HIV/ I S and Its Significance for the Ental Profession Remember To

JOURNAL OF THE CANADIAN DENTAL ASSOCIATION

December 2007/JanuaryJC 2008, Vol. 73, No. 10 DAwww.cda-adc.ca/jcda

Remember to Register for the ODA Annual Spring Meeting in Conjunction with CDA in Toronto April 10-12, 2008

HIV/AIDS and its Significance for the Dental Profession

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Publisher Canadian Dental Association Mission Statement

Editor-In-Chief The Canadian Dental Association is the national voice for dentistry, dedicated to Dr. John P. O’Keefe the advancement and leadership of a unified profession and to the promotion of Writer/Editor optimal oral health, an essential component of general health. Emilie Adams

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Columns & Departments

Editorial ...... 869 893 President’s Column ...... 871 Letters ...... 873 News & Updates ...... 879 Highlights of the 2007 FDI Annual World Dental Congress . . . . 893 JCDA Special Feature ...... 897 Partnering to Reverse the Trend: Early Childhood Caries Conference Report

CDSPI Reports ...... 903 You Ask, We Answer ...... 905 When I search the web for clinical information, how can I avoid getting too many results, many of which are not relevant? Clinical Showcase ...... 907 897 Gingival Response to Crowns: A 3-Year Report Point of Care ...... 911 What is the significance for dental professionals of the recently documented case of patient-to-patient transmission of hepatitis B? . . . . . 911 What part of the patient record from a general dental practice is most useful for identifying the victims of disaster through forensic odontology? ...... 917 How can I protect my practice from complaints and malpractice claims? . 919 907 Where does cone beam computed tomography fit into modern dental practice? ...... 921

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Debate & Opinion

Leadership in Ethics: Where is CDA?...... 925 Barry Schwartz Early Childhood Dental Disease — What’s in a Name?...... 929 Allan Narvey, Luke Shwart

Clinical Practice

Resin-Bonded Fixed Partial Dentures: What’s New?...... 933 933 Chris C.L. Wyatt This month, JCDA features 4 clinical articles on the epidemiology, oral manifestations and management of HIV-associated disease:

The Third Decade of HIV/AIDS: A Brief Epidemiologic Update for Dentistry ...... 941 Linda M. Kaste, Helen Bednarsh

949 Essential Medical Issues Related to HIV in Dentistry...... 945 Arthur H. Moswin, Joel B. Epstein

Changes in the Pattern of Oral Lesions Associated with HIV Infection: Implications for Dentists...... 949 Herve Y. Sroussi, Joel B. Epstein

Oral Malignancies Associated with HIV...... 953 Joel B. Epstein

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generation of dentists came to naturally expect infection control practices. HIV/AIDS is now considered a chronic condition. The profile of sufferers has changed over the past 25 years, with far more women and HIV/AIDS: members of minority communities affected. The pattern of oral lesions associated with HIV Yesterday, Today infection — often the first signs of infection — is also changing. The overall messages in the HIV/AIDS articles are that dentists have a vital and Tomorrow role to play in providing equitable health care to these patients, we must be well informed about the disease and be on the lookout for signs that could lead to early detection. Dr. John P. O’Keefe itting at a departure gate in New York’s While in New York, I attended a very inter- LaGuardia Airport on December 1, I was esting lecture by Dr. Anthony Vernillo of New Sforcibly reminded that it was World AIDS York University predicting that dentists may be Dentists have a Day as I watched a lengthy CNN report about at the forefront of early detection of HIV in- “ vital role to the desperate plight of AIDS sufferers in Africa. fection in the future. With the US Centers for play in providing HIV/AIDS is devastating sub-Saharan Africa, Disease Control and Prevention (CDC) urging where early detection is almost unheard of and care to HIV/AIDS easier means of getting consent for HIV testing, most cannot afford treatment. While Canada is patients, must be with the emergence of rapid testing for HIV affected much less dramatically, Health Canada through swabbing oral exudates and with oral well informed has estimated that at the end of 2002, more care providers being seen regularly by many about the disease than 56,000 Canadians were either infected by patients, Dr. Vernillo believes the dental office and be on HIV or suffering from AIDS. Most shocking is is an ideal location for rapid detection of HIV the lookout for the estimate that almost one-third of infected infection, with follow-up referral to a physician signs that could Canadians did not know it. for definitive diagnosis. Early detection and treatment of HIV is lead to early While there may be many hurdles to over- transforming the quality of life and life expect- come before that becomes reality, Dr. John detection. ancy of people afflicted by the virus. While there Molinari’s Point of Care article (p. 911) re- ” is still no cure and much ignorance surrounds minds us that serious infectious diseases can the condition, you are more and more likely to be transmitted from patient to patient in the see people with HIV/AIDS in your office. For oral health care setting. There is an old saying this reason, Dr. Joel Epstein and colleagues at that “success breeds failure,” especially when the University of Illinois at Chicago have 4 arti- we become complacent in our practices. cles in this issue which update dentists on HIV/ Dr. Molinari’s article reinforces that there can AIDS and its significance in dental practice. be no grounds for complacency when it comes When I began practisin��g�� in 1980, I seldom to the implementation of standard precautions wore gloves or facemasks and routine steriliza- in dental practice. tion of handpieces was unknown. Suddenly, To coincide with World AIDS Day, I gave AIDS arrived on the scene and there was a lot myself an early holiday gift. I became a member of fear about this acute mystery disease. The of the Organization for Safety and Asepsis dental profession, with CDA at the forefront, Procedures (www.osap.org) for just $100 US. showed great leadership in adopting precautions This non-profit organization with close links to designed to make all patients feel they could CDC and other international leaders in infection be treated safely in dental offices and to make control is the only organization truly dedicated dental care workers feel safe dealing with all to keeping the oral health community up-to- patients. date on infection control. I felt good knowing Leadership in times of uncertainty can be I was doing a little bit to advance safety for a lonely furrow to plough; detractors said the dental patients and my colleagues in the oral likelihood of AIDS transmission in dental of- care sector. fices was very low and that universal precautions John O’Keefe were unnecessary and too expensive. Over time, 1-800-267-6354, ext. 2297 universal precautions became standard as a new [email protected]

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p r E s i d e n t ’ s C o l u m n

growing trend of obtaining these requirements in the United States, which currency parity may accelerate. Your local and provincial dental associations, universities and specialty organizations The Effect of have a real stake in providing you with the programs you need to advance your career. And we the Rising Dollar have a personal responsibility to support our colleagues who provide continuing education programs and trade shows across Canada. on Dentistry The myth that educational opportunities south of the border are better is false! Local organizers have found that many of the most sought after speakers have priced their services Dr. Darryl Smith he rapid rise of the dollar has made most Canadians proud that our currency is now in US dollars. The financial barrier to getting these high-quality speakers has suddenly dis- so strong against its American counterpart. T appeared. Having travelled to meetings and con- However, economists and business analysts are We have a tinuing education programs from the smallest portraying this as a catastrophe with dire con- to the largest around the globe, I can tell you personal responsibility sequences. With any change comes a period of “ that bigger does not always mean better. If you to support our adjustment, adaptation and new opportunities. I want to hear a so-called “guru” in dentistry, colleagues who am no economist, but a look at the relationship you do not necessarily have to head to that next between Canada and the United States tells me provide continuing big meeting. The greatest learning experiences we are headed into a time of currency parity that education programs can occur at those small dental society and as- is long overdue. and trade shows sociation meetings where presenters are inte- The pricing of many dental products in across Canada. grated into the whole program and there is more Canada is significantly higher than in the United opportunity for one-on-one interaction. Giant ” States. This cannot be explained solely by differ- tradeshows can leave one’s head spinning and ences in the exchange rate. While I recognize the more modest size of those in Canada let you that we do have different regulatory environ- see the same range of products, but in a friend- ments, distribution cost structures and tax sys- lier setting. tems, it is difficult to believe that these issues, in Canada is the greatest country on earth, but combination with the exchange rate, can totally you must see it throughout all its seasons to fully explain the significant price differences. Has free appreciate its beauty. Look at your travel plans trade between Canada, the United States and for the next year, evaluate your continuing edu- Mexico actually brought its supposed advan- cation needs and make an effort to attend some tages to Canadian dentists and, ultimately, the of these meetings brought to you by your col- public we deliver care to? leagues. My 2008 calendar already has the dental Dr. Jim Armstrong, president-elect of the association meetings of Manitoba in January and British Columbia Dental Association, who has British Columbia in March pencilled in as part significant postgraduate training in business ad- of my schedule as president of CDA, but I have ministration, firmly believes that the differential also added Alberta in May and Prince Edward pricing that has existed in the marketplace for Island in June to my personal calendar as a start. so long is unjustified. The economic commit- Please see the list of provincial and other dental tees of the provincial dental associations need to association meetings on page 891. There is also examine the pricing issue and what can be done a very special meeting in Toronto from April about it. 10–12, where the Ontario Dental Association One advantage of our strong currency is and CDA will partner to host a meeting that that travel, particularly to the United States, has will showcase the best continuing education and suddenly become much cheaper. At this time products anywhere. I look forward to seeing you of year, as the first snowflakes fall, many of us at these meetings! already anticipate going south for a break from winter to recharge our batteries. Since dentists are required to obtain continuing education Darryl Smith, BSc, DDS credits as part of licensure, there has been a [email protected]

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Sunstar Perioglas NEW E/F 4/C l E t t e r s

VELscope: The Debate Continues

am dismayed at the article written Clinical Research Associates the British Columbia Oral Cancer I by Dr. Balevi stating there is no (CRA) out of Provo, Utah, one of the Prevention Program2 as well as evidence that routine use of the most respected research organiza- Lingen and others.3 VELscope in general practice can tions in the world, recently tested the Dr. Neuman, who I understand save lives.1 His statistics on the prev- VELscope and concluded: “Detection does promotional lectures on the alence of oral cancer are shockingly of oral cancer is the responsibility VELscope on behalf of its manu- low. One person dies of oral cancer of the dental profession. CRA’s facturer (LED Dental Inc.), did every hour of every day. Three times “First Look” indicates VELscope is not address any of the issues and as many deaths are expected from an easy-to-use in-office oral cancer arguments I made, except to ac- oral cancer in 2008 than from cer- screening for precancerous and can- cuse me of citing “shockingly low vical cancer. cerous lesions, and is a significant statistics” on the prevalence of oral Dr. Balevi’s article seems to mini- adjunct to a normal soft tissue exam. cancer. Interestingly Dr. Neuman mize the importance of anything Investigating suspicious lesions is states, without giving his source, that would allow earlier detection of potentially life saving and VELscope that “one person dies of oral cancer cancer and thus automatically save has been shown to fluoresce abnor- every hour every day.” I am left to lives. malities not evident under white wonder which geographic context he Dentists are the primary givers light examinations, helping identify is referring to (Canada, the United 2 of oral care. As a general practitioner pathology significantly earlier.” States or globally). I will speculate with a desire to do the best I can for As a general practitioner, I would that he is probably referring to the 4 my patients, it only makes sense that put my trust in the word of CRA United States. If so, Dr. Neuman if I have a way to prevent even one rather than the personal opinions may be surprised to learn that when death from oral cancer in my entire of Dr. Balevi. I am proud to let my you do the math, the mortality rate career, I should be willing to use any patients know we care about them he reports is actually lower than the tool available to achieve this. enough to embrace any new tech- already “shockingly low” rate I cited in my article. Does Dr. Balevi not believe in nology that can help them in any I reported a Canadian incidence the use of radiographs as an adjunct way. rate of 12 new cases of oral cancer to our visual exams? Should we not Dr. Ken A. Neuman Vancouver, British Columbia in 100,000 people, of which a third use adjunctive imaging tools to add will die in 5 years.5 This comes to to what we see — and in the case References an estimated annual oral cancer of radiographs and the VELscope, 1. Balevi B. Evidence-based decision-making: mortality rate of about 4 deaths per to detect what we cannot see? It should the general dentist adopt the use of the VELscope for routine screening for oral cancer? 100,000 people. J Can Dent Assoc 2007; 73(7):603–6. is quite true the VELcope doesn’t Dr. Neuman essentially states have bells and whistles that go off 2. Clinical Research Associates. Intraoral precancerous and cancerous lesion screening. that in a year there will be 8,760 when oral cancer is present, but be- Clinical Research Associates Foundation deaths from oral cancer in the Newsletter 2007; 31(8):2. yond any doubt, it will alert me to a United States (i.e., 1 death/hr × 24hr/ tissue change. After that, it’s up to day × 365 days/year = 8,760 deaths). me to use my knowledge, care, skill The Author Responds This annual mortality rate is signifi- and judgment to determine what appreciate the opportunity to re- cantly higher than the 5,370 deaths the next step should be. Yes, there I spond to Dr. Neuman’s letter as a reported by the US National Cancer will be false positives, but would we forum to further the scientific de- Institute.6 But even if we accept have made the tremendous strides bate on the VELscope. It is obvious Dr. Neuman’s estimate, his mortal- in cervical cancers and pap smears that we both agree on the import- ity rate from oral cancer is only 2.92 without some false positives? ance of the soft tissue examination in 100,000 (assuming a US popu- I would much rather be remem- as a routine part of our patients’ care. lation of 300 million). By either bered as the dentist who sent my We simply disagree on the value of measure, oral cancer is “shockingly” patient for further inspection of the VELscope in general practice to rare. something that turned out to be routinely screen and distinguish oral Dr. Neuman makes another bold not serious, than as the dentist who cancer from all other sorts of oral le- statement when he says that Clinical missed picking up a potentially can- sions. My claim that there is no evi- Research Associates (CRA) is “one cerous lesion because it was not evidence that the VELscope saves lives of the most respected research or- dent visually. in general practice1 is supported by ganization in the world.” According

��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 873 ––– Letters ––– to whom? Although many dentists likelihood of a dentist encountering Again, thank you for your query. may be familiar with CRA, it is a one case of squamous cell cancer will It is a good question that deserves stretch, in my opinion, to put them occur every 7–10 years. Would you an answer. in the same league as the many be kind enough to show me the cal- Dr. Ben Balevi universities and health care re- culations which allowed you to ar- Vancouver, British Columbia search centres around the world rive at this figure? I think that I have who currently perform rigorous clin- References it right, but would like your input. 1. Balevi B. Evidence-based decision-making: ical research protocols. To further In any case, I really appreciated should the general dentist adopt the use of the strengthen my argument, CRA is not VELscope for routine screening for oral cancer? J reading your article. As a profession Can Dent Assoc 2007; 73(7):603–6. indexed or cited on MEDLINE, which we are so inundated at times with 2. Statistics Canada. Available: www.statcan. indexes over 5,000 scientific peer- new technology that appears, on the ca/english/edu/clock/population.htm 7 reviewed publications. surface, to be of value but which, 3. Canadian Dental Association. 2007 number As dental professionals, our of oral health providers by province [CDA mem- on further investigation, might not bers’ only website]. Available: www.cda-adc. patients rely on us to critically ap- ca/en/members/resource/fact_sheets/providers_ live up to the promise in the ad- praise the VELscope and any other by_province.asp. vertisements. I think that you did 4. Canadian Dental Association. Percent of popu- new dental technology that becomes a wonderful job and a great service lation having consulted a dental professional in available based on patients’ prefer- the past twelve months by age group (2005). to Canadian dentists who read the [CDA members’ only website] Available: www. ences and the merits of all the scien- JCDA. cda-adc.ca/en/members/resource/fact_sheets/ tific and clinical evidence available population_consulted.asp instead of simply adopting it on Dr. John F. Miner the opinion of CRA or any self- Ottawa, Ontario Quoting Canadian Sources proclaimed or perceived expert. Reference Dr. Ben Balevi 1. Balevi B. Evidence-based decision-making: he authors of the peer-reviewed Vancouver, British Columbia should the general dentist adopt the use of the Tarticle on systemic antibiotic VELscope for routine screening for oral cancer? therapy1 appear to have forgotten References J Can Dent Assoc 2007; 73(7):603–6. 1. Balevi B. Evidence-based decision-making: that their paper was published in a should the general dentist adopt the use of the Canadian journal. There were con- VELscope for routine screening for oral cancer? J The Author Responds Can Dent Assoc 2007; 73(7):603–6. stant quotes and citations from US 2. Laronde DM, Poh CF, Williams PM, Hislop TG, ou ask a very appropriate ques- sources. Furthermore, no men- Zhang L, MacAulay C, and other. A magic wand tion was made of spiramycin for the community dental office? Observations Ytion that, in hindsight, I wish I from the British Columbia Oral Cancer Prevention had clarified in the article.1 (Rovomycin), which is supposed to Program. J Can Dent Assoc 2007; 73(7):607–9. be secreted in crevicular fluid. I have The data: 3. Lingen MW, Kalmar JR, Karrison T, Speight been to a few periodontal courses in PM. Critical evaluation of diagnostic aids for the • Population in Canada: 33 million2 detection of oral cancer. Oral Oncol 2007 Sep 6; the United States, and when peri- [Epub ahead of print]. • Number of dentists in Canada: odontists find out I am from Canada, 4. National Institute of Dental and Craniofacial 18,861 (as of January 2007)3 Research, National Institutes of Health. Archive: they are envious because spiramycin Oral cancer — confronting the enemy. Available: • Percent of population seen by a isn’t available in their country. www.nidcr.nih.gov/HealthInformation/ dentist (in last 12 months): 63.74 DiseasesAndConditions/SpectrumSeries/ Dr. Robert Letnick OralCancerEnemy.htm (accessed 2007 Nov 29). The calculations: Maple Ridge, British Columbia 5. Canadian cancer statistics 2006. Ottawa: • Number of people per dentist in Canadian Cancer Society, National Cancer Institute of Canada and Statistics Canada; Canada: 33 million/18,861 = 1,750 Reference 2006 Available: www.ncic.cancer.ca/vgn 1. Bidault P, Chandad F, Grenier D. Systemic anti- /images/portal/cit_86751114/31/23/935505938 • Number of people per dentist biotic therapy in the treatment of periodontics. cw_2006stats_en.pdf.pdf (accessed 2007 Nov who went for a dental visit in J Can Dent Assoc 2007; 73(6):515–20. 29). the last 12 months: 1,750 × 0.637 6. National Cancer Institue, National Institutes of Health. Oral cancer. Available: www.cancer.gov/ = 1,115 The Authors Respond cancertopics/types/oral (accessed 2007 Nov 29). • Number of new cases of oral cancer t is true that our review of the lit- 7. United States National Library of Medicine, per 100,000 people per year: 12 1 National Institutes of Health. Fact sheet — Ierature dealt principally with Medline. Available: www.nlm.nih.gov/pubsfact- • Number of new cases per den- studies conducted in the United sheets/medline.html (accessed 2007 Nov 29). tist per year = 12 new cases per States, which, by the way, is the prin- 100,000 people × 1,115 = 0.134 cipal source of recommendations in VELscope: The Math Behind new case per dentist per year, periodontology. This decision can be the Numbers or 1.3 new cases per dentist explained in particular by the fact r. Balevi, in your article on the per 10 years, or 1 new case in that few studies aimed at assessing DVELscope,1 you estimate that the 7.7 years. the effectiveness of antibiotics on

874 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • ––– Letters ––– periodontal infections and that re- tient develops cardiac valvulopathy, Reference spect currently accepted methodo- is immunosuppressed or has been 1. Lee KD, Antoniazzi A. A patient new to my logical criteria (minimum number directed by the cardiology team to practice had a heart transplant a few years ago. What are the chief considerations in the of subjects, confirmed operator ex- have antibiotic coverage, prophylaxis management of this patient? [Point of Care]. pertise, blind testing required, etc.) is unnecessary.” J Can Dent Assoc 2007; 73(7):595–6. have been carried out in Canada. How can such patients not be Given that spiramycin is used more immunosuppressed? They have Response in Europe and that there have been to take immunosuppressants for e thank Dr. Ajar for his helpful few evaluations of its clinical efficacy their graft not to be rejected. But in treating periodontitis, we chose the authors’ statement above would Wand constructive feedback. not to include it in our review. imply that these patients should be We agree that the term “immuno- As spiramycin (Rovamycin) is given prophylaxis. This is a little compromised” would be more ap- a macrolide that demonstrates bac- misleading as they may be grouping propriate to the clinical setting teriostatic action more specifically the concept of immunocompro- we described in the article,1 be- on Gram positive bacteria, it has mised (lowered absolute neutro- cause heart transplant patients are the advantage of concentrating in phil count [ANC]) secondary to immunosuppressed to prevent rejec- tissues, saliva and crevicular fluid immunosuppressive therapy with tion. The “Point of Care” article fo- and is therefore of interest in the immunosuppression. cused on key issues for the general treatment of oral infections. A study Also, the authors fail to mention dental practitioner faced with the conducted in Canada by Bain and 3 potential problems with dental others2 demonstrated that spira- management of these patients: care of a heart transplant patient in the community. We agree with Dr. mycin, as a complement to scaling/ 1) Given that they are immunosup- planing, provides a statistically sig- pressed, care must be taken by the Ajar that the article did not cover nificant improvement in the probing dental practitioner not to spread any all the issues. Dr. Ajar’s additional depth of pockets compared with of the herpetoviridae family into comments serve to emphasize the mechanical treatment alone. In addi- these patients, as frequently their complexity of care of some patients, tion, the combination of spiramycin grafts can be compromised by cyto- notably those in frail condition after and metronidazole (Rodogyl), due to megalovirus (CMV) or herpes sim- the complementarity of the spectra a heart transplant, and the import- plex virus (HSV) endocarditis. of antibacterial activity and a syn- ance of cross-infection control. The ergic effect on parodontopathogenic 2) Except for the table on the side article stressed the need for close bacteria, is the treatment of choice effects of immunosuppressive medi- liaison with the patient’s clinicians in France and is recommended by cation, the authors make no men- (e.g., family physician, cardiologist, tion that these patients can be the French Health Products Safety cardiothoracic surgeon, infectious pharmacologically anticoagulated Agency. disease specialist) in their dental or thrombocytopenic secondary to Dr. Philippe Bidault management. After such collabora- Dr. Fatiha Chandad their medications, making them a Dr. Daniel Grenier bleeding risk with the minor oral tion, the health status of some heart Laval University surgical procedures that the authors transplant recipients would clearly Quebec City, Quebec indicated can be performed on contraindicate routine dental care in them. References the community, and such patients 1. Bidault P, Chandad F, Grenier D. Systemic anti- 3) Ultimately, the premise that con- would be referred for specialist care biotic therapy in the treatment of periodontics. J Can Dent Assoc 2007; 73(6):515–20. ventional antibiotic prophylactic or to a hospital dentistry clinic. regimens (if indicated in the specific 2. Bain CA, Beagrie GS, Bourgoin J, Delorme Dr. Ian Matthew F, Holthuis A, Landry RG, and others. The ef- situation of cardiac transplanta- fects of spiramycin and/or scaling on advanced Faculty of Dentistry periodontitis in humans. J Can Dent Assoc 1994; tion) are effective is not mentioned. University of British Columbia 60(3):209, 212–7. I fail to see how an immunosup- Vancouver, British Columbia pressed patient with an underlying Dr. Krista Lee complication of pancytopenia will Dental Management of Cardiac Dr. Anthony Antoniazzi respond to 2 g of amoxicillin, given Transplantation Patients that their risk of bacteremia (and Reference n the “Point of Care” article on the type of infecting bacterial species) 1. Lee KD, Antoniazzi A. A patient new to my practice had a heart transplant a few years ago. Idental management of heart trans- is different. What are the chief considerations in the man- 1 plant patients published in JCDA, Dr. Amir H. Ajar agement of this patient? [Point of Care]. J Can the authors state that, “Unless a pa- Vancouver, British Columbia Dent Assoc 2007; 73(7):595–6.

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We consider the venous route iron overload. Excess iron may Transient Binocular Vertical to have caused the diplopia, as the lead to liver cirrhosis and cardiac Diplopia Following Posterior thin vessel walls of the pterygoid siderosis. The dentist is advised to Superior Alveolar Nerve Block venous plexus facilitate penetra- avoid large volumes of local anes- tion of the anesthetic agent into the he article by Dr. Ngeow and others thetic in view of the metabolism of blood, which, via the emissary vein, Ton transient loss of power of ac- amides in the liver and the effect of reaches the cavernous sinus where commodation of the eye following epinephrine on a myocardium al- inferior alveolar nerve block was in- the trochlear nerve in the lateral wall ready prone to arrhythmias. Reduced teresting.1 We would like to report a gets anesthetized — the only barrier body weight may further limit the case of transient binocular vertical being the thin endothelial lining of the cavernous sinus (similar for the safe dosage of local anesthesia. diplopia. abducent nerve).5 A 35-year-old man was referred Pediatric thalassemic patients This letter is to emphasize the for extraction of decayed right may be at risk for cardiac failure, fact that the type of diplopia can upper second and third molars. which necessitates anxiety reduction provide insight into the particular His medical and dental history was protocols before and during dental nerve involved. unremarkable. He received 1.8 mL extraction. Massive splenomegaly Dr. Joanna Baptist of 2% lidocaine (with 1:80000 ad- Dr. S.M. Sharma might necessitate splenectomy, renaline) for the posterior superior Department of oral and maxillofacial surgery which lowers systemic immunity. alveolar nerve block and 0.4 mL of A.B. Shetty Memorial Institute of Dental Sciences Diabetes mellitus, which is usu- 2% lidocaine for the greater palatine Mangalore, India ally considered to affect older age nerve block. These were admin- groups, may predispose thalassemic istered using a needle measuring References patients to postextraction infection. 0.55 mm in diameter and 25 mm 1. Ngeow WC, Shim CK, Chai WL. Transient loss of power of accommodation in 1 eye following In addition, poor leukocyte function in length. The extractions were un- inferior alveolar nerve block: report of 2 cases. as a result of iron overload further eventful. The patient complained of J Can Dent Assoc 2006; 72(10):927–31. supports consideration of antibiotic double vision as he was preparing 2. Magliocca KR, Kessel NC, Cortright GW. Transient diplopia following maxillary local anes- prophylaxis for extractions. to leave. On examination, he exhib- thetic injection. Oral Surg Oral Med Oral Pathol ited vertical binocular diplopia (in Oral Radiol Endod 2006; 101(6):730–3. Lastly, the disease is common in 3. Peñarrocha-Diago M, Sanchis-Bielsa JM. the downward and medial gaze) that Ophthalmologic complications after intra- African, Asian and Mediterranean lasted 30 minutes. oral local anesthesia with articaine. Oral Surg regions where multiple blood trans- Oral Med Oral Pathol Oral Radiol Endod 2000; We believe this was due to par- 90(1):21–4. fusions would carry a higher risk esis of the superior oblique muscle 4. Koumoura F, Papageorgiou G. Diplopia as a of transmission of HIV or hepatitis complication of local anesthesia: a case report. (innervated by the trochlear nerve), Quintessence Int 2001; 32(3):232–4. B or C because of less-than-ideal which causes diplopia in a vertical 5. Gabella G. Cardiovascular system. In: Williams health care infrastructure. direction below the horizontal PL, editor. Gray’s anatomy. London: Churchill Livingstone; 1995. p. 1585–8. In conclusion, dental considera- plane. Previous articles report dip- tions in this disease go beyond the lopia caused by paresis of the lateral recognition of “chipmunk facies” rectus muscle (innervated by the ab- Considerations for Extraction in and “hair-on-end” appearance of ducent nerve) that causes horizontal Thalassemic Patients bone; thalassemic patients need to diplopia.2–4 Diplopia caused by pos- ecently, a patient with thalas- terior superior alveolar nerve block have regular intravenous iron-chela- Rsemia major was referred to us tion therapy with desferrioxamine. occurs either by the arterial, venous by our hospital’s physician for dental 1 Because patient compliance may or bony routes. We excluded the ar- extractions. We wish to highlight as- be poor, serum ferritin assessment terial route in our case, as the aspir- pects of care unique to this heredi- ation was negative. Bony pathway tary hematological disease since any may help gauge the overall fitness of was excluded as the patient was dentist affiliated with a hospital is these patients. With systematic con- seated in a semi-supine position for likely, at some time in their practice, sideration of general medical health, the procedure. (The supine position to treat a such a patient. the thalassemic patient may safely helps the anesthetic agent to track Thalassemia causes a deficiency undergo oral surgery. upwards into the pterygopalatine of hemoglobin and is not curable, Dr. Nakul Uppal fossa, then to the inferior orbital fis- so patients typically receive multiple Dr. Mohan Baliga sure and around the apex of the orbit and frequent transfusions of whole Manipal College of Dental Sciences affecting the trochlear nerve.) blood, which eventually result in Mangalore, India

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vised parents of the very high sugar inadvertently switched. The correct Pediatric �ecay Rates re Too content of these perceived healthy follow-up times should have read: High food groups. In every case, when the “Maximum and median follow-up read and enjoyed Dr. Smith’s re- consumption habit has stopped and times were 7.2 and 0.8 years, re- I cent column on decay prevention a modest attempt has been made to spectively, for patients with SLA in the pediatric dental population1 improve oral hygiene, the decay rates implants, and 9.7 and 4.6 years, re- and would like to add my views. have dropped close to zero. We see spectively, for those with TPS im- I have been in practice for 25 no siblings with decay in these fam- plants.” Also, early failure rates for years and have seen, first-hand, the ilies. However, we eventually treat all SLA implants were 2.1% and not reported increase in pediatric decay the members of families who con- 1.9%, as indicated. rates. I provide general anesthetic tinue to provide these snacks. Readers should note that these services and dentistry to this very Unless we do a better job edu- errors appeared in the abridged ver- population and am constantly cating the public, I believe we will sion only. The electronic version of 1 amazed at both the number of de- continue to see needlessly high decay the article contained the correct cayed teeth and the extent of the rates. information. decay I am seeing. I have decided David G. Harper Hamilton, Ontario Reference that the education of our patients, es- 1. Arlin ML. Survival and success of sandblasted, pecially parents, seems to be failing. large-grit, acid-etched and titanium plasma- sprayed implants: a retrospective study. J Can The consumption of bottled water Reference 1. Smith D. Are we going backwards with pre- Dent Assoc 2007; 73(9):821. Available: www. as a perceived healthier choice is a vention? [President’s Column] J Can Dent Assoc cda-adc.ca/jcda/vol-73/issue-9/821.html. 2007; 73(7):555. good place to start if this population Email Address is to access the benefits of fluoride. The email address provided at the The introduction of the new sports Errata end of Dr. Wayne Halstrom’s “Point drinks has not helped in decreasing of Care” article1 was incorrect. Dr. sugar intake. I would argue that the Applied Research Article Halstrom’s email address is: lwh1@ biggest cause of decay is diet and the In the abridged version of Dr. telus.net. JCDA regrets the error. advent of the so-called “healthy” Murray Arlin’s article on sand- snack foods, especially fruit products blasted, large-grit, acid-etched Reference with a sticky consistency, that have (SLA) and titanium plasma-sprayed 1. Halstrom W. What role does dentistry play in the diagnosis and treatment of sleep-disordered increased in the last 10 years. Over (TPS) implants, the follow-up times breathing? [Point of Care] J Can Dent Assoc the past 5 or 6 years, we have ad- for the SLA and TPS implants were 2007; 73(9):805–6.

