Preventive Dentistry Canada

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Vol. 2 No. 2

I August 2011 I Summer Issue

Preventive

Dentistry Canada

Ask the Expert Communicating with our Patients about Diet Pop and Energy Drinks

Clinician’s Corner Fulcrum Considerations with Ultrasonic Instrumentation Special Features

Gingival Recession – Etiology and Treatment Periodontists Dr. Mark Nicolucci and Dr. Murray Arlin Share their Expertise

The Periodontium: A Review Dr. Graham Cope Discusses the Complexity and Structure of Periodontal Tissues

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Preventive

Vol. 2 No. 2

Dentistry Canada

in this issue

features 6

Palmeri Publishing Inc. Publisher: Ettore Palmeri, MBA, AGDM, B.Ed., BA

I August 2011

Gingival Recession – Etiology and Treatment

Editor-in-Chief: Dani Botbyl, RDH

Canadian Office: 35-145 Royal Crest Court, Markham, ON L3R 9Z4 Tel: 905-489-1970 Fax: 905-489-1971 Email: ettore@palmeripublishing.com

Mark Nicolucci, D.D.S., M.S., cert. perio implant, F.R.C.D.(C) and Murray Arlin, D.D.S., dip perio, F.R.C.D.(C)

Preventive Dentistry Canada is committed to presenting cutting edge education in order to optimize patient care. A quality journal for hygienists and dental assistants who want to keep up-to-date on education and developments in preventive dentistry.

Articles published express the viewpoints of the author(s) and do not necessarily reflect the views and opinions of the Editorial Board.

All rights reserved. The contents of this publication may not be reproduced either in part or in full without written consent of the copyright owner.

Publication Dates: May, September, December Design & Layout: Lindsay Hermsen B.Des.Hon. Printed in Canada Canadian Publications Mail Product Sale Agreement 40020046

12

The Periodontium: A Review

19

Q&A: Ask the Expert –

Dr. Graham Cope

editorial board

Dani Botbyl, RDH Murray Arlin, DDS, Kathleen dip perio, FRCD(C) Bokrossy, RDH

May Diakoloukas, Stephanie Donnelly, CDA Level II RDh, BSc

Marilyn Goulding, Laura Iorio, RDH

Sylvie Martel,

Carolyn Rose,

Beth Ryerse,

RDH, BSc, MOS

RDH, HD

RDH, BA

RDH

Energy Drinks and Diet Soda Jennifer Turner, RDH

departments 4 Editorial 17 Clinician's Corner 20 PDC Products & Courses Dani Botbyl, RDH

Dani Botbyl, RDH

Lisa Shoemaker, Cheri Wu,

Jennifer Turner,

RRDH, BA

RDH

RDH, BDSc

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Editorial

Gone Fishing Dani Botbyl, RDH

H

ave you posted your ‘gone fishing’ sign enough this summer? Every new year that comes about seems to fill itself with larger tasks and shorter deadlines, so I have committed to myself to ‘go fishing’ as often as possible in the months of July and August.

I have quickly come to realize that fishing excursions don’t have to be long to be invaluable. Where might you find me? I take

Real Canadians know how short the summer months are - and our time before the arrival of that last long weekend of the season is precious. That said, please enjoy this issue of Preventive Dentistry Canada, and then take some more time to enjoy whatever it is you like to do when you ‘go fishing’ - as Labour Day is just around the corner.

“Real Canadians know how short the summer months are and our time before the arrival of that last long weekend of the season is precious.” every opportunity to ride my bike through each nook and cranny of Niagara on the Lake; to sit by the shore of Lake Ontario and throw rocks without purpose into the water; to stretch out and enjoy wine and cheese on a blanket in Simcoe Park; to laugh with friends and family on the back deck; to visit the lights and action of all that is a tacky tourist trap on Clifton Hill in Niagara Falls; or to sit under a shaded tree while enjoying an ice coffee (no sugar of course).

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Gingival Recession – Etiology and Treatment Mark Nicolucci, D.D.S., M.S., cert. perio implant, F.R.C.D.(C) Murray Arlin, D.D.S., dip perio, F.R.C.D.(C)

Dr. Mark Nicolucci

Dr. Murray Arlin

About the Authors Mark Nicolucci, D.D.S., M.S., cert. perio implant, F.R.C.D.(C) is a Master of the Misch International Implant Institue and a Diplomate of the International Congress of Oral Implantology.

He lectures and practices primarily in the Toronto area.

Murray Arlin, D.D.S., dip perio, F.R.C.D.(C) has taught at the University of Toronto at the undergraduate and post-graduate levels.

He has presented numerous seminar lectures internationally and has authored many articles in leading dental journals. Dr. Arlin is a co-founder of the Toronto Implant Study Club and the founder of the Dental Hygienist Periodontal Study Club of Toronto.

