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oralhygiene CONTENTS

BOOK REVIEW The Dental Diet Dr. Steven Lin Why Physicians Die by Suicide Michael Myers, MD

ORAL HYGIENE Alternative Rinses: Moving Away from Chlorhexadine Sheri B. Doniger, DDS

ORAL HEALTH Hand Ergonomics in Dentistry: The Effects of Hand Fatigue

Patty Taylor, RN, BA

RADIOLOGY Kissing Mandibular Teeth

Dr. Hans Ulrich Brauer, Dr. Bruce Pynn

PRACTICE MANAGEMENT Dentistry Must Engage With Multi-Generational Patients

Lisa Philp, RDH, CMC

The Role of the Team in Communicating Treatment Possibilities

Debra Engelhardt-Nash

CLINICAL Is It Really Periodontal Disease?

Irene M. Iancu, BSc, RDH, CTDP

DEPARTMENTS Editorial

Your Perception is Your Reality

News

Update on Tax Proposals; What Patients Say and Why

46 Dental Marketplace 49 Product Profiles

November 2017 www.oralhealthgroup.com

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EDITORIAL

Your Perception Is Your Reality I am not a dentist. I am not a dental hygienist. Admittedly, I never had the desire to learn about the importance of our teeth. I am not an expert, nor will I ever be when it comes to dentistry, but I have a responsibility to become an expert at my job and establish authority in the industry. I’ll be the first to admit that when I joined the Oral Health team almost five years ago, I was entering an entire new world. Of course I knew the importance of routine check ups with my dentist and hygienist, and to be diligent with my oral healthcare routine. Did I ever think my career would be based around the field of dentistry? Absolutely not. But what I do know now, more than ever, is that we aren’t so different. I have found a strong desire to stay current, to educate myself, to be willing to grow, and to most importantly deliver my best – as all experts do. No matter how much you think you know; ideas and content are constantly evolving. As dentists and hygienists, you have the responsibility to be an expert. You are a trusted resource, not just to your team but also to your patients. Your duty is to be constantly learning, putting forth your best effort and to develop skill sets that prove you are the expert. Even though our education and training are on opposite ends of the spectrum, my desire to succeed is similar. As an

editor for the Oral Health Group, I am a trusted resource for our readers. I have the responsibility to deliver the best quality content, as you have the responsibility to deliver the best quality care to your patients. Determination is essential when it comes to succeeding in your career. As hygienists, being passionate about your job will not only have a positive impact in the office, and on your coworkers, but more importantly, on your patients. Having a strong desire to evolve is a key factor in ensuring growth and happiness throughout the span of your career. Alongside passion, I strongly believe that networking is vital. One fail-proof way to impact your career is to develop and maintain a network of contacts. In dentistry, continuing education, tradeshows, conferences, study clubs and conversations with peers are beneficial to your professional and personal growth. Creating a network of support can more than likely provide you with an outlet for discovery. No matter which field your career is in, the fundamentals for success are essentially the same. Visualize where you want to be and use your skills to make it your reality. Taking steps to be viewed as a leader in your industry is important for marking your territory. I am not an expert but I’m here to start conversations. So let’s start talking.

Jillian Cecchini Assistant Editor

November 2017 www.oralhealthgroup.com

NEWS BRIEFS

What patients say and why A recent report from the American Dental Association’s Health Policy Institute had two intriguing charts. One compared what patients say and what they do, when it comes to going to the dentist. And the second chart showed why two of three Americans avoid the dentist.

Just imagine the increase in dental attendance with more affordable and effective preventive are. Visit www.partnersinprevention.ca.

Update on Liberal Tax Proposals 1. The Federal small business tax rate will be lowered: • 0.5% decrease from 10.5% to 10%, effective January 1, 2018 • A further 1% decrease from 10% to 9%, effective January 1, 2019 As a result of the above, the combined Federal and the Ontario provincial corporate tax rate for taxable income up to $500,000 will decline from the current rate of 15% to 14.5% effective January 1, 2018 and 13.5% effective January 1, 2019 for all professional, hygiene or technical corporations. If your corporation’s fiscal year-end is other than December 31, then the new corporate rate will be pro-rated based on the period before and after these effective dates. 2. The government will move forward with measures to limit income sprinkling (i.e. introduce reasonableness tests for dividends paid to adult family members) using private corporations. However, the government has committed to making some changes to simplify the original proposals; details are not yet available at this time. It still appears, at this time, that dividends paid to family members after December 31, 2017 will be subject to reasonableness tests. 3. The government will NOT be moving forward with measures that limit access to the Lifetime Capital Gains Exemption. It still appears that you could introduce new family members into your corporation to take advantage of the LCGE and that existing family m ember shareholders should be entitled to claim the LCGE when their shares are sold. Visit dcy.ca for more information.

oralhygiene A NEWCOM Business Media Publication

Editorial Director: Catherine Wilson 416-510-6785 catherine@newcom.ca

Associate Publisher: Hasina Ahmed 416-510-6765 hasina@newcom.ca

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OFFICE: Located at 80 Valleybrook Drive, Toronto ON M3B 2S9. Telephone 416-442-5600, Fax 416-510-5140. Oral Hygiene serves dental hygienists across Canada. The editorial environment speaks to hygienists as professionals, helping them build and develop clinical skills, master new products and technologies and increase their productivity and effectiveness as key members of the dental team. Articles focus on topics of interest to the hygienist, including education, communication, prevention and treatment modalities. Please address all submissions to: The Editor, Oral Hygiene, 80 Valleybrook Drive, Toronto, ON M3B 2S9.

Subscription rates: Canada $25.00/1 year; $47.00/2 years; USA $46.95/1 year; Foreign $46.95/1 year; Single copies Canada & USA $10.00, Foreign $18.00. GST/ HST #103862405RT0001.Printed in Canada. All rights reserved. The contents of this publication may not be reproduced either in part or in full without the written consent of the copyright owner. From time to time we make our subscription list available to select companies and organizations whose product or service may interest you. If you do not wish your contact information to be made available, please contact us via one of the following methods: Phone: 416-614-5831; Fax: 416-614-8861; E-mail: mary@newcom.ca; Mail to: Privacy Officer, 451 Attwell Drive, Etobicoke, ON M9W 5C4. Canada Post product agreement No. 40063170. Oral Hygiene is published quarterly by Newcom Business Media Inc., a leading Canadian magazine publishing company. ISSN 0827-1305 (PRINT) ISSN 1923-3450 (ONLINE)

November 2017 www.oralhealthgroup.com

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ORAL-22045

BOOK REVIEW

THE DENTAL DIET:

The Surprising Link Between Your Teeth, Real Food, and Life-Changing Natural Health Dr. Steven Lin

Modern dental health is a disaster zone. We are in i the midst of an orthodontia epidemmillion U.S. kids need braces and ic. Four F million need wisdom teeth extractions. 10 m Gum disease affects half of all U.S. adults, Gu tooth decay is the most chronic disease in too children today, and oral health concerns ch are both warnings and causes of other illar nesses that harm the entire body. But rene vversing the trend is easier than we think; iin fact, it all starts with your pantry. In The Dental Diet: The Surprising Link between Your Teeth, Real Food, and Life-Changing Natural Health (Hay House, Inc., January 9, 2018), Dr. Steven Lin merges dental health and science to reveal how the right nutrition can improve your teeth and overall health. An experienced dentist and the world’s first dental nutritionist, Dr. Lin lays out the ultimate dietary program to ensure you have a healthy mouth and body for the rest of your life. He even reveals why crooked teeth are the result of a nutritional program, and how parents can prevent braces by feeding children the right food starting with the earliest stages of their lives. The Dental Diet arms readers with the tools they need – including a 40-day meal plan, exercises for the mouth, recipes, and simple cooking techniques to use in everyday life. Combining cutting-edge research with real world applications, Dr. Lin’s approach will revamp your eating habits for a long and healthy life. Using actionable steps to achieve better dental health, Dr. Lin challenges readers to rethink their diets, unveiling: • Your teeth matter the most: How your diet

can completely prevent dental diseases • No braces, no problem: How parents can raise kids who develop naturally straight teeth • The missing factor in dietary guidelines: What needs to change about modern nutrition • His 4-Step Diet for Healthy Teeth: The 40Day Program to make your teeth and body healthier • From teeth to tummy: Why your tooth decay could be a sign of digestive issues • The one mistake every dentist has been making: Why focusing on brushing and flossing is fundamentally wrong • The key nutrient that helps grow strong straight teeth and prevent disease all over the body Dr. Steven Lin is a board-accredited dentist, passionate health educator, and TedX speaker. As the world’s first dental nutritionist, Dr. Lin is on a mission to prevent dental diseases, instead of simply treating them, by focusing on the link between nutrition and dental health. Trained at the University of Sydney with a background in biomedical science, he merges anthropological, physiological, and nutritional science with oral health to integrate effective prevention strategies into his own dental practice. Dr. Lin’s work has been published in MindBodyGreen, About.com, and The British Dental Journal, among other publications. Learn more about Dr. Steven Lin at www. drstevenlin.com, or connect with Dr. Lin on Facebook. The Dental Diet is currently available for pre-order on Amazon and will be available through all major booksellers on January 9, 2018.

