Can Dental Burs Be Sterilized Effectively for Reuse?

JCDAJournal of the Canadian Dental Association

Vol. 71, No. 3 March 2005

Distraction Osteogenesis and Dental Implant Therapy

Iatrogenic Paresthesias of the Third Division of the Trigeminal Nerve

Sporadic Burkitt’s Lymphoma of the Jaws

Clinical Showcase: Removing a Bur from the Maxillary Sinus Glass pin by Dr. Christopher and Dianne Robinson

Special Oral and Maxillofacial Surgery Issue in conjunction with the Canadian Association of Oral and Maxillofacial Surgeons

Canada’s Peer-Reviewed Dental Journal PM40064661 R09961 • www.cda-adc.ca/jcda • A trip to the dentist can feel this good

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CDA Executive Director George Weber Editor-In-Chief Mission statement Dr. John P. O’Keefe Writer/Editor CDA is the authoritative national voice of dentistry, dedicated to the Sean McNamara representation and advancement of the profession, nationally and Assistant Editor internationally, and to the achievement of optimal oral health. Natalie Blais Coordinator, French Translation Nathalie Upton Coordinator, Publications Rachel Galipeau Editorial consultants Writer, Electronic Media Dr. Catalena Birek Dr. Ernest W. Lam Melany Hall Manager, Design & Production Dr. Gary A. Clark Dr. James L. Leake Barry Sabourin Dr. Jeff Coil Dr. William H. Liebenberg Graphic Designer Dr. Pierre C. Desautels Janet Cadeau-Simpson Dr. Kevin E. Lung Associate Editors Dr. Terry Donovan Dr. Debora C. Matthews Dr. Michael J. Casas Dr. Robert Dorion Dr. Anne Charbonneau Dr. David S. Precious Dr. Robert V. Elia Dr. Mary E. McNally Dr. Richard B. Price Dr. Sebastian Saba Dr. Joel B. Epstein All statements of opinion and supposed fact Dr. N. Dorin Ruse are published on the authority of the author Dr. Kenneth E. Glover who submits them and do not necessarily Dr. George K.B. Sándor express the views of the Canadian Dental Dr. Daniel Haas Association. The editor reserves the right to Dr. Benoit Soucy edit all copy submitted to the Journal. Publica- Dr. Felicity Hardwick tion of an advertisement does not necessarily Dr. Gordon W. Thompson imply that the Canadian Dental Association Dr. Robert J. Hawkins agrees with or supports the claims therein. Dr. Aleksandra Jokovic Dr. Robert S. Turnbull The Journal of the Canadian Dental Associa- tion is published in both official languages — Dr. Asbjørn Jokstad Dr. David W. Tyler except scientific articles which are published in the language in which they are Dr. Richard Komorowski Dr. Peter T. Williams received. Readers may request the Journal in the language of their choice. The Journal of the Canadian Dental Association is published 11 times per year (July-August combined) by the Canadian Dental Association. Copyright 1982 by the CDA Board of Directors Canadian Dental Association. Publications Mail Agreement No. 40064661. Registration President Dr. Gordon Johnson No. 09961. Return undeliverable Canadian Dr. Alfred Dean North Battleford, Saskatchewan addresses to: Canadian Dental Association at 1815 Alta Vista Drive, Ottawa, ON K1G 3Y6. Sydney, Nova Scotia Postage paid at Ottawa, Ont. Subscriptions Dr. Robert MacGregor are for 11 issues, conforming with the calen- President-Elect Kentville, Nova Scotia dar year. All 2005 subscriptions are payable Dr. Jack Cottrell in advance in Canadian funds. In Canada — Port Perry, Ontario $81 ($75.70 + GST, #R106845209); United Dr. Jack Scott States — $110; all other — $136. Notice of Vice-President change of address should be received before Edmonton, Alberta the 10th of the month to become effective the Dr. Wayne Halstrom following month. Member: American Associat- Vancouver, British Columbia ion of Dental Editors and Canadian Circulations Dr. Robert Sexton Audit Board • Call CDA for information and Dr. Michael Connolly Corner Brook, Newfoundland and Labrador assistance toll-free (Canada) at: 1-800-267-6354 Charlottetown, Prince Edward Island • Outside Canada: (613) 523-1770 • CDA Fax: (613) 523-7736 • CDA E-mail: reception@ Dr. Darryl Smith cda-adc.ca • Web site: www.cda-adc.ca Dr. Craig Fedorowich Valleyview, Alberta Hamiota, Manitoba ISSN 0709 8936 Printed in Canada Dr. Don Friedlander Dr. Deborah Stymiest Ottawa, Ontario Fredericton, New Brunswick

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 139 Esthetics were rated excellent to very good in 97% of restorations.*

FiltekTM Supreme Universal Restorative. (It’s good to be king.)

*THE DENTAL ADVISOR, Vol. 21, No. 5, June 2004 3M, ESPE and Filtek are trademarks of 3M or 3M ESPE A.G. Used under license in Canada. 0501-MG-21485 © 3M, 2005 CONTENTS Journal of the Canadian Dental Association

D EPARTMENTS C LINICAL P RACTICE

Guest Editorial ...... 143 Management of a Patient with an Accessory Maxilla and Congenital Facial Fistula ...... 161 President’s Column ...... 145 Vesa T. Kainulainen, DDS, EHL, PhD George K.B. Sándor, MD, DDS, PhD, FRCD(C), FRCSC, FACS Letters ...... 147 Douglas W. Stoneman, DDS, FRCD(C)

News...... 151 Sporadic Burkitt’s Lymphoma of the Jaws: The Essentials of Prompt Life-saving Referral and Management ...... 165 About the CAOMS...... 156 Ahmed Jan, DDS Point of Care ...... 193 Kashyap Vora, BDS, FDS RCS (Eng) George K.B. Sándor, MD, DDS, PhD, FRCD(C), FRCSC, FACS Clinical Showcase ...... 200 Mandibular Distraction Osteogenesis for CDSPI Reports ...... 203 Endosseous Dental Implants...... 171 David A. Walker, DDS, MS, FRCD(C) New Products ...... 205

Classiﬁed Ads ...... 207 PPLIED ESEARCH Advertisers’ Index ...... 214 A R Resterilization of Instruments Used in a Hospital-based All matters pertaining to the Journal should Oral and Maxillofacial Surgery Clinic ...... 179 be directed to: Editor-in-chief, Journal of the Nicholas J.V. Hogg, MSc, DDS Canadian Dental Association, 1815 Alta Vista Archibald D. Morrison, DDS, MSc, FRCD(C) Drive, Ottawa, ON, K1G 3Y6. E-mail: [email protected]. Iatrogenic Paresthesia in the Third Division of the • Toll-free: 1-800-267-6354 • • Tel.: (613) 523-1770 • Trigeminal Nerve: 12 Years of Clinical Experience ...... 185 • Fax: (613) 523-7736 • René Caissie, DMD, MSc Jacques Goulet, DMD, FRCD(C) All matters pertaining to classiﬁed advertising Michel Fortin, DMD, PhD, FRCD(C) should be directed to: Ms. Beverley Kirk- Domenic Morielli, BSc, DDS patrick c/o Canadian Medical Association, 1867 Alta Vista Dr., Ottawa, ON K1G 3Y6 • Toll-free: 1-800-663-7336 , ext. 2127 • • Tel.: (613) 731-9331• • Fax: (613) 565-7488 •

All matters pertaining to display advertising should be directed to: Mr. Peter Greenhough c/o Keith Communications Inc., 104-1599 Hurontario St., Mississauga, ON L5G 4S1 • Toll-free: 1-800-661-5004 • • Tel.: (905) 278-6700 • • Fax: (905) 278-4850 •

Publication of an advertisement does not necessarily imply that the Canadian Dental Association agrees with or supports the claims therein. An independent review* has concluded that oscillating- “We acknowledge the ﬁnancial support rotating technology, pioneered by Oral-B, is the most of the Government of Canada through effective at reducing plaque and gingivitis. the Publications Assistance Program *For more information, and to read the published abstract, visit the Cochrane Collaboration website at towards our mailing costs.” www.update-software.com/toothbrush. Please see our advertisement opposite the Editorial page.

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 141 The best oral careyourpatients can get between appointments.

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©2004 Oral-B Laboratories 1 Heanue M et al. Manual versus powered toothbrushing for oral health (Cochrane Review). In: The Cochrane Library, Issue 1, 2003, Oxford: Update Software 2 Sicilia A et al. A systematic review of powered vs manual toothbrushes in periodontal cause-related therapy. J Clin Periodontol 2002; 29(Suppl 3):39-54. 3 van der Weijden, GA et. al. Powered toothbrushing compared to a professional polish. J Dent Res 2001; 80 (Spec Iss): 743 Abstr.1734. Guest Editorial

tive surgical techniques for treating to the professional literature. With mandibular fractures described by more than 18,000 practising dentists FROM Edward Ellis (1993). Unquestionably, and dental specialists throughout the peer-reviewed publications represent country, there must be an abundance PRACTICE TO one of the most effective means of of interesting material from which we communicating pertinent and timely could all benefit. This information PUBLICATION information to dental specialists and can be published and there are people generalists alike. willing to help practitioners bring In the past 2 decades, major this worthwhile material through to changes have taken place in general publication. and specialized dentistry. Much of the I vividly recall the trepidation that early oral surgery literature dealt with I experienced when preparing my basic exodontia, removal of wisdom first article in consideration for publi- teeth, maxillofacial trauma, infec- cation. Years later, I still feel anxious tions, cysts and tumours. More each time I submit an article, but my recently, there has been a shift in anxieties are tempered with a sense of emphasis to orthognathic and recon- accomplishment and fulfillment. structive surgery, temporomandibular These feelings compel me to continue joint surgery, implants, distraction to submit articles. osteogenesis, endoscopic procedures There is no more noble pursuit Dr. Bruce R. Pynn and esthetic surgery. These changes in than the sharing of knowledge surgical focus demonstrate how our amongst professional colleagues. In specialty uses basic information this regard, I would encourage practitioners engaged in private practice to extbooks have historically gleaned from publications to develop and implement new surgical proce- share their expertise, knowledge and served as a major professional interesting cases, so that we may all reference and information dures. This principle is illustrated in T this edition of JCDA by Dr. David learn from each other. Dr. Daniel source. However, by the publication Walker, who describes a case involving Laskin, editor emeritus of the Journal date much of the information of Oral and Maxillofacial Surgery, contained in a textbook may no bilateral intraoral distraction osteogenesis, and by Drs. Friedlich and once stated that “through such shar- longer be current. The unfortunate ing of knowledge everyone benefits, reality is that new and important Rittenberg, who report on a case in which a bur fragment was retrieved because it leads to closer cooperation information can take years before it is between specialties and the dental from the maxillary sinus of a patient finally published in this format. community at large, ultimately lead- using an endoscopic technique. Both Indeed, if it were not for the exis- ing to better patient care.” Teachable papers demonstrate how the authors’ tence of peer-reviewed professional moments happen every day in our experience became the source of inter- journals, many of our innovative practices. Take advantage of these esting and useful information, worthy techniques might have taken an inor- moments by writing them down, of being shared with colleagues. dinate amount of time to become researching and refining your ideas In Canada, we are fortunate to incorporated into our armamentar- and submitting a paper to a journal. have internationally recognized oral ium. Prime examples of this include By doing so, you will not only help to and maxillofacial surgeons such as the pioneering work of Robert Hall enlighten your colleagues, but more Dr. David Precious at Dalhousie (1959), who reported on the benefi- importantly, your efforts may eventu- University and Drs. Simon Weinberg cial effect of the high-speed turbine ally translate into improved patient unit for bone removal in a variety of and George Sándor at the University care. oral and maxillofacial surgical proce- of Toronto, all of whom are regular dures; the research of William Bell contributors to the dental literature. (1975), whose anatomic studies However, our dental specialists and formed the biological basis for our generalists should not have to depend Bruce R. Pynn, MSc, DDS, FRCD(C) modern advanced orthognathic solely upon our academic institutions Thunder Bay, Ontario surgical techniques; and the innova- as the primary source of contributors Dr. Pynn is the CAOMS liaison to JCDA

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 143 Most toothpastes offer no protection against plaque after brushing – let alone after eating and drinking, when teeth become more vulnerable to bacterial attack. But Colgate Total* is different. Its unique formula protects against plaque for 12 hours, even after eating and drinking.1,2

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cists and accountants, dentists were ment has a role to play in oral health. rated the highest in terms of level of Almost 90% suggested that the professionalism. government should play a larger role LISTENING These results point to the fact that in raising awareness of oral health dentists are doing a good job of among Canadians. The federal govern- TO THE maintaining the public’s confidence ment has moved one step closer to about their role in delivering good fulfilling this role by appointing a PUBLIC oral health care. This is especially Chief Dental Officer position at significant when you consider that Health Canada. Dr. Peter Cooney will almost two-thirds of those surveyed assume this new role and part of his said that their dentist is their main mandate includes promoting improve- source of oral health care and treatments in the oral health status of ment information. Canadians. It was also interesting to When asked about levels of service, note that 80% of those asked expres- dentistry also performed very well. sed a desire to see the national health Almost 90% of participants responded care system expanded to include some positively to questions related to office level of dental care. location, hours of operation, being I’ve just summarized a lot of statis- able to communicate in the language tics but what do they all mean? CDA of their choice and being able to see must plan future public education the dentist of their choice. strategies and develop materials for our The public appears to be hearing members by continually monitoring our profession’s messages about the the attitudes and needs of our patients. Dr. Alfred Dean This information helps identify areas importance of good oral health. The where greater efforts can be directed to number of people reporting good improve relationships with patients. hygiene habits is on the rise, as is the One such area that could benefit number reporting a dental visit at least t can be difficult to see yourself as from increased examination is the once a year. Dental phobias seem to be others see you. In my experience, seniors population in Canada. In decreasing, with more patients expres- I many dentists have a distorted February, I attended the first ever sing how benign a dental visit has idea of how they are viewed by the Seniors Oral Health Forum — a become relative to many years ago. general public. Moreover, the dental meeting between CDA and the The survey revealed that communi- profession as a whole has trouble provincial dental associations — where cation with patients may be an area for seeing itself through the public’s eyes. we began the process of identifying the One way to determine the public’s improvement. When asked, very few key issues and steps for action to perception of dentistry is to ask. CDA patients had been consulted on general address this looming health care crisis. did just that in a national telephone health issues. Two-thirds of respon- The dental profession needs to survey of over 1,800 Canadians conduc- dents said that their dentist did not learn more about the specific needs ted at the end of 2004. For the most discuss a link between oral health and of seniors. Surveys and statistics gathe- part, the results are quite encouraging other conditions such as diabetes, rings are ways to engage Canadians and should be considered a source of heart disease or stroke. Similarly, of all ages in a dialogue about oral pride for the profession. results showed that dentists do not health. I believe that opportunities for Overwhelmingly, patients see appear to talk to their patients about exchanges between patients and the dentists as skilled and professional and the symptoms of oral cancer. However, profession inevitably lead to opportu- having their best interests in mind. patients reported that they are very nities for improvements in the delivery Survey participants said they trust the interested in receiving information in of oral health care. advice their dentist gives them and the form of brochures and they enjoy they feel dentists provide reliable infor- reading this material when it is made mation about their oral health. In fact, available. when ranked against other professions, Respondents were not shy about Alfred Dean, DDS such as lawyers, physicians, pharma- saying that they believe that govern- [email protected]

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 145 A-DEC 500TM. Synergizing Access And Comfort.

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Editor’s Comment only parties harmed by Gilbert’s busi- pyramid system, to their CDA represen- The Journal welcomes letters from ness practices. tatives in order to be heard. If it works for other provinces, it can be made to readers about topics that are relevant Ronald B. Stern to the dental profession. The views Director work for Quebec, providing a reasona- expressed are those of the author and do Excel Dental Supplies Ltd. ble attitude of accommodation prevails not necessarily reflect the opinions or Chai Wan, Hong Kong and that no hidden agenda exists. official policies of the Canadian Dental Dr. Charest’s assertion that Quebec’s Association. Letters should ideally be no Reference representatives in CDA would not longer than 300 words. If what you 1. Rogue dental supply company declares “have the right to represent their home want to say can’t fit into 300 words, bankruptcy [News]. J Can Dent Assoc 2004; provincial association and must exclusi- 70(9):592. please consider writing a piece for our vely serve the greater interests of CDA” Debate section. QDSA’s Withdrawal from CDA is balderdash. Under any system, Dr. Chantal Charest, the president provincial representatives would only of the Quebec Dental Surgeons have to refer back to their constituents Gilbert Medical Dental Association (QDSA), did her best to to obtain guidance to negotiate as duly Supplies Trading as Excel-Dent explain the reasons for her organization’s elected board members. withdrawal from CDA,1 but I remain Unity, an essential goal in a country One of our Canadian customers unconvinced. On careful analysis, the as diverse as Canada, can only be achie- recently sent us a copy of an article1 justifications she gave certainly do not ved if we keep the following truism in published in JCDA concerning the make a lot of sense, nor do they present mind: differences divide, similarities unsavoury business practices of Gilbert a convincing case for the “s” word — unite. There is no implication of boring Medical Dental Supply (“Gilbert’s”). separation. uniformity in this adage, but merely We are especially concerned that Her contention that a professional the recognition that exploiting the natu- Gilbert’s seems to have carried out many organization must understand and ral attractive forces among people over of these practices in the name of Excel- respond appropriately to the concerns the divisive ones is more constructive; Dent, a name that bears an uncanny and views of its members, making its it endorses the logic of unity over resemblance to the name of our entire resources available in the process, disunity. company, Excel Dental Supplies Ltd. is correct. And that is precisely what Excel Dental Supplies is incorpora- CDA sets out to do for its entire Dr. Donald F. Mulcahy Edmonton, Alberta ted in Hong Kong and manufactures membership, including Quebec gutta-percha and absorbent paper dentists, through their elected CDA Reference points in China for the endodontic representatives. If, as a democratically 1. QDSA’s withdrawal from CDA. [Letter] market. We have been doing business conceived and structured national body, J Can Dent Assoc 2004; 70(10):663. CDA is able to satisfy the needs of for over 15 years and have customers in Is Dentistry a Profession? most major markets, including Canada. dentists in all other provinces, there is I am astounded at Dr. Welie’s A sizeable portion of our business is no reason to presume it could not concluding remarks in the final article private label business, but we do sell adequately represent the interests of of his series on professionalism,1 where products under the “Excel” label. Quebec practitioners. That assumption he suggests that because dentists attend We believe that the similarity in is only valid, of course, in the absence of some other, unstated motive, such as seminars on how to build a successful names between our company and Excel- covert nationalism. While Quebec business or perform cosmetic procedu- Dent has created uncertainty in the dentists continue to emphasize the res, this somehow reflects a desire on minds of our current and potential differences that they claim constitute a dentistry’s part to relinquish its status as customers and has resulted in harm to separate national identity, the rest of us a profession. our reputation. We realize this is a matter are intent on forging the necessary cohe- When was the last time any profes- that should be resolved in a court of law, sion among all dentists that we regard as sion pursued the goal of earning less but legal fees being what they are and the only effective tool for dealing with income? Am I the only one who finds because we would need to file “out of (often recalcitrant) governments. that a health care system run by for- jurisdiction,” it seems that the costs No matter how complex and diffe- profit physicians who essentially earn might exceed any potential benefit we rent a dental administrative structure their income from tax dollars is a little would be able to realize. might be within a given province, the bit insane? All I ever hear from the We would simply like CDA to know dentists of that province merely need to doctors I rub shoulders with is how they that Canadian dentists were not the funnel their input, via some structured want to earn more money. Most of the

