist.
REFERENCES: 1. Grossman, E.; Reiter, G.; Sturzenberger, O.P.; De la Rosa, M.; Dickinson, T.D.; Ferretti, G.A.; Ludlam, G.E.; Meckel, A.H.: “Six-month study of the effects of a chlorhexidine mouth rinse on gingivitis in adults.” J. Periodont. Res. 1986; 21 (Suppl. 16): 33-43.
PHARMACOLOGY: HUMAN CLINICAL TRIALS: The efficacy of Peridex chlorhexidine gluconate 0.12% in the treatment and prevention of gingivitis has been supported in three pivotal clinical trials and in several supporting studies. The pivotal clinical studies are summarized in Chart 1 below.
MICROBIOLOGY: In-Vitro Because of its nonspecific mechanism of action, chlorhexidine has a wide range of antimicrobial activity against both Gram-positive and Gram-negative bacteria. An in-vitro study of the microbicidal effect of Peridex Chlorhexidine Gluconate 0.12% Oral Rinse following a 30 second exposure resulted in greater than a 99.9% reduction in the following microorganisms: Actinomyces viscosus, Candida albicans, Staphylococcus aureus, Streptococcus mutans, Streptococcus sanguis, Fusobacterium nucleatum, Neisseria sicca, Pseudomonas aeruginosa, Veillonella parvula. To determine the efficacy of Peridex in-vivo, various bacteria in the microbial flora of plaque were assayed in subjects who had used either Peridex or a placebo.
Peridex chlorhexidine gluconate 0.12% therapy should be initiated directly following a dental prophylaxis. Patients using Peridex should be reevaluated and given a thorough prophylaxis at intervals no longer than six months; they should be referred for periodontal consultation as necessary. Recommended use is twice daily oral rinsing for 30 seconds, morning and evening after tooth brushing. Usual dosage is 15 mL (marked in cap) of undiluted Peridex. Peridex is not intended for ingestion and should be expectorated after rinsing. Rinsing the mouth (with water or other mouthwashes), brushing teeth, eating or drinking should be avoided for about 30 minutes after using Peridex.
No evidence of mutagenicity was observed when chlorhexidine gluconate was evaluated by the dominant lethal assay in mice and micronucleus assay in hamsters. Mutagenicity studies, using bacterial cell system, with or without metabolic activation, produced contradictory results, which are unexpected with drugs having antibacterial activity. While Suessmuth et al. (1979) and Ackerman-Schmidt et al. (1982) obtained positive results, Evans et al. (1978) and Sakagami et al. (1988) found no evidence of genotoxicity for chlorhexidine. The clinical significance of these results is unclear. A variety of regimens were used in an attempt to induce and elicit immediate hypersensitivity to chlorhexidine gluconate in guinea pigs, rabbits, rats and man. No evidence of immediate hypersensitivity was observed in any of the tests.
In-Vivo
DOSAGE AND ADMINISTRATION:
Mutagenicity
Immediate Hypersensitivity
• Peridex should not be used by persons who have a sensitivity to chlorhexidine gluconate.
ADVERSE REACTIONS:
The effect of chlorhexidine gluconate on various aspects of reproductive processes has been evaluated using both the rat and rabbit as a model. An apparent embryotoxic effect was observed in rabbits that received a daily 40 mg/kg dose of chlorhexidine by gavage, and in rats that ingested a 300 mg/kg dose of chlorhexidine from their diet each day. These doses are about 140 and 1040 times, respectively, the estimated daily ingestion from Peridex with the recommended dose.
During six months’ Peridex use,2,3 subjects showed reductions in total load/tooth, streptococci and actinomyces ranging from 54% to 97%. Neisseria and fusobacteria were not detected in over half of the subjects assayed. No changes in numbers of yeast-like organisms and Gram-negative enterics were observed. There were no adverse changes in the oral microbial flora. Three months following cessation of treatment, the reductions observed during mouth rinsing were no longer evident, indicating no “carryover” effect. The results were interpreted as indicating that the use of Peridex was associated only with a decrease in the number of microbes in plaque and no change in bacterial sensitivity.
2. Briner, W.W.; Grossman, E.; Buckner, R.Y.; Rebitski, G.F.; Sox, T.E.; Setser, R.E.; Ebert, M.L.: “Effect of chlorhexidine gluconate mouth rinse on plaque bacteria.” J. Periodont. Res. 1986; 21 (Suppl. 16): 44-52. 3. Briner, W.W.; Grossman, E.; Buckner, R.Y.; Rebitski, G.F.; Sox, T.E.; Setser, R.E.; Ebert, M.L.: “Assessment of susceptibility of plaque bacteria to chlorhexidine after six months’ oral use.” J. Periodont. Res. 1986; 21 (Suppl. 16): 53-59. 4. Loe, H.; Rindom-Schiott, C.; Glavind, L.; Karring, T.: “Two years’ oral use of chlorhexidine in man: I. General design and clinical effects.” J. Periodont. Res. 1976: 11: 135-144. 5. Rindom Schiott, C.; Briner, W.W.; Loe, H.: “Two years oral use of chlorhexidine in man. II. The effect on the Salivary Bacterial Flora.” J. Periodont. Res. 1976: 11: 145-152. 6. Warner, V.D.; Lunch, D.M.; Kim, K.H.; Grunewald, G.L.: “Quantitative structure – Activity relationships for Bi-guanides, Carbamimidates and Bis bi-guanides as inhibitors of Streptococcus mutans.” J. Med. Chem. 22: Issue 4, 1978, 359-66. 7. Suessmuth, R.; Lingens, F.; Ackermann, B.: “Mutagenic effect of 1,1’-Hexamethylene-Bis [5-(p-Chlorophenol)-Bi-guanide)].” Chem-Biol. Interact.: 28 (2-3) 1979, 249-258. 8. Achermann-Schmidt, B.; Suessmuth, R; Lingens F.: “Effects of 1,1’-Hexamethylene-Bis [5-(p-Chlorophenol)-Bi-guanide)] on the genome and on the synthesis of nucleic acid and proteins in the bacterial cells.” Chem-Biol. Interact.; Vol. 40, Issue 1, 1982, 85-96. 9. Evans, R.T.; Baker, P.J.; Coburn, R.A.; Genco, R.J.; Paigen, B.J.:” Evaluation of chlorhexidine, Tribromsalan and a limited series of alkyl bis bi-guanides in an in-vitro mutagenicity assay.” J. Dent. Res.; 1978, 57:290.