November 2017 www.oralhealthgroup.com

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ORAL HYGIENE

ALTERNATIVE RINSES: Sheri B. Doniger, DDS is a leading dental clinician, author, international educator, and consultant who currently practices dentistry in Lincolnwood, IL. Dr. Doniger is an avid researcher, frequently contributing to an array of dental publications on a variety of topics. She is a member of the IZUN Oral Healthcare Scientific Advisory Team. Please free to contact Dr. Doniger at www.donigerdental.com. Clinical photos courtesy of Dr. William Z. Levine

Moving Away From Chlorhexadine

eriodontal disease is at an epidemic level. “Periodontal diseases and dental caries are the most prevalent chronic diseases, affecting children, adolescents, adults and the elderly.”1 Over seventy percent of Canadians have some form of periodontal disease. The statistics are similar in the United States. Gingivitis is present at all ages. 2 Fifty percent to 94% of patients are experiencing some form of gingivitis, depending on clinical definition of gingivitis and the sample studied. 3 According to a recent article in the New York Times, “More than 75% of American adults have some form of gum disease, but according to a major survey, only 60% have any significant knowledge”. The oral-systemic link, which has shown implications in diabetes, cardiovascular disease and now possibly stroke, is hard evidence for the importance of oral care. Periodontal disease occurs with an initial inflammatory response to bacterial infection. This activates the innate immune system. Amplification of this initial localized response results in the release of an array of cytokines and other mediators and propagation of inflammation through the gingival tissues. The failure to encapsulate this “inflammatory front” within gingival tissue results in expansion of the response adjacent to alveolar bone. The inflammatory process then drives the destruction of connective tissue and alveolar bone that is the cardinal sign of periodontal disease.4 Periodontal disease is very cyclic (Figure

1). Periodontal disease occurs when the bacteria infect the biofilm, causing an inflammatory response from the gingival sulcus area. Once it is infected, inflammation increases. If unchecked, this inflammation will cause destruction to gingival tissues and surrounding bone structures, hence causing a periodontal pocket. 5 By not addressing the inflammatory response, it will continue to destroy tissue and bone. Normally, inflammatory responses to tissue will assist in healing the injured tissue. Periodontal disease represents a state of dysfunctional healing. The inflammatory response is not effective in resolving the lesion but actually perpetuating it. Interestingly, we know that all inflammation is not always bad. It is a healthy bodily response. When we injure our knee or our back, we know that ice is necessary to reduce the swelling that occurs. If we don’t target the inflammation, future issues may arise. Using a similar thought process, treating the inflammation should be the primary target for periodontal disease. So, what are we going to do about this? We need to target plaque and treat inflammation. Dental hygienists are truly the periodontal oral healthcare champions of our practice. They are on the front line of disseminating oral self-care instructions to our patients on a daily basis. Along with explaining the ravages of periodontal disease to our patients, they give fastidious oral hygiene instruction including brushing, flossing and rinsing. Rins-

November 2017 www.oralhealthgroup.com

ORAL HYGIENE ing should be an integral part of basic oral hygiene instructions. Why rinsing? Rinsing is simple, fast and easy. Rinsing allows for a broad delivery system and can penetrate interdentally. Additionally, rinsing will deliver therapeutic agents, such as antiseptics, fluoride and antiinflammatory agents) in a short period. The ideal rinsing product should have a combination effect of reducing bacterial load while delivering a therapeutic benefit to the tissue. The reduction of bacterial load should not be from the act of rinsing but the therapeutics in the rinsing liquid. Several rinses are currently available.6 Essential oils disrupt cell wall viability to achieve antibacterial effects. Since the majority of these rinses contain alcohol, data is equivocal if effect is due to the actual essential oils or high alcohol content. An example in this category is Listerine, which contains eucalyptol, menthol, thymol, and methyl salicylate. Potential side effects include: tissue dryness and trauma from alcohol concentration. Some cell toxicity may also occur due to alcohol â€“ a concern for surgical cases. Delmopinol hydrochloride 0.2% is found in GUM PerioShield. It does not kill bacteria, but interferes with the synthesis of glucan. It reduces biofilm formation and interferes with bacterial adherence. Side effects include a significant taste alteration and staining (though less than chlorhexadine). Chlorine dioxide, which is found in CloSYS, TheraBreath, Oxyfresh, and ProFresh

Bacteria + Host Response = Clinical Sequellae FIGURE 1: Periodontal Pathogenesis 5

(sodium chlorite), has an anti-bacterial effect that is combined with increased reduction of volatile sulfur compounds. The primary benefit of these products is fresh breath. As far as the bactericidal rinses, chlorhexadine and cetylpyridinium chloride (i.e. Cepacol) utilize a cationic charge to bind anionic bacterial cell wall to achieve bactericidal effect. Both products have significant side effects but chlorhexadine is significantly worse. Chlorhexadine contains alcohol and will cause significant staining. Other side effects include altered taste, oral mucosal erosion, parotid gland swelling due to stenosis of the parotid and enhanced supergingival calculus formation.7 Chlorhexadine has overdose issues with children. Ingestion of 1-2 ounces of CHX by small child may lead to gastric distress including nausea or signs of alcohol intoxication. Chlorhexadine is also available alcohol free, though the staining and other issues remain. There is a natural alternative. Utilizing plant botanicals to target inflammation and plaque, PeriActiveTM mouth rinse is a great alternative in this rinse category. Developed

November 2017 www.oralhealthgroup.com

ORAL HYGIENE

TABLE 1: Active ingredients in PeriActiveTM Oral Rinse 8, 9, 10, 11

Herbal

Mode of Action

Echinacea purpurea

Anti viral, anti bacterial, anti cytotoxic, reduces inflammation and gingivitis

Centella asiatica

Increases collagen formation, wound healing, reduces inflammation and gingivitis

Sambucus nigra

Pro-inflammatory properties stimulates gingival healing and repair

FIGURE 2: Strong anti-bacterial effect. PeriActiveTM reduction in bacteria

FIGURE 3: Change in Number of Bleeding Sites utilizing PeriActiveTM 11, 12

FIGURE 4: PeriActiveTM has similar antibacterial effect to chlorhexadine, post implant surgery13, 14

by Izun Pharmaceuticals Corporation Oral Care Division, there is a rinse utilizing natural bio-active compounds that exhibited powerful anti-inflammatory and wound-healing properties. PeriActiveTM contains three botanicals that work synergistically to reduce inflammation: Echinacea purpurea, Centella asiatica and Sambucus nigra. Echinacea purpurea and Centella asiatica reduce irritation and gingivitis. Sambucus nigra, in addition to reducing inflammation and gingivitis, is a gingival repair stimulator. These three products together promote healing (Table 1). PeriActiveTM is antibacterial, promotes tissue healing and has no alcohol. It is safe for daily use and causes no staining or drying of oral tissues. The bonus is the natural botanicals in the formulation. PeriActiveTM will block inflammation in several sites and induces fibroblasts to migrate, deposit matrix proteins, and secrete factors associated with healing. PeriActiveTM harnesses the polymolecular nature of plant extracts to block inflammation at multiple sites, which is a beneficial approach to controlling inflammatory damage. PeriActiveTM may also be utilized with the toothbrush, in lieu of toothpaste. Patients claim there is no â€œmorning breathâ€? if this product is used at night. PeriActiveTM has been shown to actively reduce bacteria after two minutes (Figure 2). This is important in reigning in the active pathogens, such as P. gingivalis and A. viscosus, which are factors in periodontitis. Additionally, there has been evidence of decrease percentage in bleeding sites after using PeriActiveTM 12 (Figure 3). Finally, PeriActiveTM has shown to have similar antibacterial effect compared to Chlorhexadine, when utilized post implant surgery (Figure 4). Healing of the surgical site, two weeks post-operative, demonstrates healthy tissue without the use of alcohol or staining13,14 (Figures 5 & 6).

November 2017 www.oralhealthgroup.com

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FIGURE 5: Immediately post surgery 6. 7.

FIGURE 6: PeriActiveTM rinse two weeks post surgical procedure used in conjunction with PerioPatchTM 10.

We all struggle with compliance for our patient’s oral health maintenance. We aren’t able to be with our patients 24/7. We need to assist them with a solution to their inflammation and enlist them in stopping the cycle of their own periodontal disease. Along with brushing and flossing, using an anti-inflammatory rinse, these oral care regimens will assist our patients in keeping their teeth for a lifetime. For practitioners and patients who prefer a more natural approach to healthcare, without the staining and alcohol, PeriActiveTM is an excellent, bioactive choice. It prevents plaque, is antibacterial, reduces bleeding and inflammation, soothes the tissues with botanicals post operatively, while enhancing tissue repair.

References: 1.

Archived, Chronic Diseases in Canada http://www.phac-aspc.gc.ca/publicat/hpcdppspmc/30-4/preface-eng.php Accessed December 6, 2016 Coventry J, et al. BMJ. 2000;321:36–39; 2.

11.

12.

13.

14.

15.

