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SEPTEMBER 2018

Inside this issue ORAL HYGIENE

Dental Hygiene Care for Survivors of Childhood Abuse Linda M. Douglas, RDH, BSc

An Emerging, Integrated Model of Oral Health Care Julie DiNardo, RDH

Significant Trends in Global Oral Health and Oral Cancer: The Power of Cultural Oral Habits Sherry Priebe, RDH, BDSc, MSc

Periodontitis Staging and Grading Beth Ryerse, RDH

5 Ways to Boost Your Immune System This Fall Uche Odiatu

DEPARTMENTS 5

EDITORIAL Turning Over A New Leaf

NEWS Difference in Mouths of Youth Born with HIV May Increase Risk of Dental Decay Plaster Which Sticks Inside Mouth Will Revolutionize Treatment of Oral Conditions Oral Sex to Blame for Erythema Discovered During Check Up

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EDITORIAL

Turning Over a New Leaf

Jillian Cecchini Managing Editor

SEPTEMBER 2018

Simply put, change in inevitable. All around us, change is happening on a daily basis. Why is it that so many of us are instantly turned off by the thought of change? It’s constantly happening, yet we still allow ourselves to let it become overbearing. If we could only learn to let change encourage us, the positive benefits could potentially allow us to become happier in our careers and the experience creates personal and professional growth. Summer is quickly coming to an end and a new season is upon us. Though most of society associates new beginnings with a new year, the beginning of Fall in September is the ideal time to embrace change before the year comes to an end. After all, Fall is dubbed the ‘season of change’. And with change comes chance – the perfect opportunity to reassess and recharge. Implementing change can seem like a daunting task, yet we know the benefits can be rewarding. It’s always smart to take time to conduct a self-assessment and try to establish what you would like to improve within your everyday life. Let’s take work for example. September is an appropriate time to start planning for the following year. Oral Health recently had our annual strategy session where we did just this. Getting together outside of the office, away from daily distractions and interruptions, allowed our team the opportunity to plan and collaborate on new ideas and projects for the following year. It’s also a time for engaging in open conversation regarding new ideas, and how to improve processes that are already in place.

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Here are my top three steps to consider when implementing change: Number 1: Self-assessment. Taking the time to sit down and talk to yourself about what you would like to improve upon is key. A self-evaluation may seem like a strange suggestion but I guarantee the benefits will outweigh the task at hand. In order to achieve overall satisfaction, whether at work or in your personal life, thinking about your values, skills, interests and characteristics will be a strong motivational driver. Number 2: Talk to someone. Confide in a trusted team member, friend or mentor with whom you can discuss potential areas of change. As previously mentioned, the thought of change can be daunting. A trusted listener will of course listen, ask questions, and refrain from interjecting their own opinions (unless asked). After all, an outside perspective can be rewarding. Number 3: Be proactive. Figure out how your desired changes can be implemented and the necessary steps to take in order to accomplish your goals. It’s all about taking the first step. My suggestion: make a to-do list in order to track your goals. This will hold you accountable and act as a motivator towards success. Though I am not an expert on processing change, trust me – I find it difficult myself, hopefully these steps can encourage and motivate. Remember, the secret of change is to focus all of your energy, not on fighting the old, but on building the new.

May 2017

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NEWS

Differences in Mouths of Youth Born with HIV May Increase Risk of Dental Decay A team of scientists from The Forsyth Institute, a global leader in oral health research, in collaboration with the NIH-funded Pediatric HIV/AIDS Cohort Study (PHACS), has published the results of a new study indicating that differences in the mouth bacteria of youth born with HIV may increase their risk of cavities. The researchers found that HIV-infected youth, compared with uninfected youth, had lower numbers of Corynebacterium, a microbe that is abundant in dental plaque of healthy individuals. “At the Forsyth Institute, we encourage our scientists to explore the

unknown and equip them with the resources and partnerships to do so,” said Dr. Wenyuan Shi, CEO and Chief Scientific Officer at the Forsyth Institute. “This group of researchers did exactly that. When there was limited information on the potential role of oral bacteria in HIVinfected youth, they spearheaded a study to fill in these research gaps and understand more globally how systemic diseases, or their treatment, may affect the microbes that help keep us healthy or cause disease.” Find the full story: https://eurekalert.org/pub_releases/2018-07/ fi-dit071018.php

Plaster Which Sticks Inside Mouth Will Revolutionize Treatment of Oral Conditions Scientists from the University of Sheffield’s School of Clinical Dentistry, working in close collaboration with Dermtreat A/S from Copenhagen, have developed a unique patch using special polymers which are able to stick to moist surfaces. The patch successfully administers steroids directly to oral ulcers or lesions whilst also creating a protective barrier around the affected area, accelerating the healing process. The novel plaster is a breakthrough therapy for the treatment of mucosal conditions such as oral lichen planus (OLP) and recurrent aphthous stomatitis (RAS), which

are diseases that cause painful lesions and affect 1-2 per cent of the population. Until now, ulcers and lesions inside the mouth have been treated using either creams or mouthwashes, which are used in the whole mouth rather than targeting the specific area, making them less effective. However, the biodegradable Rivelin® patch, has a long adhesion time and a high flexibility which conforms to the surface inside the mouth. Find the full story: https: //www.sciencedaily.com/releases/2018/06/180625122449.htm

Oral Sex to Blame for Erythema Discovered During Check Up After performing oral sex, a 47-year-old man developed a wound inside his mouth, according to a new case study by a team of dentists from Mexico. The report titled “Fellatio-associated erythema of the soft palate: an incidental finding during a routine dental evaluation” was published in BMJ Case Reports on June 11. The unnamed patient from Mexico did not experience any symptoms as the wound was only noticed during a dental check-up at the School of Dentistry at the Universidad de Montemorelos, Nuevo Leon.

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ORAL HYGIENE

DENTAL HYGIENE CARE FOR SURVIVORS OF CHILDHOOD ABUSE

Linda M. Douglas, RDH, BSc. graduated as a dental hygienist from the Royal Dental Hospital in London, England. After graduation she worked in periodontology before moving to Toronto, where she has worked in private practice since 1990. Linda is also the Clinical Director for Hygienetown, a supportive online community for dental hygienists. Linda’s desire to help anxious patients has instigated in-depth study of the issues faced by survivors of childhood abuse, and other individuals with dental phobia. Linda also writes and speaks on xerostomia management, and caring for dental patients with eating disorders.

e have all been mystified and even exasperated by our more challenging clients, for example: those with inadequate self-care despite having sufficient manual dexterity; and people who attend irregularly for dental care, or fail to show up for scheduled appointments. We might also encounter individuals who panic if reclined in the chair, or seem angry, or apathetic. I became aware that these behaviours could be related to mental health issues, like dental phobia. Dental phobia is classified as a specific phobia within the Diagnostic and Statistical Manual of Mental Disorders.1 Dental phobia is frequently a consequence of previous negative experiences with dental care. 23 Others with dental phobia might have been childhood victims of violence, or sexual abuse. Survivors of abuse have experienced betrayal, trauma, and violation of their personal boundaries; they are often stigmatized, and made to feel powerless. Childhood sexual abuse, particularly of young children may also be oral in nature, causing survivors to experience difficulties tolerating various aspects of oral healthcare.

PREVALENCE OF CHILDHOOD ABUSE The incidence of child abuse, especially sexual abuse, is under-reported because the victims are usually coerced into secrecy; most survivors maintain this silence into

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adulthood, often out of shame. A 2003 study found that 32.3% of women and 14. 2% of men reported sexual abuse in childhood, and 21% of adults who reported histories of childhood sexual abuse also experienced other physical maltreatment.4 Research has shown that child abuse occurs in all countries studied 5, and is not limited by ethnicity or socio-economic status; children with disabilities are more likely to be abused.6 Studies suggest that sexual abuse of male children by adult females occurs more frequently than was previously thought. Sadly, this might be taken less seriously, although males experience as much trauma as female survivors.

FACTORS WHICH MIGHT COMPROMISE SELFCARE AND REGULAR ATTENDANCE A history of trauma or abuse could lead to depression and low self-esteem, causing survivors to feel unworthy of proper health care. They might have an aversion to being touched, and to having their personal space invaded. Certain aspects of a dental visit could trigger flashbacks: this can manifest as distrust, anxiety, hypersensitivity, irritability and a tendency to startle easily. Some individuals also display anger, or aggression. Triggers vary, from sights, sounds and smells, to something about a clinician’s appearance which reminds a survivor of their abuser. The view SEPTEMBER 2018

of the ceiling while lying in the dental chair could be a trigger, which reminds the survivor of the position they were forced into while being abused. Some victims cope with the violation of their body by entering a dissociative state, in order to detach themselves from the abuse they are powerless to fight off. During dissociative episodes, they experience altered perception, sensation and sense of time. These individuals have also learned to dissociate from pain, which could lead them to ignore symptoms of disease and delay seeking help, thus delaying an accurate diagnosis. If they are stressed during their dental appointments, they might become dissociative, causing them to appear inattentive or apathetic.