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 147 Letters

physicians in my city are living lifestyles Reference many members that the Association that seem built on consumption. All 1. Welie JV. Is dentistry a profession? Part 3. spends a huge amount of money the dental procedures done in one year Future challenges. J Can Dent Assoc 2004; annually for the services of an out-of- would be dwarfed by the medical 70(10):675–8. province accountant/statistician to profession’s “cosmetic interventions.” Who Should Represent “develop” the fee guide and create a Every day I deal with dental patients Dentists? report of dubious practical value. with active disease who, even in this era, Who do I believe should represent Dr. Richard Busse’s letter1 in the have to be convinced that it would be a dentists? An independent organization November issue of JCDA painted an (such as an Association) whose budget good idea to repair their decay. Right idyllic picture of organized dentistry in comes from voluntary membership fees, after they turn down treatment because British Columbia. According to Dr. whose offices are separate from all other they aren’t in pain yet, they rush to their Busse, the separation of membership dental or government organizations and Botox and laser hair removal appoint- functions (undertaken by the agencies, whose employees are not ments. Association) and licensing/regulatory involved in the activities of other dental roles (performed by the College) has Dr. Kim W. Scott organizations, and whose sole purpose been complete and has successfully alle- Medicine Hat, Alberta and interest is the representation and viated all scepticism and fear amongst support of its members. An organiza- Reference the membership. tion that would stand behind members 1. Welie JV. Is dentistry a profession? Part 3. In reality, this separation is far from who are having disciplinary and regula- Future challenges. J Can Dent Assoc 2004; being complete or satisfactory. Indeed, 70(10):675–8. tory problems. An organization that there is a growing number of dentists in would represent its members against Response from the Author B.C. who believe that the separation is organizations such as SOCAN, which, I am quite pleased with Dr. Scott’s hardly more than window dressing. as I see it, is attempting to exploit the response because he (unwittingly?) Dr. Busse also states that the funding members and to discriminate against supports my concerns. I never claimed model used in B.C., which is manda- our profession. that medicine, unlike dentistry, is a tory through the licence fee, is the same genuine profession and not at risk. If as in the other provinces. However, he Dr. Emil Sztopa Dr. Scott’s description of the physicians fails to mention that this is not the case Port Coquitlam, B.C. in his town is correct, and if that in Canada’s 2 largest provinces, Ontario and Quebec, which represent approxi- Reference description were to apply to all physi- 1. Busse R. Who should represent dentists? cians (as he seems to suggest), it would mately 64% of Canada’s dentist popula- [Letter] J Can Dent Assoc 2004; 70(10):663–4. merely show that the medical profession tion. Dentists residing in those provin- is not or is no longer a profession as I ces can freely decide if they want to Dr. Busse1 gives a very concise and have defined that term. But I am far less belong to their provincial or national interesting historical account of the pessimistic than Dr. Scott. I am quite organization. evolution and development of organi- certain that many physicians, and like- Dr. Busse gives 2 examples of how zed dentistry in British Columbia. As wise many dentists, seek to be genuine the public’s interest is being served by all you may already know, the findings of professionals rather than successful dentists belonging to their member B.C.’s Seaton Commission were businesspersons. Granted, it may not association: access to continuing educa- congruent with those of Ontario’s always be easy to reach that goal: tion and to professional counselling. Woods-Gordon Report of the 1960s. The fact of the matter is that dentists are financial gain is always a temptation and On the basis of this report, the govern- overwhelmed by continuing education ment forced dentists in Ontario to sepa- there are many systemic barriers to this opportunities and hardly need the help rate the Royal College of Dental aspiration. But for many health care of the Association in that regard. In Surgeons of Ontario, the licensing body providers, it nevertheless remains a terms of counselling, an increasing for dentistry, from the Ontario Dental goal worth striving for. Unfortunately, number of dentists turn to the free Association (ODA), the voluntary asso- Dr. Scott’s stated practice philosophy counselling services offered through ciation of dentists. shows that not all health care providers CDSPI because they are concerned with Since graduating in 1954, I have are so inclined, which is why I deemed confidentiality issues. been a member of CDA, ODA, the it urgent to sketch a view of professio- I am glad that Dr. Busse did not Niagara Peninsula Dental Association nalism that is admittedly idealistic and mention as a “members’ benefit” our (my regional component society), and aspirational. But isn’t that what ethicists seriously flawed and much contested fee the St. Catharines Dental Society. I are supposed to do? guide, which, for more and more practi- joined FDI when I became aware of this Dr. Jos Welie tioners, represents a hindrance to organization and realized its relevance Creighton University Medical Center running a practice in a fiscally prudent and usefulness to me. I got full value Omaha, Nebraska manner. It is an additional annoyance to and great benefits for all dues paid.

148 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Letters

However, I also appreciate that not all JCDA for giving me the opportunity to References dentists agreed with my assessment of carry on this dialogue with like-minded 1. Mendes RA, Rocha G. Mandibular molar autotransplantation — literature review with membership benefits, and I strongly dentists around the world. The CDA clinical cases. J Can Dent Assoc 2004; believe that they had the right to not journal has established itself as a signifi- 70(11):761–6. join, whatever their reasons. I still cant player in the global knowledge 2. Castaldi CR, Brass GA. Dentistry for the believe that no one should be forced to network. This is a testament to the adolescent. Philadelphia: W.B. Saunders; 1980. pay dues to a society, union or any asso- quality and unique nature of JCDA, and ciation if they choose not to join. is something we should all take pride in. As a dentist, I had to constantly Dr. Barry Schwartz produce quality care and please my School of Dentistry clients to retain them. I had to prove to University of Western Ontario my clients that I was competent and London, Ontario Continuing Dental that my services were beneficial to them Education and worth the cost. Likewise, our Mandibular Third Molar voluntary dental associations must CDA maintains a current prove their relevance, worth and benefit Autotransplantation listing of continuing dental to their clients, namely the dentists in My reaction to the article by Drs. education courses to help 1 their jurisdiction. Mendes and Rocha on mandibular dentists stay informed about Democracy and free market systems third molar autotransplantation is: “Plus various learning opportunities are not always the most efficient nor the ça change, plus c’est la même chose.” offered to them in Canada and cheapest way of accomplishing certain I would like to refer you to the text- abroad. To view the complete objectives. Our Bill of Rights gives us book Dentistry for the adolescent,2 writ- calendar of CDE events, visit the freedom of choice. ten by Castaldi and Brass. Both these CDA’s Web site at www.cda- I see no justification for compulsory authors, as I’m sure you know, were adc.ca. membership and dues to all the levels of distinguished Canadian academics and organized dentistry because it “elimina- clinicians. tes the necessity of costly membership It was my privilege to contribute drives and the possibility of dentists Chapter 21, “Dental reconstruction benefiting from services without paying with transplants,” to this fine text. My for them.” contribution included 4-year radiogra- If the number of dentists is small and phic follow-up of case histories dating as they unanimously agree to “compul- far back as 1966. The sequential radio- sory” membership for any reason, then graphs provided evidence of ongoing that would be acceptable. Otherwise, it’s pulpal vitality, maturation and growth not a voluntary association but an unpa- of root structure, as well as accelerated latable tyranny of the majority. maturation of coronal pulp chambers. I have been a member of CDA Dr. Ivan Hrabowsky during my entire practice life. I St. Catharines, Ontario commend you for the excellent evolu- Reference tion and improvement in our scientific 1. Busse R. Who should represent dentists? journal, particularly under your watch. [Letter] J Can Dent Assoc 2004; 70(10)663–4. However, the peer-reviewed article by CDA and Global Networking Drs. Mendes and Rocha seems to be a little “old hat” to me, given that I I have written a number of debate conducted presentations on the proce- articles for JCDA recently, mostly on dure at provincial and national meetings dental ethics and communications, and as far back as 1968. have received many positive responses, It was unfortunate that in their not only from dentists across Canada, historical review for a Canadian publi- but from dentists around the world. cation, the authors did not find the From the e-mails I have received from detailed description and clinical guideli- Brazil, Mexico, Spain, India, Pakistan nes for the procedure in a Canadian and Australia, I have discovered that our text. professional issues in Canada are of interest to many others in diverse cultu- Dr. Walter H. Sussel res and distant lands. I want to thank Chilliwack, British Columbia

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 149

News

National Oral Health Month health care” in its February 2005 Global Tobacco Treaty In April, CDA will conduct its edition of the International Dental Officially Enacted annual National Oral Health Month Journal. Developed in collaboration The Framework Convention on campaign. This year’s campaign aims with the International Association for Tobacco Control (FCTC) will offi- to reinforce the importance of good Dental Research (IADR), the report cially become international law in oral health in relation to overall condenses the findings of IADR’s 21 March 2005. This international health and the role of the dentist as special research groups with respect tobacco treaty has a primary objective primary oral health care provider. to scientific developments in each “to protect present and future genera- The Oral Health — Good for Life tions from the devastating health, group’s particular field of study. campaign will be broadly dissemina- social, environmental and economic The new report is targeted ted using many communication vehi- consequences of tobacco consump- cles, including a supplement in the towards the general practitioner and tion and exposure to tobacco smoke.” National Post and Le Journal de summarizes the research that will The treaty required the ratification Montréal. Downloadable patient impact the future delivery of oral of 40 countries to become internatio- education fact sheets and materials health care. Results of the findings nal law and this number was achieved are available on the CDA Web site, have been presented at 2 FDI–IADR in December 2004. Commenting on along with more details of the 2005 science transfer seminars, held in the ratification, Dr. J.T. Barnard, National Oral Health Month collaboration with IADR’s annual executive director of the FDI World C campaign. convention in 2003 and 2004. Dental Federation, said: “Dentists need to play an active role in smoking FDI and IADR Publish For direct access to the report, cessation with their patients and see the March JCDA bookmarks. Report on the Future Delivery dental associations need to become of Oral Health Care Further information on the report effective public health advocates.” The FDI World Dental can be obtained by writing to The FCTC has been negotiated Federation recently published a Professor Asbjørn Jokstad, FDI’s under the auspices of the World report entitled “Cutting edge scientific affairs manager, at science@ Health Organization (WHO) with research that will impact future oral fdiworldental.org. C FDI participating in the negotiation and lobbying process from the beginning. COVER ARTISTS For more information on the FCTC, see the March JCDA book- This month’s cover art comes from marks C Dr. Christopher Robinson and his wife Dianne of Edmonton, Alberta. The Cone-beam CT Unit a First couple has been married for 33 years for UBC Dentistry and during that time they have engaged The University of British Columbia in various artistic pursuits individually (UBC) plays host to the first cone- and collectively. beam CT (CBCT) unit to be instal- The artwork on the cover depicts an led in a dental school in Canada. original composition of a kiln-fired Dr. Elaine Orpe, a clinical assistant fused dichroic glass pin. This material gains its vibrant colours from an aero- professor at UBC who has relocated space coating that is applied to colourless glass in a vacuum chamber. Glass her private practice to the university, art has interested the couple for over 25 years. Originally drawn to flat, is the owner of the iCAT unit from stained glass construction they are now more focused on hot glass. Imaging Sciences International. Dr. Robinson is an oral and maxillofacial surgeon who is a past president Dr. David MacDonald (PubMed: of the Canadian Association of Oral and Maxillofacial Surgeons (CAOMS) MacDonald-Jankowski), associate and now serves as its executive director. He was a founder and first chair of professor and chair of the oral and CDA’s Committee on Specialist Affairs. C maxillofacial radiology division at Cover photo by Dr. Robinson. Photo of artists by Dr. Glen Zenith of Edmonton. UBC, explains the main features of the CBCT unit. “Formerly, the

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 151 News

relied on both clinical examination Junior Researcher Wins Best According to the CIHR Web site, and conventional radiology to assess Manuscript Prize the purpose of this RFA is “to generate and diagnose lesions affecting the jaw In March, the American Dental relevant evidence to inform important bones,” says Dr. MacDonald. Education Association (ADEA) decisions that will be taken by health “Unfortunately, the radiograph gene- presented its ‘Best Manuscript of care and public health policy makers rally reveals only a coarse image of the 2004’ by a junior researcher in the and managers in Canada over the lesion. This is partly due to the lack of “Critical Issues in Dental Education” next few years.” The registration deadline for the sensitivity to display small changes in category to Sonya Smithers of RFA is May 1, 2005, and the full the bone and partly due to the super- Bedford, Nova Scotia. Ms. Smithers application is due on June 1, 2005. imposition of all structures within the was lead author on the article “What Predicts Performance in Canadian More details can be found on 3D volume of bone, displayed only as CIHR’s Web site at: www.cihr-irsc. Dental Schools?”, which appeared in a 2D image. This is particularly so gc.ca/e/25651.html. C with regards to the panoramic radio- the June 2004 edition of the Journal of graph,” explains Dr. MacDonald. Dental Education. A PPOINTMENTS He also notes that while spiral CT The winning manuscript was based on a study examining the validity of has assisted to some extent, its spatial NDEB Names New President resolution, or the ability to separately both cognitive and non-cognitive identify 2 minute points, was still factors used for selection to Canadian dental schools. The authors looked at inadequate. Dr. MacDonald believes whether the addition of a personality CBCT overcomes this previous short- measure would increase the validity of coming. “Spiral CT uses a planar predicting performance beyond that geometry and 2D reconstruction, achieved by an interview and the whereas CBCT perform non-planar Dental Aptitude Test. It was the ﬁrst geometry and a 3D reconstruction,” of 2 pilot studies leading to a current Dr. MacDonald continues. “As multicentre study in Canadian dental CBCT interrogates a much smaller schools on admission criteria and its volume of tissue, it is also called assessment. ‘micro CT.’ The advantage of CBCT Data for the study were collected Dr. Craig Meyers is the superior spatial resolution of as part of Ms. Smithers’ master’s tissues with high contrast, like mine- Dr. Craig Meyers of Prince Albert, thesis project at St. Mary’s University, Saskatchewan, is the new president of ralized tissue such as teeth and bone. where she is also a part-time faculty the National Dental Examining Board It also imparts a lower radiation dose member. Contributing authors on of Canada (NDEB). than spiral CT.” the article were Dr. Vic Catano, chair Dr. Meyers has held several posi- While there are currently other of the department of psychology at tions on NDEB, including chair of CBCT units (iCAT, Newtom and St. Mary’s University, and Dr. Don the Board’s Examinations, By-Laws, MercuRay) used in specialist private Cunningham, assistant dean of the Appeals and Finance Committees. He practice, the iCAT is the only unit faculty of dentistry at Dalhousie has also been on the NDEB executive C C with Canadian wheelchair access. University. since 1996. A 1980 graduate of the CIHR Issues a Request for University of Saskatchewan, Dr. Meyers Applications practises general dentistry in Prince Albert. He is a former president of the In December 2004, CIHR’s College of Dental Surgeons of Institute of Health Services and Policy Saskatchewan. He is a fellow of the Research (IHSPR), in collaboration American College of Dentists and the with the Institute of Aboriginal Academy of Dentistry International. Peoples’ Health (IAPH), the Institute Dr. Meyers will serve a 2-year term as of Population and Public Health NDEB president. C (IPPH) and the Knowledge Translation Branch, launched a Request for Winnipeg Specialist Named Applications (RFA) entitled Scoping MDA President Drs. Elaine Orpe and David MacDonald Reviews and Research Syntheses: Priority Dr. Lee McFadden of Winnipeg shown with the iCAT cone-beam CT unit. Health Services and System Issues. has been elected president of the

152 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association News

W EB R ESOURCES

Oral Pathology Dr. Ken Serota, an endodontist from Mississauga, Ontario, and Dr. Cathy Birek, a JCDA editorial consultant, recommend the following Web sites on oral pathology. The information contained on these sites includes definitions and images of oral lesions, case studies and quizzes. •University of Southern California School of Dentistry www.usc.edu/hsc/dental/opfs/ •Marquette University School of Dentistry Dr. Lee McFadden Department of oral and maxillofacial pathology Manitoba Dental Association (MDA) www.dental.mu.edu/oralpath/diagnosislist.htm at MDA’s annual meeting held on •Victoria Commonwealth University January 27, 2005. Oral pathology review images Dr. McFadden has been practising www.library.vcu.edu/tml/oralpathology/ as an oral and maxillofacial surgeon in •University of Iowa College of Dentistry Winnipeg since 1984. He has also Atlas of Oral Pathology taught on a part-time basis at the www.uiowa.edu/~oprm/AtlasWIN/AtlasFrame.html University of Manitoba’s faculty of dentistry. Dr. McFadden has served •University of Oklahoma College of Dentistry Department of oral and maxillofacial pathology on a number of MDA committees, Oral pathology case review including the Hospital Services, http://dentistry.ouhsc.edu/intranet-Web/ContEd/caseofthemonth/ Registration and Licensing Review and aHomeCaseMonth.html Executive Committees. Dr. McFadden has been a member of MDA’s board Food Recalls since January 2000 and became vice- The Canadian Food Inspection Agency (CFIA) is the federal govern- president in 2004. C ment’s regulator for food safety, animal health and plant protection. CFIA is Clarification responsible for investigating potential hazards associated with foods. In cases where a product poses a serious health risk, CFIA will issue a public warning In October 2004, JCDA published advising consumers through the media. Members of the public can sign up a News item on Gilbert Medical to receive CFIA’s free e-mail bulletin “Allergy Alerts and Food Recalls” at Dental Supplies (“Gilbert’s”) and its www.inspection.gc.ca. Subscribers will automatically receive the food recall related companies (Vol. 70, p. 592). public warnings and be notified as to which products are being recalled from One of the associated company names the marketplace. C listed in the article was Excel-Dent (please note the hyphen). Assessing Health Stories in the Press There has been some confusion in The UK National electronic Library for Health (NeLH) has commissio- regards to companies who have similar ned the Centre for Reviews and Dissemination to produce evidence-based names, in particular ExcelDent summaries of recent health news stories that appear in major national (without a hyphen). ExcelDent is a newspapers. The project, titled Hitting the Headlines, assesses the reliability fully CDAnet-certified company and of both the journalists’ reporting of health stories and the research on which is not related to Gilbert’s in any way. they are based. Hitting the Headline summaries go live within 48 hours of JCDA regrets any misunderstanding newspaper publication. In the past 6 months, summaries have been produ- and trusts this clarifies the matter. C ced on a variety of topics, including influenza vaccinations for high-risk younger patients, Vioxx and coronary heart disease, hormone replacement therapy and risk of stroke, laser cure for bad breath and mercury in baby vaccinations. For more information on Hitting the Headlines or to view the archived summaries, visit www.nelh.nhs.uk. C For direct access to the Web sites mentioned in the News section, go to the March JCDA bookmarks If you would like to recommend a health-related Web site to at http://www.cda-adc.ca/jcda/ appear in JCDA, e-mail Dr. John O’Keefe at [email protected]. vol-71/issue-3/index.html.

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 153 C ANADIAN D ENTISTS’ INVESTMENT P ROGRAM CDA Funds CHECK OUT OUR PERFORMANCE ✔ Superior Long-Term Returns ✔ Leading Fund Managers ✔ Low Fees CDA Funds can be used in your CDA RSP, CDA RIF, CDA Investment Account and CDA RESP.

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CDA CANADIAN GROWTH FUNDS Aggressive Equity fund (Altamira) up to 1.00% 2.0% 13.4% 8.3% 10.1% Common Stock fund (Altamira) up to 0.99% 7.2% 4.9% 1.2% 7.8% Canadian Equity fund (Trimark)†1 up to 1.65% 9.4% 6.3% 8.7% 9.6% Special Equity fund (KBSH)†2 up to 1.45% 12.0% 6.4% -4.8% 16.1% TSX Composite Index fund (BGI)†† up to 0.67% 9.2% 7.7% 2.7% 9.9% CDA INTERNATIONAL GROWTH FUNDS Emerging Markets fund (KBSH) up to 1.45% 0.7% 9.7% 1.1% 0.9% European fund (KBSH) up to 1.45% -7.0% -10.4% -11.6% 3.9% International Equity fund (KBSH) up to 1.45% -6.1% -5.0% -11.7% 3.6% Paciﬁc Basin fund (KBSH) up to 1.45% -6.7% -1.0% -20.5% 0.7% US Equity fund (KBSH)†3 up to 1.20% -3.5% -8.9% -8.1% 9.5% Global fund (Trimark)†4 up to 1.65% 1.6% 2.7% 7.0% 10.3% Global Stock fund (Templeton)†5 up to 1.77% 3.9% 0.7% 0.0% n/a S&P 500 Index fund (BGI)†† up to 0.67% -2.0% -5.7% -5.5% 9.4% CDA INCOME FUNDS Bond and Mortgage fund (Fiera) up to 0.99% 4.1% 5.8% 6.7% 7.3% Fixed Income fund (McLean Budden)†6 up to 0.97% 6.3% 6.6% 7.7% 8.6% CDA CASH AND EQUIVALENT FUND Money Market fund (Fiera) up to 0.67% 1.6% 2.0% 3.0% 3.8% CDA GROWTH AND INCOME FUNDS Balanced fund (KBSH) up to 1.00% 4.6% 2.7% 1.2% 7.8% Balanced Value fund (McLean Budden)†7 up to 0.95% 7.2% 5.5% 7.1% 10.0%

CDA ﬁgures indicate annual compound rate of return. All fees have been deducted. As a result, performance results may differ from those published by the fund managers. CDA ﬁgures are historical rates based on past performance and are not necessarily indicative of future performance. The annual MERs (Management Expense Ratios) depend on the value of the assets in the given funds. MERs shown are maximum. †Returns shown are those for the following funds in which CDA funds invest: 1Trimark Canadian Fund, 2KBSH Special Equity Fund, 3KBSH US Equity Fund, 4Trimark Fund, 5Templeton Global Stock Trust Fund, 6McLean Budden Fixed Income Fund, 7McLean Budden Balanced Value Fund. †† Returns shown are the total returns for the index tracked by these funds. For current unit values and GIC rates call CDSPI toll-free at 1-800-561-9401, ext. 5024 or visit the CDSPI Web site at www.cdspi.com/funds.