ORAL HYGIENE (Photos Courtesy of Dr. William Z. Levine)

Richards D. Evid Based Dent. 13;14: Eke PI, Dye BA, Wei L,et al. J Periodontol. 2015;86:611–622 Mariotti A, Hefti AF. BMC Oral Health. 2015;15(Suppl 1):S6 https://www.ncbi.nlm.nih. gov/pmc/articles/PMC4580771/ Accessed October 12, 2016 Journal of Periodontology August 2008, Vol. 79, No. 8s, Pages 1569-1576, DOI 10.1902/ jop.2008.080233 (doi:10.1902/ jop.2008.080233) Inflammation and Bone Loss in Periodontal Disease David L. Cochran* Kornman, K. Mapping the Pathogenesis of Periodontitis: A New Look. J Periodontology, August 2008 Vol. 79, No. 8s, Pages 1560-1568 Goldstep, F. Oral Rinses for Periodontal Health. Oral Health Journal. December 1, 2014 Side effects of chlorhexidine mouth washes., Flötra L, et al. Scand J Dent Res. 1971;79(2):119-25 Accessed October 7, 2016 Shetty BS, Udupa SL, Udupa AL, Somayaji SN. Effect of centella asiatica L (Umbelliferae) on normal and dexamethasone-supressed would healing in wistar albino rats. Int J Low Extrem Wounds. 2006;5(3):137-143 Harokopakis E, Albzreh MH, Haase EM, et al. Inhibition of proinflammatory activities of major periodontal pathogens by aqueous extracts from elder flower (Sambucus nigra). J Periodontol. 2006;77(2):271-279 Woelkart K, Marth E, Suter A, et al. Bioavailability and pharmacokinetics of Echinacea purpurea preparations and their interaction with the immune system. Int J Clin Pharmacol Ther. 2006; 44(9):401-408. Samuels N, Grbic J, Saffer A, et al. Effect of an herbal mouth rinse in preventing periodontal inflammation in an experimental gingivitis model: A pilot study. Compendium of Continuing Education in Dentistry. Aegis Communications. March 2012, Vol 33, Issue 3. Levine, WZ, Samuels, N, Williams, R. Effect of a Botanical Mouth Rinse on Dental Plaque Formation: A Randomized, Double-blinded, Placebo-controlled Trial Journal of Oral Hygiene and Health August 10, 2014 Rosen PS, Levine WZ. A Pilot Study Comparing An Alcohol Free Botanical Rinse to Chlorhexidine Rinse in Managing Post-Surgical Inflammation with Dental Implants. Submitted Rosen P. and Levine W. A pilot study comparing a botanical rinse to chlorhexidine rinse in managing postsurgical inflammation around dental implants. http://periobasics.com/immunology-of-periodontal-diseases.html Accessed March 2, 2017

November 2017 www.oralhealthgroup.com

ORAL HEALTH Patty Taylor RN, BA is Vice President of Professional Education and Clinical Affairs for Ansell. She received her bachelor’s degree from the University of Western Ontario, Canada. Patty is a registered nurse with more than 20 years of international experience focusing on perioperative safety, quality and education in Canada, England and the United States. Being an active member of professional associations and networking groups for more than 30 years is a key factor in her professional growth and success.

HAND ERGONOMICS IN DENTISTRY Ergonomics refers to the interaction between a human’s musculoskeletal system and his or her workspace. Studies show that various job functions performed by dental professionals expose them to risk factors for musculoskeletal disorders (MSDs).

THE EFFECTS OF HAND FATIGUE Hand fatigue is a serious work place issue. The tasks that dental professionals perform can often be tedious, repetitive and can cause strain to muscles, nerves, and tendons in their hands, wrists and arms. Additionally, when a glove is worn that restricts movement, he or she must exert more muscle effort to perform tasks, thereby increasing the risk of strain which can lead to hand fatigue and carpal tunnel syndrome. Such strain can result from glove use when the gloves are thick, rigid, slippery, ill-fitting or otherwise uncomfortable. MSDs, such as Carpel Tunnel Syndrome and tendinitis, are leading causes of lost workday injuries and illnesses.1 In fact, according to the U.S. Bureau of Labor Statistics, MSD cases accounted for 33 percent of all worker injury and illness cases in 2013. 2 Study reviews indicate, that over 50% of dental professionals reported hand fatigue, 3 9.2 percent of dentist have been diagnosed with

some form of repetitive motion disorder4 and 65% of registered dental hygienists reported having carpal tunnel syndrome. 5 Signs of MSDs include decreased grip strength and loss of coordination, decreased range of motion, and loss of normal sensation. These conditions are reported as painful and may result in loss of productivity, loss of work, medical costs, and potential l ong term complications, if untreated.6

ERGONOMICALLY DESIGNED GLOVES According to US Ergonomics, “A product that has received certification provides measurable ergonomic benefits to the user by improving comfort and fit and by minimizing the risk factors that may contribute to the development of ergonomic injuries”.7 A ergonomically designed disposable medical glove considers the toll of occupational activities and applies cutting-edge technologies to engineer solutions that maximize the dexterity,

November 2017 www.oralhealthgroup.com

ORAL HEALTH comfort and fit of single-use gloves. Selecting high performing medical gloves with a certified ergonomic design is a trusted method for reducing muscle effort during repetitive tasks, improving worker performance and supporting occupational hand health. A glove that is carefully designed to deliver optimum fit ensures superior comfort and maximum range of motion. At the same time, the amount of grip a glove delivers plays a major role in the amount of muscle effort required to securely handle, hold or manipulate objects. Ultimately, innovations in sizing, formulation, material type, and texture all contribute to a softer, more comfortable, better fitting glove.

CONCLUSION As dental professionals, your hands are your livelihood. Choosing a glove with an ergonomic certification ensures the gloves you wear are designed to help prevent MSDs, protecting your hands and your career.

References 1. U.S. Occupational Safety & Health Administration, “Prevention of Musculoskeletal Disorders in the Workplace” https://www.osha.gov/SLTC/ ergonomics/index.html Accessed October 6, 2017. 2. U.S. Bureau of Labor Statistics, “Nonfatal Occupational Injuries and Illnesses Requiring Days Away from Work, 2013”. 3. Guignon, Anne Nugent RDH, MPH. What’s happening to your hands? Accessed October 6, 2017. 4. HAMANN, CURT M.D. Prevalence of carpal tunnel syndrome and median mononeuropathy among dentists. Accessed October 6, 2017. 5. SIMMER-BECK, MELANIE RDH, MS. Noting harmful chair side postures through assessment and observation and making necessary adjustments can make the difference in maintaining a healthy career in dental hygiene. Accessed October 6, 2017. 6. http://office-ergo.com/hand-wrist-arm-pain/ 7. www.us-ergo.com

November 2017 www.oralhealthgroup.com

RADIOLOGY

KISSING MANDIBULAR TEETH

An Unexpected Radiological Finding Dr. Dr. Hans Ulrich Brauer is Oral Surgeon, and Chief of Dentistry, Dorow Clinic Loerrach, Germany. He is also an editorial board member of the German dental journal ZWR.

Dr. Bruce Pynn is Oral Health’s editorial board member for oral and maxillofacial surgery. He is an Associate Professor, North Ontario School of Medicine, Lakehead University, and Chief of Dentistry, Thunder Bay Regional Health Science Center.

INTRODUCTION Kissing teeth are extremely rare incidental radiological findings. Only very few cases have been reported in the literature. Kissing mandibular teeth can be divided into kissing molars (KM) and kissing canines (KC).

KISSING MOLARS KM are impacted permanent molars that have occlusal surfaces contacting each other in a single follicular space with roots pointing in opposite directions (Boffano & Gallesio 2009) (Figure 1). “Kissing molars” were first descripted by Van Hoof in 1973. He reported a case of four impacted molars (two bilateral KM) in a 31-year-old patient (Van Hoof 1973). This special term was used again from Robinson et al. in 1991 (Robinson et al. 1991). In the present literature KM are also named as “rosette formation“ and “rosetting of molars“ (Menditti et al. 2015), or entitled as ”impacted love“ (Gulses et al. 2012). KM often are retained, distally angulated second molar and a mesially angulated, displaced wisdom teeth. KM are an unusual form of impaction that is very infrequently reported in dental literature (Brauer 2017).

Fig. 1: Panoramic scan showing third and fourth molars. In the lower right jaw are characteristic unilateral kissing molars (KM, class III).

KM can occur unilateral or bilateral (Robinson et al. 1991). Gulses et al. further divide in class I (first and second lower molar), class II (second and third lower molar), and the extremely rare class III (third and fourth supernumerary lower molar) (Gulses et al. 2012). KM usually are asymptomatic and often an incidental finding in panoramic radiographs (Brauer 2017). The etiology and pathogenesis are unknown. However, the association to metabolic connective diseases such as mucopolysaccharidosis has been suggested (Menditti et al. 2015). Indications for surgery involve a history of pain, recurring infections, or cystic lesions (Arjona-Amo et al. 2016, Scheuber et al. 2014). The surgical approach for this condition requires a meticulous understanding of the anatomy of the region, advanced surgical abilities, and an individual rigorous planning process (Arjona-Amo et al. 2016, Boffano & Gallesio 2009).

KISSING CANINES Bilateral impacted mandibular canines when transmigrated can present as kissing phenomenon in the panoramic radiograph (Figure 2). Qaradaghi termed bilateral mandibu-

Fig. 2: A special form of kissing mandibular canines: KC on the same vertical axis parallel to each other.