1/3 p. DOCS Ad Eng only B/W p/u Noiv p. 843 (french Journal has alternate placement of this ad)

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Voco NEW E/F 4/C News & U p d a t e s

CDAlert on Fraud, New Passport Policy

Fraudsters Posing as Representatives from Insurance Carriers n November 1, 2007, CDA notified its members of fraudulent incidents where individuals claiming to be Orepresentatives of insurance carriers called dental offices asking for all patient claims submitted during a particular period to be resubmitted. The callers alleged the information was needed because of a system failure. The dental offices were told either to fax the information or that a courier would pick it up. These calls were not legitimate and CDA is asking members to be aware of potential fraud involving people claiming to be representatives of insurance carriers. This For more information on this alert, or past CDAlerts, type of incident is not new and is very similar to inci- visit the News and Publications section of CDA’s mem- dents involving credit card companies and banks. bers’ website. Should you receive any calls asking for patient or per- CDAlerts are sent as a special service to keep CDA sonal information and you are unsure if it is legitimate, members informed of urgent or time-sensitive informa- do not provide any information and report the incident tion. To ensure you don’t miss out on these important to the company in question immediately. email bulletins, please contact CDA at reception@cda- adc.ca, or phone 1-800-267-6354 to provide us with an New Guarantor Policy for Passports updated email address. n the same alert, CDA also informed its members that Ithe federal government implemented a new policy, effective October 1, 2007, that allows most Canadian adults to act as guarantors for passport applications. This will likely reduce the amount of requests to dentists to act as professional guarantors. However, the new policy does require guarantors to provide their Canadian passport numbers and dates of issue and expiry as part of the application process. It is your right to choose not to provide this additional information and to not act as a guarantor. For more information, visit Passport Canada at www.ppt.gc.ca. a

CDA Store Off to a Successful Start DO I NEED A Dental Checkup? Good Food Gum Disease HEALTHY TEETH PREVENTING TOOTH LOSS Within 2 weeks of its launch in mid-October, CDA’s online store had received more than 1,000 orders for CDA’s new Patient Information Brochures (PIBs). Marketing efforts have focused on the value of the brochures as an information resource for patients, and the ease with which the brochures can be ordered online have made them a popular item in dental offices. Orders are filled within 2–3 days with a 100% customer satisfaction policy. The most popular brochures so far are Your Child’s Oral Health, Dental Implants – Replacing Missing Teeth, Root Canal Treatment, Gum Disease – Preventing Tooth Loss and the Patient Information Brochure Sample Pack. a CDA members can use a discount code found on the members’ side of CDA’s website for Visit the store at http://store.cda-adc.ca. 25% off merchandise.

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CDA Helps Shape Media Attention on Dental Issues

DA works year-round to keep on top of the issues of import- and dental care be included in universal coverage. CDA’s response Cance to dentistry. It closely monitors what is being said outlines dentistry’s preferred option for addressing unmet dental about dentistry and what is not said, but should be. Dr. Darryl needs, that is, a needs-based approach aimed at providing oral Smith, president of CDA, recently sent 2 letters to editors of a care services to socioeconomically disadvantaged Canadians. national and a provincial newspaper in response to issues con- The second issue that came to CDA’s attention was a letter cerning dentistry. to the editor of the Hamilton Spectator in response to an article One letter was in response to a news article in the National about the VELscope, a new diagnostic tool for dentists to examine Post which reported that Dr. Brian Day, president of the Canadian patients for oral cancer.2 The writer suggested that charging for Medical Association, called for universal coverage and access this diagnostic test was simply a way for dentists and CDA to to medical and dental care as part of Canada’s health policy.1 make a profit. In his response, Dr. Smith clarified that although The title of the article, “Extend dental coverage, doctors urge,” the systems of payment are different, all medical and dental was misleading because the article itself did not touch on the diagnostic services provide value for money spent. issue of dental coverage. Letters to the editor are a reactive media response tool Dr. Day had made refer- that CDA deploys on an as-needed basis. We also work to build Dr. Smith’s letters to the ence to this issue in a relationships with key health writers and reporters to promote National Post and the Hamilton speech in which he dis- accuracy in coverage and profile of dental issues.a Spectator are posted on CDA’s cussed access to care and References website at www.cda-adc.ca/ coverage for all members 1. Blackwell T. Extend dental coverage, doctors urge. National Post 2007 en/cda/news_events/media/ of society, and suggested Oct 12; Sect. A:6. 2. Varga, S. New dental diagnostic test should be free for patients. The submissions_2007.asp. that prescription drugs Hamilton Spectator 2007 Oct 30; Sect A:14.

DAT Program Grows Online he Dental Aptitude Test (DAT) program reached a new peak in 2006–2007, with 2,375 registrants applying to the program. “In the last four years, the number of students applying to the DAT pro- T For more information gram has gone up 40%,” says Fatna Moussali, coordinator of the DAT program at on the DAT program, CDA. “Medical students are applying, and many are telling me they think being visit www.cda-adc.ca/ a dentist is one of the best careers.” en/dental_profession/ This past September’s registration session saw the DAT program move entirely dat/DAT_news.asp. online for the first time, where 1,791 prospective students registered. The popu- larity of online applications is growing: 93% of November 2006 and February 2007 applicants registering electronically. a

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Dentistry Gets Seats on 3 Electronic Health Standards Groups

kos Hoffer, manager of practice services at CDA, has been elected chair of the Standards Collaborative Working Group (SCWG) #3: Managing the Health System. The SCWG is part of a Astrategic committee formed by Canada Health Infoway. Canada Health Infoway is a not-for-profit organization established in 2001 and made up of members from Canada’s 14 federal, provincial and territorial deputy ministers of health. Its mission is to accelerate the incorporation of electronic health information systems and electronic health records (EHRs) across the country. The group collaborates with health ministries, regional authorities, health care organizations and information system vendors to provide strategic direction for EHR implementation. As chair, Mr. Hoffer will ensure his working group makes progress in establishing the feasibility of an electronic claims environment and in finalizing a new standard for electronic claims. In addition to the seat on the SCWG, the Standards Collaborative Strategic Committee (SCCC) recently approved the extension of SCCC and the clinical subcommittee (CSC) memberships by one member each to include a seat for a dentist. The SCCC is responsible for the coordination of health information standards across Canada and provides guidance on the processes and services provided by the Standards Collaborative. The CSC supports clinical alignment and harmonization across pan-Canadian health information standards and provides cross-clinical guidance on Standards Collaborative services and activities. Dr. Tony Gill, past president of the British Columbia Dental Association, played a large role in lob- bying for the inclusion of a dental representative in the Standards Collaborative governance structure. Participation in these groups ensures that dentistry is involved during the entire standards development process and that CDA can influence electronic standards that will affect the way dentists communicate with other health care providers, patients, insurers and other parties. a

National Guidelines for the Disclosure of Adverse Events Proposed he Canadian Patient Safety Institute (CPSI) held its annual general meeting in Ottawa on October 10, 2007. Established Tin 2003, CPSI is an independent not-for-profit corporation, operating collaboratively with health professionals and organizations, regulatory bodies and governments to build and advance a safer health care system for Canadians. CDA, one of over 50 national organizations that are voting members of CPSI, was in attendance to receive an update on the development of National Guidelines for the Disclosure of Adverse Events. The guidelines are intended to assist and support health care providers, interdisciplinary teams, organizations and regulators in developing and implementing adverse event disclosure policies, practices and training methods across Canada. There are legal considerations associated with disclosure of adverse events. It has been found that the frequency of litigation and/or claims against health professionals increases with non-disclosure and ineffective disclosure. Overall, disclosure does not appear to prompt litigation. The draft guidelines can be found on the CPSI website www.patientsafetyinstitute.ca. The national guidelines are expected to be released in early 2008. a

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hy do we need standards? Many people probably think International Dental they are developed simply to make our lives difficult, Wbut few realize their importance. In business or health care, international standards define aspects of safety, quality and Standards reliability. Standards deliver market credibility and integrity by demonstrating a manufacturer’s commitment to its products By Derek W. Jones, BSc, PhD and customer service excellence. Clearly standardization makes sense, especially since we now live in a global environment. Did you know that an international standard specifies dimensions of a driver’s licence or credit card? Or that Dr. Kathy Russell and Dr. Benoit Soucy, there are international standards for paper sizes? Apart members of the from Canada and the United States, every other indus- Canadian Delegation trialized country uses European A4-size paper complying to ISO/TC 106. with International Organization for Standardization (ISO) 216, in which paper sizes have a height-to-width ratio of the square root of two (1.4142). If you cut one of these pieces of paper in half, it will still have the same height-to-width ratio. Perhaps the best Dr. Martin Tyas, leader of the example of why we need standards is ISO 8601, Australian delegation, Professor Xu Heng Chang, leader of the which specifies the numeric representations of date Chinese delegation and and time. No one can get mixed up if we all use the Dr. Derek Jones, chair of ISO/TC system YYYY-MM-DD to depict the date. For ex- 106, in Beijing, China, in 2006. ample, writing 2007-09-10 for September 10, 2007, not October 9, 2007. Each of the approximately 15,600 international standards developed and published by ISO has a unique identifying number. When a product’s packaging indicates that it complies with an ISO standard, the date of the standard version being ref- erenced should follow the number. A product may have been tested to comply with a standard published in 2002, but may not comply with an updated version published in 2007. ISO international standards are not legally enforceable; however, they may be adopted by a country as national standards and thus become enforceable in that country, as is the case in the European Union. The Canadian Advisory Committee to ISO/TC 106 in 1981. ISO’s Central Secretariat office is in Geneva, From left: Pierre Desautels, Peter Williams, Ralph Barolet, Switzerland. Its funding is provided by contributions Len Johnson, Derek Jones, chairman, Canadian Advisory from member bodies (national standards organizations) Committee to TC 106, leader of the delegation and secre- who participate in the development of voluntary stan- tary, ISO/TC 106/SC1 and Dan Gau, chair ISO/TC 106/SC1. dards, as well as from the sale of published standards. In Canada, the member body is the Standards Council of Canada (SCC). Consensus standards are developed by committees that are open to representatives from all interested parties. National standards organizations and the corporate sector provide funding to support expert delegates, who must be nominated by their respective member bodies, to attend national and ISO meetings. The majority of experts and delegates involved with developing international standards are volunteers. The Canadian Advisory Committee to the ISO Technical Committee on Dentistry (ISO/TC 106) is comprised of experts appointed by SCC. Canadian experts participate in writing and developing standards, and the chair of the advisory committee votes on Canada’s behalf during the stages leading up to final publication. Dr. Benoit Soucy, CDA’s director of membership and professional services, is the current chair. Canada is recognized by the international community for its leadership in the development of dental standards and for its high quality of dentistry. It is clearly an advantage for Canada to participate in writing and developing international dental standards that also reflect the needs of Canadian dentistry.

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Highlights of ISO/TC 106 Meeting Held in 2007 marks the 60th anniversary of ISO’s creation. The FDI Germany World Dental Federation produced the first 9 international standards. In 1963, the newly formed ISO/TC 106 took on the re- he 43rd meeting of the International Standards sponsibility for developing international dental standards, and TOrganization Technical Committee on Dentistry (ISO/TC since then Canada has been actively involved with international 106) was held in Berlin, Germany, from October 15–20, dental standards development. In 2004, CDA took over the respon- 2007. Over 325 experts and delegates from 18 countries par- sibility for the secretariat of ISO/TC 106 from the British Standards ticipated in 50 working groups and plenary meetings. Also in attendance were representatives from the FDI Dental World Institute, who had held the secretariat for the first 41 years of its Federation, the European Committee for Standardization existence. Canada has held the secretariat of Subcommittee 1 – (CEN) and the World Health Organization’s Global Oral Filling & restorative materials, since its inception in 1963. In 2004, Health Program. Canada assumed responsibility for the entire secretariat of ISO/TC The Canadian delegation included Dr. Kathy Russell, 106, which is housed at CDA. Dalhousie University, Drs. Paul Santerre and Laura Tam, The ISO/TC 106 committee has 46 member bodies; 25 are University of Toronto, and Dr. Benoit Soucy, CDA’s director active participants and 21 have observing status. In addition to of membership and promotional services. The 3 newest ISO/TC 106, there are 7 subcommittees and 44 working groups members to ISO/TC 106 are Dr. Asbjørn Jokstad, University who have input and participation from close to 300 international of Toronto, Dr. Lex MacNeil, University of British Columbia, dental experts from the member countries. ISO’s dental standards Dr. Lise Payant, Laval University. Dr. Jokstad joined committee works closely with the European Union, FDI and the Subcommittee 8 – Dental implants, Dr. MacNeil joined World Health Organization. Subcommittee 6 – Dental equipment, and Dr. Payant joined With 13.4 billion in dental products and some 11.5 billion in Subcommittee 2 – Prosthodontic materials. dental consumer products sold worldwide annually, the develop- Dr. Peter Williams from the University of Manitoba ment of international dental standards is vital to assure product has retired from the Canadian Advisory Committee to ISO/TC 106, where he was an expert for Subcommittee 2 safety and quality. ISO/TC 106 has developed 156 dental standards – Prosthodontic materials. Many thanks to Dr. Williams for for products used by dental health care professionals and oral hy- his important contribution to the development of dentistry giene products used by the public. standards. During the course of a work day — seated on an operating stool, Some highlights of the meeting include the creation of a leaning over the patient in the dental chair, illuminated by a dental working group to develop standards dealing with CAD/CAM light and surrounded by the sound of various drills and suction systems for indirect dental restorations and a joint working equipment — no doubt the dentist’s thoughts are far away from group with the International Electrotechnical Commission international standards. However, all pieces of equipment, devices to develop standards relating to dental electrical require- and materials in a dental office must comply with international ments. A new committee scope was developed and will standards to ensure the quality and safety of the procedures the be submitted to ISO’s Technical Management Board for practitioner conducts each day. approval. Two new chairs were nominated: Professor John ISO standards specify everything from the maximum per- McCabe from the University of Newcastle, United Kingdom, mitted amount of soluble arsenic or lead in a zinc oxide cement to was appointed to Subcommittee 1 – Filling & restorative the amount of ultraviolet irradiance emitted by a dental operating materials and Mr. Axel Pieper of the German delegation was light, and an ISO designated system is used to record the location appointed to Subcommittee 4 – Dental instruments. of each tooth for a patient’s dental chart. It may be surprising to The list of standards published in 2007 and those published in 2008 can be found on the CDA website at: many dentists just how many ISO standards are involved in routine www.cda-adc.ca/en/cda/news_events/media/dentistry_ dental procedures. news/2007/12_07_isotc.asp. For example, there are numerous standards involved in placing A delegation from Canada will attend the next meeting an amalgam restoration and more than 12 standards for materials of ISO/TC 106 in Göteburg, Sweden, from September 29 to and equipment for cleaning, shaping and sealing a routine root October 4, 2008. a canal. There are more than 20 ISO dental standards involving def- initions, codes and designations, materials, devices and equipment used for the production and placement of an anterior jacket crown. Shaping the preparation for a crown requires a variety of instruments conforming to ISO standards. In addition to performance standards, extensive coding systems are used to classify rotary instruments with limits for bore sizes and dimensions for discs, wheels and cutting burs. ISO standards have been developed for impression materials, die materials, casting alloys for copings and ceramic materials. Dental materials are also covered by ISO biocompatibility tests. If the product you are using has a statement on the package that it meets the relevant ISO standard, it is your guarantee that the company’s product was evaluated to comply with the various international standard specifications. a

Dr. Jones is professor emeritus of biomaterials, Dalhousie University. He is chair of ISO/TC 106 for the term of 2005–2010.

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On Top Health Care for an Aging Population: Personal Wellness Investment Funds

he question at the heart of the evolving public policy debate about the cost of health care for an Taging Canadian population is: are Canadians prepared or adequately covered for the cost of health care during their retirement years? The answer has serious implications for dentistry. According to CDA’s own national poll conducted this autumn,1 73% of Canadians do not have a plan for how they will pay for dental care after retirement. Of those who do have a plan, 62% are relying on of the Hill post-retirement benefits offered by their employer. As a record number of Canadians are reaching retirement age, employer-sponsored health benefits are in sharp decline. According to a 2006 report,2 57% of organizations surveyed plan to reduce post-retirement health care benefits over the next 3 years. Several of Canada’s large corporations have already made announcements to do just that, including Nortel, Sun Life, Bell, Sears and Manulife Financial. Other companies are investigating options to deal with the rising demand for extended What Is CDA Doing? health benefits. Some are examining eligibility requirements — In 2006, CDA developed a federal policy proposal to address funding gaps for establishing stricter screening the oral health care of retired Canadians. In our view, the federal government can or a minimum number of years play an important role in ensuring that retired Canadians have access to quality of service. About 1 in 3 com- oral health care by creating financial incentives to health savings. panies said they plan to add or CDA supports the creation of Personal Wellness Investment Funds (PWIF), increase retiree contributions which can be used to fund medical expenses, including oral health expenses that to their retirement health care are not currently covered under provincial health plans. Individuals would con- programs to offset the rising costs of an aging workforce. tribute funds incrementally to the account and draw upon the balance as required Some plan to cap the amount for medical services. The PWIF would be taxed similar to an RRSP or an RESP, paid out for certain medical providing preferential tax treatment to the extent that funds are used to pay for services or eliminate services medical costs incurred by individuals age 65 and over. altogether. Regardless of the The PWIF proposal was a top priority for the CDA government relations at chosen path, the outcome is not the 2006 Days on the Hill and during a series of focused political meetings this likely to benefit dentistry in the fall. CDA is currently working with party leaders, cabinet ministers, opposition long term. Additionally, none of critics, supporting members of Parliament and the federal department of finance these options have any impact to strengthen the PWIF proposal and to discuss all policy solutions to increase on the rising cost of health care access to oral health for Canadians in their retirement years. a plans for wage workers and the self-employed.

References 1. Angus Reid Strategies. Dental care in retirement poll. November 2007. Available: www.cda-adc.ca/en/cda/about_cda/government_ relations/news_emerging.asp. 2. Hewlitt Associates. The future of postretirement health care benefits. August 2006. Available: www.hewittassociates.com/Intl/NA/ en-CA/KnowledgeCenter/ArticlesReports/PostRetirement.aspx (accessed November 15, 2007).

884 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • Patient Information Brochures I P/U Oct p 671 What Is CDA Doing? E/F 4/C

In 2006, CDA developed a federal policy proposal to address funding gaps for the oral health care of retired Canadians. In our view, the federal government can play an important role in ensuring that retired Canadians have access to quality oral health care by creating financial incentives to health savings. CDA supports the creation of Personal Wellness Investment Funds (PWIF), which can be used to fund medical expenses, including oral health expenses that are not currently covered under provincial health plans. Individuals would contribute funds incrementally to the account and draw upon the balance as required for medical services. The PWIF would be taxed similar to an RRSP or an RESP, providing preferential tax treatment to the extent that funds are used to pay for medical costs incurred by individuals age 65 and over. The PWIF proposal was a top priority for the CDA government relations at the 2006 Days on the Hill and during a series of focused political meetings this fall. CDA is currently working with party leaders, cabinet ministers, opposition critics, supporting members of Parliament and the federal department of finance to strengthen the PWIF proposal and to discuss all policy solutions to increase access to oral health for Canadians in their retirement years. a Patient Information Brochures I P/U Oct p 672 E/F 4/C ––– News & Updates –––

B.C. Adult Dental Health Survey Results In

he British Columbia Dental Association recently released its final report related to the fourth Adult TDental Health Survey completed in December 2001. This latest report comprises results from Part I of the survey, which was completed by dentists and focused on the oral health status of their patients, and Part II, which asked patients to evaluate their own oral health and home health care. The frequency of dental visits was used as an indicator of the importance patients place on oral health care. The report found a link between the frequency of dental visits and rates of decayed, missing and filled teeth (DMFT) and the frequency of visits and periodontal status. The highest DMFT score occurred in patients who visit their dentist every 6 months. The lowest score was for patients who visit the dentist once every 3 to 5 years. Interestingly, the group with the healthiest gingiva are those who see the dentist every 3 to 5 years. It appears from these data that those experiencing dental problems seem to seek care more frequently than those who are not. In home care, tooth-brushing remained the same as the previous survey, with 97% of respondents indicating they brushed daily, and flossing was up slightly, from 36% to 40%. Twenty-two per cent reported using a daily mouth rinse. Results indicated that those seeking frequent care did so because of oral health problems, and were more likely to be conscientious of home care. Among the other major findings, patients with private insurance coverage were 17% more likely to have visited a dentist in the preceding 12 months than patients without coverage. Seventy-four per cent of patients with insurance, and 57% without, had visited a dentist in that time frame. This represented little change since the previous survey in 1996. Although patients were increasingly basing their decision on whether to attend the dentist on self-diagnosis and affordability, almost half of those without insurance indicated they see the dentist at least annually. Insurance figured in the percentages for preventive treatments as well, with those insured receiving 20% more preventive treatments than those without insurance. A small decline in the overall number of treatments for the insured, however, indicated that preventive procedures may have reached a saturation point, or be limited by insurers. Still, findings indicated that patients with insurance have overall stronger oral health. Seventy-five per cent of patients expressed happiness with the general appearance of their teeth. Patients receiving annual regular care reported the highest level of satisfaction. These patients also reported fewer biting, chewing or bleeding problems. Of those who did, the highest proportion was from those who visited the dentist more than every 6 months because they felt they had an ongoing oral health problem. Problems with biting and chewing were also found to increase with age, as well as with longer times between dental visits. The percentage of patients restricting their intake of sugar declined slightly, dropping from 45% to 41%, with the percentage increasing significantly with age. The average patient received 3.1 procedures per visit. The largest increase in numbers of procedures was among the 56–65 age group. a

Ivey MBA Health Sector Program Aimed at Dentists

he Richard Ivey School of Business at the University of Western Ontario has launched a new MBA Health Sector Program Taimed at dental professionals. The purpose of the 12-month program is to help dentists balance the clinical and business sides of their profession by covering such day-to-day health care administration issues as finance, management, health care politics, intellectual property and pharmacoeconomics, to create a stronger environment for patient care. Information on the program can be found at www.ivey.ca/healthsector/. a

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Shortage of Dentists in Saskatchewan

combination of dental school graduates leaving the province and an aging practitioner population is resulting in a Alack of practising dentists in Saskatchewan. “The retention rates of our graduates is not stellar,” says Dr. Gerry Uswak, acting dean of the Saskatchewan College of Dentistry. “And given that the baby boom population makes up the greatest percentage of dentists across the country, we’re going to see a huge retirement over the next 5 to 10 years. Are there the numbers to fill those places?” “A large part of it is, what are we doing to engender a feeling amongst our graduates that they want to stay here?” he asks. “What has to be done by the province, the schools, the communities to get them to say, people invested in me, I want to invest back in the province?” Two-thirds of dental students now leave the province upon graduation. This is a problem, as Saskatchewan already has the second lowest number of dental professionals per capita in Canada. Rural Saskatchewan would be especially hard hit by the lack of dental services. Dr. Uswak believes additional incentives would help solve the problem. “If you look at other health care professions, the government provides bursaries or return-of-service agreements, or other incentives to set up practices in underserviced areas,” says Dr. Uswak. “If I spend my career as a dentist in the province, think of the money I’m putting back into the public coffers. The government is paid back tenfold or more, plus, you retain someone to care for the oral health needs of the population.” Dr. Uswak also believes the time for a national discussion on dental manpower planning is long overdue. “We don’t have any concept in Canada of what an underserved area is,” he says. “In America, the government has thresholds. We don’t do that here. We don’t do oral health surveys (to) calculate treatment needs and have our manpower needs based on the oral health of our population. It points out the problem in this country that, until now, we didn’t have a national or provincial oral health surveillance system. We were not collecting the baseline information to make edu- cated decisions and informed choices.” Dr. Uswak would like to see a coordinated effort to achieve these goals. “Manpower and training and succession planning...it’s the responsibility of all of us as members of the profession working together, and sometimes I think we don’t,” he says. “We need a strong line between practice, education and our advocacy bodies, including CDA. Everyone working together for the same goals. That’s important.” There are some big pluses to practising in Saskatchewan, adds Dr. Uswak. “Once you’re here, you see the beauty and the value of it. It’s a well kept secret. The myth that you don’t do well financially in Saskatchewan? Actually, you will do very well in terms of retained income. You’ll be in demand.” a

DIAC’s 12th Annual Future of Dentistry Survey in Next JCDA CDA will carry the Dental Industry Association of Canada’s (DIAC) 12th Annual Future of Dentistry Jquestionnaire in the February 2008 edition. Once again, your input is valuable in helping DIAC’s For more information, contact Eric Jones, pres- member companies, which include manufacturers, dealers, ident, Eric P. Jones & Associates Inc., 90 Welland laboratories and service providers, develop products and ser- Avenue, St. Catharines, ON L2R 2N1; tel.: (905) vices to satisfy the changing needs of Canada’s dentists. a 684-2771; fax: (905) 684-4601; email: ejones@ vaxxine.com.

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Shortage of Dentists in Saskatchewan New President of New Executives for CARDP Canadian Association combination of dental school graduates leaving the province and an aging practitioner population is resulting in a of Orthodontists lack of practising dentists in Saskatchewan. A Dr. Gordie Organ of “The retention rates of our graduates is not stellar,” says Dr. Gerry Uswak, acting dean of the Saskatchewan College Mississauga, Ontario, has been of Dentistry. “And given that the baby boom population makes up the greatest percentage of dentists across the elected president of the Canadian country, we’re going to see a huge retirement over the next 5 to 10 years. Are there the numbers to fill those places?” Association of Orthodontists “A large part of it is, what are we doing to engender a feeling amongst our graduates that they want to stay here?” (CAO). Dr. Organ was elected he asks. “What has to be done by the province, the schools, the communities to get them to say, people invested in Dr. Gordie Organ at the CAO’s 2007–2008 annual me, I want to invest back in the province?” general meeting in St. John’s, From left: President Dr. Michael Racich and past president Newfoundland. Dr. Dennis Nimchuk, both from Vancouver, British Columbia, Two-thirds of dental students now leave the province upon graduation. This is a problem, as Saskatchewan already Dr. Organ has practised orthodontics in and president-elect Dr. Stanley Blum of Montreal, Quebec. has the second lowest number of dental professionals per capita in Canada. Rural Saskatchewan would be especially Mississauga since 1979. He has also been an hard hit by the lack of dental services. Dr. Uswak believes additional incentives would help solve the problem. “If you associate in dentistry and a clinical instructor The Canadian Academy of Restorative Dentistry and Prosthodontics (CARDP) held its look at other health care professions, the government provides bursaries or return-of-service agreements, or other at the University of Toronto departments of undergraduate and graduate orthodontics for annual general meeting in Winnipeg, Manitoba, incentives to set up practices in underserviced areas,” says Dr. Uswak. “If I spend my career as a dentist in the prov- from September 13 to 15, 2007. In addition ince, think of the money I’m putting back into the public coffers. The government is paid back tenfold or more, plus, over 25 years. He is a past president of the Ontario Association of Orthodontists and a to attending the scientific program, the group you retain someone to care for the oral health needs of the population.” recipient of their Distinguished Service elected its 2007–2008 executive officers. The Dr. Uswak also believes the time for a national discussion on dental manpower planning is long overdue. “We don’t a 2008 CARDP meeting will be held in Vancouver, Award. a have any concept in Canada of what an underserved area is,” he says. “In America, the government has thresholds. British Columbia, from September 11 to 13. We don’t do that here. We don’t do oral health surveys (to) calculate treatment needs and have our manpower needs based on the oral health of our population. It points out the problem in this country that, until now, we didn’t have a national or provincial oral health surveillance system. We were not collecting the baseline information to make edu- cated decisions and informed choices.” Dr. Uswak would like to see a coordinated effort to achieve these goals. “Manpower and training and succession CAE Names New Officers CAP Names New planning...it’s the responsibility of all of us as members of the profession working together, and sometimes I think and President President we don’t,” he says. “We need a strong line between practice, education and our advocacy bodies, including CDA. The Canadian Academy of Dr. Dan Price is the new pres- Everyone working together for the same goals. That’s important.” Endodontics (CAE) elected its ident of the Canadian Academy There are some big pluses to practising in Saskatchewan, adds Dr. Uswak. “Once you’re here, you see the beauty officers for 2007–2008 at the of Periodontology (CAP). He re- and the value of it. It’s a well kept secret. The myth that you don’t do well financially in Saskatchewan? Actually, you Academy’s annual general meeting ceived his certificate of periodon- in Vancouver this past summer, tics from Dalhousie University will do very well in terms of retained income. You’ll be in demand.” a and Dr. Wayne Maillet was named after graduating with his dental Dr. Wayne Maillet president. Dr. Dan Price diploma from University of Dr. Maillet received his BSc Manitoba. from Mount Allison University and his dental Dr. Price is a fellow of the Royal College degree from Dalhousie University. He obtained of Dentists of Canada and a diplomate of the his Certificate in Endodontics at the University American Academy of Periodontics. He served as of Toronto. Dr. Maillet maintains a private prac- an instructor in the surgical periodontics course tice in Halifax and Truro, Nova Scotia, and is a for the Canadian Armed Forces and is currently part-time dental faculty member at Dalhousie a periodontal examiner at the Royal College of DIAC’s 12th Annual Future of Dentistry Survey in Next JCDA University, where he has been a clinical instructor Dentists of Canada. a and lecturer for the past 20 years. He is a past CDA will carry the Dental Industry Association of Canada’s (DIAC) 12th Annual Future of Dentistry president of the Nova Scotia Dental Association Jquestionnaire in the February 2008 edition. and the Nova Scotia Dental Specialists Society. Once again, your input is valuable in helping DIAC’s For more information, contact Eric Jones, pres- Officers named alongside Dr. Maillet were member companies, which include manufacturers, dealers, ident, Eric P. Jones & Associates Inc., 90 Welland president-elect Dr. Ian D. Watson, treasurer Dr. laboratories and service providers, develop products and ser- Avenue, St. Catharines, ON L2R 2N1; tel.: (905) Michael Hepworth, constitution and bylaws officer vices to satisfy the changing needs of Canada’s dentists. a 684-2771; fax: (905) 684-4601; email: ejones@ Dr. Majinder Lalh, executive secretary Dr. Wayne vaxxine.com. Acheson, and past president Dr. Jeff M. Coil. a

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New Dentist-in-Chief at O B i t u a r i E S Hospital for Sick Children Bookhalter, Paul: Dr. Bookhalter of Regina, Saskatchewan, passed away on July 28. He was a 1949 graduate of the University Following an international of Manitoba and a graduate of the University of Oregon. search, Dr. Peter Judd has been Bourgeault, Roger Edward Michael: Dr. Bourgeault of West named dentist-in-chief at Toronto’s Vancouver, British Columbia, passed away on October 16, 2007. Hospital for Sick Children. Dr. A 1965 graduate of the University of Manitoba, Dr. Bourgeault Judd will also continue his duties practised in West Vancouver for 42 years. as associate professor of dentistry Boyko, William: A 1950 graduate of the University of Toronto, Dr. Peter Judd at the University of Toronto. Dr. Boyko of Oshawa, Ontario, passed away on December 12, Dr. Judd is an alumnus of dis- 2006. tinction of the University of Western Ontario Burgess, Elizabeth Ann: Dr. Burgess of Edmonton, Alberta, School of Dentistry and received his diploma in passed away on October 17, 2007. She was a 1979 graduate of the pediatric dentistry and master’s of science degree University of Alberta. from the University of Toronto. He has been a Ferland, Ronald: A 1968 graduate of the University of Montreal, fellow of the Royal College of Dentists of Canada Dr. Ferland of Saint-Constant, Quebec, passed away on August 1. since 2003. a Kazemi, Narges: Dr. Kazemi of Saint-Bruno, Quebec, passed away in September. She was a 1997 graduate of McGill University. Kreutzer, Jakob (Jack): Dr. Kreutzer of Toronto, Ontario, passed away on September 30, 2007, at the age of 98. Mombourquette, Terry J.: Dr. Mombourquette of Sydney, Nova Scotia, passed away on August 26. He was a 1981 graduate of Dalhousie University. Turcotte, Jean-Yves: A 1958 graduate of the University of Montreal, Dr. Turcotte of Quebec City, Quebec, passed away on August 12. An oral and maxillofacial surgeon, Dr. Turcotte Members inthe News was a past director of the faculty of dental medicine at Laval University. Dr. Alastair E. MacLeod of Point Edward, Watts, Dr. Gordon C.: Dr. Watts of Simcoe, Ontario, passed away Nova Scotia, was inducted into the Cape in July. He was a 1973 graduate of the University of Toronto. Breton Business Hall of Fame in September Wintermans, Thomas: Dr. Wintermans of Thunder Bay, Ontario, passed away on July 26. He graduated from Dalhousie University for his distinguished accomplishments in in 1973. a business and the community. In 1983, Dr. MacLeod founded the Mayflower Dental Centre in Sydney, Nova Scotia, which today employs 34 people, making it one of the largest dental practices in Canada. a

If you are a member of CDA and have news that you think might be of interest to JCDA readers, please send your information to [email protected] for our consideration.

