February 2009, Volume 75, Issue 1

Transcription

JCDA
JOURNAL OF THE CANADIAN DENTAL ASSOCIATION
www.cda-adc.ca/jcda
R09961
Dr. Peter Cooney
Canada’s Chief Dental Officer
PM40064661
February 2009, Vol. 75, No. 1
Past and Future Activities
of his Office p. 29
JCDA • www.cda-adc.ca/jcda • February 2009, Vol. 75, No. 1 •
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February 2009, Vol. 75, No. 1
Publisher
Canadian Dental Association
Mission Statement
Editor-In-Chief
Dr. John P. O’Keefe
The Canadian Dental Association is the national voice for dentistry, dedicated to
Writer/Editor
Sean McNamara
optimal oral health, an essential component of general health.
the advancement and leadership of a unified profession and to the promotion of
Assistant Editor
Natalie Blais
a s s o c i at e e d i t o r s
Coordinator, French
Translation
Natalie Ouellette
Dr. Michael J. Casas
Dr. Anne Charbonneau
Dr. Ian R. Matthew
Dr. Mary E. McNally
Coordinator, Publications
Rachel Galipeau
Writer, Electronic Media
Emilie Adams
Manager, Design & Production
Barry Sabourin
Graphic Designer
Janet Cadeau-Simpson
All statements of opinion and
supposed fact are published on
the authority of the author who
submits them and do not neces
sarily express the views of the
Canadian Dental Association. The
editor reserves the right to edit
all copy submitted to the JCDA.
Publication of an advertisement
does not necessarily imply that
the Canadian Dental Association
agrees with or supports the claims
therein.
Call CDA for information and
assistance toll-free (Canada) at:
1-800-267-6354; outside Canada:
(613) 523-1770
CDA fax: (613) 523-7736
CDA email: [email protected]
Website: www.cda-adc.ca
© Canadian Dental Association 2009
E d i t o r i a l c o n s u lt a n t s
Dr. James L. Armstrong
Dr. Manal Awad
Dr. Catalena Birek
Dr. Gary A. Clark
Dr. Jeff Coil
Dr. Pierre C. Desautels
Dr. Terry Donovan
Dr. Robert V. Elia
Dr. Joel B. Epstein
Dr. Ian M. Furst
Dr. Daniel Haas
Dr. Felicity Hardwick
Dr. Kathy Russell
Dr. George K.B. Sándor
Dr. Benoit Soucy
Dr. Susan Sutherland
Dr. David J. Sweet
Dr. Gordon W. Thompson
Dr. David W. Tyler
Dr. Margaret Webb
Dr. J. Jeff Williams
Dr. James R. Yacyshyn
CDA B o a r d o f D i r e c t o r s
President
Dr. Deborah Stymiest
Dr. Michael Brown
Dr. Robert MacGregor
Dr. Peter Doig
Dr. Jack Scott
President-Elect
Dr. Don Friedlander
Dr. Steve Goren
Dr. Lloyd Skuba
Dr. Colin Jack
Dr. Robert Sutherland
Vice-President
Dr. Ronald G. Smith
Dr. Gordon Johnson
Dr. Grahame Usher
Dr. Gary MacDonald
Dr. David Zaparinuk
Cover photo: FDI World Dental Federation
The Journal of the Canadian Dental Association is published in both official languages —
except scientific articles, which are published in the language in which they are received.
Readers may request JCDA in the language of their choice.
T he Journal of the Canadian Dental Association is published 10 times per year (July/
August and December/January combined) by the Canadian Dental Association.
Copyright 1982 by the Canadian Dental Association. Publications Mail Agreement No.
40064661. PAP Registration No. 09961. Return undeliverable Canadian addresses to:
Dr. Robert J. Hawkins
Dr. Asbjørn Jokstad
Dr. Richard Komorowski
Dr. Ernest W. Lam
Dr. Gilles Lavigne
Dr. James L. Leake
Dr. William H. Liebenberg
Dr. Kevin E. Lung
Dr. Debora C. Matthews
Dr. David S. Precious
Dr. Richard B. Price
Dr. N. Dorin Ruse
Canadian Dental Association at 1815 Alta Vista Drive, Ottawa, ON K1G 3Y6. Postage
paid at Ottawa, Ont. Subscriptions are for 10 issues, conforming with the calendar
year. All 2009 subscriptions are payable in advance in Canadian funds. In Canada — $108
($102.85 + GST, #R106845209); United States — $142; all other — $237. Notice of change
of address should be received before the 10th of the month to become effective the
following month. Member: American Association of Dental Editors and Canadian
Circulations Audit Board.
ISSN 0709 8936 Printed in Canada
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contents
JCDA
J o u r n a l o f t h e C a n a d i a n D e n ta l A s s o c i at i o n
Columns & Departments
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
The Spirit of Our Profession
President’s Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
The Inspiration to Volunteer
Letters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
A Salute to Our Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
News & Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
FDI Policy Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
29
CDSPI Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Getting Home & Auto Insurance That’s Right for You
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CREATIVE
f7722 PRODUCTION
The JCDA Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
CLIENT: P&G
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You Ask, We Answer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Evidence-based Dentistry: Part 1. An Overview
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ARTIST: Danny
ARTIST: SP Chief Dental Officer
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Classified Ads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
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Advertisers’
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
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Debate & Opinion
Charging for Missed Appointments ............................................................. 33
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creative in research
contents
professional Issues
Infectious Dental Diseases in Patients with Coronary Artery Disease:
An Orthopantomographic Case–Control Study..........................................35
Kyosti Oikarinen, Mohammad Zubaid, Lukman Thalib, Kari Soikkonen, Wafa Rashed, Tryggve Lie
Applied Research
Dental Burs and Endodontic Files:
Are Routine Sterilization Procedures Effective?.........................................39
Archie Morrison, Susan Conrod
Clinical Practice
43
Dental Surgery for Patients on Anticoagulant Therapy
with Warfarin: A Systematic Review and Meta-analysis.......................... 41
Adeela Nematullah, Abdullah Alabousi, Nick Blanas, James D. Douketis, Susan E. Sutherland
Oral Health Care for the Pregnant Patient...................................................43
James A. Giglio, Susan M. Lanni, Daniel M. Laskin, Nancy W. Giglio
The Changing Field of Temporomandibular Disorders:
What Dentists Need to Know...........................................................................49
Gary D. Klasser, Charles S. Greene
Dental Pulp Neurophysiology: Part 1. Clinical and Diagnostic
Implications.......................................................................................................... 55
Ashraf Abd-Elmeguid, Donald C. Yu
“We acknowledge the financial
support of the Government of
Canada through the Publications
Assistance Program towards our
mailing costs.”
All matters pertaining to JCDA should
be directed to: Editor-in-chief,
Journal of the Canadian Dental Association,
1815 Alta Vista Drive, Ottawa, ON K1G 3Y6
• Email: [email protected]
• Toll-free: 1-800-267-6354
• Tel.: (613) 523-1770
• Fax: (613) 523-7736
Tell us what you think!
Complete the Dental Industry Association of Canada
survey polybagged with this edition of JCDA.
All matters pertaining to classified advertising
should be directed to: Mr. John Reid,
c/o Keith Communications Inc.,
104-1599 Hurontario St.,
Mississauga, ON L5G 4S1
• Toll-free: 1-800-661-5004, ext. 23
• Tel.: (905) 278-6700
• Fax: (905) 278-4850
All matters pertaining to display advertising
should be directed to: Mr. Peter Greenhough,
c/o Keith Communications Inc.,
104-1599 Hurontario St.,
Mississauga, ON L5G 4S1
• Toll-free: 1-800-661-5004, ext. 18
• Tel.: (905) 278-6700
• Fax: (905) 278-4850
Publication of an advertisement does not necessarily imply that the Canadian Dental Association agrees with or supports the claims therein.
Furthermore, CDA is not responsible for typographical errors, grammatical errors, misspelled words or syntax that is unclear, or for errors in translations.
Together, guiding the way to long-term oral health.
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© 2009 P&G
7572NOV1E
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Editorial
The Spirit of
Our Profession
Dr. John P. O’Keefe
“
In the coming
year, I would like
to expand the
“community of active
engagement” of
JCDA by attracting
new readers,
”
authors, reviewers
and advertisers.
I
n this issue, I salute the 100 colleagues who
reviewed manuscripts for JCDA in 2008. Some
reviewed just one paper, while others evaluated considerably more. Whatever the number,
they all gladly gave of their time and expertise
without receiving any direct compensation for
their efforts. Knowing that these reviewers are
busy people, I always approach them gingerly
when I ask them to volunteer their time. Yet
I am always amazed by the selfless generosity
they display. Let me give you one example of the
outstanding professionalism of our reviewers.
At the end of last year, one of our regular
reviewers sent me his usual comprehensive comments and constructive suggestions about a
manuscript. He also included an apology, saying
that his judgment might not be up to its usual
standard as one of his parents had passed away
the previous week. He added that because he had
committed to reviewing the paper by a certain
date, he felt honour-bound to meet the deadline.
I cannot tell you how touched I was by this revelation and how privileged I feel to work with
such dedicated colleagues.
The contribution of this reviewer toward
the advancement of our profession captures the
spirit of JCDA perfectly for me. As JCDA enters
its 75th year, I am reminded that this spirit has
a long and distinguished history. I recently went
back and read the English and French editorials
from JCDA’s first issue, published in 1935. They
spoke of the publication as a project that was
years in the making, but which was seen as crucial to the development of a proud knowledgebased profession that could stand shoulder to
shoulder with our international confreres and
other senior professions in Canada. Pledging
to fight for the “highest and noblest principles,
thus representing the best traditions of Canadian
dentistry,” the sentiment evoked in these initial
columns is as true today as it was then.
The current JCDA is also devoted to advancing Canadian dentistry as a knowledge-based
profession and projecting the image of dentists
as a group of ethical people dedicated to improving the oral health of all Canadians. The
discourse in today’s JCDA is clearly different
from that found in some of the commercial publications that land on your desk in increasing
numbers. The loudest messages in these publications often relate to increasing your profitability
and efficiency as a businessperson.
While dental practice is inevitably a commercial enterprise, the discourse of business can
never be allowed to dominate our publications.
If business becomes its primary focus, dentistry can expect to be regulated in the same
manner as other modern industries. Our justifiable claim to a special status in society rests
on other attributes, namely science and ethics,
which must, in my view, always be reflected in
the pages of JCDA.
A spirit of committed volunteerism has carried JCDA through to its 75th birthday and this
same spirit will be required if we are to reach a
century of service to the profession. JCDA operates in an environment that is rapidly changing,
at a variety of levels: the composition of the
profession is different, dental associations are
evolving, sources of information are plentiful
and increasingly varied, information consumption patterns are shifting. Combined with rising
production costs, these factors all make the publication of a scientific journal quite a challenge.
Together, I am certain that we can find opportunity in these challenges. In the coming
year, I would like to expand the “community
of active engagement” of JCDA by attracting
new readers, authors, reviewers and advertisers.
There is so much energy and goodwill in our
sector that can be harnessed for the good of
JCDA and our profession.
You can contribute immeasurably to our national dental journal and our profession by volunteering your ideas on the look and content of
our publication. You can enter the spirit of the
profession through JCDA, our one true national
meeting place dedicated to the benefit of all dentists in Canada. I look forward to continuing an
active dialogue with you.
John O’Keefe
1-800-267-6354, ext. 2297
[email protected]
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PRe s i d e n t ’ s
Column
The Inspiration to
Volunteer
Dr. Deborah Stymiest
“
I have come
to believe that the
acts of individuals
truly do matter,
and that one by
”
one, we can make
a difference.
W
ith the new year upon us and resolutions still top of mind, I would like to
share with you one special commitment
that I have made for 2009. In February, I will
be travelling to Honduras as part of a volunteer
health care team that will provide medical and
dental care to the local population. Volunteering
my services in a developing country is something that I have always wanted to do, and after
25 years of practising dentistry, I now feel confident enough to follow through on this goal.
What inspired me to go on this mission?
Last spring, a first-year university student approached me with a proposal. The student
had formed a local chapter of Global Medical
Brigades (GMB) at her university. GMB describes itself as a secular, international network
of university clubs and volunteer organizations
that provide communities in developing nations
with sustainable health care solutions.
When asked if I might be interested in joining
an upcoming GMB mission, I thanked the student and explained that having just started my
term as CDA president, I felt I would be too busy
in the next 12 months for such an endeavour.
Not wanting to rule it out completely, I asked
her to keep me informed about the project’s
progress.
Later in the year, I received an email with details about the local GMB chapter’s new website
and its first planning and recruitment meeting.
Over 70 students attended this meeting, and
through a fair and considerate process, 30 were
selected for this year’s mission while the others
were placed on a list for the 2010 brigade.
By mid-fall, the student reported that a team
of doctors, dentists and nurses had been formed.
Health care professionals from Canada, Colorado
and Jamaica were eager to join the team travelling to Honduras. I was impressed as I read more
about the team member’s various specialties and
level of expertise and especially that a colleague
from British Columbia, Dr. Awdesh Chandra,
would be a dentist on the brigade.
There was still the outstanding issue of
securing medical and dental supplies. Through
written correspondence, phone calls and persistence, the group of students successfully
acquired some $30,000 in supplies from one of
Canada’s largest drug companies. This includes
3 dental kits and 6 medical kits — enough to
provide ethical and effective treatment for hundreds of Honduran citizens.
So, when my phone rang again in November
and that same university student asked, “Now
will you come, Mom?”, I just had to say yes.
That’s right, my daughter Laura, co-president
of GMB at Mount Allison University, is my inspiration to volunteer. She is part of the current generation of students making a difference
in the world; young people with such strong
convictions and drive that they are simply
unstoppable.
While I am looking forward to providing preventive and urgent dental care to the Honduran
villagers, I fully expect to witness first-hand the
devastating effect of poverty on dental health.
Many colleagues have shared their experiences
about international volunteering and have offered advice to help me prepare for the journey.
I am sure that like those who have gone before
me, I will be deeply affected by the experience.
I admit to having moments of self-doubt,
wondering what contribution one dentist can
possibly make. After seeing the organizational
work performed by the GMB students, and
sharing in their enthusiasm and exuberance, I
have come to believe that the acts of individuals
truly do matter, and that one by one, we can
make a difference.
I hope that sharing my own inspiration to
volunteer might encourage you to also consider
volunteering, in whatever form, and perhaps instill a sense of hope and confidence in the young
people who will form the dental profession of
the future. I conclude with a promise to report
back on the mission and leave you with some
words from Mother Teresa that have provided
me with added inspiration: “We ourselves feel
that what we are doing is just a drop in the
ocean. But the ocean would be less because of
that missing drop.”
Deborah Stymiest, BSc, DDS
[email protected]
11
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09-55 (1) 12/08
lEttErs
Suggestive Advertisement
Raises Ire of Dentist
I
want to draw Canadian dentists’
attention to the all-time low in
marketing that Discus Dental has
sunk to in promoting its “Zoom!”
whitening system. The marketing
campaign, titled “The Naked Truth,”
was displayed prominently at the
2008 American Dental Association
convention in San Antonio, Texas,
and is now making the rounds in
non-scientific dental periodicals. It
features a naked woman holding up
2 signs. The first sign reads “Better
results with Zoom! lamp” and covers
her breasts. The second features statistics about the supposed efficacy of
the product’s proprietary lamp and
is strategically held by the model to
cover her upper legs and bikini area.
Discus Dental’s Canadian branch
claimed to be unaware of this marketing campaign when contacted by
phone. Regardless of the genesis of
this totally unprofessional venture,
Canadian dentists should consider
the images associated with products and services they may choose
to offer. For my practice, the decision to sever any ties with marketing
such as this was an easy one.
We need to keep the focus of
our profession on health care. I urge
other dentists offended by this marketing to contact Discus Dental. In
this age of changing roles, we do
not need dentists to be thought
of as “cosmeticians with fi rst-aid
training.” The support (or silence)
of the dental community regarding
advertising campaigns such as this
one heightens that risk.
Dr. Jonathan Skuba
Edmonton, Alberta
Commercializationofthe
DentalProfession
I
would like to commend Dr. Lang
for his comments on the commer-
cialization of our profession in his
letter published in the November
2008 issue of JCDA.1 I see that he
keeps well informed of emerging
issues, which is a result of his expertise within the profession.
I would like to let your readers
know about a seminar that will be
held on May 25 during the upcoming
Journées dentaires internationales
du Québec. One of the issues to be
discussed will be professionalism
as perceived by dentists and ways
to take corrective action and gain
new appreciation of our profession’s
primary purpose — oral health
based on the patient’s needs.
•
Dr. Hubert R. LaBelle
Montreal, Quebec
Reference
1. Lang M. Increased commercialization of our
profession [Letters]. J Can Dent Assoc 2008;
74(9):764.
•
DentistryinCanada:
IsHistoryRepeatingItself?
A
s the leaders of the national and
provincial dental associations
prepared to attend the CDA General
Assembly in Ottawa in November,
I reflected back on 25 years of attending these meetings and wondered whether or not we were getting
anywhere. I decided to perform
a short literature search related to
the efforts and deliberations of our
former colleagues as they worked
for the betterment of the profession in their time. Three quotations
struck me, spread over 100 years
and reflecting a disturbing similarity.
They made me wonder if we may be
repeating history.
Here are the excerpts in question:
• “I trust that because our present
system of licensing is good, it
will not prevent us from seeing
that a common standard for
the whole country is the best.
Certain protection to the profession is simply an unavoidable
concomitant; but on the other
hand it is apparent to any reasonable man that a dentist who
is fit to practise under license
in one part of Canada, is, morally speaking, fit to practise in
any part of Canada.” — 1902,
Dr. F.A. Stevenson, CDA
president.
“May we appeal again to every
dentist in Canada to support
enthusiastically our National
Dental Organization, and thus
strengthen the only body capable
of dealing with problems so vital
not only to the interests of the
dentist but also to those of the
general public.” — 1939, CDA
Journal.
“If we fail to make our services
available or place them beyond reach of the public, then
our status as a profession and
our legal power of self-regulation will quickly disappear.” —
1963, Dr. W.G. McIntosh, CDA
past-president.
On the positive side, the fact that
these former trailblazers in our profession felt that these topics were of
great importance gives credibility to
the reality that they are still topof-mind concerns with the current
generation of dentists. The reasons
CDA is still of major importance and
needed by all dentists in Canada are
the same as when the organization
was formed. The current leaders are
like-minded and aware that it may
seem repetitive to evaluate and try
to solve the same problems year after
year. The principles we should adhere
to haven’t changed and the threats to
our profession are ongoing. The fact
that these threats keep coming up
really shouldn’t surprise anyone; it’s
JCDA•www.cda-adc.ca/jcda • February 2009, Vol. 75, No. 1 •
–––
the answers that seem to be hard
to come by. Be assured, we’re still
looking after all these years because
maybe there is no final answer, just
similar responses tailored to the
current times.
Dr. Brian Barrett
Executive director
Dental Association of Prince Edward Island
Creating Partnerships to Help
Patients with Cleft Palate
I
congratulate Dr. O’Keefe on his
editorial1 in the November issue of
JCDA and would like to comment on
what I see as an almost insurmountable problem related to aging patients
with cleft palate and those with other
similar anomalies. As a prosthodontist long associated with maxillofacial patients, I have found that
the re-treatment of these patients is
the most challenging of all. Unless
the patient is totally edentulous, an
experienced team of specialists is required to both plan and execute care
in most cases. While these teams
certainly do exist, they are almost
always associated with university
dental schools and their hospitals.
There was a time when complex care
could be rendered under the cover
of a “great teaching case,” where reduced cost or actual pro bono care
could be provided. Given the financial restrictions within U.S. dental
schools that I am familiar with,
these teaching cases have long since
disappeared. This leaves the patient
with little choice but to search for
funding for treatment that often involves complex combinations of fixed
and removable prosthetics, running
to tens of thousands of dollars.
As I see it, the problem is twofold. First, trying to develop funding
sources for these special patients
through some national body, a task
that I am afraid will be more difficult than we could ever anticipate.
Second, and an area in which we
have great potential for success, is
mobilizing our knowledge and experience so that clinicians in both
14
Letters
–––
the United States and Canada can
use the latest communication technologies (such as the Internet) to
create specialist treatment teams.
These virtual teams could offer guidance in treatment planning and the
actual execution of care, effectively
removing geography as a barrier to
quality care.
Dr. James S. Brudvik
Professor emeritus in prosthodontics
University of Washington
Seattle, Washington
Reference
1. O’Keefe J. Breaking down the access issue
[Editorial]. J Can Dent Assoc 2008; 74(9):761.
Rapid Orthodontics Debate
and the Importance of
Professionalism
T
wo letters in the November issue
of JCDA prompted me to respond. The first, titled “Orthodontic
Myths,”1 offered bold extrapolations
based on one journal article that
cited 3 case studies.2 I would like to
attempt to debunk the myths about
the myths presented in this letter.
The author, who describes himself “as a general dentist who promotes ‘rapid orthodontics’ as a
conservative alternative to porcelain
veneers,”1 cited conclusions from the
journal article2 focusing on root resorption as the only parameter to
evaluate the outcome of orthodontic
tooth movement. The author did not
cite other content from the journal
article that says “researchers have
clearly shown that although considerable variation typically exists,
continuous forces tend to produce
more extensive root resorption than
intermittent forces.” 2 Similarly,
“resorption of the root apex after
tooth intrusion can be seen easily
on two-dimensional radiographs,
whereas the root resorption seen on
periapical radiographs after lateral
root movement is not as clearly visible.”2 Rapid orthodontic treatment
referred to in the letter is generally
the result of heavy lateral forces that
cause quick tooth movement that is
neither periodontally stable nor biologically sound.
I have been a dentist for 30 years
and was a general dentist for 10
years before I returned to graduate
training in both orthodontics and
periodontics. I now have the opportunity to perform periodontal
procedures on pre- and postorthodontic patients and I am
often surprised by the lack of tolerance of the periodontal tissues
(3-dimensionally) to orthodontic
forces. Efficient tooth movement is
the result of applying light forces to
a healthy periodontium, a phenomenon that is well supported in both
the orthodontic and periodontal
literature. Heavy continuous orthodontic forces potentially cause much
more damage than what can be read
from a radiograph. Overdevelopment
of arch form in rapid orthodontics
and the tipping of teeth off the alveolar support can have tremendous
periodontal ramifications during,
or most likely many years after, the
orthodontic treatment.
Wise case selection and treatment planning comes from specialty
training and a good knowledge of
the dental literature. The ultimate
goal is to provide the orthodontic
patient with a functional, esthetically pleasing and healthy dentition
and to minimize the risk of trading
a crowded dentition for one of periodontal and occlusal discord.
The second letter I wish to respond to is about the increased
commercialization of the dental
profession. 3 The author cites the
wisdom and professionalism displayed in columns by Dr. Deborah
Stymiest4 and Dr. Diane Legault, 5 in
which both express concerns about
the shift from oral health to oral esthetics. I found this letter refreshing
and was reassured that a message is
being sent, and hopefully heard, to
all of us who are fortunate enough
to call ourselves dentists. I hope we
continue to provide our patients
with the care that they need, care
–––
Letters
that should be based on the best
interests of our patients more than
the financial benefit of individual
providers.
Dr. Brian Rinehart
Fredericton, New Brunswick
References
1. Zuk M. Orthodontic myths [Letter]. J Can Dent
Assoc 2008; 74(9):764.
2. Kokich VG. Orthodontic and nonorthodontic
root resorption: their impact on clinical dental
practice. J Dent Educ 2008; 72(8):895–902.
3. Lang MR. Increased commercialization of
our profession [Letter]. J Can Dent Assoc 2008;
74(9):764.
4. Stymiest D. Back to basics [President’s
Column]. J Can Dent Assoc 2008; 74(6):483.
5. Legault D. President’s message. ODQ 2008;
45:291.
Battling Childhood Dental
Disease Requires Cooperation
O
ur CDA president’s message
about childhood caries1 serves
as a wake-up call. When viewed in
the context of Dr. O’Keefe’s editorial
about the crisis in access to care, 2 a
variation on the famous line from
Apollo 13 comes to mind: “Ottawa,
we have a problem.”
In a nation like Canada, adequate
dental care should be available to
all children and the focus should
be on prevention. In her column,
Dr. Stymiest echoes the findings
of the 2007 Calgary Conference on
Early Childhood Dental Disease, 3
namely that the oral health of children is too important to remain
the sole responsibility of the dental
profession. We cannot do it alone.
Too many children suffer from
caries before the parent ever thinks
of a dental check-up. We need the
eyes and ears of people who see
these children routinely — nurses,
physicians, social workers, daycare
operators, teachers and others. They
should know how to watch for the
risks, signs and symptoms of tooth
decay, and how to take steps to
combat it. Dr. Stymiest’s examples
of collaborative initiatives are perfect — let’s incorporate oral health
–––
into immunization and preschool
screening programs.
One result of the Calgary conference was a plan outlining the
next steps to reduce caries in children, which included developing a
nationwide children’s oral health
promotion initiative. To maximize
its efficiency and scope, the project
should come under the auspices
of an existing national organization dedicated to children’s health.