November 2017 www.oralhealthgroup.com

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RADIOLOGY lar canines as KC or alternative as “mirror image canines” in cases which are defined as the migration of both canines at the same rate and on the same horizontal axis parallel to each other and meeting each other at the midline (Qaradaghi 2010). KC can be associated with cystic formation and/or transmigration. Transmigration is usually defined as a phenomenon in which more than half of the length of an unerupted tooth has passed the midline. There are very few cases of KC reported in the literature. For example, Sanjay et al. reported an unusual case of a 24-year-old female with kissing dentigerous cysts involving mandibular canines (Sanjay et al. 2015). Similarly, Dongol et al. described a case of bilateral mandibular canine impaction with transmigration in a 32-year-old male patient (Dongol et al. 2017) and Sharma et al. reported a case of KC with their labial surfaces facing each other and sharing a common follicular space in a 21-year-old man (Sharma et al. 2014). In contrast, Omami & Mathew reported a case of KC with a dentigerous cyst in a 12-year-old girl (Omami & Mathew 2015). The etiology and pathogenesis are unknown. Management of KC includes periodic observation, surgical exposure and orthodontic alignment, transplantation, and surgical removal (Dongol et al. 2017, Sharma et al. 2014).

References: 1. Arjona-Amo M, Torres-Carranza E, BatistaCrusado A, Serrera-Figallo MA, Crespo-Torres S, Belmonte-Caro R, Albisu-Andrade C, TorresLagares D, Gutiérrez-Pérez JL. Kissing molars extraction: Case series and review of the literature. J Clin Exp Dent 2016; 8(1): e97-e101

2. Boffano P, Gallesio C. Kissing molars. J Craniofac Surg 2009; 20(4): 1269-1270 3. Brauer HU. Kissing molars – Ein unerwarteter, seltener radiologischer Befund. ZWR 2017; 126(5): 245 4. Dongol A, Acharya P, Yadav RP, Mahat AK, Yadav AK, Shrestha A, Jaisani MR. Kissing canines associated with dentigerous cyst, a case report of transmigrated bilateral mandibular canines. Int J Oral Craniofac Sci 2017; 3(1): 14-16 5. A, Varol A, Sencimen M et al. A study of impacted love: kissing molars. Oral Health Dent Manag 2012; 11(4): 185-188 6. Menditti D, Laino L, Cicciu M et al. Kissing molars: report of three cases and new prospective on aetiopathogenetic theories. Int J Clin Exp Pathol 2015; 8(12): 15708-15718 7. Omami G, Mathew R. Kissing canines associated with a dentigerous cyst: case report and mini review. Int J Dentistry Oral Sci 2015; 2(6): 84-86 8. Qaradaghi IF. Bilateral transmigration of impacted mandibular canines: report of two cases and review. Rev Clín Pesq Odontol 2010; 6(3): 271-275 9. Robinson JA, Gaffney W Jr, Soni NN. Bilateral “kissing” molars. Oral Surg Oral Med Oral Pathol 1991; 72(6): 760 10. Sanjay CJ, David CM, Kaul R, Shilpa PS. Kissing dentigerous cysts involving mandibular canines: report of unusual case with review of the literature. J Calif Dent Assoc 2015; 43(1): 29-33 11. Scheuber S, Bornstein M. Kissing molars. A peculiar radiologic finding. Swiss Dent J 2014; 124(1): 16-17 12. Sharma S, Raghavan V, Kumari S. Kissing mandibular canines: serendipity at its best. J Indian Acad Oral Med Radiol 2014; 226(1): 82-84 13. Van Hoof RF. Four kissing molars. Oral Surg Oral Med Oral Pathol 1973; 35(2): 284

November 2017 www.oralhealthgroup.com

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PRACTICE MANAGEMENT Lisa Philp

DENTISTRY MUST ENGAGE WITH MULTI-GENERATIONAL PATIENTS

entistry is a "people business" that serves a broad spectrum of age demographics that span multiple generations â€“ from the millennials to the Gen X to the boomers, silent generation and so on. Itâ€™s well-known that there are significant generational differences that are common to each segment, depending on when they were born and what the common things they were exposed due during maturation that impact lifestyle, health care, service expectations, attitudes, and technology use. A one-size-fits-all approach to patient engagement and the same tried and true ways of attracting satisfying and serving dental patients no longer works with all patient segments equally. Future dental patient goodwill and retention will be reliant on the ability to open their mind, let go of judgements, and to understand and ADAPT to the largest and most influential generation on the globe. The youth segment of children born from 1981-2000 are named Gen Y or Millennials. Millennials are the largest generation in history and comprise approximately are 27% of the population, which is the highest ever in North American history. They are currently in young adulthood and have overcome their

delayed independence and are now making decisions on the brink and tipping point of commanding the largest buying power and have the highest influence in history. Millennial buying power and spending today is estimated by the U.S. census board at $200 billion annually, with confirmation that they will influence another $300 billion to $400 billion in buying. They are predicted to have a lifetime spending total of $10 trillion as consumers. At this rate, they will exceed the baby boomers in spending and decisionmaking. Their influence is expansive, as 80% of Millennials name one of their parents as their best friend, rather than naming a peer. And more than a third of Millennials of all ages say they influence what products their parents buy, what shops and restaurants they visit and what trips they take. This lack of conflict between these generations means that millennials will become vital carriers of a dental practice message, to not only their friends, but also their parents. They spread the word at a rate and impact that one day almost everyone will pass for a millennial, as attitude and buying patterns go. Dentistry must find its path in appealing to this segment of youthful patents for growth,

is the Chief Visionary Officer of TGNA - Transitions Group North America. Lisa is committed to being an eternal student in the areas of personal growth, leadership, change management, human capital development, adult learning, advanced training techniques and communication skills. She may be contacted at www.tgnapracticemanagement or info@tgnadental.com

November 2017 www.oralhealthgroup.com

PRACTICE MANAGEMENT

retention, and profitability. This may involve older generations letting go their judgments on the perception that Gen Y are entitled, engorged, cell phone addicted, ramen-eating, impatient, impecunious, underemployed, see through the clichés and accept that it is normal for every generation to view the generation born BEFORE THEM is old fashioned and the generation born AFTER THEM as crazy. We must open our mind to Millennials and we must take the time to understand their distinctions and adapt to their characteristics, upbringing, beliefs, wants and how they see things and treat them, and also how they want to be treated in the dental experience. Gen Y or Millennials are the children of the boomers/X and they are generally optimistic, idealistic and associated with a group orientation. They have been well-looked after and have taken longer to become adults. They travel in packs or herds and are the most ethnically diverse generation ever. Their view of the future is short-term and they have huge goals. Boomer parents have taught their children that every voice matters, that bullying is bad and equality is worth fighting for – that it takes a village. In large part, this generation polls as a gentle, loving generation, specifically speaking. Polls conducted at a similar age with previous generations displayed less of these civic-value inclinations. They are accomplished multi-taskers who watch TV while seated at their computers listening to MP3, burning CD’s, instant messaging their friends and pretending to do homework. They value education and fun and find all mega corporations irrelevant to them and their future. They tend to be inventive, optimistic and want information quickly

but don’t want to be told what to do. They must make their own decision, as they were asked about their opinion from a very young age. They believe in community and were raised with everyone being equal and everybody wins, regardless of the result and often many received a lot of trophies and awards for little true accomplishments. They grew up in the least structured family unit and tend to have the most positive relationships with their parents and consider them their friends, in which they want to spend time with the most. This makes them very big influencers with the older generations. Offline, Millennials are more likely than other generations to shop, dine and travel with groups, whether these are organized interest groups, less formal groupings of peers or excursions with extended family. One (1) in four (4) teens live in a single parent household and they all know someone who is gay and have been exposed to drugs, pornography and anything else via the internet, Facebook and instant messaging. They are younger than their biological age by approximately five years when compared to older generations at the same time period in growth and their pet peeve is hearing older people tell them what they did at their age. They don’t need to struggle like previous generations and have lived a life of instant gratification. They expect to be handed what they want, when they want it. They are the first generation to grow up online. Millennials (in large part) don’t watch television during scheduled times, attend church and sleep with their cell phone. They have hundreds of people they call friends and are on social networks and see all people on

November 2017 www.oralhealthgroup.com

PRACTICE MANAGEMENT

the internet as their potential friend and strongly influenced by the internet, Facebook and peer reviews. Growing up with the internet has given them confidence and incredible skills in obtaining information quickly and applying it. They do have ambitious goals of high return with the least path of work and resistance. They’ve grown up with digital devices that bundle communication, entertainment, shopping, mapping, and education all in one. This causes them to identify with technology and adopt new technologies more quickly, compared with the more skeptical approach of previous generations. Millennials are concerned with more than political and ethical issues. They also care about what’s genuine and authentic. This interest falls somewhere between a purely aesthetic preference and a search for honesty and for truth. And it’s a powerful force for motivating millennial customers. Now that we understand some distinctions, their strengths and characteristics, we can now guide the dental experience by looking at the date of birth and age of a patient. We must learn the steps and ways to adapt to their language, mode of communication, technology, use of the internet and their social networks. All of this impacts their characteristics that relate to the dental practice, dental care, health decision-making and spending. Millennials have been termed the “drive-

through generation” because they expect healthcare delivered quickly and efficiently and have changed the view that small boutique offerings is their choice. They have been reported to prefer retail clinics and acute care clinics as the fastest way to obtain health care. They don’t like the wait and want answers and treatment now and today, if possible. Dentistry can ADAPT by operating with organizations and systems for consistency in the process of daily preparation, speficially patient flow and protocols for smooth operations that respect their impatience and time. Be sure that they know the time allotted to their visit and what time they are expected – when they show up on time, they demand to for you to RUN ON TIME. Millennials want you to speak their language, as they prefer more of a casual conversation and down-to-earth tone, combined with efficient and effective assistance from a helpful stranger. Dentistry can ADAPT by not using the jargon-heavy dental explanations with a clinical and technical monologue. Keep it simple and use terms as a casual sit-down conversation, not a rigid script used for everyone. Millennials are visual and noisy about sharing their activities, consumption of food, beverages, services, and products, while showing them to the masses. They take photos of their meals, where and when they are eating it, where they’re coming from, and where they’re headed.