To access the websites mentioned in this section, go to December 2007/January 2008 JCDA bookmarks at www.cda-adc.ca/jcda/vol-73/ issue-10/index.html.

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Provincial and OtherMeetings Dental Association Meetings

Manitoba Dental Association 124th Annual Meeting Dental Association of PEI Annual Meeting and Convention Rodd Mill River Resort Winnipeg Convention Centre Woodstock, Prince Edward Island Winnipeg, Manitoba June 12–14, 2008 January 24–26, 2008 Email: [email protected] www.manitobadentist.ca College of Dental Surgeons of Saskatchewan- 2008 Annual Scientific Session Northwest Territories & Nunavut Dental Association TCU Place and Yukon Dental Association Saskatoon, Saskatchewan Tentatively scheduled for February 2008 September 11–13, 2008 Location TBD www.saskdentists.com Email: [email protected] Association of Canadian Faculties of Dentistry Annual Pacific Dental Conference 2008 General Meeting in conjunction with Vancouver Trade and Convention Centre the ADEA 85th Annual Session and Exposition Vancouver, British Columbia Hilton Anatole March 6–8, 2008 Dallas, Texas www.pdconf.com March 31–April 1, 2008 www.adea.org Ontario Dental Association Annual Spring Meeting, in conjunction with the Canadian Dental Association 2008 Canadian Association of Oral and Maxillofacial Metro Toronto Convention Centre - South Building Surgeons Annual Conference Fairmont Newfoundland Toronto, Ontario St. John’s, Newfoundland April 10–12, 2008 May 28–31, 2008 www.oda.on.ca www.caoms.com 2008 Jasper Dental Congress Canadian Academy of Periodontology Annual Meeting 2008 Fairmont Jasper Park Lodge Fairmont Hotel MacDonald Jasper, Alberta Edmonton, Alberta May 22–25, 2008 June 26–28, 2008 www.abda.ab.ca www.cap-acp.ca

37th Annual Convention, Ordre des dentistes du Québec 86th General Session & Exhibition of the International Les Journées dentaires internationals du Québec Association for Dental Research, concurrently with the Palais des congrès de Montréal 32nd Annual Meeting of the Canadian Association for Dental Research Montreal, Quebec Metro Toronto Convention Centre May 24–27, 2008 Toronto, Ontario www.ordredesdentistesduquebec.qc.ca July 2–5, 2008 New Brunswick Dental Society Annual Meeting www.dentalresearch.org or www.cadr-acrd.ca Fairmont Algonquin 45th Canadian Academy of Endodontics Annual General St. Andrews, New Brunswick Meeting May 30–31, 2008 Fairmont Newfoundland www.nbdental.com St. John’s, Newfoundland August 19–23, 2008 Newfoundland and Labrador Dental Association www.caendo.ca AGM and Convention Fairmont Newfoundland Canadian Association of Orthodontists St. John’s, Newfoundland Delta Winnipeg Hotel Winnipeg, Manitoba June 5–7, 2008 September 11–13, 2008 www.nlda.net www.cao-aco.org Nova Scotia Dental Association Annual Meeting 2008 Canadian Academy of Pediatric Dentists Annual Rodd Grand Hotel General Meeting Yarmouth, Nova Scotia Charlottetown, Prince Edward Island June 6–8, 2008 September 12–14, 2008 www.nsdental.org www.capd-acdp.org

��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 891 DCF NEW 4/C E/F Highlights f d i D u b a i 2 0 0 7 2007 FDI Annual World Dental Congress

he beautiful city of Dubai, United Arab Emirates, showcasing advanced dental technology and current a juxtaposition of dazzling modernity and Middle trends and product development in dentistry. TEastern tradition, was the site of the 95th Annual The 2007 Welcome Ceremony featured a spec- World Dental Congress. This is the second time an tacular light show with dance, music and local folklore FDI Congress has taken place in a Middle Eastern presentations. Attendees also witnessed the symbolic country. The first was in Tel Aviv, Israel, in 1966. installation of Dr. Burton Conrod of Sydney, Nova Members of the official Canadian delegation were Scotia, as the first Canadian president of FDI. Dr. Dr. Wayne Halstrom, leader of the delegation and Conrod officially assumed duties as president for a 2- CDA immediate past president, Dr. Darryl Smith, CDA year term from Dr. Michèle Aerden at the end of the president, and Dr. Deborah Stymiest, CDA president- congress. elect. Drs. Jack Cottrell, CDA past president, and John O’Keefe, editor-in-chief and CDA’s National Liaison Dr. Burton Conrod Becomes FDI President Officer to FDI, were official alternate delegates. Thousands of visitors attended the conference at the Dubai International Convention and Exhibition Centre, a state-of-the-art venue for the FDI World Parliament’s business meetings, scientific program and exhibitions. The scientific program, titled “Dental Diversity in the Land of Tomorrow,” boasted an im- pressive line-up featuring more than 130 invited international speakers. Two Canadians presented during the scientific program: Dr. Debora Matthews was part of a panel discussion on “Oral Health and Diabetes,” and Dr. David Isen presented “Pain Management in Dentistry.” The program also featured specialty work- Dr. Darryl Smith congratulates Dr. Burton Conrod during the CDA reception in his honour. shops and forums on oral health promotion. Dr. Peter Cooney, chief dental officer of Canada, discussed the CDA hosted a private reception in Dr. Conrod’s process Canada is currently using to revise its fluoride honour to celebrate his installation as FDI president. policies in a presentation to the Science Committee More than 100 people gathered to mark this significant Forum of the FDI Joint World Dental Development achievement for Canadian dentistry. In addition, CDA’s and Health Promotion Committee, Public Health annual Canadian Reception, always a popular event Section. with official delegates, was held at the Jumeirah Beach This year’s World Dental Exhibition was one of the Hotel and attended by 350 guests from over 50 FDI largest in FDI history, with more than 340 companies member associations and international organizations. CDA would like to thank Procter & Gamble for its generous sponsorship of the CDA Canadian Reception. CDA is also grateful to GlaxoSmithKline for its sponsorship of the private CDA reception for Dr. Conrod.

Bilateral Relationships While at the congress, the Canadian delegation strived to create new links and reinforce existing ones with national associations who face similar professional and political issues to those of CDA. There is great benefit to sharing information and resources related to common issues such as access to care, accredit- Dr. Burton Conrod and Dr. Michèle Aerden look on as His ation and dental workforce shortages. This endeavour Highness Sheikh Hamdan Bin Rashid Al Maktoum, deputy ruler of Dubai, cuts the ribbon to mark the opening of the World began at the American Dental Association meetings Dental Exhibition. in San Francisco in the fall, and the delegation had

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stranger to working with FDI, Dr. Forest was chair of the local organizing committee for the 2005 FDI Congress in Montreal. The Education Committee’s main role is organizing the scientific program of the Annual World Dental Congress and other continuing educational activities of FDI, as well as to address dental education issues. There were 11 candidates for 4 positions, 2 positions voted on by the General Assembly and 2 by the Council. Unfortunately, although support for Dr. From left: Dr. Piret Väli, president of the Estonian Dental Forest was strong throughout the election, he did not Association, Dr. Burton Conrod, Dr. Kathleen Roth, immediate win a seat. past president of the American Dental Association (ADA), Dr. Deborah Stymiest, president-elect of CDA, and Dr. Mark Feldman, president of ADA. Oral Health Policy Strategy

very good meetings with representatives of Australia, The FDI World Dental Parliament brings together Germany, Great Britain, New Zealand and the United representatives from FDI member associations to es- States. The intention is to forge and strengthen more tablish the organization’s strategic direction and adopt of these relationships at future international venues. policy statements that influence the world of dentistry. During the FDI General Assembly, delegates from member countries, invited guests and organization Partnerships with Industry Leaders representatives discuss and review global policy state- The Canadian delegation also sought to establish or ments on oral health. This year, CDA lobbied exten- strengthen relationships with dental industry leaders sively for changes to the policy development process in order to discuss their vision of the future of the at FDI that would see policies written at a more global profession. Meetings were held with 5 companies and level. Individual countries would then fill in the details the International Dental Manufacturers Association. appropriate to their own jurisdictions, ensuring the These meetings provided valuable insights into how resulting policies would be relevant and not in conflict the dental profession and the dental industry can work with those of their countries. together as key strategic partners. University of Sharjah Joint Dental Education Committee Education Project

Dr. John O’Keefe with Dr. Denis Forest, candidate for FDI’s Dr. Kathleen Roth, past president of the American Dental Education Committee. Association, Dr. Darryl Smith, CDA president, and Dr. Christopher Fox, executive director, International Association for Dental This year, the Canadian delegation threw its sup- Research, look on as His Highness Dr. Sheikh Sultan bin Mohammed port behind Dr. Denis Forest of Montreal, Quebec, in Al Qasimi, ruler of Sharjah, United Arab Emirates, speaks. his bid for a seat on FDI’s Education Committee. Dr. Forest is editor of the Journal of the Order of Dentists Dr. Johann DeVries took Dr. Darryl Smith and of Quebec (ODQ) and the director of the Journées a small group of international delegates, including Dentaires of ODQ. He is professor emeritus at the leaders from the Canadian, Australian and American faculty of dentistry of the University of Montreal. No Dental Associations on a tour of the facilities at the

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University of Sharjah, located in one of the 7 emirates into 6 chapters: principal features of dental ethics, of the United Arab Emirates. Dr. DeVries is dean of dentists and patients, dentists and society, dentists and the faculty of dentistry at the University of Adelaide, colleagues, ethics and research, and responsibilities of Australia, and former dean of the faculty of dentistry dentists and the future of dental ethics. Dr. John R. at the University of Manitoba. In 2005, the University Williams, an adjunct professor in the faculty of medi- of Adelaide and Sharjah University reached an agree- cine at the University of Ottawa and former director ment that saw the University of Adelaide provide the of ethics at the Canadian Medical Association and the curriculum for the bachelor of dental surgery degree at Sharjah’s new college of dentistry. Visitors World Medical Association, wrote the manual with were very impressed with the extremely modern and the support of the FDI Working Group on Ethics and technologically advanced dental facilities at Sharjah Legislation and an advisory panel. The manual can be University. downloaded from FDI’s website. In addition, with the assistance of the French Dental Association, the “Tobacco or Oral Health” ad- Resources Launched in Dubai vocacy guide, produced jointly by FDI and the World The congress was the site of unveiling for FDI’s Health Organization, was released in French. The first Dental Ethics Manual. Intended as a resource Chinese version of the guide was released last year at guide for dental professionals, the manual is divided FDI’s Annual Congress in Shenzen, China.

Bridging A Gap That Probably Wasn’t There By Dr. David Isen

was fortunate enough to receive an invitation to speak at this year’s FDI World Dental Congress in I Dubai. Although honoured to be asked, I have to admit that since I am Jewish, I had some reserva- tions about travelling into an Arab country, as did some of my family and friends. However, upon discussion with people who had been there and a little research regarding the political climate, it appeared that it would be quite safe. So off I went, confident I would be okay, but still unsure about what I would experience. It became clear to me very quickly that Dubai is a city made up of many different faces. People from the Philippines, Pakistan, India and throughout the Middle East live among impossibly modern skyscrapers that overlook squalid neigh- bourhoods. The streets are filled with people clad in different national and religious dresses and the latest European fashions. At first, Dubai’s seeming lack of identity because of all this contradiction made it seem a little cold. And then I started to get to know the people. My first social encounter occurred the night I arrived, when I was invited to dinner with a number of FDI delegates. I broke bread with 9 others from Jordan, Lebanon, Saudi Arabia, Kuwait, Oman and Egypt and, boy, did we have a great time! They knew I was Jewish because we discussed politics a little, yet still they treated me with open arms and cama- raderie. During the evening, many of them gave me their business cards and invited me to their countries. The fellow from Oman offered to take me on a tour of his country the next morning! My next beautiful experience was with a Syrian man who works for a dental company in Dubai that was exhibiting at the show, who took it upon himself to act as my host. He drove me here and there, took me on a desert safari and, best of all, invited me into his home and introduced me to his wife and children. His family was so warm, hospitable and engaging. I don’t think they could have fed me enough chocolate and Syrian coffee. I was very touched by their generosity and gestures of friendship. That encounter is the best memory of my adventure. This trip reinforced for me that politics do not have to influence relationships. It should be only the inherent good in each of us that draws us together. This is possible for everyone should they choose this path. I think that the vast majority of people in the world are inherently good, despite the political climate in which they live. However, this is hard to see when we are inundated daily with sad news stories based on the hate, greed and killing that politics can breed. What amazes me about my experience in Dubai is that it took a dental convention to bring these thoughts forward in my mind. The community of dentistry is alive and well and FDI offers us a great opportunity to travel around the world and experience this unity. If we can, we should all take advantage of it. As Depeche Mode sings, “People are people. . ..” •

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International Audience Canadian Professor Wins Prize at for Canada’s Fluoride International Poster Contest Policy

he appointment of Dr. Peter TCooney as chief dental officer has provided Canada with a voice in a variety of international dental fora, namely the FDI World Dental Federation (FDI) and the World Health Organization (WHO). In 2006, Dr. Cooney was appointed chair of the International Chief Dental Officers Public Health Section of FDI. It was in this role that he was asked to speak to the Science Committee Forum of the Joint World Dental Development and Health Promotion Committee, Public Health Section in Dubai about the process Canada is undertaking to revise its fluoride poli- Dr. Komiyama, professor emeritus at the University of cies. Dr. Cooney’s presentation was very well received by Saskatchewan, stands before his winning poster at the forum attendees. FDI/Unilever Poster contest. In spring 2006 Health Canada initiated a review of ex- Dr. Kunio Komiyama, professor emeritus at the posure to fluorides from drinking water and its potential University of Saskatchewan College of Dentistry, was health effects. Three scientific reviews were provided to the winner of the 2007 FDI/Unilever Poster Award. Health Canada in 5 specific areas: the total daily intake Dr. Komiyama’s project was on the antibacterial ef- of fluoride, dental fluorosis, other health effects, risk fects of solar-powered TiO2 semiconductors on por- assessment, and the risks and benefits of water fluor- phylomonas gingivalis and prevotella intermedia. Of idation. Specialists in fluoride research and policy experts the 170 posters presented, 12 were chosen as finalists were brought together for a 2-day consultation to discuss and 6 were selected as winners. Each winner received evidence-based recommendations. The meeting partici- free registration to a future FDI congress and a mon- pants reached a consensus and Health Canada’s federal, etary prize toward their participation. provincial and territorial stakeholders are now vetting the resulting recommendations. The Office of the Chief Dental Officer has used the

Future FDI Congresses results from the scientific research and resulting recom- The 2008 Congress will be held in Stockholm, mendations to help facilitate the formation of consistent Sweden, from September 24 to 27. The 2009 congress national fluoride guidelines between Health Canada and will take place in Singapore and the 2010 congress will CDA. The 2 organizations have already reached an in- be held in Salvador da Bahia, Brazil. formal agreement to release uniform fluoride statements For more information about FDI World Dental in early 2008. Federation, visit www.fdiworldental.org. • At the same time that Canada initiated its review of fluoride, a global review of fluoride and oral health was also taking place. This global consultation, held in Geneva, Switzerland, in November 2006, was jointly organized by FDI, the International Association for Dental Research (IADR) and WHO. The goal was to discuss the development of effective legislation, necessary directives and programs to ensure access to fluoride for oral health in all countries. The consultation reaffirmed the efficacy, cost-effectiveness and safety of the daily use of fluoride and that universal access to fluoride is part of the basic right to health. These results not only support the use of fluoride internationally to improve oral health, but also reinforce Canada’s fluoride policy work. •

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International Audience Canadian Professor Wins Prize at for Canada’s Fluoride Partnering to Reverse the Trend: International Poster Contest Policy Early Childhood Caries Conference Report he appointment of Dr. Peter TCooney as chief dental officer September 28–29, 2007, Calgary, Alberta has provided Canada with a voice in a variety of international dental fora, namely the FDI World Dental Federation (FDI) and the World Health ore than 250 allied professionals and and to explore collaborative new pathways to Organization (WHO). In 2006, Dr. Cooney was appointed community stakeholders gathered in prevent the disease. chair of the International Chief Dental Officers Public MCalgary to learn about the latest re- Forum for Active Participation Health Section of FDI. It was in this role that he was search on early childhood caries and explore asked to speak to the Science Committee Forum of the how they can work together in new ways to Partnering to Reverse the Trend: Early Joint World Dental Development and Health Promotion reduce the rates of this increasingly common Childhood Caries Conference was hosted by Committee, Public Health Section in Dubai about the disease. the Calgary Health Region and the Canadian Academy of Pediatric Dentistry. The confer- process Canada is undertaking to revise its fluoride poli- Early childhood caries has become one of ence provided a forum for participation by Dr. Komiyama, professor emeritus at the University of cies. Dr. Cooney’s presentation was very well received by the most prevalent childhood diseases world- a wide range of delegates, including dental Saskatchewan, stands before his winning poster at the forum attendees. wide. After decades of decline, it has begun to FDI/Unilever Poster contest. professionals from private practice and public In spring 2006 Health Canada initiated a review of ex- increase in children. This preventable disease profoundly affects the quality of life for thou- health, academics, pediatricians, child de- Dr. Kunio Komiyama, professor emeritus at the posure to fluorides from drinking water and its potential velopment professionals and representatives sands of Canadian children and their families, University of Saskatchewan College of Dentistry, was health effects. Three scientific reviews were provided to of dental professional bodies, government and increases the burden on the health care the winner of the 2007 FDI/Unilever Poster Award. Health Canada in 5 specific areas: the total daily intake and community organizations serving fam- system. Dr. Komiyama’s project was on the antibacterial ef- of fluoride, dental fluorosis, other health effects, risk ilies with young children and disadvantaged Calgary’s oral health programs and pedi- fects of solar-powered TiO2 semiconductors on por- assessment, and the risks and benefits of water fluor- populations. phylomonas gingivalis and prevotella intermedia. Of idation. Specialists in fluoride research and policy experts atric dentists formed the Early Childhood The models for early childhood caries pre- the 170 posters presented, 12 were chosen as finalists were brought together for a 2-day consultation to discuss Caries Taskforce to address the issue, which vention that have been used in the past seem and 6 were selected as winners. Each winner received evidence-based recommendations. The meeting partici- led to this seminal conference. The aim was to inadequate, and initiatives need to expand be- free registration to a future FDI congress and a mon- pants reached a consensus and Health Canada’s federal, provide the dental community and non-dental yond dentistry to involve other professions etary prize toward their participation. provincial and territorial stakeholders are now vetting the stakeholders with an opportunity to focus on and community interests. This diverse group resulting recommendations. the current science behind early childhood of delegates learned that some segments of the The Office of the Chief Dental Officer has used the caries, the roles of family and community, population are experiencing the worst level of

Future FDI Congresses results from the scientific research and resulting recom- childhood caries ever. They were challenged The 2008 Congress will be held in Stockholm, mendations to help facilitate the formation of consistent to look at the problem from their perspectives Sweden, from September 24 to 27. The 2009 congress national fluoride guidelines between Health Canada and and bring that view to a new understanding of will take place in Singapore and the 2010 congress will CDA. The 2 organizations have already reached an in- the disease. As the conference closed, everyone be held in Salvador da Bahia, Brazil. formal agreement to release uniform fluoride statements was encouraged to make a personal commit- For more information about FDI World Dental in early 2008. ment to taking action. Federation, visit www.fdiworldental.org. • At the same time that Canada initiated its review In particular, the conference sought to: of fluoride, a global review of fluoride and oral health • Explore the knowledge base of early child- was also taking place. This global consultation, held in hood caries with a focus on new research. Geneva, Switzerland, in November 2006, was jointly or- • Review early childhood caries risk factors ganized by FDI, the International Association for Dental and behaviours and include the perspectives of caregivers and interdisciplinary Research (IADR) and WHO. The goal was to discuss the professionals. development of effective legislation, necessary directives • Review, discuss and generate interdisci- and programs to ensure access to fluoride for oral health plinary strategies to minimize early child- in all countries. The consultation reaffirmed the efficacy, hood caries (biological, psychosocial, cost-effectiveness and safety of the daily use of fluoride public health, prevention, policy change and that universal access to fluoride is part of the basic and access to care). right to health. These results not only support the use of • Collect information for presentation in fluoride internationally to improve oral health, but also formal documentation. reinforce Canada’s fluoride policy work. • Dr. Allan Narvey, co-chair of the Early Childhood Caries Planning Committee, and Dr. Jacques Véronneau, speaker at the conference on the scientific background of The inclusion of two dozen community early childhood caries prevention. stakeholders who work with young children

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The medical perspective of early childhood caries: contributing factors and consequences Dr. Glenn Berall, gastroenterologist and nutrition specialist, chief of pediatrics at North York General Hospital and assistant professor, department of pediatrics, University of Toronto The scientific background of early childhood caries prevention: what works and what doesn’t Dr. Jacques Véronneau, assistant professor in the faculty of dentistry at McGill University and a specialist in dental public health for the Cree Nation, James Bay, Quebec The broader context of early childhood caries: impact on the family and diverse communities, the social determinants of health, upstream and down- stream strategies Dr. Ross Anderson, who provided an overview of early childhood caries as viewed by a pediatric dentist, speaks Dr. Rosamund Harrison, professor and chair during one of the conference’s interactive sessions. of pediatric dentistry, University of British Columbia Stimulating discussion followed the presenta- and at risk families brought an exciting and mo- tions and included dialogue about infectivity of tivational flavour to the event. The stakeholders dental caries, fluoridation, use of products to re- represented various health and social concerns: duce caries risk, infant feeding practices, healthy • Aboriginal health school guidelines, impact of stress, genetic com- • community health ponent, high-risk populations, parental respon- • education sibility, public policy, cross-disciplinary action • government health benefits and leadership. • immigrant and refugee health • nutrition Collaborative Strategies • pediatrics The second half of the conference focused on • poverty reduction collaborative brainstorming and action planning. • primary health care To begin, the 6 presenters were asked: “If you • social work had a question, the answer to which would make the most difference in reversing early childhood Different Perspectives caries, what would that question be?” The ques- The first half of the conference focused on tions proposed by the presenters were: joint discovery and discussion. Delegates heard 1. How can we create a national awareness of presentations from these speakers: early childhood caries as a health issue for pol- iticians, caregivers and families? Overview of early childhood caries as viewed by a 2. What is the most effective way to change the pediatric dentist determinants of early childhood caries in Dr. Ross Anderson, head, division of pedi- Canada? atric dentistry, faculty of dentistry, Dalhousie 3. How can we work together to decrease the University, and chief of dentistry, IWK Health number of families living in poverty in Centre, Halifax, Nova Scotia Canada? 4. How can we get the public to understand Local, provincial and national data about the ex- that oral disease in general among kids is the tent of early childhood caries, cost of care, issues number one chronic disease in Canada. How around access then do we impart the idea that there are the Dr. Luke Shwart, manager for community oral same risk factors related to oral health as there health services for the Calgary Health Region and are for other chronic diseases? Dr. Peter Cooney, chief dental officer for Health 5. When will we have a vaccine against tooth Conference participants brainstorm during an inter- Canada decay? active session.

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The medical perspective of early childhood caries: 6. How can we open the medical model to a com- minants of health, counteracting inequalities from contributing factors and consequences munity model to reach caregivers and make how health services are organized) Dr. Glenn Berall, gastroenterologist and nutri- everyone responsible for those children to take Strategy: National policy with joint responsibility tion specialist, chief of pediatrics at North York it on? of health care system and caregivers (medical as- General Hospital and assistant professor, depart- Thought-provoking discussion included sessments in infancy, consistent messaging among ment of pediatrics, University of Toronto challenges in the Aboriginal population; health dentists, allied health groups and child care pro- The scientific background of early childhood caries promotion messages and risk behaviours; op- fessionals) to take action on early childhood caries prevention: what works and what doesn’t portunities for collaboration; understanding of to promote health care, address “damage control,” Dr. Jacques Véronneau, assistant professor in the disease transmission and screening; payment for prevent dental neglect and ensure availability of faculty of dentistry at McGill University and a spe- anticipatory guidance; terminology; coordinated prevention and treatment dollars. cialist in dental public health for the Cree Nation, prenatal screening and early childhood screening; Building healthy public policy (developing health- James Bay, Quebec educating other health professionals; reporting enhancing policies, supporting healthy choices and early childhood caries; dental neglect and en- The broader context of early childhood caries: im- promoting healthy living and working conditions) suring equal access to dental care; coping with pact on the family and diverse communities, the Strategy: Ensure governments include oral health increased demand on the dental profession; and social determinants of health, upstream and down- in overall health programs, with the goal of im- enlisting corporate support to cover costs of stream strategies proving childhood health for Canadian children. screening. Dr. Ross Anderson, who provided an overview of early Policies need to address the barriers to good oral childhood caries as viewed by a pediatric dentist, speaks Dr. Rosamund Harrison, professor and chair The conference facilitator led delegates through health from the perspective of communities and during one of the conference’s interactive sessions. of pediatric dentistry, University of British a brainstorming process using the 5 key method- include the clients and providers. Columbia ologies found in the Ottawa Charter for Health Stimulating discussion followed the presenta- Promotion. Discussion and a voting process se- Developing personal skills (improving an individ- and at risk families brought an exciting and mo- tions and included dialogue about infectivity of lected these 5 key strategies as a place to start. ual’s behaviour that will enable that individual to tivational flavour to the event. The stakeholders dental caries, fluoridation, use of products to re- Creating supportive environments (establishing deal effectively with the demands and challenges represented various health and social concerns: duce caries risk, infant feeding practices, healthy policies that support healthy physical, social and of everyday life) school guidelines, impact of stress, genetic com- • Aboriginal health economic environments) Strategy: Piggyback skill development, relation- • community health ponent, high-risk populations, parental respon- ship building and follow-up with other com- • education sibility, public policy, cross-disciplinary action Strategy: Use agency structures and existing tools to encourage a healthy environment for children’s munity health/health promotion programs, e.g., • government health benefits and leadership. oral and general health, e.g., Canada’s Food Guide, link to well-baby clinics and other places where • immigrant and refugee health multidisciplinary workforce, well-baby clinics, child is seen on a regular basis. • nutrition Collaborative Strategies health care professional curricula and dental Strengthening community action (collective ef- • pediatrics The second half of the conference focused on coverage for children under 4 years of age. forts by a community to increase control over the • poverty reduction collaborative brainstorming and action planning. factors that influence health) • primary health care To begin, the 6 presenters were asked: “If you Reorienting health services (identifying oppor- • social work had a question, the answer to which would make tunities in health care for addressing the deter- Strategy: Social marketing targeted at public and the most difference in reversing early childhood health professionals. caries, what would that question be?” The ques- Different Perspectives Some presenters and delegates noted that, if tions proposed by the presenters were: The first half of the conference focused on new strategies are undertaken, the group must en- 1. How can we create a national awareness of joint discovery and discussion. Delegates heard sure there is evidence before selecting initiatives, early childhood caries as a health issue for pol- presentations from these speakers: build on learnings from other health issues, not iticians, caregivers and families? Overview of early childhood caries as viewed by a 2. What is the most effective way to change the overlook the determinants of health, involve other pediatric dentist determinants of early childhood caries in health disciplines, coordinate local and national Dr. Ross Anderson, head, division of pedi- Canada? efforts, measure the effectiveness of initiatives that atric dentistry, faculty of dentistry, Dalhousie 3. How can we work together to decrease the are undertaken and be prepared to address access University, and chief of dentistry, IWK Health number of families living in poverty in to care issues if more families seek dental care for Centre, Halifax, Nova Scotia Canada? their children before they reach age 1. 4. How can we get the public to understand Many disciplines can play important roles in Local, provincial and national data about the ex- that oral disease in general among kids is the the effort to reduce early childhood caries. These tent of early childhood caries, cost of care, issues number one chronic disease in Canada. How common themes emerged: around access then do we impart the idea that there are the • Terminology should change to ‘early child- Dr. Luke Shwart, manager for community oral same risk factors related to oral health as there hood dental disease’ (instead of early child- health services for the Calgary Health Region and are for other chronic diseases? hood caries) to more accurately reflect the Dr. Peter Cooney, chief dental officer for Health 5. When will we have a vaccine against tooth Conference participants brainstorm during an inter- seriousness of the situation (see Debate article Canada decay? active session. on p. 929).