The idea requires seed money and
cooperative leadership from key
stakeholders, such as those identified at the Calgary conference. We
need to work upstream to facilitate
change at the universities and in the
training programs used in the many
disciplines that work with children.
As a leader in our profession,
CDA must continue to make childhood dental disease a priority. A
lot of work still needs to be done.
Dentistry is just one part of the village it takes to raise a child — with a
healthy smile.
Dr. Allan Narvey
Dr. Luke Shwart
Calgary, Alberta
References
1. Stymiest D. Spreading the message on childhood caries [President’s Column]. J Can Dent
Assoc 2008; 74(10):851.
2. O’Keefe J. Breaking down the access issue
[Editorial]. J Can Dent Assoc 2008; 74(9):761.
3. Early Childhood Caries Conference Planning
Committee. Partnering to reverse the trend: Early
Childhood Caries Conference Report, September
28–29, 2007, Calgary, Alberta. J Can Dent Assoc
2008; 73(10):897–900.
15
A Salute
to Our Reviewers
The peer review process is the cornerstone of JCDA. It ensures that the material presented in the publication
meets certain criteria of quality, accuracy and relevance to practice. In my opinion, the reviewers listed below are
the unsung heroes of JCDA. They are all very busy professionals, yet they cheerfully provide me with high-quality
advice with regard to the manuscripts they evaluate. They give their valuable time and expertise without monetary
compensation. I extend to them, on behalf of the Canadian dental profession, a profoundly felt thank you.
Dr. Paul Allison
Dr. Aurelio A. Alonso
Dr. Ajit Auluck
Dr. Manal Awad
Dr. Henry Barry
Dr. Izchak Barzilay
Dr. Bettina Basrani
Dr. Christophe Bedos
Dr. Catalena Birek
Dr. Veronica Bucur
Dr. Yvonne Buischi
Dr. Sharon Campbell
Dr. Michael J. Casas
Dr. David Clark
Dr. Gary A. Clark
Dr. Cameron M.L. Clokie
Dr. Jeffrey M. Coil
Dr. Darren Cox
Dr. John Curran
Dr. Tom Daley
Dr. Thuan Dao
Dr. Jed Davies
Dr. Terry Donovan
Dr. Robert V. Elia
Dr. Omar El-Mowafy
Dr. Jocelyne Feine
Dr. Stephen Ferrier
Dr. Timothy F. Foley
Dr. Helen Foster
Dr. Clive Friedman
Dr. Ian M. Furst
Dr. Seema Ganatra
Dr. Gino Gizzarelli
Dr. Wayne Halstrom
Dr. Alan G. Hannam
Dr. Felicity K. Hardwick
Dr. Robert J. Hawkins
Ms. Donna Hennyey
Dr. Ivonne Hernandez
Dr. Anthony Iacopino
Dr. Richard Jordan
Dr. David B. Kennedy
Dr. Martin Kinirons
Dr Bruce Kleeberger
Dr. Richard Komorowski
Dr. Jim Yuan Lai
Dr. Ernest W. Lam
Dr. Gilles J. Lavigne
Dr. William H. Liebenberg
Dr. Hardy Limeback
Dr. James P. Lund
Dr. Paul W. Major
Dr. Don Marianos
Dr. Ian Matthew
Dr. Debora C. Matthews
Dr. Randall D. Mazurat
Dr. Dorothy McComb
Dr. John McComb
Dr. Christopher McCulloch
Dr. W. Tim McGaw
Dr. Mary McNally
Dr. Bob Mecklenburg
Dr. Yukiko Nakano
Dr. Donald Nixdorf
Dr. Anne O’Connell
Dr. Garnet V. Packota
Dr. Athena Papadakis
Dr. Hiran Perinpanayagam
Dr. Ed Peters
Dr. Suzanne Philip
Dr. Catherine Poh
Dr. James L. Posluns
Dr. David S. Precious
Dr. Michael J. Racich
Dr. John D. Regan
Dr. Robert S. Roda
Dr. Morley Rubinoff
Dr. Lance Rucker
Dr. Frederick A. Rueggeberg
Dr. N. Dorin Ruse
Dr. Kathy Russell
Dr. George K.B. Sándor
Dr. Gildo Coelho Santos Jr.
Mr. Andrew Smyk
Dr. Benoit Soucy
Dr. Ken Sutherland
Dr. Susan E. Sutherland
Dr. Riitta Suuronen
Dr. Peter Taylor
Dr. Howard C. Tenenbaum
Dr. Norman Thie
Dr. J. Mark Thomason
Dr. Gordon Thompson
Dr. Kraig Vandewalle
Dr. Lesia Waschuk
Dr. Ian Watson
Dr. Margaret Webb
Dr. P. Michele Williams
Dr. Robert E. Wood
Dr. Donald C. Yu
If I have failed to recognize publicly the efforts of anyone who has reviewed manuscripts in the past year,
I apologize. I am always on the lookout for more help with reviewing manuscripts. If you would like to contribute to
the profession by reviewing English or French submissions, please don’t hesitate to contact me.
Dr. John O’Keefe, Editor-in-Chief
16
News
&
U pdate s
CDA Participates in New Tobacco Cessation Initiative
C
DA was invited to participate in the inaugural annual general meeting of the Canadian Action Network for the
Advancement, Dissemination and Adoption of Practice-Informed Tobacco Treatment (CAN-ADAPTT), held in
Toronto in November 2008.
CAN-ADAPTT is a practice-based research network that facilitates research and knowledge exchange between
front-line practitioners and health care providers and researchers working in the area of smoking cessation. Funded
by Health Canada, the group is encouraging a bottom-up approach that will ultimately produce smoking cessation
guidelines that are clinically relevant and readily usable by practitioners, who are in the best position to help people
quit smoking.
The network has identified a need to develop a system that will deliver the latest information, research findings
and tangible resources to health care providers who offer smoking cessation services in their practices. To ensure
that the tobacco cessation guidelines are effective, the group is exploring the use of a “wikiguideline” model (based
on the Wikipedia open content model) that will quickly evolve and adapt as new knowledge is incorporated.
With its participation at the inaugural meeting, CDA is now a member of the CAN-ADAPTT Advisory Committee.
CDA has a strong record in supporting tobacco control initiatives, most notably with its involvement with the
Canadian Coalition for Action on Tobacco (CCAT) — a coalition of national and provincial health agencies that work
together to reduce the consequences of tobacco use in Canada and around the world. CDA is a full-voting member
of CCAT and was chair of the coalition’s Advocacy Committee in 2008. a
CAN-ADAPTT is currently looking to recruit practitioners into its research
network, including dentists and oral health researchers. Those interested
in learning more about the group and its projects can visit www.can-adaptt.net.
T
Forum on Patient Safety
he Canadian Patient Safety Institute (CPSI) is presenting a forum on patient safety and
quality improvement in Toronto from April 28 to 30.
This forum is a learning opportunity for health care providers, educators and researchers. It
will focus on medication safety, infection prevention and control, and patient safety. The forum
will feature speakers who are recognized for their expertise in implementing and managing
strategies in patient safety and quality improvement.
Established in 2003, CPSI is an independent not-for-profit corporation that operates collaboratively with health professionals and organizations, regulatory bodies and governments to
build and advance a safer health care system for Canadians. CDA is currently a voting member
of CPSI. a
For more information on CPSI and the forum, visit:
www.patientsafetyinstitute.ca/news/canada_forum_2009.html.
17
––– News & Updates –––
Hamilton to Continue Water Fluoridation Program
I
n November 2008, the city council of Hamilton, Ontario, voted 9 to 7 in favour of continuing to fluoridate its municipal water supply, based on the recommendations of its public health department. The
narrow decision in Hamilton, a city of approximately 600,000 residents, was significant as the neighbouring Niagara region
recently terminated its fluoridation program. A similar result in Hamilton might have generated a momentum leading other
large municipalities to follow suit.
In a letter to the editor written for the Hamilton Spectator, Ontario Dental Association president Dr. Larry Levin declared,
“Our sincere thanks to the City of Hamilton for continuing with water fluoridation. Your leadership on this issue is to be
highly commended. The benefits of water fluoridation in community water supplies are many, and the evidence of its safety
is overwhelming. When national and international experts present convincing proof, it is important to pay attention, and we
congratulate you for doing so.”
Dr. Stephen Birch, a professor in the department of clinical epidemiology and biostatistics at McMaster University in
Hamilton, followed the city’s fluoridation debate closely. During public consultations on the issue, he found that many
ungrounded claims were put forward by anti-fluoridation groups, notably that fluoride is toxic and that there is a possible
link between fluoride and autism. After performing a literature search and consulting with international leaders in autism
research, toxicology and oral health, Dr. Birch found no evidence in the scientific literature that would support such dubious
arguments.
“Perhaps the case in favour of fluoridation needs to be made in more direct terms to the public and municipal representatives by providing estimates of the expected change in prevalence and severity of caries in the community, and the impact this
would have on child health and well-being,” notes Dr. Birch. “The broader community of fluoridation supporters can help by
emphasizing the impact of caries on children and their families in graphic terms, as members of the public are unlikely to be
convinced by scientific findings alone.”
The Hamilton city council requested that its public health department examine the costs of alternative programs for caries
prevention, such as recruiting additional providers or establishing mail-out programs to deliver toothbrushes and toothpaste.
However, the department’s report found that these methods would be more costly than renewing and upgrading the infrastructure of the city’s existing water fluoridation program.
Nearby, the Halton region plans to hold a vote on the future of its water fluoridation program in early 2009. a
Dentists interested in donating dental and medical resources and textbooks
(published within the past 10 years) can contact Books With Wings
(http://torontomeds.com/bookswithwings). These books will be sent
to Afghanistan to restock medical and dental libraries in need.
18
Multidisciplinary Needs of Adult Patients with Cleft Lip or Palate
A
study1 published in the Cleft Palate–Craniofacial Journal documented the benefits of specialist multidisciplinary cleft clinics that provide continuing care for adult patients with cleft lip or palate.
The researchers examined 145 patients of a multidisciplinary cleft clinic in Great Britain, ranging in age
from 15 to 70 years. The study showed that even younger adult patients continue to have a wide range of
problems relating to their cleft. Many patients required multiple interventions such as dental rehabilitation,
psychological assessments and support as well as speech assessment and therapy.
The authors’ felt that the planning of such complex surgical and nonsurgical care was greatly enhanced
through the coordination of the various specialties that a multidisciplinary clinic can provide. a
Reference
1. Chuo CB, Searle Y, Jeremy A, Richard BM, Sharp I, Slator R. The continuing multidisciplinary needs of adult patients with cleft lip and/or
palate. Cleft Palate Craniofac J 2008; 45(6):633–8.
Dr. Anderson is the director of the
Odette Cancer Centre’s craniofacial
prosthetic unit at the Sunnybrook
Health Sciences Centre in Toronto. He
is professor emeritus in the division
of prosthodontics at the University of
Toronto. JCDA sought Dr. Anderson’s
insights about this study when it was
published.
Commentary by James D. Anderson, BSc, DDS, MScD
Multidisciplinary regional centres devoted exclusively to the treatment of adults with cleft lip or palate have been operational in the United
Kingdom since 2000 (similar centres are not commonly found in other
countries). The article by Chuo and colleagues, which focuses on the
experience of one of these centres, is equally important for what it does
not report as for what it does. While the article is based on the patients
of this particular centre, it does not (and cannot) explore the needs of
pediatric patients who did not continue care in the adult centre, or of the
affected adults in the population who were never in the pediatric system.
While these people might not be patients because they have no perceived problem, they also might not
know about the service or feel that nothing can be done. Among patients who attend the adult service in this
study, a disproportionately large number of them have cleft lip, while patients with isolated cleft palate are
underrepresented. This finding, and other similar self-assessments, suggests that in addition to dental occlusion,
facial esthetics and speech issues motivate patients to seek treatment. Patients in the study had an average of
3 problems each, most commonly related to their facial appearance or speech.
Taken together, these data suggest that while dental practitioners are well positioned to manage the malocclusion, exploration of the facial and speech issues may reveal problems that lead to more referrals for necessary multidisciplinary treatment. Indeed, the authors point out that only a trivial number of patient referrals
to the centre originated from dental practitioners. Hopefully, articles such as this one will sensitize the dental
community to the value of a multidisciplinary service and the multidimensional nature of the problems facing
patients with cleft lip or palate. a
19
International Guidelines for Dentists Against Torture
A
n article1 in the December 2008 edition of the Journal of the American Dental Association provides an indepth examination of the development of an international declaration on the involvement of dental professionals in torture.
Members of the International Dental Ethics and Law Society (IDEALS), working in collaboration with the
FDI World Dental Federation, urged the international dental community to follow the lead of the World Medical
Association in developing an equivalent declaration on the involvement of dentists in hostile interrogation and
torture.
The IDEALS membership adopted a draft declaration during its 7th International Congress on Dental Law
and Ethics, held in Toronto in May 2007. FDI subsequently passed the Policy Statement on the Guidelines for
Dentists against Torture at the FDI Annual World Dental Congress held in Dubai, U.A.E., in October 2007. The
complete guidelines are reprinted below with permission of the FDI World Dental Federation. a
Reference
1. Speers RD, Brands WG, Nuzzolese E, Smith D, Swiss PB, van Woensel M, and other. Preventing dentists’ involvement in torture: the developmental history of a new international declaration. J Am Dent Assoc 2008; 139(12):1667–73.
FDI Policy Statement
Guidelines for Dentists against Torture
Adopted by the FDI General Assembly: 26th October 2007, Dubai
The FDI World Dental Federation supports and endorses the World Medical Association guidelines, from which this
statement has been adapted.
1. It is the privilege of the dentist to practise dentistry in the service of humanity, to preserve and restore oral health
without distinction as to persons, and to ease the dental suffering of his or her patients. The utmost respect for
human life is to be maintained even under threat. Without discrimination, all sick and injured shall be treated on the
basis of their clinical needs and dental resources available. No use is to be made of any medical or dental knowledge
contrary to the laws of humanity.
2. Whilst respecting generally acknowledged patients’ rights, dentists must have complete clinical independence in
deciding upon the care of persons for whom they are dentally responsible. The dentists’ primary role is to alleviate
the dental distress of their fellow human beings and no motive, whether personal, collective or political, shall prevail against this higher purpose.
3. The dentist shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman
or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or
guilty, and whatever the victim’s beliefs or motives, and in all situations, including armed conflict and civil strife.
4. Dentists shall not use nor allow to be used, as far as they can, medical or dental knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal, of those individuals.
5. The dentist shall not provide any premises, instruments, substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such
treatment.
6. Dentists shall not be present during any procedure during which torture or any other forms of cruel, inhuman or
degrading treatment is used or threatened and shall denounce any such request to attend.
7. When providing dental assistance to detainees or prisoners who are, or could later be, under interrogation, dentists
must ensure the confidentiality of all personal medical and dental information of these individuals.
8. A dentist shall keep proper dental records and shall not alter these records or otherwise suppress information relevant to the patient’s dental condition and treatment, if such alteration is to facilitate the practice of torture or other
forms of cruel, inhuman or degrading procedures or to conceal such acts from public scrutiny and retribution.
20
9. Where authorities are participating in torture or other forms of cruel, inhuman or degrading treatment, a dentist
must denounce and is to resist these authorities to the fullest extent that prudence will permit. A breach of the
Geneva Conventions shall in any suspected case be reported by the dentist to the relevant authorities; the report
should safeguard the confidentiality of the victim to help protect the victim from further such harm.
10. The FDI World Dental Federation will support, and should encourage the international community, the national
dental associations and fellow dentists to support, dentists and their families in the face of threats or reprisals
resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment.
New Resource for Nurses Delivering Oral Health Care
T
he Registered Nurses’ Association of Ontario (RNAO) has produced a best practice guideline document designed to sup-
RNAO Recommendations from Oral
Health: Nursing Assessment and
Interventions.
port nurses who provide oral hygiene care to adults with special
Category 1: Practice
needs.
• Nurses should use a standardized
valid and reliable oral assessment
tool to perform their initial and ongoing oral assessment.
• Nurses should provide, supervise,
remind or cue oral care for clients
at least twice daily, on a routine
basis. This includes clients who have
diminished health status or have a
decreased level of consciousness.
Oral Health: Nursing Assessment and Interventions is a comprehensive document that offers a series of practical recommendations based on the best available evidence. It is intended for
nurses who work in a range of practice settings, including longterm care facilities and community health centres. The guidelines
broadly define clients with special needs as encompassing the
medically compromised, intellectually challenged, physically challenged, or frail elderly who may be dependent on caregivers for
help with daily living.
The document examines the risk factors associated with poor
oral hygiene, the current attitudes and beliefs of nurses providing
oral hygiene care and the optimal oral hygiene interventions for
oral health in vulnerable populations.
The recommendations are divided into 3 main categories:
practice, education, and organization and policy. For each of the
21 guidelines, there is an accompanying discussion of the level of
evidence along with comments and testimonials from clients who
interact with the nurses.
One feature that makes the document so practical are its
resources and tools. There are examples of care plans, oral health
Category 2: Education
• Nurses who provide oral hygiene
care to their clients, either directly
or indirectly, must participate in and
complete appropriate oral hygiene
education and training.
Category 3: Organization and Policy
• Heath care organizations should develop oral health care policies and
programs that recognize that the
components of oral health assessment, oral hygiene care and treatment are integral to quality client
care.
assessment tools, a list of medications that may affect oral health
and toothbrushing techniques. For this last category, visual aids
demonstrate proper techniques for the provision of oral care. a
The complete RNAO guideline document, along
with a summary of the recommendations,
can be found at: www.rnao.org/Page.
asp?PageID=122&ContentID=1567.
21
oBituariEs
Balmer, Dr. John E.: Dr. Balmer of Vancouver, B.C., passed
away on October 10, 2008. He graduated from the University
of Toronto in 1956.
Delaney, Dr. Kevin P.: A 1974 graduate of Dalhousie University,
Dr. Delaney of Bay Roberts, Newfoundland, passed away on
December 2, 2008.
Galante, Dr. Victor A.: A 1965 graduate of the University of
Toronto, Dr. Galante of Hamilton, Ontario, passed away on
November 24, 2008.
Hinkelman, Dr. Kenneth W.: Dr. Hinkelman of Edmonton,
Alberta, passed away on August 7, 2008. A 1965 graduate of the
University of Pittsburgh, Dr. Hinkelman received Honourary
Membership in the Alberta Dental Association and College in
2007.
Miller, Dr. James A.: Dr. Miller of St. John’s, Newfoundland,
passed away on September 10, 2008. He graduated from
Dalhousie University in 1960.
Reddam, Dr. Peter J.: Dr. Reddam of Windsor, Ontario, passed
away on September 29, 2008. He graduated from the University
of Western Ontario in 1987.
Rosin, Dr. Raivo: A 1972 graduate of the University of Toronto,
Dr. Rosin of Pickering, Ontario, passed away in May 2008.
Tozman, Dr. Eugene: Dr. Tozman of North York, Ontario,
passed away on July 2, 2008. He graduated from the University
of Toronto in 1951. a
To access the websites mentioned in this
section, go to the February 2009 JCDA bookmarks at
www.cda-adc.ca/jcda/vol-75/issue-1/index.html.
JCDA
JOURNAL OF THE CANADIAN DENTAL ASSOCIATION
www.cda-adc.ca/jcda
Policy on Advertising
It is important for readers to remember that the Canadian Dental
Association (CDA) does not endorse any product or service advertised in the publication or in its delivery bag. Furthermore, CDA is
in no position to make legitimizing judgments about the contents
of any advertised course. The primary criterion used in determining
acceptability is whether the providers have been given the ADA
CERP or AGD PACE stamp of approval.
John O’Keefe
1-800-267-6354 ext. 2297
[email protected]
Mark these dates on your calendar now!
IN CONJUNCTION WITH
Essential reading for Canadian dentists
Pacific Dental Conference
March 5th - 7th, 2009 Vancouver, BC
Join your colleagues for an
enriching learning experience!
• Joint meeting with the Canadian Dental Association
• Over 12,000 attendees expected
• Over 500 exhibitor booths
• International line-up of speakers
• Up to 12.5 hours of CE credits
• 2 hour drive to world famous
Whistler Mountain for skiing
Visit either website for details
Pacific Dental Conference
22
www.pdconf.com
www.cda-adc.ca
Policy Statements
The following FDI policy statements were approved in September 2008 at the FDI General Assembly held in Stockholm,
Sweden. All FDI policy statements are available on the FDI website at www.fdiworldental.org.
Sugar substitutes and their role in caries prevention
Non-cariogenic sugar substitutes are widely used in
medications, foods and confectionery, including gums,
candy and drinks. Such substitutes include sorbitol, xylitol,
saccharin, aspartame, sucralose and acesulfame K.
The use of these sugar substitutes may have contributed in a limited way to the decline in the prevalence of
dental caries in industrialized countries. In recent years
the potential of using specific non-cariogenic sugar substitutes in drinks and chewing gum in order to promote
remineralization of initial caries lesions has been investigated. The anticariogenic effect of the sugar substitutes
themselves has yet to be supported by evidenced-based
data. However, enhancement of salivary flow when using
chewing gums may have a caries‑preventive effect.
The FDI World Dental Federation supports the
following generally accepted opinion on sugar
substitutes:
• many sugar substitutes are non-cariogenic
• when sugars are replaced with non-cariogenic sugar
substitutes in foods and drinks the risk of dental
caries is reduced
• non-cariogenic sugar substitutes, when used in products such as confectionary, chewing gum and drinks,
reduce the risk of dental caries
• the regular use of chewing gum containing noncariogenic sweeteners such as xylitol, has a role to
play in preventing dental caries because of its noncariogenic nature and its salivary stimulatory effect.
Bibliography
Matsukubo T and Takazoe I. Sucrose substitutes and their role in caries prevention International Dental Journal 2006 56(3):119–30.
Burt B. The use of sorbital and xylitol sweetened gum in caries control. J Am
Dent Assoc 2006 137(2):190–6.
Adopted by the FDI General Assembly
26th September 2008, Stockholm, Sweden
Recommendations for Clinical Trials of Restorative Materials
Background
Criteria for the clinical evaluation of restorative materials (the ‘Ryge’, or ‘United States Public Health Service
(USPHS)’ criteria) were published in the early 1970s.
However, since then, numerous modifications have been
made to these criteria in a non-coordinated way, and in
addition restorative materials have improved considerably. Consequently, a new clinical evaluation protocol
system is recommended.
Statement
• The high cost of clinical trials of restorative materials
necessitates designs which are standardized, quantitative, sensitive, reliable and valid.
• Clinical trials are required both in an academic environment in order to assess new materials and techniques (‘efficacy studies’) and in a practice-based
environment in order to assess their performance
under ‘field’ conditions (‘effectiveness studies’).
• Appropriate ethical approval must be obtained prior
to conducting a clinical trial.
• Biological, functional and aesthetic criteria should be
evaluated for the appropriate period of time.
• Statistical analysis should include provision for restorations unable to be evaluated, e.g., by using survival (life table) analysis.
• The FDI World Dental Federation recommends that
researchers on dental restorative materials should use
relevant study designs and evaluation criteria published in the following reference.
Bibliography
Hickel R, Roulet J-F, Bayne S, et al. Recommendations for conducting
controlled clinical studies of dental restorative materials. Clin Oral Invest
2007 11:5-33, J Adhes Dent 2007 9(Supp 1):121–147, Int Dent J 2007
57(5):300–302.
23
Sports Mouthguards
Background
Participants of all ages, genders and skill levels are
at risk of sustaining oral injuries in sports at both recreational and competitive levels.1-3 Traumatic oral injuries also occur in non-contact activities and exercises.1,3
Studies have consistently shown that custom-made
mouthguards with adequate labial and occlusal thickness
offer significant protection against intraoral injuries by
providing a resilient, protective surface to distribute and
dissipate impact forces. There is, however, insufficient
evidence to confirm that mouthguards prevent concussion injuries.
In a meta-analysis, 2 the overall injury risk during
athletic activity was found to be 1.6-1.9 times greater
for mouthguard non-wearers compared to mouthguard
wearers. A study4 of collegiate basketball teams found
that athletes who wore custom-made mouthguards sustained significantly fewer oral injuries than those who
did not.
Evidence suggests1 that custom-made mouthguards
provide the best level of protection and wearer comfort,
that mouth-formed (‘boil-and-bite’) mouthguards are less
adequate, and that stock mouthguards provide the lowest
level of protection and wearer comfort.
sports mouthguards, including the prevention of orofacial injuries
• that appropriate oral health care professionals determine if their patients participate in any sports, or any
activities which carry a risk of oral injury
• that people of all ages use a mouthguard while participating in any such sports or activities
• that patients are educated about the benefits of
mouthguards in preventing orofacial injuries, including appropriate guidance on mouthguard types,
their protective properties, costs and maintenance
requirements.
References
1. American Dental Association Council on Access, Prevention and
Interprofessional Relations; American Dental Association Council on Scientific
Affairs. Using mouthguards to reduce the incidence and severity of sportsrelated oral injuries. J Amer Dent Assoc 2006 137:1712–1720.