HOW WE CAN HELP Understanding how these factors affect our clients is termed traumainformed practice7: this integrates with the principles of sensitive practice 8 , to create an environment in which clients feel safe.

TRAUMA-INFORMED PRACTICE The principles of trauma-informed practice were distilled from the literature, and clinician input. • Trauma Awareness—the foundation of trauma-informed care begins with awareness of the commonness of traumatic experiences, and how the impact of SEPTEMBER 2018

trauma can profoundly affect one’s development. We also need to be aware of the various adaptations people make to cope and survive after trauma, and the relationship of trauma to substance use, physical health, and mental health concerns. • Emphasis on Safety and Trustworthiness—Physical, emotional, and cultural safety for clients is crucial to trauma-informed practice, because trauma survivors often feel unsafe. They are likely to have experienced abuse of power in important relationships, and may currently be in unsafe situations. Facilitate safety and trustworthiness by making the office environment welcoming and non-threatening, providing clear information, and ensuring informed consent. • Opportunity for Choice, Collaboration, and Connection— the trauma-informed approach creates safe environments that foster a sense of efficacy, dignity, and personal control for clients. This includes open communication, providing choices as to treatment preferences, and working collaboratively with clients. • Strengths Based and Skill Building—Helps clients to identify their strengths and develop coping skills by recognizing triggers, calming, centering, and staying present.

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THE PRINCIPLES OF SENSITIVE PRACTICE FORM THE UMBRELLA OF SAFETY9: 1. Respect means acknowledging the inherent value of each individual, and suspending critical judgement. Respect means a great deal to survivors of abuse; we can show respect by listening to the client, and heeding their concerns. 2. Taking time to make the client feel genuinely heard and not rushed. 3. Rapport is built by showing caring, concern and empathy, and using active listening techniques. 4. Sharing Information: Being transparent, by informing clients of their choices so they can give us their informed consent. They also need to know what to expect during their treatment, and the rationale for each procedure. Follow up verbal oral health counseling with written materials. 5. Sharing Control: Helping clients to feel a sense of control during treatment by working with, not just on the client addresses abuse-related fears and facilitates compliance. In addition to obtaining informed consent before a procedure, we should ask our clients what they can tolerate, and reaffirm consent at different stages of the appointment. They should be assured that they can stop for a break at any time, and they can

May 2017

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Virtual Reality (VR) utilizes advanced technologies to immerse clients in an interactive, virtual environment, which distracts their attention from pain perception, and allays anxiety.

indicate if they are not comfortable by communicating with previously agreed hand signals. Respecting Boundaries: The disregard of personal boundaries during abuse teaches victims that their wants and needs are of no consequence. We should ask for consent before entering the client’s personal space, as well as before beginning a procedure. Fostering Mutual Learning: Many survivors of trauma have learned not to question professionals, and may need encouragement to assert their autonomy and participate fully in their own health care. We clinicians can also learn from our clients how best to manage their care. Understanding non-linear healing: The ability of a survivor to tolerate examination and treatment might vary from one visit to the next, as they experience good days, and bad days. Demonstrating awareness and knowledge of interpersonal violence by having educational materials in the office to show victims and survivors that they are not alone.

RECORDING A DISCLOSURE If a client chooses to disclose their history to us, we must ask them

oralhygiene

whether they want other healthcare providers to be informed, and if so, ensure that they are comfortable with how we record the disclosure in our notes. For example, one male survivor spoke of health care professionals who wrongly assumed he was a perpetrator because of an ambiguous entry in his clinical notes stating “history of sexual abuse”, an assumption also made because of his gender.

MANAGEMENT OF ANXIETY AND PAIN DURING TREATMENT Stress is known to precipitate medical emergencies10 11 due to sympathetic stimulation, and pain during treatment is a significant stressor. Clients with dental phobia frequently decline local anaesthetic injections: alternative modalities to relieve sensitivity during scaling include pre-treatment application of a rapid-acting desensitizing paste, for example: one containing bioavailable calcium and phosphate, or Pro-Argin.12 Another option is Non–Injectable Local Anesthesia (NILA): such as a thermosetting liquid gel mixture of lidocaine 2.5% and prilocaine, 2.5%, delivered subgingivally.13 Nitrous oxide and oxygen sedation might be administered by the dentist during treatment, but many

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survivors dislike the feeling of loss of control they experience under sedation. Drug-free options for management of dental anxiety and pain include eupnea (deep breathing);14 and sensory modulation in the form of a weighted blanket15; or virtual reality.16 Psychology plays a significant role in pain perception: in order to experience pain, conscious attention is required.17 Eupnea reduces pain, and calms by means of distraction, and parasympathetic stimulation. This increases levels of oxygen and melatonin, while decreasing cortisol and blood pressure. Weighted blankets relieve anxiety by deep pressure stimulation, which activates the parasympathetic nervous system.18 Virtual Reality (VR) utilizes advanced technologies to immerse clients in an interactive, virtual environment, which distracts their attention from pain perception, and allays anxiety.19

MOTIVATIONAL INTERVIEWING FOR ORAL HEALTH COUNSELING Motivational interviewing20 integrates well with the principles of trauma-informed, sensitive practice, because it is a non-judgmental and non-confrontational technique that promotes client autonomy. Knowledge alone of the dire conSEPTEMBER 2018

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Virtual Reality Impact on Pain

These images from an fMRI scan show areas of the brain affected by pain, and how they shrink when he patient is immersed in a vitual reality world. (Dr. Sam Sharar/University of Washington)

sequences of lack of care is not sufficient to motivate change; instead we emphasise the positive results clients can achieve by improving their self-care. Empathy from us is necessary to facilitate change. Active listening techniques include open-ended questions to encourage clients to do most of the talking, affirmations to validate their feelings, reflective listening to show that we respect what they have to say, and summarizing to demonstrate that we have been listening carefully. We collaborate with our clients to find doable solutions which aid effective day-to-day care, and facilitate regular attendance for continuing care and support. The clientâ€™s personal

desire for better health, and their participation in finding solutions delivers more lasting and effective motivation to change behaviour.

CONCLUSION We can screen for anxiety by utilizing a questionnaire21, however, we cannot always distinguish clients who are survivors of abuse; because child abuse, especially sexual abuse is under-reported, with less than half of survivors disclosing their experiences to anyone. Therefore, creating a comfortable office environment which facilitates traumainformed, sensitive practice will benefit all of our clients.

REFERENCES 1

DSM5, 2013

Locker D, Shapiro D, Liddell A. Negative dental experiences and their relationship to dental anxiety. Community Dent Health. 1996;13(2):86-92.

Humphris G, King K. The prevalence of dental anxiety across previous distressing experiences. J Anxiety Disord. 2011;25(2):232-6

Brier, J, & Elliott, D.M. (2003). Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse and Neglect, 27(10), 1205-22.

Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse & Neglect, 18(5), 409-417.

Hibbard, R.A., Desch, L.W.,American Academy of Committee on Child Abuse and Neglect, and American Academy of Pediatrics Council on Children With Disabilities. (2007). Maltreatment of children with disabilities (Clinical report). Pediatrics. 119(5),1018-25.

SEPTEMBER 2018

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Trauma-Informed Practice Guide bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf

Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse Researched and Written by... Candice L. Schachter, DPT, PhD Adjunct Professor, School of Physical Therapy University of Saskatchewan, Saskatoon, SK Carol A. Stalker, PhD, RSW Professor, Faculty of Social Work Wilfrid Laurier University, Waterloo, ON Eli Teram, PhD Professor, Faculty of Social Work Wilfrid Laurier University, Waterloo, ON Gerri C. Lasiuk, RN, PhD Assistant Professor, Faculty of Nursing University of Alberta, Edmonton AB Alanna Danilkewich, MD, FCFP Associate Professor, College of Medicine University of Saskatchewan, Saskatoon, SK

10 Fehrenbach MJ. Stress reduction for the oral health care patient at high risk for medical emergency. Access (ADHA). July 2004. 11 Fehrenbach MJ. ASA Physical Status Classification System for Dental Patient Care 2018. Updated January 5, 2018. Available from: http://www.dhed.net/ ASA_Physical_Status Classification_ SYSTEM.html 12 Desensitizing Agents, In-Office: https://www.ada.org/en/publications/ada-dental-product-guide/productcategory?catid=117 13 Oh Canada! Volume 1 Issue 4: Non Injectable Local Anesthesia (NILA) for Periodontal Debridement: A Review and Discussion for Subgingival Application by Dani Botbyl, RDH: https://www.cdha.ca/AM/images/OhCanada_winter_28-30.pdf 14 Can J Dent Hyg 2018;52(2): 140-143 Eupnea prior to oral injection Sameep S Shetty*,MDS; Nancy Agarwal§, MDS; Premalatha Shetty‡, MDS 15 Australas Psychiatry. 2012 Oct;20(5):401-6. doi: 10.1177/1039856212459585. Epub 2012 Sep 26. Pilot study of a sensory room in an acute inpatient psychiatric unit. Novak T1, Scanlan J, McCaul D, MacDonald N, Clarke T. 16 Stud Health Technol Inform. 2014;199:94-7.Quantifying the effectiveness of virtual reality painmanagement: a pilot study. Sulea C1, Soomro A2, Wiederhold BK1, Wiederhold MD3.