November 2017 www.oralhealthgroup.com

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PRACTICE MANAGEMENT Dentistry can ADAPT by asking them to help you build your social media presence. They love to share their dental exn perience on the internet, 'Like' you on Facebook, follow you on Twitter, as well as post videos on YouTube. Millennials are more likely to communicate via their cellphone as their only phone: as over 40% have no landline and the heir majority of them sleep with, or next to, their cellphones. They own more cell phones and s. use for texting more than other generations. Dentistry can ADAPT by collecting smart phone numbers at every checkout and researching the best software for auto text messaging to contact, communicate, and to confirm and remind them of their dental appointments. They also are known to change their coordinates of their cell phone numbers, online addresses, social media profiles, and email addresses quite frequently. Dentistry can ADAPT by regularly keeping the records up-to-date and constantly making sure that we have their current contact information. Millennials are known to prefer an “experiential” environment, where their visit is more than a transaction and the pleasure of being in the practice isn’t limited to the procedure and technical aspects. Dentistry can ADAPT by involving them in their exam, and talking out loud as you perform it, and asking them to follow along. They need to feel empathy that you are customizing their experience and this is done by asking open-ended questions about them, their pref-

erences and goals, and then reassuring them that we have listened to their unique and distinct wants. Gen Y’s were brought up in an atmosphere of equal relationships and co-decision-making. Parents and educators throughout their childhood emphasized collaboration and cooperation, where Millennials enjoy the possibility of collaborating with the practice as long as they believe that their say matters to the loyalty of their blurred role of the patient and service provider. Dentistry can ADAPT by presenting treatment planning solutions with words that encourage collaboration and mutual decisionmaking. Words like 'oral health partnership we will decide together', 'together with your input', 'develop', 'plan', 'train', and 'explore and expand'. Be sure to use visual technology and begin with the positive findings first, as they tend to not take the negative news well when delivered before the positive aspects. New Patient Millennials don’t choose you, they STALK YOU and spend a lot of time

November 2017 www.oralhealthgroup.com

PRACTICE MANAGEMENT

doing their homework o omework about lss, as being smart your credentials, is COOL to them. e They search for em. d if an easy link will you online and click through to your website home page. They gather online information before ever calling you and often have researched dental procedures and advice they find through the internet. Dentistry can ADAPT by making sure the practice has an updated and current website with a mobile application, and that the practice is on Google Maps. Your website must have regular updates and activity to rank high on search engines. Be sure your Facebook, LinkedIn and Twitter are all connected to the website and cross-link easily for search engine optimization. You can also sign up your practice for cross-linking free directoriesm like Rate MD, Angels List, Google Maps, etc. Millennials are very aware in their spending of out-of-pocket expenses and often are known to delay dental treatment, due to rising costs. They more so than any other generation want and expect an accurate estimate prior to making a decision to accept the dentistry. Dentistry can ADAPT by making sure all needed dentistry costs are transparent and predictable, especially when there is out-ofpocket expenses. Be sure to provide them with a detailed quote and estimate of what will be done and the financial arrangements agreed upon. Word of mouth is especially important to

M Millennials. That includes, of cou course, whatâ€™s said online. In th e past p the year, 1 in 4 Millennials r report reading online reviews for healthcare providers. These consumers are also twice as likely as non-Millennials to have participated in online communities in the past year, and theyâ€™re more trusting of the information they find there. Dentistry can ADAPT by asking Millennials to write a review and refer their friends, as they are very comfortable sharing their own symptoms and treatment experiences through patient networks and their social peers. They often can do it while in the office on their mobile device and can be a benefit for posting reviews, rating the experience on directories, and post videos and photos for your practice brand and benefit. Although generational diversity guides us with generalizations that prove valuable in understanding the different age groups so you may adapt your approach, your patient is an individual first, and a millennial second. On average, descriptions tend to match the patientâ€™s generational cohort to a T. However, the specific patient in front of you may not have the same preferences or goals that are common to their generation. Ask a series of open-ended questions to get to know your patient as an individual. The potential to have an outstanding practice can depend on your level of engagement with your patients on a generational and individual level and providing services that will relate with each of the generations.

November 2017 www.oralhealthgroup.com

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CLINICAL

IS IT REALLY PERIODONTAL DISEASE?

think we can all agree that we have acquired newfound knowledge since graduating Dental Hygiene School. For myself, a 2007 graduate I can attest to the wealth of knowledge I have ascertained moving from working environment to working environment. New opportunities with every resignation and new knowledge with every new team. My journey has led me from Peado to Perio, GP realm to Ortho and now education. My burning question that has puzzled me for years has been, “is this really Perio?” It can’t possibly be so simple and it can’t possibly be so easy to diagnose. Over the years I have berated the Internet or “Dr. Google” as some might call it and in reality I’m finding images that can’t possibly be what perio is by definition. Unlike our brothers and sisters from the south, the Canadian Academy of Periodontology doesn’t have a true definition on their website as the AAP does. Where the AAP defines Periodontal Disease as the following: “Periodontal disease is an inflammatory disease that affects the soft and hard structures that support the teeth. In its early stage, called gingivitis, the gums become swollen and red due to inflammation, which is the body’s natural response to the presence of harmful bacteria. In the more serious form of

Irene M. Iancu BSc, RDH, CTDP

periodontal disease called periodontitis, the gums pull away from the tooth and supporting gum tissues are destroyed. Bone can be lost, and the teeth may loosen or eventually fall out. Chronic periodontitis, the most advanced form of the disease, progresses relatively slowly in most people and is typically more evident in adulthood. Although inflammation as a result of a bacterial infection is behind all forms of periodontal disease, a variety of factors can influence the severity of the disease. Important risk factors include inherited or genetic susceptibility, smoking, lack of adequate home care, age, diet, health history, and medications”1 Suspect for me to believe it is that easy. Where the diagnosis is said to “rely on a visual assessment of the patient’s overall oral condition in addition to charting pocket depths with a periodontal probe.” 2 Now this information is being broadcasted to our clients who really don’t know any different than the two realms of information: the Internet and chairside communication.

THE INTERNET More often than not, our clients direct their questions to the virtual world. Posing questions in forums and looking at images that would help them make the decision to accept

November 2017 www.oralhealthgroup.com

One in four has it.

Many don’t know it.

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Dry Mouth is an oral health concern that affects people on multiple medications the most.3 Yet some people aren’t aware that it’s a problem.2 Talk to your patients about Dry Mouth and how Biotene can help provide relief.† ®

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GlaxoSmithKline Consumer Healthcare Inc., Mississauga, Ontario L5N 6L4 © 2017 GSK group of companies or its licensor. All rights reserved. * Dry mouth can disrupt the oral health environment and lead to halitosis, demineralization, and increased caries.4,5 † Mouthwash, Gel and Spray. ‡ As measured in a 28-day clinical study.6 1. GSK data on file. Biotène dry mouth growth opportunity (with Canadian U&A data). July 16, 2014. 2. Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004;38:236–240. 3. Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth, 2nd edition. Gerodontology. 1997;14:33–47. 4. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138:15S–20S. 5. Fox PC. J Clin Dent. 2006;17(Spec Iss):27–28. 6. GSK data on file 2014, RH01986.

CLINICAL or question treatment recommendations. When searching Periodontal Disease on Google.ca, this is what comes up on images:3 Now as specialists in the oral cavity moving from left to right on the screen, can we all agree that many of these images are not really telling us the whole story. My question to you is; Can this be related to malocclusion and systemic health concerns? Are our Perio clients truly those that have an uncontrollable amount of harmful pathogens, suffering from bacterially induces oral disease or could this all have started with poor occlusion and less-well controlled systemic diseases? Could this have been prevented and can this epidemic be reduces with the correction of occlusal forces caused by traumatic occlusion?