T

his article focuses on the recognition and understanding of recession defects of the oral mucosa. Specifically, which cases are treatable, how we treat these cases and why we chose certain treatments. Good evidence has suggested that the amount of height of keratinized or attached gingiva is independent of the progression of recession (Miyasato et al. 1977, Dorfman et al. 1980, 1982, Kennedy et al. 1985, Freedman et al. 1999, Wennstrom and Lindhe 1983). Such a discussion is an important consideration with recession defects but this article will focus simply on a loss of marginal gingiva.

Recession is not simply a loss of gingival tissue; it is a loss of clinical attachment and by necessity the supporting bone of the tooth that was underneath the gingiva. Recession is measured by the distance from the CEJ to the gingival margin, but the gingival margin in health typically covers 1-3mm of the crown and does not rest at the CEJ. When we measure a recession defect of 1mm, it is not simply 1mm of attachment loss, but instead 2-4mm of attachment. This is why we include both the recession and the pocket depth when calculating attachment loss. It also hopefully brings to light an important point – when we detect recession, significant attachment loss has already occurred.

Recession defects typically present to us as 3 different patient scenarios. The most common is the asymptomatic patient who often is never even aware of the attachment loss unless notified by a dental professional. The other two common scenarios are a patient with tooth or gingival sensitivity or a patient displeased with his or her esthetic appearance.

Reasons to Treat First we need to understand why we would treat any of these patients. The latter two scenarios provide the answer in the patient’s complaint: they either want to alter the appearance of the gingiva or cover the exposed root to prevent discomfort. For these cases, if there is a reasonable expectation of a successful treatment outcome, then treatment should be recommended. In asymptomatic patients the

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reason is often a prophylactic one; that is we want to prevent the recession from getting worse. This reasoning is also true for the esthetic and sensitivity scenarios as well. Severe recession is not only more difficult to treat, but can also be associated with food impaction, poor esthetics, gingival irritation, root sensitivity, difficult hygiene, increased root caries, loss of supporting bone and even tooth loss . To avoid these complications we would want to treat even the asymptomatic instances of recession if we anticipate them to progress. However, nonprogressing recession with no signs or symptoms does not need treatment. In order to know which cases need treatment, we need to distinguish between non-progressing and progressing recession. In order to do that, we need to understand the causes of recession.

Etiology Typical causes of recession are trauma, periodontitis, tooth position or local inflammation (Wennstrom and Prato 2003). This list is not inclusive, as diseases, cysts, non-carious cervical tooth lesions, occlusal trauma or aberrant frena may also contribute to tissue defects, however they are the most common causes of recession.

Trauma resulting in recession is typically from aggressive tooth-brushing (Wennstrom and Prato 2003). Patients should understand that the term is tooth-brushing¬ and not tooth-scrubbing.

Khocht et al. (1993) showed that hard toothbrushes are also more likely to cause recession soft tooth-brushes. Tongue and lip rings can cause trauma to the marginal gingiva as can iatrogenic damage from scaling or other dental treatment and factitious habits, such as using tooth picks inappropriately or scratching the gingiva with finger nails or other devices.

Traumatically induced lesions need to be first treated by addressing the etiology. If a tooth scrubber will not stop scrubbing his or her teeth, then treating the defect will only provide a temporary benefit and the defect will continue to progress. These recession defects are almost exclusively found on the facial and sometimes lingual surfaces of teeth.

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Fig. 1: 1.3 with a 2mm mid-facial recession defect in a patient who confesses to aggressive tooth-brushing.

Fig. 2: Circumferential loss of marginal gingiva due to periodontitis.

Figs. 3a and 3b: A prominently positioned 3.2 moved outside of the maxillary alveolus with associated severe recession.

another major cause of recession (Baker and Seymour 1976). Patients who have a thin biotype or sensitive tissues are especially susceptible to this type of recession. It is theorized that localized inflammation, whether due to plaque or trauma, can sometimes involve the entire width of the gingiva, more commonly with thin and sensitive tissue. The epithelium may then proliferate and overcome the connective tissue, resulting in a subsidence of the epithelium that results in recession. This is likely the primary etiology for recession commonly found around supragingival calculus and restorations where the plaque accumulation at such sites can easily exacerbate local inflammation.

Fig. 4: Severe recession at 3.5 caused by traumatic injury.

Periodontitis associated recession defects are caused because the alveolar bone supports the gingiva. When the bone is lost, the gingiva becomes unsupported. Sometimes the gingiva remains in place due to intrinsic gingival fibers, but when recession occurs, it is difficult to regenerate because of the lack of underlying bone. These types of defects can be found on any surface of the tooth.