2. Knapik JJ, Marshall SW, Lee RB, Darakjy SS, Jones SB, Mitchener TA, de la
Cruz GG, Jones BH. Mouthguards in sport activities: history, physical properties and injury prevention effectiveness. Sports Med 2007 37:117–144.
3. Kumamoto DP, Maeda Y. A literature review of sports-related orofacial
trauma. Gen Dent 2004 52:270–280.
4. Labella CR, Smith BW, Sigurdsson A. Effect of mouthguards on dental
injuries and concussions in college basketball. Med Sci Sports Exerc 2002
34:41–44.
Statement
The FDI World Dental Federation recommends:
• that national dental associations promote to the public
and to oral health care professionals the benefits of
24
CDSPI
R E PORTS
Getting Home & Auto Insurance
That’s Right for You
By Susan Roberts, BA, FLMI, ACS, AIAA
W
hen you are shopping for home or auto insurance, you may be faced with many choices. So
how do you determine what coverage is best for
you? The Personal Insurance Company, the Canadian
home and auto group insurer which underwrites CDSPI
Home & Auto Insurance, explains the factors that are
considered when calculating home and auto premiums,
and offers the following suggestions to help you compare
insurance quotes accurately.
Home Insurance
The type of dwelling and location are the first things
an insurer considers to determine eligibility for home
insurance and the premium for it. Your premium will
depend on whether you live in a single family dwelling,
2-story house or bungalow, the city or country, suburbs
or downtown, or historical area. The route and distance
from your local fire department and proximity to a fire
hydrant are also typically taken into account. For homeowners, the value of your property and outbuildings or
detached private structures will affect your home insurance premium. The higher the rebuilding cost, the higher
your premium. If you own a condo or rent, the value of all
your belongings (clothes, furniture, electronic equipment,
computer, etc.) will influence your premium. Before you
obtain a quote, take an inventory of these things so you
don’t forget anything and then calculate the replacement
cost to determine how much coverage you require.
Whether you rent or own, if you choose to purchase
additional coverage beyond the limits provided in the
policy, you may do so by adding endorsements to insure valuables such as furs, jewellery and collectibles.
An additional premium is charged for these things. The
home insurance policy for renters and owners includes
liability coverage, which applies to involuntary damages that you cause to other people or their belongings,
such as a water leak that originates from your apartment
and affects adjacent tenants. Many policyholders choose
$1 million in third party liability protection. However,
you can request a higher amount for only a small additional premium.
To compare quotes accurately, you would need to
ask for the same deductible and amount and type of
coverage, including endorsements. (Your deductible is
the amount you agree to pay in the event of a claim. The
industry standard is $500, but higher or lower amounts
can be requested.) It may be that, when you review your
coverage, you are offered a more complete package than
you currently have. As well, mention to all of the companies any additional factors (e.g. monitored home alarm,
nonsmoking status if you are a home owner, and renovations) that could influence the type of home policy or premium that you are offered. Then determine how well the
suggested coverage matches your needs. Take these factors into consideration, as well as the financial strength
and stability of the insurance company, when comparing
the attractiveness of the premiums offered.
Auto Insurance
In Canada, you’re required by law to have basic insurance for operating your automobile. It is an offence not to
have this basic coverage. You’ll also have to pay for damages yourself if you are uninsured, and a conviction for
failure to have insurance can affect your premium.
Most auto insurance policies are similar and include
mandatory coverage such as third party liability protection (for damage you cause to individuals or their property), accident benefits (to cover medical expenses and
loss of income following an accident) and direct compensation property damage coverage (to protect your vehicle
in case of an accident that is not entirely your fault). You
can also purchase optional coverage, such as increased
third party liability protection, collision,1 comprehensive,1 replacement cost and transportation replacement
coverage.
As with home insurance, it’s best to compare apples
with apples when obtaining quotes, so give the same
information to each insurance company you approach.
This information includes age, date licensed and driving
record for all drivers, including tickets in the last 3 years
and accidents and claims for the last 6 years. Other information required is postal code, year, make, model,
body type, engine size and age of the vehicle, presence
of anti-theft devices, vehicle use (personal or business),
length of business commute (if applicable) and annual
kilometres travelled. (Some people believe that red cars
25
CDSPI R E PORTS
are more expensive to insure. However, the colour of the
automobile makes no difference. The same vehicle in a
different colour (e.g. black, silver, taupe or red) will have
the same rate.)
If your car is less than 10 years old, you may want to
include both collision and comprehensive protection to
cover the much higher costs of repairing or replacing a
newer vehicle. For a car that is more than 10 years old,
you may consider removing collision or comprehensive
coverage, if your vehicle is not worth much more than
the premiums charged for these 2 types of coverage. Your
decision will depend on how comfortable you are with
paying for these damages yourself. You may also choose
to increase the deductible from $500 to $1,000 or more
to help reduce your premium. Be sure you can pay the
higher deductible in case of an accident.
The auto insurance quotes you receive should include
all the coverage you require. As part of your research
when obtaining quotes, you can add or remove optional
coverage or change deductible amounts to see how they
affect the premiums. If the coverage being offered is the
same, you can pick the lowest premium.
Additionally, you may wish to take into consideration
whether the insurance companies provide exceptional,
value-added services such as 24/7 claims assistance for
home and auto emergencies, and identity theft assistance at no extra charge with home insurance. Then, if
the unexpected happens, you’ll have the peace of mind
of knowing that your situation will be handled efficiently
and reliably. a
Get a Quote and
You Could Win $20,000
CDSPI Home & Auto Insurance† provides preferred
group rates for dental professionals, their spouses and
dependents, and others in organized dentistry. You could
enjoy significant savings — with low rates not offered to
the public. Get a home or auto insurance quote and you
will be automatically entered in a draw for a chance to win
$20,000. Call 1-877-293-9455, ext. 5002, for a quote
or go to www.cdspi.com/quote. (Contest closes on
December 31, 2009. Entry and participation is at all times
subject to the complete contest rules. Eligibility requirements, terms and conditions do apply. No purchase is
necessary. Residents of Quebec are not eligible. Visit
www.cdspi.com/more-info for complete contest rules.)
CDSPI Home & Auto Insurance is underwritten by The Personal
Insurance Company. This auto insurance is not available to residents of
Manitoba, Saskatchewan and British Columbia and this home and auto
insurance is not presently available to residents of Quebec.
†
THE AUTHOR
Ms. Roberts, a licensed life and health insurance agent and a
licensed general insurance broker, is the service supervisor of
the insurance services department at CDSPI Advisory Services
Inc. In Quebec, Ms. Roberts is licensed as a financial security
advisor, an advisor in group-insurance plans and a damage
insurance broker.
1. Collision and comprehensive protection will be required by the lessor
or creditor if your vehicle is leased or purchased with financing. Collision
coverage protects you against damage caused to your vehicle if it tips over or
collides with another object. Comprehensive coverage protects you against
loss or damage to your vehicle that isn’t included in collision coverage, such
as theft, earthquake, vandalism, flood, falling objects and fire.
The Canadian Dentists’ Insurance Program is sponsored by CDA and
co-sponsored by participating provincial dental associations
and is administered by CDSPI.
26
Notable
You
ask
W
nu
em
abe
n srwe
s r
Evidence-based Dentistry: Part 1. An Overview
N
ow that evidence-based practice is
becoming increasingly common in
dentistry, it might be time for a refresher. This month, we’ll take a look at
the basics of evidence-based dentistry and
provide some online resources to get you
started.
CDA’s Resource Centre
offers a full range of services to meet members’
clinical, practice management and oral health
research needs. This
article is part of an
occasional series to help
better inform readers on
topics of interest by providing answers to actual
questions posed to the
Resource Centre. If you
have a topic you would
like the CDA Resource
Centre to address, email
your question to
[email protected].
What is evidence-based dentistry
(EBD)?
The American Dental Association’s
definition is by far the most comprehensive, as it captures the core elements of
EBD. They define it as “an approach to
oral health care that requires the judicious
integration of systematic assessments of
clinically relevant scientific evidence, relating to the patient’s oral and medical
condition and history, with the dentist’s
clinical expertise and the patient’s treatment needs and preferences.”1
History of the evidence-based
movement
The evidence-based movement first
took hold in the medical field. Formally
introduced in the 1990s by David
Sackett and Gordon Guyatt of McMaster
University, evidence-based medicine outlines a methodical way to incorporate the
best available evidence into the decisionmaking process for clinical practice and
patient treatments. These principles ensure that decisions regarding patient care
are not only based on experience and expertise, but on current medical research.
EBD’s incorporation into dentistry is
progressing quickly. Dental schools are
integrating the principles into their curriculum and resources are becoming more
widely available. Various countries have
established centres for evidence-based
dentistry (most notably the Centre for
Evidence-Based Dentistry in the United
Kingdom and DSM-Forsyth Center for
Evidence-Based Dentistry in the United
States) and the Cochrane Collaboration
has an Oral Health Group. In addition,
there are journals focusing on EBD practice which offer reviews of the current literature on dental-related topics.
How does evidence-based practice
benefit a profession?
Today, evidence-based principles are
widely being incorporated in most health
care fields, as well as some non-health professions. Academic institutions, human
resources, even library studies are using
evidence-based principles to guide their
day-to-day decisions. Evidence-based
principles help strengthen professions by
identifying knowledge gaps and encourage
us to formulate clear questions regarding
the evidence that we need. A cycle starts
to emerge: the more gaps that are identified means more questions are asked,
the more questions that are asked means
more research is performed, the more research that is available means better decisions are made, thereby strengthening the
profession.
How to practise EBD:2
1. Recognize a need for information and
formulate an answerable question.
2. Find best evidence with which to answer that question. Look for systematic
reviews, meta-analyses and doubleblind randomized controlled studies.
3. Evaluate the evidence for its validity,
reliability, relevance and usefulness.
4. Integrate the evidence with your clinical expertise and your patient’s needs.
5. Evaluate the overall results and your
process. Make any necessary changes.
Where do you find this evidence?
Some of the best sources of evidence
that are fast and easy to use are online.
Initially, some sites might seem daunting,
but there are tricks of the trade that will
help the novice researcher. In addition,
the CDA Resource Centre offers professional literature searches and a document
delivery service for CDA members. The
27
You
CDSPI
Ask, R
We
E PORTS
Answer
information specialist is available to answer your
questions on how to search for information. Below
are some essential online resources for evidencebased research.
PubMed
• PubMed is a free medical database provided by
the U.S. National Library of Medicine and the
National Institutes of Health (NLM). Highly
authoritative and up-to-date, PubMed gives
you access to MEDLINE, NLM’s database of
citations and abstracts in the fields of medicine,
nursing, dentistry, veterinary medicine, health
care systems and preclinical sciences. Updated
daily, PubMed gives you access to over 14 million citations dating back to the 1950s. Records
are indexed using the NLM’s Medical Subject
Headings (MeSH).
• You can narrow down your results to include
systematic reviews by selecting Clinical
Queries on the left-hand sidebar, or in the
Limits screen under “Subsets.”
• For more information visit: www.pubmed.gov
The Cochrane Library
• The Cochrane Library is an international
collection of 7 evidence-based health care
databases updated quarterly. With the latest research on the effectiveness of health care treatments and interventions, current technology
assessments, economic evaluations, and individual clinical trials, the Cochrane Library is
the best single source of the world’s highest
quality research studies and current evidence
on clinical treatments.
• The Library includes the Cochrane Database
of Systematic Reviews (Cochrane Reviews),
which is recognized as the gold standard in
28
evidence-based health care. The international
Cochrane Oral Health Group produces systematic reviews of evidence-based research on oral
health care topics. For more information visit:
www.ohg.cochrane.org/
• The Cochrane Collaboration is an international
non-profit and independent organization dedicated to providing information and evidence
via the Cochrane Library to support clinicians,
researchers, patients and policy makers.
• Access to the Cochrane Library is part of your
CDA Membership. The Cochrane Library offers podcasts of audio summaries of selected
reviews.
• Questions about how to search the Cochrane
Library? See the “You Ask, We Answer” on
the Cochrane Library3 or contact the Resource
Centre at [email protected].
The next installment of “You Ask, We Answer”
will provide tips on how to frame dental research
questions, search strategies and more online resources to locate scientific evidence. a
References
1. American Dental Association. Evidence-based dentistry: glossary of terms. Available: www.ada.org/prof/resources/ebd/glossary.
asp#ebd (accessed 2009 Jan 12).
2. Centre for Evidence-Based Medicine University Health Network.
How do we actually practice EBM? Available: www.cebm.utoronto.
ca/intro/howpract.htm (accessed 2009 Jan 12).
3. De Gannes-Marshall R. The Cochrane Library and the world of
systematic reviews. J Can Dent Assoc 2007; 73(7):577–8. Available:
www.cda-adc.ca/_files/members/resource/research/jcda_2007_73_
7_577.pdf.
THE AUTHOR
Danielle Rabb-Waytowich is acting information
specialist at the Canadian Dental Association.
PRe
T h es iJd
CDA
e n t I’ n
s tCeorlvui m
ew
n
Dr. Peter Cooney: Canada’s Chief Dental Officer
F
or many years, CDA advocated for the
creation of a Chief Dental Officer position
in Canada. Health Canada’s appointment
of Dr. Peter Cooney to this role in 2004 has
helped to raise awareness of oral health issues
among Canadians. It has also enabled the
federal government to coordinate its public
education efforts and facilitate the collection
of comprehensive oral health data.
CDA continues to maintain a strong
working relationship with the Office of the
Chief Dental Officer, and this JCDA interview
is intended to provide an update on the ongoing activities and initiatives of Dr. Cooney
and the Office.
JCDA: Can you tell JCDA readers a little bit
about your background and your involvement
in public health policy throughout your career?
Dr. Peter Cooney: I’ve always been interested
in oral health. I grew up in Ireland where
decay rates were quite high. So we all had to sit
and have ourselves drilled. These experiences
evolved into a general interest in the whole
issue of oral health. I was in private practice
for a number of years in London, England.
Then I did my Canadian exams and bought
a practice in Newfoundland. I spent 5 years
there and loved it.
In 1991, after I completed my specialty,
master’s and fellowship in community dentistry, I joined Health Canada and worked in
the Medical Services Branch in the Manitoba
Region. Then in 1997, I moved to Ottawa to
take on the position of National Dental Officer
at the head office of the Medical Services
Branch (now the First Nations and Inuit
Health Branch), and went from there to be
director general of the Non-Insured Health
Benefits division from 1999 to 2003.
I have had the opportunity to hold the
position of president with the Canadian
Association of Public Health Dentistry and I
am currently the chief examiner for the specialty of Dental Public Health with the Royal
College of Dentists of Canada.
After I became the Chief Dental Officer
at Health Canada in 2004, I had many different and exciting opportunities open up to
me, including being appointed chair of the
International Chief Dental Officers Public
Health Section of the FDI World Dental
Federation.
JCDA: How did the Office of the Chief Dental
Officer come to be?
Dr. Cooney: The Office of the Chief Dental
Officer was created in 2004 to improve the
oral health status of Canadians and to increase awareness about the prevention of oral
diseases. This position came about as a result
of a number of dental stakeholders, including
CDA, advocating for Canada to have a Chief
Dental Officer. There was a need for this position nationally, and for Canada to be represented internationally as well. Canada joins
about 160 other countries worldwide that have
a Chief Dental Officer.
JCDA: Who works in the Office of the Chief
Dental Officer?
Dr. Cooney: Our personnel have a combination of skills and backgrounds. There is a
dental therapist, a dental hygienist and 2 dentists, as well as people with a background in
health promotion, finance and administration.
29
––– The JCDA Interview –––
The Office of the Chief Dental Officer (OCDO)
works to:
• Provide evidence-based oral health perspectives on
a wide range of health policy and program development issues
• Provide expert oral health advice, consultation and
information
• Integrate oral health promotion with general health
(wellness) initiatives
• Assist in gathering epidemiological information for
program planning on federal/provincial/community
levels and establish priorities for research
• Develop integrated collaborative approaches to preventing and controlling oral and associated diseases
• Provide a point of contact/liaison with professional
associations, provinces, academic institutions, and
other non-government organizations on oral health
issues
The OCDO is involved in:
• Oral health status data collection
• Federal, Provincial, Territorial Dental Working Group
• Working with First Nations and Inuit Health Branch’s
Children’s Oral Health Initiative
• Promotion of water fluoridation
• International oral health activities
Each summer we also have 1 or 2 students who are
doing either their master’s degree or a PhD.
JCDA: What materials does the Office produce?
Dr. Cooney: The Office does not produce materials in the sense of pamphlets or posters, but
rather strives to provide expert advice on oral
health, consultation and information. To meet this
mandate, we have been busy over the last 4 years
conducting various environmental scans, surveys
and other types of needs assessments to get information about dental public health in Canada and
make it accessible to the public.
JCDA: What interested you about taking on the
role of Chief Dental Officer?
30
Dr. Cooney: I worked in private practice for a
number of years, and while I enjoyed it, it can be
frustrating to treat one person at a time. Public
health dentistry enables me to work with the
whole population and I am able to have a much
broader effect. This is the area that interests me
and what motivated me to take on the role of the
Chief Dental Officer of Canada.
JCDA: What does the Office of the Chief Dental
Officer do for Canadian dentists?
Dr. Cooney: The Office of the Chief Dental Officer
aims to be a point of contact on oral health issues
for dentists and other health professionals. For
instance, the Office has recently supported both
dentists and dental organizations on the promotion of water fluoridation.
JCDA: What is the Office of the Chief Dental
Officer’s role globally?
Dr. Cooney: My Office has had a very active international role over the past 4 years. As mentioned,
I was appointed chair of the International Chief
Dental Officers Public Health Section of FDI and I
now network with 194 Chief Dental Officers from
about 160 countries.
I have also had the opportunity to represent
Canada on a 4-country advisory group that worked
on the development of an oral health strategy
with the Pan American Health Organization
(PAHO) for 2005–2015. The purpose of this oral
health strategy is to improve general health in the
Americas through improvements in oral health.
The details of the strategy can be found on the
PAHO website at www.paho.org/english/gov/cd/
CD47.r12-e.pdf.
JCDA: Can you talk about the importance of the
relationship between CDA and the Office of the
Chief Dental Officer?
Dr. Cooney: My Office and CDA have had a good
relationship from the time we opened our doors
in 2004, and we work hard to maintain this positive and collaborative relationship. We have been
working with CDA on an oral health promotion
campaign that will focus on oral cancer awareness and the connections between oral health and
general health. This project has been in development for a few years and we hope it will launch
this year.
––– The JCDA Interview –––
JCDA: What has the Office of the Chief Dental
Officer accomplished since its inception?
Dr. Cooney: I think that the Office has accomplished quite a bit. We have worked hard to begin
filling in some of the knowledge gaps in the dental
field and are participating in surveys to continue
to get a better understanding about the oral health
status of Canadians. For example, we now know
the type of dental public programming that exists
across Canada and who is working in these programs. We also know the percentage of Canadians
who had access to fluoridated drinking water in
2005 and 2007 for each province and territory in
Canada.
To obtain the current oral health status of
Canadians, the Office is involved in 4 different
surveys. The first is a partnership with Statistics
Canada on its Canadian Health Measures Survey
(CHMS). The data collection methods for this
survey are unique in Canada and involve a selfreport questionnaire on oral health, nutrition,
smoking habits, alcohol use, medical history and
current health status, as well as demographic and
socioeconomic variables. Following the self-report questionnaire, direct measurements will be
collected in a clinical setting, including blood
pressure, height and weight, blood and urine sampling, clinical oral examination and physical fitness testing. This type of data collection will take
2 years and is planned to be completed by this
March.
My Office has also partnered with First Nations
and Inuit organizations to get a better understanding of the oral health status of First Nations
on reserves and in Inuit communities. For these
2 surveys, we are using the same protocols as the
CHMS so that direct comparisons can be made to
the general population. This survey will be completed at the same time as the CHMS, in March.
Finally, our Office has also partnered with
Statistics Canada on a Healthy Aging survey.
Through this survey, we hope to get a better
understanding of how people’s oral health status
and access to oral health services change as we get
older. This survey will begin data collection this
winter and will have a collection period of about
one year.
JCDA: What goals would the Office of the Chief
Dental Officer like to accomplish in the short- and
long-term?
Dr. Cooney: We look forward to the results from
the CHMS and other surveys to help us determine
the current oral health status of Canadians, to
evaluate the association of oral health with major
health concerns such as diabetes, respiratory and
cardiovascular diseases, and to determine relationships between oral health and certain risk factors like poor nutrition and socioeconomic factors
related to low income levels and education.
My Office plans on releasing an Oral Health
Report Card in 2010 that will highlight the oral
health status of Canadians including the First
Nations and Inuit populations.
In the long term, we want to continue our
relationship with the provinces and territories,
professional associations, academic institutions
and regulatory bodies and work with these organizations to improve the oral health of Canadians.
JCDA: Can you elaborate on the importance of the
CHMS? How do you plan to translate the preliminary results of the survey into action by the profession and governments?
Dr. Cooney: The oral health module of the CHMS
is very important for the dental field. We haven’t
had solid evidence on the oral health status of
Canadians for over 30 years. We need the results
from the survey to support policy and program
development within the field.
Our plan is to release the results of the survey
in 2 different reports. The first report will be directed to the general population, our leaders and
other stakeholders, and will highlight the findings
from the survey. The second report will be aimed
at dental professionals and will go into the findings in more depth.
My Office intends to examine the results with
our stakeholders, such as CDA, other professional
associations and the provinces and territories,
and then we will determine how to address the
findings. a
For more information on the Office of the Chief Dental
Officer, visit www.hc-sc.gc.ca/ahc-asc/branch-dirgen/
fnihb-dgspni/ocdo-bdc/index-eng.php.
31
Embrace Tax Avoidance
Imagine not having to pay tax on your investments.
Now, you can embrace that concept — by using the CDA TFSA
(tax-free savings account). With this new plan, you can:
r Invest up to $5,000 annually and pay no tax on your investment returns
r Withdraw funds tax-free — then re-deposit them later if you wish,
without penalty
r Select from over 30 CDA funds offering distinct advantages —
including low management fees
r Benefit from the expert planning advice of non-commissioned
Certified Financial Planners
To put your savings in this superior environment, get an
application today.
1-877-293-9455
www.cdspi.com/cda-tfsa
to reach a licensed advisor at CDSPI Advisory Services Inc.
D
e
n
T
I
S
T
S
The CDA TFSA is a part of the Canadian Dentists’ Investment Program — a member benefit of the CDA.
F
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09-54 12/08
Debate
&
opinion
Charging for Missed Appointments
Contact Author
Cyndie Dubé-Baril, DMD, Cert Pedo, LLB, LLM
Dr. Dubé-Baril
Email: [email protected]
For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-75/issue-1/33.html
I
n a particularly interesting article that appeared in JCDA, Dr. Andrew Nette listed
10 conclusions he had reached over the
years that increased his enjoyment of our wonderful profession.1 It is always helpful to pass
along useful tips or share difficulties we may
have encountered in our dental practices. This
allows our peers to benefit from the lessons we
have learned from our experiences.
Among the conclusions mentioned by
Dr. Nette was a recommendation to charge
patients for missed appointments. I believe
some clarification of this point is needed to
allow dentists who are using or wish to use
this method of dissuasion and compensation 2,3
to do so appropriately. Dr. Nette rightly notes
that “missed appointments are bad for staff
morale as well as the bottom line.”1 On the
other hand, charging for missed appointments
does not fully rectify the situation and can
cause other problems. As the author accurately points out, “you hope for 1 of 2 desirable
outcomes: the charge stings and encourages
the client to act more responsibly next time,
or the charge annoys them enough that they
leave your practice.” However, a different outcome could also be possible — the patient may
be offended, refuse to pay the charge for the
missed appointment (which forces the dentist
to go to court to claim the amount owed)4,5
and lodge a complaint. Such a complaint was
brought before the College of Physicians and
Surgeons of New Brunswick.6
A patient claimed that a physician had
wrongly refused to continue treating her be
cause she had failed to pay a fee for a missed
appointment. She alleged that it had been impossible to contact the physician’s office to let
him know she couldn’t attend the appointment, and mantained that she had not been
informed in advance that she would have to
pay such a fee.
In his defence, the physician argued that
an answering machine was available after
hours and asserted that he had other reasons
for refusing to see the patient.
The committee responsible for reviewing
the case highlighted a number of interesting
points in the guidelines of the College of
Physicians and Surgeons of New Brunswick.7
For example, the office policy regarding
missed appointments must be clearly communicated and patients must know how to
inform the office if they are unable to make
their appointments. In this case, the investigation revealed that although the office did have
an answering machine, it did not specifically ask patients to leave messages related to
cancelled appointments. The committee also
determined that is was difficult for patients to
communicate with the staff or leave a message.