154 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association (SFBUNJOETUIJOLBMJLF

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President’s Message pioneers of the specialty. They learned appropriate access to care for the in the field and developed surgical patients in their community, with procedures in response to extreme situ- the necessary support of all of our ations. Today, new advances are fuelled dental colleagues. The Association’s by research and education. Oral and redesigned Web site (www.caoms.com) maxillofacial surgery retains its histori- provides access to a Canada-wide cal ties to dentistry; this synergy directory of surgeons and houses ensures that our specialty continues to excellent information for patients evolve so we can meet the growing wishing to learn more about their needs of our patients. surgical treatment options related to CAOMS was founded in 1953 to dental implants, orthognathic surgery, establish a national forum to discuss facial trauma, removal of wisdom surgical problems, to oversee the teeth, cleft palate repair, temporo- rapidly changing format of graduate mandibular joint problems and the education and to expedite progress in delivery of anesthesia. Dr. Joseph J. Friedlich oral and maxillofacial surgery. These CAOMS is very fortunate to have as efforts were founded on the fraternal- its executive director Dr. Christopher The Canadian Association of Oral ism that allowed our members to Robinson, whose diligent work in and Maxillofacial Surgeons (CAOMS) develop friendships with colleagues representing the specialty of oral and welcomes the opportunity to engage in from across Canada and to grow maxillofacial surgery and the profes- this collaborative effort with JCDA. personally and professionally. CAOMS sion of dentistry equitably in the A special thank you goes out to and its members remain committed to national arena is unprecedented. Dr. John O’Keefe and the editorial staff He embodies the zeal that has charac- of JCDA, Dr. Bruce Pynn, CAOMS terized our past 44 presidents and liaison to JCDA, and all of the contrib- constitutes a tremendous role model utors who devoted time and effort to for our current executive, which is the development of this special edition. The members of CAOMS composed of Dr. Walter Dobrovolsky, Oral and maxillofacial surgery has remain committed immediate past president, Dr. Lee evolved as a specialty over a rather short to providing McFadden, president-elect, Dr. Archie period of time. In Canada, Dr. George timely and appropriate Morrison, treasurer, and Dr. Pierre- Beers of Montreal is recognized as the Éric Landry, secretary. Our executive is first dentist to specialize in oral surgery access to care made up of representatives from each in the late 1800s. Oral and maxillofa- for the patients in of our component regional associa- cial surgery is considered to be the first their community, with tions. It is a pleasure to work with this dental specialty. It has been said that the necessary support team of highly skilled and dedicated the First and Second World Wars were of all of our volunteers. With the continued the catalyst behind its rapid develop- dental colleagues. support of CDA, we look forward to ment. Dr. Fulton Risdon, who was forging the strong interdisciplinary assigned to the Maxillofacial Centre for bonds that are required for all of us to the Canadian Forces at Sidcup during the continued advancement of the do what we do best... care! World War I, returned to Toronto as specialty through close professional Dr. Joseph J. Friedlich a pioneer specialist in plastic and oral connections. The Association holds an President, CAOMS surgery. He was later appointed annual scientific meeting that high- professor of oral surgery at the lights cutting-edge research through University of Toronto. abstract presentations. These educa- During the war, the number of tional meetings are usually open to all wounded needing facial bone recon- dentists in Canada and the format of struction was overwhelming. Patients the event allows for a broad dissemina- fell under the care of dentists, who tion of information. were the recognized jaw specialists of The members of CAOMS remain the time. These dentists were the true committed to providing timely and

156 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association A bout CAOMS

The Foundation for surgery for cleft lip and palate. Most Dalhousie University Continuing Education and recently, the Dr. Ron Warren awards The oral and maxillofacial surgery Research (CAOMS) were presented to: Dr. Daisy Chemaly specialty program at Dalhousie is a Canadian research in oral and from the University of Manitoba (for 6-year program that includes a master’s maxillofacial surgery is greatly research in the field of oral cancer), degree in oral and maxillofacial surgery supported by the Foundation for Dr. Albert Hadad from the University and a medical degree. One resident is Continuing Education and Research of Toronto (bone substitutes), accepted per year in addition to one (CAOMS). Members of CAOMS Dr. Brett Habijanac from McGill fellow. The fellowship position has founded this arm’s-length, non-profit University (maxillofacial trauma), recently been formalized and is of one organization in 1988. The objective of Dr. Nicholas Hogg from Dalhousie year’s duration. Dalhousie faculty are the Foundation is to contribute to the University (bacteriology/infection all fellowship-trained; areas of subspe- welfare of the public by the advance- control) and Dr. Annie-Claude cialty training include orthognathic ment of the specialty of oral and Valcourt from Laval University surgery, trauma, preprosthetic recon- maxillofacial surgery through contin- (temporomandibular dysfunction). structive and implant surgery, cleft lip uing education and the diffusion of The vital and practical benefits that and palate surgery and head and neck knowledge. The Foundation is the this research provides for both our cancer surgery. Research is ongoing in only national philanthropic organiza- patients and the profession include the following areas of interest: obstruction with a mission that is dedicated improved quality of care, scientifically tive sleep apnea, cleft lip and palate, to the financial support of research validated and evidence-based care, the sterilization of instruments, prepros- and education in the specialty of oral establishment of new and innovative thetic surgery, temporomandibular and maxillofacial surgery. techniques and direct scientific disorders, orthognathic surgery and pathology. The Foundation’s initial mandate support for the expanding scope of was to provide for comprehensive practice of the dental profession. literature reviews on various subjects These benefits can only be realized Department of Oral and Maxillofacial in the form of “risks and benefits.” Sciences through the generous support of our The Foundation has published “risks Dalhousie University corporate partners, colleagues and and benefits” reviews for impacted Faculty of Graduate Studies patients. Voluntary donations to the 5981 University Avenue third molar surgery, orthognathic Foundation can be made through Halifax, NS surgery and surgery related to internal B3H 3J5 derangements of the temporo- CAOMS, 174 Colonnade Road, Unit 25, Ottawa, ON K2E 7J5. www.registrar.dal.ca/calendar/gr/ mandibular joint. ORAL.htm#1 Currently, the Foundation is evolv- The Foundation is tirelessly ing into an organization that, in addi- administered by Dr. William L. tion to internal projects, now directly Frydman, chair, Dr. Ken Bentley, Laval University supports specific research endeavours secretary/treasurer, and the Board of The oral and maxillofacial surgery through funding and guidance. These Tr ustees, composed of Dr. Richard graduate training program at Laval projects are undertaken in both the Bell, Dr. Ben Davis, Dr. George University/Hôpital de l’Enfant-Jésus academic and private practice settings. Sándor and Dr. Dany Morais. is a 5-year residency leading to a An innovative study is now underway master of science degree and diploma to examine the nature of the relation- qualification. Ten regular residents ships between general dental practi- are currently engaged in training. tioners and oral and maxillofacial Canadian Residency Programs An additional position is held for a candidate with a special contract who surgeons. This study should help oral in Oral and Maxillofacial and maxillofacial surgeons better is required to return to practice in a relate to and support their colleagues Surgery remote underserviced area following in general dental practice. The efforts of CAOMS and the graduation. The program attracts Various grants, ranging in amounts Foundation are easily recognized in international interest, with regular from $2,000 to $10,000, have been the 5 residency programs in oral and rotation of residents from France and awarded to many researchers in our maxillofacial surgery in Canada. Switzerland who wish to expand academic institutions across Canada. These university-based programs have their French-language education. A Past projects have made valuable developed international reputations formal fellowship in orthognathic, contributions to the fields of anesthe- and attract high calibre candidates trauma and reconstructive surgery siology, distraction osteogenesis and from Canada and around the world. will be offered in the next 2 to 3 years.

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 157 A bout CAOMS

Currently, leading-edge research is also very grateful to funding organi- Department of Oral and Maxillofacial projects are in progress by residents zations such as the CAOMS Surgery wishing to obtain doctoral qualiﬁca- Foundation and the Order of Dentists University of Toronto tion in osseous distraction and neural of Quebec. Faculty of Dentistry regeneration. The research in osseous 124 Edward Street Toronto, ON distraction is being undertaken in Division of Oral and Maxillofacial M5G 1G6 Surgery Dr. Antonio Nanci’s laboratory at the www.utoronto.ca/dentistry/academic/ University of Montreal, while the McGill University graduate/graduateprograms.html research in neural regeneration is 1650 Cedar Avenue Montreal, QC taking place at Dr. François Auger’s H3G 1A4 University of Manitoba Laboratory of Experimental Tissue www.mcgill.ca/dentistry/graduate/ Engineering (LOEX) in Quebec City. The oral and maxillofacial surgery program at the University of Manitoba is of 4 years’ duration and Department of Oral and Maxillofacial University of Toronto Surgery The graduate program in oral and leads to a master’s degree in oral and Laval University maxillofacial surgery and anesthesia at maxillofacial surgery. Five residents Faculty of Dentistry the University of Toronto is a 4-year are currently enrolled in the program. 2435 Pavillon Jean-Charles-Bonenfant program with a compulsory master’s Generally, one new resident is Quebec City, QC accepted each year, with the possibil- G1K 7P4 degree based on a research project. ity of additional resident positions. www.fmd.ulaval.ca/index.html Residents may choose to enroll in a doctoral program instead of the master’s On-service rotations provide residents program. There are 8 funded residency with broad exposure to both adult and McGill University positions, with 2 students in each year, pediatric oral and maxillofacial surgery. The residents are also sched- The McGill University graduate and up to 2 international fellowships uled in off-service rotations in internal training program in oral and maxillo- per year, one in pediatric oral and medicine, adult and pediatric anesthe- facial surgery is a fully accredited, maxillofacial surgery and one in sia, surgical intensive care, emergency 4-year program leading to a diploma reconstructive oral and maxillofacial room medicine, otolaryngology and in oral and maxillofacial surgery and a surgery. The graduate program is newly surgical oncology. Interaction and master of science degree. Two resident housed at Mount Sinai Hospital, where cooperation between the residents in positions are available each year. One dentistry is a protected program. The oral and maxillofacial surgery and is a fully funded position open to faculty of dentistry is affiliated with the those in the graduate orthodontic graduates of North American dental program, as are the Hospital for Sick program ensures a diversity of experi- schools. The second position is open Children, the Bloorview MacMillan ence. Present research includes studies to non-North American graduates Children’s Centre, and Sunnybrook in oncology, trauma, implants and who have funding from their home and Women’s Health Centre. Residents orthognathic surgery. country and have made a commit- gain clinical exposure in all areas of oral ment to return to their country and and maxillofacial surgery. A new rota- work within the health care system. tion to a cleft lip and palate unit at the Division of Oral and Maxillofacial Surgery The major research initiatives of this University of Oulu in Finland has been University of Manitoba program are bone physiology, bone established. This initiative has received Faculty of Dentistry healing and bone regeneration (in generous funding and support from 790 Bannatyne Avenue collaboration with the McGill Bone the Ontario Society of Oral and Winnipeg, MB and Periodontal Research Centre) and Maxillofacial Surgeons. There are also a R3E 0W2 www.umanitoba.ca/faculties/dentistry/ osseointegrated implants. Funding number of community-based gradPrograms/grad_OMS.html for these initiatives is obtained from practices in oral and maxillofacial 3 principal sources. Alumni provide surgery that graduate residents may generous support through the choose to visit during their elective Kenneth C. Bentley alumni fund and rotations. Research in the graduate the Fund for Oral and Maxillofacial program focuses primarily on bone Surgery Research and Continuing regeneration, hyperbaric oxygen Education (FORCE), which has been therapy, laser surgery, treatment of successful in generating funds from congenital malformations and surgical industry sources. The McGill program orthodontics.

158 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association A bout CAOMS

Dr. Walter Dobrovolsky, past Participants in the president of Maligne Canyon walk CAOMS, speaking during the 2005 at the President’s CAOMS Jasper Ski & reception at the Learn Meeting. CAOMS annual meeting.

Some past presidents of Dr. David “Crocodile” CAOMS were Chimilar performing recognized at the at the CAOMS CAOMS Gala in Annual Gala. Quebec City.

Speakers at the 2005 CAOMS Ski Drs. Vic Goodyear & Learn Meeting (left) and Daniel in Jasper (left to Morais at the recent right): Drs. Daniel CAOMS Annual Ricard, Joseph Gala held in Quebec Friedlich, Kevin City. McCann and Tim Head.

CAOMS Meetings and Gatherings CAOMS organizes various events that contribute to the professional development of its members. The following meetings are planned for 2005 and 2006: •March 10–13, 2005 Banff, Alberta Advanced Digital Technology in Head and Neck Reconstruction Conference •June 22–25, 2005 Halifax, Nova Scotia Joint Meeting and Scientiﬁc Sessions (CAOMS in conjunction with the American College of Oral and Maxillofacial Surgeons) • May 23–27, 2006 Victoria, British Columbia CAOMS Annual Meeting •Winter 2006 2nd Annual CAOMS Ski & Learn Meeting For more information about these events, visit the CAOMS Web site at www.caoms.com.

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 159 The Science of a Toothbrush

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Management of a Patient with an Accessory Maxilla and Congenital Facial Fistula

• Vesa T. Kainulainen, DDS, EHL, PhD • • George K.B. Sándor, MD, DDS, PhD, FRCD(C), FRCSC, FACS • • Douglas W. Stoneman, DDS, FRCD(C) •

Abstract

Although accessory jaws are a rare occurrence, the presence of such accessory tissue may cause some bothersome symptoms. This case report helps identify these unusual developmental lesions so that dentists can refer such patients for deﬁnitive care and management.

MeSH Key Words: child; dental ﬁstula/radiography; maxilla/abnormalities; tooth supernumerary/radiography

evelopmental aberrations may result in the Case Report formation of supernumerary or extra structures. An 8-year-old boy was referred for assessment of a fistula D Polydactily or extra fingers or toes and supernu- that occasionally drained milk-like fluid from an opening merary teeth are examples of such developmental duplica- on the left nasolabial groove of the face. The parents stated tions. Accessory or supplementary jaws are duplicated that this drainage had been present since birth. The portions of jaws or entire jaws, with or without teeth.1 In patient had been previously diagnosed as having an incom- the case of the maxilla, such accessory jaws are called disto- plete facial cleft. Serial panoramic radiographs and a mus.2,3 Distomus formation is extremely rare.2 Accessory computed tomography (CT) scan revealed the progressive jaws may be associated with the formation of an accessory development of first 2, then 3 tooth-like structures in the rudimentary or vestigial mouth.1 Reports indicate that left cheek in a cavity with a fluid-filled lumen. A diagnosis distomus has been observed more commonly in association of odontoma was dismissed, on the basis of the appearance with lateral facial clefts.2 Congenital facial clefts, which and position of the lesion. Rather the lesion was thought to have been classified by Tessier,4 may occur where embry- resemble an accessory maxilla. The past medical history was otherwise unremarkable. ologic processes fuse. The most common facial clefts are The patient was followed regularly with semi-annual cleft lip and palate; the prevalence of cleft lip with or with- visits over the next 7 years. A creamy-white milk-like fluid out cleft palate in the largest study to date is 1.2 per 1,000 was initially expressible by palpation of a dimple of the left live births.5 The incidence of lateral facial clefts in various cheek in the nasolabial groove (Fig. 1). The volume of the 5,6 series ranges from 0.3% to 0.67% of all facial clefts. drainage progressively increased over the years of follow-up, Facial clefts associated with duplication of various oral such that each time the patient smiled, he expressed the 7–11 1 structures have also been reported. Stoneman and fluid spontaneously onto his cheek. This steadily increasing DeGurse and others2 have reported cases of a congenital spontaneous drainage became distressing to the patient, to facial fistula with an accessory maxilla and teeth. the point of being socially unacceptable. Bacterial culture This article reports the management, over 9 years, of a and sensitivity testing of the facial discharge revealed patient with an accessory maxilla with supernumerary teeth normal skin flora with a scant growth of coagulase-negative and a congenital facial fistula, who required treatment due Staphylococcus species. Surgery had been delayed at the to increasingly bothersome symptoms. request of the boy’s parents. At the age of 15 years, the

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 161 Kainulainen, Sándor, Stoneman

patient had a fistula on the left cheek approximately 3 cm lateral to the left oral commissure. It was secreting spontaneously or when the left cheek was rubbed. Radiographic examination revealed a 4-cm–wide round cavity with 3 supernumerary teeth in the left maxillary sinus area (Fig. 2). In panoramic radiographs taken 6 years earlier, there were 2 premolar-like Figure 1: Drainage of a milk-like fluid from Figure 2: Preoperative panoramic the left nasolabial groove. radiograph showing 3 supernumerary teeth supernumerary teeth. A CT scan developing in a bony cavity in the left showed a cavity with a sharp delin- maxillary sinus. eation from the maxillary bone and its zygomatic process. The lesion extended from the orbital floor to the zygomatic buttress area. It did not extend into the inferior part of the left maxillary sinus or into the maxillary alveolar process. Otherwise the whole sinus was full of accessory tissue. The teeth within the lesion were attached to the bony walls of the cavity (Fig. 3a). This bony cavity was filled with fluid and connected to a cavity in the soft tissues of the left cheek (Fig. 3b). Figure 3a: Computed tomography image Figure 3b: Computed tomography image Surgery was performed under (coronal view) showing the lesion (axial view) showing the lumen of the soft- general anesthesia. A plastic catheter occupying most of the left maxillary sinus. tissue lesion located lateral to the anterior maxillary wall. was threaded into the fistula and methylene blue dye was injected into the catheter to help delineate the accessory structures connected to the fistula (Fig. 4). A vestibular incision was used to expose the entire anterior maxilla. Bone over the soft tissue capsule was removed (Fig. 5). The fistula and the soft tissues surrounding the blue-stained structures in the left cheek were removed Figure 4: A catheter is threaded through the in 1 piece. The teeth and the bony cutaneous opening of the fistula into the cavity, which contained a brownish lumen of the lesion in the left cheek. liquid, were removed in a separate piece. Care was taken not to damage Figure 5: The anterior wall of the left maxilla is exposed and removed. A separate bony the parotid duct and branches of the wall is removed to gain access to the bony facial nerve. The specimens were cavity of the lesion. sent for histopathologic evaluation (Fig. 6). Histologic sections revealed bone, developing teeth and Discussion a stratified squamous epithelium lining the lumen of the This case report presents the long-term management bony and soft-tissue cavities. Postoperative healing was and closely supervised follow-up of a congenital facial uneventful and neither the lesion nor the fistula has shown fistula with an accessory maxilla and teeth. The diagnosis of any clinical or radiographic signs of recurrence in over incomplete facial cleft had been suggested when the patient 3 years of follow-up (Fig. 7). was 6 years of age. Because the only complaint was a fistula

162 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Management of a Patient with an Accessory Maxilla and Congenital Facial Fistula

References 1. Stoneman DW. Congenital facial fistula with formation of accessory bone and teeth. Report of a case. Oral Surg Oral Med Oral Pathol 1978; 45(1):150–4. 2. DeGurse K, Chung H, Pharoah M. Facial dimple with accessory bone and teeth. Dentomaxillofac Radiol 1995; 24(2):135–8. 3. Worth HM. Principles and practice of oral radiologic interpretation. Chicago (IL): Year Book Medical Publishers; 1963. p 114–5. 4. Tessier P. Anatomical classification of facial, Figure 6: Teeth with the excised bony and Figure 7: After 3 years of follow-up, a cranio-facial and latero-facial clefts. soft-tissue specimens. panoramic radiograph shows a normally J Maxillofac Surg 1976; 4(2):69–92. pneumatized left maxillary sinus with no 5. Cooper ME, Stone RA, Liu Y, Hu DN, signs of recurrence. Melnick M, Marazita ML. Descriptive epidemiology of nonsyndromic cleft lip with or without cleft palate in Shanghai, China, that was occasionally draining, the parents opted for long- from 1980 to 1989. Cleft Palate Craniofac J 2000; 37(3):274–80. term observation. The drainage progressively worsened 6. Fogh-Andersen P. Rare clefts of the face. Acta Chir Scand 1965; until the patient found it intolerable and requested removal 129:275–81. 7. Pitanguy I, Franco T. Nonoperated facial fissures in adults. of the lesion. Serial assessments were conducted to ensure Plast Reconstr Surg 1967; 39(6):569–77. that the patient was not lost to follow-up and that the 8. Smylski PT. Accessory jaw bones; a report of a case. J Oral Surg Anesth related structures near the lesion were growing and Hosp Dent Serv 1952; 10(1):70–4. developing normally. 9. Chowdhury SR, Roy A. Duplication of the upper lip and maxilla. The development of an accessory jaw is very rare. The Br J Plast Surg 1991; 44(6):468–9. 10. Avery JK, Hayward JR. Case report: duplication of oral structures lesion may occur as a mass of bone containing teeth or as a with cleft palate. Cleft Palate J 1969; 6:506–15. complete jaw.1,2,7–11 Stoneman1 and DeGurse and others2 11. Ball IA. Klippel-Feil syndrome associated with accessory jaws have suggested that some facial fistulas are vestiges of facial (distomus). Br Dent J 1986; 161(1):20–3. clefts. In this case, in addition to the accessory jaw tissue, a fistula connected the skin to a separate lumen or rudimentary mouth in the cheek. The management of such lesions must be guided by the symptoms and their potential to interfere with the development of surrounding structures. The timing of their removal depends on these 2 factors and the progressive development of bothersome symptoms. Dentists can contribute to the management of such lesions by identifying them and referring the patient for definitive management. C

Dr. Kainulainen is a former fellow in oral and maxillofacial surgery, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, and is currently an assistant professor in oral and maxillofacial surgery, University of Oulu, Oulu, Finland.