Tooth position is also a cause of recession defects. As said earlier, the bone supports the gingiva. If a tooth is moved outside of its alveolar housing, as in some orthodontic cases, then the tooth will often lose bone on the surfaces that extends outside. This can easily be detected by assessing root prominences. This can occur on any tooth that is moved outside the alveolus, either facially or lingually.

Finally, localized inflammation is theorized to be

Treatment Treatment of recession depends on its etiology. Recession due to periodontitis cannot be easily treated because there is no bone for grafted tissue to be supported by. It will continue to progress if the periodontitis is not stabilized.

Recession due to a tooth being positioned outside of the alveolus can be treated either before the tooth positioning occurs, by thickening the gingiva and making it more resistant to recession, or after it has occurred, by either tissue grafting, tissue grafting with root reduction or simply repositioning the tooth back into the alveolar housing (Wennstrom 1996). It is important to note that recession on roots outside of the alveolus may not be as predictably treated by tissue grafting alone because of the lack of bone to support the tissue graft.

This etiology is self-limiting; once the tooth has lost the bone and gingiva covering the root prominence it tends to cease. However, if the recession has only occurred on a part of the root prominence, it may progress the entire length of the prominence unless treated.

Recession due to trauma should only be treated if the etiology is first arrested and it will tend to progress until the etiology is removed. Once removed, the recession typically does not progress.

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Fig. 5a: Same picture as in Figure 1, demonstrating recession due to what was believed to be traumatic tooth-brushing.

Fig. 5b: Preparation of the connective tissue graft recipient site.

Fig. 5c: Connective tissue graft sutured in place.

Fig. 5d: Connective tissue graft after 6 weeks.

Fig. 5e: Connective tissue graft after 6 months.

Fig. 6a: Recession before treatment with a connective tissue graft.

Fig. 6b: Connective tissue graft after 6 months.

Recession due to local inflammation can be treated two ways. First, if a restorative margin is at or below the gingival margin, the tissue can by prophylactically thickened in order to resist recession (Koke et al.

2003). Second, if the recession has already occurred, the tissue can be regenerated and thickened at the same time, although not as predictably as treatment prior to the occurrence of the recession. In both scenarios, consideration should be made towards limiting any suspected etiology in the area. If an overhung margin was the initial cause, regenerated tissue may suffer the same fate if it remains after treatment.

Finally, we must understand that the etiologies of recession are not always clear. It is not rare to have recession due to a factitious habit which appears to be due to an overhung restorative margin. Nor is it rare to have multiple etiologies, such as recession on a facially positioned tooth with a bulky crown margin in a patient who scrubs his teeth because he has periodontitis. These etiologies can be elusive and simultaneous. We should be cautious in discerning which etiologies we believe to be relevant to specific recession defects.

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Fig. 7a: Recession before connective tissue graft.

Fig. 7b: 6 months after connective tissue graft.

Fig. 7c: 5 years after connective tissue graft.

Fig. 8a: Recession before connective tissue graft.

Fig. 8b: 2 weeks after connective tissue graft.

Fig. 8c: 2 years after connective tissue graft.

Summary

References

Recession defects can create several oral health issues and in extreme cases tooth loss. Just because a defect is asymptomatic does not mean it should not be treated. If recession is expected to progress we should attempt to prevent it from doing so. Recession is predominantly caused by tooth brushing trauma or periodontitis, but can also be caused by other types of trauma, prominent tooth positioning, local inflammation or other more uncommon conditions. Teeth with recession and no bone to support tissue grafting, such as in periodontitis and prominently positioned teeth, are difficult to predictably treat. Other recession defects can be more easily treated but the etiologies should be assessed and controlled prior to treatment.

Baker DL and Seymour GJ. The possible pathogenesis of gingival recession. A histological study of induced recession in the rat. J Clin Periodontol. 1976;3(4):208-219.

Dorfman HS, Kennedy JE and Bird WC. Longitudinal evaluation of free autogenous gingival grafts. J Clin Perio. 1980;7:316-324 Dorfman HS, Kennedy JE and Bird WC. Longitudinal evaluation of free gingival grafts. A four-year report. J Perio. 1982;53:349-352 Freedman AL, Green K, Salkin LM, Stein MD and Mellado JR. An 18-year longitudinal study of untreated mucogingival defects. J Perio. 1999;70:1174-1176 Kennedy JE, Bird WC, Pacanis KG and Dorfman HS. A longitudinal evaluation of varying widths of attached gingiva. J Clin Perio. 1985;12:667-675 Khocht A, Simon G, Person P and Denepitiya JL. Gingival recession in relation to history of hard toothbrush use. J Perio. 1993;64:900-905 Koke U, Sander C, Heinecke A and Muller HP. A possible influence of gingival dimensions on attachment loss and gingival recession following placement of artificial crowns. Int J Periodontics Restorative Dent. 2003;23(5):439-45.