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SEPTEMBER 2018

17 Locker D. Psychosocial consequences of dental fear and anxiety. Community Dental Oral Epidemiology 2003; 31:144–151 18 Brian Mullen BS, Tina Champagne MEd, OTR/L, Sundar Krishnamurty PhD, Debra Dickson APRN, BC & Robert X. Gao PhD (2008) Exploring the Safety and Therapeutic Effects of Deep Pressure Stimulation Using a Weighted Blanket, Occupational Therapy in Mental Health, 24:1, 65-89, DOI: 10.1300/ J004v24n01_05 19 Cyberpsychol Behav Soc Netw. 2014 Jun 1; 17(6): 359–365. doi: 10.1089/ cyber.2014.0203 PMCID: PMC4043252 Clinical Use of Virtual Reality Distraction System to Reduce Anxiety and Pain in Dental Procedures Mark D. Wiederhold, MD, PhD, FACP, Kenneth Gao, BS, and Brenda K. Wiederhold, PhD, MBA, BCB, BCN Virtual Reality Medical Center, San Diego, California. Interactive Media Institute, San Diego, California. Virtual Reality Medical Institute, Brussels, Belgium. Corresponding author. Address correspondence to:, Prof. Mark D. Wiederhold, Virtual Reality Medical Center, 9565 Waples St., Suite 200, San Diego, CA

92121, E-mail:Email: mwiederhold@vrphobia.com Copyright 2014, Mary Ann Liebert, Inc. 20 Motivational Interviewing: Helping People Change; William R. Miller and Stephen Rollnick; Guilford Press, Sep 1, 2012. 21 The Prevalence of Dental Anxiety in Dental Practice Settings: Angela M. White, Lori Giblin and Linda D. Boyd American Dental Hygienists’ Association February 2017, 91 (1) 30-34;

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ORAL HYGIENE

AN EMERGING, INTEGRATED MODEL OF ORAL HEALTH CARE

Julie DiNardo, RDH Graduated in 1987 and working independently since 2008, Julie has a well established private practice, the Gleam Smile Centre, in Hamilton Ontario. Focusing on the wellbeing of her community, she was the recipient of the Community Service Award in 2016 for her advocacy efforts towards better oral health. Julie is past president of the Business Executives Organization and continues to be on their board of directors. As a founding member of the American Association for Oral Systemic Health, Julie has been able to bring forward the message of better oral health for improved patient care.

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he traditional model of medicine treats the body as individual systems and organs. This “dis-integrated” model of medical care also frequently excludes the oral cavity. Some examples we are all too familiar with: a physician or an endocrinologist overlooks the mouth when considering a diseasemanagement program for a diabetic patient; a patient suffering from chronic lung disease (COPD) has little advice from his/her medical team about managing his/her dental plaque and; a stroke survivor goes unaware that his/her oral health will likely deteriorate to cause further inflammation and risks for another adverse medical event. Moreover, in these cases where patients with multiple chronic conditions (MCC) are told to “see their dentist” by the medical team, a trip to the dentist happens all too infrequently. Either the patient has no dentist, or is anxious about going to the dentist because of the large copay on dental work, because of dental costs for those without insurance, and because of perceived pain and trauma and difficulty of getting to and from the dental practice. The cost of “dis-integrating” oral care from medical care is significant and growing. The evidence from intervention studies (those where changes to oral health are monitored for subsequent changes in overall health) now shows that poor oral health is not only an independent risk factor for MCC but can aggravate chronic conditions.

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For example, it is becoming clear that reduced inflammation of the gums can stabilize glycemic control amongst Type 2 diabetics (Chart 1). It is also clear that improved oral hygiene (both above and below the gum line) can slow the decline of lung capacity of COPD patients, as well as reduce exacerbations for these patients.1 See chart 1. Where: GC = control group without SRP and GT = treated group with SRP at baseline *results at at p<0.05 Source: Mauri-Obradors E, et al. 2018. Benefits of non-surgical periodontal treatment in patients with type 2 diabetes mellitus and chronic periodontitis: a randomized controlled trial. J Clin Periodontol., 45 (3) March: 345-353 So, as the population ages and MCC grows, a critical question is: can our community afford to continue with this separation of dental care from medical care? Put another way: is the separation of the mouth from the body a sensible, evidence-based approach to managing the health of rapidly growing numbers of older Canadians?

THE ORIGINS OF POOR ORAL HEALTH Poor oral health, as indicated by chronic periodontitis and/or (recurrent) caries emerges when the microbial biofilm has a change in the balance of microorganisms. The color, texture and consistency of gum tissue changes from a pink, SEPTEMBER 2018

HbAiC

PPD

7.8

7.6 7.4

GC mean

7.2

GT mean

7 6.8

GC mean

GT mean

1 0

Baseline

6 months

Baseline

3 months

6 months

Chart 1 Six-month effect on HbAIC (glycated hemoglobin) and probed periodontal pocket depth (PPD) in 90 patients with type 2 diabetes, after one session of scaling and root planing (SRP)*

firm, stippled look to red, spongy and smooth, indicating infection and inflammation. In terms of the hard tissues, root caries often emerges quickly and repetitively in patients with MCC. Both pathologies arise when the mix of bacteria shifts from being symbiotic or commensal with the host to being dysbiotic. Disease promoting bacteria dominate the biofilm and cause poor oral health. Oral dysbiosis emerges most commonly with advancing age and the onset of MCC. Many times, it is “the chicken or the egg” scenario when it comes to diabetes, which came first – diabetes or periodontal disease. Chronic obstructive pulmonary disease (COPD) and rheumatoid arthritis (RA) are also common diseases where oral dysbiosis is a contributing factor, not to mention the emerging connections between poor oral health with heart disease and Alzheimer’s.

WHAT IT MEANS TO MANAGE THE PRIMARY CAUSE OF POOR ORAL HEALTH What might work for managing oral dysbiosis cost-effectively and if this condition can be managed, what are its implications for the SEPTEMBER 2018

conduct of hygiene services? Will it help to overcome the separation of dental care from medical care which limits our role in Canadian communities as they age. These are complex but vital questions that are presently under investigation by several Canadian organizations such as Sinai Health System (Toronto) and my practice of independent dental hygiene called the Gleam Smile Centre in Hamilton. For years, my practice has served MCC patients with Prevora (DIN 02046245). Prevora is a high strength, sustained-release topical antiseptic coating applied to the hard tissues and the gingival margin. It works by re-adjusting the composition of the plaque on the teeth, at the gum line and in the gingival crevice. Prevora shifts this mix of bacteria from dysbiotic to symbiotic. And when this happens, almost universally the patients experience better oral health, and often remark they feel better too. The consequences of Prevora’s pronounced treatment effect have become increasingly apparent over time. Gleam’s original focus for Prevora on preventing root caries, has expanded to include the prevention of inflammation in the

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May 2017

oralhygiene

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.

mouth and most recently, the delivery of oral health consultation and care to diabetic patients in the setting of a group medical practice. In this journey, we have learned that by getting patients healthier the patient becomes very loyal, very willing to pay for services, and indeed, very willing to give testimonials. We should not be surprised about this response by the Prevora patient. Any treatment which manages both caries and periodontal disease at the same time is clearly cost-effective to those with and without insurance. Any treatment which minimizes discomfort and pain has merit. Lastly, a treatment which manages a threat to overall health becomes a priority; after all, we know how informed the patients have become about the linkages between the mouth and their overall health.

BABY STEPS TOWARDS INTEGRATED CARE Most recently, Gleam is participating with a Toronto family medical practice in a pilot study to improve the oral health of Type 2 diabetic patients using mobile hygiene with Prevora. This practice has several diabetic patients daily. Many of these patients have a dental plan or are regular visitors to a dentist yet few if any, have a dental focus on managing oral dysbiosis or even understand the importance of doing so. The pilot study is designed to evaluate three endpoints: first, how best to integrate hygiene into the patientâ€™s regular visit to the medical practice; second, how best to engage the patient to participate in managing oral dysbiosis as part of their diabetes program, and; third, what effect has improved oral hygiene on glycemic control (e.g. AIC levels) for these patients. In this pilot study, Gleam is providing a short consultation with the diabetic patient about oral dysbiosis and diabetes, about the Prevora treatment plan, and about its costs SEPTEMBER 2018

and convenience. Our consultation is upon referral by the family doctor and is tracked by the medical clinic in the electronic medical record of the patient. In this manner, our hygiene service has been integrated into the patient pathway.