Dr Sándor is an associate professor and director, graduate program in oral and maxillofacial surgery and anesthesia, University of Toronto, and the coordinator of oral and maxillofacial surgery at The Hospital for Sick Children and Bloorview MacMillan Children’s Centre, Toronto, Ontario, and docent in oral and maxillofacial surgery, University of Oulu, Oulu, Finland.

Dr. Stoneman is deceased; he was professor emeritus in oral radiology at the University of Toronto, and consultant oral radiologist at The Hospital for Sick Children, Toronto, Ontario.

Correspondence to: Dr. George K.B. Sándor, The Hospital of Sick Children, S-527, 555 University Ave., Toronto ON M5G 1X8. E-mail: [email protected]. The authors have no declared ﬁnancial interests.

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 163 Master Teams Topics • Didier Dietschi / Roberto Spreafico • Extensive Rehabilitation • Mauro Fradeani / Giancarlo Barducci • Choice of Ceramic Systems • David A. Garber / Pinhas Adar • Interdisciplinary Implant • Ueli Grunder / Hans-Peter Spielmann and Esthetic Treatment • John C. Kois / Steven McGowan • Dentist-Technician • Edward A. McLaren / Shane White Teamwork • Konrad H. Meyenberg / Walter M. Gebhard • Avishai Sadan / Markus B. Blatz • Henry Salama / Maurice A. Salama • Frank M. Spear / Vincent G. Kokich • Alan V. Sulikowski / Aki Yoshida • Thomas F. Trinkner / Matt Roberts

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Sporadic Burkitt’s Lymphoma of the Jaws: The Essentials of Prompt Life-saving Referral and Management

• Ahmed Jan, DDS • • Kashyap Vora, BDS, FDS RCS (Eng) • • George K.B. Sándor, MD, DDS, PhD, FRCD(C), FRCSC, FACS •

Abstract

Burkitt’s lymphoma is an undifferentiated non-Hodgkin’s B-cell lymphoma. Three clinical subtypes are recognized: African (endemic), American (sporadic) and HIV associated. Sporadic Burkitt’s lymphoma is a rare malignancy among western populations. This report describes a case of sporadic Burkitt’s lymphoma of the jaws with an alarmingly rapid spread associated with acute renal failure. This type of rapid progression bespeaks the need for prompt recognition and life-saving referral by the dental practitioner. The clinical features of Burkitt’s lymphoma involving the jaws include severely hypermobile, ectopically displaced and supra-erupted teeth. The purpose of this case report and review of the literature is to illustrate the clinical and histopathologic features of Burkitt’s lymphoma to help clinicians recognize such cases readily and facilitate prompt and potentially life-saving referral.

MeSH Key Words: Burkitt lymphoma/diagnosis; case report; mandibular neoplasms/pathology

urkitt’s lymphoma is a malignant tumour of B-cell Burkitt’s lymphoma is probably the fastest growing lymphocyte origin and is classified as a non- malignant neoplasm to affect humans. It can double in size Hodgkin’s lymphoma (NHL). Three clinical variants in 24 hours with 80% of its cells undergoing mitosis at any B 5 are recognized: African (endemic), American (sporadic) and point. The symptoms are rapidly progressive. Multifocal HIV associated.1 Sporadic Burkitt’s lymphoma is a rare extranodal involvement is common to all subtypes of malignancy among western populations. In most series, the Burkitt’s lymphoma.1 annual incidence is 2–3 cases per million.2 Burkitt’s lymphoma is thought to account for 40% of all 2 During the early 20th century, Sir Albert Cook, while in childhood NHL. Its incidence is greatly dependent on East Africa, described a common malignancy among young geographic location; in equatorial Africa, it accounts for 50% to 75% of all malignancies in children.6 Sporadic African children that predominantly affected the jaws and Burkitt’s lymphoma is not as common. Its annual incidence occasionally various abdominal organs. Half a century later, is 2–3 cases per million. Burkitt’s lymphoma accounts for a surgeon, Denis Burkitt, who was working in Kampala, 40% of HIV-associated NHL.2 Uganda, noticed the same lesions on the faces of young Endemic Burkitt’s lymphoma is usually diagnosed African children, with occasional intestinal involvement. between the ages of 5 and 7 years and involves the jaws as In 1958, Burkitt published his ﬁndings, calling the lesion well as other facial bones in 60% to 80% of cases. Less “a sarcoma involving the jaws.”3 Epstein and others ﬁrst commonly, it involves the abdomen and bone marrow. demonstrated a herpes virus in a biopsy sample derived Endemic Burkitt’s lymphoma is virtually always associated from Burkitt’s lymphoma in 1964. The virus was later with EBV, as positive titres are found in over 90% of cases.7 designated Epstein-Barr virus (EBV) and was considered a In contrast, sporadic Burkitt’s lymphoma is associated potential etiologic factor of Burkitt’s lymphoma.4 with slightly older children (average age 12 years). The

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 165 Jan, Vora, Sándor

Figure 1: Orthopantomogram showing the Figure 2: Periapical radiograph showing Figure 3: Diffuse sheets of monomorphic displaced teeth germs of the lower third severe alveolar bone resorption around the lymphoid cells with scattered macrophages molars coronally and medially relative to lower second premolars. producing a “starry sky appearance.” their bony crypts. Severe alveolar bone resorption is visible around the lower second molars.

abdomen is the most common site of presentation. About posterior teeth was noted. Both lower second molars were 25% of sporadic Burkitt’s lymphoma cases involve the head supra-erupted and in premature occlusal contact with the and neck, most commonly in the form of cervical upper first molars causing a massive open bite. The left lymphadenopathy. Maxillofacial bony involvement occurs lower second molar was more supra-erupted than the right. in fewer than 30% of cases. EBV-positive titres are found in The gingiva was pale, pink and swollen with spontaneous only 20% of cases.7 areas of bleeding. Adult Burkitt’s lymphoma patients are almost always An orthopantomogram and intraoral periapical radi- afflicted with AIDS. Burkitt’s lymphoma accounts for ographs were taken. Severe alveolar bone loss around the 40% of HIV-associated NHL cases.2 Like sporadic Burkitt’s lower second premolars as well as the lower second molars lymphoma, the HIV-associated variant often involves the was noted (Figs. 1 and 2). These teeth were floating. The abdomen and it involves the bone marrow in 30% of cases. developing lower third molars were displaced coronally and Unlike endemic Burkitt’s lymphoma, EBV titres are medially relative to their crypts, indicating possible infiltra- elevated in only 30% of cases of adult HIV-associated tion of these structures (Fig. 1). Burkitt’s lymphoma.2 Based on the clinical examination and past medical and dental history, a decision was made to extract the lower left Case Report second molar and perform an incisional biopsy of the soft A 13-year-old white girl was referred to the oral and tissue in the tooth socket. maxillofacial surgery service of The Hospital for Sick Children in Toronto with the chief complaint of spontaneous Histopathology intermittent pain in her lower back teeth and inability to The histopathology was consistent with diagnosis of chew food comfortably. A month earlier, she had complained a high-grade B-cell NHL with features of Burkitt’s to her parents of progressively loosening teeth. The pain lymphoma. Routine hematoxylin- and eosin-stained sections revealed fibrofatty tissue diffusely infiltrated with had been present for 2 weeks. She was referred by her sheets of a monomorphic population of lymphoid cells. general dentist to a periodontist, who immediately referred Numerous scattered phagocytic cells all around the section the patient for oral and maxillofacial surgical assessment. imparted a “starry-sky appearance” (Fig. 3). Immunohisto- The past medical history revealed a diagnosis of microcytic chemical staining was positive for CD20, CD22 and hypochromic anemia and infectious mononucleosis 3 weeks CD79, which are specific for B-cell lymphocytes. CD10 before presentation. Results of a complete blood count and was focally positive, which is consistent with the early serology were consistent with these 2 diagnoses. phases of B-cell proliferation. MIB1 staining was positive Physical examination revealed a lethargic young woman in more than 95% of cells, revealing increased nuclear with obvious pallor. Bilateral palpable mobile submandibu- DNA synthesis. lar lymph nodes were found in her head and neck. The mandibular and maxillary divisions of the trigeminal and Definitive Referral facial nerves were intact. Generalized teeth mobility ranged The patient was immediately referred to the hematol- from 1+ in upper and lower anterior teeth to 3+ in lower ogy–oncology department for assessment and definitive second premolar and second molars. This was noted despite care. Further laboratory results revealed a secondary the absence of any visible plaque on the teeth surfaces. diagnosis of acute renal failure necessitating emergency life- Severe buccal expansion of the alveolus next to the lower saving dialysis. The effects of the patient’s renal failure

166 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Sporadic Burkitt’s Lymphoma of the Jaws

were corrected by the dialysis, she responded well to subse- tumour’s development. There may be greater involvement quent chemotherapy and is currently in remission. of EBV in sporadic Burkitt’s lymphoma than previously documented, suggesting that EBV DNA may, in some Discussion instances, be lost after initiation of the neoplasm. Although The differential diagnosis of hypermobile teeth with screening tests may be insufficient to determine the absent local factors includes: generalized juvenile periodon- EBV status of all neoplasms,12 the data suggest that titis, HIV periodontitis, Langerhan’s cell histiocytosis, EBV may play a prominent role in the pathogenesis Papillon-Lefèvre syndrome, hypophosphatasia, cyclic of Burkitt’s lymphoma.13 neutropenia, vitamin-D resistant rickets, acrodynia, The overexpression of c-myc oncogene and the func- leukemia and lymphoma. Head and neck involvement tional loss of wild type p53 gene are considered as possible occurs in only 25% of sporadic Burkitt’s lymphoma etiologic factors as well. Immunodeficient patients, particu- cases and most commonly in the form of cervical larly those with AIDS, and cardiac or renal transplant 2 lymphadenopathy, which can make the diagnosis quite patients are more susceptible to developing NHL.14 challenging in contrast to endemic Burkitt’s lymphoma. Burkitt’s lymphoma may be the first manifestation of The clinical findings may vary according to the AIDS in many cases.15 anatomical site of involvement and the timing of presenta- Investigations for suspected Burkitt’s lymphoma should tion. The range may be from no signs and symptoms to include an incisional biopsy to establish a definitive diag- airway obstruction, intestinal obstruction and biliary nosis. In the maxillofacial region, plain radiography is obstruction. Inferior alveolar nerve parasthesia has also usually sufficient but may be augmented by computed been reported to be the only presenting sign of sporadic tomography and magnetic resonance imaging. In most 8 Burkitt’s lymphoma. Signs and symptoms of oral Burkitt’s institutions, lumbar puncture to examine the cerebrospinal lymphoma, including mobile teeth, toothache, oral masses, fluid is a routine measure to look for malignant cells in the gingival enlargement, pain, jaw expansion, swelling and central nervous system.2 sensory disturbances, have been recorded by some workers Burkitt’s lymphoma is one of the first human malignan- 7 with pain being the most common presenting symptom. cies shown to be curable by chemotherapy alone. A combi- In this case, pain was also the predominant presenting nation of cyclophosphamide, doxyrubicin, vincristine and symptom and generalized mobility of teeth with the prednisone is one example of a drug therapy. Radiotherapy absence of any obvious causative factor was the most strik- is reserved for overt central nervous system disease that is ing sign. The unusual aspect of this case was the severity of resistant to chemotherapy and is reported to be useful in disease, exemplified by the rapidity of the development of certain emergencies, such as airway obstruction.7 Bone acute renal failure, which left untreated would have resulted marrow transplantation may be necessary after completion in a terminal outcome. of chemotherapy cycles. The surgical management of Although EBV is strongly considered as a potential etio- Burkitt’s lymphoma is limited to biopsy.7 logic factor of Burkitt’s lymphoma, its precise role is not The prognosis of Burkitt’s lymphoma depends on the well understood, especially in sporadic Burkitt’s lymphoma. extent of the disease, the patient’s age and the timing of EBV is an enveloped herpes virus that contains double- diagnosis.3 It is excellent in children, where it approaches 9 strand linear DNA of 170 to 175 kb in the nucleocapsid. 100% disease-free survival in early stages and 75% to After entering the oropharynx and adjacent structures, this 85% of patients survive free of disease in later life.7 Adults virus preferentially infects B-cells via the C3d complement are less fortunate, with a survival rate of 50% to 75%.7 receptor, CD21. Primary infection during early childhood Adults are almost always HIV-positive patients and may die is mostly asymptomatic, whereas infection during adoles- of other causes.16 cence results in acute infectious mononucleosis in 30% to 50% of cases.10 Immunodeficiencies may allow viral Conclusion reactivation and the excessive proliferation of EBV-infected The role of the dentist in the early diagnosis and prompt B-cells, which may lead to the development of EBV posi- referral of patients with Burkitt’s lymphoma cannot be tive B-lymphoproliferative diseases or lymphomas.11 overemphasized. Life-threatening complications occur Approximately 90% of African Burkitt’s lymphoma suddenly and unexpectedly in the development of Burkitt’s tumours contain EBV DNA, whereas only 20% of sporadic lymphoma. These complications include airway obstruc- Burkitt’s lymphomas are EBV associated. However, tion, abdominal obstruction and acute renal failure, as in disrupted and aberrant expressions of the viral genome have this case report. recently been discovered in the United States in cases of Dentists must be suspicious when faced with a child sporadic Burkitt’s lymphoma that were diagnosed as EBV patient presenting with unexplained hypermobility of teeth, negative in standard screening. This suggests that the viral supra-eruption of permanent teeth and severe alveolar bone genome itself may be dispensable at some stage of the resorption around these teeth, where the local etiologic

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 167 Jan, Vora, Sándor

factors of periodontal disease are not present. The unex- 2. Banthia V, Jen A, Kacker A. Sporadic Burkitt’s lymphoma of the head plained displacement of developing teeth from their crypts and neck in the pediatric population. Int J Pediat Otorhinolaryngol 2003; 67(1):59–65. is another worrisome sign. Unexplained paresthesia of the 3. Burkitt D. A sarcoma involving the jaws of African children.Br J Surg mandibular branch of the trigeminal nerve is also ominous. 1958; 46(197):218–23. When any of these symptoms or signs exists, the dentist 4. Epstein MA, Achong BG, Barr YM. Virus particles in cultured must have a high index of suspicion and act promptly. lymphoblasts from Burkitt’s lymphoma. Lancet 1964; 15:702–3. 5. Durmus E, Oz G, Guler N, Avunduk M, Caliskan U, Blanchaert RH Failure to refer such a patient in a timely manner may Jr. Intraosseous mandibular lesion. J Oral Maxillofac Surg 2003; rapidly lead to disastrous consequences. C 61(2):246–9. 6. Shapira J, Peylan-Ramu N. Burkitt’s lymphoma. Oral Oncol 1998; 34(1):15–23. 7. Ardekian L, Rachmiel A, Rosen D, Abu-el-Naaj I, Peled M, Laufer D. Burkitt’s lymphoma of the oral cavity in Israel. J Craniomaxillofac Surg Dr. Jan is an intern in oral and maxillofacial surgery, 1999; 27(5):294–7. University of Toronto, Toronto, Ontario. 8. Landesberg R, Yee H, Datikashvili M, Ahmed AN. Unilateral mandibular lip anesthesia as the sole presenting symptom of Burkitt’s lymphoma: case report and review of literature. J Oral Maxillofac Surg 2001; 59(3):322–6. Dr. Vora is a fellow in oral and maxillofacial surgery, 9. Bornkamm GW, Hammerschmidt W. Molecular virology of Epstein- The Hospital for Sick Children and University of Barr virus. Philos Trans R Soc London B Biol Sci 2001; 356(1408):437–59. Toronto, Toronto, Ontario. 10. Cohen JI. Epstein-Barr virus infection. New Engl J Med 2000; 343(7):481–92. Dr Sándor is an associate professor and director, 11. Ohga S, Nomura A, Takada H, Hara T. Immunological aspects of graduate program in oral and maxillofacial surgery and Epstein-Barr virus infection. Crit Rev Oncol Hematol 2002; anesthesia, University of Toronto, and coordinator 44(3):203–15. of oral and maxillofacial surgery at The Hospital for Sick 12. Razzouk BI, Srinivas S, Sample CE, Singh V, Sixbey JW. Epstein-Barr Children and Bloorview MacMillan Children’s Centre, virus DNA recombination and loss in sporadic Burkitt’s lymphoma. Toronto, Ontario, and docent in oral and maxillofacial J Infect Dis 1996; 173(3):529–35. surgery, University of Oulu, Oulu, Finland. 13. Sandlund JT, Downing JR, Crist WM. Non-Hodgkin’s lymphoma in Correspondence to: Dr. George K.B. Sándor, The Hospital of Sick childhood. N Engl J Med 1996; 334(19):1238–48. Children, S-527, 555 University Ave, Toronto ON M5G 1X8. 14. Tsui SH, Wong MH, Lam WY. Burkitt’s lymphoma presenting as E-mail: [email protected]. mandibular swelling — report of a case and review of publications. The authors have no declared ﬁnancial interests. Br J Oral Maxillofac Surg 2000; 38(1):8–11. 15. Carbone A. Emerging pathways in the development of AIDS-related lymphomas. Lancet Oncol 2003; 4(1):22–9. References 16. Carbone A. AIDS-related non-Hodgkin’s lymphomas: from 1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillo- pathology and molecular pathogenesis to treatment. Hum Pathol 2002; facial pathology. 2nd ed. Philadelphia: W.B. Saunders; 2002. p. 608. 33(4):392–404.