CHART 1
Study Location
Study Duration
No. Patients
Age
San Antonio,TX Northfield, NJ London, ON
3 Month 6 Month 2 Year
597 430 456
18-60 18-60 18-72
Sex Male and Female Male and Female Male and Female
Reduction in*
Usage Regimen
Plaque Index Scores
Gingival Inflammation Index Scores
Bleeding Sites
According to pkg. instructions 15 mL bid
36.1% 60.9% 34.6-56.4%
27.8-45.8% 33.5-45.4% 39.6%
48.4% 41.6-52.2% 50.3%
*Results shown are those obtained for the final examination at completion of test product use. The data are expressed as covariance adjusted % reduction vs. placebo; a range is reported when there were duplicate examiners. All reductions were significantly different from placebo (p<0.05; nonparametric Wilcoxon pair test). © 2008, 3M. All rights reserved. 3M and ESPE are trademarks of 3M or 3M ESPE AG. Peridex is a registered trademark of 3M or 3M ESPE AG. Used under license in Canada. 0808-3169
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The Evolution of Dental Imaging Untitled-3 1
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David Gane, D.D.S., B.Sc. (Hons) Current vice-president of dental imaging for Carestream Dental
A
century in business is an achievement recognized by only a special few in dentistry. As a fellow Canadian I feel a kinship to Oral Health, not because I rarely miss an issue, but because the company I represent, Carestream Dental, also has a century-old tradition of service. Founded by George Eastman and grounded in its humble beginnings, Eastman Kodak and its dental film quickly became the de facto dental imaging standard and the company evolved into a true digital dental imaging technology leader. During this period of time, dentistry has witnessed amazing transformations: the emergence of dental schools; the birth of the dental specialties;
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and the development and invention of many powerful techniques and technologies. But arguably it is the discovery and evolution of radiographic imaging that has made the greatest contribution. The evolution of dental radiography took the combined effort of many brilliant minds, including: Roentgen (and those that contributed to his momentous discovery), Kells, Hounsfield, Mouyen and many other skilled clinicians and researchers. It was not long after Kellâ&#x20AC;&#x2122;s very first dental images were taken using a fluoroscope in the late 1800s that the first dental radiographs were acquired on Eastman NC roll film. Kodakâ&#x20AC;&#x2122;s dental health group, now Carestream Dental, released the first
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DENTAL IMAGING modern dental x-ray film in 1919, introducing a powerful new diagnostic tool and a new standard for dental radiography. It was only a few years later that this concept was refined further to produce bitewing x-ray films, ideal for imaging the dental crowns and related alveolar bone. These radiographs gave dentists of the early 20th century the ability to literally see things they had never seen before. The introduction of periapical film in the 1940s helped to revolutionize endodontic therapy by providing a reliable means of evaluating the tooth roots and “guiding” endodontic file movements. By combining several anterior and posterior periapical images with bitewings, the full mouth series was born, a more coherent and comprehensive screening evaluation of overall oral health. Over time, the full mouth series proved to be a time-consuming way to screen for oral health, so in the 1960s the lower dose, faster panoramic x-ray was born and
widely adopted by the profession. The invention of digital sensors in the 1980s by Francis Mouyen marked another major breakthrough for dentistry. Mouyen, working with French digital imaging pioneer Trophy Radiology, also a Carestream Dental company, helped transform the way dentists imaged their patients. Over the span of two decades, Trophy was responsible for the world’s first dental digital radiography system; the world’s first digital sensor for film-based dental panoramic systems; and the first fully digital dental panoramic system. During this period Trophy also introduced the RVGui, the first intraoral sensor to equal or exceed dental x-ray film in spatial resolution. Once digital image quality rivaled that of film, digital imaging quickly became the standard among endodontists,and was again widely adopted by the profession. With the advent of digital imaging and the concurrent im-
provement in computer processing power, came a number of new innovations that further expanded the range and utility of radiological imaging. The ability to quickly capture and display digital clinical images greatly enabled the dentists’ diagnostic ability and also reduced patient absorbed dose. Digital radiographs could be quickly acquired and easily stored, accessed and shared, thus enabling more efficient collaborative care. Untitled-3 1
Thanks to the work of Godfrey Hounsfeld and the shorter reconstruction times made possible by ever-faster computer processors, cone beam computed tomography (CBCT) has emerged as the most recent innovation in dental radiographic imaging. CBCT brings an information-rich way of visualizing patients in 3D, as they truly exist in nature, with amazing accuracy. This technology helps overcome the inherent shortcomings of planar 2D radiographic images, moving dental imaging from pure diagnosis to the realm of image guided treatments in endodontics, orthodontics and implant dentistry. Image processing and visualization software has further enhanced diagnostic and treatment planning capabilities, using digital image data to “uncover” additional information that can positively impact diagnosis and improve on patient treatment outcomes. As I reflect on these important developments in dental radiographic imaging, I’m mostly thankful for the many contributions of the great people and great companies that have shaped our storied profession during the past 100 years. OH
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Peter Jordan President of Clinical Research Dental Inc.
Predictability and consistent clinical success were imperative. “I have to be able to sleep well at night,” he would say
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“Better Dentistry” Pioneer, Teacher, Clinician, Father I
t’s been almost 17 years since my father’s passing, yet dentists still stop me to say, “I attended your father’s lectures, and he changed the way I do dentistry!” Or, “I owe my success to the foundation your father gave me when I was his student.” Ronald E. Jordan, DDS, MSD, loved and lived to share his breadth of knowledge and enthusiasm for dentistry. His positive attitude toward innovation, his unwavering commitment to excellence, and his aptitude for mentoring are why he remains a legend. Indeed, no Canadian educator before or since has impacted dentistry around the world the way that he did. He gave 80 lectures each year, traveling internationally to approximately 40 countries, and authored hundreds of peer-reviewed articles reporting his research. Dr. Jordan was honoured with the Elmer S. Best Award from the Pierre Fauchaud Academy, the Academy of Dentistry International Award of Distinction, the American Academy of Cosmetic Dentistry for Outstanding Contributions to Cosmetic Dentistry, the University of Alberta Outstanding Achievement Award, as well as numerous other awards. He was an Honorary Fellow of the Academy of Dentistry International, the AGD, AAED, the Royal College of Dentists of Canada, the
American College of Dentists, and the International College of Dentists, and was Chief Examiner for the National Dental Examining Board of Canada. His colleagues and students around the world continue to teach, write, and practice the tenets of his didactic and clinical methodologies. As Dr. Norman Feigenbaum once wrote, “Every dentist who has ever placed a composite restoration owes Ronald E. Jordan a debt of gratitude.” My father’s career began in private practice in Winnipeg in 1954 before taking a sharp turn into dental education. He taught at the University of Washington, Dalhousie University, and the Cleft Palate Institute at the University of Pittsburgh before joining the founding faculty of the School of Dentistry at the University of Western Ontario in 1966. Twenty-three years later he returned to his roots in Western Canada as Dean of the School of Dentistry at the University of Manitoba from 1989 to 1994. In each of his administrative, teaching, and clinical roles, my father had one goal in mind: better dentistry. ‘Drill and fill’ dentistry, which had dominated the midtwentieth century, was beginning its slow slide to obsolescence. In its place, restorative dentistry was taking on an exciting new look and feel due to advances in composite materials used with www.oralhealthjournal.com
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Ronald E. Jordan, DDS, MSD
resin adhesive systems to bond to dentin and enamel. Early on, he possessed the conviction that to do less was better. He believed that common clinical challenges -- hypoplastic defects, white spot lesions, diastema spaces, cervical erosion/abrasion/ abfraction lesions, root caries, posterior wear and accompanying loss of vertical dimension -could all be treated conservatively and esthetically with composite bonding rather than invasive restorations. Dr. Jordan’s vision of ‘better dentistry’ always began with a clinical problem. He listened to his patients, colleagues, clinicians, and to his students. In Canada, he was among the first to acknowledge and respond to the simple fact that dentists want and need straight, practical answers: “What technique should I use, and why? Will this product work in my practice?” My father, Dr. Jordan, believed www.oralhealthjournal.com