TRIALS AND TRIBULATIONS â€“THEN A BREAKTHROUGH?: Change in any profession or industry is difficult and slow, but in healthcare and dental care, it can be glacial. We are rooted in our procedures, in our silos and by our insurance systems. But change we must when considering the emerging science and studies showing the linkages between oral health and overall health (Chart 1), when we are compelled to treat an aging population with co-morbidities which include poor oral health, and when we can show that by integrating our services with those of the physician, we can improve our practice and the health of our patients. Ten years ago, Gleam opened its doors and offered a range of conventional hygiene services. Today, we are practicing much differently and even in new venues. One reason for our change is our ability to manage the cause of poor oral health, with an affordable, topical antiseptic procedure. This ability has made better management of MCC patients a possibility, even in a medical practice. Gleam believes we could be on the cusp of a breakthrough for independent hygiene.

A treatment which manages a threat to overall health becomes a priority; after all, we know how informed the patients have become about the linkages between the mouth and their overall health.

REFERENCES 1. Zhou, X et al. 2014. Effects of periodontal treatment on lung function and exacerbation frequency in patients with chronic obstructive pulmonary disease and chronic periodontitis: a 2 year pilot randomized controlled trial. J Clin Periodontol, 4: 41(6), 564-572

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May 2017

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ORAL HYGIENE

SIGNIFICANT TRENDS IN GLOBAL ORAL HEALTH AND ORAL CANCER: The Power of Cultural Oral Habits

O Sherry Priebe RDH, BDSc, MSc Sherry impacts the lives of people globally with her dental hygiene life focus to “assist people to attain optimum oral health through research, education and clinical practice”. Sherry graduated with her Dip.DH (UofA), BDSc and MSc (UBC). She has published in the Vietnam J of Med and Pharm, the Can J of Dent Hyg, the Int’l J of Dent Hyg and the Dent Health J (UK). Sherry was awarded the ‘World Dental Hygiene Award in Research’ by SUNSTAR and the International Dental Hygiene Federation for her pioneering study in oral cancer and cultural risk factors in Vietnam. She mentors UBC students in further study by taking them annually to Vietnam to learn about risk factors and oral cancer victims.

oralhygiene

ral cancer is a serious disease and for dental professionals, the stakes are high. Detrimental cultural oral habits are deeply entrenched in today’s global societies resulting in greater potential for people to develop mucosal lesions and oral cancer. By learning and providing this new knowledge of how specific cultural oral habits can cause oral cancer, oral healthcare providers can make a huge difference through education and providing people with the care and assistance they need to prevent this disease. Today, 24.6 million people worldwide are living with cancer. Of all cancers that exist globally, 2.7 percent are found in the lips and oral cavity, and oral cancer is the 8th most common kind of cancer to die from. The significant trends in global oral health are the following:

1. MOVEMENT OF PEOPLE AROUND THE WORLD BRINGS CULTURAL ORAL HABITS WITH THEM Globalization is occurring at rapid rates; as people opt to live in foreign countries, they bring their cultural oral habits with them. It is not uncommon to find people chewing incredibly addictive substances including: khat, betel nut, coca leaves, kola nuts, and smokeless tobacco. In the countries of the Horn of Africa, khat is an evergreen shrub chewed for its enhanced relaxation and socially stimulating effects.

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Many young men chew khat leaves and are stoned most of the day, being unproductive and a drain on society. Cathinone is the alkaloid present in khat which acts as a stimulant on the nervous system giving the sense of euphoria. Chewing khat causes severe gum disease and high incidences of stomach and oral cancers. A study by Gorsky and Epstien in 2010 showed that 83 percent of users developed leukoplakia, which can become cancerous if left untreated. Canadian authorities reported that in 2008, khat was the most common drug illegally smuggled through the country’s airports. Betel nut is a combination of the leaf of the betel vine, burnt limestone with a pink dye spread on it, followed by a slice of the soft inner nut from the areca palm tree. It is wrapped up into a quid, placed in the cheek and chewed for about 15 minutes. Betel nut is chewed for its euphoric and exhilarating effect due to the stimulant arecoline. This culturally approved ‘drug’ acts as a stress reducer while heightening awareness, suppressing hunger, increasing the capacity to work, and providing a hot sensation in the body. A person who chews betel nut will often develop damaged gums with the possibility of resulting cancer of the mouth, esophagus, or stomach. Coca leaves are commonly chewed in South America. Coca leaves provide energy and stop SEPTEMBER 2018

hunger; however, the most common use is to help counteract altitude sickness as people walk distances with various elevation changes. People who chew coca leaves regularly often notice increased joint pain. Coca leaves were at one time used as flavouring in the soda drink Coca-Cola. Coca leaf is most known in the world when refined as cocaine. Kola nuts are found in rural West Africa, often given to those in authority as a sign of respect, leadership and honour. Kola nuts enhance physical energy thereby increasing body temperature, respiratory rate, and blood pressure. As with coca leaves, the makers of Coca Cola have been known to use kola nuts as well SEPTEMBER 2018

for flavouring in their soda. Kola nuts are addictive, impacting oral health by staining teeth, inhibiting bone formation in children and may cause esophageal or stomach cancers. Smokeless tobacco is consumed widely around the world, particularly among adolescent males. 85.8 percent of smokeless tobacco users will have used cigarettes at some point in their lives. The irritation of the tobacco on the mucosa can cause tissue dysplasia and become cancerous. In recent years, public figures have come forward to show the huge disfigurement of surgical removal of oral cancer as a deterrent of smokeless tobacco use. Chewing a variety of plant-based stimulants is a popular pastime for

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many cultures. Unfortunately, these stimulants are extremely addictive, and their use may cause oral lesions progressing to become oral cancer.

2. ORAL CANCER IS ON THE RISE AS LIFESTYLE RISKS INCREASE Oral cancer is rising at an alarming rate in people under 45 years of age. Research demonstrates that the human papilloma virus (HPV) is rising worldwide due to the practice of oral sex particularly in younger populations. Globally, HPV incidence increased from 23 percent in the 1960â€™s to 68 percent in the 2000â€™s. As well, it is now common for a person to have 4-6

May 2017

oralhygiene

An increased trend of oral cancer is documented worldwide. In Canada, 4,700 people were diagnosed with oral cavity cancer in 2017 and approximately one third died. sexual partners in their lifetime, creating a three-fold increased chance of developing oral cancer. Usually 90% of HPV viruses clear within 2 years when a personâ€™s immune system is functioning well. However, if HPV is persistent, there is a ten-fold increased correlation of cancer.

3. AWARENESS OF ORAL CANCER IS LOW An increased trend of oral cancer is documented worldwide. In Canada, 4,700 people were diagnosed with oral cavity cancer in 2017 and approximately one third died. Twice as many men were diagnosed with oral cancer compared to women. In the USA, 52,000 people will be diagnosed with oral cancer this year. In Central and Eastern Europe, this is plainly seen as oral cancer cases have doubled in the last 35 years. In South-Central Asia, 80 percent of head and neck cancers are found in the oral cavity (Parkin DM et. al, 1999). In Tai-

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wan, young men being diagnosed with oral cancer has tripled in 25 years. Researchers in India attribute their peopleâ€™s sudden spike in throat and tongue cancer statistics with the use of Gutka, a smokeless tobacco product of nicotine, betel nut and spices etc. that is mass produced in India. Traditionally, Gutka has been chewed by all ages of the Indian population throughout the world. The reported etiological agents and risk factors of oral cancer include tobacco and frequent alcohol use, the use of betel nut, a history of cancer, diet, acid reflux, human papilloma viruses (16 and 18), and a compromised immune system. However, 25% of people have no risk factors, so by assuming that patients who drink and smoke are at greater risk is not always accurate.

4. DIAGNOSIS OF ORAL CANCER IS IN LATE STAGES Why is oral cancer diagnosed in such late stages? The answers could

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possibly be due to limited access to health care, lack of economical resources, and fear may impede some from getting care early. Commonly diagnosis is delayed as people are unaware of oral cancer and do not seek out professional help. To compound matters, many individuals possess misconceptions about oral cancer. Some people think that overly spicy food or biting the cheek will cause cancer. Some believe that cancer is contagious. A patient’s knowledge of oral health should not be taken for granted by the oral health provider. Around the world, training is lacking and even in Canada there is a low awareness of risk factors and prevention of oral cancer. Still, there is hope. Counseling for the cessation of tobacco use is readily available from many sourcSEPTEMBER 2018

es. As we know, some oral diseases are preventable when appropriate behaviours are reinforced and encouraged by public health promotions. Health promotion is key to minimizing the impact of oral diseases worldwide. Oral health professionals have a prime opportunity to perform visual extra-oral and intra-oral examinations and adjunctive light activated oral screenings. These light-activated screening tools can assist to detect healthy tissue, bacteria, and squamous cell carcinomas of the oral cavity. Today, in Canada, the British Columbia Cancer Agency widely uses the ‘Velscope’ in research and diagnosis of oral cancer. The photo below shows oral squamous cell carcinoma due to no fluorescence of the tissues and revealing the black spread of cancer cells.