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• There is a lack of consistency in messages Observations about first visit by first birthday. Many parents The planning committee was struck by the find that their family dental office will not see delegates’ passionate concern for the topic and for children until age 3. the children affected. One presenter remarked, • Early childhood caries is shockingly common, “Before coming here I thought I was alone. And and its severity too often overlooked. now I see another 250 of you who care.” Delegates • This is a disease process affecting the whole engaged vigorously in the strategizing process. child — it is not just tooth decay. Some ideas targeted all socioeconomic groups and • Dental disease shares risk factors with child- others focused more directly on those living in hood obesity, malnutrition and tobacco usage. poverty. The common understanding is that early • Non-dental health providers who see young chil- childhood caries is a general health issue, not just dren could be involved in oral health screening. a dental issue. • Early childhood caries needs to be more It is time for multidisciplinary groups to work strongly incorporated into the education cur- collaboratively on a national level to combat early ricula for all allied health professionals. childhood caries. The next step is to explore • Poverty is a key determinant of oral health. leadership possibilities for such collaboration. • Parental responsibility is crucial to a child’s Funding must be secured to support communica- oral health. Parenting skills could be taught in tion between groups and to develop initiatives. perinatal education programs. In the meantime, delegates are starting to follow • Many practitioners share an interest and con- through on the personal commitments they made cern for preschooler oral health. Align with at the conference. an existing group already working to improve child health (e.g., Canadian Pediatric Society). Conclusion A national collaboration is needed to focus on Early childhood caries is a complex and effective strategies to promote oral health. common disease. Although it affects families from all facets of society, it stalks the disadvantaged, Future Action and despite treatment, recurs too often. Evidence- The conference demonstrated how multi- informed strategies for preventing and minimizing disciplinary planning generates collaborative the disease exist, but require more research and willingness to address early childhood caries. action at a young age before most children ever see Representatives from a number of organizations a dental professional. Dental professionals should indicated an interest in participating in a national spearhead efforts to involve health and allied pro- initiative (pediatrics, pediatric dentistry, general fessionals working with young families to help dentistry, dental hygienists, immigration services, prevent the disease. a refugee health, Aboriginal health, public health, child welfare, community health services, nutrition services, child and women’s health, breast- The conference planning committee expresses its appreciation feeding groups, government and professional to the Calgary Health Region and the Canadian Academy of organizations). Much work needs to be done. Pediatric Dentistry for hosting the conference, and to the Alberta Logistical considerations must be addressed Dental Association and College, Health Canada, GC America before a national task force can be established. Inc., RBC Royal Bank, Henry Schein Ash Arcona, Patterson Dental, Oral B, Sunstar, Calgary and District Dental Society and Decisions need to be made about terms of ref- the College of Registered Dental Hygienists of Alberta for their erence, membership, funding, administrative generous sponsorship. support, level of operation and methods of communicating between members. Health Canada Early Childhood Caries Conference Planning Committee Dr. Allan Narvey (co-chair), Dr. Luke Shwart (co-chair), may be able to provide leadership but is unable to Vickie McKinnon, Linda Lathrop (facilitator), Dr. Krista Baier, fund the group or its initiatives. Efforts need to Dr. Robert Barsky, Andrea Blakie, Dr. Warren Loeppky and focus on promising and best practices. Pauline White.

The speakers’ presentations and other strategies identified by conference delegates can be viewed on the conference website: www.ecc-calgary.ca.

900 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • English: Toothbooth 4/C English: New French: CDA Seal of Recognition Ad CDSPI (Fishhooks) P/u Feb 07 p.49 E/F 4/C CDSPI R E p o r t s

How We Can Help You Make the Most of Your RRSP

By Michael Holmes, CFP

nce again, the RRSP season is upon us. For many savings need to be invested more aggressively, or that people, that simply involves pulling together as you’ll need a pool of savings on top of your RRSP. Omuch money as possible to put into their plans for (For a more detailed analysis of your finances — in- tax relief — often after having a brief conversation with cluding your registered and non-registered investments, their advisors about choosing funds. as well as your insurance and estate planning needs — Fortunately, participants in the Canadian Dentists’ call to learn about the Investment Program’s ClearView Investment Program’s RRSP — the CDA RSP — can Financial PlanTM. A valuable planning tool, it provides expect a much higher level of investment service. Here dentists with a comprehensive financial plan at no cost.) are just some examples of the ways we can assist you in making the most of your RRSP this season. Help You Avoid Having a Portfolio that’s Too Safe or Overly Aggressive Potentially Increase Your Returns To help you achieve your retirement savings goals, By contributing the maximum amount to your CDA we can assist you in establishing (and maintaining) an RSP (which is the lesser of $19,000 or 18% of your earned asset allocation model for your RRSP investments, based income for the 2007 tax year) before the contribution on your tolerance for risk and the time remaining until deadline, you’ll not only minimize your tax payable to retirement. the greatest extent possible, you’ll also build up more sav- For example, suppose you’re a 40-year-old dentist ings for retirement. with a relatively high tolerance for risk. You’ve positioned To help you accomplish this for the coming 2008 tax your portfolio so that 60% of your assets are invested in year, consider making your maximum contribution in equity funds, while 40% are invested in cash and income regular (e.g. monthly) instalments instead of making funds. a lump-sum contribution. In the industry, investing Consider what happens if your cash and income funds smaller amounts on a regular basis like this is called performed better than your equity funds. As a result, “dollar cost averaging”. Buying CDA investment funds your portfolio becomes weighted 40% in equities and in this fashion can allow you to purchase more units in a 60% in cash and income funds. Because your asset al- fund when markets are low — making your investments location is out of alignment, your portfolio has become perform better. too conservative to allow you to reach your retirement To set up automatic contributions to your CDA RSP, savings goals. To get back on track, you need to rebalance simply use our no-cost ��Pre-Authorized Chequing (PAC) your portfolio by selling some of your cash and income service. With PAC, your contributions are regularly de- funds in favour of buying more equity funds. This helps ducted from your bank account at specified intervals. ensure that your portfolio adheres to your tolerance for risk. Conversely, if your equities outperform, rebalancing Show You if Your Plan Is Properly Funded can bring your risk down to where you are comfortable. If you’re like many dentists, you hope to achieve a To make portfolio rebalancing effortless, use the specific income level from your RRSP when you reach Investment Program’s Portfolio Rebalancing Service. retirement to obtain the lifestyle you want. But how can Available at no-cost, the service automatically rebalances you be certain you’ll achieve that goal? your portfolio every 6 months (or annually) to ensure it Fortunately, the Investment Program offers a no-cost conforms to your personally approved asset allocation service that can help you. It’s called Retirement InsightTM. model. It’s a written retirement savings progress report, which shows you how much annual income you can expect to Help Ensure You’re Investing Tax-Efficiently achieve in retirement. If the report shows you’ll have less Having the wrong types of investment funds in your retirement income than you’re hoping to achieve, you RRSP could result in significant dollars being lost to the can speak to a certified financial planner at Professional tax man. It’s usually a good strategy to place interest- Guide Line Inc. to discuss strategies that may help you bearing investments (e.g. bond funds) inside your regis- achieve your goals. For example, you may learn that your tered plan and to hold investments that enjoy preferential

��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 903 c d s p i R E p o r t s Notable n u m be r s tax treatment (e.g. dividend funds) outside your RRSP, in a non-registered portfolio. We can help ensure your RRSP investments are best structured for tax-efficiency, and advise you about other tax-saving strategies — including establishing a spousal RRSP and our distinctive “Mini RIF” technique.

Give You Free Professional Planning Advice Decisions you make today about your RRSP investments can have a profound impact on your financial well-being at retirement. To�� maximize your retirement savings, you need the information and sound advice that a financial professional can provide. ��For no-cost, non- commissioned planning advice from licensed advisors who work exclusively for dental professionals and their families, call us at Professional Guide Line Inc. a

THE AUTHOR

Michael Holmes is vice-president, Investment Services, Professional Guide Line Inc. — A CDSPI Affiliate.

CDSPI is the administrator of the Canadian Dentists’ Investment Program — a member benefit of CDA. For no-cost investment planning advice from a licensed, non-commissioned advisor at Professional Guide Line Inc., dial 1-877-293-9455 (toll-free) or (416) 296-9455, extension 5023. Restrictions may apply to advisory services in certain jurisdictions.

Win RRSP Money! Contribute to your CDA RSP before this year’s contribution deadline of February 29, 2008, and you could win* up to $9,500 toward your 2008 tax-year contribution! If you contribute before January 31, 2008, you’ll have 2 chances to win! Call or visit our website for details.

*Some contest restrictions apply. Residents of Quebec are not eligible due to provincial regulations. No purchase is necessary. For complete contest rules, visit www.cdspi.com/more-info.

904 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • NotableYou ask Wn ue m abe n srwe s r

When I search the web for clinical information, how can I avoid getting too many results, many of which are not relevant?

ne answer is the specialized search screen (link to the right of the search engine Google Scholar, search box). Owhich searches the web but limits A Google Scholar search can lead you the search to more academic websites. ��It to references that are available in full- CDA’s Resource Centre is as easy to use as Google, the ��web’s most text, or to documents for which only offers a full range of ser- popular search engine,�� but you will notice an abstract or an extract is available. vices to meet members’ a difference in your search results. Many references will lead you to a pub- clinical, practice manage- Google Scholar indexes and searches lisher’s website, where you can usually ment and oral health articles, theses, books, conference ab- download a copy of a full-text article for research needs. This stracts, technical reports and other litera- $35–$40 US. Members can order article article is part of an ture not included in many other databases copies from CDA’s Resource Centre at a significantly reduced price. occasional series to help (e.g., PubMed/MEDLINE), such as un- You may find references marked with better inform readers on published papers and conference proceed- topics of interest by pro- “[citation]” that are not hyperlinked. ings. It also includes PubMed references. viding answers to actual These are articles which other scholarly It covers peer-reviewed journals in a var- questions posed to the articles have referred to, but are not avail- Resource Centre. If you iety of disciplines, with better coverage able online. This serves as a reminder that have a topic you would of science and technology than the there is still a body of scholarly literature like the CDA Resource humanities. that exists only in print. Even if an article Centre to address, email How do I get started? is available online, it’s not often available your question to for free. [email protected]. Go to http://scholar.google.ca/ to You may also note “Cited by” below access the basic Google Scholar search each of your resulting references. This screen. Although this service has been link lists sources that have cited the docu- available for more than 3 years, it is still ment originally retrieved in the search in beta testing, so improvements and and may help to locate other subject- changes may happen at any time. Enter related documents. Google Scholar only search terms on the basic screen or do a includes articles that are indexed within more detailed search from the Advanced its database, so it cannot be relied upon as a comprehensive citation analysis. Likewise, clicking “Related Articles” will help to identify other references on your topic of interest within the Google Scholar database. Some references may be marked with a reference to other versions. This is helpful for locating preprints, abstracts, conference papers or other adaptations that may be more easily accessible.

What’s the downside to Google Scholar? While Google Scholar is a very easy to use search tool with many helpful features, you should also be aware of its limitations.

��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 905 Youc d sA psk, i RWeE p A onswer r t s Clinical s h o w c a s e

Unless you are quite specific in your search or are researching an obscure topic, you may get several hundred or thousand results, just like you would with a regular Google search.�� When�� faced with an over- whelming number of references, it is hard to believe that Google Scholar searches only some of the scholarly literature. And you are still not getting everything! Google Scholar offers an advanced search page, which allows you to get more specific with your search terms, search by author, publication or date, or limit to selected subject areas. ��Google Scholar gathers data from many sources, and sometimes information may be incomplete or even incorrect. A date-restricted search will not return articles for which Google Scholar Many questions about how Google Scholar was unable to determine a date of publication. functions remain unanswered. The selection pro- Likewise, different sources may use different name cess for sources indexed is not completely clear. formats, so it may be necessary to search a number How does Google determine whether or not some- of variations (e.g. [author:��“��J�� Doe”], [author:��“JD�� thing is scholarly? Moreover, what is missing? How Doe”], or [author:“��John D Doe”]).�� The bottom line many databases, journal titles and other websites is to use limits with caution. are included? Webcrawler software takes care of What’s the verdict? Google Scholar indexing, so it can take some time For clinical information, Google Scholar pro- for new items to be indexed. How current is the vides superior results compared to a regular Google information? search. Because of its limitations, Google Scholar Dealing with results can be problematic. Google should be a supplement to, rather than a replace- uses a complex algorithm to rank relevance. Unlike ment for, sources such as PubMed/MEDLINE and many other databases, current articles are not dis- the Cochrane Library. Google Scholar is not a de- played first, which means that you may miss the finitive source in your search for the best evidence, most up-to-date articles. Results cannot be sorted but it can be a helpful starting point. a by author, title, date or publication. Always be Do you have questions or need more help? The prepared to look beyond the first and maybe even CDA Resource Centre offers professional literature the tenth page! At the top of your results page, search and article document delivery services to there is a link to “Recent articles.” When you click CDA members. For more information, go to www. this, results are re-sorted, but not by a strict date cda-adc.ca/resource_centre. sort. According to Google Scholar Help, “The new ordering considers factors like the prominence of the author’s and journal’s previous papers, as well Renée de Gannes-Marshall is the information as the full-text of each article and how often it has specialist at the Canadian Dental Association. been cited.”

906 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • Clinical s h o w c a s e Gingival Response to Crowns: A 3-Year Report

Omar El-Mowafy, BDS, PhD, FADM

hen crowns are made with poor The gingival length of the crowns was marginal fit, an adverse gingival mismatched by 2 mm, and 1 crown looked Wresponse, particularly inflamma- wider in mesiodistal dimension than the tion and edema, is sure to follow. However, other. From the facial perspective, metal if poorly fitting crowns are later replaced was evident at the incisal edges, perhaps with properly fitted crowns, the gingival because of wear. The crown margins were tissue can heal and the damage can be poorly fitted, and there was extensive reversed. Dentists can now select from a hyperplasia and inflammation of the gin- “Clinical Showcase” is a wide variety of nonmetallic restorations. gival tissues. The colour of the porcelain series of pictorial essays that The restorations that are suitable for cases veneer was too yellow and did not match focus on the technical art of with demanding esthetic requirements in- that of adjacent teeth, and the glaze layer clinical dentistry. The section clude all-porcelain crowns and porcelain was partially lost. features step-by-step case veneers, which are associated with clin- Assessment of the periodontal pocket demonstrations of clinical depth on the buccal aspects of the cen- ical success and long service when used in problems encountered in tral incisors revealed that gingivectomy the anterior region of the mouth.1–3 They dental practice. If you would to bring the margins of the gingival tis- offer life-like esthetic results that can be like to propose a case or sues of both teeth to the same level would highly satisfying for both the patient and recommend a clinician leave sufficient depth for adequate bio- who could contribute to the dentist. In the following clinical case, logic width. this section, contact editor- such restorations were used to address an The maxillary lateral incisors were in-chief Dr. John O’Keefe adverse gingival response combined with too small relative to the central incisors, at [email protected]. a severe esthetic problem caused by im- which resulted in lack of harmony in the proper use of porcelain-bonded-to-metal set-up of the anterior teeth. Radiographic crowns. examination revealed that 1 of the 2 central incisors had previously undergone Clinical Case endodontic treatment. A 25-year-old otherwise healthy man presented with unsightly and failing Treatment: Plan and Execution porcelain-fused-to-metal crowns on his Following removal of the old crowns, maxillary central incisors and asked the tooth 11 was to undergo post and core practitioner to improve their appearance build-up. Gingivectomy was to be carried (Fig. 1). out to optimize clinical crown length for

Figure 1: Facial view of the anterior teeth shows 2 porcelain-fused-to-metal crowns on the maxillary central incisors. The crowns have undergone incisal wear, which has revealed the metal backing. Partial loss of the glaze layer has resulted in a granular surface texture. The 2 crowns do not match in terms of either height or width. The gingival tissues are inflamed and hyperplastic because of the ill-fitting margins. The lateral incisors appear much smaller than the central incisors (contrary to what would usually be expected), which creates a lack of harmony in the set-up of the anterior teeth.

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Figure 2: The 2 old crowns were sec- Figure 3: After scaling, gingivectomy was Figure 4: The 2 all-porcelain crowns tioned and removed. When the crown was carried out to increase the clinical crown and the 2 porcelain veneers as received removed from tooth 11, the core became length of tooth 21 to match that of tooth 11. from the laboratory. dislodged, so it was also removed. Tooth 11 was restored with a nonmetallic post and a composite core build-up and was then re-prepared to receive an all- porcelain crown with a wrap-around shoulder finish line. Tooth 21 underwent the same re-preparation. Teeth 12 and 22 were prepared to receive porcelain veneers.

Figure 5: The fitted surfaces of the 2 por- Figure 6: Immediate postoperative view Figure 7: Postoperative view 3 years celain crowns. The core was made of an following cementation of the 2 porcelain after placement of the crowns and aluminum oxide-based porcelain. crowns and the 2 porcelain veneers. the porcelain veneers. There is better Although there is significant improvement healing of the gingival tissues and in tooth esthetics at this point, the gingival proper shaping of the interdental tissue has not completely recovered, and papilla between teeth 11 and 12. there is evidence of gingival hyperplasia.

teeth 11 and 21. Both of these teeth were to be re- porcelain veneers (Fig. 3). Double retraction cords prepared to receive all-porcelain crowns. Teeth 12 were placed around the crown margins of teeth and 22 were to be prepared to receive porcelain 11 and 21 before use of a silicon impression ma- veneers that would increase their size (for better terial and a stock tray to take an impression. Tooth harmony with the central incisors). shade was determined in daylight with a shade Scaling and polishing was carried out to remove guide. Porcelain crowns with aluminum oxide calculus and stain. When the 2 old crowns were core were made for teeth 11 and 21, with matching removed, the core material on tooth 11 was also feldspathic porcelain veneers for teeth 12 and 22 dislodged (Fig. 2). Gingivectomy was performed (Figs. 4 and 5). The 2 crowns were first secured to increase the clinical crown length of tooth 21 with a resin cement that had performed well under to match that of tooth 11. Tooth 11 received a laboratory testing conditions.4 The try-in paste of nonmetallic fibre post secured with resin cement the resin cement was tested with the 2 veneers to and composite core build-up. As planned, dia- determine the optimum colour match, and the 2 mond burs were used to re-prepare teeth 11 and 21 veneers were then cemented with the appropri- with a 1.2-mm finish line all around the shoulder. ately shaded cement. Although some manufac- Similarly, teeth 12 and 22 were prepared to receive turers of all-porcelain crowns are highly confident

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Figure 2: The 2 old crowns were sec- Figure 3: After scaling, gingivectomy was Figure 4: The 2 all-porcelain crowns Figure 8: Close up view of the left side. Figure 9: Close up view of the right side. Figure 10: Lingual view shows shaping tioned and removed. When the crown was carried out to increase the clinical crown and the 2 porcelain veneers as received of the interdental papilla between teeth removed from tooth 11, the core became length of tooth 21 to match that of tooth 11. from the laboratory. 11 and 21 is ideal. dislodged, so it was also removed. Tooth 11 was restored with a nonmetallic post and a composite core build-up and was then re-prepared to receive an all- porcelain crown with a wrap-around shoulder finish line. Tooth 21 underwent the same re-preparation. Teeth 12 and 22 of the strength of their products, to the point that to the finish lines of the preparations. This aspect were prepared to receive porcelain veneers. they do not recommend the use of resin cement is important because it eliminates the causes of for cementation, research has shown that micro- gingival irritation and promotes proper healing of leakage occurs when resin cement is not used, the gingival tissues. and this may cause recurrent caries over the long This case provides clear evidence that if the term.5 Facial photography of the restored teeth interproximal gingival spaces are not violated (Fig. 6) immediately after the procedure showed by overextension of the crown margins, proper significant improvement in the esthetics of the healing of the gingival tissues can occur. teeth relative to the preoperative view, but the gingival tissues had not yet completely recovered and Conclusion there was evidence of some remaining gingival The preparation of crown restorations with hyperplasia. A facial view obtained 3 years after proper marginal fit and appropriate dimensions Figure 5: The fitted surfaces of the 2 por- Figure 6: Immediate postoperative view Figure 7: Postoperative view 3 years placement of the crowns and the porcelain veneers results in healthy gingival tissues and satisfactory celain crowns. The core was made of an following cementation of the 2 porcelain after placement of the crowns and a aluminum oxide-based porcelain. crowns and the 2 porcelain veneers. the porcelain veneers. There is better (Figs. 7–9) provided evidence of proper healing esthetic results. Although there is significant improvement healing of the gingival tissues and of the gingival tissue between teeth 11 and 21 and in tooth esthetics at this point, the gingival proper shaping of the interdental proper shaping of the interdental papilla. A lin- tissue has not completely recovered, and papilla between teeth 11 and 12. THE AUTHOR there is evidence of gingival hyperplasia. gual view obtained at the same time showed ideal shaping of the interdental papilla between teeth 11 and 21 (Fig. 10). Dr. El-Mowafy is professor, department of clinical This clinical case demonstrates the conse- sciences, faculty of dentistry, University of Toronto, Toronto, Ontario. teeth 11 and 21. Both of these teeth were to be re- porcelain veneers (Fig. 3). Double retraction cords quences of poor-quality crown restorations with badly fitting margins and for which there was prepared to receive all-porcelain crowns. Teeth 12 were placed around the crown margins of teeth Correspondence to: Dr. El-Mowafy, Department of Clinical and 22 were to be prepared to receive porcelain 11 and 21 before use of a silicon impression ma- no attempt to control dimensional matching. Sciences, Faculty of Dentistry, University of Toronto, 124 Edward veneers that would increase their size (for better terial and a stock tray to take an impression. Tooth Although the age of the porcelain-fused-to-metal St., Toronto, ON M5G 1G6. Email: [email protected] harmony with the central incisors). shade was determined in daylight with a shade crowns was unknown, over the years they had broken down and become extremely unsightly. References Scaling and polishing was carried out to remove guide. Porcelain crowns with aluminum oxide When the replacement crowns were planned, pro- 1. Odén A, Andersson M, Krystek-Ondracek I, Magnusson D. Five- calculus and stain. When the 2 old crowns were core were made for teeth 11 and 21, with matching year clinical evaluation of Procera AllCeram crowns. J Prosthet Dent vision was made to ensure that the crowns would 1998; 80(4):450–6. removed, the core material on tooth 11 was also feldspathic porcelain veneers for teeth 12 and 22 be matched in size (by gingivectomy to increase 2. Calamia JR. Etched porcelain veneers: the current state of the art. dislodged (Fig. 2). Gingivectomy was performed (Figs. 4 and 5). The 2 crowns were first secured the length of the clinical crown of tooth 21). The Quintessence Int 1985; 16(1):5–12. to increase the clinical crown length of tooth 21 with a resin cement that had performed well under original preparations were refined to ensure defin- 3. El-Mowafy OM. The�� use of both porcelain veneers and all-por- 4 celain crowns in restoring anterior teeth. J ��Can Dent Assoc 2006; to match that of tooth 11. Tooth 11 received a laboratory testing conditions. The try-in paste of itive finish lines that would be easy for the techni- 72(9):803–6. nonmetallic fibre post secured with resin cement the resin cement was tested with the 2 veneers to cian to follow. The impression-taking procedure 4. El-Mowafy OM, Rubo MH, El-Badrawy WA. Hardening of new and composite core build-up. As planned, dia- determine the optimum colour match, and the 2 was carried out carefully, with proper gingival re- resin cements cured through ceramic inlay. Oper Dent 1999; 24(1):38–44. mond burs were used to re-prepare teeth 11 and 21 veneers were then cemented with the appropri- traction to ensure that all important details of the 5. Albert FE, El-Mowafy OM. Marginal adaptation and microleakage with a 1.2-mm finish line all around the shoulder. ately shaded cement. Although some manufac- margins were captured by the impression material. of Procera AllCeram crowns with four cements. Int J Prosthodont Similarly, teeth 12 and 22 were prepared to receive turers of all-porcelain crowns are highly confident The margins of the new crowns were ideally fitted 2004; 17(5):529–35

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The “Point of Care” section answers everyday clinical questions by providing practical information that aims to be useful at the point of patient care. This month’s answers are provided by speakers at the ODA Annual Spring Meeting held jointly with CDA. For more information on the meeting, see page 913.

Q u e s t i o n 1 What is the significance for dental professionals of the recently documented case of patient-to-patient transmission of hepatitis B?

hile speaking with dental professionals in others2,3 has brought HBV back to the forefront recent years, I have found an increasing of attention among dental practitioners. The fol- Wconcern on their part with the potential lowing discussion highlights the major aspects of occupational risk of hepatitis C virus (HCV) and this unusual case and considers its implications for HIV infections, even though clinical and scientific dental professionals. evidence has overwhelmingly shown hepatitis B virus (HBV) to be the most infectious bloodborne Frequency of HBV Transmission in the pathogen. The success of dental infection control Dental Setting practices over the past 20 to 30 years, especially The recently reported case, summarized below, vaccination of health care workers, safer hand- is the only proven instance of patient-to-patient ling of contaminated sharps, and routine use of transmission of a bloodborne pathogen in a dental gloves, masks and eyewear, has changed how some setting and the first documented transmission of health care workers perceive HBV. As a result, HBV to dental patients since 1987. Earlier inves- many health care providers have turned their at- tigations of HBV transmission in dental practice tention to other infection control issues, such as settings, carried out in the 1970s and 1980s, dem- contamination of the water in dental units and onstrated that some dentists had unknowingly in- environmental asepsis. This shift in thinking is not fected patients with this resistant virus, which is surprising, given that the last instance of dentist- able to remain viable for up to 7 days in blood out- to-patient transmission of HBV was reported by the side the body (Table 1). Since then, adherence to Centers for Disease Control and Prevention (CDC) infection control practices, including vaccination in 1987.1 In contrast to the situation for medicine, of health care workers, has been extremely suc- where sporadic HBV outbreaks continue to occur, cessful in preventing dental transmission of HBV; dentistry has a good record for safety with regard in contrast, sporadic reports of viral transmission to transmission of HBV and other infectious dis- in medical facilities continue to appear. eases. Unfortunately, a recent report by Redd and The Case Table 1 Reports of patients infected by dentist A 60-year-old woman had 7 teeth extracted in carriers of hepatitis B (United States only) a single visit to an oral surgery office in October No. of patients Type of 2001. She had no risk factors for HBV infection, Year infected practitioner and had not been vaccinated against HBV. She began to exhibit symptoms of HBV infection in 4 1974 13 General dentist February 2002, but subsequently recovered. This 5 a 1975 0 General dentist acute case of HBV infection was reported to the 19766 37 Oral surgeon 7 New Mexico Department of Public Health in April 1976 15 Oral surgeon 2002. Subsequent investigation determined that 19778 55 Oral surgeon 9 the source patient was a 36-year-old woman who 1981 3 Oral surgeon had undergone extractions by the same oral sur- 198110 6 General dentist 11 geon and clinical staff in a procedure that ended 1982 12 Oral surgeon 161 minutes before the second one began. The 198312 4 General dentist younger woman, who had been an HBV carrier 198613 26 General dentist (positive for hepatitis B surface antigen and hepa- 19871 4 Oral surgeon titis B e antigen) since at least 1999, had had a high aNo overt symptomatic infection. viral load at the time of the oral surgery. However,

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she did not self-identify as an HBV carrier to the therefore the numbers of HBV infectious per- oral surgeon or staff in the oral surgery office. The sonnel. If the source individual and the index 15 practice employees were tested for HBV, and 14 patient had been vaccinated, this incident would of them had evidence of HBV vaccination. None of probably have been avoided. In fact, the confirmed the 15 employees demonstrated serologic evidence HBV immunity of the office staff and other pa- of prior HBV infection. Using molecular epidemi- tients treated on the day of the transmission event ologic techniques, the public health department was probably an important factor in preventing determined that this was the first instance of HBV further viral transmission in that dental facility. transmission from one patient to another in a dental setting. Conclusions The unfortunate transmission of a life-threat- Infection Control in the Oral Surgery Office ening disease, HBV infection, was recently re- CDC investigators visited the office on ported to have occurred in a dental practice. The September 26, 2002, and observed several regu- rarity of the event attests to the overall success of larly scheduled procedures. The investigators re- infection control practices in place today. Its oc- ported that the facility was modern and clean, currence, however, is a reminder of the necessity with appropriate anesthesia and infection con- to perform everyday cleaning, disinfection and trol practices in place. Standard infection con- sterilization consistently and correctly. This case trol practices were followed during the observed reinforces the principle that standard infection procedures, including appropriate hand asepsis, control precautions may be effective at minimizing anesthesia, and operation and monitoring of the the potential for cross-infection, but they do not autoclave. Gloves, masks and gowns were changed necessarily eliminate all risks. Redd and others2 between appointments. Plastic barriers were used speculated that contaminated environmental sur- on high-touch surfaces and were changed between faces might have been the mechanism of transmis- appointments. After removal of these barriers, the sion of HBV in this case. They also suggested that surfaces were sprayed with an intermediate-level universal HBV vaccination should be extended to disinfectant. For all of the patients treated in a cover presumed “low-risk” individuals, in addition single morning, fresh, sterile instruments were to children, health care workers and those in other used; no instruments were used in common among high-risk categories. a procedures. In addition, there was no evidence of viral transmission related to the use of multidose vials during oral surgical procedures. THE AUTHOR

Presumed Mechanism of Transmission Dr. John A. Molinari is professor and chair, depart- In the absence of definitive evidence of cross- ment of biomedical sciences, University of Detroit infection, the CDC investigators could only specu- Mercy School of Dentistry, Detroit, Michigan. Email: [email protected] late on the mechanism of transmission. HBV is a hardy virus that can persist in dried blood for up to 7 days, and infectious virions can remain References on surfaces even in the absence of visible blood. 1. Centers for Disease Control (CDC). Outbreak of hepatitis B associated with an oral surgeon — New Hampshire. MMWR Morb One possibility expressed by the investigators was Mortal Wkly Rep 1987; 36(9):132–3. that cross-contamination might have occurred by 2. Redd JT, Baumach J, Kohn W, Nainan O, Khristova M, Williams I. Patient-to-patient transmission of hepatitis B virus associated with means of an environmental surface. For example, oral surgery. J Infect Dis 2007; 195(9):1311–4. Epub 2007 Mar 21. a lapse in environmental aseptic procedures fol- 3. Rare case of dental patient-to-patient hepatitis B virus transmis- lowing treatment of the source patient or contam- sion recorded. [Press release] April 3, 2007. Infectious Diseases Society of America. Available: www.eurekalert.org/pub_re- ination of non-operatory surfaces by the source leases/2007-04/idso-rco040307.php. patient might have set the stage for subsequent cross-infection. The references associated with Table 1 are listed in the electronic Written discussion of the case also mentioned version of this article at www.cda-adc.ca/jcda/vol-73/issue-9/911. html. the role of vaccination against HBV in preventing

disease. Susceptibility to viral infection is neces- Dr. Molinari’s presentations at the joint ODA/CDA meeting, sary for transmission. HBV vaccination programs titled “Fighting the flu: respiratory infections and protection” (morning session) and “Update on vaccine recommendations” in place since 1982 have effectively reduced the (afternoon session), will be presented on Thursday, April 10. numbers of susceptible health care workers and

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Q u e s t i o n 2 What part of the patient record from a general dental practice is most useful for identifying the victims of disaster through forensic odontology?

he clinical diagnostic and treatment records tics, either because of custom-made restorations of dentists have many uses in a wide variety or because of the numerous anatomic traits that Tof legal contexts, but few such situations are collectively represent the person’s unique data set. more important than those in which we are asked In some people, especially those who have experi- to supply antemortem data for missing persons enced minimal or no restorative intervention, a who might be our patients. When people partici- combination of these 2 data sets may be needed for pate in high-risk activities that result in death or comparison at autopsy. are caught in natural or human-caused disasters, Restorative treatments are considered to pro- dental records can be an important source of com- vide the best basis for comparative identification. parative data to establish the identity of recovered That is because dentists extend cavity preparations, bodies. The release of antemortem data by dentists the margins of fixed prostheses and other hard- goes far beyond the scope of routine practice and tissue interventions to encompass decay, fractures emphasizes the significant societal role that prac- or other clinical problems that are specific to the titioners can play on behalf of Canadian citizens. particular patient. These unique extensions are Increasingly, as dentists learn about the role of for- visible on radiographs. If you imagine the shapes ensic odontology in mass casualty incidents, ques- of these restorative treatments as 3-dimensional tions arise about the aspect or aspects of a patient’s objects separate from the tooth, and then consider record that are most useful for the purposes of the projection of these shapes onto 2-dimensional identification and thus the records that should be radiographic film, the resulting radiographic released to authorities in these circumstances. This image of the object provides a unique 2-dimen- article aims to provide insights about how clin- sional shadow for forensic comparison. Figure 1 icians can determine which records to release so as illustrates the use of the shapes of dental restora- to provide the most up-to-date and useful data for tive treatments for identification purposes. In the forensic identification. case of a partial or complete removable prosthesis or appliance, the most important way a clinician Human Identification Based on Dental can assist in any future forensic investigation is to Features instruct the laboratory to insert the patient’s name Human identification by means of the teeth in the acrylic of the device. is based on the premise that each person’s denti- Normal variants in the shape and size of ana- tion contains a collection of unique characteris- tomic structures and various presentations of

Figure 1: Comparison of antemortem and postmortem bitewing radiographs to establish identification. The film on the left was exposed during the patient’s recall exam on January 16, 2007. The film on the right was exposed at autopsy on October 3, 2007, on a body found in a lake.