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and taught that clinical research paves the only path to better dentistry. He devoted his work life to developing and testing procedures, techniques and products, then consistently, honestly, scientifically evaluating the results. When he shared his findings, whether lecturing to a room full of dentists or meeting one-onone with a dentist, he used his step-by-step, research-proves-it methodology. “This is what the research proves; this is how I do it,” he would say, “and this is how you can do it, too, starting Monday.” My father’s rapid-fire lecture style often delivered answers before they could be asked, because his clinical research provided both the clear evidence and the corresponding rationale for his groundbreaking teachings. His product recommendations were accompanied by “whether, when, why, and how” to use it, or not, as well as any technique sensitivities that might arise along the way. Predictability and consistent clinical success were imperative. “I have to be able to sleep well at night,” he would say. Because he continually asked, “Is this the best way?” and “What else is possible?” my father was recognized as a progressive thought-leader among his peers. He set the standard for applied clinical dental research, and gave credence and academic legitimacy to aesthetic techniques related to adhesive/composite ma-
terials. Yet, connecting with the dentist in the field was his true passion. Dr. Makoto Suzuki, who my father mentored and worked alongside for most of his career, accurately noted, “He always valued the voice of clinicians.” Untitled-3 1
My father respected his peers, and was respected in return. Dr. Gordon Christensen counted my father as “a friend, confidante, tireless worker, excellent teacher, capable administrator, enthusiastic, positive human and a wonderful example to the world of our best in dentistry.” I knew my father to be all of this, and more. His commitment to excellence permeated every aspect of his professional and personal life, and it was contagious. As a dad, he was loving and supportive of my five siblings and me. He was often away, but when he was home we all felt how important his family was to him. Each of his children took his focus, determination, care for fellow humans, and generosity toward others along with them on their individual paths to happiness and success in life, and we all miss him dearly. For me, he inspired me to start Clinical Research Dental and later, Clinician’s Choice Dental Products Inc., and gave me the direction on how I could help to improve dentistry in Canada and worldwide. I am proud to say Dr. Ronald Jordan is my dad. OH 100 th Anniversary Issue 2011
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Brian S. Allen Director of Equipment for Henry Schein Canada
The Effects of New Technology on Dental Office Design tion area and mechanical room. Ultimately, optimal utilization and design of dental office space translates to numerous advantages.
THE ART AND SCIENCE OF DENTAL OFFICE DESIGN
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ffective office design can make a good impression when fostering patient relationships, be inviting and comfortable to instill patient confidence in oral healthcare services and abilities, and maintain and increase patient flow. Coordinating design and ergonomics creates a gratifying and relaxing environment for patients, reducing stress and dental phobias. Efficient utilization of space, equipment, and design also reduces stress for the dentist and staff, while increased comfort and flow improves patient care and increases productivity. When designing a dental office, many considerations are taken into account. Is it a remodel or a new build? Existing plumbing, electricity, and internal columns are factors affecting a remodel. Whether a new build or remodel, patient volume impacts the size of the reception area and number of treatment rooms. The number of doctors and staff affects the size of treatment and staff rooms, which in turn impacts the size of the steriliza130
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The dental profession is undergoing a face lift, with new dental technologies radically improving oral healthcare. Technology and design are decreasing the stigma of fear and discomfort associated with dental procedures and increasing their acclaim. New and more advanced in-office technologies have enhanced not only the types of procedures and services available to the patient, but also the efficiency and reliability of those treatments. Cutting-edge diagnostic technology improves care and eases dental anxiety, and more in-office, technology-driven services accommodate patient schedules, can be performed faster,
and increase comfort for everyone. The effects of technology and equipment on dental office design are evident in the reduced need for space and storage, and in the specialized configurations designed to accommodate new technologies. For example, advancements over the past decades-such as computerization, digital diagnostic technologies, laser dentistry, in-office CAD/CAM, and digital impression scanning-have required consideration of operatory configuration and function. Treatment and consultation rooms now often include computer equipment for doctors and patients to view digital images, hailed for their quality, clarity, and time saving features. Digital diagnostic technologies, including intraoral x-rays, panoramic x-rays, and digital x-ray sensors that eliminate patient
This page: Digital panoramic x-ray (left), operatory using digital x-ray (right). Opposite page: High-end sterilization area. www.oralhealthjournal.com
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discomfort, reduce radiation exposure and produce an exceptional visual record that can be stored on a computer to save space, are now commonplace in dental operatories and an integral part of today’s office design. Digital images provide fast and easy access to visuals to inform and educate patients regarding procedures. In the modern dental office, digital x-ray technology eliminates the need for a special room to develop film-a space consideration for dental offices of the past-and is environmentally advantageous, eliminating the need to store and dispose of contaminated solution. Additionally, because laser dentistry provides more choices for clinical treatment procedures for patients while providing greater accuracy and reducing pain, recovery time, and cost, today’s dental operatories often include cabinetry to conveniently house or easily relocate these technologies. Because of the many benefits and savings of in-office CAD/CAM technology, patient wait times and the need for additional appointments can be reduced for dentists who often have an operatory dedicated to these procedures. As more dentists recognize that digital impressions decrease chairtime for patients by eliminating several steps associated with traditional impressions while simultaneously increasing their productivity and accuracy, this equipment, too, is being accommodated in operatory design. Further affecting dental office space considerations is the computer software incorporated into the practice. Today’s dental practice management software reduces paperwork and eliminates www.oralhealthjournal.com
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the need for space to store paper files, improves record keeping, and provides continuous, up-to-date detailed patient records. Various software makes it easier to market and manage patient information, scheduling, and other tasks involved in running a dental practice. Overall, today’s state-of-the-art dental office designs include open and spacious reception areas with ample available seating, window views, a user-friendly, designated play area for children, and patient education and marketing monitors interspersed throughout. Hallways are designed with curves and rounded edges to create a calm and inviting environment, and windows in the operatories provide ample natural light. A common sterilization room, removed from patient traffic flow, is incorporated for easy access from all treatment rooms, along with separate entrances for access to staff lounges. Affluent storage areas are designed to facilitate an organized and clutter free work space.
THE DENTAL OFFICE DESIGN OF THE FUTURE
Dental offices of the future will continue to include strong interior design elements. Their design will accommodate computer network-
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ing, audio and visual distribution, unified communication systems, automated services, continued integration of digital technology, and wireless access. Dental equipment that interfaces with computers and other diagnostic and treatment devices that help the practice remain organized, run more efficiently, flow smoother, save the dentist and staff time, and the decrease patient anxiety and discomfort will be embraced by the profession. These, also, will impact the manner in which dental office design, furnishings, and equipment are incorporated in operatory and common space areas.