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Around the world, training is lacking and even in Canada there is a low awareness of risk factors and prevention of oral cancer.

May 2017

oralhygiene

As global societies become more intertwined and cultural practices continue to spread in new ways through globalization, there is a need for dental professionals to become educated about and create greater public awareness regarding the health risks associated with chewing and consuming certain historically accepted substances. Education about the harms of chewing specific substances is imperative for younger

age groups. This is especially true for expatriates who relocate for employment, as they will adapt to the cultural oral habits and practices of the country they reside in, not realizing the health risks or effects. The provision of support and care is necessary as people learn and recognize the potential harm of different cultural rituals and

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oral practices. Increasing awareness of the hazardous and addictive effects of tobacco use, alcohol abuse, and any leaf or nut chewing habits will diminish the risks of developing oral cancer. With this knowledge, dental and healthcare professionals can be promoters of health and increased lifespan, positively impacting abundant living around the world. SEPTEMBER 2018

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ORAL HYGIENE

PERIODONTITIS STAGING AND GRADING

Beth Ryerse, RDH Beth Ryerse has been actively and meaningfully involved with the dental hygiene profession for more than 30 years. Her passion for her career has led to a depth of experience and accumulated knowledge gained through; clinical experience, educating, lecturing, consulting, authorship and mentoring. She is an active member in provincial and international dental hygiene associations, is the elected CDHA Ontario Board Director, a key opinion leader and a certified soft-tissue diode laser trainer. Beth is an engaging, enthusiastic, dynamic professional educator who has fun when she interacts and takes joy in growing with her peers in their commitment to life-long learning.

oralhygiene

e are being challenged every day to grow as professionals. It is often difficult to keep up with all of the new information that seems to bombard us. The necessity of oral cancer screening, routinely, on a younger demographic. Infection Prevention and Control guidelines that must be implemented. The impact on oral health that the legalization of cannabis will have. Pre-med requirements. Elder Abuse and how to respond when we see signs of it in our treatment room. MeToo in the workplace. Periodontal disease associated with a myriad of other afflictions. And so much more. Maintaining professionalism when faced with ever-changing information is a daunting task. Each one of the topics mentioned above deserves investigation to ensure that we are provided true best-practice, based on current knowledge. In this article we will focus on the disease that we deal with on a daily, often hourly, basis. There is exciting news on this front. Fortunately, we have recently been presented with new classifications for periodontal disease which will clarify diagnosis and therefore, treatment protocols. This is cause for celebration! The 1999 Periodontal Classifications, were structured as (broad categories only here):

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Gingival Diseases: Dental plaque induced gingival diseases Non-plaque induced gingival lesions 2. Chronic Periodontitis 3. Aggressive Periodontitis 4. Periodontitis as a Manifestation of Systemic Diseases 5. Necrotizing Periodontal Diseases 6. Abscesses of the Periodontium 7. Periodontitis Associated with Endodontic Lesions 8. Developmental or Acquired Deformities and Conditions For some, the many sub-categories within each of these headings, seemed to complicate an already difficult disease and it was not always beneficial in helping to determine a diagnosis and an appropriate treatment plan. In 2016, the Canadian Journal of Dental Hygiene published an article titled, “Current status of the classification periodontal diseases” .¹ In this paper, the authors point out that a World Workshop in Clinical Periodontics was planning to meet in November 2017. The focus would be the limitations of the existing periodontal classifications, including clinical attachment levels (CAL) as main classification criterion, distinguishing between ag-

SEPTEMBER 2018

gressive versus chronic, and localized versus general periodontitis. The task force involved in this meeting wanted to include additional parameters (beyond CAL) such as inflammation, bleeding on probing, increased probing depths and radiographic bone loss. Often times as clinicians, using only CAL as the main classification criterion, left us unsettled. We know so much more about this disease than we did in 1999. What we know about periodontal disease and the best methods of treatment continues to evolve. The classifications in 1989 were an advancement over what was available before that time. The 1999 groupings were a significant improvement over that. Now, we have ‘Stages’ and ‘Gradings’ to further our commitment to better diagnosis and treatment of this disease. The World Workshop was held as

SEPTEMBER 2018

planned in November 2017, with expert participants that included members of the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP). The purpose of the workshop was to review new technology, research and information with the goal of creating revised periodontal classifications. The results of that workshop are these new AAP guidelines that were announced in June 2018. You may want to print some of these documents out and have them laminated to use as chairside resource tools. The information they contain will be a valuable asset to client education. They can be found in printable version at: perio. org/2017wwdc This introductory paper provides an overview and is a good place to start with this new information. The steps and staging and grad-

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ing will make consistent diagnosis, easier. It will also help clients to understand when we are communicating that diagnosis. The new classifications present periodontitis in much the same way that other diseases are categorized, as stages. Most people are familiar with the concept that Stage IV cancer is more serious than Stage I. The same is true for periodontitis. The “Three Steps to Staging and Grading a Patient” include: Step 1: “Initial Case Overview to Assess the Disease” – then using the findings from this assessment you determine the ‘stage’ of disease. Step 2: “Establish Stage” – divided into two sections “mild to moderate” and “moderate to severe”. Then, to address severity, complexity and extent and distribution of periodontitis, you assign a ‘grade’. Step 3: “Establish Grade” – focus

May 2017

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on client characteristics and risk factors, systemic influences and evaluation from previous treatment(s). The four stages of periodontitis are based on the amount of damage that has already occurred. The facSEPTEMBER 2018

tors measured include: interdental clinical attachment loss, radiographic bone loss, tooth loss and probing depths for Stage I and II. Additionally, furcation involvement, ridge defects and bite collapse

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are involved in Stages III and IV. The â€˜Gradingâ€™ portion of the new classification system allows us to incorporate other indicators of disease in order to determine how much risk a client has for further

May 2017

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progression of periodontitis. The “Primary criteria are bone loss or CAL, age, case phenotype and biofilm deposits. Grade modifiers include smoking and diabetes. For example, a client could have Stage III which indicates damage so there has been previous active disease. They are a Grade A though, now in ‘remission’ so the risk of progression is low. This client would obviously need different therapy than one who was Stage III, Grade C. As we continue to learn about the causes of periodontal disease and the many associations with systemic health and wellness, the experts will undoubtedly be required to provide further revisions to these classifications in the future. As healthcare professionals, it is our responsibility to stay current with the results of the research that is being done. However, if we only read about the developments and do not put that new knowledge into practice, the only ones to benefit are ourselves. I would encourage you to become familiar with the documents from the AAP and feel confident in your knowledge of the four stages of periodontal disease. Be able to discuss the implications of the severity, complexity, extent and distribution of each stage, in client terms. Then you will be able to educate your client in a manner that is clear and understandable for them. That will, in turn, lead to acceptance of the therapy protocol that is truly required. When a client has a clear understanding of their disease and the potential for further destruction, they are better equipped to make the best decision for their own health. That is where the grading system offers such significant help. The ability to connect risk factors to the rate of periodontitis progression, using the chart as a guide, allows us to ‘paint a picture’ that is specific to particular client characteristics. True quality assurance means that we not only investigate new concepts, skills and technology but actually adapt our practice to include current, evidence-based knowledge so that we are always striving to provide best practice.