In short, the committee concluded that the
charge was inappropriate and even questioned
whether the conflict over the invoice was sufficient reason to refuse to continue treating
the patient, noting that “where there is an outstanding invoice, denial of care is a poor way
to enforce it. Such may generate a complaint
and seldom causes the bill to be paid.”6
33
––– Dubé-Baril –––
Some Guidelines for Consideration
To protect themselves from excessive cancellations,
dentists who charge or wish to charge fees for missed appointments should proceed with caution and assess each
situation carefully to avoid regrettable consequences. To
this end, the following guidelines should be considered:
• Know and respect existing laws and regulations.
Verify positions adopted by the regulatory authority
or the provincial association and comply with them.
• Establish a clear policy for charging for missed appointments, applicable to all patients.
• Discuss fees in advance with all patients and ensure
that they understand and accept this policy. Once
patients have been duly informed and agree to the
policy, have them sign an approval form that outlines
all the required information.
• Charge a reasonable amount that reflects actual costs
incurred because of missed appointments and not the
amount of the intended service.
• Provide a telephone messaging service at all times
that will allow patients to advise your office if they
cannot make their appointments and be sure to inform patients of this service.
• Ensure that the patient did not cancel an appointment
at least 24 hours in advance or that the missed appointment was not due to an unforeseen event.
• Be available to see the patient at the time of the appointment. If you were able to fit in another patient
during the time slot left open by a cancellation, no fee
should be charged.
Given that communication is the key to success in the
relationship between patient and dentist, it is important
to properly explain to the patient from the outset the importance of mutual cooperation. For some dentists, providing clear explanations to patients about the importance
of respecting appointments may suffice, without having to
resort to more radical steps such as charging for missed
appointments. A “3 strikes and you’re out” style of policy
(where 3 missed or cancelled appointments without sufficient notice automatically leads to termination of treatment and the end of the contractual relationship between
the dentist and patient) may be a suitable alternative or
complementary strategy to this type of billing. However,
it should be noted that certain rules must be respected
before ending a contractual relationship.9 Finally, those
wishing to charge for missed appointments but who fear
a negative reaction from patients (this practice could be
seen as a way to get money from patients) might consider
donating the revenues from these fees to a charitable organization. This way, while the dentist and patient both
lose out because of a missed appointment, at least the
money will go to a good cause. a
These guidelines do not address all the issues surrounding this subject, particularly certain ethical questions that may arise from such a practice (including
reciprocity). A debate within regulatory authorities on
a clear regulation for charging for missed appointments
would be desirable. The regulatory authority for psychologists in Quebec recently amended its code of ethics8
to add a clause allowing for charges for missed appointments on the condition that there was an agreement in
writing between the psychologist and the patient. In such
cases, the psychologist may “require administrative fees
for an appointment missed by the client according to predetermined and agreed-upon conditions, those fees not
to exceed the amount of the lost fees.”8
Moreover, it would be inappropriate to refuse to provide care due to an unpaid fee for a missed appointment.
A patient’s frequent failure to show up for appointments
may, however, constitute justification for terminating
your contractual relationship with him or her.9
In conclusion, it is not illegal to require reasonable
fees for a missed appointment. However, to be in a position to levy such a charge, the dentist must adequately
and clearly inform the patient of this policy and the patient must agree to these conditions.
The views expressed are those of the author and do not necessarily reflect
the opinions or official policies of the Canadian Dental Association.
34
The Author
Dr. Dubé-Baril is a legal advisor and manager for a private company in
Laval, Quebec. She is also a lecturer and clinical instructor in pediatric
dentistry at McGill University, Montreal, Quebec.
Correspondence to: Dr. Cyndie Dubé-Baril, 5310 des Laurentides Blvd.,
Laval, QC H7K 2J8.
This article has been peer reviewed.
References
1. Nette AL. I’ve learned a thing or two… J Can Dent Assoc 2007;
73(7):611–2.
2. Immeubles Christian Bélanger inc. c. Association de la construction du
Québec, (C.A., 1998-01-22), SOQUIJ AZ-98011148, J.E. 98-308, [1998]
R.J.Q. 395, REJB 1998-04452.
3. WMI-99 Holding Company (Winners Merchant Inc.) c. Immeubles WCG
inc, (C.S., 2006-07-18), 2006 QCCS 3817, SOQUIJ AZ-50383711, J.E. 20061625, EYB 2006-107809 Requête en rejet d’appel rejetée (C.A., 200703-19), 500-09-016976-060, SOQUIJ AZ-50432081. Règlement hors cour
(C.A., 2007-06-20), 500-09-016976-060.
4. Pagé c. Janelle, 2007 QCCQ 6615 (CanLII), 200-32-039806-053 (2007-0615). Available : www.canlii.org.
5. Desjardins c. Berryman, 2006 QCCQ 16602 (CanLII), 500-32-092145-053
(2006-10-24). Available : www.canlii.org.
6. College of Physicians and Surgeons of New Brunswick. Bulletins; December
2003. Available: www.cpsnb.org/english/Bulletins/December%202003.html.
7. College of Physicians and Surgeons of New Brunswick. Guidelines
– charging for uninsured services; 1999. Available: www.cpsnb.
org/english/Guidelines/guidelines-8.html.
8. Ordre des psychologues du Québec. Code of ethics (R.S.Q.,c.C-26,a.87).
2008. Available: www.ordrepsy.qc.ca/en/protection/code_ethics.html.
9. Code de déontologie des dentistes (R.R.Q., 1981, c. D-3, r.4) art.
3.03.03 & 3.03.04. Available: www2.publicationsduquebec.gouv.qc.ca/
dynamicSearch/telecharge.php?type=3&file=/D_3/D3R4.htm.
Professional
Issues
Infectious Dental Diseases in Patients
with Coronary Artery Disease:
An Orthopantomographic Case–Control Study
Kyosti Oikarinen, DDS, PhD; Mohammad Zubaid, MB, ChB, FRCPC;
Lukman Thalib, PhD; Kari Soikkonen, DDS, PhD;
Wafa Rashed, MD, FRCP (UK); Tryggve Lie, DDS, PhD
Abridged Version
The complete article is published in the electronic JCDA
at www.cda-adc.ca/jcda/vol-75/issue-1/35.html
For citation purposes, the electronic version is the definitive version of this article.
S
everal studies have suggested an association
between cardiac diseases and oral infections.
Both acute myocardial infarction and dental
infection are common in Kuwait.
Purpose: We investigated whether coronary artery
diseases were related to the type and severity of
radiographically diagnosed dental infections in
patients who had experienced and received treatment for a first episode of coronary artery disease
in Kuwait’s largest hospital.
Materials and Methods: The type and severity
of dental infections were analyzed by means of
panoramic radiography and several background
factors were recorded for 88 patients
with coronary artery disease and the
same number of controls matched
Radiographically
for age, sex and nationality. All padiagnosed signs
tients and control participants were
of dental infections
interviewed and examined by a
cardiologist, and radiographs were
were more frequent
analyzed by an experienced radioloamong patients
gist. Several signs of dental infection
with coronary artery
such as caries, marginal bone loss,
disease than among
furcation lesions and periapical ostematched controls.
olysis were recorded. The severity
of signs of periodontitis, classified
as either mild or severe, was determined according to magnitude of marginal bone
loss. Cases and controls were also compared by
means of a total dental index.
Results: Cases and controls were well matched for
age, sex, marital status, professional status and
household income. Diabetes mellitus was more
frequent and cholesterol levels, glucose levels and
white blood cell counts were higher among cases
than among controls. Cases and controls did not
differ in terms of the mean number of teeth present
or the number of teeth with fillings, root fillings or
caries. The number of teeth needing extraction was
significantly greater among cases than among controls. The numbers of periapical lesions and molars
with furcation lesions and the extent of severe
marginal bone loss provided further evidence of
worse dental health among the cases than among
the controls. The total dental index, which quantified the severity of oral infections, was higher
among cases than among controls.
Discussion and Conclusions: This study yielded
evidence that radiographically diagnosed signs of
dental infections were more frequent among patients with coronary artery disease than among
matched controls. In this study, the dental infections were diagnosed from radiographs only, so
the data must be evaluated with caution. Clinical
examination would have been needed to confirm
periodontitis. Although these results agree with
the findings of many earlier studies, a causal relation between coronary artery disease and oral
infections is difficult to prove because of several
confounding factors. As expected (given the criteria used to define the cases), more patients than
controls had elevated cholesterol levels and hypertension. Further studies are needed to confirm this
relation. In particular, longitudinal epidemiologic,
clinical and interventional studies are needed.
Although the literature is far from unanimous,
the authors recommend that dental infection be
listed as a possible contributing factor to coronary
artery disease, along with smoking, overweight,
high lipid concentration and high blood pressure.
To date, however, dental infections have not been
mentioned in books dealing with risk factors for
coronary artery disease. a
35
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Applied
Re s e a r c h
Dental Burs and Endodontic Files: Are Routine
Sterilization Procedures Effective?
Archie Morrison, DDS, MS, FRCD(C); Susan Conrod, DDS
Abridged Version
D
iseases may be transmitted by indirect contact when dental instruments contaminated
by one patient are reused for another patient
without adequate disinfection or sterilization between uses. Resterilization is the repeated application of a sterilization procedure to an instrument
or device to remove contamination, allowing for
its use in treating multiple patients. Resterilization
is used on dental burs and endodontic files in
many dental offices. These devices can become
contaminated with blood, saliva, necrotic tissue and pathogens; thereRoutine resterilization
fore, if such devices are to be reused,
it is important to ensure sterility
procedures for
and minimize any associated risk
previously used
of cross-contamination. However,
burs and files are
the complex miniature architecture
ineffective, and more
of dental burs and endodontic files
makes precleaning and sterilization
rigorous sterilization
difficult. Devising a sterilization
procedures are needed.
protocol for endodontic files and
dental burs requires care, and some
have suggested that these instruments be considered single-use devices.
Purpose: One purpose of this study was to determine the effectiveness of various sterilization
techniques currently used in dentistry for the
resterilization of dental burs and endodontic files.
The second aim was to determine whether new
dental burs and endodontic files, as supplied in
packages from the manufacturer, are sterile.
Materials and Methods: The sterility of new (unused) and used dental burs and endodontic files
before and after various sterilization procedures
was analyzed. New burs and files were tested immediately after removal from manufacturers’
packaging, with or without prior sterilization.
Burs and files that had been used in various dental
offices were precleaned, packaged, resterilized and
then tested for various pathogens. Each test group
(unused sterilized burs and files, unused and unsterilized burs and files, and used burs and files
sterilized using 1 of 5 techniques) consisted of
40 items. There were many differences between
the groups, such as methods of precleaning, type
of packaging, length of sterilization cycle and
type of sterilizer. Each item was individually removed from the sterilization packaging, transferred by sterile technique into Todd-Hewitt broth,
incubated at 37°C for 72 hours and observed for
bacterial growth.
Results: The 5 techniques of resterilization tested
in this study were deemed inadequate. Rates of
contamination ranged from 15% of the items in
one group of used burs (p < 0.001) to 58% of the
items in one group of used files (p < 0.001). Even
the new burs and files had contamination rates of
42% and 45%, respectively, when the devices were
tested without sterilization. The only groups with
no bacterial contamination were the previously
unused burs and files that were sterilized before
testing.
Conclusions: Dental burs and endodontic files are
not sterile at the time of purchase and should be
cleaned and sterilized before first use. Sterilization
procedures were successful for burs and files that
had not been previously contaminated by organic
debris. The comparison of new and used items in
this study revealed that the problem with sterilization procedures may lie in the method employed to
remove gross debris from the burs and files, which
in turn probably relates to the small size and complex surface detail of these items. Routine resterilization procedures for previously used burs and
files are ineffective, and more rigorous sterilization
procedures are needed. If such procedures cannot
be devised, these instruments should perhaps be
considered single-use devices. a
39
Clinical
practicE
Dental Surgery for Patients on Anticoagulant
Therapy with Warfarin: A Systematic Review
and Meta-analysis
Adeela Nematullah, BHSc; Abdullah Alabousi, BHSc;
Nick Blanas, BSc, DDS, FRCD(C); James D. Douketis, MD, FRCP(C);
Susan E. Sutherland, DDS, MSc
AbridgedVersion
W
arfarin therapy is used by more than
4 million patients in North America
for conditions such as atrial fibrillation,
mechanical heart valve and venous thromboembolism. Despite widespread use of this therapy,
the management of patients taking warfarin who
require dental procedures varies considerably.
Although continuation of the regular dose of warfarin before dental procedures may increase the
risk for perioperative bleeding, discontinuation
of warfarin increases the risk for life-threatening
thromboembolic events such as stroke.
Purpose: We conducted a systematic review of
the published literature to evaluate the effect of
continuing warfarin therapy on the bleeding risk
for patients undergoing elective dental surgical
procedures.
Methods: Data sources were the MEDLINE and
EMBASE databases, the Cochrane Central Register
of Controlled Trials, a manual citation review of
the relevant literature, content experts and relevant
abstracts from the proceedings of the International
Association for Dental Research. Study selection
was carried out independently by 2 reviewers.
Two reviewers also independently assessed study
quality, with differences resolved by consensus.
Eligible studies were randomized controlled trials
that compared the effects of continuing the regular
dose of warfarin therapy with those of discontinuing or modifying the dose on the incidence of
bleeding for patients undergoing dental procedures. All reported bleeding events were reclassified
into the following 3 categories to allow comparison
between studies: major bleeding, clinically significant nonmajor bleeding and minor bleeding. Data
extraction was done independently by 3 reviewers;
disagreements were resolved by consensus and
discussion with a fourth reviewer. A sensitivity
analysis to exclude studies of low quality was
planned. Two subgroup analyses were done after
the fact, one in patients maintained at an international normalized ratio (INR) > 3 and the other
in studies that used hemostatic interventions.
Results: Five trials (a total of 553 patients) met
the inclusion criteria. Compared with interruption of warfarin therapy (either partial or complete), perioperative continuation of warfarin with
patients’ usual dose was not associated with an
increased risk of clinically significant nonmajor
bleeding or an increased risk for minor bleeding.
Because 4 of 5 trials were assessed as low quality,
a sensitivity analysis that excluded studies of
low quality could not be conducted. The results
of the primary analyses were supported by the
subgroup analyses done in studies with a mean
INR > 3.0. Results from the subgroup analyses of
studies that used antifibrinolytic agents were also
not significant.
Conclusions: Continuing the regular dose of
warfarin therapy does not seem to confer an increased risk of bleeding when compared with discontinuing or modifying the warfarin dose for
patients undergoing minor dental procedures.
However, pragmatic questions arise about the
management of patients with comorbid factors,
use of additional local measures and antifibrinolytic agents, and indications for specialist referral,
hospital care or bridging therapy. Clinical experts
from both medicine and dentistry need to review the available evidence, apply their collective
knowledge and clinical expertise, and develop
concrete practice guidelines to assist practitioners
in the management of the dental patient on anticoagulant therapy. a
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09-39 11/08
Clinical
practicE
Oral Health Care for the Pregnant Patient
James A. Giglio, DDS, MEd; Susan M. Lanni, MD; Daniel M. Laskin, DDS, MS;
Nancy W. Giglio, CNM
ContactAuthor
Dr. Giglio
ABSTRACT
Pregnancy is a unique time in a woman’s life, accompanied by a variety of physiologic,
anatomic and hormonal changes that can affect how oral health care is provided.
However, these patients are not medically compromised and should not be denied
dental treatment simply because they are pregnant. This article discusses the normal
changes associated with pregnancy, general considerations in the care of pregnant
patients, and possible dental complications of pregnancy and their management.
M
ost pregnant patients are generally
healthy and need not be denied dental
treatment solely because they are
pregnant. However, even a healthy pregnancy
causes major changes in maternal anatomy,
physiology and metabolism. These can include
changes in the cardiovascular, respiratory and
gastrointestinal systems, as well as changes in
the oral cavity and increased susceptibility to
oral infection. Although these adaptations of
maternal organ systems are normal, they do
necessitate consideration and adjustments in
treatment by any dentist who is providing oral
health care and prescribing medications for
the patient. Th is article discusses the various
changes that occur during normal pregnancy
and suggests modifications in dental management that should be considered.
SystemicChanges
Cardiovascular System
Cardiovascular changes in pregnancy
include increases in cardiac output, plasma
volume and heart rate. A benign systolic ejection murmur, caused by increased blood flow
across the pulmonic and aortic valves, occurs
in 96% of pregnant women,1 but no treatment is
required. In addition, as a result of vasomotor
instability, pregnant patients are susceptible to
postural hypotension. Consequently, changes
in dental chair position from reclining to upright should be performed very slowly. As the
uterus increases in size, it causes pressure on
the vena cava and aorta, which can result in
decreases in cardiac output, venous return
and uteroplacental blood flow. Aortocaval
compression, which occurs specifically in the
supine position, leads to supine hypotensive
syndrome, which is characterized by symptoms and signs such as lightheadedness, weakness, sweating, restlessness, tinnitus, pallor,
decrease in blood pressure, syncope and, in
severe cases, unconsciousness and convulsions. Patients who experience this syndrome
are usually aware of its occurrence and can
alert their caregivers if they begin to notice
symptoms developing. The condition can be
corrected by having the patient roll on her left
side and placing a pillow or rolled towels to
elevate her right hip and buttock by about 15°.
Th is manoeuvre lifts the uterus off the vena
cava and re-establishes aortocaval patency.2
4
––– Giglio –––
Oral changes
Pregnant dental patient
● Gingivitis
● Pyogenic granuloma
● Ptyalism
● Enamel erosion
● Xerostomia
● Tooth mobility
Radiography
(if necessary for diagnosis)
● Panoramic radiographs
● Periapical radiographs as
needed
● Bitewing radiographs
● Digital radiographs
Emergency care
● Perform at any time in
pregnancy for pain relief and
infection control (pulp
extirpation, incision and
drainage, uncomplicated
extractions)
● Notify obstetrician of
patient’s condition
Systemic changes
● Increased cardiac output,
plasma volume and heart rate
● Systolic ejection murmur
● Supine hypotensive syndrome
● Nasal congestion, epistaxis
● Increased intragastric
pressure, gastric acid reflux
Elective care
● Scaling and curettage
● Routine restorations
● Elective extractions
● Endodontic therapy
● All best performed in second
or third trimester, except
scaling and curettage, which
can be done anytime
Drugs (FDA pregnancy safety category)
Analgesics
Acetaminophen (B)
Codeine with acetaminophen (C)
Hydrocodone with acetaminophen (C)
Ibuprofen (B, D)a
Oxycodone with acetaminophen (C)
Propoxyphene (C)
Antimicrobials
Amoxicillin (B)
Cephalexin (B)
Chlorhexidine rinse (B)
Ciprofloxacin (C)a
Clindamycin (B)
Doxycycline (D)
Erythromycin (B)
Metronidazole (B)a
Penicillin (B)
Tetracycline (D)
Local anesthetics
Articaine (C)
Bupivacaine (C)
Epinephrine (C)
Lidocaine (B)
Mepivacaine (C)
Prilocaine (B)
Anxiolytics
Barbiturates (D)
Benzodiazepines (D)
Nitrous oxide (not
rated; avoid in first
trimester)
Figure 1: Summary of somatic changes associated with pregnancy and diagnostic and treatment options in dental management of pregnant
women. See Table 1 for definitions of U.S. Food and Drug Administration (FDA) drug risk categories. aSee text for further explanation.
Respiratory System
Increased estrogen production during pregnancy
causes the capillaries in the mucosa of the nasopharynx
to become engorged, which results in edema, nasal congestion and predisposition to epistaxis.1 Nasal breathing
becomes more difficult, and there is a tendency to breathe
with the mouth open, especially at night. If xerostomia
subsequently develops, patients lose the protection
against dental decay afforded by saliva. 3 Patients who
are experiencing these problems, especially those with a
high caries index, should undergo early caries control
to minimize deleterious effects on the dentition.
Gastrointestinal System
The increase in progesterone levels during pregnancy
causes a decrease in lower esophageal tone and gastric
and intestinal motility. The combined effects of hormonal
and mechanical changes in the gastrointestinal system
and greater sensitivity of the gag reflex also increases
the risk of gastric acid reflux. In addition, the stomach is
displaced superiorly as the uterus increases in size, which
44
increases intragastric pressure. Consequently, the chair
should be kept as upright as possible during dental treatment to relieve abdominal pressure and keep the patient
comfortable.
Ptyalism (excessive secretion of saliva) is a complication of pregnancy that occurs most often in women
suffering from nausea. The presence of excessive saliva
in the mouth may also reflect the inability of nauseated
women to swallow normal amounts of saliva rather than
a true increase in production. In some cases as much as
2 L of saliva per day is lost through drooling. Reducing
the consumption of complex carbohydrates may improve
this condition.1
High-Risk Patients
Obstetric consultation is usually not required before
initiating dental treatment for normal, healthy pregnant
patients. However, consultation should be sought before
caring for patients who have been identified by the obstetrician as being at risk for pregnancy complications,
such as those with pregnancy-induced hypertension,
––– Pregnant Patients –––
Table 1 Pregnancy drug risk categories, as defined by the U.S. Food and Drug Administration4
Category
Evidence
A
Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal
abnormalities.
B
Animal studies have revealed no evidence of harm to the fetus, however, there are no adequate and wellcontrolled studies in pregnant women.
or
Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant
women have failed to demonstrate a risk to the fetus
C
Animal studies have shown an adverse effect and there are no adequate and well-controlled studies in
pregnant women.
or
No animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women.
D
Studies, adequate well-controlled or observational, in pregnant women have demonstrated a risk to the
fetus. However, the benefits of therapy may outweigh the potential risk.
X
Studies, adequate well-controlled or observational, in animals or pregnant women have demonstrated
positive evidence of fetal abnormalities. The use of the product is contraindicated in women who are or
may become pregnant.
gestational diabetes, threat of spontaneous abortion or
history of premature labour. High-risk pregnant patients
can usually be identified by taking a good medical history and asking questions about the course and nature
of the pregnancy. Careful measurement and recording of
baseline blood pressure, pulse and respiratory rate are required before any invasive procedure, including administration of a local anesthetic. Blood pressure is often at
or below the range expected for healthy women of childbearing age. If blood pressure is repeatedly elevated, especially above 140/90 mmHg, and fear and pain can be
ruled out as causes, the obstetrician should be notified.
Dental Treatment
Figure 1 summarizes physiologic and other changes
associated with pregnancy, and outlines the various diagnostic and treatment options for dental concerns. These
patients have a heightened awareness of and sensitivity to
taste, smell and environmental temperature. Unpleasant
tastes and odours can cause severe nausea or even gagging and vomiting, and overheating can lead to fainting.
Acknowledged awareness and concern on the part of the
dental staff and control of the office environment to the
extent possible will contribute to patients’ comfort and
sense of well-being. Hypoglycemia may cause fainting; it
can be prevented by recommending that the patient eat
a snack containing protein and complex carbohydrates
before the appointment. Patients should be well hydrated,
and the duration of chair treatment time should be as
short as possible.
Timing of Treatment
Coronal scaling, polishing and root planing may
be performed at any time as required to maintain oral
health. However, routine general dentistry should usually only be done in the second and third trimester of
pregnancy. Organogenesis is completed by the end of
the first trimester, and uterine size has not increased to
the extent that sitting in the dental chair is uncomfortable. Moreover, nausea has generally ceased by the end of
the first trimester. Extensive elective procedures should
be postponed until after delivery. Any treatment should
be directed toward controlling disease, maintaining a
healthy oral environment and preventing potential problems that could occur later in the pregnancy or during
the postpartum period. 3
Radiography
Oral radiography is safe for pregnant patients, provided protective measures such high-speed film, a lead
apron and a thyroid collar are used. No increase in congenital anomalies or intrauterine growth retardation has
been reported for x-ray radiation exposure during pregnancy totalling less than 5–10 cGy, 5,6 and a full-mouth
series of dental radiographs results in only 8 × 10 –4 cGy.5
A bitewing and panoramic radiographic study generates
about one-third the radiation exposure associated with
a full-mouth series with E-speed film and a rectangular
collimated beam.7
Patients who are concerned about radiography during
pregnancy should be reassured that in all cases requiring
45
Infection
Odontogenic infection should be
treated promptly at any time during
pregnancy. Although pregnant patients are usually not immunocompromised, the maternal immune
system does become suppressed in
response to the fetus.1 As such, there
is a decrease in cell-mediated immunity and natural killer cell activity.
Consequently, odontogenic infections
Figure 3: Pyogenic granuloma.
Figure 2: Pregnancy gingivitis.
have the potential to develop rapidly
into deep-space infections and to
compromise the oral–pharyngeal
airway. Abscesses should be drained
such imaging, the dental staff will practise the ALARA (As and the offending pulp extirpated or the tooth removed
Low As Reasonably Achievable) principle and that only to control the infection. The obstetrician should be informed of the patient’s status and the planned course of
radiographs necessary for diagnosis will be obtained.8
and rationale for treatment discussed. Patients who are in
Periodontal Disease
acute dental pain should be cared for in a similar manner.