CONCLUSION
Dental professionals are looking to the future when considering office design, space and function. With advancements in dental technology has come a shift in the design and focus of the dental office. Considering or reconsidering office design reflects a renewed commitment to the dental profession and patients. By providing a bright, open, spacious, and inviting environment with up-to-date, state-of-the-art technology, dentists are establishing an image that they take their practice-and their patients-seriously. OH 100 th Anniversary Issue 2011
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A ‘C’ Change in Office Management Untitled-3 1
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Cheryl Kanhai, B. Admin, Adv. Int’l Bus. President of Maxim Software Systems, developers of Maxident Dental Software
Today, forward-thinking software companies are implementing Artificial Intelligence (AI) into their charting applications. This may sound futuristic but the reality is already here
S
imple, intelligent advances in dental technology are being introduced and adopted throughout the industry with great enthusiasm. With the new wave of paperless office software, dental practices are being transformed from paper-heavy operations to enhanced efficiency and greater productivity. An examination of the three evolutions of dental software — the past, the present and the future — helps us reflect upon where we started, where we are today, and where we are headed in the future.
THE PAST
Imagine your office, staffed with employees manually handwriting claim forms for every patient seen. Your receptionist had to refer to the paper fee guide to confirm procedure codes and fees, take a calculator and tally up total charges. At the end of the day, the dentist had to review each claim form for accuracy and then take the time to sign each one. Once those forms were completed, they were sent out via postal mail. Statements had to be written up and mailed and then the collection process began with account receivables totaling into thousands and thousands of dollars. Claims took several weeks to process with most payments being received by cheques in the mail. Offices were cluttered with pa-
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per schedulers and recall systems with huge filing cases filling every available corner. Desks were littered with pencils, sharpeners, pens, typewriters, correction fluid and other office supplies necessary in a paper-reliant office. The first sea change was about to occur with the advent of dental software and CDAnet (EDI).
THE PRESENT
Even with the first evolution of dental software, and the development and CDAnet, an unrequited fear of computers was predominant. Dentists simply did not understand the value or capabilities of computer technology or the benefits of implementing these tools. Computers were viewed with wariness and concerns over loss of data, system crashes and security breaches seemed to outweigh any possible advantages in the minds of many. It has taken the better part of 30 years for computers to become widely adopted and for the majority to overcome the fears that seem to be inherent to adopting new technology. Dental software started with practice management. This meant that all the clerical tasks that were traditionally done manually became automated. Dental software expanded to communicate with insurance companies via CDAnet. A computer with CDAnet certified dental practice management software reduced the time it took to get rewww.oralhealthjournal.com
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quired paperwork completed and process patients. Communication with insurers was completed with speed and accuracy. The result? Account receivables significantly dropped, preauthorizations were expedited, patient care improved; cash flow increased, drudgery and repetitive tasks and the paper appointment book disappeared. Time was saved, processes were more efficient and everyone was happier!
THE FUTURE
Just as practice management software has improved the overall functioning of the dental office and the quality of patient care in the last 30 years, a new era in dental software is coming! There is a shift to automate clinical tasks. Today, forwardthinking dentists are embracing technology. They are learning that computers, software and the right digital equipment can aid in diagnosis, accuracy and efficiency. Many dentists are taking these advances to the next level by shifting their offices from paper to paperless. They are appreciating the intelligent simplicity of these tools and recognizing the great value they offer to the performance of their dental practice. Even though you may have practice management software, reflect upon the process of preparing charts for tomorrow’s patients. You have a receptionist calling patients to confirm appointments. Most often, your receptionist will leave a message for www.oralhealthjournal.com
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the patient either at home, or at work. Hopefully, your patient will receive the message.
Imagine a touch screen computer in your operatory, with an intelligent and easy to use interface and the ability to enter in treatment and treatment plans graphically. Imagine a computer that can comprehend the treatment and convert it to procedure codes. Instantly, your treatment is ready to be communicated with the insurer. Untitled-3 1
The next step in the process is to pull charts. Let’s face it — oftentimes the charts are not where they are supposed to be. They may have been misfiled, off-site, or missing all together. Additionally, the process to prepare for patients to arrive the upcoming day is laborious. Thankfully, with the continued advancement of technology, the next evolution in dental office software is upon us! Just imagine your office with no dental charts — just a nice clean, clutter-free office. So what does going paperless mean? First of all, it eliminates the need to pull and file charts. Charts are never misfiled, misplaced or lost. Imagine the time saved! Instead, patient charts are available instantly from any computer. However, not all electronic charting systems are created equal. Research is required to ensure that your office chooses the best system available to truly realize the potential that cutting edge technology can offer to your practice. Today, forward-thinking software companies are implementing Artificial Intelligence (AI) into their charting applications. This may sound futuristic but the reality is already here. Simply put, AI is technology that learns as it is being used. It gains an understanding of the treatment procedures in your office and comprehends the treatment you are entering.
A charting program this intelligent and easy to use gives you the power to query your clinical database and find patients with specific conditions that need specific treatment. You could never do this with a cabinet full of paper charts! This is just one example of the preciseness and accuracy a charting system with AI can provide. Another technology that is gaining momentum is automated appointment reminder systems. Today, most patients carry smart phones so they can readily access information anytime, anywhere. Smart technology designed to automatically send appointment reminders via email, text or voice recording allows for less time to be spent calling patients and leaving messages. This results in fewer missed appointments and huge time savings which translate to less money being spent and a boost in efficiency and productivity. Automated appointment reminder systems allow employees to focus on income-producing tasks and relationship-building aspects to help build up your practice. 100 th Anniversary Issue 2011
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Technology keeps moving forward to enhance our lives. Evolutions in dental software are imminent. When you choose software, you have to look for a dental software technology partner that truly understands your business and the challenges that you face. The company behind the software you choose must have the drive and strategic plans to continually invest in research and development to stay ahead of the curve. You need your software vendor to see you through these upcoming evolutions. 21/07/11 1:40 PM
As technology progresses, it continues to become more intelligent, intuitive, user-friendly and secure. Artificial Intelligence,
voice activation, bio-metric capacities, and more use of the internet will help all dental professionals to provide better services and improved dental experiences for patients.
• e nhanced security • reduced harm to the environment • i mproved relationships with patients
In the last 30 years and looking towards the future, consider how computers and software have improved dentistry and how it will continue. Also, consider the benefits that paperless dental technology can offer you.
Today, we are writing history for the next generation of dentists. With continued paperless office solutions advancement, the next decade will move towards a complete paperless dental office. Twenty years from now, dentists won’t be able to imagine writing up a paper chart!
Embracing paperless office soft ware can mean: • f inancial savings • increased productivity • decreased physical storage needs • streamlined information sharing
No one knows precisely what the future will hold, but computers and software is becoming a dentist’s best friend. These friendships are improving dentistry and transforming the future! OH
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A Lesson from the Past for Use in the Future Untitled-3 1
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Paul L. Child Jr., DMD, CDT Prosthodontist, Certified Dental Technician, CEO of CR Foundation (formerly CRA), private practice, Provo, UT
turers can focus on new methods and products for improvement, while clinicians primarily focus on acceptable delivery and quality of care for the patient. However, dentists and manufacturers must adhere to ethical standards when introducing new products and concepts.