CHAIRSIDE COMMUNICATION Before we get into the description of this case let’s take a moment to evaluate the images

presented below. Imagine this is your 4 p.m. client presenting for routine maintenance. Upon intra oral assessment of soft tissue you determine the ever so slight presence of gingival recession and clefting. Old Irene in 2007, would likely have told this client she brushed to hard. 2016 Irene scratches her head and wonders, “Could this be related to Malocclusion?” I am this client. These photos taken in January 2014 to further evaluate what I was told was Aggressive tooth brushing. As a client newly diagnosed as an aggressive tooth brusher I navigated to images in comparison to my latest diagnosis. As a clinician I was scared to find anterior open bite cases, cross bites, localized gingival recession, edge-to-edge bites and abfraction lesions only 2 or 3 teeth in a quadrant. I don’t know about you but my clients aren’t really that talented to be brushing only on 2 or 3 teeth creating excessive damage.4

November 2017 www.oralhealthgroup.com

CLINICAL

Upon further evaluation of my function and an occlusal assessment it was quite evident that the cause of my newly discovered recession, wearing, shifting and chipping was the destruction of my teeth. I had never been recommended for orthodontics. I was never referred to an orthodontist and I was never told that there would be long-term effects to what seemed to be minor imperfections in a relatively aligned dentition. I suppose, Iâ€™m depicting my own dentition as a learning tool. For us to evaluate everyone as part of comprehensive care. We would not

let a client out the door without a visit from the DDS if we spotted a questionable lesion on soft tissue or possibly a carious lesion. Malocclusion should be no different and even the most minimal of rotations or inclinations can make a significant difference long-term, as it has for my own dentition. I will never get back the 1-3 mm of attachment or my once natural cusps. My challenge to all of us is to pose that question silently while doing our intra oral and extra oral evaluations. Can this be related to malocclusion?

1,2

Periodontal Disease Fact Sheet | Perio.org. (n.d.). Retrieved June 12, 2016, from https://www.perio.org/newsroom/periodontal-disease-fact-sheet

Images.google.com/periodontaldisease - Google Search. (n.d.). Retrieved June 12, 2016, from https://www.google.ca/search?q=images.google.com/periodontaldisease

Images.google.com/aggressivetoothbrushing - Google Search. (n.d.). Retrieved June 12, 2016, from https://www.google.ca/search?q=images.google.com/aggressivetoothbrushing

November 2017 www.oralhealthgroup.com

BOOK REVIEW

WHY PHYSICIANS DIE BY SUICIDE:

Lessons Learned From Their Families and Others Who Cared Michael F. Myers, MD

Every day, we know doctors save lives. But you may not know that each day in the United States, a doctor dies by suicide. The common thread in nearly every one of those cases: a struggle with mental illness. While this heartbreaking epidemic may be largely preventable, the toxic stigma attached to mental health care for doctors is unrelenting. That stigma has been largely ignored – until now. Through Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared (February 2017), Michael F. Myers, MD, a psychiatrist and specialist in physician health, unravels the mystery of why 300-400 doctors kill themselves every year. Combining his lifelong clinical experience as a “doctors” doctor with gripping anecdotes of those who have lost a physician loved one to suicide, Dr. Myers sheds light on what has become a national tragedy.

“The words of the loved ones of doctors who have taken their own lives are treasures because they capture the complexity, the inner conflict, and the irony of self-destruction and despair in our guardians of life,” says Dr. Myers. “Ultimately, they shine much needed light on the darkness and confusion of suicide.” Using personal narrative and real-life case examples, in Why Physicians Die By Suicide, Dr. Myers guides readers through the variety of factors that contribute to physician suicide. He then makes practical, across-theboard recommendations in an effort to end the epidemic, arriving at the encouraging conclusion that everyone has a role to play in saving a doctor’s life. “This challenge – saving the lives of physicians – requires building bridges and cooperative work – linking he expertise of trained professionals with the words of courageous grieving individuals who have poured out their hearts on these pages,” adds Dr. Myers. “We must continue to be candid and rigorous and we must keep talking about a subject that, sadly, is not going away. When that day comes, and it will, we can be quiet.” In this moving and critically important resource for medical educators, physicians and their families, and anyone touched by physician suicide, you’ll discover:

November 2017 www.oralhealthgroup.com

BOOK REVIEW

Dr. Myers has devoted the bulk of his decades-long private practice to treating physicians and their families.

•

The multitude of triggers that cause doctors to take their own lives – including burnout, depression, bipolar illness, drug use, and PTSD

•

The deliberating impact of the stigma related to mental health care and doctors, causing many of them to receive no treatment whatsoever

•

Why many physicians who do go for mental health care “fall through the cracks”

•

Captivating insights from those who are affected when doctors die by suicide – including bereaved loved ones, medical training directors, and patients

•

How the culture of medicine must change, providing support and treatment for doctors with mental illness

•

The important role that family members play in a doctor’s treatment, and how they should be involved in their recovery process

Michael F. Myers, MD – the “Doctors’ Doctor” – is a specialist in physician health, a lec-

turer, and Professor of Clinical Psychiatry at SUNY Downstate Medical Center in Brooklyn, NY. Treating more than 700 doctors throughout his career, Dr. Myers has devoted the bulk of his decades-long private practice to treating physicians and their families. As the immediate past president of the American Foundation for Suicide Prevention (New York City Chapter), Dr. Myers has also served as a board member for both the American and Canadian Psychiatric Associations, and is currently on the Advisory Board of the Committee for Physician Health of the Medical Society of the State of New York. Through his award-winning scholarly work, Dr. Myers examines the training of medical students and doctors, and has authored (or co-authored) seven previous books, including The Physician as Patient: A Clinical Handbook for Mental Health Professionals (with Glen O. Gabbard, MD) and Touched by Suicide: Hope and Healing After Loss (with Carla Fine). He is board certified in Psychiatry by both the Royal College of Physicians & Surgeons of Canada and the American Board of Psychiatry & Neurology. Learn more about Dr. Michael Myers at www.michaelfmyers.com and connect with him at @DownstateDoctor. Why Physicians Die by Suicide is available on Amazon and Barnes & Nobel.

November 2017 www.oralhealthgroup.com

PRACTICE MANAGEMENT Debra Engelhardt Nash Founding member and served two terms as President of the Academy of Dental Management Consultants. She is currently the Vice-President/ President Elect for that academy. She is an active member of the American Dental Assistants Association Foundation and serves on the board of the American Dental Assistants Association Foundation. Debra is also a member of the American Academy of Dental Practice Administration. She has been repeatedly recognized by Dentistry Today as a Leader in Continuing Dental Education and in Dental Consulting.

THE ROLE OF THE TEAM IN COMMUNICATING TREATMENT POSSIBILITIES T here are influential moments during a patient’s visit when opportunities occur to discuss and validate treatment options. Finding these occasions to perpetuate and sustain the perception of quality care is the responsibility of every team member. From the initial moment of contact to post treatment continuing care visits, the Team builds a quality culture at all patient encounters. Every team member is responsible for those critical moments in and out of the operatory. The Receptionist or Front Office Team member plays a critical role in introducing the practice attributes and advantages. The hygienist has ample opportunities to discuss outstanding treatment plans and introduce new treatment possibilities. Being chairside with patients is an exceptional opportunity to communicate quality and endorse treatment. Together, they all validate the doctor’s treatment suggestions and extol the quality of care being delivered in their office. There are a myriad of duties in the daily regimen of the Chairside Assistant - orchestrating the delivery of treatment, arranging armamentarium, complying with OSHA, and HIPPAA, and maneuvering the schedule to optimize chair time. In addition, the Clinical Assistant is responsible for communicating quality at the chair. This is accomplished by demonstrating knowledge, empathy, enthusiasm, sincerity and presence.

KNOWLEDGE

Additional training to learn new techniques and technology will boost team confidence in talking to patients. A well-informed auxiliary can help patients better understand treatment recommendations. The more knowledgeable in materials, treatment processes and technol-

ogy, the more information they are able to share with the patient. Confirming the doctor’s diagnosis and helping define the treatment plan aids in patient understanding and promotes treatment acceptance. A commitment to ongoing training keeps the team abreast in the latest clinical techniques and practice management. Providing in office training programs, sharing journals and manufacturer’s materials for review helps the team stay current in dentistry. Team meetings focused on patient communication familiarizes auxiliary with patients’ questions and appropriate responses. With the use of visual aids, the chairside assistant can explain treatment. Photographs, intra-oral cameras, and media learning improve patient communication. The chairside assistant should be adept with learning technology use them to augment patient learning. Teaching the assistant to share patient information improves chairside efficiency and doctor/auxiliary utilization. This team member can assume a lot of the responsibility of patient communication while the doctor is attending to other treatment needs. Knowing the details of patient care helps the chairside assistant become the treatment ambassador.

EMPATHY Patients are looking for validation of treatment choices. They want the assurance that they have chosen the right office and the right doctor for their dental care. When the chairside assistant introduces the practice philosophy and praises the doctor’s care, she is fulfilling the need for treatment validation. In essence, the assistant becomes the second opinion at the chair. The dental assistant can take the time to lis-

November 2017 www.oralhealthgroup.com

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PRACTICE MANAGEMENT

ten to patient concerns, expectations and questions. The assistant becomes the liaison between doctor and patient. Time must be allocated to listen without interruption. Appropriate body language telegraphs empathy and interest to the patient. The assistant should sit at eye level with the patient, at their side, and slightly forward. Eye contact must be maintained and the assistant leans into the patient. This body language says, “What you are saying is important and I am paying attention.” Data entry and record keeping is integrated in such a way that does not take precedence over patient focus. Full attention is paid to what the patient is conveying, not what the response will be. Other distractions to patient focus is eliminated or minimized.