Pregnancy gingivitis (Fig. 2) usually appears in the Long-term use of analgesics instead of definitive treatfirst trimester of pregnancy. This form of gingivitis re- ment is inappropriate. The patient should not have to wait
sults from increased levels of progesterone and estrogen until after delivery before treatment is provided.
causing an exaggerated gingival inflammatory reaction
to local irritants. The interproximal papillae become Medications
red, edematous and tender to palpation, and they bleed
Another concern is the prescribing and administration
easily if subjected to trauma. In some patients, the of drugs. The most obvious concern is that the drug will
condition will progress locally to become a pyogenic cross the placental barrier and cause teratogenic effects to
granuloma or “pregnancy tumour,” which is most com- the fetus. The U.S. Food and Drug Administration (FDA)
monly seen on the labial surface of the papilla (Fig. 3). has defined categories of pregnancy risk associated with
Small lesions respond well to local debridement, chlor- various drugs (Table 1), and guidelines for safely prehexidine rinses and improved oral hygiene measures, but scribing drugs during pregnancy have been published.4
large lesions require deep excision. Because intraoperaAnalgesics
tive bleeding can be difficult to control, such surgery
Analgesic drug categories are based on short-term
should be performed by clinicians with requisite training
use (over 2 or 3 days) to treat a specific disease process.
and experience.
Acetaminophen, which is in pregnancy risk category B, is
Tooth mobility is a sign of periodontal disease
the safest analgesic for use during pregnancy. However,
caused by mineral changes in the lamina dura and disbecause various strengths and preparations are available
turbances in the periodontal ligament attachments.
and because there is a potential for liver toxicity, paVitamin C deficiency contributes to this problem, so
tients should be instructed on how to take the drug and
the patient should be advised accordingly. 3 Removal the maximum recommended daily dose (no more than
of local gingival irritants, therapeutic doses of vita- 4 g/day for adults).
min C and delivery typically result in reversal of the
The majority of the other commonly prescribed antooth mobility. 3
algesics are in pregnancy risk category C. It should be
Some observational and interventional studies have remembered that although category C drugs are generally
shown an association between periodontal disease and safe, information from well-controlled human studies
adverse pregnancy outcomes such as preterm labour is not available. Therefore, prescriptions for these drugs
and low birth weight,9,10 but other studies have shown should specify the most effective therapeutic dose for
no relation between periodontal disease and pregnancy the shortest time. Ibuprofen is a category B analgesic
outcomes.11 While research continues into the patho- in the first and second trimesters, but it is a category D
physiology of a cause-and-effect relation between oral drug during the third trimester because it has been ashealth and pregnancy outcomes, it is prudent to keep the sociated with lower levels of amniotic fluid, premature
pregnant patient’s periodontal system as free of disease closure of the fetal ductus arteriosus and inhibition
of labour when taken during this time.12 It should be
as possible.
46
––– Pregnant Patients –––
prescribed only after consultation with and advice from
the obstetrician. Obstetricians often prescribe a combination of acetaminophen and codeine or oxycodone in place
of nonsteroidal anti-inflammatory drugs. Prolonged use
of narcotic analgesics in the third trimester can lead to
neonatal respiratory depression. 3 In general, this does
not appear to be a concern for the dose regimens typically prescribed in association with dental treatment.
Recently, however, concern has been raised about the
use of codeine by nursing mothers. In some women,
codeine is more rapidly metabolized into morphine, and
the morphine can be passed along by a mother who is
breast-feeding an infant. Genetic testing is the only way
to determine whether someone is a “rapid metabolizer,”
so nursing mothers who are taking codeine should be
made aware of the signs of morphine overdose in their
infants. A mother should contact her doctor if her baby
shows signs of increased sleepiness (more than 4 hours at
a time), limpness or difficulty nursing or breathing.13
Antibiotics and Antimicrobials
Most antibiotics that are commonly prescribed by
dentists are category B drugs, with the exception of tetracycline and its derivatives (e.g., doxycycline), which are
in category D because of their effects on developing teeth
and bone. Ciprofloxacin, a broad-spectrum floroquinolone antibiotic used to treat periodontal disease associated with Actinobacillus actinomycetemcomitans, is
in category C. Its use in pregnancy has been restricted
because of arthropathy and adverse effects on cartilage
development observed in immature animals. There are
not enough data to definitively determine its safety in
humans.14 Metronidazole is in category B. Some authors
caution against its use in the first trimester because of potential harm to the fetus; however, recent studies showed
no definitive teratogenic effects.15–17 The risk–benefit ratio
for the patient should be determined and the obstetrician
consulted before prescribing this drug. The estolate form
of erythromycin should be avoided because of deleterious
effects on the mother’s liver. Chlorhexidine gluconate is a
category B antimicrobial mouth rinse.
Local Anesthetics
Local anesthetics are relatively safe when administered properly and in the correct amounts. Lidocaine and
prilocaine are category B drugs, whereas mepivacaine,
articaine and bupivacaine are in category C. Epinephrine
is also a category C drug. This drug has been studied
in amounts of up to 0.1 mg added to local anesthetics
used for epidural anesthesia (administered for pain
relief during labour); no unusual side effects or complications have been reported in this context.18 During
administration of a local anesthetic with epinephrine, an
intravascular injection may, at least theoretically, cause
insufficiency of uteroplacental blood flow. However, for
a healthy pregnant patient, the 1:100,000 epinephrine
concentration used in dentistry, administered by proper
aspiration technique and limited to the minimal dose
required, is safe.3
Fluoride
Fluoride is a category C drug. Fluoride treatment may
be needed for patients with severe gastric reflux caused
by nausea and vomiting during early pregnancy, which
can cause erosion of tooth enamel. In these cases, fluoride
treatment and restorations to cover the exposed dentin
can diminish the sensitivity of and injury to the dentition. Topical fluoride gel may cause nausea, so application
of a fluoride varnish may be better tolerated. The application of topical fluoride should follow evidence-based
guidelines.19
Sedatives and Anxiolytics
Barbiturates and benzodiazepines are category D
drugs and should be avoided during pregnancy.
Benzodiazepines have been implicated in the development of cleft lip and palate. Nitrous oxide is not rated in
the FDA classification system, and its use during dental
treatment is still controversial. The results of a survey of
more than 50,000 dentists and dental hygienists, which
suggested that long-term exposure to nitrous oxide may
be associated with reproductive problems such as spontaneous abortion and birth defects, have been called
into question because of perceived inherent biases of the
study design. However, nitrous oxide is known to affect
vitamin B12 metabolism, rendering the enzyme methionine synthase inactive in the folate metabolic pathway.
Because methionine synthase is vital for the production
of DNA, it is best to avoid the use of nitrous oxide in
the first trimester of pregnancy, when organogenesis is
occurring.20
The greatest concern for patient safety during the administration of nitrous oxide analgesia is the potential for
hypoxia. The use of modern anesthetic machines, which
are equipped with fail-safe and flow-safe systems, greatly
diminishes the potential for hypoxia. If nitrous oxide is
necessary for patient comfort, the analgesia technique
should be discussed with the patient and obstetrician to
be sure the pregnancy is progressing normally. After the
first trimester of pregnancy, short-term administration of
nitrous oxide (to ease apprehension during administration of a local anesthetic), with a minimal concentration
of 50% oxygen, should be safe. 3,20
Conclusions
Optimal oral health is very important for the pregnant
patient and can be provided safely and effectively. Paying
attention to the physiologic changes associated with
pregnancy, practising careful radiation hygiene measures, prescribing medications on the basis of drug safety
47
categories and timing appointments and aggressive management of oral infection appropriately are important
considerations. Given the possibility that periodontal
disease may affect pregnancy outcomes, dentists need to
play a proactive role in the maintenance of the oral health
of pregnant women. a
THE AUTHORS
Dr. Giglio is a professor and director, pre-doctoral education, department of oral and maxillofacial surgery, School of
Dentistry, and a professor of surgery, department of surgery,
division of oral and maxillofacial surgery, School of Medicine,
Virginia Commonwealth University, Richmond, Virginia.
Dr. Lanni is an associate professor and director, labor and delivery,
department of obstetrics and gynecology, School of Medicine, Virginia
Commonwealth University, Richmond, Virginia.
13. Medscape Alerts. FDA warns against codeine for mothers of nursing infants. Available: www.medscape.com/viewarticle/561590?src=mp (accessed
2008 Nov 10).
14. U.S. Food and Drug Administration/Center for Drug Evaluation and
Research. Cipro (Ciprofloxacin) use by pregnant and lactating women.
Available: www.fda.gov/cder/drug/infopage/cipro/cipropreg.htm (accessed
2008 Nov 10).
15. MedicineNet, Inc. Metronidazole. Available: www.medicinenet.com/
metronidazole/article.htm (accessed 2008 Nov 10).
16. Diav-Citrin O, Shechtman S, Gotteineer T, Arnon J, Ornoy A. Pregnancy
outcome after gestational exposure to metronidazole: a prospective controlled cohort study. Teratology 2001; 63(5):186–92.
17. Kazy Z, Puhó E, Czeizel AE. Teratogenic potential of vaginal metronidazole
treatment during pregnancy. Eur J Obstet Gynecol Reprod Biol 2005;
123(2):174–8.
18. Gurbet A, Turker G, Kose DO, Uckunkaya N. Intrathecal epinephrine in
combined spinal-epidural analgesia for labor: dose–regimen relationship for
epinephrine added to a local anesthetic-opioid combination. Int J Obstet
Anesth 2005; 14(2):121–5.
19. Levy SM. An update on fluorides and fluorosis. J Can Dent Assoc 2004;
69(5):286–91.
20. Clark MS, Branick AL. Handbook of nitrous oxide and oxygen sedation.
2nd ed. St. Louis: CV Mosby; 2003. p. 173–90.
Dr. Laskin is a professor and chairman emeritus, department of oral and maxillofacial surgery, School of Dentistry,
and professor of surgery, department of surgery, division of
oral and maxillofacial surgery, School of Medicine, Virginia
Commonwealth University, Richmond, Virginia.
Ms. Giglio is a certified nurse-midwife in private home birth practice,
Richmond Birth Services, Inc., Richmond, Virginia.
Correspondence to: James A. Giglio, Virginia Commonwealth University
School of Dentistry, Department of oral and maxillofacial surgery, P.O.
Box 980566, Richmond, VA 23298-0566.
Natural,
Clinically Tested,
OTC Treatments
for Cold Sores &
Canker Sores
The authors have no declared financial interests.
References
1. Gordon MC. Maternal physiology in pregnancy. In: Gabbe SG, Niebyl JR,
Simpson J, editors. Obstetrics: normal and problem pregnancies. 4th ed.
New York: Churchill Livingstone; 2002. p. 63–91.
2. Thornburg KL, Jacobson SL, Giraud GD, Morton MJ. Hemodynamic
changes in pregnancy. Semin Perinatol 2000; 24(1):11–4.
3. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of
the medically compromised patient. 7th ed. St. Louis: CV Mosby; 2008.
p. 268–278, 456.
4. Meadows M. Pregnancy and the drug dilemma. FDA Consumer 2001;
Vol. 35, No. 3. Available: www.fda.gov/fdac/features/2001/301_preg.html
(accessed 2008 Nov 10).
5. National Council on Radiation Protection and Measurements.
Recommendations on limits for exposure to ionizing radiation. Bethesda,
Md. NCRP, 1987. NCRP report no. 91.
6. Katz VL. Prenatal care. In: Scott JR, Gibbs RS, Karlan BY, Haney AF, editors. Danforth’s obstetrics and gynecology. 9th ed. Philadelphia: Lippincott,
Williams and Wilkins; 2003. p. 1–20.
7. Freeman JP, Brand JW. Radiation doses of commonly used dental radiographic surveys. Oral Surg Oral Med Oral Pathol 1994; 77(3):285–9.
8. Carlton RR, Adler AM, Burns B. Principles of radiographic imaging. 3rd ed.
Clifton Park, New York: Thompson Delmar Learning; 2000. p. 158.
9. Offenbacher S, Lieff S, Boggess KA, Murtha AP, Madianos PN, Champagne
CM, and others. Maternal periodontitis and prematurity. Part 1: Obstetric
outcomes of prematurity and growth restriction. Ann Periodontol 2001;
6(1):164–74.
10. López NJ, Smith PC, Gutierrez J. Higher risk of preterm birth and
low birth weight in women with periodontal disease. J Dent Res 2002;
81(1):58–63.
11. Michalowicz BS, Hodges JS, DiAngelis AJ, Lupo VR, Novak MT, Ferguson
JE, and others. Treatment of periodontal disease and the risk of preterm
birth. N Eng J Med 2006; 355(18):1885–94.
12. Organization of teratology Information Specialists. Ibuprofen and pregnancy. Available: www.otispregnancy.org/pdf/Ibuprofen.pdf (accessed 2008
Nov 10).
48
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Clinical
Practice
The Changing Field of Temporomandibular
Disorders: What Dentists Need to Know
Contact Author
Gary D. Klasser, DMD; Charles S. Greene, DDS
Dr. Klasser
ABSTRACT
Diagnosis and treatment of temporomandibular disorders (TMDs) have been within the
domain of dentistry for many decades. However, the field of TMDs and other causes
of orofacial pain is undergoing a radical change, primarily because of an explosion of
knowledge about pain management in general. As a result, etiological theories about
TMDs are evolving toward a biopsychosocial medical model from the traditional dental
framework. Conservative and reversible management approaches (especially of chronic
pain conditions) are becoming the norm rather than the exception in treating TMD
patients, and already certain biological and psychosocial factors are known to affect
the outcomes. Current research in this field is focused on genetic and environmental
susceptibility factors as well as individual adaptive potentials. To continue as the main
providers of care for TMD patients, dentists will need to recognize and appreciate these
important changes.
T
emporomandibular disorders (TMDs)
are defined by the American Academy
of Orofacial Pain as “a collective term
that embraces a number of clinical problems
that involve the masticatory muscles, the TMJ
[temporomandibular joint], and the associated
structures.”1 Pain and dysfunctional symptoms or signs such as limitations in opening,
asymmetric jaw movements and TMJ sounds
are the most common findings (Box 1).
The concept of TMDs as part of the constellation of musculoskeletal disorders, rather
than some special kind of dental condition,
is relatively recent. In 1918, Prentiss2 initiated interest in the dental community when
he suggested that the development of “TMJ
problems” was due to the following process:
“When the teeth are extracted, the condyle
is pulled upward by the powerful muscula
ture and pressure on the meniscus results in
atrophy.” This was soon followed by several
articles from other dentists, who emphasized
missing teeth and lost vertical dimension
leading to displacement of the mandible as the
cause of the signs and symptoms displayed by
patients with TMD. 3–5
It was not until 1934 that dentists were
given ownership of this problem, when J.B.
Costen, an otolaryngologist, pronounced that
the TMJ was a separate source of facial pain
and several other associated symptoms, due to
nerve impingement from overclosure of bites,
lack of molar support and malocclusion.6 Over
the next 5 years, he followed up with 11 more
articles emphasizing these structural concepts
as the etiology for TMDs and urging dentists
to take responsibility for managing them.
49
––– Klasser –––
Box 1
Common signs and symptoms of temporomandibular disorders
• Pain or tenderness in the temporomandibular
joint, muscles of mastication, facial areas, ear
region, shoulder and neck
• A clicking, popping or grating sound when
opening or closing the mouth or while chewing
• Catching or locking of the joint with deviations
or deflections of the mandible on opening or
closing the mouth
• Limitations in opening or closing the mouth
• Difficulty or discomfort while chewing
• Sensation of an uncomfortable bite
It was subsequently shown that Costen’s explanation
of the anatomic relations between the TMJ and ear and
sinus structures was incorrect.7,8 However, terms such
as overclosed vertical dimension, condylar malposition,
trapped mandibles, occlusal disharmony and neuromuscular imbalance developed from the initial conceptual framework, and treatments to correct these problems
became the basis for a variety of invasive and irreversible
dental therapies, including bite-opening, occlusal adjustments, major restorative dentistry, orthodontics and even
surgeries. Whatever one may think of these concepts
and interventions, it is clear that they were the basis for
a mechanical, dentistry-oriented etiological viewpoint
and that the related therapies were seen as being antietiologic. In fact, the word definitive was often used to
describe the curative value of these approaches to TMD
treatment.
Over the next 7 decades, the field of TMDs experienced many taxonomic and conceptual changes. Various
labels, such as TMJ syndrome, TMJ pain-dysfunction
syndrome and myofascial pain-dysfunction syndrome,
were applied to TMDs. Fortunately, single-disease concepts have been discarded because of their simplicity and
naiveté, and the early dental mechanical theories of misaligned jaws or faulty occlusal relations have largely been
discredited.9 Today, TMDs are being studied and treated
from a medical perspective that involves orthopedic principles, combined with a biopsychosocial understanding
of how chronic pain disorders affect those who have
them.10,11 Furthermore, studies of patients with TMD
have shown that many of them, especially females, experience a multitude of other functional (nonorganic)
disorders, such as fibromyalgia, interstitial cystitis, irritable bowel syndrome and pelvic pain, while others have
reported multiple sites of pain throughout their bodies.12
These high levels of comorbidity with other conditions
have led to hypotheses about centrally mediated dys50
regulatory problems producing multiple symptoms in
susceptible patients.
The aim of this paper is to make dentists aware of the
significant conceptual and practical changes that have
already occurred or are in the process of emerging in the
field of TMDs, so that they can continue to play an important role in the management of these disorders.
Etiology of TMDs
Greene13 defined etiology as the following: “We want
to know why a particular patient began to have both the
biology and the perception of his/her pain (in the absence
of frank trauma).” It is within the context of this definition that the etiology of TMDs is discussed here.
In addition to the early views described above, various
disciplines of dentistry and other areas of health care
have proposed theories about the etiology of TMDs. For
example, the field of orthodontics developed its own version of structural disharmony concepts and corrective
treatments within an orthodontic framework.14 Another
structural concept of TMD etiology, proposed by some
physical therapists, chiropractors and dentists, is based
on the notion that “bad” craniocervical relations may
be causing TMDs. Although this idea has enjoyed some
popularity in the past (and is still popular in some regions of the world), several studies have demonstrated
that there are no consistent postural findings that differentiate TMD patients from other people.15–18 Although
many patients complain of concomitant cervical pain
and TMDs, this should be understood as comorbidity
resulting from functional rather than structural relations. In addition, this common clinical finding may be
a result of heterotopic (referred) pain in these areas, due
to the neuroanatomic and neurophysiologic convergence
of cervical and cranial sensory nerves in the brainstem
nuclei.19,20
The theories of TMD etiology that have made the
largest impact are related to various types of occlusal imperfection. Occlusion is a very important subject within
the profession of dentistry, especially as it pertains to
orthodontics, restorative dentistry and prosthodontics;
however, its relevance to the etiology of TMDs is questionable, especially in chronic conditions. In a review of
57 epidemiological studies of the relation between occlusion and TMDs, Okeson 21 found that 35 suggested a relation compared with 22 studies that suggested no relation.
The “positive” occlusal findings in the 35 studies varied
so widely that no consistent feature could be identified.
The occlusal disharmonies cited in these studies were also
prevalent among many symptom-free people.
McNamara and others22 reviewed the role of morphologic and functional occlusal factors with respect to
development of TMDs and found only a weak relation
between them. Koh and Robinson 23 systematically reviewed the literature pertaining to occlusal adjustments
––– Changing Field of TMDs –––
Table 1 Relations among diagnosis, etiology and treatment in TMDs
Standard
Diagnosis
Etiology
Treatment
Ideal
Correct
Measurable
Demonstrable
Specific
Measurable
Treatable
Anti-etiologic
Definitive/curative
Successful
Acceptable
Presumptive
Probably correct
Universal labels
Unclear
Complex
Reversible
Validated response
Matched to diagnosis
Conservative
Wrong/bad
Personal label
Technologic diagnosis
Possibly correct
Experience based
Morphofunctional analysis
Mechanistic
Prolonged use of an oral appliance
Bite-changing procedures
Jaw-repositioning procedures
Fringe
Misdiagnosis of pain
Neglect pathology
Neglect chronicity
Guru/cult concepts
Quackery concepts
Specialty bias
Whole-body procedures
Unorthodox treatments
Extreme dental intervention
Adapted with permission from Greene.13
for treating and preventing TMD. After reviewing specific outcome measures, they concluded that there was no
evidence for the use of occlusal adjustment procedures
for either the treatment or prevention of TMD.
In addition to structure, other etiological factors24,25
have been proposed and discussed as a result of large
studies of patient populations. For example, trauma at
both the macro and micro levels has been noted in the
history of certain TMD patients, with a rather clear relation to onset of symptoms in many cases.13 A psychophysiological theory of the etiology of TMDs was
developed in the 1950s and 1960s, with particular emphasis on the category of myofascial pain and dysfunction.26–28 Even though Laskin’s classic article about the
etiology of myofascial pain and dysfunction 26 served as
the basis for much of this work, eventually his psychophysiological theory proved to be incomplete as an explanation for the development of myofascial pain. Today,
the importance of psychological factors in the onset,
progression, treatment and persistence of various TMDs
is well recognized as foundational knowledge in this field.
However, the reasons why some patients exhibit TMD
symptoms while others do not remains unexplained by
the psychophysiological theory of etiology.
Currently the most popular theories regarding TMD
etiology are based on the biopsychosocial model, which
involves a combination of biological, psychological and
social factors.10,29 These 3 words provide an excellent descriptor of the world that most patients with pain (and
especially patients with chronic pain) are living with on a
daily basis. They have a biological problem (i.e., activation
of pain pathways, with or without a demonstrable pathologic condition) that may have psychological antecedents
as well as behavioural consequences. This situation exists
in a social framework that includes interpersonal relationships with friends, families and health care pro
viders, which almost always produces major negative
experiences for the patients as well as for their immediate
families. Unlike the mechanistic dental theories of etiology, the biopsychosocial model encourages a rehabilitation–management approach rather than providing the
unrealistic expectation of a permanent cure (which is
even less likely in chronic conditions). Unfortunately, due
to the limitations of current physical diagnostic procedures for assessing pain conditions, as well as the crude
psychometric tools that are currently available, the biopsychosocial model lacks the ability to assess all of these
variables at the individual patient level and, therefore, is
useful only at the group level.
Dentists should appreciate and recognize that the inability to identify precise etiologies or the lack of a perfect
theoretical model does not prevent the rendering of reasonable and effective treatment. It is acceptable, as occurs
daily in the medical profession, to provide a presumptive
diagnosis that is probably correct, then to deliver reversible, conservative, noninvasive and empirically validated
targeted treatments (Table 1). For example, a painful
TMJ that began to cause pain without any specific initiating event or cause can still be successfully treated using
medications, appliances or physical therapy in various
combinations. By following these foundational concepts,
dentists can take a “low-tech and high-prudence” therapeutic approach to TMD patient care. 30
Future Directions in the Field of TMDs
The changes taking place in the field of TMDs are not
driven purely by dental research, but are coming more
from progress in the larger field of pain management.
Multiple research projects around the world involving
basic and clinical sciences as well as translational activities (the merging of basic and clinical activities) are
greatly influencing our understanding of pain. TMDs are
51
––– Klasser –––
currently being investigated in terms of orthopedic principles, neurophysiological aspects of pain, neuroanatomic
regions of pain processing, molecular and cellular pathophysiology of muscle and joints and behavioural aspects
of chronic pain. From these domains, 3 main areas of
investigation have emerged.
Genetics
Human genetic studies are providing us with a better
understanding of inherent susceptibility to pain, variability in pain perception and responses and the factors
that predict risk of chronification of pain. 31–33 Some investigators have looked at catechol-O-methyltransferase
(COMT), an enzyme that is responsible for metabolizing
catecholamine and is involved in pain perception, cognitive function and mood. 34 Studies have reported that
carriers of the low-pain haplotype on the gene that codes
for COMT appear to have 2.3 times less risk of developing
myogenous TMD. 35 In another study, people who have
genetic coding for certain levels of adrenergic receptor
expression were shown to be about 10 times less likely
to develop TMDs. 36 Numerous other genes code for the
neurotransmitters and neuromodulators that influence
pain sensitivity. 37 The implications of these findings for
the management of patients with pain may ultimately be
to tailor treatment approaches to the individual or provide pharmaceutical agents targeted at specific receptors.
Pathophysiology
A plethora of information is erupting regarding the
molecular chemistry and cellular biology of various types
of pain. Understanding of the pathophysiology of conditions that affect the TMJ has been greatly enhanced
by these discoveries. For example, inflammation in the
synovial tissues of the TMJ is the main determinant
of whether the joint becomes painful. Complex cellular
processes such as activation of T cells, macrophages
and plasma cells with the expression of a multitude of
inflammatory mediators, such as prostaglandins, serotonin, proinflammatory cytokines and their antagonists,
drive the inflammatory cascade. 38 It appears that both
the absolute levels of this inflammatory “soup” and the
balance between pro- and anti-inflammatory substances
are important in the pain process and the propensity
for chronification. 39 In addition, neurochemicals from
sympathetic efferents (neuropeptide Y, norepinephrine
and others) and neuroendocrine peptides (substance P,
calcitonin gene-related peptides and others) are involved
by having bidirectional communication with the immune
system and, thus, contributing to TMJ pain. 38
Currently, the pathophysiology of muscle pain is not
as well understood. Numerous mechanisms have been
considered as sources of muscle pain, yet the literature
has not provided definitive answers. Localized factors,
such as microtrauma, local ischemia or hypoperfusion
52
can produce structural or functional consequences, because of the release of endogenous algesic substances
(glutamate, histamine and others) from tissue cells and
afferent nerve fibres leading to excitation or sensitization of muscle nociceptors.40 Central processes involving
neuroendocrine factors (endogenous and exogenous hormones) as well as neurophysiological mechanisms (peripheral and central sensitization) also play a role in the
pathophysiology of muscular pain.41 Combinations of
local and central factors must also be considered.