THE PAST
T
he introduction of new dental products, concepts, and techniques has a storied history and generally stem from three areas: 1. Patient need or desire (e.g. white, less expensive, or improved function and comfort); 2. D entist desire or demand (e.g. faster, easier, or more profitable); 3. Manufacturer directed (e.g. innovative, “game-changing,” or better). An observation of the past 100 years reveals varied levels of interaction among all three areas, some being more dominant or responsible for the introduction of these new products (e.g. white restorations as a driving force by the patient). However, in the past 10-20 years, manufacturers have been the noticeable and driving force behind the integration and adoption of new products and devices. As new and improving methods have become available to communicate with clinicians, this is to be expected. This should be viewed positively, as manufac136
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It is almost deplorable to mention the modified proverb: “A wise man learns from his mistakes; but a wiser man learns from another’s mistakes.” (Modified from: “Only a fool learns from his mistakes, a wise man from the mistakes of others.”) Yet, man is sometimes set on repeating the mistakes of yesterday. This holds true for dentistry as well, for both dentists and manufacturers. A sample of the failed concepts of the past include: polymer bonded to metal restorations; various cements; several methylacrylatebased restorations for direct use; many ceramics; several periodontal, occlusion, and dental caries “cures,” and many more. Occasionally, dentists or manufacturers get over optimistic about a new product or concept before adequate research can be provided or longevity established. Conversely, many exciting materials and concepts that have been introduced previously have become mainstays in dentistry, and far outweigh any failures of the past, such as: resin-based composites (Fig. 1); endosseous
implants; air driven and electric handpieces; adhesive-based dentistry; anterior indirect veneers; bleaching; bone grafting procedures; advanced radiology; etc. Practicing dentistry without some of these concepts would seem incomprehensible! Today, some of the same methods of proclaiming all-in-one solutions and touting the next “cure” to a specific dental problem continue. Dentists are advised to be just as cautious today as in the past. Perhaps more so now with the many paid manufacturer speakers, evaluation groups, product endorsements, and blurring of sponsored education.
THE PRESENT
There are four key characteristics every dental product or concept should have, considering both patient and dentist needs: Is it faster? Is it easier? Is it less expensive? And most important — is it better? Clinicians Report (formerly CRA) has been seeking the answers to these questions for over 35 years. Too often a product is faster and easier, but far from better (unfortunately, many new products introduced today fall into this category). In addition, cost rarely has a direct correlation with a product being better, as often a product that is better, may warrant the additional cost (e.g. using cone beam CT for diagnosis and treatment planning of implants and other surgeries, see Figure 2). However, www.oralhealthjournal.com
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DENTAL PRODUCTS & TECHNOLOGY the reverse may be true — choosing a product that is less expensive — because its characteristics are equal or comparable to the best in its category (e.g. some cements or impression materials). Finally, some products are truly better, but so technique sensitive and difficult, that dentists will abandon the proper use of them, making them actually worse (too many to name, but unfortunate due to the fact that they are actually “better”). Present areas of emphasis of dental products and concepts continue to be centered on esthetics and strength. Both patients and manufacturers are driving this direction. New types of crowns are being introduced that may replace the PFM crown. Examples include lithium disilicate (IPS e.max CAD/Press or CAD-on) and full-contoured zirconia (BruxZir and many others). Patients and dentists are excited about these new restorations and initial results are promising. These new restorations appear to meet the above four criteria, but time will prove if they are better. The use of CAD/CAM from both a laboratory and chairside perspective has significantly improved the efficiency of crown fabrication. Another area of growth, driven by both dentists and manufacturers, is anything related to digital dentistry. The very least of this area that a dentist should have in their office is computers with patient/practice management software. These, along with digital radiography, are the entry points into digital dentistry. Both meet the above four characteristics, when implemented and used properly. The rapid integration of digital concepts being used in other industries into dentistry is www.oralhealthjournal.com
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clearly changing what is considered traditional dentistry. New methods for patient communication with tablets, computers, smart phones and internet based solutions, are driving patient expectations to new levels. Some patients are drawn to clinicians and offices where technology or new products are heavily “promoted.” Many patients want to feel like they are receiving the best care possible and may look primarily at technology as the indicator of quality of care. There is rarely a direct correlation with an offices level of technology and their clinical skills. Past experience has demonstrated widespread advertising to patients, such as: in-office, light-enhanced bleaching; exclusive use of lasers for everything; veneers or cosmetic dentistry only; the CAD/ CAM office that over promotes same day indirect restorations; or similar ads for teeth-in-an-hour implant services. A look at all areas of dentistry will reveal a wide array of other digital devices and new technology that are used as marketing hype to draw patient’s into the office. Some manufacturers and dentists clearly know and may even acknowledge that a device or concept is beyond its average hype period, but continue to sap money from dentists or patients until its last drop of excitement has been spent. This model is no different from other consumer industries, offering services or products at reduced prices until the trend completely dies, but is highly unethical of a profession as dentistry. Using or promoting a concept or product purely for financial gains, regardless of actual quality rendered, should be discouraged in the dental profession. Comparing
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business models to other industries, including medicine, using one device, product, or concept for all revenue generating procedures, is rare and a poor business decision, as history has demonstrated and will continue to reveal failure of that model.
THE FUTURE
A plethora of new products and concepts are expected to be introduced to our profession in coming years. With digitization of much of the world in all areas of life, new techniques and dental products will improve efficiency and patient outcomes. Many will be highly useful and desirable. Yet, many will fall into the category of failed concepts and products, failing to learn from our past.
Digital dentistry, in all its many forms, is more about improved efficiency, rather than being significantly better, exciting, or “eyecandy” for our patients. Much of it is borrowed technology from other industries that has already proven itself. The delayed integration of digital dentistry into clinician’s practices may result in decreased potential revenues and even better service for patients. But for the clinician who only cares for their patient’s well-being (and puts financial priorities a distant second), by practicing with older technology that is well-proven, but may be slower or deemed outdated, no difference in patient outcomes should be expected. For this dying breed of dentist, it is completely acceptable to stay with
proven concepts and products until something truly innovative and revolutionary replaces them. All three key driving forces for new products, concepts, and techniques — patients, clinicians, and manufacturers — should place a high priority on treatments and products that are truly better, not just faster, easier, or less expensive. A balanced combination of the four main characteristics identified, with better being the leading focus, will result in improved patient care — no matter what the future may hold. Ethical considerations must be incorporated into every aspect of our profession, especially as it relates to dental materials, products, and new technology. OH Untitled-3 1
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MATERIALS & TECHNOLOGY
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Lisa Citton-Battel, Country Business Manager, 3M ESPE
Decades of Innovations Advance Dentistry W
ith more than 100 years in its own history, 3M has shared the experience of witnessing dramatic changes in the healthcare industry, and providing dentists with the tools they need to evolve with the times.
Dentists of even one or two generations ago would likely be amazed at the capabilities of the modern clinician
As dentists know, the past decades have seen outstanding advances in the healthcare field. Dentists of even one or two generations ago would likely be amazed at the capabilities of the modern clinician, and today’s patients are reaping the benefits of the incredible advances that have been made in the past decades.