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common morphological traits, taken in combina- which will be returned to the dentist on comple- Q u e s t i o n 3 tion, also produce a unique collection of identi- tion of the identification process. fiers for each individual. Traits such as curved The importance of original records in a legal How can I protect my practice from complaints and malpractice claims? or dilacerated roots, pulp stones, accessory root context cannot be overstated. For example, the canals, supernumerary teeth, patterns of alveolar right–left laterality marker (dimple) that appears isk management is not new to dentists or diagnosis to our patients. As dentists, we need to bone trabeculae, periapical inflammatory le- on intraoral radiographic films is not visible on other health care professionals. The principle take this responsibility seriously and ensure that sions, periodontal defects and osteomas are not duplicate films, so this orientation information is Rof “do no harm” has been entrenched in each and every patient record contains a diagnosis uncommon in the general population. However, lost when films are copied. Similarly, photocopied medical practice since the times of the Hippocratic and a well-thought-out treatment plan based upon charts do not contain the often-crucial multicol- when a number of these traits appear together in oath. That is why, over the years, dentists have that diagnosis. oured notations appearing on original documents. one person’s mouth, the combination of identifiers adopted risk management principles such as infec- Diagnosis is also a key element of the informed These issues are of considerable concern and is usually sufficient for the purposes of forensic tion control, informed consent, and accurate and consent process, which is discussed in the next underscore the potential value of any and all data comparison. complete documentation. To ensure to the extent section. and the impossibility of predicting what dental possible that patients are satisfied with the dental The “Best” Forensic Dental Record information will be recovered and available after a  Always Obtain Informed Consent services they receive and that these services are person’s death. Thorough, detailed and comprehensive dental provided in a safe, competent and ethical manner, Take the time to provide your patients with In the final analysis, all original documents, treatment records that document all aspects of dentists can implement the following 6 key prin- sufficient information to allow them to make an radiographs, photographs, appliances and casts, the treatment modality provide the best data for ciples, which will go a long way toward preventing informed treatment choice. Six key elements must comparative purposes. Details of the restorative along with any associated materiel that records be covered in the informed consent process: the dental status of a missing person during their complaints and potential legal action. materials used; the type, location and length of • diagnosis lifetime, are crucial to successful identification of the retentive pin or post; the shades and moulds of  Keep Good Records • nature and purpose of the recommended human remains. a prosthetic teeth; and notes about unusual findings Bad things can happen to good dentists because treatment or treatments are but a few examples of traits that of poor records. In fact, a problem with record- • benefits and risks of the recommended have been crucial to successful identifications. THE AUTHOR keeping is often the primary reason why a dentist treatment The “best” aspect of the dental record to release cannot be defended in a malpractice claim. • treatment alternatives, including their risks for comparison with postmortem data recovered Dr. David Sweet is professor and director of the Make sure your records are detailed and ac- and benefits from an unidentified body depends on what part Bureau of Legal Dentistry (BOLD) Laboratory at the University of British Columbia, faculty of dentistry, curate, and are maintained for the required reten- • consequences of no treatment of the dental complex is recovered after death. For Vancouver, British Columbia. tion period in your jurisdiction. In Ontario, for • cost of the recommended treatment. example, if only part of the victim’s jaw is found, Email: [email protected] example, records must be maintained for at least It is also important to document details of then only data from that aspect of the antemortem 10 years after the last entry; for children, the reten- the informed consent dialogue. Consent is usually clinical record is needed. However, at the time Further Reading Morlang WM. Dentistry’s vital role in disaster preparedness. tion period is 10 years after the child reaches the obtained verbally, but the fact that it was obtained a person is reported missing and the authorities J Calif Dent Assoc 1996; 24(5):63–6. age of 18. should be documented in writing. Many dentists arrive at the dental office requesting antemortem Pretty IA, Sweet D. A look at forensic dentistry – Part 1: The role The following guidelines cover most types of like to use consent forms, and these can be helpful. data, the type of postmortem data that will eventu- of teeth in the determination of human identity. Br Dent J 2001; 190(7):359–66. dental records: If a form is used, it should include a paragraph, ally become available is not usually known. Thus, Rothwell BR, Haglund W, Morton TH. Dental identification in serial to be signed off by the patient, stating that she or • Entries should be dated, written in ink, and there is no way to predict which aspect of the homicides: the Green River Murders. J Am Dent Assoc 1989; he has read and understood the form and has had 119(3):373–9. signed or initialled. missing person’s dental record will be most useful. an opportunity to ask questions. If these 3 things Sweet D, DiZinno JA. Personal identification through dental evidence • Radiographs should be labelled and dated, and In fact, all aspects of the dental record are poten- — tooth fragments to DNA. J Calif Dent Assoc 1996; 24(5):35–42. have occurred, then informed consent is typically the radiographic findings documented in the tially invaluable; therefore, all clinical records in deemed to have been obtained. patient’s dental record. the dentist’s possession (including working casts, Practitioners should be aware, however, that • Medical histories should be complete and up to laboratory set-ups, appliances, spare prostheses, Dr. Sweet’s full-day session at the joint ODA/CDA meeting, a signed consent form on its own is not evidence but excluding accounting and financial details) titled “One dentist’s role in helping to solve murders in date. Canada!” will be presented on Friday, April 11. that informed consent was obtained. The best evi- should be released to authorities. • Each patient’s record should contain a diag- dence is documentation in the daily record of the Most importantly, only original dental records nosis and treatment plan. discussion of the key elements (e.g., “I.C. discus- should be provided for forensic use. This recom- • Progress notes should be detailed and sion as per consent form for extraction of wisdom mendation runs contrary to the belief of most clin- accurate. tooth”). icians that they should never release original data The importance of recording a diagnosis for to parties outside the practice. The forensic identi- every patient and every procedure cannot be  Make Excellent Communication a fication of human remains is an acceptable reason overemphasized. In Ontario, dentistry is one of a Priority for such release. The original records should be handful of regulated health professions and the Most patient complaints and lawsuits incor- duplicated before their release, and these dupli- only regulated dental profession that, by virtue of porate some element of poor communication. cates should be kept on file in the dental office. The practitioners’ educational background and profes- Despite your best efforts, communication lapses clinician should obtain a signed and dated receipt sional training, has been given the privilege and can and will occur; therefore, make an extra ef- from the authority collecting the original records, legal right of diagnosing and communicating a fort to ensure that checks are in place to minimize

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common morphological traits, taken in combina- which will be returned to the dentist on comple- Q u e s t i o n 3 tion, also produce a unique collection of identi- tion of the identification process. fiers for each individual. Traits such as curved The importance of original records in a legal How can I protect my practice from complaints and malpractice claims? or dilacerated roots, pulp stones, accessory root context cannot be overstated. For example, the canals, supernumerary teeth, patterns of alveolar right–left laterality marker (dimple) that appears isk management is not new to dentists or diagnosis to our patients. As dentists, we need to bone trabeculae, periapical inflammatory le- on intraoral radiographic films is not visible on other health care professionals. The principle take this responsibility seriously and ensure that sions, periodontal defects and osteomas are not duplicate films, so this orientation information is Rof “do no harm” has been entrenched in each and every patient record contains a diagnosis uncommon in the general population. However, lost when films are copied. Similarly, photocopied medical practice since the times of the Hippocratic and a well-thought-out treatment plan based upon charts do not contain the often-crucial multicol- when a number of these traits appear together in oath. That is why, over the years, dentists have that diagnosis. oured notations appearing on original documents. one person’s mouth, the combination of identifiers adopted risk management principles such as infec- Diagnosis is also a key element of the informed These issues are of considerable concern and is usually sufficient for the purposes of forensic tion control, informed consent, and accurate and consent process, which is discussed in the next underscore the potential value of any and all data comparison. complete documentation. To ensure to the extent section. and the impossibility of predicting what dental possible that patients are satisfied with the dental The “Best” Forensic Dental Record information will be recovered and available after a  Always Obtain Informed Consent services they receive and that these services are person’s death. Thorough, detailed and comprehensive dental provided in a safe, competent and ethical manner, Take the time to provide your patients with In the final analysis, all original documents, treatment records that document all aspects of dentists can implement the following 6 key prin- sufficient information to allow them to make an radiographs, photographs, appliances and casts, the treatment modality provide the best data for ciples, which will go a long way toward preventing informed treatment choice. Six key elements must comparative purposes. Details of the restorative along with any associated materiel that records be covered in the informed consent process: the dental status of a missing person during their complaints and potential legal action. materials used; the type, location and length of • diagnosis lifetime, are crucial to successful identification of the retentive pin or post; the shades and moulds of  Keep Good Records • nature and purpose of the recommended human remains. a prosthetic teeth; and notes about unusual findings Bad things can happen to good dentists because treatment or treatments are but a few examples of traits that of poor records. In fact, a problem with record- • benefits and risks of the recommended have been crucial to successful identifications. THE AUTHOR keeping is often the primary reason why a dentist treatment The “best” aspect of the dental record to release cannot be defended in a malpractice claim. • treatment alternatives, including their risks for comparison with postmortem data recovered Dr. David Sweet is professor and director of the Make sure your records are detailed and ac- and benefits from an unidentified body depends on what part Bureau of Legal Dentistry (BOLD) Laboratory at the University of British Columbia, faculty of dentistry, curate, and are maintained for the required reten- • consequences of no treatment of the dental complex is recovered after death. For Vancouver, British Columbia. tion period in your jurisdiction. In Ontario, for • cost of the recommended treatment. example, if only part of the victim’s jaw is found, Email: [email protected] example, records must be maintained for at least It is also important to document details of then only data from that aspect of the antemortem 10 years after the last entry; for children, the reten- the informed consent dialogue. Consent is usually clinical record is needed. However, at the time Further Reading Morlang WM. Dentistry’s vital role in disaster preparedness. tion period is 10 years after the child reaches the obtained verbally, but the fact that it was obtained a person is reported missing and the authorities J Calif Dent Assoc 1996; 24(5):63–6. age of 18. should be documented in writing. Many dentists arrive at the dental office requesting antemortem Pretty IA, Sweet D. A look at forensic dentistry – Part 1: The role The following guidelines cover most types of like to use consent forms, and these can be helpful. data, the type of postmortem data that will eventu- of teeth in the determination of human identity. Br Dent J 2001; 190(7):359–66. dental records: If a form is used, it should include a paragraph, ally become available is not usually known. Thus, Rothwell BR, Haglund W, Morton TH. Dental identification in serial to be signed off by the patient, stating that she or • Entries should be dated, written in ink, and there is no way to predict which aspect of the homicides: the Green River Murders. J Am Dent Assoc 1989; he has read and understood the form and has had 119(3):373–9. signed or initialled. missing person’s dental record will be most useful. an opportunity to ask questions. If these 3 things Sweet D, DiZinno JA. Personal identification through dental evidence • Radiographs should be labelled and dated, and In fact, all aspects of the dental record are poten- — tooth fragments to DNA. J Calif Dent Assoc 1996; 24(5):35–42. have occurred, then informed consent is typically the radiographic findings documented in the tially invaluable; therefore, all clinical records in deemed to have been obtained. patient’s dental record. the dentist’s possession (including working casts, Practitioners should be aware, however, that • Medical histories should be complete and up to laboratory set-ups, appliances, spare prostheses, a signed consent form on its own is not evidence but excluding accounting and financial details) date. that informed consent was obtained. The best evi- should be released to authorities. • Each patient’s record should contain a diag- dence is documentation in the daily record of the Most importantly, only original dental records nosis and treatment plan. discussion of the key elements (e.g., “I.C. discus- should be provided for forensic use. This recom- • Progress notes should be detailed and sion as per consent form for extraction of wisdom mendation runs contrary to the belief of most clin- accurate. tooth”). icians that they should never release original data The importance of recording a diagnosis for to parties outside the practice. The forensic identi- every patient and every procedure cannot be  Make Excellent Communication a fication of human remains is an acceptable reason overemphasized. In Ontario, dentistry is one of a Priority for such release. The original records should be handful of regulated health professions and the Most patient complaints and lawsuits incor- duplicated before their release, and these dupli- only regulated dental profession that, by virtue of porate some element of poor communication. cates should be kept on file in the dental office. The practitioners’ educational background and profes- Despite your best efforts, communication lapses clinician should obtain a signed and dated receipt sional training, has been given the privilege and can and will occur; therefore, make an extra ef- from the authority collecting the original records, legal right of diagnosing and communicating a fort to ensure that checks are in place to minimize

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problems in your dialogue with patients, in your have been referred to a specialist. Therefore, you discussions with staff and when speaking to col- should develop relationships with the specialists in leagues as part of the patient referral process. your area, and you should not hesitate to refer difficult cases for a second opinion or for treatment.  Develop Strategies for Preventing Again, communication is key. Mishaps Procedural mishaps that can happen in dental  Personally Review Records from Your practices include treatment of the wrong tooth, in- Practice before Transferring Them or gestion or inhalation of instruments or materials, Sending Accounts to Collection and burns, cuts or abrasions to the soft tissues. Dentists are legally required to comply with Although such mishaps are not usually considered a patient’s request to transfer records, but such to represent negligence, they may lead to patient records may include personal information that the injuries. Various strategies are available to mini- patient would not want revealed to anyone else. mize such incidents in your practice: For example, a teenager who confided that she • Make sure the patient’s current radiographs was taking birth control pills or was being treated and records are available at each appointment. for a sexually transmitted disease may have asked • Ensure that the treatment being contemplated that this information not be shared with others, is appropriate for the problem. especially her parents. In such a case, and in light • Use a rubber dam whenever possible. of the fact that most dentists prefer to obtain a new • When it is not possible to use a rubber dam, medical history themselves, you may choose not to consider protecting the throat with gauze. provide the medical history to the new dentist. • Ensure that patients wear safety glasses. Before sending a patient’s account to collec- • Ensure that office staff are aware of safety- tion, it is advisable to review the file to find out if related information for the various materials the results of treatment were less than desirable or used in the practice. if the patient has already expressed dissatisfaction. Many patients who are unhappy with their treat- Even with preventive strategies in place, ment are initially reluctant to file a complaint or mishaps may still occur, and it is important a claim against a health care provider, However, to remember that what a dentist does after the when the patient leaves the practice, sending the occurrence of such an incident is often as account to collection or instituting an action in important as the incident itself in determining small claims court to collect the outstanding bal- what happens next. It is crucial that patients be ance may the last straw for the patient, who may informed when untoward mishaps occur and the file a counterclaim. a appropriate corrective action or referral takes place. THE AUTHORS  Recognize Your Limitations and Treat within Your Comfort Level Dr. Don McFarlane is director of the Royal College When patients seek dental services, they have of Dental Surgeons of Ontario’s Professional Liability a right to expect that they will receive appropriate, Program. competent and up-to-date dental care. Even if you do not realize it from the outset of a difficult procedure, you will soon find out if you are “in over Dr. Judi Heggie is dental advisor at the Royal College your head” when treating a patient whose needs are of Dental Surgeons of Ontario’s Professional Liability beyond your competencies. When this occurs, you Program. Email: [email protected] must take appropriate action to resolve the issue, such as referring the patient to a more experienced Suggested Reading colleague or a dental specialist. However, it is pref- RCDSO’s Dispatch Magazine (www.rcdso.org/pubs_resources/ publications/dispatch.html) erable to be able to recognize your limitations The Risk Management Guide of the Professional Liability Program before undertaking any procedure. (www.rcdso.org/prof_liability/risk_management.html) When a treatment outcome is unfavourable, one of the most common allegations made by the On Thursday, April 10, senior RCDSO staff will be presenting the seminar “Staying safe in your dental practice” at the joint patient is that the treatment was beyond the den- ODA/CDA meeting. tist’s scope of practice and that the patient should

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Q u e s t i o n 4 Where does cone beam computed tomography fit into modern dental practice?

one beam computed tomography (CT) is a This modality should be viewed as an addition to novel digital imaging modality that uses a the diagnostic imaging armamentarium of dent- Crotating x-ray source and a single-panel de- istry. Image quality and the higher radiation doses tector (Fig. 1). Cone beam CT is unlike the CT associated with cone beam CT are 2 of the fac- found in most hospitals, in that the patient remains tors that may ultimately limit its use in dentistry. stationary during image acquisition. However, the However, when advanced imaging is required, it result of the 2 modalities is similar: acquisition of a may be the modality of choice for evaluating os- 3-dimensional volumetric set of image data for the seous temporomandibular joint anatomy (Fig. 3), region of interest. These data can be reconstructed localizing impacted teeth (Fig. 4), performing and viewed as thin-slice images in multiple planes the investigations needed to plan dental implants or rendered 3-dimensionally (Fig. 2). (Fig. 5), and diagnosing and monitoring oral The first application of cone beam CT in oral and maxillofacial diseases (Fig. 6). As a result of and maxillofacial radiology was described in 1998,1 its unique capabilities for multidimensional re- and since that time, a number of systems have formatting, other potential applications of cone become available worldwide. Each is unique, dif- beam CT include investigations of the paranasal fering in size (including diameter) of the imaging sinuses, assessment of palatal clefts and investiga- volume, resolution and radiation dose. Imaging tion of oral and maxillofacial trauma. volumes range from small cylindrical-shaped volumes measuring 3 cm (diameter) by 4 cm (depth) The Limitations of Cone Beam CT to large spherical volumes measuring 30.5 cm in In addition to issues of image quality and radi- diameter, with smaller-field-of-view systems pro- ation dose, a third major limitation of cone beam ducing higher-quality images. Radiation doses also CT relates to management of the image data. In vary between systems, ranging from 59 microsie- medicine, radiographic images are reported by vert (µSv) to 599 µSv (3 to 28 times the dose associ- radiologists, who accept liability for the findings. ated with a panoramic radiograph).2,3 For the most part, however, dentists act as their own radiologists. As such, they are responsible for The Uses of Cone Beam CT interpreting normal anatomy, anatomic variants Many believe that new technologies supersede and pathoses depicted on images of their own older ones, with the older technologies becoming patients, unless the images are interpreted and obsolete. This is not the case for cone beam CT. reported by a second party, such as an oral and

Figure 1: Cone beam computed tomography system showing Figure 2: Axial or transverse (top left) sagittal (middle left) the x-ray source (to the left of the model) and the receptor. and coronal (bottom left) images, and a 3-dimensional rendering of a patient’s image data (right).

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Figure 3: Sagittal (top row), axial or transverse (bottom left) and coronal (bottom right) images through a normal temporomandibular joint.

Figure 4: Oblique reconstruction Figure 5: Buccolingual cross- Figure 6: Pseudopanoramic image through along the axis of an impacted maxil- sectional image through the left hemimandible demonstrating scler- lary canine. an edentulous mandible. A osis and periosteal new bone formation, an radiopaque marker (over- appearance consistent with osteomyelitis. The lying the mandible) shows image was generated along an arc defined the proposed site of implant by the curvature of the mandibular body. placement. This image is not, however, directly compar- able with a traditionally acquired panoramic image.

maxillofacial or medical radiologist. Although the American Journal of Orthodontics and Dentofacial anatomic region depicted is limited with small- Orthopedics4 has commented that “It only makes field-of-view cone beam CT systems, systems sense that, as specialists in orthodontics, we with larger fields of view encompass radiographic understand when to refer our patients’ [cone beam anatomy that may be unfamiliar to many dentists, CT] scans to specialists in radiology — for the for example, the paranasal sinuses, the skull base, best possible care.” Fortress Insurance, a com- the tympanic cavity, the craniovertebral junction pany that provides professional liability insurance and the cervical spine. for dentists in the United States, states that “the In response to recent interest in cone beam CT dentist has a responsibility to read the entire film, systems in orthodontics, the editor-in-chief of the or have it read by a radiologist.”5 Moreover, for

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jurisdictions where patients are given the option THE AUTHOR of absolving the dentist of liability for failing to

interpret abnormalities outside of a specified area Dr. Ernie Lam is an associate professor in the disci- of primary interest, Fortress opines that “[the den- pline of oral and maxillofacial radiology, faculty of tist] cannot have the patient sign away liability.” dentistry, University of Toronto, Toronto, Ontario. Email: [email protected] Presumably, patients undergoing diagnostic testing, including cone beam CT, do so because of References a specific finding in the medical or dental history 1. Mozzo P, Procacci C, Tacconi A, Martini PT, Andreis IA. ��A new or because of a clinical sign or symptom that re- volumetric CT machine for dental imaging based on the cone-beam technique: preliminary results. Eur Radiol 1998; 8(9):1558–64. quires investigation. Recently, Cha and others6 2. Ludlow JB, Davies-Ludlow LE, Brooks SL, Howerton WB. reviewed the findings of 500 mainly orthodontic Dosimetry of 3 CBCT devices for oral and maxillofacial radiology: CB Mercuray, NewTom 3G, I-CAT. Dentomaxillofac Radiol 2006; and implant patients who underwent cone beam 35(4):219–26. CT. Incidental findings, mainly airway or sinus- 3. Ludlow JB, Davies-Ludlow LE, Mol A. Dosimetry of recently related abnormalities, were identified in 24.6% of introduced CBCT units for oral and maxillofacial radiology. 16th International Congress of Dentomaxillofacial Radiology, Beijing; patients. Of the 252 orthodontic patients, only 8 2007. had reported a previous medical history of allergy, 4. Turpin DL. Befriend your oral and maxillofacial radiologist. Am J asthma or sinusitis, and only 4 had reported a pre- Orthod Dentofacial Orthop 2007; 131(6):697. 5. Holmes SM. iCAT scanning in the dental office. Fortress Guardian vious history of temporomandibular joint symp- 2007; 9(3):2. toms. Thus, although the frequency of abnormal 6. Cha JY, Mah J, Sinclair P. Incidental findings in the maxillofacial area with 3-dimensional cone-beam imaging. Am J Orthod findings may be small and most of the abnormal- Dentofacial Orthop 2007; 132(1):7–14. ities benign, the results of this study indicate a clear and timely need to develop ordering guide- Dr. Lam will be presenting 2 sessions at the joint ODA/ lines for cone beam CT, such that the burden of CDA meeting on Friday, April 11: “Risk vs. benefit: the radiation dosing to patients is kept as low as rea- ins and outs of radiologic decision making” (morning session) and “Principles of image interpretation” (after- sonably achievable, particularly for children and noon session). adolescents. Cone beam CT has revolutionized imaging The responses in the “Point of Care” section reflect the in oral and maxillofacial radiology, and oral and opinions of the contributors and do not purport to set maxillofacial radiologists are excited about of- forth standards of care or clinical practice guidelines. fering our expertise in multidimensional imaging Readers are encouraged to do more reading on the topics to the dental community. a covered.

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Procter & Gamble Prof p/u Nov 07 p.779 E/F 4/C Debate & o p i n i o n Leadership in Ethics: Where is CDA?

Contact Author Barry Schwartz, DDS, MHSc (Bioethics) Dr. Schwartz Email: barry.schwartz@ schulich.uwo.ca

For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-73/issue-10/925.html

he Canadian Dental Association (CDA) profession, CDA still has the opportunity to has persistently reminded us that it pro- demonstrate leadership by implementing an Tvides Canadian dentists with leadership organizational ethics committee. in all of the essential areas of dentistry. In We should be concerned about ethical August 2004, CDA restructured its commit- issues that focus on answers to the question: tees to achieve its stated strategic objectives: to “What ought dentists and our organizations ensure that CDA is recognized as the national do?” when faced with challenges such as fair- leader and advocate in oral health and to en- ness, integrity, conflicts of interest, account- courage an environment in which the profes- ability, mutual trust and respect for cultural sion can achieve viable practice. Maintaining diversity, all of which have direct implications an ethics committee — to guide the profession for patients, organizations, insurance com- through ever changing and challenging ethical panies and dentists. Ethical behaviour should issues — was not part of that restructuring. be central to how individuals and organiza- Is this an indication of the lack of import- tions govern themselves while they pursue ance that ethics has in our profession and the success.1 current direction in which CDA is moving? Because dentistry is a business as well as There are now CDA committees to deal with a health profession, it should not ignore the the business of dentistry, dental academia, and business community’s response to ethical clinical and scientific affairs, to name just 3, challenges. Business has already incorporated which all have ethical implications regarding ethics committees proactively to advise com- both policy and practice. These diverse company policy and avoid scandals that could af- mittees all make decisions and recommen- fect public trust. In terms of dentistry, reports dations based on input from their various in the media since 1991 have included Second members, who most likely have distinctly dif- Opinion on Dental Ethics2 (a discussion of the ferent perspectives, as well as different levels ethics of cosmetic dentistry and access to care), of training and expertise in ethics. It is the Dental Boot Kamp3 (which suggested that ethical implications of those decisions, which dentists are pushing unnecessary treatment could provide inconsistent direction within on patients for their own monetary gain) and the organization and for dentists across the Dentists’ Fraud Growing4 (exploring the rising nation, that troubles me. number of fraudulent insurance claims). The An ethics committee at CDA would offer National Post recently carried a story about consistency and direction regarding dental a Saskatoon dentist who carried out $16,000 ethics and could be valuable to other com- worth of unnecessary procedures.5 All of these mittees in an advisory capacity. Organized reports have increased patient awareness of dentistry needs committees to tackle complex ethical issues, with implications for the level issues that affect the practice of dentistry, as of trust that patients place in their dentist. well as the operational policies of organiza- As more patients become aware of innovative tions like CDA. If ethics is important to our marketing strategies that are finding their way

��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 925 ––– Schwartz ––– into dental practice, caveat emptor (buyer beware) will sociations. Thus, in Canada, levels of guidance on dental potentially influence the entire trust-based relationship ethics are inconsistent from province to province because and erode the position of dentistry as one of the most enforcement of regulations has been integrated with the respected professions. The latest Gallup poll has dentistry provincial codes of ethics. already slipping to fifth place on a list of the most re- Consider the following: there is no guidance on a spected professions/occupations.6 Patients are more often national ethics educational curriculum, standardization openly questioning the honesty and integrity of their of codes of ethics or ongoing leadership for CDA’s own dentists.7 Who shall Canadian dentists turn to for guid- committees on ethical issues. There is no formal inter- ance on patient trust issues? active mechanism in place to deal with day-to-day issues A national ethics committee could also provide guid- that have both ethical and professional implications. The ance on patient and third-party relationships on an on- present system does allow for ad hoc committees to be going basis. CDA is an advocate of better government formed whenever pressing issues need to be discussed. services for the working poor, which was recently an This results in committees that are hastily formed and election issue in Ontario. However, dentists in large num- comprise people who have no experience working with bers refuse to participate in existing plans because many one another, which compromises their effectiveness. feel that their financial sacrifice is too great. Quite pos- Ad hoc committees only continue the reactive damage sibly with leadership from a CDA ethics advisory com- control approach that has proven to be ineffective in mittee, more dentists might shoulder their social contract maintaining public trust. An ethics committee could be responsibilities. proactive in advising members on breaking issues that Back in 1991, a CDA ethics committee developed affect the profession. the code of ethics. Over the last 16 years, the code has In my estimation, our leaders should be taking a remained basically unchanged while new conflict-of- more proactive position on issues that the public, CDA interest as well as other challenging ethical issues have and individual dentists continually confront. An ethics confounded dentists. The CDA code currently “serves committee that meets regularly can develop policies and as a basis for self-evaluation” for dentists,8 whereas the educational strategies to prevent foreseeable problems. American Dental Association (ADA) has an active ethics A national ethics committee could offer recommenda- committee (the Council on Ethics, Bylaws and Judicial tions to dental schools regarding establishing an effective Affairs), a constantly evolving code of ethics and requires ethics curriculum. its members to voluntarily agree to abide by the ADA It is incumbent on dental organizations to build en- code as a condition of membership in the association. abling environments that will ensure that consistent eth- They recognize that continued public trust in the dental ical principles and values are part of the underpinnings of profession is based on the commitment of individual den- the guidelines and bylaws of the organization. Guidance tists to high ethical standards of conduct.9 ADA does not can be given to members on what is acceptable conduct simply put out a code of principles, it offers a code of pro- in a manner that is adaptable to changing moral values fessional conduct and detailed advisory opinions as well. and legislation. For our national leaders to defer those Ethics committees are currently being struck in both ethical challenges to their provincial counterparts and large corporations and smaller businesses, which are now the licensing bodies is not the exemplar function that I also hiring ethics managers to deal with ethical issues envision for CDA. If CDA’s mandate is to provide leader- more proactively. This has become a business necessity ship to our profession based on the advice of its standing as ethical issues that arise in the workplace may result in committees, a committee providing guidance on dental lawsuits that can drain operating budgets or incur gov- ethics issues that impact on the organizational structure ernment penalties. In terms of public relations, it is also and the policies of that organization must be a part of the good for businesses to show that they are taking steps process. to raise their level of transparency and accountability CDA is currently undergoing another governance re- to a savvier public who demands solutions to the ethical view, which will likely entail re-examining its committee quagmires of the past. structures. If you, as readers of JCDA, share my opinion, Medicine has long seen the value of ethics commit- I encourage you to write to the president and directors of tees; consequently, those committees play an integral CDA to voice your disapproval of the status quo. Possibly, role in policy recommendations and guidelines, educa- in that way, we can get the leadership on ethics that we tion and case review at the treatment and organizational deserve. Furthermore, I would like to propose terms of levels. CDA, on the other hand, disbanded its ethics reference for an organizational ethics committee that committee years ago. The reasons given by CDA revolve could serve as a guiding framework for the creation of around the fact that regulations, as well as their enforce- such a committee. The terms of reference are described in ment, are provincially controlled. CDA has, therefore, Appendix 1, which is available at www.cda-adc.ca/jcda/ deferred guidance on ethics to provincial colleges and as- vol-73/issue-10/925.html. a

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3. Walsh P. Dental boot kamp. CBC Disclosure, Feb. 18, 2003. THE AUTHOR 4. Blackwell T. Dentists’ fraud growing. National Post 2002, Sept.27. ��Canada Dr. Schwartz is an assistant professor in practice administration at the Section A4. Schulich School of Medicine and Dentistry, University of Western Ontario, 5. Dentist must cough up for unnecessary procedures. National Post 2007, London, Ontario. Oct. 2. News Section A2. 6. Saad L. Nurses top list of most honest and ethical professions. Gallup Correspondence to: Dr. Barry Schwartz, 14 Ravencliffe Rd., Thornhill, News Service; Dec. 14, 2006. Available:�� www.calnurse.org/media-center/ ON L3T 5N8 in-the-news/2006/december/page.jsp?itemID=29117737&print=t ��(accessed 2007 Oct. 28). The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the Canadian Dental Association. 7. Schwartz B. Dental ethics: our future lies in education and ethics committees. J Can Dent Assoc 2004; 70(2):85–6. References 8. Code of ethics. Ottawa: Canadian Dental Association; Aug 1991. 1. Dempsey A. Building an ethical organizational culture. Chumir Ethics Available: www.cda-adc.ca/en/cda/about_cda/code_of_ethics/index.asp (ac- Forum 2004; 4(3):7. cessed 2007 Oct. 28). 2. Second Opinion, program 894320 with Dr. Jos Welie, ethicist from 9. ADA principles of ethics and code of professional conduct. Introduction. Creighton University, James Highland and Donald Mulcahey. Toronto: TV Chicago: American Dental Association; 2005. Available: www.ada.org/prof/ Ontario; March 10, 2004. prac/law/code/index.asp (accessed 2007 Oct. 28).