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Mandibular Distraction Osteogenesis for Endosseous Dental Implants

• David A. Walker, DDS, MS, FRCD(C) •

Abstract

Patients with complete or partial edentulism who have insufficient bone for endosseous dental implant treatment present a challenge for the dental practitioner. Alveolar distraction osteogenesis is a technique for creating bone and soft tissue, without the need for bone grafting and its potential complications. In this article, alveolar distraction osteogenesis is compared with traditional bone grafting techniques. A case is presented to illustrate successful bilateral mandibular vertical distraction osteogenesis with creation of adequate bone volume for endosseous implant-supported dental restoration.

MeSH Key Words: alveolar ridge augmentation/methods; dental implantation, endosseous; osteogenesis, distraction/methods

ental practitioners frequently encounter partially alveolar distraction osteogenesis to allow dental implant- edentulous patients. Replacement of the lost supported restoration. dentition by dental implant-supported restoration D Case Report offers many advantages over ﬁxed bridgework or removable partial dentures. A 52-year-old woman reported that she did not like her Some patients present with insufficient bone for conven- lower removal partial denture (RPD) and rarely wore it. The tional implant-supported restoration. Traditional treatment mandibular posterior teeth had been extracted 36 years approaches have included augmentation of the alveolar before, and one removable mandibular partial denture had ridge with autologous, homologous or xenogenic bone. been made 15 years ago. The patient related that the RPD Alloplastic materials and various other osteoinductive or moved under function, which resulted in food trapping, and osteoconductive biomaterials have also been used for ridge she never felt comfortable eating while wearing the denture. augmentation.1 Autologous bone grafting has many advan- The patient had undergone uterine surgery for tages over other techniques but is not without risks and endometriosis 1 year before the current presentation, and potential complications, including wound dehiscence, she had undergone cosmetic facial surgery 10 years before, infection, partial or total loss of the bone graft, and donor without complications. Her medications included hormone site morbidity.2 The difficulties that can be encountered replacement therapy and calcium supplements. with vertical ridge augmentation by means of bone grafting Clinical examination confirmed that the posterior techniques are frequently limited to soft-tissue tolerances mandibular alveolar ridges were thin bilaterally, and there and bone graft resorption.3 was adequate maxillary structure for her complete upper Alveolar distraction osteogenesis is a surgical technique denture (Figs. 1a, 1b). The patient had a Class II occlusion, that encourages creation of new bone and soft tissue with moderate mandibular retrognathia, and there were no through incremental lengthening of osseous segments.4 The significant findings on examination of the temporo- technique is relatively uncomplicated and avoids the need mandibular joint. Panoramic radiography conﬁrmed a for bone grafting. The secondary effect of stretching and moderate bilateral saddle defect of the posterior mandible creating new soft tissues, a technique called distraction (Fig. 2). Tomography revealed a bony width of 3 to 4 mm histogenesis, is particularly helpful in vertical ridge in the crestal region bilaterally in the posterior mandible augmentation. The following case illustrates successful (Fig. 3).

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 171 Walker

Figure 1a: Clinical evaluation showing Figure 1b: Clinical evaluation showing Figure 2: Panoramic radiograph showing knife-edged right mandibular ridge. knife-edged left mandibular ridge. moderate saddle defect.

Figure 3: Tomographic image of the left and Figure 4: Panoramic radiograph obtained Figure 5: Panoramic radiograph at the right posterior mandible demonstrating immediately after placement of the alveolar completion of 8 mm of vertical distraction. 3- to 4-mm width of the crestal region of the distraction devices. alveolus.

On the basis of the clinical and radiographic evaluation, mylohyoid muscle. The distraction osteogenesis device was the patient consented to bilateral mandibular alveolar re-applied, stabilized with the monocortical and bicortical distraction osteogenesis. 1.5-mm screws, and tested for movement of the transport bone segment. Mucosal closure was accomplished with Surgical Procedure interrupted 4.0 Vicryl horizontal mattress sutures with The patient received intravenous sedation and local running 4.0 gut oversew (Ethicon, Johnson & Johnson, anesthesia. A vestibular incision was made in the right Somerville, N.J.) The same procedure was performed for posterior mandible 5 mm inferior to the junction of the the left mandible. attached gingiva and alveolar mucosa; the incision extended The patient was given postoperative instructions to from the retromolar region to the bicuspid region. A maintain a liquid or pureed diet for 1 month and to subperiosteal dissection was developed inferiorly to allow identification of the mental foramen and the mental progress to a soft diet after that time. Acetaminophen with neurovascular bundle with minimal dissection on the codeine was prescribed for analgesia, and oral clindamycin superior aspect of the alveolus. The alveolar distraction 150 mg 4 times daily was maintained for 10 days. device (KLS Martin Track Plus, Jacksonville, Fla.) was Chlorhexidine gluconate 0.12% mouth rinse 15 mL twice contoured to fit the bony anatomy, and the outline of daily was used for 2 weeks postoperatively. the osteotomy for the transport disk was marked with a The latency (waiting) period, for initial healing, was #701 bur. A vertical vector of distraction close to the 5 days, and the distraction rate was 0.33 mm, 3 times a day sagittal plane was selected to avoid lingual distraction of the (for a total of 1 mm/day), which resulted in total device transport segment. Holes were drilled for placement of activation of 8.33 mm over 8 days (Figs. 4 and 5). During monocortical and bicortical 1.5-mm screws, to stabilize the the follow-up period, portions of the superior arm of the device, and the device was subsequently removed. The distraction device became exposed bilaterally, and 2 loose trapezoidal osteotomy of the transport segment was care- screws were removed, the first at 3 months and the second fully completed with the #701 bur, reciprocating saw, and at 4 months after the completion of distraction (Fig. 6). spatula osteotome. Care was taken to protect the vascular The patient experienced mild bilateral paresthesia, which pedicle and to leave soft-tissue attachments to the transport completely resolved by 2 months after distraction. Four segment except in the areas of the flaring vertical osteotomy months after insertion of the distraction devices, they were cuts. The vascularity of the transport segment is predomi- removed under intravenous sedation and local anesthetic. nantly from the lingual periosteum, the mucosa and the The distraction regenerate was well ossified and stable. Four

172 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Mandibular Distraction Osteogenesis for Endosseous Dental Implants

Figure 6: Alveolar distraction device with Figure 7a: Placement of the right Figure 7b: Placement of left mandibular a portion of the bone plate exposed, mandibular implant through the distraction implant through distraction regenerate. 2 months after the distraction procedure. regenerate 4 months after distraction (the distraction device has been removed).

Figure 8: Panoramic radiograph 6 months Figure 9a: Placement of healing abutments Figure 9b: Placement of healing abutments after placement of the implant, at the time in the right mandible in the left mandible of abutment placement; the distraction regenerate has matured well.

Figure 10a: Final restoration, right mandible Figure 10b: Final restoration, left mandible. Figure 10c: Final restoration, occlusal view. (prosthodontist Dr. G. Zarb).

cylindrical threaded endosseous implants (TiUnite, Nobel Discussion Biocare, Goteborg, Sweden) were placed through the Distraction osteogenesis techniques were pioneered in transport segment and the distraction regenerate (Figs. 7a modern times by a Russian orthopedic surgeon, Dr. Gavriel and 7b). The following implants were placed: right Ilizarov.5,6 Distraction osteogenesis involves an osteotomy mandible, 11.5 mm × 3.75 mm fixture and 8.5 mm × or cut through the bony segment, a latency or waiting 5 mm fixture; left mandible, 11.5 mm × 3.75 mm fixture period to allow resolution of inflammation and initial heal- and 10 mm × 5 mm fixture. The implant treatment was ing, a distraction or callus manipulation period and a bony performed in 2 stages, with abutment connection occurring consolidation period. 6 months after placement of the implant fixtures. Clinical Maxillofacial distraction techniques have led to success- and radiographic examination revealed that the implants ful lengthening of the mandible and maxilla. The proce- were osseointegrated at the time of stage II placement of dures have been particularly helpful in patients with cranio- transmucosal healing abutments (Figs. 8, 9a, 9b). The fixed facial syndromes, cleft maxilla or tumour defects of the prosthodontic rehabilitation was carried out 2 months after maxillofacial region.7–10 Alveolar distraction osteogenesis is placement of the abutment, and the fixtures were loaded the latest application of this exciting technique, and success over a follow-up period of 8 months (Figs. 10a, 10b, 10c). has been widely documented.11–13 In addition, develop-

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 173 Walker

ment of miniaturized distraction devices has made distrac- distraction regenerate.6 Patient cooperation is important to tion osteogenesis of small bone segments feasible. achieve successful activation of the distraction device. Alveolar distraction osteogenesis offers many advantages Adequate consolidation time is required for maturation over traditional bone grafting techniques. An increase in of the distraction regenerate so that it can support dental alveolar bone height and concomitant increase in vestibular implant placement. Various consolidation times have been alveolar mucosa is a result of gradual bone distraction. reported, but 3 to 4 months is typically adequate.4 Further Onlay bone grafting techniques can present difficulties, remodelling of the distraction regenerate occurs during the mainly because of the acute soft-tissue stretch required to implant healing period. In this case, the distraction devices cover block or particulate bone grafts. This factor becomes were easily removed at the same time as the titanium more complex when a scarred tissue bed is present. Wound implants were placed. The endosseous implants were placed dehiscence is a potentially serious complication resulting in in a 2-stage technique, similar to that used with conven- exposure of the nonvital bone graft to oral microflora and tional bone grafting techniques. Excellent primary implant potential infection. When such infection occurs, the result stability was achieved at all implant fixture sites. The patient had mild to moderate requirements for anal- can be partial or total loss of the graft, which necessitates gesia over the first 5 days and experienced no pain during retreatment. activation. There was no evidence of infection around the Donor site complications of the hip (ilium)2 and tibia14 distraction device during the 4-month consolidation have been reported, including infection, peritonitis, persis- period, even though a portion of the stabilization plate tent pain, hip or tibia fracture, permanent paresthesias and became exposed and 2 screws loosened. The distraction permanent gait disturbance. Potential morbidity of cranial regenerate has neovascularity, which appears to be more or rib donor sites include scalp hematoma, intracranial resistant to infection20 than is the case with bone grafting. hemorrhage and brain injury for the former and pneu- The loosening of 2 screws at 3 and 4 months after distrac- 15,16 mothorax and persistent chest wall pain for the latter. tion appeared to have no clinical impact, as the distraction Potential complications associated with intraoral donor regenerate was mature enough by then to support the sites include pain, bleeding, infection, and temporary or placement of titanium implants. permanent paresthesia or dysesthesia of the teeth, gingiva, Continued bony maturation during the consolidation lip and chin.3,17 Although such donor site complications period was evident on the panoramic radiographs. The can be serious, they are uncommon. Nonetheless, implants remained stable under functional loading during alveolar distraction osteogenesis avoids the inherent risks, the 8-month follow-up period. At the time of writing, the complications and donor site morbidity associated with patient was contemplating a fixed maxillary implant- bone grafting. supported prosthesis. Because there was insufficient bone A variety of intraosseous and extraosseous devices are stock in the maxilla for distraction osteogenesis, autologous available for alveolar distraction osteogenesis.18 The bone grafting was an option. extraosseous device used in the case presented here allowed Conclusions good stability of both the device and the transport bone Alveolar distraction osteogenesis can be used to augment segment during distraction and consolidation. It also allowed deficient bony ridges to allow subsequent endosseous intraoperative adjustments to the vector of distraction. The implants. The procedure is associated with minimal morbid- height of the transport osseous segment was 5 mm and its ity and avoids the need for bone grafting and potential donor length was 2 cm bilaterally. Adequate osseous volume is site morbidity. This report has documented the creation of necessary for stabilization of the device and successful adequate height and volume of bone for placement of an creation of the distraction regenerate. The location of the endosseous implant-supported dental restoration. C trapezoidal osteotomy was based on the position of the inferior alveolar nerve, the location and vector of the device, and the thickness of the alveolar bone. Acknowledgements: I would like to thank Dr. George Zarb for prosthodontic restoration of this patient’s occlusion, and I would like A 5-day latency period was allowed, and distraction was to thank Goretti Sozinho for typing the manuscript. started on the fifth postoperative day. The latency period is Dr. Walker is an assistant professor and staff oral and maxillofacial surgeon at the implant prosthodontic unit, important for resolution of inflammation from the initial faculty of dentistry, University of Toronto, Toronto, surgical procedure. It also allows cellular induction and Ontario; staff oral and maxillofacial surgeon, The differentiation of fibroblasts, formation of collagen and Hospital for Sick Children, Toronto; and a Diplomate of the American Board of Oral and Maxillofacial Surgery. subsequent induction of osteoblasts during the early stages Correspondence to: Dr. David A. Walker, 419–170 St. George St., of new bone formation.19 The distraction rate for this To ronto, ON M5R 2M8. E-mail: [email protected]. patient was 1 mm/day, performed in 3 activations. The The author has no declared financial interests in any company greater the frequency of activation, the more favourable the manufacturing the types of products mentioned in this article.

174 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Mandibular Distraction Osteogenesis for Endosseous Dental Implants

References 11. Hidding J, Lazar F, Zoller J. The Cologne concept on vertical distrac- 1. Levin L, Barber D, Betts N, MacAfee K, Feinberg S, Fonseca R. Bone tion osteogenesis. In: Arnaud E, Diner P, editors. 3rd International induction and the biology of grafting. In: Fonseca R, Davis W, editors. Congress on Cranial and Facial Bone Distraction Processes (June 14–16, Reconstructive preprosthetic oral and maxillofacial surgery. 2nd ed. 2001, Paris, France). Bologna (Italy): Monduzzi Editore; 2001. p. 65–72. Philadelphia: W. B. Saunders; 1995. p. 41–72. 12. Chin M. Alveolar distraction osteogenesis with endosseous devices in 175 cases. In: Arnaud E, Diner P, editors. 3rd International Congress on 2. Cricchio G, Lundgren S. Donor site morbidity in two different Cranial and Facial Bone Distraction Processes (June 14–16, 2001, Paris, approaches to anterior iliac crest bone harvesting. Clin Implant Dent Relat France). Bologna (Italy): Monduzzi Editore; 2001. p. 73–80. Res 2003; 5(3):161–9. 13. Gaggl A, Schultes G, Karcher H. Vertical alveolar ridge distraction 3. Clavero J, Lundgren S. Ramus or chin grafts for maxillary sinus inlay with prosthetic treatable distractors: a clinical investigation. and local onlay augmentation: comparison of donor site morbidity and Int J Oral Maxillofac Implants 2000; 15(5):701–10. complications. Clin Implant Dent Relat Res 2003; 5(3):154–60. 14. Marchena JM, Block MS, Stover JD. Tibial bone harvesting 4. Clarizio L. Vertical alveolar distraction versus bone grafting for implant under intravenous sedation: morbidity and patient experiences. cases. In: Jensen O, editor. Alveolar distraction osteogenesis, Chicago: J Oral Maxillofac Surg 2002; 60(10):1151–4. Quintessence Publishing; 2002. p. 59–68. 15. Sawin PD, Traynelis VC, Menezes AH. A comparative analysis of 5. Ilizarov GA. The tension stress effect on the genesis and growth of fusion rates and donor-site morbidity for autogeneic rib and iliac crest tissues. Part I. The influence of stability fixation and soft tissue bone grafts in posterior cervical fusions. J Neurosurg 1998; 88(2):255–65. reservation. Clin Orthop 1989; (238):249–81. 16. Bolger WE, McLaughlin K. Cranial bone grafts in cerebrospinal fluid 6. Ilizarov GA. The tension stress effect on the genesis and growth leak and encephalocele repair: a preliminary report. Am J Rhinol 2003; of tissues. Part II. The influence of rate and frequency of distraction. 17(3):153–8. Clin Orthop 1989; (239):263–85. 17. Nkenke E, Radspiel-Troger M, Wiltfang J, Shultze-Mosgau S, 7. Chin M, Toth BA. Distraction osteogenesis in maxillofacial surgery Winkler G, Newkam FW. Morbidity of harvesting retromolar bone grafts: a prospective study. Clin Oral Implants Res 2002; 13(5):514–21. using internal devices: review of five cases. J Oral Maxillofac Surg 1996; 54(1):45–53. 18. Stucki-McCormick, Moses J, Robinson R, Laster Z, Mommaerts M, Jensen O. Alveolar distraction devices. In: Jensen O, editor. Alveolar 8. McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH. distraction osteogenesis. Chicago: Quintessence Publishing; 2002. Lengthening of the human mandible by gradual distraction. Plast Reconstr p. 41–58. Surg 1992; 89(1):1–8. 19. Samchukov M, Cope J, Cherkashin A. Biological basis of new bone 9. Molina F, Ortiz Monasterio F. Mandibular elongation and remodeling formation under the influence of tension stress. In: Samchukov M, Cope by distraction: a farewell to major osteotomies. Plast Reconst Surg 1995; J, Cherkashin A, editors. Craniofacial distraction osteogenesis. St. Louis 96(4):825–40. (MO): Mosby; 2001. p. 21–36. 10. Walker DA. Management of severe mandibular retrognathia in the 20. Walker D. Buried bidirectional telescopic mandibular distraction. In: adult patient using distraction osteogenesis. J Oral Maxillofac Surg 2002; Samchukov M, Cope J, Cherkashin A, editors. Craniofacial distraction 60(11):1341–6. osteogenesis. St. Louis (MO): Mosby; 2001. p. 313–22.

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™™ ™ HEALTHY GUMS. HEALTHY LIFE.™ A PPLIED R ESEARCH

Resterilization of Instruments Used in a Hospital-based Oral and Maxillofacial Surgery Clinic

• Nicholas J.V. Hogg, MSc, DDS • • Archibald D. Morrison, DDS, MSc, FRCD(C) •

Abstract

Objective: The transmission of pathogens from one patient to another via contaminated devices has been a high- profile issue in infection control. Although single-use devices have been promoted as a preventative strategy, resterilization of instruments has been a common practice in dentistry. The purpose of this study was to investigate the rate of bacterial contamination of instruments resterilized for use in oral and maxillofacial procedures in a hospital-based clinic. Methods: The experiment was a prospective randomized controlled study. The test group consisted of burs that had been used in surgical procedures. These burs were grossly debrided before being cleaned and gas sterilized in the central sterilizing department of the hospital. The burs were transferred in a sterile fashion into a culture medium selected to grow oral bacteria. The control group comprised new unused instruments treated in an identical fashion before culturing. All burs were incubated and monitored daily for 72 h. Results: The rate of bacterial contamination in the test groups was significantly higher than in the control group (p < 0.05). Conclusions: Reuse of instruments can be cost-effective if the safety of patients can be assured; however, there is increasing evidence that the sterilization process may not be completely effective. Consideration should be given to the classification of certain types of dental burs as single-use devices if sterilization cannot be guaranteed.