ADVANCES THAT MAKE DENTISTRY BETTER
While today’s most impressive technologies include sophisticated digital tools and products utilizing nanoparticles, an examination of past breakthroughs helps demonstrate just how far the field of dentistry has come in a few decades. For example, tooth-coloured resin composite was introduced in the ‘60s, and took many more years to become the material of choice for most restorations. The successive generations of this material demonstrate the ongoing evolution of the chemistry and technology needed to per-
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fect such a product. The original macrofill composites, with their large particle sizes, gave way to microfills, and then hybrids, microhybrids and nanohybrid restoratives. While in the past, many materials forced dentists to choose between strength and esthetics for a restoration, today’s composite delivers both, and maintains excellent esthetics over the long term (Figs 1 & 2: SEM of nanoclusters). Impression-taking, too, has seen advances that would boggle the mind of past generations. While polyether impression material, introduced in the 1960s, still remains a reliable choice in many practices, today’s clinicians can also opt for VPS materials, which were engineered in the ’70s. More recently, the introduction of digital impression-taking tools has given dentists a paradigm-shifting alternative to traditional impression materials. With the ability to capture a digital impression and view the results in real time on a chairside monitor, dentists can make the impression taking experience much more comfortable for patients, and can also help create better-fitting final restorations. These tools enable a new level www.oralhealthjournal.com
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...today’s patients are reaping the benefits of the incredible advances that have been made in the past decades
of communication between the dentist and laboratory that can dramatically improve productivity and accuracy. More digital tools in the dental laboratory are making it easier for labs to create great-fitting restorations, whether or not the dentist utilizes a digital impression device. Labs now have the ability to digitize any impression and utilize CAD/CAM tools to create restorations (Fig 3: Lava™ C.O.S.). As the capabilities of these technologies grow, digital dentistry will continue to enable faster and better treatment of patients.
DEVELOPMENT INTO THE FUTURE
As these examples have shown, dental technologies are advancing at an incredible speed and dentists must stay ahead of continual changes being made in materials and techniques. In this environment, both dental media and manufacturers can play an important role in delivering reliable technical insights and continuing education. Open communication between clinical researchers, material scientists, journalists and dental professionals helps the entire industry move forward and advance toward an even more impressive future. OH www.oralhealthjournal.com
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FIGURES 1 & 2—Zirconia/Silica Nanoc luster, 100K magnification, SEM via 3M Laboratories; Filtek™ Supreme Ultra nanocluster, SEM: Dr. J. Perdigao, University of Minnesota.
FIGURE 3—3M™ ESPE™ Lava™ Chairside Oral Scanner C.O.S. 100 th Anniversary Issue 2011
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Risk Management & Orthodontic Practice Untitled-3 1
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Duncan Y. Brown, BSc, DDS, D. Ortho
O
ral Health, in its 100th year of publication, recently received one of the 2011 “Awards of Distinction” from the University of Toronto Alumni Association, for consistent support of the Canadian dental community. In speaking with many of my colleagues at the event, the common reflections focused on how the profession has changed over the years, and how many of those changes have made orthodontic practice more challenging. Ever increasing operating costs, increased and sometimes unreasonable patient expectations, and the growing number of litigations against orthodontists were some of the common concerns consistently voiced by orthodontists. Many conclude that the “golden age” of orthodontics has passed. While I agree with the concerns, there is reason to be optimistic about our future as a profession, and excited about what contemporary practice has to offer our patients in improving their “oral health.” Let me try to explain why: 142
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We are better prepared to understand the factors that contribute to patient satisfaction and dissatisfaction Patient satisfaction with orthodontic treatment depends as much on the “quality of the patient experience” or on psychological factors, as on the orthodontist’s perception of the “quality of the treatment result.” By focusing on the patient’s perception of what matters during treatment, it has been shown that understanding increases both patient and parent satisfaction with treatment outcomes. Armed with modern technologies, orthodontists are better able to respond to patient needs The practice of orthodontics has evolved tremendously with the appropriate application of advanced technology. CBCT radiography, modern self-ligating appliances, advanced diagnostic and treatment concepts, TAD’s, and soft tissue lasers have contributed to contemporary orthodontic practice and improved the lives of our patients. Each of these advances brought with it demands for further training, revisions of existing office systems, and in many cases, legislative reform to ensure their appropriate application. Experience shows that the most sophisticated technologies cannot effectively be applied in the absence of sound office systems.
THE ‘ORAL HYGIENE MODEL’
For most of my 34 years in orth-
odontic practice, one of greatest challenges revolved around oral hygiene concerns in patients during treatment. Even with technological improvements from full banding to bonding, improved “cleansability” of modern fixed appliances, and more efficient methods of treatment, consistent challenges remained. Patients’ gingival conditions commonly deteriorated through treatment causing prolonged treatment times. Appointments were uncomfortable. Parents became disgruntled as their children received “re-education” at almost every appointment as their gingival condition failed to improve. Referring dentists and hygienists were critical of the “quality of care” being provided, viewing the hygiene concerns as reflective of the treatment as a whole. Too frequently, either dental restorations of periodontal revisions were required as decalcification combined with gingival hypertrophy and inflammation took its toll. Team members felt helpless to be able to effectively change this.
A BRIGHT FUTURE
We are entering a new era in orthodontics, with greater competition, higher patient expectations, and increased legislative involvement. Fortunately, improved technology (Product), ease of stakeholder involvement (People), and adoption of TQM principles (Process), has never been easier. The future is so bright “you have to wear shades!” OH www.oralhealthjournal.com
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OH 100th p143 Element AD.indd 143
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Go to: www. oralhealthjournal.com/marketplace •Looking for a dental hygenist? •Need to hire a dental assistant or Associate fast? •Need to sell your practice? Instantaneous placement online and response. Post your ads on oralhealthjournal.com/marketplace any day of the week! To place an ad, call Karen Shaw at Tel: 416-510-6770, Fax: 416-510-5140, Toll Free in Canada: 800-268-7742 ext 6770, Toll Free from USA: 800-387-0273 ext 6770
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Association ental industry D e th l of rs ns of the Ora of Directo ary celebratio d the Board rs an ve rs ni be an ar em the m 0th ye join in the 10 On behalf of e delighted to ar e w a, ad of Can l. Health Journa n our nge has give sional intercha es with of a pr ad d an an ross C ucation to dentists ac t n to dental ed ou tio h bu ri ac nt re co cle to Oral Health’s valuable vehi panies an in m lutions. co so r e be tic em ac m e their pr nc ha en to es opportuniti outstanding rtisers on this ve ad d an rs tion to dental ntributo lth’s contribu rs, editors, co ea H he l is ra bl O pu of e s year late th the next 100 We congratu ok forward to lo d an e on milest anada. dialogue in C
a, RDT Jamie Mater President
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OH 100th p155-157 Birthday ads.indd 156
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Congratulations to Oral Health! JOHN McMILLAN — Barrister & Solicitor Serving Dental Professionals
Tel: 416-364-4771 E-mail: johnmcmillan@bellnet.ca
Happy 100th!