Resources: Canadian Dental Hygienists Association – www.cdha.ca Can J Dent Hyg 2016;50(3): 140-144 American Academy of Periodontology – www.perio.org The American Academy of Periodontology. Proceedings of the World Workshop in Clinical Periodontics. Chicago: The American Academy of Periodontology; 1989:I/23- I/24 Tables from Tonetti, Greenwell, Kornman. J Periodontal 2018;89 (Suppl 1): S159-S172. SEPTEMBER 2018

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ORAL HYGIENE

5 WAYS TO BOOST YOUR IMMUNE SYSTEM THIS FALL

Uche Odiatu Dr. Uche Odiatu is the author of The Miracle of Health, a professional member of the American College of Sports Medicine and a practicing dentist in Toronto. This busy dad of four is an NSCA Certified Personal Trainer and has lectured in England, Canada, the USA, the Bahamas, Denmark, Bermuda and Norway. Website: www.DrUche.com Twitter: @FitSpeakers Instagram: @FitSpeakers

SEPTEMBER 2018

s this you? “I get two bad colds a year, one in the winter and another in the summer.” A week or two of down time for a cold or flu can cost you thousands of dollars in sick days as a busy health care provider. I am going to share with you some insider strategies to shorten your sick days or eliminate them altogether. Instead of over the counter meds and Echinacea I am going to give you another way to look at fortifying your body to weather the sickness storms of life Caution: this article contains FIVE foundational methods to support a healthier immune system and boundless energy this summer From the Latin immunis meaning untouched, the term immune system refers to your Superman or Superwoman cape that protects you from harm. Some of the strategies I will share will make intuitive sense but some will blow your mind. Let’s start with the first one: 1. Scientists report that Immunoglobulin A in saliva is the front of the line defender against influenzas and pneumonia. 95% of infections start in the nose and mouth.1 It is immunoglobulin A or IgA that neutralizes and protect the body from penetration by viruses. 2 My favorite E word exercise has been proven to boost IgA and lower the chance of getting a cold or flu. A study in the European

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Journal of Exercise Physiology showed that a physical active group (compared to an inactive group) who did aerobic style exercise (for as little as half an hour three times a week for twelve weeks) had 50 percent higher levels of IgA - your first line of defense immune soldiers. 3 I know my dental colleagues can be over-achievers. Nothing wrong with that – it got us through dental school. Regular exercise is very good for you but more isn’t necessarily better. Ultra-endurance exercisers have depleted glutathione levels for more than a month after an intense race. Glutathione or GSH has many functions besides being the body’s most abundant antioxidant. It also regulates the immune system.4 In the months following a marathon, these gladiator type athletes (I might be describing some readers) experienced a two to six-fold increase in upper respiratory infections. 5 NOTE to self, “keep your GSH levels up by not overdoing your new exercise program.” 2. Get more quality and quantity of sleep to have a stronger immune system. But this sense of, “I ought to go to bed” or “tonight I will catch up on sleep” doesn't make the cut. Getting to bed on time sounds easy to

May 2017

oralhygiene

We live in harmony with over 100 trillion single celled bacteria. 80% of them live in your digestive tract and a recent ground-breaking article in Scientific American reported their influence on our health is shaking the very foundation of medicine and nutrition. do BUT what is easy to do is also easy not to do. An average adult gets by on less than seven hours of sleep a night. This doesn’t bode well for the dentist intense work day, which starve you of sunlight and keep you packed in the operatory in close contact with legions of patients – the last thing you want is a lackluster immune system. Staying awake for 18 hours a day isn’t a great idea. When you’re awake, your body’s repair/recover/rebuild system is running on standby mode. It is only while you’re sleeping that your body launches its powerful offensive where close to 95% of resources are poured into regeneration mode. Muscles relax, heart rate lowers and the kidneys detoxify. Fifty-million cells are renewed per second as the unsung hero of your immune system – your lymphatic system disposes of damaged cells.6 Next time you are sitting next to someone coughing and sneezing on a plane you are going to think back to this article and remember that I told you regeneration of your immune system is limited to the deepest phases of your slumber. And I know you’re going to pledge to go to bed earlier before you

oralhygiene

travel when you realize that in a long-term study by the BBC in the UK reported that people who regularly get less than seven hours a night are three times as likely to catch a cold. Good night my frequent flyer friend. You know who you are… 3. Mind your guts. Not the outside but the gut flora on the inside of your belly. You see we live in harmony with over 100 trillion single celled bacteria. 80% of them live in your digestive tract7 and a recent ground-breaking article in Scientific American reported their influence on our health is shaking the very foundation of medicine and nutrition.8 The bacteria in your gut play an important role in immune system modulation. Three quarters of the cellular constituents of your whole immune system are located in this area.9 If you want to build the strongest foundation for your immune system you need to do these things to keep your gut flora in good shape: A) Eat 25 to 30 grams of fiber each day. (The average North American consumes half that amount). Fiber is the gut bacteria’s number one choice of nutrition on which all other interactions depend reported Justin Sonnenburg PhD assistant

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professor in the department of microbiology and immunology at the Stanford University School of Medicine. B) Regular exercise makes your gut bacteria more diverse in their make-up. This adds to the stability and potency, and most of all, keeps pathogens in balance.10 C) Limit your use of hand sanitizers outside the operatory. Robynne Chutkan MD author of The Microbiome Solution wrote that part of developing a balanced gut flora means having them less disrupted by overboard sanitization at home (and the overuse of antibiotics). Indiscriminant use of these drugs can decimate your gut flora from six to twelve months after a single course of antibiotics. It takes that long to recolonize your microbiome. D) Unmanaged stress also decreases diversity in your gut flora and therefor hampers fabrication of the cellular constituents of your immune system. E) Probiotics are good bacteria found in cheese, yogurt, kefir, sauerkraut, miso soup and assorted vegetables. If consumed regularly they will support optimal gut health and the fortification of an empowered immune system. How about probiotic supplements? Great question. Everyone seems SEPTEMBER 2018

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to be interested in this popular supplement. There is a very recent study in the Journal of Strength and Conditioning Research, that just came out in January of this year.12 It looked at thirty hard driving athletes and it showed that probiotic supplementation would help rebuild the first line defense or humoral immune system that gets beaten up from intense training in the winter months. So, the athletes who took the probiotic had less respiratory illnesses. There are different formulations and numerous brands available in high-end health food stores, grocery stores and pharmacies. I prefer room temperature stable varieties with multiple strains that are easy to swallow. 4. Manage the stresses in your life. Chronic activation of your fight-flight nervous system overloads your immune system

and increases the odds of you coming down with a virus (cold, flu, etc). Yes, there’s real science as to how you can “worry yourself sick.” Natural Killer (NK) cells patrol your entire body continually looking to attack and obliterate bacteria, viruses and cancer cells. NK cells are blocked or get passively stuck to the walls of your 60,000 miles of blood vessels by elevated cortisol and noradrenaline. This allows viruses and bacteria to linger in your system longer than they ought.11 Stop sweating the small stuff – hire a good consultant to take you to the next level, delegate (don't micro-manage) and empower the talented team you hired, so you all get to the finish line (or spring) without down time from sicknesses. 5. Stay hydrated throughout the summer and into the fall.

Drinking adequate water (if you are thirsty, you are already too late – the body has already tapped into the contents of your colon in a preprogrammed plan of recycling the water in your fecal matter – sorry I had to tell you this little know physiological fact). Water is a major player in lymph production and helps keep this vital part of your immune system functioning well. Did I mention vitamin C and Echinacea? Sorry these wellknown immune boosters aren’t going to help you if your foundation is not solid. My goal was to provide with core strategies that will provide you, my fellow health care providers, with the best chance of making it through the year without getting a cold or flu. If you utilize the five strategies above you will have my personal insider tools to enjoy vibrant health and energy year-round.

References 1. Neville V et al “Salivary IgA as a risk factor for upper respiratory infections in elite professional athletes” Medicine and Science in Sports and Exercise 2008. 2. Otsuki T et al “Salivary secretory immunoglobulin A secretion increases after 4 weeks ingestion of chlorella-derived multicomponent supplement in humans: a randomized cross over study” Nutrition Journal 2011. 3. Klentrou P et al “ Effect of Moderate Exercise on salivary immunoglobulin A and infection risk in humans” European Journal Applied Physiology 2002. 4. Turner J et al. “Prolonges Depletion of Antioxidant Capacity after Ultraendurance Exercise” Medicine & Science in Sports and Exercise 2011. 5. Walsh NP et al “Position statement. Part one: immune function and exercise. Exercise Immunological Review 2011. 6. Idea and Discovery Magazine April 2016. 7. Bermon S et al. “The microbiota: an exercise immunology perspective. Exercise Immunology Review 2015. 8. Scientific American 2015 Special report. Pp S1-S15. 9. Campbell SC & Wisniewski P “Exercise is a novel promoter of intestinal health and microbial diversity” October 2016 American College of Sports Medicine Journal. 10. Clarke SF et al. “Exerise associated dietary extremes impact on gut microbial diversity.” Gut 2014. 11. David Servan Schreibner MD, PhD © 2008 Anti-Cancer: a New Way of Life. Harper Collins. 12. Michalickova DM et al “Lactobacillus Helveticus Lafti L10 Supplementation Modulates Mucosal and Humoral Immunity in Elite Athletes: a randomized, double blind, placebo controlled Trial” Journal of Strength and Conditioning Research 31(1) Jan 2017.

oralhygiene

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SEPTEMBER 2018

dentalcorp is hiring Dental assistants, dental hygienists, and more across Canada. Join a fun, collaborative workplace with competitive pay including signing bonuses for select opportunities.

Reach out to careers@dentalcorp.ca

dentalcorp.ca/careers

Searching for that one of a kind associate, specialist, locum, hygienist, dental assistant, office manager, practice sale, seminar/conference, equipment... Maximize the visibility of your open job positions by advertising in the dental marketplace section in

print and online.

ne e i g y h l ora

The Oral Health Group of publications offer classified advertising sections in each and every issue. We carry more classified ad pages than all other Canadian dental magazines combined.