MeSH Key Words: cross infection/prevention & control; dental instruments; disinfection methods; equipment reuse

terilization of instruments ensures that they are free of instruments as defined by the United States’ Food and Drug “all microbial life including microbial spores which Administration and can be reused if sterility can be guaran- S are the most difficult of micro-organisms to kill.”1 teed.3 However, there is now evidence that the sterilization If the sterilization process is effective in killing bacterial process is complex and that if strict adherence to an effec- spores, it will also be effective against mycobacteria and all tive protocol is not followed, contamination of instruments viruses, including herpes simplex virus, hepatitis and HIV.1 may result. Resterilization is “the repeated application of a terminal In the past decade, single-use devices (SUDs) have process designed to remove or destroy all viable forms of been promoted in many dental and medical practices as a microbial life, including bacterial spores, to an acceptable strategy to prevent the transmission of blood- and tissue- sterility assurance level.”2 Resterilization of instruments borne pathogens from patient to patient. This practice has used on one patient for reuse on another has been common also been influenced by high-profile legal cases that have practice in dentistry and oral and maxillofacial surgery. brought the issue of SUDs to the attention of the media Some instruments used in oral and maxillofacial and ortho- and the public.4 For example, in Toronto in 2002, a case pedic procedures, such as bone drills and saws, are Class I involving a patient who contracted the hepatitis B virus via

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 179 Hogg, Morrison

Test group: #701 fissure burs Test group: #8 round burs 45%

Growth Growth No growth No growth

55% Control group: #701 fissure burs Control group: #8 round burs

Growth Growth No growth No growth

Figure 1: The 2 types of burs tested were Figure 2: The instruments were placed into Figure 3: Bacterial contamination after the #701 ﬁssure bur and the #8 round bur. test tubes and stored vertically in racks in a culture in the 2 types of burs in the test 37°C incubator. group compared with the control group after 72 h of observation.

contaminated electroencephalogram electrodes resulted in The purpose of this study was to investigate the rate of a $27.5-million settlement against the neurologist and bacterial contamination of instruments resterilized for use hospital.4 SUDs are convenient and their use has become in oral and maxillofacial procedures in a hospital-based widespread in hospitals around the world. However, the use clinic. of disposable instruments does not come without a significant cost to the health care system as well as environmental Materials and Methods concerns.5 The test group consisted of 2 types of bone burs: Currently, numerous articles address the transmission of #8 round burs and #701 fissure burs that had been used in blood- and tissue-borne pathogens from one patient to a hospital-based clinic during surgical procedures requiring another via contaminated devices.6–8 Many studies look at bone removal or re-contouring or sectioning of teeth the bacterial and viral contamination of dental and medical (Fig. 1). The staff who worked in the clinic processed the instrumentation and the safety of sterilizing and reusing these instruments.9,10 burs initially; they grossly debrided the 2 types of burs There have also been concerns over the possible trans- before sending the instruments to the central sterilizing mission of prions by contaminated surgical instruments.6 department (CSD) of the hospital. In the CSD, the burs The contact of endodontic files with the peripheral were unpackaged and placed in an ultrasonic cleaner for branches of the trigeminal nerve may present a risk of 3 minutes to remove gross organic and microbial contami- transmission of Creutzfeldt-Jakob Disease (CJD), although nation. Following this, they were run through a washer– there is no evidence of transmission of CJD in dentistry.6,11 decontaminator station that flushed them with water Although SUDs have been promoted as a strategy to heated to 98°C. The burs were then processed in a drying prevent cross-infection of patients, resterilization of station and packed in paper and plastic peel-back packages previously used instruments is still common as cost is a before entering the gas sterilization cycle. significant factor in the decision to reuse instruments in Gas vapour sterilization involved a gas mixture consist- dentistry and oral and maxillofacial surgery.12 The practice of reprocessing used instruments is becoming more and ing of 10% ethylene oxide and 90% CO2. The burs were more prevalent with the overall goal of saving money subjected to a 1-h conditioning cycle, 3-h sterilization and decreasing environmental pollution.2 Supporters of (55°C) cycle, 20-minute exhaust cycle, and a 12-h aeration resterilization believe that the labelling of some devices cycle. The gas vapour sterilization process was monitored as SUDs by manufacturers is done so that they can increase using physical, chemical and biological indicators. On profits and avoid liability with regard to cross-infection completion of the procedure, the burs were transferred in of patients on whom their instruments are used. sterile fashion into test tubes containing a culture medium Modern dental and medical equipment can be intricate selected to grow oral bacteria (Todd-Hewitt broth). The and contain small lumens, as in endoscopic equipment, control group comprised new unused instruments treated and therefore requires more rigorous procedures to in an identical fashion before culturing. All samples ensure sterilization. Some instruments cannot be consis- tently and reliably sterilized; because of the risk of cross- (n = 160) were then placed in an incubator maintained at contamination with these instruments, disposable devices 37°C (Fig. 2) to mimic body temperature. The burs were became established in the health care industry. There is still examined daily over 72 h to check for evidence of bacterial much debate regarding the reuse of instruments in both growth. Chi-squared tests were used to test for significant dentistry and medicine.4,6–8 differences between the 2 groups and subgroups.

180 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Resterilization of Instruments Used in a Hospital-based Oral and Maxillofacial Surgery Clinic

Table 1 Statistical analysis

Groups compared X2 value DF p value Test group (n = 80) vs. control group (n = 80) 87.870 1 p < 0.0001 Fissure burs, test group (n = 40) vs. round burs, test group (n = 40) 27.649 1 p < 0.0001 Fissure burs: test group (n = 40) vs. control group (n = 40) 76.050 1 p < 0.0001 Round burs: test group (n = 40) vs. control group (n = 40) 20.717 1 p < 0.0001

DF = degrees of freedom.

Results failure of the sterilization process, and Lowe, Bagg and In the test group, 100% of the #701 fissure burs and others14 agree with the possibility of using disposable 45% of the #8 round burs showed evidence of bacterial systems to eliminate risks, although cost may be a deterrent growth after 72 h of observation (Fig. 3). No instruments to the widespread acceptance of this practice. in the control group showed any evidence of bacterial Endodontic files are another type of instrument that is growth after 72 h (Fig. 3). The bacterial growth on the commonly reused. In a survey of general dentists in the dental burs was examined. The colony structure and Gram United Kingdom, Bagg and others11 found that 88% of staining were consistent with the growth of streptococcus practitioners reused endodontic files. Smith and others6 species. Chi-squared tests showed significant differences compared used endodontic files that had been collected between the groups (p < 0.05) (Table 1). from general dental practices with files from a dental Discussion hospital, and found that 76% of the former were visibly This study showed that the sterilization technique used contaminated when inspected under a dissecting micro- in the hospital clinic and CSD was not effective in cleaning scope, as opposed to 14% of those from the dental hospital. some of the instruments used in oral and maxillofacial These authors also concluded that the cleaning methods surgical procedures. Surprisingly high rates of bacterial used were insufficient to remove the organic material on the contamination were noted with both types of bone burs. endodontic files. They suggested that a cost–benefit All of the #701 fissure burs showed evidence of bacterial analysis would be helpful in determining whether these files contamination after 72 h of observation. would be suitable for designation as single use. Other studies have also shown that reuse of instruments The clinical applicability of studies that look at the risk is common and that cleaning of these instruments may not of cross contamination as a result of using contaminated always be effective. For example, Lowe, Burke and others12 instruments depends on the amount of the pathogen trans- conducted a survey of general dentists in Scotland and ferred, the infectivity of the pathogen and host resistance.16 found that 93% of those who answered the survey reused The ultimate outcome depends on the long-term course of matrix bands on multiple patients in their practices. the disease caused by the pathogen. Attention has been Although 99% of respondents used a steam autoclave to focused on bacterial infection, but as the oral cavity is a sterilize instruments, they used a variety of presterilization contaminated environment to begin with, the clinical cleaning methods, ranging from a pre-soak only to a applicability of the research is difficult to elucidate. There combination pre-soak, ultrasonic cleaning and hand has been public concern over handpiece and waterline scrubbing. The importance of pre-cleaning instruments contamination issues as these topics were widely covered in before steam autoclaving has been well reviewed.13 the media. There have also been ethical studies looking at In a subsequent study, Lowe, Bagg and others14 looked the issues of reuse and reprocessing and whether the patient at blood contamination of matrix bands; they collected is at risk from these practices.17 Resterilization is a contro- used matrix bands and matrix band retainers from general versial issue that has yet to be resolved. dentists in the community. The instruments had been sterilized according to the regular protocol within each office, This study revealed a high rate of bacterial contamina- which included steam autoclaving after pre-cleaning. They tion of rotary instruments despite pre-cleaning and gas found that 34% of hand scrubbed and 4% of ultrasonically sterilization in a hospital-based sterilization department. cleaned matrix bands had evidence of blood contamination, Other studies have shown that pre-cleaning and steriliza- and blood was detected on 32% of hand scrubbed and tion in dental offices may not be as effective at rendering 3% of ultrasonically cleaned matrix band retainers. These instruments free from contamination as is commonly results show the benefit of ultrasonic cleaning before steam thought. Cost–benefit analysis may show that for some autoclaving as confirmed by other studies.15 The results are instruments it may be more cost-effective to use them once also similar to the present study in that they showed a high and discard them rather than attempt a cleaning and rate of contamination. The data confirm that there was a sterilization process that may not be effective.

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 181 Hogg, Morrison

Conclusions 9. Lewis DL, Arens M. Resistance of microorganisms to disinfection in Sterilizing instruments is a labour-intensive process that dental and medical devices. Nat Med 1995; 1(9):956–8. 10. Lewis DL, Arens M, Appleton SS, Nakashima K, Ryu J, Boe RK, requires careful attention to detail. Reuse of rotary instru- and others. Cross-contamination potential with dental equipment. ments can be a cost-effective measure in the practice of oral Lancet 1992; 340(8830):1252–4. and maxillofacial surgery if the safety of patients can be 11. Bagg J, Sweeney CP, Roy KM, Sharp T, Smith A. Cross infection control measures and the treatment of patients at risk of Creutzfeldt assured. Yet there seems to be increasing evidence that the Jakob disease in UK general dental practice. Br Dent J 2001; sterilization process may not be completely effective due to 191(2):87–90. human, mechanical or microbial factors. Consideration 12. Lowe AH, Burke FJ, McHugh S, Bagg J. A survey of the use of should be given to the classiﬁcation of rotary instruments matrix bands and their decontamination in general dental practice. C Br Dent J 2002; 192(1):40–2. as SUDs if sterilization cannot be guaranteed. 13. Woods R, Amerena V, David P, Fan PL, Heydt H, Marianos D. Sterilisation: Part 2. Heat and chemical sterilisation. FDI World 1996; 5(3):13–6. 14. Lowe AH, Bagg J, Burke FJ, MacKenzie D, McHugh S. A study of Acknowledgement: Source of funding for this research: the John P. blood contamination of Siqveland matrix bands. Br Dent J 2002; Laba Memorial Research Fund. 192(1):43–5. 15. Rutala WA, Gergen MF, Jones JF, Weber DJ. Levels of microbial Dr. Hogg is chief resident, department of oral and contamination on surgical instruments. Am J Infect Control 1998; maxillofacial sciences, faculty of dentistry, Dalhousie 26(2):143–5. University, Halifax, Nova Scotia. 16. Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Centers for Disease Control and Prevention. Guidelines for infection control in dental health care settings – 2003. MMWR Recomm Dr. Morrison is director of graduate training in oral Rep 2003; 52(RR-17):1–67. and maxillofacial surgery, department of oral and 17. Ball CK, Schafer EM, Thorne D. Reusing disposables: same old maxillofacial sciences, faculty of dentistry, Dalhousie story — more characters added. Insight 1996; 21(3):77–84. University, Halifax, Nova Scotia. Correspondence to: Dr. Archibald D. Morrison, Department of Oral and Maxillofacial Sciences, Faculty of Dentistry, Dalhousie University, Halifax, NS B3H 3J5. E-mail: [email protected]. The authors have no declared ﬁnancial interests. Got an opinion? Discuss this article in the CDA Members’ Forum at www.cda-adc.ca/forum. Not sure how to log in? References 1. Woods R. Sterilisation: Part 1. Instrument preparation. FDI World It’s as easy as… 1996; 5(2):7–10. 2. Dunn D. Reprocessing single-use devices — the ethical dilemma. AORN J 2002; 75(5):989–99. 1. Go to the Web address provided above 3. Dunn D. Reprocessing single-use devices — regulatory roles. 2. Type in your password AORN J 2002; 76(1):100–6, 108–12. 4. Mackay B. No ban on reuse of single-use medical devices imminent. 3. Choose a topic and start “chatting”. CMAJ 2002; 166(7):943. 5. Dunn D. Reprocessing single-use devices — the equipment connection. AORN J 2002; 75(6):1143–58. Don’t know your password? Forgot your password? 6. Smith A, Dickson M, Aitken J, Bagg J. Contaminated dental instruments. J Hosp Infect 2002; 51(3):233–5. 7. Linsuwanont P, Parashos P, Messer HH. Cleaning of rotary nickel- Online instructions are provided to help you retrieve that titanium endodontic instruments. Int Endod J 2004; 37(1):19–28. information. Or contact CDA at 1-800-267-6354, between 8. Heeg P, Roth K, Reichel R, Cogdill P, Bond WW. Decontaminated single-use devices: an oxymoron that may be placing patients at risk for 8a.m. and 4 p.m. EST, e-mail: [email protected]. cross-contamination. Infect Control Hosp Epidemiol 2001; 22(9):542–9.

182 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association / iÊLi>ÕÌÞÊvÊ>ÃÌ}Ê>ÌÕÀ>ÊiÃÌ iÌVÃ°

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A PPLIED R ESEARCH

Iatrogenic Paresthesia in the Third Division of the Trigeminal Nerve: 12 Years of Clinical Experience

• René Caissie, DMD, MSc • • Jacques Goulet, DMD, FRCD(C) • • Michel Fortin, DMD, PhD, FRCD(C) • • Domenic Morielli, BSc, DDS •

Abstract

Background: Iatrogenic paresthesia in the third division of the trigeminal nerve remains a complex clinical problem with major medicolegal implications. However, most lawsuits can be prevented through better planning of procedures and by obtaining informed consent. The purpose of this article is to present the authors’ clinical experience over the past 12 years, to review the principles of prevention and management of trigeminal paresthesia and to highlight the resulting medicolegal implications. Methods: The ﬁles of all 165 patients referred to the oral and maxillofacial surgery department for evaluation of iatrogenic paresthesia in the third division of the trigeminal nerve were reviewed. The characteristics of the subgroup of patients who had taken an attending dentist to court were compared with those of the other patients. Results: Surgical extraction of impacted molars was the main cause of paresthesia in 109 (66%) of the 165 subjects. The alveolar nerve was affected in 89 (54%) subjects, the lingual nerve in 67 (41%) subjects, and both nerves were affected in 9 (5%) subjects. There were more female than male patients (ratio 2.2:1). Lawsuits were initiated in 33 (20%) of the cases; patients who initiated lawsuits were younger, were more likely to have experienced anesthesia and were more likely to need microsurgery (all p < 0.001). Poor surgical planning and lack of informed consent were the most common errors on the part of the dentists. Conclusions: An accurate evaluation of surgical indications and risk, good surgical technique, preoperative informed consent and sufficient postoperative follow-up should help to reduce the frequency of neurosensory deﬁcits after dental treatment and attendant lawsuits.

MeSH key words: molar, third/surgery; postoperative complications; sensation; trigeminal nerve/injuries

hanges in feeling in the orofacial region may neuroma located at the site of the trauma, changes in the interfere with speaking, chewing and social autonomic nervous system (sympathetically mediated pain) interactions.1 Even apparently minor changes can or alterations in the central nervous system (central C 2 significantly affect a patient’s quality of life. Trauma to a neuropathic pain). Allodynia is a type of dysesthesia peripheral nerve may result in a deficiency ranging from characterized by a painful response to normally nonpainful total loss of sensation (anesthesia) to a mild decrease in feel- stimuli, such as light touching or shaving. Hyperalgesia is ing (mild hypoesthesia). These sensory deficits may be an exaggeration of the pain response to stimuli, whereas either temporary or permanent. Some patients may also hyperpathia is an exaggerated response to pain that persists experience dysesthesia, which is characterized by abnor- even after the stimulus has been removed.3 The pathophys- mally painful sensations. Such pain may be caused by a iology of these neuropathies is complex, and treatment

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 185 Caissie, Goulet, Fortin, Morielli

Table 1 Causes of paresthesia in the third division of the trigeminal nerve

Nerve affected; no. (and %) of patients Alveolar nerve Lingual nerve Both Total Cause of injury (n = 89) (n = 67) (n = 9) (n = 165) Exodontics 50 (56) 52 (78) 7 (78) 109 (66) Injection 5 (6) 14 (21) 0 19 (12) Osteotomy 15 (17) 0 2 (22) 17 (10) Implant 8 (9) 1 (1) 0 9 (5) Endodontics 5 (6) 0 0 5 (3) Accident 4 (4) 0 0 4 (2) Parodontics 2 (2) 0 0 2 (1)

Table 2 Factors inﬂuencing probability of lawsuits

No. (and %) of patients Lawsuit No lawsuit Total Factor (n = 33) (n = 132) (n = 165) p value Mean age (years) 32.8 36.1 35.4 < 0.001 Sex ratio (F/M) 21/12 (1.75) 93/39 (2.38) 114/51 (2.2) 0.46 Anesthesia 9 (27) 9 (7) 18 (11) < 0.001 Dysesthesia 5 (15) 31 (23) 36 (22) 0.35 Microsurgery required 17 (52) 16 (12) 33 (20) < 0.001 Lingual nerve affected 14 (42) 62 (47) 76 (46) 0.68

results are often disappointing.4 The presence of anesthesia, Results dysesthesia or spontaneous pain also indicates poor The cohort consisted of 165 patients. The most prospects for recovery without surgical intervention. common cause of paresthesia in the third division of the Overall, 25% of patients with iatrogenic paresthesia suffer trigeminal nerve was extraction of impacted third molars permanent effects.5 (109 patients), followed by trauma due to injection The risk of iatrogenic paresthesia of the third division of (19 patients) (Table 1). In 135 patients, the lesion was the trigeminal nerve depends on the procedure performed, located at the level of a single nerve, the lower alveolar nerve the technique used and the surgeon’s experience. Iatrogenic in 82 (61%) of these patients and the lingual nerve in paresthesia remains a complex clinical problem with major 53 (39%). Twenty-one patients had bilateral pain in the medicolegal implications. The purpose of this article is lower alveolar or the lingual nerve, and 9 patients had pain to present the authors’ clinical experience over the past 12 in both of these nerves on the same side. One hundred and years, to review the principles of prevention and manage- fourteen (69%) of the subjects were female (ratio of women ment of trigeminal paresthesia and to highlight the result- to men 2.2:1). During the initial evaluation, most patients ing medicolegal implications. presented with hypoesthesia (103 [62%]) or anesthesia (17 [10%]). Dysesthesia was seen in 36 (22%) of the cases, Methods and the proportion of female subjects was significantly The files of all patients referred to the authors’ oral and higher in this subgroup (p = 0.007). Thirty-three patients maxillofacial surgery department between 1990 and 2001 (20%) underwent microsurgery for ablation of a neuroma, for evaluation of iatrogenic paresthesia in the third division reanastomosis or neural decompression. of the trigeminal nerve were reviewed. All patients had been Legal proceedings were initiated by 33 (20%) of the seen and treated by the same surgeon. The data extracted 165 patients. Patients who initiated lawsuits were younger, from the files included age, sex, description of the trauma, were more likely to have experienced anesthesia and were lesion location, initial diagnosis, need for microsurgery and more likely to have needed microsurgery (Table 2). The type of surgery performed. The sample was divided into average amount granted in the legal proceedings was 2 subgroups according to whether the patient had initiated $17,956, which was 42% of the average amount requested, a lawsuit against the dentist who had performed the surgery. $43,047 (Table 3). The highest amount awarded was These subgroups were compared by the Student t-test to $35,347 and the lowest $5,167. Most disputes were settled determine whether any of the independent variables were amicably or out of court. In general, higher amounts were associated with initiation of lawsuits. granted to patients who had recourse to a lawyer’s services.