Notice of Meetings MEETING OF THE GENERAL ASSEMBLY INCLUDING THE ANNUAL GENERAL MEETING Friday, April 18, 2008 and Saturday, April 19, 2008

TAKE NOTICE that a meeting of the Canadian Dental Association’s General Assembly, including Annual General Meeting and Interactive Session, will be held on Friday, April 18, 2008, at 09.00 hrs through to Saturday, April 19, 2008, at the Fairmont Château Laurier Hotel, 1 Rideau Street, Ottawa, Ontario.

Joel Neal Executive Director & Secretary (Acting) Canadian Dental Association

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CDSPI (Dice) p/u Feb 07 p.66 E/F 4/C Debate & o p i n i o n Early Childhood Dental Disease — What’s in a Name?

Contact Author Allan Narvey, DDS, Cert Pedo, FRCD(C), Luke Shwart, DMD, MBA Dr. Shwart Email: luke.shwart@ calgaryhealthregion.ca

For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-73/issue-10/929.html

“What’s in a name? That which we call a rose, by any other name would smell as sweet.” William Shakespeare, Romeo and Juliet, Act II, Scene ii

hakespeare knew that a name is more body. Worse yet, the term may delay recogni- than the title we assign to a person or tion and access to treatment. Sthing — it can include the qualities of Over the last 3 decades we fought hard for a subject so that it can easily be identified recognition of the importance of a healthy oral and put in context. The expanded promotion environment for everyone, not only cardiac, of health information means that non-dental cancer, diabetic, transplant and special needs professionals and the public are exposed to patients. Those of us currently engaged in the dental terminology, so it behooves dentists to battle know how much work it takes to change take care with names. One that has evolved a paradigm. The idea that good oral health is over time is the label applied to tooth decay linked to good general health is gaining recog- in very young children. It has been known as nition in many areas of society. Just as people bottle mouth, baby bottle tooth decay, nursing no longer shrug about smoking or drinking caries, labial caries and, most recently, early and driving, we no longer ignore the health childhood caries (ECC). At a workshop on risks related to dental diseases. The battle’s ECC in 1999,1 participants defined the disease tide is turning in our favour, but we still have and set the parameters for its most rampant work to do. version: severe early childhood caries. Young patients, the next generation of Can you see the trend? Many of these labels Canadians, must be our priority. Children are presumed an etiology. We now find that the the most vulnerable members of society, yet most recent term, ECC, leaves something to they are being ravaged by some of the worst be desired. At a conference on ECC in Calgary levels of dental disease many pediatric den- in September (see page 897), the collective tists have ever seen. This disease, which is wisdom of delegates representing diverse mostly preventable, affects all strata of the areas of interest, from medicine, nursing, so- socioeconomic scale, although it is concen- cial work, immigrant and refugee aid, poverty trated in immigrant and refugee groups, First reduction and teaching, told us that ECC is a Nations residents and those trapped in rising misnomer that perpetuates the unfortunate poverty levels. If society is judged by how concept that the mouth is separate from the it treats our most vulnerable, we have some

��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 929 ––– Shwart ––– serious questions to ask ourselves as those responsible for Our universities, the Canadian Dental Association, the oral health of our nation. The suffering among those the Canadian Academy of Pediatric Dentistry, the affected is endless and better prevention is needed, other- Canadian Association of Public Health Dentistry, Health wise we will never have enough pediatric dentists to care Canada and other organizations with a stake in child- for all those needing treatment. hood health should be among the early adopters of the The delegates at the Calgary conference came to un- new name. We can ask our colleagues in medical schools, derstand that what we have labelle��d�� ECC is linked not the Canadian Pediatric Society (which is forming an only to the pain of children who often are too young Oral Health section) and the Canadian Public Health to tell us what the problem is, but also to infection and Association to start using this new terminology. We can future sequelae. The effects of preschooler tooth decay reach across borders and encourage the change among may have an impact on the child’s family, schooling, per- our colleagues in the United States and abroad. With sonality, social relationships, mind, restful sleep, physical some help, it won’t be long before the tipping point is growth and development. In Canada, tens of millions reached and the term ECC will seem quite archaic, used of health care dollars are spent annually on this disease only by those no longer in the know. that usually begins before a parent ever thinks of taking Be a part of the change you envision. Let’s call this serious health issue a disease and begin treating it like the child in for a dental checkup or considers the general a health consequences of not doing so. one. Parents often don’t understand the word “caries.” To them, it sounds like a strange dental term that only den- THE AUTHORS tists use. Delegates at the Calgary conference, including those non-dental professionals who work on the front Dr. Allan Narvey and Dr. Luke Shwart co-chaired the Task Force and Planning Committee for the 2007 Calgary Conference on Early Childhood lines with young families, recognized that people need Caries. a term that reflects the seriousness of the disease and its consequences. We need to put the disease back into early Dr. Narvey maintains a pediatric dental practice in Calgary, childhood caries. We need to call it “early childhood Alberta. dental disease.” At the conference, this surprising proposal was met by an immediate and audible approval in the room. It struck us at once that renaming the condition is the Dr. Shwart is manager, Community Oral Health Services, right thing to do. The expression “early childhood dental Calgary Health Region, Calgary, Alberta. disease” adds context; people understand disease as something that can be prevented and has general health Correspondence to: Dr. Luke Shwart, 1509 Centre St. SW, Calgary, AB effects. It very simply replaces a confounding name with T2G 2E6. a straightforward one. The views expressed are those of the authors and do not necessarily reflect Because the risk factors of decay also contribute to the opinions or official policies of the Canadian Dental Association. childhood obesity and malnutrition, we have an opportunity to collaborate with organizations fighting those References problems. By renaming ECC a disease, we bring it to the 1. Ismail AI, Sohn W. A systematic review of clinical diagnostic criteria of early childhood caries. J Public Health Dent 1999; 59(3):171–91. forefront and make it a target for all of our colleagues 2. Canadian Dental Association. CDA position statement on first visit to who care for children and young families. the dentist. February 2005. Available: www.cda-adc.ca/_files/position_ Although we submit this proposal to change the name statements/first_visit.pdf. of this infectious disease so that it can be more univer- sally understood and recognized, it is you, the dental professionals of Canada, who can lead the way and make this change happen. Now that you are following the Canadian Dental Association’s position statement for checking children by their first birthday,2 you can call early childhood caries a disease when you see it. Among colleagues, you can refer to it as ECDD, a slightly longer acronym, but a refreshing and current one. In your clinic you can continue to use fluoride varnish, a well-researched and evidence-based strategy for halting and reversing early decalcification and an effective treatment for limiting this disease in high risk groups.

930 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • Vident ? Clinical P r a c t i c e

Stratos 4/c E/F

Eng: NEW Fr: p/u Nov 07 p.830 Clinical P r a c t i c e Resin-Bonded Fixed Partial Dentures: What’s New?

Contact Author Chris C.L. Wyatt, DMD, MSc, FRCD(C) Dr. Wyatt Email: cwyatt@ interchange.ubc.ca ABSTRACT

Background and Objective: Dentists often question the use of resin-bonded fixed partial dentures (RBFPDs) for reliable restoration of tooth-bound edentulous spaces. Initial attempts at bonding fixed partial dentures on teeth resulted in early failure due to debonding. In the 1980s and 1990s, improvements in preparation methods, metal alloys and bonding techniques made the RBFPD a more predictable option. In this paper, we summarize recent information concerning its success and failure. Methods: A MEDLINE search using key words describing RBFPDs was carried out to identify pertinent English articles appearing in peer-reviewed journals since 2000. Results: The principle reason for failure of RBFPDs remains debonding of the framework from the abutment teeth. Selection of nonmobile abutment teeth, preparation to enhance retention and resistance form, choice of the appropriate alloy and metal, and tooth bonding technique are the keys to success. The use of cantilever and nonrigid attachments may decrease interabutment forces and reduce debonding of retainers. Conclusions: The survival rate of RBFPDs is still considerably lower than that of conventional fixed partial dentures. Although RBFPDs can be used in both the anterior and posterior regions of the mouth to replace 1 or 2 missing teeth, careful abutment selection, tooth preparation, alloy selection and bonding technique are critical for clinical success.

For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-73/issue-10/933.html

he prosthetic restoration of small eden- In the 1970s, Howe and Denehy1 adapted tulous spans poses a dilemma when the the Rochette bonded cast-metal periodontal Tadjacent teeth do not require crowns. It splint concept2 to create the first RBFPD. The is difficult to justify extensive reduction of the early procedures were conservative, but prob- adjacent teeth to support a conventional fixed lems with debonding resulted in a survival partial denture. A single-tooth implant is an rate of only 28% at 7.5 years.3 To enhance alternative for patients with adequate bone retention and resistance form of posterior dimensions and who are willing to undergo a RBFPDs, Livaditis4 recommended preparation minor surgical procedure. However, oral im- of parallel guide surfaces on the interproximal plants are not the treatment of choice for many and lingual aspects of the adjacent teeth along patients and the resin-bonded fixed partial with rests on the occlusal aspect to counteract denture (RBFPD) offers a possible solution. dislodging forces. Resin bonding was further

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Patient Selection a b Patients with small edentulous spans bounded by sound teeth are good candidates for RBFPDs (Fig. 1). The potential abutment teeth should be healthy, unrestored or minimally restored, free of caries and periodontal disease, and have an adequate crown height and width. A nonmobile tooth with an adequate Figure 1: (a) Facial view of missing maxillary left lateral incisor. (b) Occlusal view of surface area of enamel provides an missing maxillary left lateral incisor. ideal abutment. Although the young are more likely to have sound teeth, a b debond rates are higher among people under 30 years of age.7 Although the RBFPD is considered a definitive solution for single- unit edentulous spaces bounded by healthy teeth, case reports on the use of this procedure as a provisional treatment continue to be published. Poyser and others8 recommend the Rochette bridge as an alterna- c d tive to an acrylic resin removable partial denture. Al-Wahadni and Al-Omari9 calculated a 90.5% success rate over the short term (35 months) for 21 RBFPDs used as provisional prostheses immediately following tooth extraction. Two mandibular posterior devices failed after 3 and 4 months due to trauma, but were Figure 2: (a) Tooth preparation finish lines for anterior resin-bonded fixed partial den- successfully rebonded. ture (RBFPD). (b) Facial view of anterior RBFPD. (c) Palatal view. (d) Occlusal view. Tooth Preparation Since 2000, modification of the tooth preparation process has been enhanced by using solid electrolytically etched base- advocated to enhance retention and resistance form of metal-alloy casting.5 The result was a doubling of the RBFPDs. The goal is to create a defined path of inser- survival rate to 64% at 7.5 years.3 In the 1980s and 1990s, tion for the framework while minimizing the display of significant advances in metal surface treatment, dentin metal. Frameworks have been extended maximally on bonding and resin cements potentially improved the clin- the lingual aspect of teeth to improve resistance form and ical success rate of RBFPDs. A meta-analysis6 identified prevent dislodgment of the restoration. The use of defined 60 papers published in the 1980s reporting success rates rest preparations (cingulum and occlusal) has been advocated to provide support or prevent dislodgement to- for various designs; Kaplan-Meier statistical analysis ward the gingival aspect. The use of proximal grooves on determined an overall survival of 74% ± 2% at 4 years for molars in preparation for RBFPDs has resulted in signifi- 1,598 RBFPDs compared with 74% ± 2% at 15 years for cant improvements in retention and resistance as meas- 4,118 conventional fixed partial dentures. ured by dislodgement forces on maxillary ivorine teeth; In this paper, we summarize outcomes of RBFPDs however, no significant improvement has been noted for published in English-language, peer-reviewed journals mandibular molars.10 Although tooth preparation is re- since 2000. In addition, new information concerning quired, less than half the amount of coronal tooth struc- preparation, material selection and bonding of RBFPDs is ture by weight is removed compared with that removed explored. Articles were identified by a MEDLINE search for complete coverage crowns.11 According to studies of using key words describing RBFPDs. debonding, the mean debonding rate for RBFPDs placed

934 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • ––– Fixed Partial Dentures ––– without retentive tooth preparation was 47% compared with only 11% for a b those with retentive preparation.7 El-Mowafy and Rubo12 recommend an anterior design involving a 0.5-mm lingual reduction of enamel and a 1-mm supragingival reduction extending to the centre of the interproximal contact, with an incisal finish line 2 mm short of the incisal edge for optimal esthetics (Fig. 2).

Adequate and parallel axial reduc- c d tion of the proximal surface adjacent to the edentulous area and extending lingual to the planned interproximal contact is required for a path of in- sertion and retention. Maximum extension onto the proximal surfaces with proximal grooves will enhance resistance for the RBFPD and prevent mesiodistal and faciolingual dislodgement. A cingulum rest with Figure 3: (a) Tooth preparation finish lines for posterior resin-bonded fixed partial denture (RBFPD). (b) Facial view of posterior RBFPD. (c) Palatal view. (d) Occlusal view. a flat floor will provide support, preventing movement toward the gingival aspect. A posterior design that creates parallelism between the proximal surfaces of the teeth maximize the surface area to enhance bonding of a rigid adjacent to the edentulous space creates an optimal in- framework. Occlusion on the pontic should be kept to a sertion path.12,13 The supragingival preparation, 0.5 mm minimum and molar-sized pontics should be avoided. within enamel, should extend from the facial line angle A review17 of 11 clinical studies using cantilevered lingual to just short of the interproximal contact area on RBFPDs concluded that this prosthetic design was re- each of the adjacent teeth. Occlusal rests and the base of liable and predictable and had greater longevity than the lingual grooves provide support, preventing move- conventional RBFPDs with 2 abutments. Compared with ment toward the gingival aspect (Fig. 3). Alternatively, conventional RBFPDs, this restoration is claimed to have slot or box preparations replacing existing restorations better esthetics, to involve less tissue damage, to be easier may be used for framework support. Creating a box with to clean, to be less expensive and to have no chance of a slight convergence toward the occlusal aspect to lock undetected debond due to its single retainer.17 When in the composite resin cement can enhance retention.12 269 2-unit cantilevered RBFPDs were followed for at least A similar posterior design has been recommended by 2 years, debonding occurred in 14 (94.8% success rate); Chow and others14 with the addition of a palatal groove no changes in occlusion occurred in relation to drifting and an occlusal strut (mesial-distal groove) to enhance 18 resistance form. Shimizu and Takahashi15 describe a pos- of abutment teeth. terior design that involves preparation extending from a The integration of a nonrigid connector between the mid-buccal to a mid-lingual groove and incorporating an abutment and the pontics of long-span, RBFPDs with occlusal rest on each abutment tooth. However, this dis- 2 or more pontics may reduce debond failure by allowing 19 play of metal on the buccal surface may not be acceptable independent movement of the abutment teeth. This de- where esthetics are a concern. sign reduces the interabutment stresses that tend to cause debonding. The nonrigid connector is designed to allow Alternative Designs movement in the vertical and horizontal planes, such that 19 The use of a single abutment to support a single pontic the least mobile retainer contains the matrix. A clinical may be a viable alternative RBFPD design, at least for success rate of 92.2% was noted for 43 RBFPDs with 2 or anterior regions. The design principles are the same as for more pontics that were followed up to 87 months.20 All the conventional RBFPD, with conservative tooth prepar- failed prostheses replaced posterior teeth, and adverse ation, but optimizing resistance form.16 The preparation occlusal contacts on the abutment teeth were speculated should be confined to enamel as much as possible and to be the cause of this failure.

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Bonding A retrospective study of 100 RBFPDs placed between The preparation of abutment teeth for RBFPDs 1993 and 2003 found that various preparation designs, using the previously described 0.5-mm axial reduction metal alloys, metal preparations, number of abutments 29 with further reduction for grooves, boxes and rest seats and pontics were not predictive of debonding. However, likely exposes dentin. An in vitro study of 20 extracted the use of rubber dam during cementation significantly premolars after RBFPD preparation noted dentin reduced the risk of debonding. exposure on all specimens; the mean area of exposure was 11.06 mm2 (16.15%).21 Preparation of 1-mm deep Esthetics interproximal grooves exposed dentin in all teeth. Axial Multiple questionnaires completed by 358 patients reduction resulted in variable dentin exposure at the during regular recalls revealed that the degree of satisfac- gingival margin. Reliance on dentin bonding in modern tion with RBFPDs was high and did not seem to be influ- RBFPD preparation designs seems a reality. enced by the occurrence of failure.30 However, satisfaction Base metal alloys, typically nickel–chromium–beryl- was correlated with complaints about colour and shape lium, are preferred over gold alloys due to their enhanced of the pontics. The metal framework of resin-bonded bond to resin cements. In vitro testing using aqueous bridges may also darken thin or translucent abutment aging and cyclic loading of Panavia-F (Kuraray Co., Ltd., teeth; 5 studies identified this problem, with an overall Osaka, Japan) cemented RBFPDs determined that de- occurrence of 18%.7 The fracture of porcelain on the bonding was a result of cohesive failure within the cement pontics is an esthetic complication that was identified in at the filler–resin interface.22 No difference in debond 15 studies with a mean incidence of 3%.7 rates over 6 and 12 months was noted between nickel– chromium based RBFPDs cemented with Panavia 21 Clinical Success and Failure Opaque (Kuraray Co., Ltd.) and Scotchbond Multi-Purpose An extensive literature review7 to identify the inci- with Scotchbond Resin Cement (3M Dental Products, dence of complications in fixed prosthodontics included St. Paul, Minn.); however, the latter (a clear cement) was RBFPDs. This study reviewed 56 publications, although associated with graying of the abutment teeth.23 when multiple reports on the same patient groups were In vitro testing of combinations of chrome–cobalt eliminated, only 8 papers published between 1984 and metal surface treatments and resin cements found the 1998 remained. A total of 1,823 complications occurred use of Unifix (Cavex Holland BV, Haarlem, Holland) and in 7,029 RBFPDs in service for 1 month to 15 years. The airborne-particle abrasion (50 micron aluminium oxide) overall debond rate of 21% affected 1,481 prostheses. The provided the firmest physical bond.24 Similar research debond rate during the first 2 years was 10%, between using nickel–chromium alloy also resulted in good bond 2–5 years the rate was 20%, and at > 5 years the rate strengths.25 Airborne-particle abrasion of the alloy sig- was 24%. The debond rate for RBFPDs with more than nificantly improved bond strength; further enhancement 1 pontic (52%) was double that for frameworks supporting was achieved by using 96% isopropanol for 3 minutes a single pontic. in an ultrasonic cleaner-than-air dryer for an additional Individual studies reporting on success of current 3 minutes.25 design principles and bonding techniques show promise. Use of tin-plating gold alloys to enhance bonding has The mean survival rate, based on bond retention, was not been predictable and led researchers to explore other 85% after 5 years for 100 RBFPDs placed between 1993 surface treatments. The use of a metal primer (Alloy and 2003 at the University of Turin.29 The annual de- Primer, Kuraray Co., Ltd.) significantly improved the bond rate over 3 years was 4.6% for 59 RBFPDs placed by tensile bond strength between gold–palladium alloys predoctoral dental students.31 The debond rate was and human enamel compared with airborne-particle 3 times higher in the mandible than the maxilla, with abrading and tin plating.26 This primer is based on the poorest survival (debond rate 13.4%) in the anterior acetone, 10-methacryloyloxydecyl dihydrogen phosphate mandible. No differences in periodontal health (bleeding and 6-vinylbenzyl-n-propyl amino triazine dithione. The on probing and pocket depth) were noted between abut- use of a vinyl-thiol primer (a solution of acetone con- ment teeth and controls. taining 0.5% 6-[4-vinylbenzyl-n-propyl] amino-1,3,5- Using Kaplan-Meier analysis, Zalkind and others32 triazine-2,4-dithiol) to bond gold alloy based RBFPDs determined that 51 conventional base-metal alloy resulted in a clinical success rate (76.9% at 10 years) sim- RBFPDs placed under controlled clinical conditions and ilar to that for conventional base-metal alloys.27 The use followed over 13 years had a mean life expectancy of of silica coating to enhance bonding of RBFPD frame- 85 months (7 years) ± 13%. Cox’s proportional hazard works resulted in a similar survival rate.28 analysis revealed that abutment teeth that were periodon- El-Mowafy and Rubo12 recommend rubber dam isola- tally involved (relative risk [RR] 9.40) and were treated tion to enhance bonding of the RBFPD to tooth structure. following orthodontics (RR 7.88) were significantly

936 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • ––– Fixed Partial Dentures ––– associated with failure of RBFPDs. Tooth mobility was ance form, appropriate alloy selection and metal and the likely cause of failure in both these situations. tooth bonding technique are critical for success. a The use of supragingival margins should allow for adequate oral hygiene to control dental plaque and pre- THE AUTHOR vent gingivitis, periodontitis and dental caries. A lack of clinical impact on gingival and periodontal condi- Dr. Wyatt is associate professor and head of the division of tions has been reported; however, 22 studies of RBFPDs prosthodontics, department of oral health sciences, faculty of reporting on caries revealed a mean occurrence of 7%.7 dentistry, University of British Columbia, Vancouver, British The complicating factor may be debonded frameworks; Columbia. 7 studies reported on caries in conjunction with de- Correspondence: Dr. Chris C.L. Wyatt, Department of Oral Health bonded retainers. Sciences, Faculty of Dentistry, University of British Columbia, The use of cantilevered RBFPDs may be a viable 2199 Wesbrook Mall, Vancouver, BC V6T 1Z3. alternative to 2 abutment RBFPDs. Kaplan-Meier sur- The author has no declared financial interests in any company manufac- vival estimates showed no significant difference be- turing the types of products mentioned in this article. tween the survival rate for 77 RBFPDs (63%) and 25 cantilevered RBFPDs (81%) after 4 years.33 A review of This article has been peer reviewed. 2-unit cantilevered RBFPDs at the Prince Philip Dental References Hospital (Hong Kong) revealed that 82 prostheses had a 1. Howe DF, Denehy GE. Anterior fixed partial dentures utilizing the acid-etch survival rate of 95.1% over the short term (mean service technique and a cast metal framework. J Prosthet Dent 1977; 37(1):28–31. life 36.7 ± 15.4 months; range 4.3–95.4 months).34 This 2. Rochette AL. Attachment of a splint to enamel of lower anterior teeth. high success rate may be due to minimal function or oc- J Prosthet Dent 1973; 30(4):418–23. 3. Creugers NH, Kayser AF, van’t Hof MA. ��A seven-and-a-half-year survival clusal load. study of resin-bonded bridges. J Dent Res 1992; 71(11):1822–5. 4. Livaditis GJ. Cast metal resin-bonded retainers for posterior teeth. Patient Satisfaction J Am Dent Assoc 1980; 101(6):926–9. 5. Livaditis GJ, Thompson VP. Etched castings: an improved retentive mecha- Mandibular bilateral distal extension cantilevered nism for resin-bonded retainers. J Prosthet Dent 1982; 47(1):52–8. RBFPDs were found to be equivalent or superior to re- 6. Creugers NH, Kayser AF, Van’t Hof MA. A�� meta-analysis of durability data on conventional fixed bridges. Community Dent Oral Epidemiol 1994; movable partial dentures for 60 patients who completed 22(6):448–52. 35 satisfaction questionnaires. No difference in quality 7. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications of life was noted between patients provided with im- in fixed prosthodontics. J Prosthet Dent 2003; 90(1):31–41. 36 8. Poyser NJ, Briggs PF, Chana HS. A modern day application of the Rochette plant crowns and those receiving RBFPDs. This study bridge. Eur J Prosthodont Restor Dent 2004; 12(2):57–62. compared 11 patients with implant crowns and 33 with 9. Al-Wahadni AM, Al-Omari WM. ��Immediate resin-bonded bridgework: RBFPDs; the 2 groups were matched for gender, age, results of a medium-term clinical follow-up study. J Oral Rehabil 2004; 31(1):90–4. edentulous span and location of prostheses within the 10. Emara RZ, Byrne D, Hussey DL, Claffey N. Effects of groove placement mouth. The self-administered quality-of-life question- on the retention/resistance of resin-bonded retainers for maxillary and naire contained 2 subscales related to oral condition mandibular second molars. J Prosthet Dent 2001; 85(5):472–8. 11. Edelhoff D, Sorensen JA. Tooth structure removal associated with various (mastication, pronunciation, swallowing, oral cleaning preparation designs for anterior teeth. J Prosthet Dent 2002; 87(5):503–9. and esthetics) and general condition (physical function 12. El-Mowafy O, Rubo MH. Retention of a posterior resin-bonded fixed partial denture with a modified design: an in-vitro study. Int J Prosthodont and psychological state). No differences were noted 2000; 13(5):425–31. between treatment types. Patient satisfaction with canti- 13. El-Mowafy O, Rubo MH. Resin-bonded fixed partial dentures — a litera- levered RBFPDs was also high; however, 10% were con- ture review with presentation of a novel approach. Int J Prosthod��ont 2000; 13(6):460–7. 34 cerned about the metal appearance of the prostheses. 14. Chow TW, Chung RW, Chu FC, Newsome PR. Tooth preparations designed for posterior resin-bonded fixed partial dentures: a clinical report. Conclusions J Prosthet�� Dent 2002; 88(6):561–4. 15. Shimizu H, Takahashi Y. Retainer design for posterior resin-bonded fixed RBFPDs can be used successfully in both the an- partial dentures: a technical report. Quintessence Int 2004; 35(3):653–4. terior and posterior regions of the mouth to replace 1 or 16. Botelho M. Design principles for cantilevered resin-bonded fixed partial dentures. Quintessence Int 2000; 31(9):613–9. 2 missing teeth. However, the survival rate of RBFPDs 17. Van Dalen A, Feilzer AJ, Kleverlaan CJ. A literature review of two-unit is still considerably less than that of conventional fixed cantilever FPDs. Int J Prosthodont 2004; 17(3):281–4. partial dentures. The principle reason for failure is de- 18. Botelho MG, Leung KC, Ng H, Chan K. A retrospective clinical evaluation of two-unit cantilevered resin-bonded fixed partial dentures. bonding of the framework from the abutment teeth. The J Am Dent Assoc 2006; 137(6):783–8. use of cantilevered and nonrigid attachments may de- 19. Botelho MG. Improved design of long-span resin-bonded fixed partial crease interabutment forces and reduce debonding of dentures: three case reports. Quintessence Int 2003; 34(3):167–71. 20. Botelho MG, Dyson JE. Long-span,�� fixed-movable, resin-bonded retainers. The selection of nonmobile abutment teeth, fixed partial dentures: a retrospective, preliminary clinical investigation. preparation designs that enhance retention and resist- Int J Prosthodont 2005; 18(5):371–6.