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OH 100th p155-157 Birthday ads.indd 157
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26/08/11 10:09 AM
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John McMillan is a Toronto business lawyer serving dental professionals. He may be reached at: johnmcmillan@bellnet.ca The author would like to acknowledge and thank Mariana Bracic, LL.B. for her assistance on the employment portion of this article. She can be reached at: mbracic@mbclegal.ca
and at the University of Washington School of Dentistry in Seattle. Dr. Bruce R. Pynn, is the Oral Health editorial board member for oral surgery. He is on staff at the Thunder Bay Regional Health Sciences Center and in practice in Thunder Bay, ON.
21/07/11 1:40 PM
Dr. Paul L. Child Jr. is a Prosthodontist, Certified Dental Technician, CEO of CR Foundation (formerly CRA), and maintains a research based practice in Provo, UT. He also co-presents the “Dentistry Update®” course with Drs. Gordon and Rella Christensen. Dr. David Gane graduated from the University of Western Ontario with an honors degree in physiology and pharmacology and a doctorate in dental surgery. He authors many publications and technique videos on digital radiography and lectures nationally and internationally on digital imaging. Dr. Gane currently serves as vice-president of dental imaging for Carestream Dental. Dr. Duncan Y. Brown, B.Sc. University of Toronto; DDS, University of Toronto; D. Ortho. University of Toronto. Lisa Philp is the President of Transitions Consulting Group, a full service coaching company for dentistry. She can be reached at transitionsonline.com. Derek Hill is the Broker for Hill Kindy Practice Sales & Realty Inc., Brokerage, specializing in practice appraisal, sales, transition and other customized practice equity transfers. Derek can be reached at www.hillkindy.com Brian S. Allen is the Director of Equipment for Henry Schein Canada. Brian can be reached at brian.allen@ henryschein.ca Timothy A. Brown is President & CEO of ROI Corporation, a company that specializes in dental practice appraisals, brokerage, consulting, Locum placements, Associate-ships and practice financing across Canada. Ben Z. Swanson, Jr. is Past-President, American Academy of Dental History; Founding Executive Director, National Museum of Dentistry, Baltimore, Maryland. Ted Croll is a diplomate of the American Board of Pediatric Dentistry and practices pediatric dentistry in Doylestown, PA. He currently has affiliate staff appointments in pediatric dentistry at the University of Texas Health Science Center (Dental Branch) in San Antonio 158
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OH 100th p158-159 Author BIOS.indd 158
Trevor R. Laingchild, RDT, Accredited Member American Academy of Cosmetic Dentistry; Director, Board of American Academy of Cosmetic Dentistry; Examiner Board of American Academy of Cosmetic Dentistry; Master Aesthetic Technician LVI; President, dentalstudios Yorkville/Burlington, ON; Editor In Chief, Spectrum Dialogue. Dr. David Farkouh is a pediatric dentist working in private practice in Toronto, ON, and is a staff pediatric dentist in the Department of Dentistry at The Hospital for Sick Children, Toronto. Dr. Farkouh is the pediatric dentistry editor for Oral Health. Dr. Keith Titley is a contributing consultant for Oral Health. Dr. Peter Nkansah is a dentist-anaesthesiologist with a private practice in Toronto. He is also Past President of the Canadian Academy of Dental Anaesthesia, an international lecturer, and a member of the teaching staff in the Discipline of Anaesthesia at the Faculty of Dentistry, University of Toronto. Dr. Nkansah is Oral Health’s board member for anaesthesia and pharmacology. Dr. Janice Goodman graduated from University of Toronto Dental School in 1979. She teaches Essix Minor Tooth Movement, was on the advisory board for Dentsply Raintree Essix and practices general practice dentistry in Toronto. She is on the editorial board of Oral Health Journal. Dr. Elliot Mechanic practices esthetic dentistry in Montreal, Quebec. He is Oral Health’s editorial board member for esthetics. Dr. Jordan Soll is the Co-Cosmetic Consultant to Oral Health and is principle of Aesthetics in Dentistry, Toronto, ON. Dr. Gary Glassman lectures globally on endodontics and is on staff at the University of Toronto, Faculty of Dentistry in the graduate department of endodontics. Gary is a Fellow of the Royal College of Dentists of Canada. He maintains a private practice, Endodontic Specialists, in Toronto, Ontario, Canada. Dr. Adam Grossman, DDS, FRCD(C). www.oralhealthjournal.com
31/08/11 11:35 AM
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AUTHOR BIOGRAPHIES
Dr. Susanne Perschbacher, DDS, MSC, DIP. ABOMR, FRCD(C) Oral and Maxillofacial Radiology. Dr. Perschbacher is a member of the editorial board for Oral Health. Dr. Bohdan Kryshtalskyj is Chief, Division of Oral and Maxillofacial Surgery at The Trillium Health Centre, Associate in Oral and Maxillofacial Surgery Faculty of Dentistry University of Toronto, Contributing consultant for oral and maxillofacial surgery, Oral Health, and President of The West Toronto Dental Society of the Ontario Dental Association. He is in private practice. Dr. George Freedman is a founder and past president of the American Academy of Cosmetic Dentistry, a cofounder of the Canadian Academy for Esthetic Dentistry and a Diplomate of the American Board of Aesthetic Dentistry. Dr. Freedman sits on the Oral Health Editorial Board (Dental Materials and Technology) is a Team Member of REALITY and lectures internationally on dental esthetics and dental technology. A graduate of McGill University in Montreal, Dr. Freedman maintains a private practice limited to esthetic dentistry in Markham, ON. Dr. Carl E. Misch is Clinical Professor and Director, Oral Implantology, Temple University, Philadelphia, PA. Dr. James Posluns is currently the director of the graduate orthodontic clinic at the University of California San Francisco. Dr. Peter Birek is an Associate Professor in the Department of Periodontics and staff surgeon with the Implant Prosthodontic Unit at the University of Toronto. He maintains a private practice in Periodontics and Implant Surgery in Toronto. Peter is the Periodontology editor for Oral Health. Dr. Bruce Glazer is the prosthodontic editor for Oral Health. Dr. Fay Goldstep on the Oral Health Editorial Board (Healing/Preventive Dentistry), has served on the teaching faculties of the Post-graduate Programs in Esthetic Dentistry at SUNY Buffalo, the universities of Florida (Gainesville) and Minnesota (Minneapolis). She has lectured nationally and internationally on healing dentistry, innovations in hygiene, dentist health issues and office design. Dr. Goldstep is a consultant to a number of dental companies, and maintains a private practice in Markham, ON. www.oralhealthjournal.com
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Dr. Aldo Boccia is a member of the editorial board of the Oral Health. Dr. Rollin M. Matsui maintains a full-time law practice in Richmond Hill, ON and a part-time dental practice in Toronto. In his law practice, he primarily acts for dentists in complaint and professional misconduct related matters and provides legal advice regarding business agreements involving dentists. He is Oral Health’s editorial board member for ethics and jurisprudence. Untitled-3 1
Dr. Steven R. Olmos DDS, DABCP, DABDSM, DACSDD, DAAPM, FAAOP, FAACP, FICCMO, FADI, FIAO is Adjunct Professor, University of Tennessee, Memphis College of Dentistry. Jean Akerman, ARIDO, IDC, is an award-winning interior designer specializing in healthcare. Based in Toronto, Jean is the founder of her namesake firm, Jean Akerman Interior Design, and has been creating office environments for dental professionals for more than 30 years. Some recent projects may be viewed at www. jeanakermandesign.com Dr. Bill Dorfman is responsible for creating dazzling smiles for some of Hollywood’s biggest stars. David Chong Yen, CFP, CA of DCY Professional Corporation Chartered Accountants, Toronto, ON, is a tax specialist and has been advising dentists for decades. David Mock has been Dean of the University of Toronto Faculty of Dentistry since 2001. He is Professor of Oral Pathology/Oral Medicine; Professor of Laboratory Medicine and Pathobiology (Faculty of Medicine); Pathologist in the Department of Pathology and Laboratory Medicine (Mount Sinai Hospital); and Associate Director of the Wasser Pain Management Centre (MSH). Cheryl Kanhai is President of Maxim Software Systems, developers of Maxident Dental Software. www. maximsoftware.com Peter Jordan is President of Clinical Research Dental Inc. Lisa Citton-Battel is Country Business Manager, 3M ESPE. She has been with 3M since 1994, and has held various roles in the Dental Industry since 2001. www.3MESPE.ca 100 th Anniversary Issue 2011
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TMD & DENTAL SLEEP MEDICINE PHASE II ORTHODONTICS FINISHING YOUR TMJ PATIENTS A SYSTEM FOR DX AND TX Directed by Dr. Steven Olmos
Directed by Dr. Ed Lipskis
3 session, 6 day mini-residency for the ◆ A 6 session, 12 day, in-office, treatment of TM Dysfunction & OSA. hands-on education program for: Learn a SYSTEM for triage of structural injuries, sleep disorders and systemic inflammatory conditions.