ENTHUSIASM Being excited about treatment possibilities transmits to patients. The chairside assistant must convey her/his zeal for the practice. Praising the doctor and exhibiting enthusiasm for what the treatment plan can offer the patient in dental health and appearance translates to the patient. When the staff is genuinely excited about the office, and apparently proud of the doctor’s care, it captures the patient’s interest. Patients like to be surrounded by a team of professionals that exude confidence and show interest in their care. The enthusiasm of the team captivates the patient. Imagine going to a theme park, such as Euro Disney and meeting apathetic employees. These are employees who aren’t excited about the thrills and adventures being offered by the park. Would that change your experience? If you asked a ride attendant if the amusement is fun or worth the wait, and they responded by saying, “I don’t know”, or “I have been on this so many times, that it isn’t fun for me anymore”, would that alter your opinion? Or, if the employee said, “This is just my job, I don’t enjoy the ambiance anymore.” Would you have a different perspective? This writer thinks that you would.

CASE IN POINT

During an in-office consultation in a practice, I watched this scene play out. The doctor I was visiting was presenting his treatment plan and

explaining the advantages. His chairside assistant was in the operatory with him, attending the consultation. During his discussion, he thought it would be helpful to use a current laboratory case as illustration. The doctor left the room to get the restorations from the lab. I thought it was interesting that he got up to get the case, and not the dental assistant, but then considered this: “What a great opportunity for the dental assistant to affirm the doctor’s treatment plan.” She could have taken these moments to comment on the doctor’s excellent care, the artistic talents and precision of the lab, and offer assurance to the patient that the results of her dentistry would be worthy of her investment in time and resources. After the doctor left the room, the patient turned to the dental assistant and asked, “What do you think about all of this?” Again, this would have been an opportune moment to validate the treatment plan and convey support of the doctor’s recommendations. The assistant could have assured the patient of the skill and care of the doctor. She could have discussed the technical expertise of the laboratory and explained the importance of having synergy between doctor and lab to achieve exceptional results. The assistant could have complimented the doctor and the lab, and shared her pride in the process of treatment provided in the office. Instead, the dental assistant turned to the patient and remarked, “Well, I have heard all of this before”. The atmosphere in the operatory made an obvious shift. When the doctor reentered the room with the lab case, the patient graciously attended to his explanation and then responded by saying, “Let me think about it”. Upon reviewing this consultation, the Team assumed they had “wasted their time” designing a comprehensive treatment plan for a patient who was limiting her treatment options to insurance covered procedures. The team determined that they had failed to identify the patient’s status correctly. There may have been something in that assumption, but I think something else happened. The lack of enthusiasm by the chairside assistant changed the direction of the

November 2017 www.oralhealthgroup.com

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PRACTICE MANAGEMENT

patient’s motivation. In other words, the case was unsold. Enthusiasm is infectious. Creativity and enthusiasm will outsell experience. Patients will respond more favorably to a positive, affirming team.

SINCERITY Patient communication must be genuine. In order to be believed, the message must be heartfelt. Team Members must communicate with authority and sincerity. Scripting may be a helpful tool in designing communication. But if the message is not believed by the team member, the patient may feel the remarks rehearsed and contrived. Time must be spent in helping the team understand and appreciate treatment philosophy, practice systems and desired treatment outcomes. Opportunity to ask for clarity and tools to help in patient communication is handled in staff meetings and team dialogue. Core beliefs are described and discussed to provide a clear understanding of practice philosophy and design to achieve sincere endorsement. The patient will witness care from all team members when everyone genuinely agrees on the core values of the practice. The message may be articulated differently, blending individuality with the philosophical foundation of the practice. But the core belief is the underlying theme in all communication processes.

PRESENCE

In order to communicate effectively, the assistant must be fully present. This is more than physical attendance. The team member must be in the moment, paying attention to the words and watching for signs that the communication connection is successful. The patient may be reluctant to tell the doctor that they don’t understand, or haven’t fully grasped the treatment dialogue. This is when the chairside assistant or treatment coordinator becomes an interpreter. When the doctor is not in the room, the chairside Assistant re-

views information, confirms treatment recommendations and asks the patient, “What questions can I answer for you?” This allows the patient to ask for more information and gain more assurance in the treatment plan and procedure. The patient may be more inclined to voice their objections including financial concerns to a team member. An important question to ask is, “Tell me what is preventing you from having this done?” A competent articulate team member can do this The schedule must be structured to allow the dental assistant to attend the patient in the operatory rather than leave them stranded while attending to non-patient duties. Sterilization time, chart completion and preparing for patient care must be factored into patient treatment time to avoid leaving the patient alone to attend to these functions. Patients want to feel well cared for, and are more interested in how they are been treated, rather than if the next operatory is being stocked. Sitting with the patient while the doctor is out of the room, or during a planned waiting period during the procedure aids in the communication process. Using this time as an opportunity to discuss their care, their potential treatment results and the additional services the practice can offer builds rapport and patient loyalty. There are many tasks that need to be accomplished by the assistant. Exceptional assistants are specialists in infection control, materials management and operatory efficiency. In addition to these clinical duties, effective patient communication is an essential skill for the chairside dental assistant. What drives all of the practice tasks is patient care. Patient care is improved when communication processes are fine-tuned. Opportunities abound to improve and enhance chairside communication. The result is that patient comfort is improved and treatment acceptance is increased. Patient satisfaction is achieved and practice potential expands.

November 2017 www.oralhealthgroup.com

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Flexi-Lume™ Flexi-Lume™ is a multi-function LEF from EMCI that conveniently directs light exactly where you need it. The hands-free Flexi-Lume™ eliminates shadows and the reliance on bulky, blinding, hot, overhead lights. The Flexi-Lume™ produces a wide variety of lights through a flexible, fibre-optic “light pipe” that you position on your target areas. Flexi-Lume™ comes standard with Daylight and Fluorescent lights for observation and colour matching; a Transdental Illuminator for Non-X-ray Diagnostics such as location fine fractures and decay; an in-office Deep Bleaching light; and No-Heat Curing Light. Also included is a Non-Curing mode that extends the time you can work with composite materials.

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JETPIK JETPIK is the world’s first and only power flosser that combines the benefits of oral irrigation + dental floss + sonic toothbrush. JETPIK’s patented Power Floss Technology combines the power of oral irrigation with actual nylon floss pulsating at a rate of 20 cycles per second. It sends a powerful jet of water and floss onto the tooth surface and in between teeth giving you the ultimate clean. While the pulsating water massages the gums, the pulsating dental floss adds a mechanical scrubbing mechanism necessary in removing resistant plaque and hard to reach food debris lodged between teeth and under the gum lines

Advantage Arrest™ Advantage Arrest™ is the only Silver Diamine Fluoride available in the United States. It provides immediate relief from dentinal hypersensitivity, kills pathogenic organisms, hardens softened dentin making it more acid and abrasion resisitant, does not stain sound dentin or enamel, and can provide important clinical feedback due to its potential to stain visible or hidden carious lesions.

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November 2017 www.oralhealthgroup.com

PRODUCT PROFILE

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Dentsply Sirona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 GC America . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 GSK-GlaxoSmithKline . . . . . . . . . . . . . . . . . . . .4, 34, IBC Kerr Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 McCaughey Consumer Products Management . . . . . .47

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DENTAL MARKETPLACE

Contact: Karen Shaw • tel: 416-510-6770 • cell: 437-991-7187 • fax: 416-510-5140 • e-mail: karen@newcom.ca Toll free: CDA 1-800-268-7742, ext 6770 • Toll free: USA 1-800-387-0273, ext. 6770

ASSOCIATESHIPS

THOMPSON, MB ASSOCIATE – NEEDED IMMEDIATELY!! Full-time, energetic, detail oriented associate needed immediately for established, busy family practice with high income potential per month. Enjoy a fully booked schedule and ability to reach your goals as a dental professional. Experience preferred. Excellent opportunity. New grads welcome. Living accommodations provided. E-mail cv: thompsondent@gmail.com 150 P: 204-939-0083.

MISSISSAUGA, ON Established Mississauga dental practice is seeking a part-time associate to join our team and replace an associate that left this past year. Opportunity to grow into a full time position in the future. Candidate must speak English fluently and have at least one year experience in general practice.