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21. Bassi GS, Youngson CC. An in vitro study of dentin exposure during 29. Audenino G, Giannella G, Morello GM, Ceccarelli M, Carossa S, Bassi F. resin-bonded fixed partial denture preparation. Quintessence Int 2004; Resin-bonded fixed partial dentures: ten-year follow-up. Int J Prosthodont 35(7):541–8. 2006; 19(1):22–3. 22. Walker MP, Spencer P, Eick JD. Effect of simulated resin-bonded fixed 30. Creugers NH, De Kanter RJ. Patients’�� satisfaction in two long-term partial denture clinical conditions on resin cement mechanical properties. clinical studies on resin-bonded bridges. J Oral Rehabil 2000; 27(7):602–7. J Oral Rehabil 2003; 30(8):837–46. 31. Aslani E, Johansson J, Moberg LE. Resin-bonded�� bridges by dental under- 23. Aboush YE, Estetah N. A prospective clinical study of a multipurpose graduates: three-year follow-up. Swed Dent J 2001; 25(1):21–9. adhesive used for the cementation of resin-bonded bridges. Oper Dent 2001; 26(6):540–5. 32. Zalkind M, Ever-Hadani P, Hochman N. Resin-bonded fixed partial denture retention: a retrospective 13-year follow-up. J Oral Rehabil 2003; 24. Van Dalen A, Feilzer AJ, Kleverlaan CJ. The influence of surface 30(10):971–7. treatment and luting cement on in vitro behavior of two-unit cantilever resin-bonded bridges. Dent Mater 2005; 21(7):625–32. 33. Chai J, Chu FC, Newsome PR, Chow TW. Retrospective survival analysis of 3-unit fixed-fixed and 2-unit cantilevered fixed partial dentures. J Oral 25. Quaas AC, Heide S, Freitag S, Kern M. Influence of metal cleaning methods on the resin bond strength to NiCr alloy. Dent Mater 2005; Rehabil 2005; 32(10):759–65. 21(3):192–200. 34. Botelho MG, Chan AW, Yiu EY, Tse ET. Longevity of two-unit canti- 26. Petrie CS, Eick JD, Williams K, Spencer P. A comparison of 3 alloy surface levered resin-bonded fixed partial dentures. Am J Dent 2002; 15(5):295–9. treatments for resin-bonded prostheses. J Prosthodont 2001; 10(4):217–23. 35. Jepson N, Allen F, Moynihan P, Kelly P, Thomason M. Patient satisfaction 27. Hikage S, Hirose Y, Sawada N, Endo K, Ohno H. Clinical longevity following restoration of shortened mandibular dental arches in a random- of resin-bonded bridges using a vinyl-thiol primer. J Oral Rehabil 2003; ized controlled trial. Int J Prosthodont 2003; 16(4):409–14. 30(10):1022–9. 36. Sonoyama W, Kuboki T, Okamoto S, Suzuki H, Arakawa H, Kanyama M, 28. Ketabi AR, Kaus T, Herdach F, Groten M, Axmann-Krcmar D, Probster and others. Quality of life assessment in patients with implant-supported L, and other. Thirteen-year follow-up study of resin-bonded fixed partial and resin-bonded fixed prostheses for bounded edentulous spaces. Clin Oral dentures. Quintessence Int 2004; 35(5):407–10. Implants Res 2002; 13(4):359–64.

Université Of Laval

French Only B/W NEW

938 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • ADA NEW Eng only 4/C Clinical P r a c t i c e

CDSPI (dart board) p/u Feb 07 p.32 E/F 4/C Clinical P r a c t i c e The Third Decade of HIV/AIDS: A Brief Epidemiologic Update for Dentistry

Contact Author Linda M. Kaste, DDS, PhD; Helene Bednarsh, RDH, MPH Dr. Kaste Email: [email protected]

ABSTRACT

Dental professionals currently entering the dental workforce are witness to a significantly different set of oral health issues with HIV than those encountered when the epidemic began. Populations at risk for infection have changed over time and, in Canada, the United States, and the rest of the world, higher proportions of minorities and women have become infected. Medication regimens that help manage HIV as a more chronic disease have affected its presentation, its frequency and, perhaps, the significance of its oral manifestations. These medications may provoke comorbidities that challenge medical and dental disease management and health promotion. The dental office may become a site for rapid testing for HIV. The complexity of HIV infection and treatment behooves all health care professionals to be aware of developments in the prevention and epidemiology of HIV infection, and in oral health care for patients who are HIV-positive.

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he identification of infection with HIV Although methods for collecting data that leads to AIDS in 1981 marks a his- differ by country, comparing global estimates Ttoric turning point in medical and dental for HIV infection with those for Canada and health.1–3 Throughout the subsequent epi- the United States provides insight into its rela- demic, the dental workforces of Canada and tive impact on each country’s patient popu- the United States have dealt with the impact lation (Table 1). Globally, an estimated 39.5 of this virus on their personal and profes- million (range 34.1–47.1 million) people are sional lives. Those currently entering the living with HIV.4 In 2006, the newly infected dental workforce will witness a significantly rate was over 10% of the number currently different disease. Medication regimens may infected. The majority (63%) of people in- hide traditional HIV oral manifestations and fected with HIV live in sub-Saharan Africa result in comorbidities that challenge medical where 5.9% of people 15 to 49 years of age are and dental disease management and health thought to be infected. The Caribbean has the promotion. The dental office may be a point of second highest rate (1.2%) of infection among contact for rapid testing for HIV infection. In adults. The rates in India, China and Russia conjunction with other papers in this series, are of increasing concern, especially the rates this paper provides a glimpse of the current among young adults. The regional estimate epidemiology of HIV/AIDS and concentrates for North America is slighlty lower than the on the global, Canadian and US epidemics. global estimate of adult infection.

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Table 1 Selected 2005–2006 statistics for HIV and AIDS around the world, and in Canada and the United States

Statistic Global 2006 Canada 2005–2006 United States 2005–2006 Prevalence of HIV/AIDS 39.5 million4 58,0005 1.2 million4 (range of estimate) (34.1–47.1 million) (48,000–68,000) (720,000–2 million) Estimate (%) of adults 1.04 0.84 0.84 15–49 years of age living with HIV Annual incidence of HIV 4.3 million4 2,300–4,5005 NAa Annual deaths from AIDS 2.9 million4 726,b 17,0117 Top exposure categories Reported regionally for For prevalent HIV5: For AIDS diagnosis4.7,c: leading exposure by 1. MSM 1. MSM selected regions4: 2. IDU 2. High-risk heterosexual • IDU in East Europe and 3. Heterosexual or from contact Central Asia non-endemic country 3. IDU • Commercial sex workers 4. Heterosexual or from 4. MSM–IDU in South and Southeast endemic country 5. Other Asia (excluding India) 5. MSM–IDU • MSM in Western and Central Europe Other notable comments In many areas, new HIV Report conclusion: Only 7 countries are estimated infections are heavily con- overall incidence is not to have more people living centrated among young decreasing5 with HIV than the United people 15–24 years of age4 States4

IDU = injecting drug use; MSM = men who have sex with men; NA = not available. aA number of states have confidential name-based reporting of HIV cases, but national estimates are available only for the incidence of AIDS.7 bAccording to the Public Health Agency of Canada, Quebec has not reported data since mid-2003, thus limiting the national data.6 cRanking corresponds to UNAIDS 2006 reporting of exposure categories for HIV/AIDS.4

The leading routes of exposure for HIV infection vary women4 and of those with new diagnoses of HIV or AIDS by geographic region (Table 1). Routes of exposure in in 2004, 27% were female, as was found in Canada. Canada and the United States seem similar. In the early Although perinatal transmission is not discussed in years of the epidemic in the United States, for example, the AIDS Epidemic Update from UNAIDS (Joint United men who had sex with men were seen as the predomin- Nations Programme on HIV/AIDS), some, but not all, ately infected population.1 This is still the leading re- sub-Saharan Africa countries have experienced about ported route of transmission in Canada5 and the United a 25% decline in HIV infections in young pregnant 4 States.4,7,8 In Canada, whose system tracks incident HIV women. The Public Health Agency of Canada found that infections, the ranking for routes of incident infection is children less than 15 years of age had 1.3% of the positive slightly different than that for prevalent infections, with HIV tests between 1985 and 2006, and that 66% of those positive cases resulted from perinatal transmission.6 In injecting drug use dropping below the 2 heterosexual the United States, perinatal (vertical) transmission has categories (data not shown in the Table).5 markedly declined with the use of antiretroviral treat- Globally, 17.7 million women (15.1–20.9 million) are 1 4 ment during pregnancy or delivery. living with HIV, just under half (48%) of the estimated Increasing rates of infection among youths and young number of adults living with HIV. In sub-Saharan Africa, adults are a global concern. New infections are quite con- women are more likely to be infected than men, and in centrated among young people (15–24 years of age), with those 15 to 24 years of age, women represent almost 80% this group representing 40% of new infections among of those who are HIV-positive. Worldwide, the number of persons 15 years or older in 2006.4 In Canada, teens 15 women and girls who are HIV-positive is increasing. In to 19 years of age represented a small percentage of the Canada, about 20% of the people living with HIV/AIDS at total of positive HIV tests (1.5%) and AIDS cases (0.4%) the end of 2005 were women, who represented 27% (620– at the midpoint of 2006.6 However, since 1997, the lar- 1,240) of new infections.5 In 2006, 26% of people 15 years gest number of annual cases of AIDS among this age of age and older living with HIV in the United States were group occurred in 2005, the last full year reported. In the

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United States, teens 13 to 19 years of age accounted for HIV is unaware of his or her infection.4,5 In the United 0.5% of the AIDS cases in 1981–1995, 0.7% in 1996–2000, States, this means an estimated 252,000 to 312,000 per- and 0.9% in 2001–2004.9 sons are unaware of their infection.1 Populations particularly vulnerable to high rates of Oral health practitioners have a role not only in diag- HIV infection and challenges obtaining care and anti- nosing an oral manifestation of HIV, but also in recog- viral medications vary tremendously by region globally.4 nizing the potential significance of the manifestation. Women are frequently disproportionately highly rep- They must take appropriate action to manage the lesion resented within these vulnerable populations around and test for HIV. In the near future, oral health practi- the world. In the HIV epidemic in Canada, Aboriginal tioners can expect to have a role in screening for HIV persons are a major concern.5 Representing about infection through rapid testing in the dental office.16 7.5% of HIV infections and 9% of new HIV infections, Aboriginals, who comprise 3.3% of the Canadian popu- Conclusion lation, have rates almost 3 times higher than those for The introduction to a special issue of the US Centers non-Aboriginals. Recently in the United States, African for Disease Control and Prevention’s Morbidity and Americans, who comprise 12% to 13% of the population, Mortality Weekly Report published June 2, 2006, ele- represented half of the HIV/AIDS cases diagnosed.4,9 The gantly summarizes the current status of HIV infection1: national estimate of HIV infection in the Hispanic popu- “HIV/AIDS remains a potentially deadly chronic dis- lation, who represent 14% of the US population, is 20% of ease. Prevention of HIV infection requires a continued infections.4 In 2005 Native Americans, who comprise 1% commitment from persons at risk, persons infected, and of the US population, had an adult AIDS rate of 10.0 per society as a whole. Prevention efforts need to keep pace 100,000, the third highest rate among reported racial and with a changing epidemic. Most importantly, younger ethnic groups.7 generations, who might not remember the deadlier, early As recently as 2004, the Fifth World Workshop on days of the epidemic, continually need to receive basic Oral Health Disease in AIDS, a review of the interactions HIV-prevention messages.” Dentistry must continue to of HIV infection with health issues concluded that “The be a member of the health care team seeking optimal evidence base for specific interactions is currently weak, health for everyone by keeping up with medical advances partly because few good-quality studies have been pub- in and prevention of this infectious chronic disease, and lished, partly because of the naïveté of the instruments by continuing its own research about evidence-based oral currently available for recording these interactions and health management. their inherent complexity.”10 This call for more rigorous The complexity of HIV infection and its treatment HIV/AIDS research is being answered. Publications behooves�� all health care professionals to be aware of about complex systemic health interactions with HIV/ ongoing developments about the prevention of HIV AIDS as causes of death and a factor in mortality rates,11 infection and the care of patients who are HIV-positive. cardiovascular disease,12 non-AIDS-defining malignan- As the epidemic progresses and further advances are cies,13 metabolic syndrome14 and reproductive health15 made in the treatment of HIV infection and related op- have begun to appear. portunistic infections, HIV infection is becoming more The need for constant monitoring and communication manageable. Oral health practitioners will find that their of findings to assist in the prevention of HIV and clinical role is similar to that for treating patients with other care for those infected with it has led to focused meetings complex medical conditions. a such as an annual conference sponsored by the Foundation for Retrovirology and Human Health, in collaboration with the US Centers for Disease Control and Prevention, Note: As this article was ready to go to press, WHO/ for clinicians and researchers to update and critique on- UNAIDS released AIDS Epidemic Update: December 2007 going developments related to progress against AIDS (www.unaids.org/en/HIV_data/2007EpiUpdate/default. (Conference on Retroviruses and Opportunistic Infections asp). This report is notable for a 16% reduction in the — CROI, www.retroconference.org); and resources such as global estimate of people living with HIV and the proposed reasoning for that decrease. The main focus of Canadian AIDS Treatment Information Exchange (www. the reduction is on 6 countries (Angola, India, Kenya, catie.ca), Canadian HIV/AIDS Information Centre (www. Mozambique, Nigeria and Zimbabwe). Given that these aidssida.cpha.ca), AIDS training and education centres countries are not at the centre of our JCDA article and (www.aids-ed.org) and HIVdent, an oral health care re- that the global HIV/AIDS and North America data remain source (www.hivdent.org). the same, we decided to keep the statistics based on the A significant challenge lies in major portions of HIV- UNAIDS 2006 report. This occurrence reinforces the need positive populations being unaware of their infection. for all health care workers and policy makers to be alert Global estimates were not found and are difficult to calcu- for updates regarding HIV/AIDS. late. In Canada and the United Sates, 1 in 4 persons with

��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 943 ––– Kaste ––– Clinical P r a c t i c e Canada, November 2006. Available: www.phac-aspc.gc.ca/aids-sida/ THE AUTHORS publication/index.html#surveillance. 7. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2005. Vol. 17. Rev. ed. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2007:1–54. Available: Dr. Kaste is associate professor, University of Illinois at www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/pdf/ Chicago, College of Dentistry, Chicago, Illinois. 2005SurveillanceReport.pdf. 8. Sanchez T, Finlayson T, Drake A, Behel S, Cribbin M, DiNenno E, and others. Human immunodeficiency virus (HIV) risk, prevention, and testing behaviors – United States, National HIV Behavioral Surveillance System: Men who have sex with men, November 2003–April 2005. MMWR Surveill Ms. Bednarsh is director, Boston Public Health Commission, Summ 2006; 55(6):1–16. Available: http://www.cdc.gov/mmwr/preview/ HIV Dental, Boston, Massachusetts. mmwrhtml/ss5506a1.htm. 9. Centers for Disease Control and Prevention (CDC 2006c). Epidemiology Correspondence to: Dr. Linda M. Kaste, UIC COD, MC 850, 801 S Paulina of HIV/AIDS – United States, 1981-2005. MMWR Morb Mortal Wkly Rep St., Chicago, IL 60612, USA. 2006; 55(21):589–92. Available: www.cdc.gov/mmwr/preview/mmwrhtml/ mm5521a2.htm. The authors have no declared financial interests. 10. Johnson NW, Glick M, Mbuguye TN. (A2) Oral health and general health. Adv Dent Res 2006; 19(1):118–21. This article has been peer reviewed. 11. Crum NF, Riffenburgh RH, Wegner S, Agan BK, Tasker SA, Spooner KM, and others. Comparisons of causes of death and mortality rates among HIV-infected persons: Analysis of the pre-, early, and late HAART (Highly References Active Antiretroviral Therapy) eras. J Acquir Immune Defic Syndr 2006; 1. Centers for Disease Control and Prevention (CDC). Twenty-five years 41(2):194–200. of HIV/AIDS – United States, 1981-2006. MMWR Morb Mortal Wkly Rep 12. Triant VA, Lee H, Hadigan C, Grinspoon SK. Increased acute myocardial 2006; 55(21):585–9. Available: www.cdc.gov/mmwr/preview/mmwrhtml/ infarction rates and cardiovascular risk factors among patients with human mm5521a1.htm. immunodeficiency virus disease. J Clin Endocrinol Metab 2007; 92(7):2506– 2. Levy JA. HIV pathogenesis: Knowledge gained after two decades of re- 12. Epub 2007 Apr 24. search. Adv Dent Rev 2006; 19(1):10–16. 13. Pantanowitz L, Schlecht HP, Dezube BJ. The growing problem of non- 3. Fairchild AL, Gable L, Gostin LO, Bayer R, Sweeney P, Janssen RS. Public AIDS-defining malignancies in HIV. Curr Opin Oncol 2006; 18(5):469–78. goods, private data: HIV and the history, ethics, and uses of identifiable public health information. Public Health Rep 2007; 122(Supp 1):7–15. 14. Samaras K, Wand H, Law M, Emery S, Cooper D, Carr A. Prevalence of metabolic syndrome in HIV-infected patients receiving highly active 4. UNAIDS. AIDS epidemic update. Special report on HIV/AIDS: December antiretroviral therapy using International Diabetes Foundation and Adult 2006. Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS) Treatment Panel III criteria: associations with insulin resistance, disturbed and the World Health Organization (WHO). Available: http://data.unaids. body fat compartmentalization, elevated C-reactive protein, and [corrected] org/pub/EpiReport/2006/2006_EpiUpdate_en.pdf. hypoadiponectinemia. Diabetes Care 2007; 30(1):113–9. 5. Boulos D, Yan P, Schanzer D, Remis RS, Archibald CP. Estimates of HIV prevalence and incidence in Canada, 2005. Can Commun Dis Rep 2006; 15. Brogly SB, Watts DH, Ylitalo N, Franco EL, Seage GR, Oleske J, and 32(15):165–74. Available: www.phac-aspc.gc.ca/publicat/ccdr-rmtc/06vol32/ others. Reproductive health of adolescent girls perinatally infected with HIV. dr3215ea.html. Am J Public Health 2007; 97(6):1047–52. 6. Public Health Agency of Canada. HIV and AIDS in Canada, Surveillance 16. Franco-Paredes C, Tellez I, del Rio C. Rapid HIV testing: a review of Report to June 30, 2006. Surveillance and Risk Assessment Division, Centre the literature and implications for the clinician. Curr HIV/AIDS Rep 2006; for Infectious Disease Prevention and Control, Public Health Agency of 3(4):169–75.

944 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • Clinical P r a c t i c e Essential Medical Issues Related to HIV in Dentistry

Contact Author Arthur H. Moswin, MD, FACP; Joel B. Epstein, DMD, MSD, FRCD(C), FDS RCSE Dr. Epstein Email: [email protected]

ABSTRACT

Management of HIV infection has progressed dramatically since the disease was first recognized, to the point that HIV infection is now considered a chronic condition. Some of these new approaches in management are related to the strides that have been made in understanding the pathogenesis of this condition. Such changes in medical care may also affect the provision of oral health care. Dental providers must therefore be aware of current management practices. This paper reviews current approaches to managing HIV-related disease.

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IV infection is now a chronic manage- dental care in the previous 6 months.3 Not able illness. Affected patients are living surprisingly, dental programs that were af- Hlonger and increasingly normal lives, filiated with a comprehensive HIV treatment thanks largely to highly active antiretroviral program were most successful, probably be- therapy (commonly called HAART). It is esti- cause of greater referrals and greater funding mated that a 21-year-old person infected with available for care in those settings. HIV today will live to 60 years of age.1 Regular There are various reasons for the disparity dental care is an important aspect of the man- between need for and availability of dental agement of HIV infection. Oral lesions can care, including lack of dental insurance and be among the earliest manifestations of this competing medical and social needs; however, infection and may develop anytime during reticence on the part of the dentist should not the course of the illness. This article summar- be a factor. Although universal precautions izes medical issues related to HIV infection of should be used for all patients, regardless of which the dentist should be aware. HIV status, occupational transmission of HIV in the course of providing dental care is ex- Overview of Dental Care in the tremely unlikely,4 despite the fact that some pa- Context of HIV-Related Disease tients will have HIV infection and despite the As many as one-quarter of people infected frequency of accidental skin punctures from with HIV are unaware of their condition.2 In a instruments. This is probably because HIV is survey of patients with HIV/AIDS conducted rarely transmitted through saliva and because in 2000, the Rand Corporation found that of the small quantities of blood involved. In 58% did not see a dentist regularly (i.e., had fact, it appears that most percutaneous in- not seen a dentist in the past 6 months), and juries associated with dental care occur during 20% reported having had an unmet need for extraoral procedures such as laboratory work

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reduce the volume of blood transmitted by 50%, even if a puncture through the glove does occur. Assess risk: Did a percutaneous or mucous No PEP not Starting antiretroviral therapy within 1–4 hours membrane exposure indicated, occur that carries no follow-up of an exposure can drastically reduce (by more significant risk of HIV needed. 9 transmission? than 80%) the incidence of HIV transmission. A procedure should be in place for testing the Ye s No PEP probably not useful. source patient, should a sharps injury occur. It Did the exposure happen Optimum start time is 1– less than 36 hours ago? 4 hours after exposure. is important to determine, in consultation with

No effect after 36 hours. medical personnel familiar with HIV exposure, the severity of the exposure and, if indicated, to Yes start prophylactic antiretroviral therapy within Is HIV status of the sour ce HIV status known to be positive. patient known? Start PEP immediately, and continue for 4 weeks. 1 or 2 hours. HAART should be continued for No 4 weeks if the source patient is positive. It may

be discontinued if the patient’s status is found Arrange for immediate Yes If result of rapid test is negative HIV testing of source, to be negative. and there is no evidence of acute using rapid test if seroconversion in source patient, available. Is result of there is no need for PEP. rapid test negative? Preoperative Management

When undertaking dental care of an HIV- No positive patient, communication with the primary treating physician is imperative and If result of rapid test is positive or rapid test is not available, should cover more than the usual (though still consult medical or infectious disease resource to determine best regimen. important) questions about bleeding, allergies, Start PEP immediately. cardiac history and antibiotic prophylaxis. Such communication should also include informa-

• Perform confidential baseline HIV testing of the exposed health care worker within tion about recent CD4 (T cell) count, HIV 72 hours of initiating HAART. • Provide source- patient with appropriate referral for post-test counselling. viral load, any other medical issues (e.g., hepa- • Refer health care worker to an HIV specialist within 72 hours of initiating HAART. titis, cardiac problems) and the patient’s current medication list (to allow identification of

If Western blot testing of potential drug–drug interactions). As patients If Western blot testing of source patient is positive or source patient is negative, with indeterminate, continue PEP with HIV age, the incidence of renal disease, no evidence of acute for 4 weeks. liver disease (often from concomitant hepatitis), seroconversion in source patient, stop PEP. cardiomyopathy and lipid abnormalities such as high cholesterol tends to increase. There may Figure 1: Management of occupational exposure to HIV. PEP = Postexposure also be a higher incidence of coronary artery prophylaxis. Adapted from reference 6. disease (although this is controversial because of the conflicting evidence) and a higher incidence of osteoporosis, especially among men; these latter patients may be taking bisphosphon- or clean-up.5 Any patient in the dental chair could be ates, such as alendronate (Fosamax). In light of recent among those with HIV who do not know they are HIV- cases of jaw osteonecrosis in non-HIV patients taking positive. Therefore, every office should have a plan in case these drugs, vigilance is advised.10 An otherwise fit HIV- of needlestick injury or other exposure to blood or body positive person with good muscle mass probably has the fluids (Fig. 1; see also Appendix 1, Recommendations on same risk of wound complications as an HIV-negative managing occupational HIV exposure, at www.cda-adc. person.11 ca/jcda/vol-73/issue-10/945.html). Studies suggest that Minor laboratory abnormalities are common in HIV- the risk of contracting HIV from a needlestick injury positive patients, whether or not they are receiving an- is 1 in 200 (0.3%) overall.7 Stated another way, 99.7% of tiretroviral therapy. Abnormalities in the complete blood exposures through needlestick injuries and cuts do not count, such as mild anemia, neutropenia and, less often, lead to HIV infection. In contrast, the risk of contracting thrombocytopenia, are common; unless these problems hepatitis B from a needlestick injury (which has always are severe, they should not delay delivery of care. Usually, been a risk in medical and dental care) during care of an no further work-up is required, as long as the primary infected patient may be as high as 30%.7 The risks of some medical provider is experienced in the care of HIV- other modes of HIV transmission are shown in Table 1. infected patients, is aware of the issues and agrees that Certain types of needlestick exposure are more risky there is no contraindication to surgery. However, than others, as outlined in Table 2. Wearing gloves may a hemoglobin level less than 0.007 g/dL (0.07 g/L), an

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Table 1 Risk of HIV transmission for various modes of should confirm that the results of chest radiography are transmissiona normal (i.e., that the patient does not have active TB) and Risk per that prophylaxis with isoniazid has been started before Mode of transmission 10,000 exposuresb initiating dental care. Percutaneous (blood) 30 Medication-Related Issues Mucocutaneous (blood) < 1 The continued success of a patient’s HIV therapy de- Receptive anal intercourse 50 pends on strict adherence to the medication regimen, Receptive vaginal intercourse 10 with no missed doses. Missing 10% of doses (essentially Insertive vaginal intercourse 5 1 or 2 doses a month) or more can cause selection of resistant virus and lead to regimen failure. Adherence is aAdapted from reference 8 bAssuming an infected source and, for intercourse-related modes of transmission, one of the guiding principles of HIV therapy, and every no condom use. attempt should be made to minimize missed doses and to encourage patients to take all scheduled medication Table 2 Risk of HIV transmission after percutaneous (needle- doses. Patients who are receiving therapy and who must a stick) exposure fast in preparation for laboratory testing or who must Risk factor Odds ratio take nothing by mouth in advance of surgery should Deep injury 16.1 be allowed to take their HIV medications with sips of water, if at all possible. In cases where the patient must Visible blood on needle 5.2 miss one or more doses, as when the jaw has been wired Device in artery or vein (vs. sub- after fracture, consultation with the treating physician cutaneous or intramuscular injection) 5.1 is important. Standard antibiotics and pain medications Source patient with high viral load 5.4 usually pose no additional concerns for patients with Use of zidovudine after exposure 0.2 HIV. However, the dental care provider must be aware of the possibility of current or prior drug abuse, which may aAdapted from reference 9 affect the choice of pain medication. Although the combination drug trimethoprim–sulfamethoxazole (Bactrim) absolute neutrophil count (total leukocytes × % polymorph- is not frequently used by dentists, up to 50% of patients onuclear leukocytes + bands) of less than 1.5 × 103/μL with HIV may be allergic to this drug, a problem that (1.5 × 109/L) or a platelet count less than 100 × 103/μL may be discovered by the dentist if he or she unknow- (100 × 109/L) may require special attention by the primary ingly prescribes it for an allergic patient. The allergic provider before surgical procedures12 but usually not before reaction usually resolves on its own once the drug is routine dental care. discontinued. Another laboratory abnormality in patients who are The most important drug with potential for drug– receiving HAART is an isolated increase in bilirubin in drug interactions is ritonavir (Norvir), which may be ad- association with normal levels of aspartate aminotrans- ministered alone or combined with lopinavir in the drug ferase and alanine aminotransferase, a phenomenon that Kaletra. This agent is involved in many known drug–drug may be seen in patients taking atazanavir (Reyataz); how- interactions and has many contraindications. The full list ever, this abnormality is of no medical consequence. It of potential problems is given in the package insert available online (www.norvir.com) or in various drug refer- (and, though more rarely, frank jaundice) is being seen ences. Among drugs that may be used in dentistry and more frequently as use of HAART increases. Patients that can interact with ritonavir or lopinavir–ritonavir, with concomitant hepatic or renal dysfunction may be at meperidine (Demerol) should not be used at all, whereas higher risk of bleeding and other complications, but the acetaminophen, ibuprofen, tramadol and oxycodone all usual caveats apply; there is no increase in risk due solely seem to be minimally affected. Proxyphene levels may to HIV status. be increased by ritonavir or lopinavir–ritonavir, and this Another important test for patients with HIV is the drug should therefore be used with caution in patients purified protein derivative (PPD) test, also known as the taking either of these HIV drugs. Antibiotics require Mantoux skin test, for tuberculosis (TB). Patients with no dose adjustments, although levels of clarithromycin HIV are at higher risk for active TB if the PPD test result (Biaxin) are increased. All ergot derivatives and the is positive; therefore, they should undergo PPD testing sedatives midazolam (Versed) and triazolam (Halcion) annually. The patient’s TB status and most recent PPD are contraindicated for patients taking ritonavir or test result should be ascertained from the primary pro- lopinavir–ritonavir and should be used with extreme vider; if the test result is positive, the dental care provider caution or avoided altogether.

��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 947 ––– Epstein ––– Clinical P r a c t i c e The Road Ahead References 1. Lohse N, Hansen AB, Pedersen G, Kronborg G, Gerstoft J, Sorensen HT, There are many new and promising drugs in the phar- and others. Survival of persons with and without HIV infection in Denmark, maceutical “pipeline.” These drugs, combined with on- 1995–2005. Ann Intern Med 2007; 146(2):87–95. going vaccine research, may further revolutionize the 2. Department of Human Health and Services. Centers for Disease Control and Prevention. HIV/AIDS prevention at CDC. 2007. Available: www.cdc. care of patients with HIV and prolong their life expect- gov/hiv/aboutDHAP.htm (accessed 2007 Oct 30). ancies. These include entirely new classes of drugs such 3. Rand Corporation. Do people with HIV get the dental care they need? Results of the HCSUS study. 2005. Available: www.rand.org/pubs/research_ as fusion inhibitors (e.g., the recently approved enfu- briefs/RB9067/index1.html (accessed 2007 Oct 30). virtide [Fuzeon]), integrase inhibitors (e.g., raltegravir 4. Cleveland JL, Barker L, Gooch BF, Beltrami EM, Cardo D; National [Isenstress]), HIV receptor antagonists (e.g., maraviroc Surveillance System for Health Care Workers Group of the Centers for 13 Disease Control and Prevention. Use of HIV postexposure prophylaxis by [Selzentry]) and others that are coming to market. As dental health care personnel: an overview and updated recommendations. the number of people living with HIV infection and J Am Dent Assoc 2002; 133(12):1619–26. AIDS continues to increase, we must work to reduce their 5. McCarthy GM, Ssali CS, Bednarsh H, Jorge J, Wangrang Simakulk K, Page-Shafer K. Transmission of HIV in the dental clinic and elsewhere. Oral unmet needs for dental care. a Dis 2002; 8 Suppl 2:126–35. 6. HIV Clinical Resource. Office of the Medical Director, New York State Department of Health AIDS Institute in collaboration with the Johns Hopkins University Division of Infectious Diseases. HIV prophylaxis following occupa- THE AUTHORS tional exposure. December 2005. Available: www.hivguidelines.org. 7. U.S. Public Health Service. Updated U.S. Public Health Service guidelines Acknowledgments: The authors wish to thank Norma Rolfsen, FNP, for the management of occupational exposures to HBV, HCV, and HIV and ACRN, for her help in preparing this manuscript. recommendations for postexposure prophylaxis. MMWR Recomm Rep 2001; 50(RR-11):1–52. Dr. Moswin is medical director, HIV Program, Provident 8. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, Hospital of Cook County, Chicago, Illinois, and medical dir- or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR ector, HIV Care Program, Michael Reese Hospital, Chicago, Recomm Rep 2005; 54(RR-2):1–20. Illinois. 9. Centres for Disease Control and Prevention (CDC). Case-control study of HIV seroconversion in health-care workers after percutaneous exposures to Dr. Epstein is professor and head, department of oral medi- HIV-infected blood — France, United Kingdom, and United States, January 1988–August 1994. MMWR Morb Mortal Wkly Rep 1995; 44(50):929–33. cine and diagnostic sciences, College of Dentistry, and director, interdisciplinary program in oral cancer, College of 10. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Medicine, Chicago Cancer Center, University of Illinois at Maxillofac Surg 2004; 62(5):527–34. Chicago, Chicago, Illinois. 11. Schecter WP, Stock P. Surgery in patients with HIV. HIV InSite Knowledge Base Chapter. February 2003. Available: http://hivinsite.ucsf. Correspondence to: Dr. Joel Epstein, UIC College of Dentistry, Oral edu/InSite?page=kb-03-03-02 (accessed 2007 Oct 30). Medicine, MC-838, 801 South Paulina St., Chicago, IL 60091, USA. 12. Practice Guidelines for blood component therapy. A report by the American Society of Anesthesiologists Task Force on Blood Component The authors have no declared financial interests in any company manufac- Therapy. Anesthesiology 1996; 84(3):732–47. turing the types of products mentioned in this article. 13. Treatment Action Group. The 2007 Pipeline Report. Experimental treatments and preventive therapies for HIV, hepatitis C, and tuberculosis. New This article has been peer reviewed. York, NY. Available: www.aidsinfonyc.org/tag/tx/pipeline2007b.pdf.