FACE: SAVING rm, Mask Fo nction Fu Fit and ED: RY SOLV MYSTE x and flu Acid Re Cavit y al The Or ED CE-BAS EVIDEN DELIVERY DE FLUORI s Dental y’s for Toda Cl t nt e i ien lie C Hygienee

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COM O U P. THGR HEAL .ORAL WWW

Place your ad in front of or a wide, targetedOaudience FF alhealth Pag IC e 73 E of Canadian dentists and hygienists Fi al indd

Y 201 8

o So You Want nT? re ild h Treat C

ions Mail Publicat

“e-dental Marketplace” Exclusive service for Dental Marketplace advertisers. Real time, online classified ads with posting guaranteed within 72 hours.

0-4204 ISSN 003 63170 • nt No. 400 Agreeme AM 8 11:18 2017-12-2

NEW!! We now offer a PREMIUM PLACEMENT online option.

DENTAL MARKETPLACE E

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Do you need help recruiting dental professionals? YOUR ADVISOR IS S IN www.oralhealthgroup.com/marketplace

WORKING 24/7 TO MEET YOUR NEEDS

Contact your advisor Karen Shaw Tel: 416-510-6770 Cell: 437-991-7187 Email: karen@newcom.ca

To advertise contact: Karen Shaw • tel: 416-510-6770 • 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

HYGIENISTS

CONTINUING EDUCATION

ABBOTSFORD, BC We are a fully digital, well established private practice, requiring an experienced dental hygienist for a permanent position, for 4 days a week, Wednesday to Saturday (no evenings & closed long weekends). Our office is patient centered, with strong team support. You will receive full in-office training allowing you to seamlessly become part of our wonderful team. Check out our google reviews to see what our patients say about our office: We offer a competitive wage, uniforms and Continuing Ed. Please email your cover letter and resume for review to admin@novodentalcentre.com Only successful candidates will be contacted.

MARKETING IN THIS OVER SATURATED DENTAL INDUSTRY

199

Full Time Dental Hygienist

ROCKY MOUNTAIN HOUSE, AB Part Time Registered Dental Hygienist required for a busy well established dental office. Candidate should be energetic, confident and possess strong communication skills. Permanent position available. Competitive wages /great income potential. Please reply to office tel: 403-845-3200/587-733-0021 fax: 403-845-4440 or email rocky.dentistry@hotmail.com

289-828-1402

Call Today to Reserve Your Time

CAREERS

LOCUM WANTED – ACROSS CANADA Orthodontist with 15+ years experience in all aspects of orthodontics available to do short or long term locums. AB licensed, but willing to travel out of province if license can be provided. Please contact juanita.mills@gmail.com for more information.

ACROSS CANADA Interested in sharing your passion and knowledge for Oral Health? WE HAVE THE JOB FOR YOU! Check out our job posting for more details (goo.gl/q18xoN) or contact Jill King at jill@kmacgroup.ca (1-800-495-1540). To apply, please follow the link to our online application system: https://goo.gl/ywW8Ac.

PRACTICES & OFFICES

MOUNTAINS OF BC – NEAR KAMLOOPS AND PRINCE GEORGE Satellite clinic for sale in the mountains of BC near Kamloops and Prince George. Sad to leave but too busy with primary clinic. Must leave by year’s end. Currently grosses $300,000 with potential for growth. Main concern is for staff and patients. Would prefer right candidate to assume operations at no cost rather than shutting down. clinicforsale2@gmail.com ESTABLISHED PRACTICE FOR SALE – WOODBRIDGE, ONTARIO Stunning, modern, recently renovated, 6 Operatory Practice! Great location, located in a Shoppers Drug Mart Plaza! Plenty of free parking! For further inquiries please contact: info@dentalacquisitions.ca

YELLOWKNIFE, NT Busy downtown Yellowknife Dental Clinic needs a full-time Registered Dental Hygienist to start October 1st. This is a well established position in an office with 3 Dentists and 2 Hygienists. E-mail: drrogerarmstrong@gsdental.ca SEPTEMBER 2018

Marketing Strategies: How to set a marketing budget Double your patient in base in one year What worries dentists have about their practice

Julie A. Louks

WHITEHORSE, YT Busy 8 Op practice requires full time Hygienist. Located in beautiful city of Whitehorse, Yukon. Population of 30 000 and growing. Great outdoor adventures waiting at your door. Kayaking, fishing, hiking, skiing. All waiting for you to experience. The office is a general practice that includes implants, endo, perio, ortho and oral surgery. Experience preferred. Please send resume to pinedental@northwestel.net

LEARN HOW TO:

Grow your practice with very little money Telephone skills that effectively convert inquires into actual booked patients Reduce Cancellations

Limited Time Offer

THE PAS, MB Hygienist Wanted New, modern, state of the art dental clinic located in The Pas, Manitoba is looking for a full time hygienist. Option to work longer days if you like. We can help you find accommodations. If interested please send resume to laura@springhilldentalthepas.com You can also check us out on facebook or call 204-623-1999.

This One Hour Seminar Comes To You! You Choose The Date And Time.

www.oralhealthgroup.com

TURNKEY PRACTICE FOR FREE

DOWNTOWN TORONTO MODERN DENTAL OFFICE 123 Edward St. upper floors across from University of Toronto dental. 1050 sq.ft. 3 ops, fully equipped practice with digital office turn key – move your patients in tomorrow. Current lease is 4200.00 per month + hst expiring May 2019 with 5 year extension or walkaway lease. Appraisal from Hill Kindy available. No charts. $22,000.00 To find out more please email: andyc@coradixgta.com TORONTO, ON (Corner of Bloor and Sherbourne) Dental practice for sale. Extremely busy, high traffic area with large ground floor exposure across subway. Inquiries call 416 558 0847.

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ASSOCIATESHIPS VAUGHAN AND BRAMPTON, ON Part-time Paediatric Associate – Dental Works 4 Kids Part-time Paediatric Dentist needed to join our Paediatric / Orthodontic specialty practice. Established practice in a growing community. Successful candidate should be a licensed Paediatric Dentist and have experience with special needs, nitrous, oral-sedation and in-office general anaesthesia. Our experienced qualified team will assist you with a fully booked schedule. Competitive salary structure and benefits to be discussed with potential candidates. Confidentiality assured. apply@dw4k-align.com

OWEN SOUND, ON

TRENTON-BELLEVILLE, ON

Seeking a part time Associate to join established, very busy dental clinic (4 Dentist) in Owen Sound, Ontario. This is an excellent opportunity for a dentist seeking 3 days weekly Monday to Wednesday with a possibility of a 4th day down the road and enjoy a wonderful lifestyle in the Georgian Bay area whilst practicing dentistry at its best. The position will be available July 1 2018.

Well established patient base, supported by a talented team of professionals is seeking a passionate full time associate/partner to join our team, that thrives on patient experience & excellence, with potential partnership. This ideal candidate must be enthusiastic, dynamic, conscientious, work well in a team environment and has 2+ years experience. Please forward resume to dentistsopportunity@gmail.com

Please e mail your resume to guychouinard@hotmail.com or phone at 519-376-4244.

ST. JOHN’S, NFLD Associate opportunity, full time

REGINA, SK Seeking motivated and dynamic Associate for long-term, full-time position in a growing, modern and well-appointed clinic. Paid on PRODUCTION! New grads welcome, mentoring available. Contact: admin@courtsidedental.ca

MISSISSAUGA, ON Seeking a part time periodontist. A great opportunity for the right candidate. Please forward your CV to info@grandparkdental.com

SASKATCHEWAN Multiple Associates smile.dentalcareers@gmail.com

WINNIPEG, MB Plessis Dental Centre is looking for a self motivated, energetic full time Dental Associate with at least one year of experience. Willingness to do all fillings, crown/bridges, RCT’s and extractions. Please email your resume to r.c.sandhu19@gmail.com or stop in the office.

oralhygiene

Email: smile.dentalcareers@gmail.com

LANCASTER/ALEXANDRIA/ALFRED/ HAWKESBURY, ON Our very busy and renowned dental practices are looking for a part time/full time associate to join our team. E-mail: rh@centresviva.com

KAMLOOPS, BC Dental Associate Needed in Beautiful British Columbia. We are looking for a motivated dentist to join our busy family dental practice in Kamloops, BC. We are a paperless, digital office with a busy recall system in place. Kamloops is home to world renowned Skiing, golf, fishing, and mountain biking. Our practice is team orientated. The position is full time and is available immediately. New Graduates welcome. Please call 250-398-0532 or email vitoratos@shaw.ca