Miyasato M, Crigger M and Egelberg J. Ginigval condition in areas of minimal and appreciable width of keratinized gingiva. J Clin Perio. 1977;4:200-209 Wennstrom JL. Mucogingival considerations in orthodontic treatment. Semin Orthod 1996;2:46-54 Wennstrom JL and Lindhe J. The role of attached gingiva for maintenance of periodontal health.

Healing following excisional and grafting procedures in dogs. J Clin Perio. 1983;10:206-221 Wennstrom JL and Prato GPP. Chapter 27 Mucogingival therapy – periodontal plastic surgery. Clinical periodontology and implant dentistry, 4th ed. Lindhe, Karring, and Lang. 2003: 580-581

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The Periodontium: A Review Dr. Graham Cope

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o carry out effective preventive dentistry, it is important to appreciate the complexity and the structure of the periodontal tissues. This knowledge will increase your awareness of diagnostic factors and their involvement in the treatment plan.

The periodontal tissues or periodontium form the supporting apparatus for the teeth.

It holds the teeth in the bony supports, prevents infections and resists the considerable forces during eating and chewing. Age reduces elasticity and flexibility, causing tooth mobility, sensitivity and recession.

The periodontium (Figure 1) is a complicated structure, being made up of the gingival complex, alveolar bone, periodontal ligament and root cementum. (Box 1). The structure of each of these elements will be described in turn.

The Gingival Complex The gingival complex is, as the name implies, a complex tissue. It is made up of the gingival margin, the gingival sulcus, the free and the attached gingivae (Box 2). The margin encircles the tooth and is the visible top edge of the gingiva, dropping down into the sulcus or crevice, which is the gap which lies between the gingiva and the tooth and which is usually between 0.5-3mm in depth.

The free gingiva is a mobile cuff lying above the alveolar crest, while the attached gingiva is a band, varying between 1-9mm in length, which is bound by collagen fibres to the underlying bone and cementum.

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The gingiva joins the oral mucosal tissue at the mucogingival junction and, as it descends into the crevice the boundary of the free gingiva, is marked by the sulcular epithelium (SE), which changes as it goes down into the sulcus; where the attached gingiva is covered by the junctional epithelium (JE).

The sulcus is bathed in gingival crevicular fluid, which seeps out very slowly, contributing about 1ml to the saliva throughout the day. This fluid mimics the serum and leaks through the gingiva and connective tissues. It contains white cells and antibodies and contributes to the immune response to infection and trauma.

However, as plaque accumulates and inflammation increases, the epithelia are disrupted and, when probed, they rupture, causing blood to pass into the crevice. This results in the important clinical sign of bleeding on probing (BOP).

The Gingival Epithelium The gingival epithelium consists of the oral epithelium, the oral sulcular/crevicular epithelium and the junctional epithelium (Box 3). The oral epithelium is a stratified squamous epithelium, whereby the boxlike basal columnar cells migrate to the surface and flatten as they do so. When on the surface, they form an impermeable fattened layer of denucleated keratinised cells, resistant to pathogens and enzymes. The cell structure of the epithelium changes as it becomes the gingival margin.

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Here the cells lining of the sulcus are not keritinsed and are more permeable.

They are actively involved in destroying bacteria and producing chemical messengers such as cytokines. These are the stimulus for the immune response to destroy pathogens. As the epithelium becomes the junctional epithelium, it becomes even more specialised. It has a very rapid turnover; it is non-keritinised and tapers to the cemento-enamel junction (CEJ) and there, it is attached to the tooth enamel. As the tooth attachment apparatus of ligaments and cementum becomes damaged by inflammation during early periodontitis, the JE migrates down the root surface in an effort to stop bacterial infection of the crevice. This migration is the first clinical indicator of periodontal attachment loss and results in

Box 1 •

• •

•

The gingival complex is the gingival margin, the sulcus and the free and attached gingivae Alveolar bone – forms the socket for the tooth Periodontal ligament – fibrous tissue holding the tooth in place and resists shock and trauma Root cementum – bone-like tissue protecting the root from chemical and physical damage

Box 2 • •

•

•

Gingival margin – the visible edge of the gingiva Gingival sulcus (or crevice) – this can vary in healthy teeth from 0.5-3mm in depth The free gingiva – a mobile edge of the gingiva which lies above the alveolar crest The attached gingiva – bound to the underlying bone and cementum by collagen fibres

Box 3 • • •

Oral epithelium – squamous epithelium forming an impermeable layer Oral sulcular/crevicular epithelium – contributes to the immune response Junctional epithelium – rapid cellular turnover going on to attach to the tooth enamel

Fig. 1: Schematic longitudinal section of a premolar and associated periodontal tissues. Applied anatomy is demonstrated alongside histology (photomicrographs) of key areas

the formation of pockets. Clinical recession is a visual gap between the gingival margin and the CEJ and clinical pocketing is measured by probing; hence the term probing pocket depth (PPD).