◆ Concepts of 3D position correction
Understand the proper steps and protocols for patient treatment to achieve reproducible results
◆ Removable versus fixed appliances
◆ The role & influence of airway
◆ Handling the symptomatic episodes
◆ Correcting cant/closing open bites All forms for data collection, documentation, tracking and billing are suppied. ◆ TADs - their use & how to place
ELECTRICAL ACUPUNCTURE FOR CRANIOFACIAL PAIN Directed by Dr. David Shirazi Two day course to enhance patient care and treatment success using needleless electro-medical modalities in the treatment of chronic cervical and craniofacial pain Hands-on clinical application Learn a physical medicine modality that can be delegated to your staff once properly trained. Gain an understanding of Chinese medicine, meridians and acupuncture.
San Diego & Toronto
Chicago, IL
San Diego, CA
Starting: Sept. 30 - Oct 1, 2011 Starting: January 20-21, 2012
Starting: November 11-12, 2011
November 18-19, 2011
Programs Directed by Dr. Steven Olmos Diplomate, American Board of Dental Sleep Medicine Diplomate, Academy of Clinical Sleep Disorders Disciplines Diplomate, American Board of Craniofacial Pain Diplomate, American Academy of Pain Management
FAAOP, FAACP, FICCMO, FADI, FIAO Dr. Steven Olmos has been in private practice for over 30 years with the last 19 years and over 4000 hours of continued education devoted to research and treatment of TMD, Craniofacial Pain and Sleep Disordered Breathing. Dr. Olmos is the founder of TMJ & Sleep Therapy Centre International, LLC with 10 licensed Centres located in the U.S., Canada and New Zealand. He has been honored for his contributions to dentistry with Fellowship in the Academy of Dentistry International and is also the 2008 recipient of the American Academy of Craniofacial Pain (AACP) Haden-Stack Award for his contributions to education in the field of TMD and Craniofacial Pain. Dr. For additional Olmos’ treatment philosophy is course information conservative, non-surgical and to view all courses therapy for better quality of life. offered in 2011/2012,
please visit our website at: www.TMJTherapyCentre.com 877.865.4325 / 619.462.0676 E-mail: Jena@TMJTherapyCentre.com Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 6/1/11 to 5/31/14
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A D V E R T I S E R ’ S
3M Espe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122-123 3M Espe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IFC A.R. Medicom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IBC AB Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134, 139 Abelsoft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 ADEI – Advanced Dental Education Institute . . . . . . . . . . . . . 138 Air Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Alpha Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117, 138, 139 Astra Tech . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Aurum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Baluke Dental Studios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Bien Air Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Cappellacci DaRosa LLP . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Carestream Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-23 CDPA – Canadian Dental Protective Association . . . . . . . . . . . 74 Clinical Research Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Colgate – Palmolive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Coltene Whaledent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 CR Foundation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Crest Oral-B, P&G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Crosstex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 David Chong Yen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Delcam Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Den Mat Holdings LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Denstply Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4, 34 Dent Corp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Dental Ez . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Dental Services Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Dentatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Dentaurum Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 DiaDent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54-55 Diatech . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Discus Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Dr Herchen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Dr Vendittelli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Element Financial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 EMS – Electro Medical Systems . . . . . . . . . . . . . . . . . . . . . . 150 Exan Mercedes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 B I R T H D A Y
Al Heaps & Associates Alglobe Construction Comapany Arya &Sher Barristers & Solicitors Broadway Dental Dalhousie University Faculty of Dentistry Dr Amundrud Dr Brown Dr Rockman Fedder, Gurau & Staniewski
www.oralhealthjournal.com
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C A R D S
I N D E X
GSK – Glaxo Smith Kline . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Hands on Training Institute . . . . . . . . . . . . . . . . . . . . . . . . . 129 HANSAmed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 HealthSmart Financial Services . . . . . . . . . . . . . . . . . . . . . . 108 Henry Schein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Hill Kindy Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-15 Ivoclar Vivadent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBC Johnson & Johnson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 KaVo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-17 Kawartha Endodontics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 LED Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Nobel Biocare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 OCO Biomedical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Oral Science . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9 Patterson Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Philips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-31 Professional Practice Sales . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Quantum Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58-59 ROI Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38-39 Safari Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Sci Can Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46-47 Seacourses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Septodont . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42-43 Shaw Lab Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Sirona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Southern Dental Industries . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Sunstar America . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Supermax Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Sybron Endo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Synca . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 TACD – Toronto Academy of Cosmetic Dentistry . . . . . . . . . . . 79 Takara Belmont . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 TIDE – Toronto Integration for Dental Excellence . . . . . 115, 128 TMJ Sleep Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Toronto Academy of Dentistry . . . . . . . . . . . . . . . . . . . . . . . . 96 Transitions Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-15 Vident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Wrigley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 —
P A G E S
Flight Dental Systems Gloria Fine Jean Akerman Interior Design John McMillan Barristers & Solicitor MacKenzie & Company McGill University Faculty of Dentistry Nadean Burkett & Associates POW Dental Laboratories Sable Industries Inc.
1 5 5 - 1 5 7
Universite de Montreal Faculty of Dentistry Universite Laval Faculte de medicine dentaire University of British Columbia Faculty of Dentistry University of Manitoba Faculty of Dentistry University of Toronto Faculty of Dentistry University of Western Ontario Faculty of Dentistry
100 th Anniversary Issue 2011
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OH 100th p164 Ivoclar AD.indd 164
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