Please send resume to info@willowdental.com

MARKHAM, ON Part-time associate position available in Markham, minimum 1 year experience, Endo, Surgical Extraction skills preferred. Please email: 150 dentalmk@gmail.com

150

BROCKVILLE, ON

KITCHENER, ON

Associate needed in a busy modern dental practice located in the beautiful 1000 islands. Please send resumes to: 150 drvijaybhatt@gmail.com

We are looking for a friendly, gentle dentist for a few days a week, the office is paperless with digital x ray and pan. Please email your info to 150 kaylashiru@gmail.com

NORTH YORK, ON

SCARBOROUGH, ON

Associate required for a busy 6 ops. Well established general practice. 3 days a week leading to full time and ownership opportunity. Digital x rays, CAD/CAM IMPLANTS ORTHO. Please email resume to: 150 Kandfdental92@gmail.com

Progressive general practice in Scarborough is seeking a conscientious associate. Part time leading to full time. If interested, please forward resume to 150 progressivedds@bellnet.ca

EASTERN ONTARIO SANDHU DENTAL GROUP is looking for a full time Associate for our 2 growing locations Dentistry @ Montreal Square and Dentistry @ Rockland. Applicant should be self motivated, hardworking, flexible and willing to train. Please check out our website for further details www.sandhudental.ca If interested please send your email to Dr Raja Sandhu: jangsandhu88@gmail.com

150

THORNHILL, ON Seeking a Licensed Orthodontist for a very busy practice in the heart of Thornhill. The office is modern with paperless charting, digital x-rays, including all new equipment and leading edge technologies. We are a rapidly growing clinic and we provide a complete range of services and a candidate must be passionate, conscientious about patient care, experience and excellence. The required candidate should have experience with early preventative techniques, light wire appliance, functional appliances and Invisalign. We are also looking for an experienced, licensed associate who is motivated, is skilled with implant surgery/placement and surgical extractions. We also need a General Dentist as well. Korean language is an asset. 150 E-mail: info@worlddental.ca

www.oralhealthgroup.com

ARTHUR, ONTARIO Associate position available at Arthur Dental. Flexible 3-5 days per week. No evenings or weekends. Depending on where you live in the Guelph/ Cambridge/Kitchener/Waterloo areas, Arthur is an easy 30-45 minute trafficfree commute. Please visit the practice website to see if this opportunity may be a good fit for you. www.arthurdental.com E-mail resume/CV to andy.smiles@hotmail.com

FREDERICTON, NB Prosthodontist seeking OMFS or Periodontist for work opportunity. Call: (506) 452-7695 150 Email: smylmkr2010@gmail.com www.drjanicewilsonprosthodontics.com

CALGARY, AB ASSOCIATE REQUIRED Do you feel under-utilized and capable of more? Do you like teamwork and collaboration and have a thirst for knowledge? Do you already have amazing communication and soft skills with the ability to consult, educate, empower and motivate people to make healthy dental decisions for themselves, but maybe the rest of the office isn’t quite there yet and cannot hit it home after you walk out of the room? If so, we have an amazing opportunity for you as a F/T Dentist in Northwest Calgary. We look at dentistry as a service industry like a fine hotel or restaurant with transparency and consistency. We can help you reach your maximum potential if you are willing to be coached and have the ability to park your ego at the door so we can all learn and grow together on a level playing field. You must be great with kids as well as being fairly broad based with the ability to recognize and diagnose from multiple dental disciplines as we do not refer much away. Please send your CV in confidence to judy@involutioninc.ca 150 We look forward to meeting you! November 2017

DENTAL MARKETPLACE

ASSOCIATESHIPS

RED DEER, AB

OTTAWA, ON ORAL & MAXILLOFACIAL SURGEON Well-established oral surgery practice centrally located in our nation’s capital seeking an oral & maxillofacial surgeon for an associate position interested in a transitional purchase. Also willing to sell outright and stay on as an associate. Compassion, excellent communication skills and a strong ethical conviction will ensure a good fit with our vision. The candidate must be eligible for licensure to practice as a specialist in oral and maxillofacial surgery in Ontario, including Fellowship in the Royal College of Dentists of Canada (RCDC). Please forward CV and inquiries to: laura-manager@rogers.com

Busy General Dental practice with great location and large patient base and New Patient flow in Red Deer Alberta, is seeking an Associate to join our dental family. Ideal candidate must be a great communicator who possesses strong clinical skills and great patient care. We provide outstanding management to help you succeed. Looking for long term commitment to our dental family. Please call 403-342-5800 or 150 email jacki@imagedental.ca

150

MISSISSAUGA, ON ELMVALE, ON

PICKERING, ON P/T ASSOCIATE required Mon, Wed, Fri for a busy Pickering Dental Office with an existing patient base. Must be fluent in English. We provide an excellent team to assist with your growth. Please email Tanya at: yongesmiles@gmail.com 150 with resume and availability.

ST. JOHN, NB Full time position available immediately. 40 year old, 2 dentists, 7 op dental practice requires new associate as previous dentist is slowing down. Partnership possibilities with right associate. Contact 506-651-6965 or send resume by email: drbellapanjwani@hotmail.com

150

(25 MINS. NORTH OF BARRIE) Associate opportunity to join our dental family. Looking for a part-time Associate to join our dental family in a progressive, well-established and growing practice. Must be friendly and a team player with good communication skills. Please send resume to 150 linda.sfd@outlook.com

OTTAWA, ON OR GATINEAU, PQ Full-time Dental Associates Great opportunity to join established dental practice with CAD/CAM, Digital xrays, Cerec and paperless systems. We offer lots of opportunity for mentorship and community support within our group of dental professionals. Contact 150 sarmstrong@mcadental.com

FREDERICTON, NB

Full and Part Time Associates needed for our Milton and Hamilton locations. E-mail: hawthornedental1@gmail.com 150

Prosthodontist seeking prosthodontist for work opportunity. 150 Call: (506) 452-7695 Email: smylmkr2010@gmail.com www.drjanicewilsonprosthodontics.com

CAREERS

Niagara Dental Office looking for a medical or dental anesthesiologist to provide GA services 2 to 3 days per month. Please contact our office at 150 hiringsleepdentistry16@outlook.com

SALES CONSULTANT – BC, AB, SK, MB, NB, NS, PEI, NL Expand your successful sales career! Become an independent Sales Consultant promoting ABELDent, Canada’s unparalleled dental practice management software. 150 For details, visit www.abeldent.com/careers

November 2017

OTTAWA, ON Our busy and well established Ottawa based practices are currently looking for full and part time Rockstar Dentists. Excellent potential! Please email in confidence to 150 amyfudge16@gmail.com

MISSISSAUGA, ON Seeking an Endodontist for 1 to 2 days per month. A great opportunity for the right candidate. Please forward your CV to 150 info@grandparkdental.com

EQUIPMENT

TORONTO, ON

MILTON AND HAMILTON, ON

NIAGARA, ON

A female associate with at least 3 years experience needed for 3 days a week in a modern dental office. Please e-mail resume to 150 m_atiya@hotmail.com

150 FOR SALE – BRAND NEW 3 IS 205 air motor hand pieces. 2 contra angle attachments. TIMAX Hi Speed handpieces (illumination). Reply to Oral Hygiene Box 51 – karen@newcom.ca

VICTORIA, BC

INSIDE SALES REPRESENTATIVE – BURLINGTON, ON Strategic Partnership. Customer Happiness. Unparalleled dental practice management software. Join the team that’s been making a difference for dental professionals for over 40 years. 150 Visit www.abeldent.com/careers for details.

DRYDEN, ON Locum dentist needed for Jan and Feb 2018. Must be able to do molar endo. Free flights and accommodations. E-mail: northerndental@yahoo.ca

150

2016 Cerec Milling Machine and Omnicam One owner, up to date on maintenance. Most current software. Active membership. All items are in mint aesthetic condition and are guaranteed to be 100% functional. Milled about 10 crowns. Includes Ivoclar Programat CS ceramic crystallization furnace, Omnicam MCX calibration kits, wireless radios, spare us, spare block crews, bur block wrenches, E.max shade kit. Total package $130,000. Will sell milling machine separate. Please contact Nicole: 150 250-686-8516

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SHE KNOWS THAT STRAWBERRIES HAVE A HIGH ANTIOXIDANT CAPACITY. WHAT ELSE WOULD SHE WANT TO KNOW? Young people today are staying informed to stay healthy.1 But do they know that healthy foods including fruit, juices and sports drinks are highly acidic and can put their enamel at risk?2-5 Exercise your inﬂuence as their trusted dental professional. Help educate every young patient about the effects of acid erosion. Because the investment in their enamel should start today.

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

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www.biotene.ca

GlaxoSmithKline Soins de santé aux consommateurs Inc. Mississauga, Ontario L5N 6L4 © 2017 Le groupe d’entreprises GSK ou son concédant. Tous droits réservés. * La bouche sèche peut perturber l’environnement de santé buccodentaire et causer la mauvaise haleine, la déminéralisation et l’augmentation de la carie4,5. † Rince-bouche, gel et vaporisateur. ‡ Tel que mesuré dans le cadre d’une étude clinique de 28 jours6. 1. Données internes de GSK. Occasion de croissance de Biotène pour la bouche sèche (incluant les données U&A canadiennes). 16 juillet 2014. 2. Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004;38:236-240. 3. Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth, 2e édition. Gerodontology. 1997;14:33–47. 4. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138:15S–20S. 5. Fox PC. J Clin Dent. 2006;17 (numéro spécial):27-28. 6. Données internes de GSK 2014, RH01986.

Contrôle la plaque, prévient la gingivite et procure un soulagement de la sensibilité? À votre santé!

Lorsque vous recommandez Sensodyne® Protection complète à vos patients, vous serez rassuré de savoir que vous les aidez à soulager l’hypersensibilité dentinaire, et que vous recommandez un produit procurant d’autres bienfaits pour la santé des gencives, comme l’élimination de la plaque et la réduction de la gingivite.

ELLE SAIT QUE LES FRAISES COMPORTENT D’EXCELLENTES PROPRIÉTÉS ANTIOXYDANTES. QUE DEVRAIT-ELLE SAVOIR DE PLUS? De nos jours, les jeunes se tiennent au courant pour vivre sainement1. Mais savent-ils que les aliments sains, comme les fruits, le jus et les boissons pour sportifs, sont très acides et qu’ils peuvent mettre leur émail à risque2-5? Usez de votre inﬂuence en tant que professionnel dentaire de conﬁance. Informez chaque jeune patient des effets de l’érosion par acide. Ils doivent investir dans leur émail dès aujourd’hui.

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

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