Another important area of epithelium is the interdental papilla which covers the bone crest between teeth (Figure 2). This is a fragile structure, with a delicate blood supply. The shape is determined by the tooth contact and is normally triangular in health, but gaps between the teeth alter the shape. In profile the lingual and labial papillae meet and form a dip or ‘col’.

This is the most vulnerable area to disease, as few people routinely brush between their teeth. Also, the epithelium is thin and non-keritinised. As a result, gingival inflammation tends to initiate here and periodontal attachment loss ensues.

The Gingival Connective Tissue The gingival connective tissue comprises ground substance, nerves, and blood and lymph vessels. The ground substance is a major constituent of the periodontal ligament and comprised of complex polymers, such as glycoproteins and proteoglycans. The ground substance associates with the numerous collagen fibre bundles that traverse the gingivae. These materials which make up the ground tissue are those associated with other tissues which are exposed to mechanical loading, such as joint cartilage. These tissues are associated with groups of collagenous fibre bundles called gingival fibres. There are different types of fibres at different orientations for maximum rigidity. These are the dentogingival fibres, alveolargingival fibres, circumferential fibres and the transeptal fibres. The purpose of these fibres is to maintain a tight cuff and close attachment of gingiva to the tooth. The main cell type is the fibroblast, which produce collagen and collagenases to allow a recycling and turnover of new fibres. If the gingivae become inflamed the few inflammatory cells that are present rapidly multiply and others migrate in to remove the infection or heal the trauma. The tissue swells from the resultant oedema, the blood vessels dilate and the fibres stretch resulting in the loosening of the gingivae.

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The Periodontal Attachment Apparatus The periodontal attachment apparatus refers to the root cementum, the periodontal ligament and alveolar bone. The cementum is a bone-like tissue that covers the root, protecting it from potentially damaging enzymes and anchors the periodontal ligament to the root. It is to the cementum that bacteria endotoxin loosely attaches and root surface debridement aims to remove the infected cementum layer or wash out the endotoxins from the surface.

The periodontal ligament (PDL) is a fibrous tissue reaching from near the CEJ and covering the entire root surface and is attached to the cementum via Sharpies fibres. It is formed from the periodontal ligament fibres, neurovascular channels, a variety of Fig. 2: An anterior view of ‘pristine gingivae’ demonstrating anatomical features from Figure 1 cells and ground substance. The fibres act like a shock absorber, protecting against strong forces, yet, because of a rapid turnover, allow small movements over time. The alveolar bone forms the socket References for the tooth. It is fine at the margins and thickens towards 1. This article is abstracted from Chapter 1. A whistle stop tour of the Periodontium in: Chapple ILC., Gilbert AD. Understanding periodontal diseases: assessment and the root apex. It has dense plates which meet at the diagnostic procedures in practice. Quintessence Publishing Co Ltd., London 2002. alveolar crest and form a continuous layer linking one socket via the crest to the next socket. The plates link at the lamina dura, and the first sign radiographically of About the Author demineralisation is the loss of the lamina dura, especially at Dr Graham Cope is an honorary senior research fellow at the University of Birmingham and is a clinical chemist by training the alveolar crest. The cortical bone is thinnest overlying and has worked on smoking-related research topics, specifically the lower incisors and thickest overlying the mandibular cotinine testing, most of his career. He is now the director of a molars. The bone can have developmental defects, medical diagnostics company specialising in point-of-care particularly over the lower incisors, whereby the bone is cotinine testing. You can contact Graham at absent, forming a ‘window’ or fenestration. These gaps can grahamcope@gfcdiagnostics.co.uk. communicate with the alveolar margin and form dehiscence or Stillman’s clefts. The health and integrity of the periodontium is vitally important for dental health and preventing inflammation and infection. Advising about regular and correcting brushing to clean and protect the periodontium is an essential role for the dental hygienist.

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Clinician’s Corner

Your Practical Resource

Principles of Ultrasonic Instrumentation:

Fulcrum

Dani Botbyl, RDH

A

About the Author

Dani Botbyl is an RDH with eighteen years of experience in the dental industry. She is a recognized national speaker and an expert in the area of ultrasonic instrumentation. A clinical educator for eleven years with DENTSPLY Canada, she lends much of her expertise to incorporating ultrasonics into the curriculums of dental and dental hygiene programs across Canada. Dani also holds a faculty position at Niagara College of Applied Arts and Technology in Welland, Ontario where she teaches tomorrow’s dental hygienists.

s a professional educator, I travel across Canada lecturing and facilitating hands on education courses to hundreds of dental professionals a year. My clinical area of expertise is ultrasonic instrumentation and I am often in a position where I am asked to critique or provide feedback to a clinician on his or her ultrasonic technique.