186 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Iatrogenic Paresthesia in the Third Division of the Trigeminal Nerve

Table 3 Settlements for lawsuits

Average amount ($) Lawsuit No. Requested Awarded Amicable settlement without legal proceedings or lawyer 6 19,478 12,838 Amicable settlement without legal proceedings but with lawyer 8 40,437 19,997 Legal action and unfavourable judgement to the patient 2 60,868 28,733 Legal action and favourable judgement to the patient 1 39,000 0 Legal action, settled out of court 6 59,878 17,062 Legal action, not settled 5 138,689 NA Denial of responsibility with lawyer, without any action taken 3 30,031 NA Discontinuation of suit before court case 1 38,000 NA Preventive notice without any action taken 1 NA NA Overall 33 17,956 43,047

NA = not applicable

Table 4 Indications and contraindications for Among patients with iatrogenic paresthesia in the third extraction of lower third molars division of the trigeminal nerve, 75% regain normal sensitivity without further treatment.5 In most cases, complete Indications recovery occurs 6 to 8 weeks after the trauma, although it Prevention and treatment of infection may take up to 24 months. If paresthesia is not completely Prevention and treatment of dental and periodontal pathology Prevention and treatment of cysts and odotongenic tumours resolved within about 2 months, the probability of a perma- Orthodontic considerations (facilitate alignment, prevent relapse) nent deficit increases significantly; it is unlikely that Contraindications complete resolution will occur if the deﬁcit is still present after 9 months.10 The prognosis of spontaneous recovery is Advanced age (> 30 years) Very young age (< 12 years) better for the lower alveolar nerve than for the lingual Imminent damage to adjacent structures nerve.8 Possibility that tooth might erupt or serve as an abutment In the preoperative evaluation for nontherapeutic extrac- Orthodontic considerations (tooth needed as an anchor or for the alignment of teeth) tion of impacted third molars, the surgeon must decide Patient refusal to accept risks associated with extraction whether the risks of surgery exceed the expected beneﬁts. This study and the authors’ clinical experience have shown that, too often, the risk of surgery had been poorly evaluated and, in certain cases, the treatment is not even indi- Discussion cated. The surgeon must be familiar with the indications for The reported incidence of paresthesia after extraction of removal of impacted third molars (Table 4). He or she must 6 7 impacted third molars varies between 0.2% and 22% for also be familiar with the radiologic signs indicating the 8 9 the lingual nerve and between 0.4% and 7% for the lower proximity of the lower alveolar nerve. The presence of alveolar nerve. These variations can be explained by differ- a radiolucent band at the apex of the third molar, loss ences in procedures and technique, in particular with regard of continuity of the upper or lower bony cortex in the to clinical evaluation and diagnostic criteria, as well as lower alveolar canal and shrinking or deviation of this canal differences in the surgeon’s experience. The risk of pares- are all reliable signs indicating closer proximity of the thesia depends on the clinical situation. It may be almost lower alveolar nerve to the root of the wisdom tooth nonexistent under the best conditions (young patient, (Figs. 1 to 3).11 incompletely formed roots, mandibular canal not in close proximity) but could exceed 50% in other circumstances Management (elderly patient, unfavourable position of the tooth, proximity of the mandibular canal). A good clinical evaluation Perioperative Precautions can be used to inform the patient about the potential risks If the patient feels a sensation like an electric shock when of surgery. Written informed consent, after the patient has the needle is inserted, the needle should be withdrawn by a received a complete description of these risks, must be few millimetres before the solution is administered. If the obtained in all cases of nontherapeutic surgical removal of position of the extracted tooth allows the lower alveolar the molars (i.e., preventive treatment). Consent is also nerve to be seen at the bottom of the alveolus, many strongly recommended in cases of therapeutic surgical surgeons prefer to place a piece of absorbable gelatin extraction (treatment of pathology) for semi-impacted or in the alveolus (e.g., Gelfoam, Pharmacia & Upjohn impacted third molars. Co, Kalamazoo, Mich.) before closing. However, the

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 187 Caissie, Goulet, Fortin, Morielli

Figure 1: A 34-year-old patient who Figure 2: A 32-year-old patient who Figure 3: A 32-year-old patient who was underwent extraction of tooth 48. underwent extraction of tooth 38. After the evaluated for hypoesthesia of the lip and Anesthesia in the area of the lip and chin surgery, the patient presented with severe chin and the vestibular mucosa after was noted upon initial examination. Neural dysfunctional hypoesthesia as well as extraction of tooth 38. There is major decompression with debridement revealed hyperalgesic neuralgia and eventually deviation of the lower alveolar canal, that the nerve had been partially cut, and launched a lawsuit. Note the classic signs of indicating close proximity between the there was intense scarring at the affected very close proximity between the lower canal and the tooth. site. Legal proceedings were initiated alveolar nerve and the apex of the third against the dentist. Note the presence of a molar, i.e., loss of continuity of the bony radiolucent band at the apex of the third cortex of the lower alveolar canal, as well as molar. its shrinking and deviation at the apex.

Figure 4: Mapping of the affected area can Figure 5: A swab may be used to evaluate Figure 6: A soft hairbrush can be used to delimit the scope of the problem and can the patient’s sensations in the affected area. assess the patient’s ability to detect be used to follow its development. Only the point of the swab should come direction of movement. into contact with the subject’s tissues, so as to obtain a reliable reading.

1. Map the affected area by pencil outline on a drawing or a photograph of the patient (Fig. 4). 2. Determine the sensations felt by the patient when a cotton swab is lightly applied to the affected area (Fig. 5). 3. Determine the ability of the patient to detect the direction of a sweeping motion (in an area of about 1 cm), applied with a resin applicator or the tip of a rolled-up tissue (Fig. 6). 4. Describe the patient’s sensations when a 27-gauge hard Figure 7: The flat tip of a 27-gauge needle is used to evaluate the patient’s perception of needle is applied in the affected region with sufficient painful stimuli. pressure to indent the skin without penetrating it (Fig. 7). The presence of dysesthesia or spontaneous pain must effectiveness of this measure, which aims to minimize fibro- be noted. Each test must be conducted at 3 sites: the lower sis and thus prevent paresthesia, has not been established. lip, the lip–chin fold and the chin. Any patient with pares- Clinical Evaluation thesia should receive corticosteroids to minimize the Patients with postoperative paresthesia must be treated inflammatory response.12 Empiric treatment with pred- promptly and should be seen as soon as possible for clinical nisone (50 mg once daily) for 7 days is often used in the evaluation. The clinical evaluation should comprise the authors’ oral surgery department. This medication must be following elements: started as soon as possible, ideally the day after surgery.

188 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Iatrogenic Paresthesia in the Third Division of the Trigeminal Nerve

Seven-day antibiotic treatment with penicillin, the gold undertaken. The well-informed general dentist should be standard for patients without penicillin allergy, or clin- able to perform an initial assessment and then refer the damycin is commonly prescribed to prevent infection, patient to a maxillofacial surgeon at the appropriate time to which would slow the healing process and decrease the maximize the chances of functional recovery of the affected likelihood of full recovery of the nerve. Clinical evaluation nerve. C should be repeated once a month to assess the presence or absence of functional recovery. Acknowledgements: The authors would like to thank the Fonds d’assurance responsabilité of the Quebec Order of Dentists, as well as Referring the Patient Pauline O’Brien and Valérie Savoie-Rosay for their contributions in Some patients must be referred to an oral and maxillo- writing this article. Dr. Caissie is a doctoral student in experimental facial surgeon. Microsurgery may be indicated in the medicine at Laval University’s faculty of medicine in following cases: confirmed transection of a nerve; total the Experimental Organogenesis Laboratory (LOEX), anesthesia of the affected area 2 months after the trauma; Quebec City, Quebec, and a second-year resident in the oral and maxillofacial program, Hôpital de lack of protective reflexes (on biting or burning of the l’Enfant-Jésus, Quebec City. tongue or lower lip) 2 months after trauma, with little or no improvement; or dysesthesia.13 Microsurgery involves general anesthesia, a period of Dr. Goulet is an oral and maxillofacial surgeon at the convalescence and a few weeks off work. The surgeon Hôpital Hôtel-Dieu de St-Jérôme, St-Jérôme, Quebec. dissects the affected nerve and, if the damage is extensive, joins the proximal and distal portions. This surgery should Dr. Fortin is an oral and maxillofacial surgeon at the Hôpital Enfant-Jésus de Québec, Lévis, Quebec. He is ideally be done within 4 months after the trauma to prevent also a Fellow in surgical oncology and reconstructive atrophy of the distal part of the nerve.14 Therefore, if it is surgery from the Jackson Memorial Hospital, felt that the patient’s condition might be improved through University of Miami. surgery (on the basis of the criteria listed above), he or she Dr. Morielli is an oral and maxillofacial surgeon at the should be referred immediately to allow the surgeon to Hôpital de l’Enfant-Jésus and a clinical professor at make his or her own assessment and measure the lack of Laval University’s faculty of dentistry, Quebec City, functional recovery over a period of 2 months before inter- Quebec. vening. Although considerable functional improvement is Correspondence to: Dr. Jacques Goulet, 208–200, rue Durand, St- seen in many patients after surgery,13,15 regaining normal Jérôme, QC J7Z 7E2. E-mail: [email protected]. sensation is not possible. Just under half of patients experi- The authors have no declared financial interests in any company ence no improvement, and all patients who undergo manufacturing the types of products mentioned in this article. surgery will have some permanent sensory deficit. In cases of dysesthesia, a more medical approach is required, since References surgery is rarely useful in these cases, especially for patients 1. Ziccardi VB, Assael LA. Mechanisms of trigeminal nerve injuries. Atlas Oral Maxillofac Surg Clin North Am 2001; 9(2):1–11. with sympathetically mediated pain or central neuropathic 2. Sandstedt P, Sorensen S. Neurosensory disturbances of the trigeminal pain.16 nerve: a long-term follow-up of traumatic injuries. J Oral Maxillofac Surg 1995; 53(5):498–505. Conclusions 3. LaBanc JP. Classification of nerve injuries. Oral Maxillofac Clin North Most cases of iatrogenic paresthesia can be prevented. Am 1992; 4(2):285–96. 4. Cooper BY, Sessle BJ. Anatomy, physiology, and pathophysiology of However, when this problem occurs, follow-up must be trigeminal system paresthesias and dysesthesias. Oral Maxillofac Clin initiated quickly, since the first few months may determine North Am 1992; 4(2):297–322. the degree of nerve healing. If there is a high risk of nerve 5. Zuniga JR, LaBanc JP. Advances in microsurgical nerve repair. trauma, the patient should be referred preoperatively to an J Oral Maxillofac Surg 1993; 51(suppl 1):62–8. 6. van Gool AV, Ten Bosch JJ, Boering G. Clinical consequences of oral and maxillofacial surgeon. Most patients recover complaints and complications after removal of the mandibular third normal sensation without treatment. However, permanent molar. Int J Oral Surg 1977; 6(1):29–37. deficits are often poorly tolerated, as indicated by the high 7. Von Arx DP, Simpson MT. The effect of dexamethasone on proportion of lawsuits in such cases. More than half of neurapraxia following third molar surgery. Br J Oral Maxillofac Surg 1989; 27(6):477–80. lawsuits are associated with lack of preoperative informed 8. Alling CC 3rd. Dysesthesia of the lingual and inferior alveolar nerves consent.17 In-depth knowledge of anatomy and surgical following third molar surgery. J Oral Maxillofac Surg 1986; 44(6):454–7. principles is also imperative. It is often easy to treat slight 9. Middlehurst RJ, Barker GR, Rood JP. Postoperative morbidity hypoesthesia, but treatment becomes complex in cases of with mandibular third molar surgery: a comparison of two techniques. J Oral Maxillofac Surg 1988; 46(6):474–6. sympathetically mediated pain or central neuropathic pain. 10. Robinson PP. Observations on the recovery of sensation following If a large area has been affected, it is impossible to regain inferior alveolar nerve injuries. Br J Oral Maxillofac Surg 1988; normal sensation regardless of the therapeutic measures 26(3):177–89.

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 189 Caissie, Goulet, Fortin, Morielli

11. Tammisalo T, Happonen RP, Tammisalo EH. Stereographic assessment of mandibular canal in relation to the roots of impacted lower third molar using multiprojection narrow beam radiography. Int J Oral Dentists & Oral Health Maxillofac Surg 1992; 21(2):85–9. 12. Gregg JM. Nonsurgical management of traumatic trigeminal neuralgias and sensory neuropathies. Oral Maxillofac Clin North Am 1992; Professionals 4(2):375–92. 13. Pogrel MA. The results of microneurosurgery of the inferior and LET US REVIEW YOUR lingual nerve. J Oral Maxillofac Surg 2002; 60(5):485–9. 14. Ruggiero S.Terminal nerve injury and repair. N Y State Dent J 1996; TAX PLANNING 62(8):36–40. You could be inadvertently committing 15. Gregg JM. Studies of traumatic neuralgia in the maxillofacial region: tax evasion through improper tax symptom complexes and response to microsurgery. J Oral Maxillofac Surg 1990; 48(2):135–40. and financial planning. Protect your 16. Gregg JM. Studies of traumatic neuralgias in the maxillofacial region: practice, family, home and assets! surgical pathology and neural mechanisms. J Oral Maxillofac Surg 1990; 48(3):228–37. Paul DioGuardi Q.C. 17. Lydiatt DD. Litigation and the lingual nerve. J Oral Maxillofac Surg Tax Lawyer Get a Tax Pardon! 2003; 61(2):197–200. 39 Years Experience Formerly Tax Avoid criminal prosecution and Counsel Revenue penalties up to 250% of the amount Canada (CRA) and Department you owe. In many cases we can reduce of Justice the tax and interest otherwise payable. Anonymity & Confidentiality assured by special legal privilege with the tax authorities. Your name is only released following our negotiations and upon legal agreement. UNLIKE US, YOUR ACCOUNTANT/FINANCIAL PLANNER/ADVISOR CAN BE FORCED TO REVEAL YOUR IDENTITY AND TESTIFY AGAINST YOU!

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190 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Jasper Dental Congress Presented by the Alberta Dental Association and College

May 26 - 29, 2005

Beautiful Jasper, Alberta in the heart of the Rocky Mountains • Technology Fair with over 90 exhibitors will be the host venue for this annual conference – four days • Thursday’s Golf Tournament at the award winning of professional development sessions and social activities Fairmont Jasper Park Lodge Golf Course with a distinctively western Canadian flare! The Congress features a world-class program of speakers targeted at the Social Events entire dental community: dentists, dental hygienists, dental • The Best of Alberta Welcome Reception assistants and dental specialists. • An Evening in Black and White with The Oceanairs • Saturday Finale: Monster Mash featuring Shakin' Not Enjoy the Great Canadian Lodge experience while you stay Stirred, one of Edmonton's hottest bands! at the host hotel, The Fairmont Jasper Park Lodge, known worldwide for its rustic elegance and natural beauty. Attend Additional activities for delegates, spouses, partners and scientific sessions and technology fair activities at the Jasper family include: Activity Centre. • War Canoe Races on • White Water Rafting Mountains of experience await! The congress schedule includes: Lac Beauvert at the • Golf Clinic Internationally renowned speakers including: Jasper Park Lodge • Pilates • Fun Run/Walk • Hiking Dr. Cal Torneck Dr. Ken Zakariasen • Youth Day Camp • Tennis Tournament • Endodontic Radiology • The Great Dental Team – • Cooking Demonstration • Classification & Getting it Right! Management of • A Systems Approach to Periapical disease of Practice Efficiency and For more information, a complete speaker Endodontic Origin Effectiveness schedule and the list of hotels where rooms Dr. Douglas Dederich Ms Sherry Froelich have been blocked and their rates, visit the • Periodontal Esthetic • Stress Busters ADA&C's website at www.abda.ab.ca or contact Enhancements the ADA&C offices at (780) 432-1012. Dr David Pfaff • Use of Lasers in Dentistry To avoid disappointment, register early! • Current Concepts in • Peak Performance Periodontics Ms Susan Isaac Dr. J. Manhart • Women's Wellness – • Nanoceramic Composites Gender Biology Research Dr. Antonio Mancuso and Perimenopause • Dental Aesthetic Barb Allen & John Webster Assessment • Determining Your Personal Dr Barbeau Investment Profile – to The 2005 Jasper Dental Congress is presented in conjunction with the Alberta Dental Choose Investment • Hand Asepsis and Surface Association and College, Alberta Dental Assistants Association and the Alberta Society Disinfection Products Right for You of Dental Specialists Get on the fast track …

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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. The responses reﬂect the opinions of the contributors and do not purport to set forth standards of care or clinical practice guidelines. This month’s responses were provided by speakers at the Annual Spring Meeting of the Ontario Dental Association, to be held May 5–7, 2005, in Toronto, Ontario.

A patient of mine has reported that she is “allergic to freezing.” What are the causes of local Question 1 anesthetic-related allergies?

Anesthetic-related allergies, even mild ones, constitute less than 1% of medical emergencies in the dental office. Box 1 Injectable local anesthetics Nonetheless, it is important to understand which available in Canada substances within a local anesthetic solution are possible Drug Available as plain solution allergens and to determine the source of a patient’s allergic Articaine No reaction. Bupivacaine No Local anesthetics are classiﬁed as esters or amides. Today, Lidocaine No all injectable local anesthetics used in dentistry are amides Mepivacaine Yes (Box 1). A wide variety of esters and amides are available as Prilocaine Yes topical anesthetics, for example, benzocaine (an ester), tetracaine (an ester) and lidocaine (an amide). If a patient is allergic to an ester-based anesthetic, the Box 2 Foods that contain sulphite allergen is not the anesthetic itself but a breakdown preservatives product, p-aminobenzoic acid (PABA), which is generated Salads served in salad bars on metabolization of any ester. Therefore, if a patient is Dried fruits allergic to one ester-type local anesthetic, he or she will be Alcoholic drinks allergic to all such anesthetics. The same is not true for Potato chips Deli meats amides, which break down into a variety of metabolites; Pickles thus, allergy to one amide should not preclude the use of Cheese another, unless testing reveals an unusual situation of Lemon and lime juices, some other fruit juices Gelatin multiple amide allergies. In fact, allergy to any amide-type Muffin mix local anesthetic is extremely rare, although some cases have Canned and dried soups been documented.1 If a patient demonstrates an allergy to Canned ﬁsh the contents of an amide-based anesthetic cartridge, the Cider and vinegar likely culprit is the preservative for the vasoconstrictor, sodium metabisulphite. Such patients might report Methylparaben is also metabolized to PABA, so it was a sulphite allergy in their medical history. They are typically potential allergen. This product is needed only in multidose sensitive to any products that contain sulphite preservatives vials and is no longer available in dental cartridges. (Box 2). This type of allergy is not the same as a sulpha When there is a question as to the cause of an allergy, the allergy, which is an allergy to a class of antibiotics called patient should be sent to an allergist. The dentist should sulphonamides. People with sulpha allergies do not demon- request testing for a few different anesthetics and for the strate cross-sensitivity to sulphites. Therefore, if a patient preservative sodium metabisulphite. It is also a good idea is allergic to sulphite preservatives but not to the local to give the patient a variety of anesthetic samples to take to anesthetic itself, he or she can safely tolerate a solution with the allergist, including a solution that does not contain no vasoconstrictor. The incidence of sulphite allergy is vasoconstrictor. higher among allergy-prone asthmatic patients than among There is also the possibility of allergy to the latex within nonasthmatic patients. the cartridge. Latex particles can enter the cartridge after At one time a bacteriostatic agent called methyl- the needle perforates the diaphragm or via the plunger (in paraben was available in dental anesthetic cartridges. some cartridges). However, it is unlikely that latex within

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 193 Point of Care

the cartridge can induce latex hypersensitivity, as there are seizures and coma may occur. Allergies do not typically no published reports of an allergic response to the latex present in this way. Patients must be counselled on the component of a dental cartridge.2 In any case, companies differences between allergic reactions and the symptoms of are now moving toward use of latex-free components. overdose and epinephrine-induced reactions. C If a patient reports an allergy to a local anesthetic, it is of paramount importance to determine the events that led Dr. David Isen maintains a private practice in Toronto, to the report. Sensitivity to epinephrine or an intravascular Ontario, where he treats patients who require advanced injection commonly leads to misinterpretation of the anesthetic care. He has lectured extensively on topics related to local anesthesia, medical emergencies and reaction as an allergy. Affected patients may experience nitrous oxide sedation. E-mail: [email protected]. symptoms such as palpitations, sweating, nausea, and a Dr. Isen’s session at the ODA meeting, titled “Advanced local anesthe- feeling of faintness, and some might call this an allergic sia - what you need to know,” will be presented on Thursday, May 5. reaction. Another clinical situation that can be mistaken for an allergic reaction is an overdose of local anesthetic. In References this situation, the patient may demonstrate a range of signs 1. MacColl S, Young ER. An allergic reaction following injection of local and symptoms, including a feeling of discomfort, tingling, anesthetic: a case report. J Can Dent Assoc 1989; 55(12):981–4. metallic taste, confusion, talkativeness, hypertension and 2. Shojaei AR, Haas, DA, Local anesthetic cartridges and latex allergy: increased pulse. In more extreme overdose situations, a literature review. J Can Dent Assoc 2002; 68(10):622–6.