As more research is undertaken and new information
emerges, dentists should be aware of it and recognize that
treatments directed at the underlying pathophysiology
of both arthrogenous and myogenous painful conditions
will inevitably result in a more precise and targeted medical approach to treatment.
Predictive Factors
Predicting responses to therapeutic interventions in
pain patients (including those with TMDs) by identifying
certain physical and psychological factors is currently
being done with some success.12,42 A major focus of current research is trying to prevent acute pain conditions
from developing into chronic ones. This requires good
early intervention and treatment strategies as well as
better predictors of who is most likely to develop such
problems. The discovery of more predictors should enhance the ability of dentists to develop appropriate treatment plans tailored to the individual patient.
Conclusions
The field of TMDs is undergoing a major transformation as a result of research findings about pain in general,
as well as specific advances within the field. As a result,
TMDs are currently recognized as a subset of musculoskeletal pain conditions, and this requires a medical
perspective to understand and manage TMD patients.
For the dental profession, the implications of this information are profound and serious in most TMD cases,
but especially in chronic conditions. Essentially, it means
that dentists should try to avoid invasive, irreversible and
aggressive treatments that are intended to “cure” these
problems. Instead, more reversible and conservative medically based management strategies are recommended to
reduce pain and improve function, an approach that has
been shown to be successful for most TMD patients.1
In the future, treatment modalities directed at the
pathophysiological processes of joint and muscle pain as
well as the psychosocial aspects of chronic pain will need
to be tailored to each patient’s individual problems. For
now, the cautious approach recommended by Stohler and
Zarb30 (low-tech and high-prudence) must be understood
and followed so that dentists can continue to serve as the
primary providers of care for TMD patients. If not, then
it seems inevitable, as scientific discovery continues and
––– Changing Field of TMDs –––
provides us with a deeper understanding of these patients, that “ownership” of this group of disorders will be
lost to other medically oriented health practitioners. a
19. Sessle BJ. Sensory and motor neurophysiology of the TMJ. In: Laskin DM,
Greene CS, Hylander WL, editors. Temporomandibular disorders: an evidence-based approach to diagnosis and treatment. Chicago: Quintessence;
2006. p. 69–88.
20. Tal M, Devor M. Anatomy and neurophysiology of orofacial pain. In:
Sharav Y, Benoliel R, editors. Orofacial pain and headache. Edinburgh:
Elsevier; 2008. p. 19–44.
THE AUTHORS
Dr. Klasser is an assistant professor in the department of
oral medicine and diagnostic sciences, University of Illinois at
Chicago, College of Dentistry, Chicago, Illinois.
Dr. Greene is a clinical professor in the department of orthodontics, University of Illinois at Chicago, College of Dentistry,
Chicago, Illinois.
Correspondence to: Dr. Gary D. Klasser, University of Illinois at Chicago,
College of Dentistry, Department of oral medicine and diagnostic sciences,
801 South Paulina Street, Room 569C (M/C 838), Chicago, IL 60612-7213.
21. Okeson JP. Etiology of functional disturbances in the masticatory system.
In: Management of temporomandibular disorders and occlusion. St. Louis:
Mosby; 2008. p. 130–63.
22. McNamara JA Jr, Seligman DA, Okeson JP. Occlusion, orthodontic treatment, and temporomandibular disorders: a review. J Orofac Pain 1995;
9(1):73–90.
23. Koh H, Robinson PG. Occlusal adjustment for treating and preventing
temporomandibular joint disorders. Cochrane Database Syst Rev 2003;
(1):CD003812.
24. Seligman DA, Pullinger AG. The role of functional occlusal relationships
in temporomandibular disorders: a review. J Craniomandib Disord 1991;
5(4):265–79.
25. Gesch D, Bernhardt O, Kirbschus A. Association of malocclusion and
functional occlusion with temporomandibular disorders (TMD) in adults:
a systematic review of population-based studies. Quintessence Int 2004;
35(3):211–21.
26. Laskin DM. Etiology of the pain-dysfunction syndrome. J Am Dent Assoc
1969; 79(1):147–53.
27. Schwartz L. Conclusions of the temporomandibular joint clinic at
Columbia. J Periodontol 1958; 29:210–2.
References
1. Temporomandibular disorders. In: de Leeuw R, editor. American Academy
of Orofacial Pain. Orofacial pain: guidelines for assessment, diagnosis and
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2. Prentiss HJ. A preliminary report upon the temporomandibular articulation
in the human type. Dent Cosmos 1918; 60(6):505–12.
3. Monson GS. Impaired function as a result of closed bite. J Natl Dent Assoc
1920; 7(5):399–404.
28. Moulton RE. Emotional factors in non-organic temporomandibular joint
pain. Dent Clin North Am 1966; Nov: 609–20.
29. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196(4286):129–36.
30. Stohler CS, Zarb GA. On the management of temporomandibular disorders: a plea for a low-tech, high-prudence therapeutic approach. J Orofac
Pain 1999; 13(4):255–61.
4. Wright WH. Deafness as influenced by malposition of the jaws. J Natl Dent
Assoc 1920; 7(12):979–92.
31. Lötsch J, Geisslinger G. Current evidence for a modulation of nociception
by human genetic polymorphisms. Pain 2007; 132(1–2):18–22.
5. Goodfriend DJ. Dysarthrosis and sub-arthrosis of the mandibular articulation. Dent Cosmos 1932; 74(6):523–35.
32. Diatchenko L, Nackley AG, Tchivileva IE, Shabalina SA, Maixner W. Genetic
architecture of human pain perception. Trends Genet 2007; 23(12):605–13.
6. Costen JB. A syndrome of ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint. Ann Otol Rhinol Laryngol
1934; 43(1):1–15.
33. Diatchenko L, Nackley AG, Slade GD, Bhalang K, Belfer I, Max MB, and
others. Catechol-O-methyltransferase gene polymorphisms are associated
with multiple pain-evoking stimuli. Pain 2006; 125(3):216–24.
7. Sicher H. Temporomandibular articulation in mandibular overclosure. J Am
Dent Assoc 1948; 36(2):131–9.
34. Nackley AG, Shabalina SA, Tchivileva IE, Satterfield K, Korchynskyi O,
Makarov SS, and others. Human catechol-O-methyltransferase haplotypes
modulate protein expression by altering mRNA secondary structure. Science
2006; 314(5807):1930–3.
8. Zimmermann AA. An evaluation of Costen’s syndrome from an anatomic point of view. In: Sarnat BG, editor. The temporomandibular joint.
Springfield: Charles C. Thomas; 1951. p. 82–110.
9. Greene CS, Laskin DM. Temporomandibular disorders: moving from a dentally based to a medically based model. J Dent Res 2000; 79(10):1736–9.
10. Dworkin SF, Massoth DL. Temporomandibular disorders and chronic
pain: disease or illness? J Prosthet Dent 1994; 72(1):29–38.
11. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique.
J Craniomandib Disord 1992; 6(4):301–55.
12. de Leeuw R, Klasser GD, Albuquerque RJ. Are female patients with orofacial pain medically compromised? J Am Dent Assoc 2005; 136(4):459–68.
35. Diatchenko L, Slade GD, Nackley AG, Bhalang K, Sigurdsson A, Belfer I,
and others. Genetic basis for individual variations in pain perception and
the development of a chronic pain condition. Hum Mol Genet 2005;
14(1):135–43.
36. Diatchenko L, Anderson AD, Slade GD, Fillingim RB, Shabalina SA,
Higgins TJ, and others. Three major haplotypes of the beta2 adrenergic
receptor define psychological profile, blood pressure, and the risk for development of a common musculoskeletal pain disorder. Am J Med Genet B
Neuropsychiatr Genet 2006; 141B(5):449–62.
13. Greene CS. The etiology of temporomandibular disorders: implications
for treatment. J Orofac Pain 2001; 15(2):93–105.
37. Kim H, Mittal DP, Iadarola MJ, Dionne RA. Genetic predictors for acute
experimental cold and heat pain sensitivity in humans. J Med Genet 2006;
43(8):e40.
14. Greene CS. Orthodontics and temporomandibular disorders. Dent Clin
North Am 1988; 32(3):529–38.
38. Kopp S. Neuroendocrine, immune, and local responses related to temporomandibular disorders. J Orofac Pain 2001; 15(1):9–28.
15. Hackney J, Bade D, Clawson A. Relationship between forward head posture and diagnosed internal derangement of the temporomandibular joint.
J Orofac Pain 1993; 7(4):386–90.
39. Uceyler N, Valenza R, Stock M, Schedel R, Sprotte G, Sommer C.
Reduced levels of antiinflammatory cytokines in patients with chronic widespread pain. Arthritis Rheum 2006; 54(8):2656–64.
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17. Olivo SA, Bravo J, Magee DJ, Thie NM, Major PW, Flores-Mir C. The association between head and cervical posture and temporomandibular disorders: a systematic review. J Orofac Pain 2006; 20(1):9–23.
18. Armijo Olivo S, Magee DJ, Parfitt M, Thie NM. The association between
the cervical spine, the stomatognathic system, and cranofacial pain: a critical
review. J Orofac Pain 2006; 20(4):271–87.
40. Sessle BJ. The neural basis of temporomandibular joint and masticatory
muscle pain. J Orofac Pain 1999; 13(4):238–45.
41. Svensson P, Graven-Nielsen T. Craniofacial muscle pain: review of mechanisms and clinical manifestations. J Orofac Pain 2001; 15(2):117–45.
42. Grossi ML, Goldberg MB, Locker D, Tenenbaum HC. Reduced neuropsychologic measures as predictors of treatment outcome in patients with
temporomandibular disorders. J Orofac Pain 2001; 15(4):329–39.
53
FDI Annual World Dental Congress
2 - 5 September 2009
Singapore
[email protected]
www.fdiworldental.org
Clinical
Practice
Dental Pulp Neurophysiology: Part 1. Clinical and
Diagnostic Implications
Contact Author
Ashraf Abd-Elmeguid, BDS, MDSc; Donald C. Yu, DMD, CAGS, MScD, FRCD(C)
Dr. Yu
Email: donaldyu@
ualberta.ca
ABSTRACT
Diagnosis in endodontics requires an understanding of pulpal histology, neurology
and physiology, and their relationship to the various diagnostic tests commonly used
in dental practice. Thermal changes in the oral environment cause rapid displacement
of dentinal tubular contents, resulting in pain. This effect, known as the hydrodynamic
effect, is the regulator of pain sensation in thermal-pulp testing. Hundreds of axons
enter the tooth from the apical foramen to provide it with its sensory supply. The nerve
supply of the dentin–pulp complex is mainly made up of A fibres (both delta and beta)
and C fibres. They are classified according to their diameter and their conduction velocity. The A fibres are mainly stimulated by an application of cold, producing sharp pain,
whereas stimulation of the C fibres produces a dull aching pain. Because of their location
and arrangement, the C fibres are responsible for referred pain. This first part of a 2-part
review examines the relation between clinical sensations during the diagnostic visit and
the neurophysiology of the dental pulp to explore the connection between the art (clinical diagnosis) and the science (neurophysiology) of endodontics.
T
he purpose of diagnosis in endodontics is
to assess the condition of a tooth — the
object of the patient’s complaint — and to
identify the cause of the pain or discomfort.
Diagnosis is the art of identifying the problem
and using scientific knowledge to determine
the cause of the problem. Knowledge of the
physiology of pain and methods of interpreting
it with available clinical diagnostic devices is
essential to reach a proper diagnosis.
The patient’s history, or more specifically,
the history of the patient’s pain, is the first
clinical data that the dentist must collect and
consider. The dentist should pay careful attention to the patient’s answers about the pain,
such as the type, duration, frequency, aggravating factors, effect of analgesics and tenderness when biting.
Once a preliminary or differential diagnosis is reached, further clinical examination
is needed to confirm the diagnosis, such as inspection of the extraoral soft tissues, examination of regional lymph nodes and an intraoral
examination that includes looking for signs
of a sinus tract, swelling of the soft tissues,
a mobile tooth or teeth, the condition of the
gingiva, and the number of decayed and restored teeth. A transillumination test1 may
reveal hidden decay or a fractured tooth and
may result in the diagnosis of a necrotic tooth
if enamel translucency is lost. In this simple
test, a strong light is placed behind the tooth.
A vital tooth transmits light well because of its
translucency, hence the term transillumination. A necrotic tooth appears dull and dark
because of its compromised blood supply and
55
––– Yu –––
Figure 1: Illustration of the movement of dentinal fluid inside
dentinal tubules in response to a hot stimulus (red arrow) and
a cold stimulus (blue arrow).
the degeneration of the pigments inside its dentinal tubules. Radiographs, along with these data, can localize
the offending tooth; then more specific tests can be done
to assess the vitality of the tooth pulp.
Assessment of pulp vitality is especially critical in
diagnosing cases where a periapical radiograph does not
show any obvious pathosis. This includes evaluating cases
of traumatized teeth or bridge abutments where a delay in
diagnosing a dead pulp or a poor evaluation before bridge
preparation may lead to inflammatory root resorption2 or
apical periodontitis3 respectively.
Pain is produced when a stimulus strong enough to
trigger a nervous response is applied to a tooth. The intensity, location and quality of pain will differ, depending
on the type of stimulus, as well as the type of nerve fibres
excited in the process. Pain is the main complaint for
which dental treatment is mostly sought. One study4
found that the most common orofacial pain is dental.
In this first part of our 2-part review, we discuss
the types and interpretation of pulpal pain induced by
various sensory fibres, using different clinical diagnostic
methods. We do not discuss the different stages of pulpal
inflammation, namely reversible and irreversible pulpitis,
and pulp necrosis as they are beyond the scope of this
review.
Types of Nerve Fibres and Their Distribution
Inside the Dental Pulp
Teeth are supplied by the alveolar branches of the fifth
cranial nerve, namely the trigeminal nerve (the maxillary
branch in the upper jaw and the mandibular in the lower
jaw). Dental pulp is a highly innervated tissue that contains sensory trigeminal afferent axons. 5,6 Sympathetic
56
efferent fibres regulate the blood flow; no consensus about
the role of parasympathetic fibres exists.7
The cell bodies of the sensory neurons of the pulp are
located in the trigeminal ganglion. Hundreds, perhaps
thousands, of axons found in the canines and premolars5,8
enter the pulp through the apical foramen where they
branch following the distribution of the blood supply all
over the pulp. The majority of the nerve bundles reach
the coronal dentin where they fan out to form the nerve
plexus of Raschkow. There, they anastomose and terminate as free nerve endings that synapse onto and into
the odontoblast cell layer (approximately 100–200 μm
deep in the dentinal tubules) and the odontoblastic cell
processes.7,9
The 2 types of sensory nerve fibres in the pulp are
myelinated A fibres (A-delta and A-beta fibres) and unmyelinated C fibres. Ninety percent of the A fibres are
A-delta fibres, which are mainly located at the pulp–
dentin border in the coronal portion of the pulp and concentrated in the pulp horns. The C fibres are located in
the core of the pulp, or the pulp proper, and extend into
the cell-free zone underneath the odontoblastic layer.10,11
The ratio of myelinated to unmyelinated fibres is difficult to ascertain because the nerve fibres in recently
erupted teeth with open apices may not yet have acquired
the myelin sheath.8,12
Clinical Implications for Intrapulpal Sensory
Nerve Fibres
The A-delta fibres have a small diameter and therefore a slower conduction velocity than other types of
A fibres, but are faster than C fibres. The A fibres transmit
pain directly to the thalamus, generating a fast, sharp
pain that is easily localized. The C fibres are influenced
by many modulating interneurons before reaching the
thalamus, resulting in a slow pain, which is characterized
as dull and aching.10
The A fibres respond to various stimuli such as
probing, drilling and hypertonic solutions through the
hydrodynamic effect.13–16 This effect depends on the
movement of the dentinal fluid in the dentinal tubules
in response to a stimulus. Although the normally slow
capillary outward movement does not stimulate the nerve
endings and cause pain,17–19 rapid fluid flow, as in the case
of desiccating or drying dentin, is more intense and is
likely to activate the pulpal nociceptors.13 Heat or cold
stimuli cause fluid movement through the dentinal tubules, resulting in a painful sensation in a tooth with a
viable sensory pulp20,21 (Fig. 1). This response is due to the
rapid temperature change that causes a sudden fluid flow
within the tubules and deforms the cell membranes of
the free nerve endings. A gradual change in temperature,
however, does not cause an immediate pain response
because rapid fluid movement excites the A-delta fibres.
––– Pulp Neurophysiology: Clinical Implications –––
The C fibres elicit a response to a gradual temperature
change.10,22,23
A recent study24 attributed the pain caused by thermal
changes to the mechanical deformation of the enamel
and dentin that causes the outward movement of the fluid
inside the dentinal tubules, triggering the nerve impulse
(indirect effect). The authors explained their findings
by the fact that fluid movement occurred before any
change in temperature reached the dentinoenamel junction. More investigation is needed, however, to verify
their results.
Application of cold decreases the blood flow because
of its vasoconstrictive effect on the blood vessels. If this
application is continued, anoxia results and the A fibres
cease to function. With continuous application of heat,
the C fibres are affected: vasodilation temporarily increases intrapulpal pressure and causes intense pain.10
Hypertonic solutions activate the intradental nerves
through osmotic pressure,16,19,25,26 manifested clinically
by the pain that results when saturated sucrose solutions come into constant contact with sensitive dentin.
The patent dentinal tubules are an important factor in
the induction of pain in sensitive dentin. This sensitivity
is a direct response to the stimulation of the A fibres.
Another example is the use of an etchant on the dentinal
surface. The osmotic pressure of the acid used for etching
the dentin is as important as the acid’s chemical composition in the induction of pain because this osmotic
pressure causes the outward fluid flow in the tubules,
together with aspiration of the odontoblastic nucleus. 26–28
The ionic concentration of the material also affects the
reduction of pain in sensitive dentin. A normally irritant
substance such as potassium chloride temporarily relieves
pain because the high concentration of potassium temporarily blocks the conduction of nerve impulses, causing
a hyperpolarization that decreases the excitability of the
nerve fibres. This hyperpolarization is the basis for the
addition of potassium ions to dentifrices.
In addition to pain from sensitive or exposed dentinal
tubules, persistent pain may decrease the threshold of the
nociceptors, usually during pulpal inflammation in which
the A and C fibres respond differently.15,16 This explains
the varying degrees of pain in pulpitis. These nociceptors,
when stimulated, may induce pulpal inflammation by
producing neuropeptides such as CGRP and substance P.
These molecules, when released inside the pulp, begin the
inflammatory reaction by dilating the blood vessels and
increasing their permeability, thus inducing the release of
histamine, which results in neurogenic inflammation. 30
Injury sensitizes the intradental nerves. This sensitivity is mediated by prostaglandins, as indicated by the
lack of symptoms after anti-inflammatory drugs are administered. 31 Serotonin sensitizes the A fibres,16,32 whereas
histamine and bradykinin activate the C fibres of the
pulp.15,16 The response of the A and C fibres to different
inflammatory mediators is regulated by the pulpal blood
flow. 33,34
The location of the C fibres within the nerve bundles
in the core or central region of the pulp may explain the
diffuse pain, called referred pain, from a specific tooth
because nerve fibres innervate multiple teeth with multiple pulps. 35 These fibres have less excitability than the
A fibres and a higher threshold, so they need more intense stimuli to be activated. The C fibres may survive
in the presence of hypoxia, 33,36 which may explain pain
sensed during preparation for the root canal of a necrotic
pulp. 37 The dentist should tell the patient that the pain
will not be completely resolved after the dental visit, and
that this pain may be caused by deafferentiation, or the
interruption of the afferent input into the central nervous
system. 38
All functional changes to the nociceptors are reversible on removal of the cause. For example, in the
case of dentin hypersensitivity, the tubules are treated
by blocking, which directly affects the A fibres (hydrodynamic cessation) and resolves the neural changes in
the pulp, causing the pain to subside. 39
In contrast to these morphologic and functional
changes in pulpal nerve endings, the pulp, through its
defensive mechanism, responds by secreting endogenous
opioids, noradrenalin, somatostatin and specific chemical
mediators in response to the toxins secreted by carious lesions to regulate the activity of nociceptors.6,40,41 Some of
these mediators are excitatory; others, such as morphine,
have an inhibitory effect. The neuroinflammatory and
the neuropulpal interactions (nerve–odontoblast interactions) still need to be clarified. 35
Based on this discussion of fibres and their responses, we
can relate the type of fibres to clinical pulp testing methods:
• Thermal pulp testing depends on the outward and inward movement of the dentinal fluid, whereas electric
pulp testing depends on ionic movement.10
• Because of their distribution, larger diameter than
that of C fibres, their conduction speed and their
myelin sheath, A-delta fibres are those stimulated in
electric pulp testing.10,36
• C fibres do not respond to electric pulp testing.
Because of their high threshold, a stronger electric
current is needed to stimulate them. 36
• Based on the hydrodynamic effect, outward movement of dentinal fluid caused by the application of
cold (contraction of fluid) produces a stronger response in A-delta fibres than inward movement of the
fluid caused by the application of heat.16,42,43
• Repeated application of cold will reduce the displacement rate of the fluids inside the dentinal tubules,
causing a less painful response from the pulp for a
short time, which is why the cold test is sometimes
refractory.10
57
––– Yu –––
• The A-delta fibres are more affected by the reduction
of pulpal blood flow than the C fibres because the
A-delta fibres cannot function in case of anoxia. 33,34
• An uncontrolled heat test can injure the pulp and release mediators that affect the C fibres.44,45
• A positive percussion test indicates that the inflammation has moved from the pulp to the periodontium,
which is rich in proprioceptors, causing this type of
localized response.
Conclusions
The dental clinician should not rely solely on the type
of pain to determine a diagnosis. Other nonodontogenic
types of pain, as well as psychological pain, may obfuscate the correct diagnosis. Type of pain has not been correlated with the histopathologic condition of the pulp.46,47
The A and C fibres are activated by different stimuli and
different inflammatory mediators, producing changes in
the quality of pain that range from a sharp shooting pain
to a dull and prolonged pain. Mechanical stimulation
such as probing causes a sharp pain by stimulating the
A-delta fibres, whereas prolonged pain manifests after the
removal of a thermal stimulus (mainly heat) activates the
C fibres. The stimulus itself may indicate the type of pain,
but does not indicate the changes occurring in the pulp
tissue or the stage of inflammation occurring. a
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Endod J 2003; 29(1):5–12.
21. Trowbridge HO. Intradental sensory units: physiological and clinical aspects. J Endod 1985; 11(11):489–98.
22. Trowbridge HO, Franks M, Korostoff E, Emling R. Sensory response to
thermal stimulation in human teeth. J Endod 1980; 6(1):405–12.
23. Narhi M, Jyvasjarvi E, Hirvonen T, Huopaniemi T. Activation of heat-sensitive nerve fibres in the dental pulp of the cat. Pain 1982; 14(4):317–26.
24. Linsuwanont P, Versluis A, Palamara JE, Messer HH. Thermal stimulation causes tooth deformation: a possible alternative to the hydrodynamic
theory? Arch Oral Biol 2008; 53(3):261–72.
Dr. Abd-Elmeguid is a PhD student, medical sciences and
dentistry, department of dentistry, University of Alberta,
Edmonton, Alberta.
Dr. Yu is a clinical professor and head of the endodontic
division, department of dentistry, University of Alberta,
Edmonton, Alberta.
Correspondence to: Dr. Donald Yu, Room 4021, Dentistry/Pharmacy
Centre, Department of dentistry, University of Alberta, Edmonton, AB
T6G 2N8.
25. Pashley DH. Sensitivity of dentin to chemical stimuli. Endod Dent
Traumatol 1986; 2(4):130–7.
26. Anderson DJ, Matthews B, Shelton LE. Variations in the sensitivity to
osmotic stimulation of human dentine. Arch Oral Biol 1967; 12(1):43–7.
27. Narhi M, Kontturi-Narhi V, Hirvonen T, Ngassapa D. Neurophysiological
mechanisms of dentin hypersensitivity. Proc Finn Dent Soc 1992; 88 Suppl 1:
15–22.
28. Narhi MV, Hirvonen T. The response of dog intradental nerves to hypertonic solutions of CaCl2 and NaCl, and other stimuli, applied to exposed
dentine. Arch Oral Biol 1987; 32(11):781–6.