In the first two articles of this series, I addressed the basic principles of ultrasonic instrumentation focusing on grasp and lateral pressure. It is important to recall the need for a balanced ultrasonic handpiece in the hands of a clinician in combination with the application of appropriate lateral pressure. (Light lateral pressure is the suggested approach for safe, effective calculus removal while extreme light or no lateral pressure is the accepted method for biofilm removal and disruption). Adhering to these practices will not only help to promote safe and effective deposit removal but will facilitate patient comfort and the musculoskeletal health of the clinician.

The principles of grasp and lateral pressure are the building blocks of the remaining ultrasonic instrumentation principles: fulcrum, insertion, adaptation and activation.

Fulcrum

Once ultrasonic instrumentation grasp is established and the principle of lateral pressure is understood, clinicians next need to look towards positioning a finger rest or fulcrum. A strategically placed fulcrum will aid with the ideal adaptation of an ultrasonic insert and will promote (i) Effective and safe deposit removal

(ii) A minimized risk of musculoskeletal disorders (iii)Patient comfort Conventional or standard hand instrumentation fulcrums are intraoral, placed near the tooth being instrumentated and serve to stabilize the clinician’s dominant hand. This type of fulcrum is designed to complement the principles of hand instrumentation. It provides the necessary leverage needed for the removal of calculus and the prevention of possible injury to the patient or clinician given a sharp, bladed instrument is in hand.

With ultrasonics, strength and leverage are not required for the removal of calculus. A fulcrum too close to the working surface may in fact interrupt a balanced ultrasonic grasp and/or impinge of the clinician’s ability to achieve appropriate light lateral pressure.

Therefore, alternate or advanced fulcrums may be a better choice.

Alternate or advanced fulcrums have been adopted by clinicians as secondary options for the execution of handscaling as they are recommended when conventional fulcrums don’t seem to work well. However, alternate or advanced fulcrums are typically primary considerations for clinicians using ultrasonic technology.

Specifically, a cross arch and opposite arch fulcrum can provide clinicians using ultrasonics with improved access and adaptation while at the same time allowing for the maintenance of proper ultrasonic instrumentation grasp and lateral pressure. Basic extra oral fulcrums such as a chin-cup or knuckle-rest technique are also other options. (See Figures 1-3).

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Fig. 1: An example of an extra oral knuckle-rest fulcrum executed from a cross arch perspective.

Fig. 2: An example of a basic extra oral fulcrum executed from a same arch/quadrant perspective.

For more information on alternate or advanced fulcrums, please refer to Fundamentals of Periodontal Instrumentation and Advanced Root Instrumentation Sixth Edition by Jill S. NieldGehrig (Lippincott Williams & Wilkins, 2007) and join us as this series continues in subsequent issues and we explore insertion, adaptation and activation.

Fig. 3: An example of an extra oral fulcrum knuckle-rest fulcrum executed from a cross arch and opposite arch perspective.

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Q&A

Ask the Expert

With the recent surge in popularity, parents are asking dental hygienists if there are any effects from their teenagers drinking diet pop and/or energy drinks. How can we effectively educate teenagers and their parents to make informed decisions?

Jennifer Turner, RDH

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eenagers today are mesmerized by the glitz, glamour and hype promised in the onslaught of advertising found in magazines, print ads, radio, television and now online in forums as Facebook and other social media sites. How can we educate society that has become accustomed to supersizing our orders to not choose the largest size of energy drinks or the 710 ml of diet soda pops?

Many teenagers consume these drinks without knowing how it can affect their body.

We need to educate them by explaining the consequences of consuming these beverages: • Increased Heart Rate • Changed or Altered Moods • Nervousness • Dehydration • Restlessness • Difficulty sleeping

• • • • • •

Headaches Overspending Addiction Irritability Nausea Blood Pressure Variances

The new predictor for risky or unusual behaviour amongst teenagers is the energy drink. Energy drinks are served cold, which can quench our thirst, but the packaging in the last few years has doubled in size allowing teenagers to consume larger amounts of drinks and more quickly than a hot beverage.

Teachers are having a difficult time controlling teenagers in their classrooms due to inappropriate behaviour associated with energy drinks. The high caffeine levels associated with diet soda and in energy drinks causes the teenager to lose his ability to focus on routine tasks at school. The caffeine levels in energy drinks are reported as almost double the amount in a regular can of cola. Caffeine

stimulates the central nervous system giving the body a false sense of alertness. Once the caffeine wears off the teenager will hit a low, lethargic state of mind and that is why many teenagers drink these beverages throughout the day.