KITCHENER, ON Part Time Associate Required for Busy, Well-Established Office Looking for a part time associate for Sundays in a very busy general practice clinic in the Kitchener/Waterloo area. Candidate must have at least 1 year experience. Ideal candidate should be proficient in all phases of dentistry, particularly emergency dentistry. Please email resume to: Kitchenerdentist01@gmail.com

www.oralhealthgroup.com

WINNIPEG, MB Full-time Associate smile.dentalcareers@gmail.com

MISSISSAUGA, ON Seeking a part time associate. Minimum 1 year experience. A great opportunity for the right candidate. Please forward your CV to info@grandparkdental.com

VANCOUVER, BC Associate Dentist opportunity Email: smile.dentalcareers@gmail.com

GTA Various clinics within the dentalcorp network Opportunity: Periodontist Flexible days per month E-mail: careers@dentalcorp.ca

SEPTEMBER 2018

ASSOCIATESHIPS

GRANDE PRAIRIE, AB Seeking an enthusiastic, motivated associate dentist for a longterm, full time position in our well established, growing practice. The position will include some evening hours with weekends off. Applicants, please forward your resume to gpfdcadm@telus.net

SUDBURY/MANITOULIN, ON FULL TIME ASSOCIATE Looking for a full time associate dentist to work at busy Sudbury or Manitoulin dental practices. Current associate is leaving in 2 weeks. Sudbury practice is fully digital and the Manitoulin practice will be upgraded in October of this year. Northern Ontario is less saturated with dentists and you would be busy from the start. Please email weebit_17@yahoo.ca for more information.

SOUTH SIDE EDMONTON, AB Well established south side Edmonton office looking for a part time associate. Great team in place. Excellent opportunity. Please forward CV to Lamtwins@telus.net

REGINA AND SURROUNDING AREAS, SK Multiple Full-time associates required for a 30-year-old well-established, family-oriented dental practice in Regina and surrounding areas. The position replaces the former owner who is transitioning into retirement. Above average earning potential, busy schedule from day one. Email a cover letter and resume in confidence to: dentistSK17@gmail.com

TORONTO, ON ORTHODONTIST Email: smile.dentalcareers@gmail.com

TRENTON, ON Full-time Associate Position Well established dental practice is currently looking for a Full-time dental associate to join our friendly and dedicated team, for long team commitment. Candidates must be a great communicator, possessing strong clinical skills in all aspects. E-mail: trentonfamdental@gmail.com PERIODONTIST Chilliwack, BC - Sydney, NS, Lethbridge, AB, - Regina, SK, Mississauga, Cambridge and Toronto ON Multiple opportunities, Full-time and Part-time. Email: smile.dentalcareers@gmail.com

OAKVILLE, ON Oakville Dental Office is currently hiring a part-time Associate Dentist to join our team. Expertise in providing wide scope of dentistry basic restorative procedures, endodontics, prosthodontics, extractions and Invisilign an asset. Future purchase opportunities available for the right candidate. Job Types: Parttime, Permanent. E-mail: romanbaksa@bellnet.ca

WINNIPEG, MB Opportunity for Oral Maxillofacial Surgeon for busy, full scope practice in Winnipeg with emphasis on Dental Implants and Reconstruction. smile.dentalcareers@gmail.com

ETOBICOKE/MISSISAUGA, ON

CALGARY, AB

Progressive and upscale offices in Etobicoke/Mississauga need an experienced FT Dentist ASAP. Email: hrdentalteam@gmail.com

Associate wanted for a busy family practice, in the Calgary inner city 3-4 days/week. The ideal candidate would have excellent communication skills and at least three years of work experience. Please email your resume to wmj@shaw.ca

COBOURG, ON

YELLOWKNIFE, NT

Associate opportunity, part time

An exciting opportunity for an associate position in the North’s most vibrant city. The office has all of the most advanced technology, 3D imaging, ITERO, fully computerized with a visiting orthodontist and its own dental laboratory. Reply to HKOBAISY@HOTMAIL.COM or Fax: 867-873-4410.

Email: careers6@dentalcorp.ca

LLOYDMINSTER, AB Modern and nicely equipped clinic with a well established and growing patient base seeking a full-time, long-term, experienced Associate. Paid on PRODUCTION! Contact: admin@oriondentalgroup.ca

WEST EDMONTON, AB FULL TIME ASSOCIATE REQUIRED

Busy, mature practice in West Edmonton is looking for an associate F/T Mon – Fri, 9 – 5. Experienced associates have an opportunity for excellent benefits and growth. Interested candidates send resume to dentalrecruitmentyeg@gmail.com SEPTEMBER 2018

EDMONTON AND AREA, AB Large orthodontic group in Edmonton and Area requires full-time Associate Orthodontist. Beautiful, modern, fully digital practices, with great team in place! This is a great opportunity for Orthodontists that would like to have a balanced work/home life, new Grads that are wanting experience without having to invest financially, or Orthodontists that have transitioned/ sold their practices. All applications will remain confidential. Email: brittany@hellodental.ca

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WHITECOURT, AB FULL TIME ASSOCIATE Family Dental Health in Whitecourt requires a Full-Time Associate for a well established, modern dental practice. We are located just 1.5 hours north west of Edmonton and only a 2 hour drive to the Rocky Mountains. Join our friendly and dedicated team today. New graduates are welcomed. Email resumes to fdh2006@hotmail.ca or Fax 780-778-2609.

WINDSOR, ON ASSOCIATE FULL-TIME Immediate start date. Email: smile.dentalcareers@gmail.com

oralhygiene

ASSOCIATESHIPS

OTTAWA, ON

VICTORIA, BC Part-time(Monday/Tuesday) associate wanted in the Westshore of Victoria, B.C. Our office offers Cerec, Invisilign, Implants, Surgery and orthodontics. We also have a periodontist on staff, as well as 9 hygienists. We are located in one of the fastest growing communities on the island. Experience, skill, and a pleasant personality an asset. This position will lead to a full-time position early in 2019. Please contact (250) 474-5308 or email resume to dawn@westshoredental.com

PERIODONTIST. Group practice in Ottawa is currently looking for a periodontist to transition in to our well established practices. Excellent potential and opportunity to work with a great team. Please email amyfudge16@gmail.com

NIAGARA FALLS, ON Progressive practice seeking part time associate Niagara Falls 3 days per week. General Dentistry including children. Reply to dentalposition@cogeco.net

GRANDE CACHE, AB

ST. ALBERT, AB

ESTABLISHED FAMILY PRACTICE IS LOOKING FOR A FULL TIME ASSOCIATE. GRANDE VIEW DENTAL CARE IS IN THE BEAUTIFUL ROCKY MOUNTAINS OF ALBERTA.

Part time associate required for our busy, friendly, well established practice. St. Albert was voted the best place to live in Canada by Money sense magazine and we have been serving the area for over 23 years. Candidates should be motivated, have excellent communication skills and be willing to work with all age of patients. Must be able to work 1-2 evenings per week and Fridays 8-5. Experience would be an asset as we have an ample patient base for the successful candidate and are continually taking on new patients. E-mail resume to: Kristen@Lacombeparkdental.com

The successful applicant will be fully booked from day one and must be comfortable with all aspects of general dentistry with special emphasis on diagnostic, restorative, oral surgery and endodontics. Strong communication and personal skills are essential. No weekends or evenings required. High gross/net office -associate can expect above average remuneration. Please email resume: grande.cache.dental.care@gmail.com

MISSISSAUGA, ON Wanted immediately Part Time Associate: Large, modern office in Central Mississauga with a great team is looking for the right person to join and grow with us. Minimum 3 years Canadian experience is preferred. If you would like to join our team please email your resume to: ddsmississauga@yahoo.com.

AD INDEX Clinical Research Dental . . . . . . . . . . . . . . . . . . . . . . . . 34 Crest, Oral-B P&G . . . . . . . . . . . . . . . . . . . 8-9, 26, 36, IBC Crosstex International Inc . . . . . . . . . . . . . . . . . . . . . . . . 29 dentalcorp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 41

SHERWOOD PARK, AB A well established family practice in Sherwood Park is seeking a Parttime/Full-time Dental Associate. North American training and a few years of experience with a broad base of dentistry is preferred. Please forward Resume: pgmanager81@gmail.com

GSK â€“ GlaxoSmithKline . . . . . . . . . . . . . . . . . . . . . . . . . 20 HANSAMed Limited . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 OralDent Pharma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Philips Oral Healthcare . . . . . . . . . . . . . . . . . . . . . . . . .IFC Premier Dental Products Company . . . . . . . . . . . . . . . . 14

LEDUC, AB

Sable Industries Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

PT ORTHODONTIST ASSOCIATE

Currently seeking a part time, licensed Orthodontist for our new state of the art Clinic. The office encourages meaningful, relationship-based care for the patients. Please forward your resume to manager@leducdentists.ca

oralhygiene

SciCan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Shofu Dental Corporation . . . . . . . . . . . . . . . . . . . . . . . 25 VOCO Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBC

www.oralhealthgroup.com

SEPTEMBER 2018

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