29. Ajcharanukul O, Kraivaphan P, Wanachantararak S, Vongsavan N,
Matthews B. Effects of potassium ions on dentine sensitivity in man. Arch
Oral Biol 2007; 52(7):632–9.
30. Olgart L. Neural control of pulpal blood flow. Crit Rev Oral Biol Med
1996; 7(2):159–71.
31. Ahlberg KF. Dose-dependent inhibition of sensory nerve activity in the
feline dental pulp by anti-inflammatory drugs. Acta Physiol Scand 1978;
102(4):434–40.
References
1. Hill CM. The efficacy of transillumination in vitality tests. Int Endod J 1986;
19(4):198–201.
2. Tronstad L. Root resorption—etiology, terminology and clinical manifestations. Endod Dent Traumatol 1988; 4(6):241–52.
3. Petersson K, Soderstrom C, Kiani-Anaraki M, Levy G. Evaluation of the
ability of thermal and electrical tests to register pulp vitality. Endod Dent
Traumatol 1999; 15(3):127–31.
4. Lipton JA, Ship JA, Larach-Robinson D. Estimated prevalence and distribution of reported orofacial pain in the United States. J Am Dent Assoc 1993;
124(10):115–21.
5. Byers MR. Dental sensory receptors. Int Rev Neurobiol 1984; 25:39–94.
6. Byers MR, Narhi MV. Dental injury models: experimental tools for understanding neuroinflammatory interactions and polymodal nociceptor functions. Crit Rev Oral Biol Med 1999; 10(1):4–39.
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7. Bergenholtz G, Hörsted-Bindslev P, Reit C. Textbook of endodontology.
Oxford, UK: Blackwell Munksgaard; 2003.
32. Olgart L, Haegerstam G, Edwall L. The effect of extracellular calcium on
thermal excitability of the sensory units in the tooth of the cat. Acta Physiol
Scand 1974; 91(1):116–22.
33. Torebjork HE, Hallin RG. Perceptual changes accompanying controlled
preferential blocking of A and C fibre responses in intact human skin nerves.
Exp Brain Res 1973; 16(3):321–32.
34. Edwall L, Kindlova M. The effect of sympathetic nerve stimulation on
the rate of disappearance of tracers from various oral tissues. Acta Odontol
Scand 1971; 29(4):387–400.
35. Hargreaves KM, Goodis HE, Seltzer S. Seltzer and Bender’s dental pulp.
Chicago: Quintessence Pub. Co. Inc; June 2002.
36. Narhi M, Virtanen A, Kuhta J, Huopaniemi T. Electrical stimulation of
teeth with a pulp tester in the cat. Scand J Dent Res 1979; 87(1):32–8.
37. Mullaney TP, Howell RM, Petrich JD. Resistance of nerve fibres to pulpal
necrosis. Oral Surg Oral Med Oral Pathol 1970; 30(5):690–3.
––– Pulp Neurophysiology: Clinical Implications –––
38. Cohen S, Hargreaves KM. Pathways of the pulp. 9th ed. Mosby; 2006.
39. Byers MR. Effects of inflammation on dental sensory nerves and vice
versa. Proc Finn Dent Soc 1992; 88 Suppl 1:499–506.
40. Stein C. Peripheral mechanisms of opioid analgesia. Anesth Analg 1993;
76(1):182–91.
41. Olgart LM. The role of local factors in dentin and pulp in intradental pain
mechanisms. J Dent Res 1985; 64 Spec No:572–8.
42. Ngassapa D, Narhi M, Hirvonen T. Effect of serotonin (5-HT) and calcitonin gene-related peptide (CGRP) on the function of intradental nerves in
the dog. Proc Finn Dent Soc 1992; 88 Suppl 1:143–8.
43. Charoenlarp P, Wanachantararak S, Vongsavan N, Matthews B. Pain and
the rate of dentinal fluid flow produced by hydrostatic pressure stimulation
of exposed dentine in man. Arch Oral Biol 2007; 52(7):625–31.
44. Narhi M. Activation of dental pulp nerves of the cat and the dog with
hydrostatic pressure. Proc Finn Dent Soc 1978; 74 Suppl 5-7:1–63.
45. Narhi M, Yamamoto H, Ngassapa D, Hirvonen T. The neurophysiological
basis and the role of inflammatory reactions in dentine hypersensitivity. Arch
Oral Biol 1994; 39 Suppl:23S–30S.
46. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp.
Oral Surg Oral Med Oral Pathol 1963; 16:969–77.
47. Baume LJ. Diagnosis of diseases of the pulp. Oral Surg Oral Med Oral
Pathol 1970; 29(1):102–16.
ODA_ASM09_JCDA_HalfPgAd:Layout 1
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ASM09
ONTARIO DENTAL ASSOCIATION
Anthony “Rick” Cardoza
Cameron Clokie
Leslie David & John Zarb
Irwin Fefergrad,
John McMillan &
David Harris
Michael Ignelzi, Jr.
Karl Koerner
APRIL 30 – MAY 2
ANNUAL SPRING MEETING | 2009 |
METRO TORONTO CONVENTION CENTRE | SOUTH BUILDING
Full program will be mailed to all dentists in Ontario and
posted on the ODA website by December 15, 2008
at www.annualspringmeeting.ca
For more information contact:
Ontario Dental Association
4 New Street, Toronto ON M5R 1P6
Tel: 416-922-3900 | Fax: 416-922-9571 | Email: [email protected]
For exhibiting opportunities contact Diana Thorneycroft:
Tel: 416-355-2266 Email: [email protected]
Forensics
Oral Surgery / Implants
Implants
Practice Management
– Limited Attendance
– Dentists & Dental Students Only
Paediatrics
Oral Surgery Lecture/
Oral Surgery
– Limited Attendance Workshop
Vincent Kokich
Tieraona Low Dog
Marc Moskowitz
Peter Nkansah
Uche Odiatu &
Kary Odiatu
Jeffrey Okeson
John Olmsted
Mary Osbourne
Lisa Philp
Jack Piermatti
Nadar Sharifi
Orthodontics
Nutrional Supplements/
Healthy Living
Aesthetics/Implants
Medical Emergencies/
Pharmacology/
Oral Health Strategy
Team Building/
Fitness/Ergonomics
Pain Control
Endodontics
Work/Life/Dealing with Change
Team Building
Implants
Removable Prosthodontics
Lecture/Denture Techniques
– Limited Attendance Workshops
Sharon Siegel
Samuel Strong &
Stephanie Strong
Women’s Health / Osteoporosis
Practice Management/Implants
59
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3M
Peridex Oral Rinse
Cadbury Adams Canada Inc.
Trident Xtra Care – Passionberry
Trident Xtra Care – Peppermint
Trident Xtra Care - Spearmint
CHX Technologies
Prevora Medicated Tooth Coating
Colgate Palmolive Canada Inc.
Colgate 2in1 Kids Strawberry Mouthwash and Toothpaste
Colgate 2in1 Kids Watermelon Mouthwash and Toothpaste
Colgate 2in1 Whitening Mouthwash and Toothpaste
Colgate 360 Toothbrush
Colgate 360 Deep Clean Toothbrush
Colgate 360 Sensitive Toothbrush
Colgate Cavity Protection Gel Toothpaste
Colgate Cavity Protection Regular Toothpaste
Colgate Cavity Protection Winterfresh Toothpaste
Colgate Fluoride Toothpaste for Kids
Colgate Luminous Crystal Clean Mint Toothpaste
Colgate Luminous Paradise Fresh Toothpaste
Colgate Massager Toothbrush
Colgate MaxFresh Toothpaste
Colgate MaxFresh Burst Peppermint Toothpaste
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Colgate Smiles Toothbrush 0-2
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Colgate Total Professional Toothbrush
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Colgate Twister Fresh Toothbrush
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GlaxoSmithKline
Aquafresh for Kids Toothpaste
Aquafresh Sensitive Toothpaste
Sensodyne Toothpaste for Sensitive Teeth
For more information on application procedures, contact:
Sensodyne-F Baking Soda Clean Toothpaste
Sensodyne-F Brilliant Whitening Toothpaste
Sensodyne-F Cool Mint Gel Toothpaste
Sensodyne-F FreshMint Toothpaste
Sensodyne-F Mint Toothpaste
Sensodyne-F ProNamel Toothpaste
Sensodyne-F Revitalizing Whitening Toothpaste
Sensodyne-F Ultra Fresh Toothpaste
Johnson & Johnson
Listerine Agent Cool Blue
Listerine Antiseptic Advanced Mouthwash
Listerine Antiseptic Cool Citrus Mouthwash
Listerine Antiseptic Cool Mint Mouthwash
Listerine Antiseptic Fresh Burst Mouthwash
Listerine Antiseptic Original Mouthwash
Listerine Antiseptic Tartar Control Mouthwash
Listerine Antiseptic Vanilla Mint Mouthwash
Listerine Antiseptic with Fluoride Mouthwash
Listerine Total Care
Procter & Gamble
Crest Cavity Protection Regular Toothpaste
Crest Complete Gel Toothpaste
Crest for Kids Gel
Crest Extra Toothpaste
Crest Glide Floss
Crest Multicare Whitening Toothpaste
Crest Pro-Health Cool Wintergreen Oral Rinse
Crest Pro-Health Cool Refreshing Clean Mint Oral Rinse
Crest Pro-Health Clean Cinnamon Toothpaste
Crest Pro-Health Clean Mint Toothpaste
Crest Pro-Health Night Toothpaste
Crest Sensitivity Protection Toothpaste
Crest Tartar Fighting Toothpaste
Fixodent Complete Denture Adhesive
Fixodent Control Denture Adhesive
Fixodent Free Denture Adhesive
Fixodent Fresh Denture Adhesive
Fixodent Original Denture Adhesive
Oral-B Advantage Toothbrush
Oral-B Cross Action Pro-Health Toothbrush
Oral-B Cross Action Vitalizer Toothbrush
Oral-B Indicator Toothbrush
Oral-B ProfessionalCare 7500 Power Toothbrush
Oral-B ProfessionalCare 8850 DLX Power Toothbrush
Oral-B Pulsar Toothbrush
Oral-B Pulsar Pro-Health Toothbrush
Oral-B Satin Floss
Oral-B Sonic Complete Power Toothbrush
Oral-B Triumph with Smart Guide Power Toothbrush
Oral-B Vitality Dual Clean Power Toothbrush
Oral-B Vitality Precision Clean Power Toothbrush
Oral-B Vitality Sensitive Power Toothbrush
Sulcabrush Inc.
Sulcabrush
Sulcabrush Travel
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Tel: (613) 523- 1770, ext. 2165 or 1-800-267-6354 (toll free)
Fax: (613) 523-7736
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Offices and Practices
ALBERTA
- Calg ar y : Wellestablished, highly successful prosthodontic practice for sale. Low overhead. 1175 square feet. 2 operatories
plus one plumbed. Located in a
professional building. In-house lab.
Appropr iate transition available.
Contact Ron Mackenzie at: (604) 6859227 or email: [email protected].
D5405
ALBERTA - Calg ar y : Premium
locations available for lease in a
new professional building on
Calgary's west side; Springborough
Professional Centre. The development
has abundant free parking and is
surrounded by the strongest demographics for retail trade in the city.
This 60,000 square foot project is well
under construction and will be ready
for tenants to occupy in the summer
of 2009. Call or email Mike Brescia
at: (403) 206-2136 or email:
[email protected] to obtain
more information on locating your
practice in this fantastic new
D5429
building.
ALBERTA - Cental Alberta: Busy
general practice billing $800,000 on a
four day week w ith potential for
expansion. Low stress, ultra low
overhead and hig h revenue.
Exper ienced staff, four Adec
operatories, pan, intra-oral camera,
great leaseholds. Willing to aid in
transition, valuation in progress to
price reasonably. Email: albertadental
[email protected].
D5446
ALBERTA - Edmonton: Wellestablished family practice for sale
in West Edmonton area in a
ver y pleasant communit y. Three
operator ies, low rent and hig hly
profitable. Great oppor tunity for
dentist who wants to start with low
investment and great new patient
flow. Available immediately. Please
call Ephraim Baragona: (780) 4871010 or (780) 904-2619. Email:
[email protected].
D4732
ALBERTA - Lac La Biche: Busy,
established general practice in
Northern Alberta lake-land area with
3 operator ies and plumbed for a
fourth. Practice has excellent longterm staff and is dental hygienist
supported. Dentist retiring. Contact
Dr. Ronald Gee at: (780) 623-4910 or
email at: [email protected].
D4691
PRACTICE WANTED IN BRITISH
COLUMBIA: Mature dentist looking
to purchase established practice in
under-serviced region. Will consider
buy in. Want to work 3 months on - 3
months off schedule and employ
depar ting dentist as associate.
Confidential email: dentistinsearch@
D4878
hotmail.com.
BRITISH COLUMBIA - Abbotsford: Established Abbotsford
endodontist has office space to share
or transfer to a general dentist or
specialist. Central location w ith
g round level access and parking .
Phone: (604) 504-7668 or fax: (604)
504-7669.
D4770
BRITISH COLUMBIA - Clearwater: Established low overhead, high
profit and stress free dental practice
for sale, lease, or associate position
ASAP. Surrounded by beautiful lakes,
rivers, mountains and gorgeous Wells
Gray Park, this is the only practice in
a radius of 120km. 1-1/4 hour drive to
Kamloops plus 1 hour flig ht to
Vancouver is excellent opportunity to
make tons of money while able to
live 2-3 days a week in big cities.
61
Real estate available to purchase if
desired. Vendor is relocating out of
countr y for other oppor tunities.
Ver y reasonably pr iced. Email:
[email protected].
D4842
BRITISH COLUMBIA - Interior:
Great practice opportunity in small
tow n BC. Ver y affordable and
profitable. Only dental office in town.
Three operatories, full time hygienist.
Low overhead. Recently renovated.
Owner relocating for family reasons.
Contact: [email protected]. D5515
CLASSIFIED ADS
BRITISH COLUMBIA - Langley:
Medical building - 20644 Eastleigh
Cres., Lanley, BC. Corner unit
available: 1,184 square feet. Well (like
new) built out for a dental specialist w ith 3 exam areas, 2 offices, and
existing medical reception area!
Existing improvement in place - just
move in. Available immediately. Call
Moojan Azizi at Impex Management
Ltd.: (604) 688-9720.
D5379
BRITISH COLUMBIA - Okanagan:
Enjoy living in the beautiful Okanagan
Valley where you will anxiously await
all four seasons. Excellent opportunity
to be par t of a well-established
practice with untapped potential for
exceptional growth. Existing dentist
would like an associate/partner (cost
sharing) to ser v ice the increasing
demand for dental care in the area.
Enjoy life working daytime weekdays
and have a partner to share costs and
management responsibilities with
while making more money at the end
of the day. Successful candidate must
associate first with agreement to buy
in. Associateship without purchase
agreement is also an option. Email:
[email protected].
D4779
BRITISH COLUMBIA - Pr ince
George: State of the art 6 operatory
clinic with ceramic lab on site, 3 fulltime hygienists and 2400+ ACTIVE
recall patients awaits you here in the
heart of beautiful BC. General practice
in accessible downtown location, long
term lease, modern top of the line
62
finishes and even a Koi pond! PG is
a universit y tow n that attracts
professionals from across the country!
Vendor offers flexible transition terms.
Contact Nadean Burkett via email:
[email protected] or phone:
(604) 939-5009.
D4809
BRITISH COLUMBIA - Shuswap/
North Okanagan: Enjoy the outdoors
and amenities of Shuswap Lake in this
turn-key 3+ operatory, well managed
and nicely equipped, productive family
practice in Salmon Arm, B.C. Strong
dental team willing to transition to
new owner/operator. Vendor is retiring
- flexible on terms and price to your
benefit. Building ownership is also
offered - be your ow n landlord!
Contact Nadean Burkett confidentially
via email: [email protected]
or phone her at: (604) 939-5009 to get
all the details of how you can work
and play in the beautiful and popular
Shuswap Lake area.
D4808
BRITISH COLUMBIA - South
Vancouver Island: Live the island
lifestyle! Four operator y, recently
extensively remodelled and upgraded
clinic with full time hygiene. This
busy, productive general practice is
located in a popular, upscale
residential neighbourhood and serves
an highly retentive adult-oriented
patient base. Vendor is retiring and
offers flexible transition terms. Fully
documented practice valuation.
Contact Nadean Burkett via email:
[email protected] or phone:
(604) 939-5009.
D4810
BRITISH COLUMBIA - Whistler
Village: Practice for sale. 400K gross
on Mon-Wed schedule. Great staff
and huge new patient numbers.
Ow ner ver y motivated to sell for
family reasons. Contact: smerkley@
gmail.com.
D5396
WESTERN NEWFOUNDLAND: For
sale: well established, pleasantly
situated, air-conditioned two operator y practice in ow n building .
Hygienist services, Panorex, lab, good
gross, rental income, recreational
facilities locally including downhill
skiing, golf, fly fishing, snowmobiling.
Air por t 5 minutes away. Fur ther
details fax: (709) 635-4535. Contact:
D5383
[email protected].
NOVA SCOTIA - Halifax: 35 minutes
from Halifax. “Goldmine for sale” - 36
year old dental practice (28 years in
same location). Hig h g ross, low
overhead, low stress. Dental practice
and building (free standing).
Transition period very flexible. Golf
courses (3) within 10 minutes; skiing,
universities (9) within easy commute.
This practice has given me a lifestyle
that I could only dream about.
Contact: [email protected] or
D4735
phone: (902) 228-2795.
NUNAVUT - Iqaluit: $1 Million
clinic for sale in Iqaluit, Nunavut. Very
productive and successful, 7 year old, 3
operatory clinic for sale for $225,000.
Gross productivity for 2007 exceeded
$1 million. For details email:
D4797
[email protected].
ONTARIO - GTA: Practices Wanted!
Altima Dental Canada seeks to
purchase 5 additional practices within
1 hour of the Greater Toronto Area,
to complement our existing 20
locations. Thinking about selling?
Contact us about our exciting
purchase incentives. Call Dr. George
Christodoulou at: (416) 785-1828, ext.
201, or email: [email protected].
Website: www.altima.ca.
D2915
ONTARIO - Ottawa: Dental office for
sale in Ottawa (Orleans). Four fully
equipped operatories. Satellite office
opened 6 months ago, superb location
and modern construction. French
speaking clientele with 100% insurance coverage. Region in vast development. Dentist occupied with his main
office. Please contact Dr. Rizk or
Roseanne: (613) 232-9282.
D3595
ONTARIO - Ottawa: Downtown practice located minutes from Parliament
Hill and surrounded by government
offices with dental insured government
employees is now available for sale.
Established in 1961 this low overhead,
high revenue office is currently operating four days per week however it can
easily be expanded. There are two fully
equipped operatories, digital x-ray and
Zoom. The retiring owner is flexible and
can stay on during transition. For more
information please contact us at:
[email protected] or leave a message
at: (613) 746-1960.
D5316
ONTARIO - Toronto: Paediatric/
SASKATCHEWAN
-
Rocanville:
Growing, family-oriented community
in rural S.E. Saskatchewan, population
1,000, requires a dentist to open a practice. Local employer, Potash Corp., is
expanding, creating 280 permanent jobs
after 2.8 billion dollar expansion.
Residents must currently travel out of
town for dental services. Please call
Traci Burke B.S.P.: (306) 645-2633 day,
(306) 645-2890 evening, (306) 645-2175
fax, or send email to: tracib@
superthrifty.com.
D4841
Positions Available
ALBERTA - Calgar y/Edmonton:
Experienced associate required
for our well-established, busy practices
in Calgar y. For more information
visit our website at: www.ihp.ca or
contact Dr. George Christodoulou,
tel.: 1 (888) 81SMILE ext. 201, or via
email: [email protected].
D2691
ALBERTA - Calgary: Great downtown
Calgary location, offering no weekend or
ALBERTA - Calgary: Pediatric dentist is
required for a caring, preventive-oriented,
idealistic private pediatric practice.
Hospital affiliation is necessary. This
position is as an associate leading to role
reversal through practice purchase. For
further information please contact: (403)
248-5015. or email: [email protected]
D4663
ALBERTA - Calgary: High-end practice
searching for an experienced associate.
Our current associate is relocating and
an opportunity has now opened in our
well-established dental practice with a
large, regular patient base and strong
hygiene and recare program. Our nonassignment practice offers extended
hours to patients where fees are
consistently 30% greater than the fee
schedule. We look forward to hearing
from enthusiastic, skilled applicants who
wish to participate on a friendly and
supportive team. Please reply to: dental
[email protected]. D3827
ALBERTA - Calgary: Full-time associate
required for progressive, busy, well
established SE family practice. Digital
radiography, computerized operatories,
Cerec, neuromuscular, implants, and
orthodontics. Tons of potential for the
right candidate, excellent patients and
long-term staff. Come join our team!
Please email resume in confidence to:
[email protected].
D4756
ALBERTA - Calgary: Associate needed.
Our well established, high end NW
practice, which has served Calgary for 25
years, is looking for part-time associate
with the possibility of leading to a fulltime position. We are a non-assignment
(fee for service) practice with minimal
AR, and we pride ourselves in providing
excellent care and patient education
utilizing the latest technology including
intra-oral cameras and laser therapy. We
have a large and loyal patient base with
a highly motivated team. Please
email resumes in confidence to:
[email protected] or fax us at: (403)
D5314
239-0133.
ALBERTA - Camrose: Wanted:
Associate dentist for busy well established
practice in Camrose, Alberta. 50 minutes
SE of Edmonton. Modern, up-to-date
facility. Forward resume by email to:
[email protected] or fax to: (780)
672-4700. Prior inquiries please call:
(780) 679-2224 to leave number where
you can be reached at.
D4887
ALBERTA - Cold Lake: The perfect
opportunity awaits an ambitious
associate to join our friendly and
dedicated team at Alberta's best kept
secret. We offer patients all areas of
general dentistry including implants,
Invisalign, orthodontics and sedation
dentistry. Please contact Bettina at: (780)
594-5056 fax: (780) 594-5965 email:
[email protected].
D4760
ALBERTA - Didsbury: Associate
required for a busy, well-established
family dental practice located 45
minutes north of Calgary. We offer all
aspects of general dentistry, modern
equipment, an excellent hygiene rogram
and a terrific team to work with. Please
fax your resume to: (403) 335-8625 or
email resume to: [email protected].
D2919
New grads welcome.
ALBERTA - Drumheller: Two full-time
associate positions available in a newly
renovated, very well established, busy
practice close to Calgary. Excellent
opportunity for new graduate or
experienced dentist. Ideal for husband
and wife team! Future ownership
possible. Please email: [email protected].
D5450
ALBERTA - Edmonton: Experienced
associate required for great opportunity
in a busy, well-established practice close
to downtown for 4-5 days/week. No
evenings or weekend hours. All
applications kept strictly confidential. Fax
Candice at: (780) 444-9411 or email:
[email protected].
D4705
63
CL
LA
AS
SS
S II F
F II E
ED
D A
AD
DS
S
C
orthodontic office with in house G.A.
facility seeking a full-time certified paediatric associate with option to purchase. Start date would be summer of
2009. The individual must have a
strong aptitude for behavior management. We have a comprehensive
preventive program based on caries
risk assessments. One location midToronto and the other just North.
Please send resumes and inquiries to:
D5449
[email protected].
evening hours, seeking a full-time
associate. Newly renovated office with
digital radiographs, hygienist, and
wonderful staff. Have autonomy in a
remarkable environment. Email:
[email protected] or fax Candice at:
D4678
(780) 444-9411.
ALBERTA - Edmonton: Associate
required to take over existing patient
base of long term associate. Full or part
time. Busy office in north Edmonton
with high new patient flow of all ages.
Excellent hygiene program supports all
aspects of general dentistry. Excellent
team to work with in newly renovated
office with no evenings or weekends
required. Phone: (780) 455-6806 or
D5372
CLASSIFIED ADS
ALBERTA - Edmonton: We urgently
require a full-time associate to take over a
full patient load. This truly is a unique
opportunity for the incoming associate to
be immediately busy virtually from day
one. Our office is bright, modern and
very well equipped. A positive attitude, a
sense of humour and some flexibility in
scheduling will lead to a very successful
and rewarding position for the right
individual. Fax: (780) 434-0824. Email:
[email protected].
D4881
ALBERTA - Edmonton: Forty year
old practice needs a French- and
English-speaking dentist for a
retirement transition. Well established
hygiene program. Call Dr. Ron Breault
at: (780) 439-3797 or cell at: (780) 9184482. Fax: (780) 439-9361, email:
D5455
[email protected].
ALBERTA - Fort McMurray: Be a part
of the action! Excellent full- time GP
associate opportunity immediately
available in the fastest growing place
in Canada. Need 1 or 2 highly
motivated, energetic individuals who
want to make a ton of money! Rapidly
expanding family practice in For t
McMurray, Alta., has an excellent
team already established but can’t keep
up. Rotary endo and Cerec already in
place. Don’t miss out on making more
money than you ever dreamed possible.
Please phone: (780) 743-3570 or fax
to: (780) 790-0809.