Teenagers are using the energy drinks as a natural high to boost their energy levels and stay awake to study or to stay up late at night. Diet pop consumption is on the rise amongst young women as they are looking at the diet soda as calorie free and it tastes better than water.

As dental professionals we must educate society on dental caries. Caries form when the bacteria in the oral cavity interacts with a high sugar consumption product that ultimately leads to decay. It is a well known fact that too much sugar affects dental health and body weight.

The seriousness of tooth erosion is far greater than decay and these beverages are contributors. Erosion can affect all the teeth at once, as the acidic levels with these fizzy drinks are high throughout the entire oral cavity, therefore, it is best to drink these types of drinks using a straw.

As dental professionals we need to stay current on the best products available to use and recommend them to our clients to prevent caries, hypersensitivity, erosion and overall health prevention and promotion.

We need to push forward past the fancy packaging, exciting commercials and facebook messages to show the long term effects of overindulgence with the beverages of today’s teenager.

About the Author

Jennifer Turner is a Professor of Dental Hygiene at Niagara College, a clinical evaluator for the College of Dental Hygienists of Ontario, an item writer for the National Dental Hygiene Certification Board and a consultant and speaker for RDH Connection. She continues to work in general and periodontal practices and is considered a highly skilled hands-on clinical coach within the profession of dental hygiene.

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Practice Gems Dry Angle for HVE High volume evacuation complimented by the use of a largebore beveled evacuation device is the superior choice for aerosol reduction during aerosol producing procedures (high speed handpiece, ultrasonics, air polishing, three way syringe use). The use of a high-volume evacuator, or HVE, has been shown to reduce the contamination arising from the operative site by more than 90 percent.1-4 Low volume evacuation (or saliva ejector) options are the inferior choice.

PDC Products & Courses Friday, September 16, 2011 - TIASC presents: Lifecycle Game Plan Business Panel

This Seminar is Most Appropriate For: • People 5 to 10 years before retirement • Those in a challenging or failed transition • Principals of Larger Practices • Principals of Specialist Practices.

As a single clinician, using HVE independently can be challenging as the device must be also used to retract soft tissue and this often produces unwanted evacuation of the tissue itself. This is specifically problematic when retracting the cheek. For improved control, try inserting a dry angle inside the cheek. This will create a platform in which the tip of the HVE device can be rested on and will prevent soft tissue entry into the bevel of the HVE.

References 1.

Bentley CD, Burkhart NW, Crawford JJ. Evaluating spatter and aerosol contamination during dental procedures. JADA 1994;125: 579-84.

2. Harrel SK, Barnes JB, Rivera-Hidalgo F. Reduction of aerosols produced by ultrasonic scalers. J Periodontol 1996;67(1):28-32.

3. Jacks ME. A laboratory comparison of evacuation devices on aerosol reduction. J Dent Hyg 2002;76(3):202-6.

4. Klyn SL, Cummings DE, Richardson BW, Davis RD. Reduction of bacteriacontaining spray produced during ultrasonic scaling. Gen Dent 2001;49(6): 648-52.

Seminar participants will leave with a clear picture of the transition steps they need to take to retire with a lifestyle equal to, or better than their current lifestyle. Those in attendance will leave with a package that assists in outlining important numbers - such as how much they can spend today without compromising their retirement goals. Our Lifecycle Advisory Group will show you how to calculate your tax free pension, as well as covering major topics such as Growth Strategy, Tax Efficient Structures, Tax Efficient Investments, Tax Efficient Extractions and Legal Preparation to minimize your stress and costs.

Those in attendance will participate in a Transition prep quiz – which will serve as a guide for dentists planning transition - now or in the future. Transition discussions on growth strategies to implement as a segment of anyone’s detailed transition plan. Key strategies will be given during this seminar to implement in your offices. In addition, you will learn how to prepare for the legal transaction to minimize your costs and stress with our preparation checklist.

Premier® Enamel Pro® Varnish Clear Enamel Pro® Varnish Clear meets the need for patient satisfaction.

Independent testing demonstrated Enamel Pro Varnish with ACP technology delivered 4x more fluoride uptake into the enamel than the leading brand transparent varnish.1 ACP has been shown to remineralize enamel and dentin.2 Give patients the clear benefits of using Enamel Pro Varnish. For more information, visit www.premusa.com.

1 2 Data on file.

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PDC Products & Courses VOCO - GrandioSO VOCO America, Inc., the leaders in nano-technology introduces GrandioSO. GrandioSO is an 89% filled universal nano-hybrid composite that combines a tooth-like modulus with low shrinkage and excellent polishability. The material also boasts excellent esthetics, is non-sticky and an extended working time under ambient light. With its “intelligent shade” system it will meet all your everyday needs. The material is available in syringes or caps.

For more information, call 888-658-2584, email info@voco.com, or visit www.vocoamerica.com.