948 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • Clinical P r a c t i c e Changes in the Pattern of Oral Lesions Associated with HIV Infection: Implications for Dentists

Contact Author Herve Y. Sroussi, DMD, PhD; Joel B. Epstein, DMD, MSD, FRCD(C), FDS RCSE Dr. Epstein Email: [email protected]

ABSTRACT

Broad access to better HIV treatment has resulted in a significant reduction in the prevalence of HIV-associated oral lesions in western industrialized countries. However, a possible increased prevalence of oral warts and a potential dissociation between CD4+ T-cell counts and oral manifestations of HIV require continued vigilance by oral health care providers. Head and neck and oral examination coupled with a careful consideration of the complications associated with hyposalivation remain essential components of a comprehensive oral health care program.

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IV is a retrovirus carried by more than of HIV disease progression.8 Oral candidiasis 40 million people worldwide.1 HIV in- (Fig. 1) and oral hairy leukoplakia (Fig. 2)9 are Hfection leads to gradual deterioration of lesions associated with fungal and viral patho- the immune system and to the development gens, respectively, and are the most frequently of AIDS. As of June 2006, 61,423�� people in occurring OMHs. Others, such as human pap- Canada had been infected with HIV; 20,493 illomavirus (HPV) related warts (Fig. 3), aph- of them had been diagnosed with AIDS, and thous-like ulcers and Kaposi’s sarcoma have at least 13,326 people with AIDS had died.2 also been reported extensively. OMHs con- Notwithstanding extraordinary progress in tribute to HIV-related morbidity and are be- understanding and managing HIV pathogen- lieved to serve as important markers of HIV esis, there is no cure for HIV-related disease infection and disease progression even in those and the treatment of choice is to target HIV on modern HIV therapy. viral replication with the expectation of de- The therapeutic breakthrough associated laying further immune suppression. With dis- with the introduction of HIV-specific pro- ease progression, the deleterious effect of HIV tease inhibitors more than 10 years ago has on the immune system results in an escalating significantly improved the prognosis of HIV incidence of widely recognized and extensively disease.10,11 The use of HIV protease inhibitors described opportunistic infections and dis- combined with therapy targeting the HIV re- eases, among which are the oral manifestations verse transcriptase enzyme (highly active an- of HIV (OMHs).3–5 A summary of the most tiretroviral therapy or HAART) is associated common OMHs and their recommended treat- with a sustained decrease in viral replication ment is presented in Table 1. and stabilization or even an increase in the Since the onset of the HIV pandemic, peripheral CD4+ T-helper cell count,12 a subset OMHs have been well documented as early of lymphocytes targeted by HIV. It is generally markers of HIV infection7 and as predictors accepted that the risk of developing an OMH

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Table 1 Most commonly observed oral manifestations of HIV and recommended treatment

Oral manifestations of HIV Treatment Comments Oropharyngeal candidiasis Clotrimazole: 10-mg troches, orally, • CDC guidelines do not recommend 5 times a day for 7–14 days prophylaxis except for exceptional Fluconazole: 100 mg, orally, once daily cases of severe or frequent recurrences. for 7–14 days • Consider drug–drug interactions and Refer when refractory to fluconazolea liver status when choosing a systemic or topical treatment. Oral hairy leukoplakia In-office application of podophyllum • There are insufficient data to support resin (25%) evidence-based treatment recommendations. Considering the inconsequen- tial nature of the lesion, systemic antiviral medication may not be warranted. Oral warts Surgical excision and biopsy; refer for • There are insufficient data to support extensive/recurrent lesionsa evidence-based treatment recommendations other than surgical excision. • Consideration should be given to the possibility of spreading HPV to other surfaces during surgery, and potential cancer risk. Oral herpes simplex Acyclovir: 800 mg, 4 times a day • Topical antiviral medication should be for 7 days considered for patients with 9 Valacyclovir: 500 mg twice daily CD4+ counts above 0.2 × 10 /L and for 7 days herpes labialis. Refer those with severe, persisting or recurrent lesionsa Recurrent aphthous-like ulcerations High-potency topical steroids, such as • The use of topical steroids may result fluocinonide and clobetasol in increased incidence of oral Refer severe casesa; systemic steroids, pharyngeal candidiasis. thalidomide or immunosuppresives • Systemic therapy should be limited to may be considered those experienced in the use of these medications. Gingival and periodontal disease Oral hygiene, prophylaxis, scaling/ • Some studies report linear gingival curettage, chlorhexidine rinse; may be erythema with a band-like pattern of combined with systemic antibiotics. erythema and increased intensity of bone and soft tissue loss Malignant lesions: oral Kaposi’s Intralesional injection of vinblastine • Patient with biopsy-confirmed disease sarcoma, squamous cell carcinoma, or sodium tetradecyl sulfate 3% and/or should be referred to physician for lymphoma low-dose radiation therapy evaluation of the involvement of other organs. • Intralesional treatment should be limited to those experienced in the use of these medications. Hyposalivation Stimulation of gland function: taste, chewing and sialogogues Prevention of oral complications (caries, candidiasis)

Source: Reference 6 aRefer to an appropriate specialist CDC = US Centers for Disease Control and Prevention; HPV = human papillomavirus.

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Figure 1: Pseudomembranous candi- Figure 2: Hairy leukoplakia, a condition Figure 3: Multiple and recalcitrant oral diasis on the hard and soft palate associated with Epstein-Barr virus, presents warts presenting as sessile and pedunculated presents as white removable plaque. as a painless corrugated lesion on the right lumps on the lower lip. lateral tongue.

increases with decreasing CD4 count and higher HIV as well as OMHs, especially oral candidiasis, the most load.13,14 However, this observation may be less accurate in commonly diagnosed OMH. patient populations with long histories of HIV infection.15 Finally, in addition to poor response or adherence to Because CD4+ counts are not a direct measure of immune HIV treatment, low CD4 counts or high HIV load, to- function, opportunistic infections, such as OMHs, may bacco use is confirmed as a risk factor for OMHs.21–23 be a more accurate reflection of HIV disease status. A Furthermore, the effect of tobacco use in addition to in- disconnect between opportunistic infections and CD4+ creased HPV disease may result in a dramatic increase in counts could also be explained by a paradoxical transient the incidence of oral cancer in HIV patients. deterioration of immune function during initial response Taken together, the epidemiology of OMHs in the post- to HIV medication, referred to as the immune reconstitu- HAART era indicates that OMHs are less frequent, but new tion syndrome.16 and poorly understood paradigms are emerging. Those paradigms include a possible upsurge in the prevalence of Although the treatment of specific OMHs has been ef- oral warts and the possibility that, with time, CD4+ T-cell fective,6 it is evident that the most successful treatment is counts and the prevalence of OMHs may not correlate. to prevent or reverse the underlying primary immunodefi- The practical significance of those 2 emerging paradigms ciency disease.17 Accordingly, the introduction of HAART is that oral health care providers have to continue to be is associated with a significant decrease in the prevalence vigilant in their examination and treatment of their HIV- of opportunistic diseases including OMHs. For example, infected patients. To deliver an optimal level of care, oral HAART is associated with a significant decrease in the health clinicians should emphasize the early detection of prevalence of oral candidiasis and oral hairy leukoplakia oral cancer. They should remain vigilant in the diagnosis 18 coupled with an improved CD4 count. of OMHs traditionally associated with low CD4+ counts Seemingly in contradiction with those findings, an (i.e., Kaposi’s sarcoma) even in patients with high CD4+ increased prevalence of oral warts has been noted by some counts. In addition, clinicians must address the complica- investigators despite a marked improvement in CD4 cell tions of hyposalivation and must offer an effective tobacco count.19 This observation may not reflect true increased smoking cessation program either by referral or by the oral prevalence in the population. However, because of the link health care provider directly. a between HPV and cancer, it suggests that, with increased life expectancy of HIV-infected patients, oral cancer may THE AUTHORS become a clinically significant long-term complication. The prevalence of OMHs is declining in populations Dr. Sroussi is assistant professor and director of oral medi in industrialized countries with the introduction of better cine, department of oral medicine and diagnostic sciences HIV therapies. However, an increase in salivary gland and Chicago Cancer Center, University of Illinois at Chicago, disease, xerostomia and oral warts has been seen.20 This Chicago, Illinois. should be of utmost interest to the dental profession because saliva is an essential contributor to oral health. Dr. Epstein is professor and head, department of oral medicine and diagnostic sciences, College of Dentistry, and dir- Xerostomia in HIV patients, either triggered by HIV dis- ector, interdisciplinary program in oral cancer, College of ease directly or as a side effect of medications, represents Medicine, Chicago Cancer Center, University of Illinois at an additional risk factor for caries and periodontal disease Chicago, Chicago, Illinois.

��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 951 ––– Epstein ––– Clinical P r a c t i c e Correspondence to: Dr. Joel Epstein, UIC College of Dentistry, Oral advanced human immunodeficiency virus infection. HIV Outpatient Study Medicine, MC-838, 801 South Paulina St., Chicago, IL 60091, USA. Investigators. N Engl J Med 1998; 338(13):853–60. 12. Autran B, Carcelain G, Li TS, Blanc C, Mathez D, Tubiana R, and others. The authors have no declared financial interests. Positive effects of combined antiretroviral therapy on CD4+ T cell homeostasis and function in advanced HIV disease. Science 1997; 277(5322):112–6. This article has been peer reviewed. 13. Adurogbangba MI, Aderinokun GA, Odaibo GN, Olaleye OD, Lawoyin TO. Oro-facial lesions and CD4 counts associated with HIV/AIDS in an adult References population in Oyo State, Nigeria. Oral Dis 2004; 10(6):319–26. 14. Margiotta V, Campisi G, Mancuso S, Accurso V, Abbadessa V. HIV infec- 1. Zarocostas J. Number of people infected with HIV worldwide reaches tion: oral lesions, CD4+ cell count and viral load in an Italian study popula- 40m. BMJ 2005; 331(7527):1224. tion. J Oral Pathol Med 1999; 28(4):173–7. 2. Public Health Agency of Canada. HIV and AIDS in Canada. Surveillance report to June 30, 2006. Surveillance and Risk Assessment Division, Centre for 15. Sroussi HY, Villines D, Epstein J, Alves MCF, Alves ME. The correlation be- Infectious Disease Prevention and Control, Public Health Agency of Canada; tween prevalence of oral manifestations of HIV and CD4+ lymphocyte counts 2006. Available:�� www.phac-aspc.gc.ca/publicat/aids-sida/haic-vsac0606/ weakens with time. J Acquir Immune Defic Syndr 2006; 42(4):516–8. pdf/haic-vsac0606.pdf (accessed 2007 Nov 12). 16. Lipman M, Breen R. Immune reconstitution inflammatory syndrome in 3. Greenspan D, Greenspan JS. Oral mucosal manifestations of AIDS? HIV. Curr Opin Infect Dis 2006; 19(1):20–5. Dermatol Clin 1987; 5(4):733–7. 17. El-Sadr WM, Burman WJ, Grant LB, Matts JP, Hafner R, Crane L, and 4. Patton LL, Phelan JA, Ramos-Gomez FJ, Nittayananta W, Shiboski CH, others. Discontinuation of prophylaxis for Mycobacterium avium complex Mbuguye TL. Prevalence and classification of HIV-associated oral lesions. disease in HIV-infected patients who have a response to antiretroviral Oral Dis 2002; 8(Suppl 2):98–109. therapy. Terry Beirn Community Programs for Clinical Research on AIDS. 5. Reznik DA. Oral manifestations of HIV disease. Top HIV Med 2005; N Engl J Med 2000; 342(15):1085–92. 13(5):143–8. 18. Nicolatou-Galitis O, Velegraki A, Paikos S, Economopoulou P, Stefaniotis 6. Baccaglini L, Atkinson JC, Patton LL, Glick M, Ficarra G, Peterson DE. T, Papanikolaou IS, and other. Effect of PI-HAART on the prevalence of Management of oral lesions in HIV-positive patients. Oral Surg Oral Med oral lesions in HIV-1 infected patients. A Greek study. Oral Dis 2004; Oral Pathol Oral Radiol Endod 2007; 103 Suppl:S50.e1–23. 10(3):145–50. 7. Lozada-Nur F, Silverman S Jr, Migliorati C, Conant M, Abrams D, Volberding 19. Greenspan D, Canchola AJ, MacPhail LA, Cheikh B, Greenspan JS. Effect PA, and other. The diagnosis of AIDS and AIDS related complex in the dental of highly active antiretroviral therapy on frequency of oral warts. Lancet office: findings in 171 homosexual males. CDA J 1984; 12(6):21–5. 2001; 357(9266):1411–2. 8. Greenspan D, Greenspan JS, Overby G, Hollander H, Abrams DI, MacPhail 20. Navazesh M, Mulligan R, Komaroff E, Redford M, Greenspan D, Phelan J. L, and other. Risk factors for rapid progression from hairy leukoplakia to The prevalence of xerostomia and salivary gland hypofunction in a cohort of AIDS: a nested case-control study. J Acquir Immune Defic Syndr 1991; HIV-positive and at-risk women. J Dent Res 2000; 79(7):1502–7. 4(7):652–8. 21. Shiboski CH, Neuhaus JM, Greenspan D, Greenspan JS. Effect of recep- 9. Greenspan D. Oral viral leukoplakia (“hairy” leukoplakia): a new oral lesion in association with AIDS. Compend Contin Educ Dent 1985; 6(3):204–6, tive oral sex and smoking on the incidence of hairy leukoplakia in HIV-posi- 208. tive gay men. J Acquir Immune Defic Syndr 1999; 21(3):236–42. 10. Louie JK, Hsu LC, Osmond DH, Katz MH, Schwarcz SK. Trends in causes 22. Chattopadhyay A, Caplan DJ, Slade GD, Shugars DC, Tien HC, Patton LL. of death among persons with acquired immunodeficiency syndrome in the Risk indicators for oral candidiasis and oral hairy leukoplakia in HIV-infected era of highly active antiretroviral therapy, San Francisco, 1994–1998. J Infect adults. Community Dent Oral Epidemiol 2005; 33(1):35–44. Dis 2002; 186(7):1023–7. 23. Sroussi HY, Villines D, Epstein J, Alves MC, Alves ME. Oral lesions in HIV- 11. Palella FJ Jr, Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten positive dental patients — one more argument for tobacco smoking cessa- GA, and others. Declining morbidity and mortality among patients with tion. Oral Dis 2007; 13(3):324–8.

952 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • Clinical P r a c t i c e Oral Malignancies Associated with HIV

Contact Author Joel B. Epstein, DMD, MSD, FRCD(C), FDS RCSE Dr. Epstein Email: [email protected]

ABSTRACT

Advances in the management of HIV infection have resulted in significant changes in survival and in the prevalence and incidence of oral diseases found in persons infected with HIV (as discussed in other articles in this series). HIV is associated with an increased risk of malignant disease that is related to immunosuppression and the activity of the HIV transactivator of transcription protein, coviral infection and exposure to carcino- gens. The presence of oral malignancies varies with the route of the transmission of HIV and varies geographically, based on behaviour, viral cofactors, HIV therapy and genetic variation. Oral health care providers can identify these lesions early.

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eople who are HIV-positive have more tobacco seems to play a major role in cancer in than a twofold increased risk of malig- patients who are HIV-positive.9 Pnant disease, and an estimated 30% to Since the introduction of highly active 40% of them will develop a malignant disease.1 antiretroviral therapy (HAART) in the mid AIDS-related cancers include Kaposi’s sar- 1990s, dramatic changes have occurred in the coma, Hodgkin’s lymphoma, non-Hodgkin’s oral manifestations of HIV (see the article lymphoma, basal cell carcinoma, cervical on the c��hanges in the pattern of oral lesions cancer, seminoma, leiomyoma and leiomyosar- associated with HIV infection on page 949),�� coma.2,3 A risk of Hodgkin’s lymphoma, hepa- including a dramatic reduction in Kaposi’s sar- tocellular carcinoma and anogenital epithelial coma. However, oral verrucous lesions caused by human papilloma virus (HPV) infection neoplasia has been associated with HIV, have increased. Lymphoma is the most rapidly whereas data about the risk of testicular sem- increasing malignant disease in patients with inoma, multiple myeloma, melanoma and oral HIV and its prevalence has not been affected squamous cell carcinoma are limited.4–6 by HAART. A number of non-AIDS-defining Oral Kaposi’s sarcoma is highly associ- malignancies have been reported with in- ated with sexual transmission and is an AIDS- creasing frequency, including melanoma, and defining condition. This sarcoma is much less cancers of the head and neck, anus, lung and 7 common in females than in males. Oral signs testis.9 Oral malignant disease may occur be- of non-Hodgkin’s lymphoma and oropharyn- fore a diagnosis of HIV, may arise during the geal squamous cell carcinoma have been progression of HIV disease or may be largely classified as malignancies and are non-AIDS- independent of the overall helper-cell counts, defining conditions. The route by which HIV such as lymphoma. The purpose of this paper is acquired carries a risk of transmission of is to help dental practitioners identify the additional viruses that may contribute to the early signs of these diseases and maintain the development of malignant disease.8 Smoking oral health of their patients with HIV.

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Figure 1: Ulcerated mass involving the Figure 2: Purple-blue discolorations in the Figure 3: Bilateral elevated purple- right anterior ventrolateral surface of the area of the greater palatine groove involving blue masses of Kaposi’s sarcoma. tongue. The lesion was associated with mild the hard palate on the right and left. Biopsy A more central lesion and pseudo- sensitivity and occasional bleeding. Biopsy revealed Kaposi’s sarcoma. The midline membranous candidiasis is present. revealed squamous cell carcinoma. lesion in the posterior aspect of the hard palate represents candidiasis.

Oral Squamous Cell Carcinoma between Epstein-Barr virus and oral squamous cell car- 14 Tobacco and alcohol use, HPV infection, immuno- cinoma in some patients. deficiency and possibly genetic changes represent risk Kaposi’s Sarcoma factors for oral squamous cell carcinoma in patients with Kaposi’s sarcoma (Figs. 2 and 3) is an angioprolif- HIV infection (Fig. 1).2 One study1 reported a more than erative disease that may arise from a mesenchymal pro- twofold increase in the incidence of oral and pharyn- genitor cell infected by human herpes virus-8.2 The risk geal cancer, although the study did not control for the of Kaposi’s sarcoma in patients with HIV, which is closely effects of tobacco and alcohol use. Oral squamous cell associated with sexual transmission, is 5 to 10 times carcinoma in patients who were HIV-positive may affect greater in male homosexuals than in other HIV-risk younger people who have no other known risk factors groups.9 The HIV transactivator of transcription protein commonly associated with squamous cell carcinoma. One may promote the growth of Kaposi’s sarcoma, the most study10 showed that patients who were HIV-positive had prevalent AIDS-associated malignancy before the advent a more advanced stage of oral squamous cell carcinoma of HAART. The reduction in the incidence of Kaposi’s and poorer survival (57% survival at 1 year and 32% at sarcoma has been attributed to the protease inhibitors in 2 years) than patients who were HIV negative (74% and HAART. 59%, respectively). The pathogenesis of oral squamous Kaposi’s sarcoma may present with localized, regional cell carcinoma in patients with HIV includes increased or widespread involvement. Oral Kaposi’s sarcoma fre- cell growth and proliferation caused by viral interference quently involves the palate, gingiva and tongue. Treat- with tumour suppressor proteins (p53, Rb) and activity of ment is related to the distribution of lesions. If they are the HIV transactivator of transcription protein and HPV. limited to the oral environment, local or regional therapy Squamous cell carcinoma of the tonsils has the highest may be considered. If these lesions are widespread, sys- 11 prevalence of HPV-16 DNA and may therefore be asso- temic chemotherapy may be used. ciated with some cases of oral squamous cell carcinoma in patients who are HIV-positive. The frequency of HPV- Lymphoma containing oral warts in adults who are HIV-positive Non-Hodgkin’s lymphoma in patients with HIV is an and are on HAART is increasing. These warts are most AIDS-defining condition. Oral signs of lymphoma may be often associated with oncogenic HPV-16 and HPV-18.12 soft-tissue masses with or without ulceration and tissue Regezi and others13 reported that 20 of 22 dysplastic warts necrosis that frequently involves the gingival, palatal and in patients with HIV showed high-proliferation protein alveolar mucosa, along with other oral tissues (Figs. 4, levels, suggesting that these lesions may carry a risk of 5 and 6). Oral lymphoma may mimic periodontal dis- malignancy, although this was not demonstrated in the ease, with thickening, mass, ulceration and radiographic study cohort. changes, including widening of the periodontal ligament Epstein-Barr virus was identified in 17.59% of all oral space, loss of lamina dura and bone destruction. The risk tumours and in 63.1% of squamous cell carcinomas of the of non-Hodgkin’s lymphoma for patients with AIDS is tongue in 12 patients, suggesting a potential relationship 15 times greater for those with low-grade and T-cell

954 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • ––– HIV: Oral Malignancies –––

Figure 4: Abnormal elevated and thick- Figure 5: A pink, firm mass in the gingiva, Figure 6: Infiltration and enlargement of ened attached gingiva with a mass in found during oral examination in a patient the mandibular gingiva with ulceration and the upper vestibule that was diagnosed being staged for lymphoma. This finding ecchymoses. Diagnosed as lymphoma, this as B-cell lymphoma. provided evidence of a more advanced stage condition responded rapidly to therapy for of disease and led to a change in medical lymphoma. management.

non-Hodgkin’s lymphoma, and up to 400 times greater lymphoma are usually treated with a combination chemo- for those with high-grade non-Hodgkin’s lymphoma than therapy regimen, such as MOPP (mechlorethamine, vin- for patients without HIV.15 Non-Hodgkin’s lymphoma is cristine sulfate, procarbazine and prednisone), or ABVD evenly distributed for different HIV transmission groups (doxorubicin hydrochloride, bleomycin, vinblastine and and is often diagnosed at an advanced stage with bone dacarbazine), or EBVP (epirubicin, bleomycin, vinblas- marrow involvement in about half of patients. The risk tine and prednisone). Autologous stem-cell transplanta- of developing non-Hodgkin’s lymphoma is 1.6% per year tion may also be considered.9 of HIV infection; the risk for patients on HAART for 3 years is 19%.16 Unlike Kaposi’s sarcoma, the incidence Conclusion of non-Hodgkin’s lymphoma has not changed since the The pattern of cancer in patients with HIV may con- introduction of HAART. tinue to change as HAART and new therapies prolong The majority of cases of AIDS-related non-Hodgkin’s the life of patients. Chronic immunosuppression because lymphoma are aggressive large-cell lymphomas or of HIV, other viral risk factors and tobacco play a signifi- immunoblastic lymphomas that are associated with the cant role in a number of malignancies in patients who Epstein-Barr virus. Most non-Hodgkin’s lymphomas are are HIV-positive. Oral Kaposi’s sarcoma is rarely seen, high-grade B-cell lymphomas. B-cell mucosa-associated- but may be identified in untreated people or be a sign of lymphoid-tissue lymphoma may involve mucosal sites or the progression of HIV. Tobacco use and HPV may play the salivary glands. Patients with HIV who have enlarge- an increasing role in oral squamous cell carcinoma in ment of the salivary glands may have benign lymphoepi- the future. Lymphoma is now the most common malig- thelial lesions involving the gland that are associated with nant disease in patients with HIV. Hodgkin’s lymphoma a 44-fold increased risk of developing lymphoma, most may be more common with injection drug users than often mucosa-associated lymphoid tissue lymphoma.17 other HIV-risk groups. Patients who are HIV-positive While the lesions are generally benign, the potential and have Hodgkin’s lymphoma have a higher frequency for the development of malignant lymphoma requires of infection with the Epstein-Barr virus than those who further study. AIDS-related non-Hodgkin’s lymphomas are HIV negative. Challenges in the management of ma- are commonly aggressive B-cell lymphomas, mucosa- lignancies include marrow suppression and opportunistic associated-lymphoid-tissue large-cell lymphomas, or infections, as well as potential drug–drug interactions immunoblastic lymphomas. T-cell lymphomas are less between chemotherapy and HAART. In most cases, common. Survival rates for patients with non-Hodgkin’s HAART is continued unless excessive toxicity develops. lymphoma are lower for those who are HIV-positive. Active prophylaxis of infections, new regimens of sys- Treatment includes systemic chemotherapy given temic chemotherapy and increased use of hematopoietic in conjunction with HAART, and supportive care with stem-cell transplantation are part of modern anticancer hematopoietic growth factors and prophylaxis for HIV- therapy when patients have HIV. The dentist’s role is to associated infections.9 High-dose chemotherapy com- identify early changes in the mucosa that lead to a diag- bined with autologous hematopoietic transplantation nosis of cancer and to maintain the patient’s oral and may be considered. Patients with advanced Hodgkin’s dental health. a

��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 955 ––– Epstein –––

THE AUTHOR

Dr. Epstein is professor and head, department of oral medicine and diagnostic sciences, College of Dentistry, and director, interdisciplinary program in oral cancer, College of Medicine, Chicago Cancer Center, University of Illinois at Chicago, Chicago, Illinois.

Correspondence to: Dr. Joel Epstein, UIC College of Dentistry, Oral Medicine, MC-838, 801 South Paulina St., Chicago, IL 60091, USA.

The author has no declared financial interests.

This article has been peer reviewed. Quantum References p/u Nov 07 1. Hessol NA, Pipkin S, Schwarcz S, Cress RD, Bacchetti P, Scheer S. The impact of highly active antiretroviral therapy on non-AIDS-defining cancers p. 817 among adults with AIDS. Am J Epidemiol 2007; 165(10):1143–53. Epub 2007 Mar 6. 4/C 2. Epstein JB, Cabay RJ, Glick M. Oral malignancies in HIV disease: changes in disease presentation, increasing understanding of molecular pathogenesis, E/F and current management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100(5):571–8. 3. Remick SC. Non-AIDS-defining cancers. Hematol Oncol Clin North Am 1996; 10(5):1203–13. 4. Rabkin CS. Association of non-acquired immunodeficiency syndrome-defining cancers with human immunodeficiency virus infection. J Natl Cancer Inst Monogr 1998; (23):23–5. 5. Serraino D, Boschini A, Carrieri P, Pradier C, Dorrucci M, Dal Maso L, and others. Cancer risk among men with, or at risk of, HIV infection in southern Europe. AIDS 2000; 14(5):553–9. 6. van der Waal I. Some unusual oral lesions in HIV infection: comments on the current classification. Oral Dis 1997; 3(Suppl 1):S197–9. 7. Shiboski CH. Epidemiology of HIV-related oral manifestations in women: a review. Oral Dis 1997; 3(Suppl 1):S18–27. 8. Cesarman E, Chang Y, Moore PS, Said JW, Knowles DM. Kaposi’s sarcoma-associated herpesvirus-like DNA sequences in AIDS-related body- cavity-based lymphomas. N Engl J Med 1995; 332(18):1186–91. 9. Berretta M, Cinelli R, Martellotta F, Spina M, Vaccher E, Tirelli U. Therapeutic approaches to AIDS-related malignancies. Oncogene 2003; 22(42):6646–59. 10. Singh B, Balwally AN, Shaha AR, Rosenfeld RM, Har-El G, Lucente FE. Upper aerodigestive tract squamous cell carcinoma. The human immunodeficiency virus connection. Arch Otolaryngol Head Neck Surg 1996; 122(6):639–43. 11. ��D’Souza G, Kreimer AR, Viscidi R, Pawlita M, Fakhry C, Koch WM, and others. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 2007; 356(19):1944–56. 12. Casariego Z, Micinquevich S, Gomez MA. HPV in “carcinoma in situ” associated with HIV/AIDS infection: a case report. Med Oral 2002; 7(2):84–8. 13. Regezi JA, Dekker NP, Ramos DM, Li X, Macabeo-Ong M, Jordan RC. Proliferation and invasion factors in HIV-associated dysplastic and nondy- splastic oral warts and in oral squamous cell carcinoma: an immunohisto- chemical and RT-PCR evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 94(6):724–31. 14. González-Moles M, Gutiérrez J, Ruiz I, Fernández JA, Rodriguez M, Aneiros J. Epstein-Barr virus and oral squamous cell carcinoma in patients without HIV infection: viral detection by polymerase chain reaction. Microbios 1998; 96(383):23–31. 15. Dal Maso L, Franceschi S. Epidemiology of non-Hodgkin lymphomas and other haemolymphopoietic neoplasms in people with AIDS. Lancet Oncol 2003; 4(2):110–9. 16. Tulpule A, Levine A. AIDS-related lymphoma. Blood Rev 1999; 13(3):147–50. 17. Harris NL. Lymphoid proliferations of the salivary glands. Am J Clin Pathol 1999; 111(1 Suppl 1):S94–103.

956 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • Classifieds Dollco” pls place pdf files provided

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958 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • Classifieds Dollco” pls place pdf files provided

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960 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • Classifieds Dollco” pls place pdf files provided

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��JCDA • www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • 963 Advertisers’ Index

3M ESPE...... 864

American Dental Association...... 939

CDA Funds...... 966

CDA Membership...... 965

CDA Patient Information Brochures...... 885–6

CDSPI...... 902, 928, 940

Dental Office Classifieds Consulting...... 877 Dollco” pls place pdf files provided - Ad index will should appear as GlaxoSmithKline...... 866 placed here. Ivoclar Vivadent ...... 968

Johnson & Johnson...... 910

Ontario Dental Association...... 913–6

P&G Professional Oral Health . . . . 865, 868, 924

Quantum ...... 956

Stratos Wealth Management ...... 932

Straumann...... 862

Sunstar Americas ...... 872

Toothbooth...... 901

Université Laval...... 938

Vident...... 931

VOCO...... 878

964 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 •

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CDA Managed Risk Portfolios (Wrap Funds) MER 1 year 3 years 5 years 10 years

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966 JCDA�� •  www.cda-adc.ca/jcda • December 2007/January 2008, Vol. 73, No. 10 • Roi Corp p/u Nov 07 IBC Eng only 4/C Ivoclar emax p/u Nov 07 OBC E/F 4/C