D1817
ALBERTA
-
Grande
Prairie:
Rewarding associateship in busy,
growing Grande Prairie. Vibrant, well
established, high grossing, family dental
practice. Excellent, motivated staff.
Please call: (780) 539-6769, fax: (780)
538-2387, or email: wpiepgrass@
msn.com.
D4847
ALBERTA - Grande Prairie: A fulltime associate/colleague needed for our
well-established, busy family practice.
We have a high new patient flow, no
stress and long-term friendly staff. Our
practice offers all aspects of family
dentistry including I-V sedation, oral
sedation and implants. If you are
trustworthy, friendly and committed to
excellence a full appointment book is
waiting for you. Experience is an asset
but not a necessity. To apply, please
contact Christa at (780) 539-6883 or fax
D2929
resume to: (780) 539-0272.
ALBERTA
-
Grande
Prairie:
Associate required for a busy, wellestablished family dental practice. We
offer all aspects of general dentistry, an
excellent hygiene program and a
terrific team to work with. Please fax
your resume to: (403) 335-8625 or
D4593
D3879
D4801
D4859
64
email resume to: [email protected].
New grads welcome.
D2571
ALBERTA - Peace River: Work
smarter, not harder! Full time associate
wanted for busy well established family
dental practice. Excellent hygiene
program. 4-5 day weeks, no evenings or
weekends. Versawave, Odyssey, Dentrix,
Schick digital x-ray, Fantastic staff
following LVI Continuum together.
New grads/experienced dentists.
Excellent income! Fax resumes to
Rosalyne: (780) 624-8596. Contact us
for photos of clinic! Tel: (780) 624-2004.
D5389
ALBERTA - Red Deer: Progressive
ALBERTA - Red Deer: Progressive
modern family dental practice in the
thriving community of Red Deer, Alberta
requires an associate for possible future
buy-in. Explore all disciplines of dentistry within our practice from oral
surgery and implants to orthodontics
and cosmetic dentistry. If you are caring,
compassionate and want to have access
to the latest technology, please contact
Jody at: (403) 340-2633 or email:
D4650
[email protected].
ALBERTA - Red Deer: Excellent family
oriented general practice centrally
located in a newer downtown plaza. Five
operatories, office with friendly certified
staff, offers flexible hours, and management free worries! Central Alberta offers
year-round recreation as well as easy
access to either Calgary or Edmonton.
Come and enjoy a lower stress lifestyle
with us if you are comfortable with
surgery, endo, and pedo.New grads welcome! Future buy-out potential for
interested candidate. (403) 309-1900
(work), (403) 309-7310 (home), (403)
D5440
346-3594 (fax).
ALBERTA - Red Deer: Excellent
opportunity available for a full-time
associate to join our dental team. Our
established, busy and progressive family
practice has just relocated to a brand
new 6-operatory office and building. We
focus on excellence in patient care with a
caring and compassionate staff. The
latest technology including digital radiography, computerized operatories,
operating microscope, intra-oral cameras and sedation is available. We are a
non-assignment office with a healthy
new patient flow, and a conscientious
D5463
65
CLASSIFIED ADS
cosmetic/family practice searching
for long-term mutual visionar y
(associate/partner) ready to excel along
with us and the rapid growth of Red
Deer. Located exactly between Calgary
and Edmonton at the foothills of the
Rocky Mountains, Red Deer has the
smaller city lifestyle with the big city
opportunities. Computerized, laser,
Cerec 3-D and digital ready are available
for expanded options of patient care.
New grads welcome with easy ownership
program available. Feel free to call:
(403) 309-4600 or fax your resume to:
(403) 340-0078. Confidence with
confidentiality can be assured by
D2938
emailing: [email protected].
hygiene program. Experience preferred
but new grads welcome. Please email CV
to Dr. Caroline Krivusoff-Sanderson at:
[email protected].
D5461
ALBERTA - Stony Plain: Associateship
position available to replace dentist in a
group practice in Stony Plain, Alberta.
We are looking for a dedicated, enthusiastic team-player, for compassionate
care. Friendly staff, future buy-in, and
in-building child care. Please send
resume by fax to: (780) 963-2904, or by
D5470
email to: [email protected].
CLASSIFIED ADS
ALBERTA - Westlock: Dental implant
surgery and teaching center. A full-time
associate position is available in one of
Canada's most successful dental implant
centers in early spring 2009. Our stateof-the-art, computerized facility with
CT-scan is located 45 minutes north of
Edmonton in a beautiful ranching community ideal for families. Patients come
from across Canada to this unique
dental facility. Become a part of our out-
going, fun and highly qualified young
dental team. Assume a very busy full service general, cosmetic dental practice
with extremely high earnings and a 50%
split. Be mentored by the senior dentist
whose practice is limited exclusively to
implantology. Please reply by faxing CV
or resume to: The Implant Smile Center,
(780) 349-2626 (Attn: Anita), or email
to: [email protected]. Phone inquiries:
(888) 877-0737 (toll free). Websites:
www.albertadentalimplants.com and:
D5397
www.implantsmilecenter.com.
BRITISH COLUMBIA - Chilliwack:
ALBERTA - Valleyview: Associate posi-
BRITISH COLUMBIA - Cranbrook:
tion available immediately. Existing
patient base, high percentage paid,
choose your lifestyle. No evenings or
weekends. Full or part time. Fast growing
region with a balanced economy. Local
government in planning stages of new
Health Care Centre where practice will be
relocating. Be in on ground floor with
affordable ownership option possible.
Apply to Dr. Darryl R. Smith: (780) 9570442 (home) or: [email protected].
D4816
Full time associate position available
to dentist committed to continuing
education/excellence in patient care.
Area offers year-round recreation
including skiing, boating, hiking, etc.
100 km east of Vancouver. There is
potential for partnership. Reply to: Dr.
Michael Thomas, Ste. 102-45625
Hodgins Ave., Chilliwack, BC, V2P 1P2;
phone: (604) 795-9818 (res), (604) 7920021 (bus), fax: (604)792-1318 or email:
D4534
[email protected].
Full-time associate position available.
Busy, modern practice. Six operatories.
Option to purchase/buy-in. An exciting
opportunity in a fabulous area. (250)
489-4551 or (250) 489-1902. Email:
D5425
[email protected].
BRITISH COLUMBIA - Fort St.
John: Full-time associate needed for
busy and profitable practice in North
East BC. This position entails two
operatories and 47% of net payments.
Our office has been non-assignement
for 4 years and currently has 11,000+
active patients. Fort St. John is a
thriving and growing community
which offers small town atmosphere
with larger center amenities. For
more information please email
[email protected] or call (250) 785D4814
1867.
BRITISH COLUMBIA - Northeast:
Four full-time positions starting at
$20/hour; relocation allowance.
Choose to work in either traditional,
modern & young or 11 operator y
mega-clinic in the city of Fort St. John.
British Columbia's growing energy
capital with airport, fast food, bigbox stores and jobs. Or choose to
work in friendly Mackenzie. Email:
[email protected] or fax resumes
to: (250) 785-0625.
D5426
BRITISH COLUMBIA - Okanagan:
D5453
66
Enjoy living in the beautiful Okanagan
Valley where you will anxiously await
all four seasons. Excellent opportunity
to be part of a well established practice
that keeps up with changes in
dentistry. Our team is a well trained
BRITISH COLUMBIA - Revelstoke:
Full-time associate required for
very busy, well-established general
practice in beautiful Revelstoke. Future
partnership opportunity for the
right candidate. We are Canada’s
most talked about mountain resort
town boasting a booming economy
and world class skiing. Check out
this mountain paradise online:
www.seerevelstoke.com. Please call:
(250) 837-9431 evenings or email us at:
D4467
[email protected].
Great opportunity! FT/PT dental
associate needed to join team of
innovative dentists, physicians and
naturopaths offering a multidisciplinar y approach to healthcare in Vancouver. Experience in
surger y/ implantology an asset participation as a team player and a
thirst for knowledge a must.
www.draraelmajian.ca. Contact us by
fax: (604) 876-1347 or email:
D5332
[email protected].
BRITISH COLUMBIA - Victoria:
Associate position. Associate to
join our diverse and busy treatment
centre. Dr. Luckhurst has many years
of experience and has taught internationally and has built a wellestablished practice offering patients
family-centred dentistry, restorative,
cosmetics, implants, and full mouth
rehabilitations. Dr. Luckhurst is looking
for a hard working, ethical, professional
individual to join our progressive team.
Replies to: Dr. A. Luckhurst, phone:
(250) 386-3044, fax: (250) 386-3064,
D3801
Associate wanted for progressive,
prevention-based, established practice
in Victoria, B.C. Flexible working
Part-time or full-time associate
required for ver y busy practice.
Current associate moving. Experience
is preferred. Please email your resume
to: [email protected]. D4870
more info: www.dentalbusiness.ca. D5514
MANITOBA - North Central: Want
to be busier and earn what you are
worth? We offer a unique practice
setting for an eager associate. Do all the
forms of dentistry you are comfortable
doing a good job with! Earn a high
minimum plus a percentage based
bonus. Accommodations and travel are
completely paid for the right candidate.
Please phone: (204) 620-1585 or email:
D3675
[email protected].
Full-time associate/locum needed
starting March 15th, 2009 in beautiful
Victoria, BC. Well established cosmetic
and general practice. High tech: fully
computerized digital radiography,
intraoral cameras, rotary endodontics,
soft tissue laser. Buy-in is possible.
Contact office manager, cell: (250) 5162154 or email: [email protected]. D5485
BRITISH COLUMBIA - West
Kootenays: Full-time associate
required for a busy general practice.
Well established patient base, new
patients daily, two hygienists, long term
staff, six operatories. We enjoy all the
seasons have to offer. Just go outside
your back door or travel less than 1
hour to all activities. Red Mountain
and White Water Ski areas for skiing in
the winter and bike trails in the
summer. The Arrow/Kootenay and
Christina lakes are right here for your
summer swimming, sailing or water
skiing. There are many golf courses for
all skill levels. Come and join our
practice. If this is the place for you
owner would like to arrange a future
buy-in or purchase of the practice.
Email: [email protected].
D5415
MANITOBA - Winnipeg: Seeking
associates to join our very progressive
practice. Currently with 4 locations in
and around Winnipeg. Potential
opportunity to make over 20K a month
net for the right candidate. New
graduates encouraged to apply. We
feature an onsite lab and a part-time
orthodontist. Expect a fully booked
schedule. Impeccable management is
the foundation to the success and
progression of this practice. Contact
D.K. Mittal: cell: (204) 297-5344 res.:
(204) 633-8280 off.: (204) 774-7774
D4765
WESTERN NEWFOUNDLAND:
Associate/long-term locum. Well
established, pleasantly situated, airconditioned two operatory practice in
own building. Hygienist services,
Panorex, lab, good gross, clinical
freedom, recreational facilities locally
including downhill skiing, golf,
fly fishing, snowmobiling. Airport 5
minutes away. For further details
fax: (709) 635-4535. Contact:
[email protected].
D5380
WESTERN CANADA: Associate and
locum positions available for qualified
dentists with our clients throughout
western Canada. Full and part time
positions with compensation of 4050% on contract. Some travel and/or
accommodation benefits may also
apply. New grads OK. Contact Nadean
at Nadean Burkett & Associates Inc.:
(604) 939-5009. Visit our website for
67
CLASSIFIED ADS
BRITISH COLUMBIA - Vancouver:
conditions in an office with 10 newly
renovated operatories and 4 existing
doctors. Suitable for a new grad. Fax
resume to: (250) 477-3722 or email:
[email protected].
D4776
D1778
group of people who makes everyone
feel at home. Expansion of the practice
is needed to meet the needs of our
patients. Enjoy life working daytime
weekdays. New grads welcome. Future
partnership is available for the right
person. Email: [email protected]. D5454
NUNAVUT - Iqaluit: Associate position(s) available for immediate start.
Established clinic offers generous
package and full appointment book to
associates. All round clinical skills are
your ticket to a wide range of recreational activities! No travel required and
housing available in Canada’s newest
and fastest growing capital city. Please
apply to: Administration, PO Box 1118,
Yellowknife, NT X1A 2N8 or tel: (867)
D1497
873-6940, fax: (867) 873-6941.
CLASSIFIED ADS
ONTARIO - 20 Locations: Experienced associate required for our wellestablished, busy practice. Enjoy a small
town or a large city atmosphere. For
more information visit our website at:
www.altima.ca or contact: Dr. George
Christodoulou, Altima Dental Canada,
Tel: (416) 785-1828 ext 201 or via
D2690
ONTARIO - Brantford: Full time
associate required to join our busy, well
established practice. We perform all
aspects of dentistry in our fully
computerized, all digital office. Please
contact: [email protected] or
D5445
fax: (519) 756-0745.
ONTARIO - Collingwood: Associate
opportunity in busy, family-oriented
practice. Must enjoy working with
children and be nitrous certified. No
evenings or weekends. Non-assignment
practice located on beautiful Georgian
Bay. Please forward resume to fax: (705)
445-8671, email: [email protected],
or mail: 186 Erie Street, Suite 101,
Collingwood, ON, L9Y 4T3.
D5484
ONTARIO/QUEBEC - Cornwall &
Hawkesbury: Choose the location you
want, very busy practices. In Quebec, only
30 minutes southwest of Montreal. Full
schedule (crown bridge, endodontics
etc.). Possible sale. Outstanding growth
income. Stability, flexibility and respect
assured! For further information call Luc
at: (450) 370-7765 or send email to: luc
[email protected].
D1674
ONTARIO - Ottawa: Part-time
associate required immediately (2 days
68
to start) in a modern, well established,
family-oriented practice. No evening or
weekend hours. Practising dentistry
with great team support. Owner wishes
to focus on her specialties in
orthodontics and TMJ treatment.
Reply to: [email protected].
D5427
spacious brand new, high-tech, highly
productive, 9 operatory clinic with a
well established patient base and
excellent new patient flow. Please call
for more information. Please contact
Cher yl: (306) 446-0007 or email:
[email protected].
D5388
ONTARIO – Sault Ste Marie: Full time
associate required immediately for a
busy, large family practice in Sault
Ste Marie. 10 new computerized
operatories with digital x-ray, Laser,
Cerec, Intraoral cameras, Caesy
Education System. It’s a great
opportunity for a motivated, teamoriented individual with good
communication skills. Come join
our team. Please fax resume to: (705)
945-5149 and visit us online at:
www.saultdentistry.com.
D5386
SASKATCHEWAN - Swift Current:
An excellent opportunity for an
associate to join our well-established
family-oriented practice. Recently
renovated office, equipped with
the latest technology and with
wonderful highly-motivated staff. We
presently have one full-time hygienist
and one part-time hygienist, and have 5
operatories with room to grow. We are
looking for a friendly, team-oriented
person. New grads are welcome. Phone:
(306) 773-9355 or fax CV to: (306)
773-5326.
D4429
QUÉBEC – Région OutaouaisGatineau : Demande dentiste à
pourcentage visant l’excellence pour
pratique de groupe multidisciplinaire
et achalandée. Excellent emplacement,
beaucoup de nouveaux patients par
mois, très faible pourcentage de
RAMQ. On recherche un dentiste
bilingue ayant de l’entregent avec une
personnalité sympathique, dynamique
et sachant travailler en équipe. Une
hygiéniste et assistante seront à votre
disposition. Envoyez vos coordonnées
au : (819) 246-2662 (téléc.) ou
[email protected] à
D5347
l’attention d’Isabelle Tremblay.
QUÉBEC – Rivière-du-Loup: Pratique
familiale recherche dentiste à temps
plein. Belle équipe dynamique.
Milieu de vie exceptionnel, près du
majestueux fleuve St-Laurent.
Association à court terme, si désirée.
Pour de plus amples renseignements:
Dre Anne Olivier ou Dr. Yvon
Morin, courriel: cliniquedentmorin
[email protected], télécopieur: (418)
862-3817.
D5387
SASKATCHEWAN - North Battleford:
Associate required for a busy
Saskatchewan office located in the
Battlefords. Experience is preferred but
new graduates are welcome. We offer a
UNITED STATES - Illinois, Texas,
and Massachusetts : A unique and
exciting opportunity is available for
general dentists in the U.S. Earn
between 250-350k per year with paid
malpractice and health insurance
while working in a great environment.
The group is owned and operated by
Canadians and will look after all
immigration needs. Must have started
or be prepared to complete US boards.
Email: [email protected], fax: (312)
D2456
274-0760.
YUKON – Whitehorse: If you are
looking for a vibrant, progressive city to
live and work in come join our two
established practitioners. The practise
has nine chairs and we are looking for
someone with a positive attitude and
exceptional clinical and patient
management skills. Check out our
website www.klondike-dental.com
Phone Dr. Pearson at home: (867) 6684618 Fax: (867) 667-4944 or Berni at
work: (867) 668-3152.
D1828
YUKON - Whitehorse: Come live and
work in Canada's outdoor city!
Whether it's fishing, hiking, hunting or
biking, Whitehorse has it all. If you're
looking for an adventure, this is the
place! Only a two hour flight from
Vancouver, Edmonton or Calgary. We're
looking for a full-time associate for our
well-established 2 dentist family
practice. Excellent, enthusiastic staff
and an opportunity to do all aspects
of general dentistry. Contact Darrin
at: (867) 668-6077 or by email:
[email protected].
D5430
Ad ve r ti se r s’
I n de x
3M ESPE. . . . . . . . . . . . . . . . . . . 4
American Dental
Association. . . . . . . . . . . . . . . . 38
Conferences
CDA Funds . . . . . . . . . . . . . . . 70
CALLING ALL FISHING DENTISTS:
“Esthetics Without Compromise”
6-8 CE AGD/PACE by Captek. A
Destination Seminar at: Pesca Maya
Lodge, Cancun, April 26-30-2009. Wolf
Lake Wilderness Lodge, Canada July
22-26, July 26-August 1, 2009. Pere
Marquette River Lodge, April 3-5, 2009,
June 12-14, 2009, August-7-9, 2009. For
More information visit our website:
www.streamsideseminars.com
D5395
Technologically advanced CDE courses
are all presented in a vacation environment and are all tax-deductible. The
flexible year-round open regi-stration
allows you to choose travel destinations
and dates that are convenient for you,
ANYTIME - ANYWHERE. Have travel
plans or planning to travel? Looking for
a conference-to-go? Visit us at:
D3429
www.neiconferences.com.
CDSPI. . . . . . . . . . . 12, 32, 42, 71
GlaxoSmithKline . . . . . . . . . . 10
ITRANS. . . . . . . . . . . . . . . . . . 40
Ivoclar Vivadent. . . . . . . . . . . 72
Ontario Dental
Association. . . . . . . . . . . . . . . . 59
P&G Professional Oral
Health. . . . . . . . . . . . . 5, 8, 36–37
CLASSIFIED ADS
LEARN VIRTUALLY ANYTIME
ANYWHERE: With NEI Conferences.
CDA Seal of Recognition. . . . 60
Pacific Dental Conference. . . 22
Quantum. . . . . . . . . . . . . . . . . 48
University of British
Columbia. . . . . . . . . . . . . . . . . 15
Vident. . . . . . . . . . . . . . . . . . . . . 2
VOCO. . . . . . . . . . . . . . . . . . . . . 6
Equipment Sales & Service
FOR SALE: Cerec 3D by Sirona with
compact milling chamber and wireless
remote. Barely used and in excellent
condition. Latest 3D software installed.
$59,900. Please contact Jamie: (780)
464-4166 ext. 102.
D4876
CEREC 3D FOR SALE: Slightly used
Cerec 3D Sirona milling unit, with
software, mobile computer terminal,
blocks/burs. Works perfectly, serviced
regularly by Patterson. Recently sold
practice outside of GTA and need to
sell Cerec unit. Please call: (519)
942-8421 or email: heritagedental@
sympatico.ca.
D4891
69
C a n a d i a n d en t is t s’ i n v es t m en t P ro gr a m
CDA Funds
Leading Fund Managers
Low Fees
CDA Funds can be used in your CDA RSP, CDA TFSA, CDA RIF, CDA Investment Account, CDA RESP and CDA IPP.
CDA Fund Performance (for period ending December 31, 2008)
MER
1 year
3 years
5 years
10 years
CDA Canadian Growth Funds
Aggressive Equity Fund (Altamira)
Common Stock Fund (Altamira)
Canadian Equity Fund (Trimark)
Dividend Fund (PH&N)†
High Income Fund (Sceptre)†
Special Equity Fund (KBSH)
TSX Composite Index Fund (BGI)††
1.00%
0.99%
1.50%
1.20%
1.45%
1.45%
0.67%
-46.8%
-33.8%
-27.5%
-32.5%
-31.4%
-44.0%
-33.0%
-17.0%
-4.5%
-8.5%
-8.9%
-7.2%
-14.5%
-5.2%
-7.7%
3.2%
-1.9%
-0.4%
2.9%
-3.5%
3.6%
1.4%
4.9%
3.5%
6.6%
n/a
1.0%
n/a
CDA International Growth Funds
Emerging Markets Fund (Brandes)
European Fund (Trimark)†
International Equity Fund (CC&L)
Pacific Basin Fund (CI)
US Large Cap Fund (Capital Intl)†
US Small Cap Fund (Trimark)
Global Fund (Trimark)
Global Growth Fund (Capital Intl)†
S&P 500 Index Fund (BGI)††
1.77%
1.45%
1.30%
1.77%
1.46%
1.25%
1.50%
1.77%
0.67%
-35.6%
-30.5%
-30.2%
-22.2%
-24.3%
-30.0%
-28.7%
-27.7%
-22.1%
-6.2%
-5.2%
-7.2%
-2.0%
-12.1%
-11.7%
-6.6%
-6.4%
-7.6%
1.9%
-3.1%
-4.4%
1.3%
-7.0%
-1.8%
-2.2%
0.0%
-4.1%
6.8%
-5.0%
-3.3%
-1.6%
n/a
n/a
2.6%
n/a
-4.6%
CDA Income Funds
Bond and Mortgage Fund (Fiera)
Bond Fund (PH&N)
Fixed Income Fund (McLean Budden)†
0.99%
0.65%
0.97%
6.1%
3.1%
5.9%
3.6%
3.2%
3.4%
3.5%
4.5%
4.4%
4.3%
5.5%
4.9%
CDA Cash and Equivalent Fund
Money Market Fund (Fiera)
0.67%
3.1%
3.3%
2.7%
3.1%
CDA Growth and Income Funds
Balanced Fund (PH&N)
Balanced Value Fund (McLean Budden)†
1.20%
0.95%
-18.5%
-12.3%
-3.5%
-1.5%
0.7%
2.6%
2.4%
4.0%
CDA Managed Risk Portfolios (Wrap Funds)
MER
1 year
3 years
5 years
10 years
Index Fund Portfolios
CDA Conservative Index Portfolio (BGI)†
CDA Moderate Index Portfolio (BGI)†
CDA Aggressive Index Portfolio (BGI)†
0.85%
0.85%
0.85%
-9.7%
-17.1%
23.7%
-0.5%
-2.2%
-3.9%
2.3%
2.3%
2.2%
2.6%
3.2%
2.9%
Income/Equity Fund Portfolios
CDA Income Portfolio (CI)†
CDA Income Plus Portfolio (CI)†
CDA Balanced Portfolio (CI)†
CDA Conservative Growth Portfolio (CI)†
CDA Moderate Growth Portfolio (CI)†
CDA Aggressive Growth Portfolio (CI)†
1.65%
1.65%
1.65%
1.65%
1.65%
1.65%
-7.4%
-13.6%
-18.1%
-21.3%
-23.9%
-28.5%
-0.4%
-1.9%
3.1%
-4.4%
-6.8%
-6.8%
2.7%
2.7%
2.6%
n/a
0.5%
n/a
3.8%
3.8%
3.9%
n/a
n/a
n/a
Figures indicate annual compound rate of return. All fees have been deducted. As a result, performance results may differ from those published
by the fund managers. CDA figures are historical rates based on past performance and are not necessarily indicative of future performance.
†
Returns shown are for the underlying funds in which CDA funds invest.
††
Returns shown are the total returns for the indices tracked by these funds.
For current unit values and GIC rates visit www.cdspi.com/values-rates.
To speak with a representative, call CDSPI toll-free at 1-800-561-9401, ext. 5020.
70
50 Years of Experience
Explains a Lot
CDSPI has provided insurance and investment solutions to
dentists for 50 years. So — when it comes to financial services
— it’s no wonder we’ve earned dentists’ trust, understand
their needs best, and provide them with superior service.
Our highly credentialed advisors can explain many planning
techniques and tools to protect your financial well-being and
make your money work better for you. Call us — and share
the experience.
1-877-293-9455
www.cdspi.com
to reach a licensed advisor at CDSPI Advisory Services Inc.
D
e
n
t
I
S
t
S
F
I
r
S
t
the insurance plans are member benefits of the CDA and co-sponsoring provincial dental associations and the investment plans are member benefits of the CDA, and are administered by CDSPI.
restrictions may apply to advisory services in certain jurisdictions.
09-53 12/08
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February 2009, Volume 75, Issue 1

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