3M ESPE introduces Clinpro 5000 3M ESPE introduces Clinpro 5000 1.1% Sodium Fluoride Anti-Cavity Toothpaste.

Clinpro 5000 1.1% Sodium Fluoride Anti-Cavity Toothpaste is indicated for the prevention and control of tooth decay. This advanced formula contains 5000 ppm fluoride and an innovative Tri-Calcium Phosphate ingredient.

Clinpro 5000 Anti-Cavity Toothpaste: • • •

Strengthens teeth better than leading brands Reverses white spots better than leading brands Delivers more fluoride to the tooth

For more information please call 1-888-363-3685.

Ultradent - Ultrapro Tx Handpiece Weighing just 2.1oz, the Ultrapro Tx handpiece is not only lightweight and comfortable to operate, it also swivels 360°allowing for full and easy maneuverability. The unit comes with detachable nose cones to ensure an aseptic environment and allow for easy cleaning. The Ultrapro Tx has an internal resistance motor with soft start to prevent splatter, and its high torque operation efficiently removes tough stains. The 5:1 reduction motor has a working output of 3,000 to 3,500 RPM at variable working pressure of 35-45psi and provides smooth, vibration-free performance. The unit also features lube-free, low maintenance bearings. For more information, contact Clinical Research Dental at 1-800-265-3444.

Cavitron® Focused Spray slimLINE 1000 Insert To dental professionals who want better ultrasonic access to interproximal and subgingival areas and appreciate the line-angle adaptation of DENTSPLY’S Cavitron® 1000 design instruments, the FSI® SLI® 1000 offers improved access and familiar adaptation so you can efficiently remove deposits while maintaining patient comfort.

This is because FSI® SLI® 1000 combines the bend profile and coined edge of the FSI® 1000 design with the slim tip and focused spray of a Slimline®. For more information, call 1-800-263-1437 or visit www.dentsply.ca

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ntinuing Education Finder SEPTEMBER 2011

16 16 20 21 23 27 30

Cavitron Ultrasonics TIASC Lifecycle Game Plan Business Panel TIASC Medical Emergencies in the Dental Office Contemporary Ultrasonics Instrumentation: A Visual Presentation Case Based Approaches to Ultrasonic Instrumentation Dani Botbyl Dentsply "Ultrasonics: Hands on" Cavitron Ultrasonics

www.conedgroup.ca www.torontoimplantstudyclub.com www.torontoimplantstudyclub.com www.murrayarlin.com www.rdhu.ca www.murrayarlin.com www.conedgroup.ca

OCTOBER 2011

16 14 & 15 18 21 22 25 28 & 29

www.torontoimplantstudyclub.com www.internationaldentalcongress.com www.rdhu.ca www.torontoimplantstudyclub.com

29

TIASC Real Life, Real Materials, Real Dentistry International Dental Congress (multiple speakers and topics) Assessing Anesthetic Options for Non Surgical Periodontal Therapy TIASC Nobel (Dr. C. Goodacre) and Astra (Dr. L. Cooper) "Update on Dental Implants" Ultrasonics/Oraqix TIASC The Cost Factor of Implant Dentistry TIASC Implant Placement: Hands On: A Two Day Surgical Skills Workshop Featuring Live Surgical Demonstration Women in Dentistry Symposium

NOVEMBER 2011

2 4 7 8 10 18 & 19 25 29

TIASC Keep More of What You Earn TIASC Implant Dentistry Panel "Compliance" Philips Jo Anne Jones TIASC What’s New in Aesthetic Dentistry!

A Unique Workshop: Achieving Clinical Confidence with Ultrasonic and Airpolishing Dr. Arlin's "Basic and Advanced Periodontics" TIASC Direct Tooth Coloured Restorations TIASC Implant Innovations: Past, Present and Future

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DECEMBER 2011

1 9

TIASC TIASC Mini Clinics "Nobel Biocare Dental Implants" with Mavis Hunter

www.torontoimplantstudyclub.com www.murrayarlin.com

MARCH 2012

23 &24

11th Annual Weekend of Learning and Leisure White Oaks Conference Resort, Niagara on the Lake, ON

carolynroseconsulting.com

www.torontoimplantstudyclub.com www.torontoimplantstudyclub.com www.womenindentistrysymposium.com

adlink 3M ESPE Acmedent Dentsply Canada Micrylium Schill Dental Inc. Voco WiDS

www.3MESPE.ca www.acmedent.com www.dentsply.ca www.micrylium.com www.schilldental.net www.voco.com www.womenindentistrysymposium.com

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1.888.363.3685 1.888.688.6555 1.800.263.1437 1.416.667.0071 1.519.658.6060 1.888.658.2584 1.905.258.0363

9 2 5•7 23 16 24 14 • 15

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