What should I know about treating dental patients who are undergoing chemotherapy and Question 2 when is it the best time for dental treatment?

Background and odontogenic abscesses as well as viral and fungal infec- The Canadian Cancer Society estimates that 145,500 tions. A myelosuppressive drug complicates treatment by Canadians will develop cancer during 2004 and that reducing platelet counts, making emergency surgery and 68,300 cancer-related deaths will occur. The management routine oral hygiene dangerous. of many malignancies includes the use of chemotherapeutic Most chemotherapy regimens for cancer comprise a drugs. As these treatments have become more intensive and combination of drugs. It is therefore not unusual for a therapeutically successful, the complications have patient to experience both mucositis and immunosuppres- increased. The mouth is a frequent site of such side effects. sion. This type of regimen may leave the patient extremely In chemotherapy, most complications are the result of susceptible to opportunistic infections. immunosuppression, myelosuppression and direct cyto- Dental Management of Cancer Patients toxic effects on oral tissues (Figs. 1 to 3). Oral complica- The most logical time to perform dental treatment for a tions in chemotherapy patients are usually acute and cancer patient is before the patient’s cancer therapy begins. subside shortly after the chemotherapeutic drugs leave the Most of the cancer patients who are treated in a dental system. Such side effects include mucositis, infections, oncology clinic, however, are seen on emergency referral hemorrhage, xerostomia and neurotoxicity. Mucositis, the from the oncologist or the dentist and are undergoing most common acute oral complication of chemotherapy, active chemotherapy. Most dental emergencies during typically appears 5 to 7 days after the start of treatment (it active chemotherapy could be avoided through a may appear as early as 3 days after initiation of cancer ther- prechemotherapy intraoral examination and a thorough apy). Unfortunately, most chemotherapeutic drugs affect periodontal cleaning and appropriate mouth care. Thus, it normal tissue as well as the neoplastic cells and tissues. It is is unfortunate that few oncologists recommend to their this lack of speciﬁcity in the majority of current therapies patients that they seek treatment from the family dentist that contributes to the wide range of oral complications. before chemotherapy commences. It is important to determine the cytotoxic, immunosup- During cancer chemotherapy, dental treatment should pressive and myelosuppressive nature of a chemotherapeu- be undertaken only on an emergency basis. Such treatment tic regime. A cytotoxic drug will induce mucositis, whereas may include periodontal cleaning, if the patient’s hygiene an immunosuppressive drug will allow microorganisms to has been neglected and he or she has active periodontal ﬂourish, putting the patient at high risk for periodontal disease. Therefore, such emergency treatment involves any

194 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Point of Care

Figure 1: Secondary bacterial and fungal Figure 2: Candida albicans infection caused Figure 3: Herpes simplex virus on the dorsum infections caused by chemotherapy- by the xerostomic and immunosuppresvie of the tongue and C. albicans on the induced mucositis. effects of chemotherapy agents. commisure of the lips caused by the immunosuppressive effects of chemotherapy.

dental treatment required to remove a source or potential 6. A nonﬂavoured, nonalcohol 0.12% chlorhexidine rinse source of infection. The practice guidelines listed below are should be prescribed for use 4 times daily and up to appropriate and safe for any general practice dentist treat- every 2 hours in the event of oral mucositis. Because ing a patient who is undergoing cancer therapy. As for any there are no clinical practice guidelines for the treatment situation, the dentist’s judgement should be based on his of chemotherapy-induced mucositis, chlorhexidine is or her own comfort zone. used at our cancer centre to treat this condition. 1. Dental treatment should be undertaken only after 7. Petroleum products should be avoided in the treatment consultation with the patient’s oncologist or a dental of dry, cracked lips; instead, lanolin should be oncologist (if there is one in your area), to coordinate recommended. C the dental treatment with the patient’s optimal hemato- logical status. • White blood cell count must be greater than Dr. Deborah Saunders is head of the dental oncology × 9 program at the Northeastern Ontario Regional Cancer 1.0 10 /L. Centre in Sudbury, Ontario. E-mail: dsaunders@ •Platelet count must be greater than 40 × 109/L and hrsrh.on.ca. the international normalized ratio must be normal. Dr. Saunders’ session at the ODA meeting, titled “Dental care for the •Antibiotic prophylaxis is required when the absolute cancer patient,” will be presented on Friday, May 6. neutrophil count is less than 2.0 × 109/L. •Patients with indwelling catheters (also called central Further Reading venous catheters or Hickman lines) require prophy- Massler CF Jr. Preventing and treating the oral complications of cancer lactic antibiotic coverage. therapy. Gen Dent 2000; 48(6):652–5. National Institutes of Health consensus development conference 2. The optimal time to perform dental treatment is just statement: oral complications of cancer therapies: diagnosis, prevention before a cycle of chemotherapy begins, to maximize the and treatment. J Am Dent Assoc 1989; 119(1):179–83. Ord RA, Blanchaert RH Jr, editors. Oral cancer: the dentist’s role in time before the patient’s condition reaches a nadir. diagnosis, management, rehabilitation and prevention. Quintessence 3. At any time, symptomatic teeth with pulpal involve- Publishing Co.; 2000. ment can be opened, debrided and closed with a U.S. Department of Health and Human Services. Oral complications of cancer therapy: what the oncology team can do. NIH Publication temporary restoration. No. 99-4360, Bethesda, MD; June 2002. Available from: URL: http:// 4. Decay can be excavated and sedative ﬁllings placed www.nohic.nidcr.nih.gov/campaign/onc_fact.htm. anytime during chemotherapy treatment. 5. Generally, extractions are contraindicated except in extreme emergencies (i.e., when an infected tooth may be the source of systemic infection).

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 195 Point of Care

Question 3 What are the choices of antibiotics for the treatment of acute odontogenic infections?

Background The complexity of the oral and dental Box 1 Antibiotic choices and dosages for dental flora has prevented clear elucidation of practitioners treating acute odontogenic infections specific causative agents in most forms of Antimicrobial drug Adult dosage Pediatric dosage odontogenic infections. Anaerobic bacte- Penicillin V 600 mg 4 times a day 30–50 mg/kg per day ria, which are part of the normal oral and in 4 divided doses dental flora, represent at least 350 Amoxicillin 500 mg 3 times a day 20–50 mg/kg per day morphological and biochemically distinct in 3 divided doses bacterial groups.1 Amoxicillin–clavulanate 500/125 mg 3 times a day 40 /10 mg/kg per day Most odontogenic infections result in 3 divided doses initially from the formation of dental Metronidazole 500 mg 3 times a day 15–30 mg/kg per day plaque and continue to develop in areas of in 3 divided doses tissue damage or trauma. Dental caries, periodontal disease, pericoronitis and Clindamycin 150–300 mg 4 times a day 10–30 mg/kg per day in 3 divided doses postsurgical wounds are common factors in odontogenic infections. Once patho- Ciprofloxacin 250–750 mg twice a day 40 mg/kg per day in 2 divided doses genic bacteria become established, they can cause a wide variety of local and disseminated complications. The most common infections infection is not responding to treatment, especially if there include dentoalveolar infections, gingival infections, and are any airway or neurological concerns. periodontitis. These can be categorized as localized infections (such as acute periodontal abscesses), spreading infec- Choice of Antibiotics tions (such as early cellulitis and infections with deep space The gold standard first-choice antibiotic has historically involvement) and life-threatening infections (such as been penicillin for patients not allergic to this drug. necrotizing fasciitis and Ludwig’s angina).2 Phenoxymethyl-penicillin, or penicillin V, can be used to Odontogenic infections are generally caused by mixed treat the vast majority of odontogenic infections. It is more aerobic and anaerobic polymicrobial bacteria from the resistant to gastric acids than its predecessor, penicillin G, same families of oral microorganisms (obligate anaerobes and it is very well tolerated orally. However, resistant bacte- and gram-positive aerobes). The microorganisms recovered rial species, particularly those that elaborate β-lactamase, from infections generally reflect the host’s indigenous oral have made the treatment of odontogenic infections more flora. Therefore the choice of antibiotic to treat odontogenic complex and difficult. Amoxicillin has a spectrum similar infections must be made according to the polymicrobial to penicillin, and its effectiveness against Haemophilus nature of such infections and local resistance patterns. influenzae can be useful. Amoxicillin can also be effective In all instances of odontogenic infections it is essential against bacterial species that produce β-lactamase if that the airway be assessed and secured if necessary, as the combined with clavulanic acid. Diarrhea may be one major initial life-saving manoeuvre. If there is an abscess to be side effect of the amoxicillin–clavulanate combination. drained or necrotic tissue requiring removal or debridement, Cephalosporins offer no major advantages over the peni- this must also be done.2,3 Attention can then turn to antibi- cillins and are much more expensive. otic choices. One common mistake is the tendency to underdose the antibiotic, which is assumed to be one of the Although penicillin is still a good first choice today, its causes of antibiotic treatment failures.4 Practitioners must spectrum of activity may need to be augmented. One be aware of the appropriate pediatric and adult dosages of possibility is metronidazole, a bacteriostatic agent that is antibiotics that are useful in odontogenic infections4 highly active against most anaerobes but which has poor (Box 1). Moreover, the course of the infection must be coverage of aerobic species. Metronidazole should never be monitored continuously both clinically and by following used on its own to treat an acute odontogenic infection. the results of culture and sensitivity testing. Widespread The use of metronidazole may not be entirely benign, and resistance of pathogens is another important cause of side effects may occur; for example, metronidazole may antibiotic treatment failures. General practitioners must be cause an Antabuse-type reaction if combined with alcohol, prepared for early referral of such cases to a specialist if the and peripheral neuropathies have been reported.

196 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association Point of Care

Erythromycin and tetracycline have limited application effective against gram-positive organisms and may be used in dentistry. Erythromycin is a bactericidal antibiotic with together with clindamycin. C a poor performance record in odontogenic infections.

There are serious compliance issues because of the intense Dr. George Sándor is an associate professor and nausea and vomiting that this drug can cause. When given director, graduate program in oral and maxillofacial surgery and anesthesia, University of Toronto, and is the intravenously, erythromycin tends to be extremely irritat- coordinator of oral and maxillofacial surgery at The ing to the veins. The usefulness of tetracycline has been Hospital for Sick Children and Bloorview MacMillan Children’s Centre, Toronto, Ontario, and docent in diminished by widespread resistance. oral and maxillofacial surgery, University of Oulu, Oulu, Finland. Clindamycin is the drug of choice for patients with a E-mail: [email protected]. history of penicillin allergy. Clindamycin has the advantage Dr. Sándor’s sessions at the ODA meeting, titled “Keeping general practitioners out of trouble when performing dento-alveolar surgery” of reliable coverage against gram-positive aerobic and and “The ever changing face of odontogenic infections,” will be anaerobic bacteria, with the possibility of attaining high presented on Friday, May 6. intra-bony levels with both intraoral and intravenous administration. The biggest disadvantage of clindamycin References is its association with pseudomembranous colitis. The 1. Sandor GK, Low DE, Judd PL, Davidson RJ. Antimicrobial treatment 2 groups at greatest risk appear to be elderly patients and options in the management of odontogenic infections. J Can Dent Assoc 1998; 64(7):508–14. patients who have recently had long-term hospital stays and 2. Fenton CC, Kertesz T, Baker G, Sandor GK. Necrotizing fasciitis are therefore at risk for nosocomial (hospital-acquired) of the face: a rare but dangerous complication of dental infection. infections. The incidence of clindamycin resistance also J Can Dent Assoc 2004; 70(9):611–5. 3. Judd PL, Sandor GK. Management of odontogenic orofacial infection seems to be increasing. in the young child. Ont Dent 1997; 74(8):39–43, 45. Ciprofloxacin may be one other antibiotic to consider. 4. Barron RP, Freilich MM, Sandor GKB. Extraction timing in paediatric Like the other fluoroquinolones, this unique fluoroquinolone odontogenic infections. Ont Dent 2001; 78(8):15–8. 5. Drlica K, Zhao X. DNA gyrase, topoisomerase IV, and the antibiotic has potent gram-negative activity inhibiting 4-quinolones. Microbiol Mol Biol Rev 1997; 61(3):377–92. DNA gyrase and topoisomerase IV.5 Ciprofloxacin is also

Question 4 I use oral sedatives in my office for children and anxious patients. Should I use pulse oximetry?

Like all drugs, sedatives produce a range of effects depending on the machine settings. This means that changes depending on patient factors. In most patients, mild in the amount of oxygen in the blood will be seen on the anxiolysis or light sedation results, but at the other end of oximeter as soon as the value is calculated. the spectrum (in rare cases) a near catatonic state can occur. When a patient loses consciousness to the point that he Sedatives can cause a patient to become unresponsive, or she is unable to maintain the airway, breathing stops. which can lead to hypoventilation or an inability to main- The level of carbon dioxide in the blood rises, creating the tain the airway. Luckily, standard benzodiazepines, alcohols urge to breathe that one normally feels when holding one’s and hypnotics have a wide therapeutic margin and are breath. As minutes tick by, oxygen dissociates from heme generally safe. So safe, in fact, that current Royal College molecules in the red blood cells and is used by the body. of Dental Surgeons of Ontario guidelines do not require At first, the amount of oxygen in the blood drops slowly pulse oximetry or other mechanical monitors when these (Fig. 2), but as hemoglobin releases oxygen, oxygen’s affin- drugs are given as a single agent by mouth. However, if a ity for the heme molecule decreases and it is released ever practitioner chooses a mechanical monitor during single- more quickly. To the clinician, this is important because the agent sedation, a pulse oximeter is an excellent first choice. drop in a patient’s oxygen saturation from 100% to 90% is What Does a Pulse Oximeter Do? relatively slow (usually minutes), but the drop from about Pulse oximeters measure the level of oxygen in the blood. 85% to 10% is very rapid (usually seconds). At the point Oximetry is generally accurate, non-invasive and sensitive to where this acceleration begins, the patient will appear blue changes in hypoventilation. The oximeter, which is attached (cyanotic) and the problem becomes quickly apparent. If to the patient’s finger using a small clip, shines a light oxygen saturation remains low for more than 4–6 minutes, through the nail bed and measures the ratio of oxygenated to death will result. The bottom line is that oxygen saturation deoxygenated hemoglobin (Fig. 1). This measurement is below 85%, in a sedated patient, must be treated immedi- calculated continuously and averaged over 5–60 seconds, ately to prevent dire consequences.

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 197 Point of Care

Figure 2: The oxygen dissociation curve Figure 3: If a patient has an oxygen showing steep drop of 85% on the vertical saturation of 37% (critically low), ventilate axis. using a bag-valve mask and 100% oxygen.

Figure 1: Oxygen saturation monitor with ﬁnger clip (the patient is breathing room air and oxygen saturation is 98%).

Practical Use of an Oximeter •Run office emergency drills to practise dealing with The good news is that the body has a certain store of some of the situations listed above. oxygen, so the drop in oxygen can be measured and the •Ensure that the protocols you use and the drugs you give process reversed before the results become permanent. If a are in accordance with the provincial guidelines. patient is on an oximeter and oxygen saturation begins A pulse oximeter is an inexpensive, easy-to-use piece of to fall, basic steps can usually reverse the problem equipment to monitor patients accurately during any level (assuming it is related to excessive sedation). of sedation. Using it can increase the margin of safety with 1. If the patient is conscious, tell him or her to take some sedated patients and provide an extra measure of comfort to deep breaths. the staff providing care. C 2. If the patient is conscious, give supplemental oxygen with a mask. Dr. Ian Furst is an oral and maxillofacial surgeon with the Coronation Dental Specialty Group and staff 3. If the patient is unconscious, try to rouse him or her, surgeon at Cambridge Memorial Hospital, Cambridge, then open the airway. Ontario. He is president of the Ontario Dental Society of Anaesthesiology. E-mail: [email protected]. 4. If the airway is patent, use a bag-valve mask (BVM) with Dr. Furst’s sessions at the ODA meeting, titled “Anesthesia and anesthet- supplemental oxygen. ics in a general dental practice,” will be presented on Thursday, May 5. 5. If the patient is unconscious but breathing, “assist” the breaths with the BVM until oxygen saturation is Further Reading 96% or more; if the patient is not breathing, give Fearnley SJ. Pulse oximetry. Update in Anaesthesia 1995; Issue 5. Available 1 breath every 5 seconds until that saturation level is from: URL: www.nda.ox.ac.uk/wfsa/html/u05/u05_003.htm. reached (Fig. 3). Guidelines: use of sedation and general anaesthesia in dental practice. Toronto: Royal College of Dental Surgeons of Ontario; January 2005. 6. Consider a reversal agent (ﬂumazenil for benzodi- Available from: URL: www.rcdso.org/pdf/guidelines/Guidelines_ azepines or naloxone for narcotics) to wake the patient. sedation_01_05.pdf. Like all pieces of equipment, the pulse oximeter can give Hata T, Nickel EJ, Hindman B, Morgan D. Procedural sedation resource center: guidelines, education, and testing for procedural sedation and inaccurate readings. The most common reasons for a false analgesia. Pulse oximetry. Iowa City: Virtual Hospital, University of low value are movement, cold ﬁngers (causing inadequate Iowa. Available from: URL: www.vh.org/adult/provider/anesthesia/ peripheral circulation for accurate measurements) and nail ProceduralSedation/PulseOximetry.html. Hill E, Stoneham MD. Practical applications of pulse oximetry. Update polish. If your office conducts sedation, consider a pulse in Anaesthesia 2000; Issue 11. Available from: URL: www.nda.ox.ac.uk/ oximeter and take the following steps: wfsa/html/u11/u1104_01.htm. • Carefully read the manual to learn over how long a The use of pulse oximetry during conscious sedation. Council on Scientific Affairs, American Medical Association. JAMA 1993; period the values are averaged, how to maintain the 270(12):1463–8. equipment and how long the battery will last without Web site on pulse oximetry. Available from: URL: www.pulseox.info/ power. index.htm. •Ensure that support equipment (supplemental oxygen) is readily available, familiar to all staff and well maintained.

198 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association !LWAYS3TRONG !LWAYS"EAUTIFUL

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Ú6IDENT Clinical Showcase

Endoscopically Assisted Caldwell-Luc Procedure for Removal of a Foreign Body from the Maxillary Sinus Joseph Friedlich, DDS, FRCD(C), Dip ABOMS Brian N. Rittenberg, BA, DDS, MSc, FRCD(C)

Traditionally, foreign bodies displaced into the maxillary that the endoscope would allow for direct visualization of sinus are retrieved either through the entrance wound (such the surgical bur and would facilitate controlled removal. as an extraction site) or through a secondary site. The The patient was given antibiotics and topical and systemic Caldwell-Luc approach was the gold standard for access to decongestants and was discharged. After approximately the maxillary sinus for treatment of various problems, 3 weeks of healing, the oroantral fistula had closed, and an including retrieval of foreign bodies, until the development appointment was scheduled for retrieval of the foreign of functional endoscopic sinus surgery (FESS). Both tech- body. niques have limitations and potential complications. This With the patient under general anesthesia, standard case presentation demonstrates the use of a modified surgical technique was used to create a small osteotomy in Caldwell-Luc approach for retrieval of a foreign body from the lateral antral wall superior to the root apices of the the maxillary sinus in a case where retrieval would not have premolar teeth. The position of the infraorbital nerve was been possible with the FESS technique because of the large identified, and the nerve was protected. The size of the size of the foreign body. The technique employed in this opening was restricted but sufficient to allow passage of a case takes advantage of lessons learned from minimally 4.0-mm endoscope (Karl Storz Endoscopy America invasive surgery and FESS. Incorporated, Culver City, Calif.) and a probe. The aperture of the ostium was approximately 1.25 cm in diam- Case History eter. The antrum was thoroughly examined through the A 54-year-old man was seen for an emergency consulta- endoscope (Fig. 4). The surgical bur was easily identified; it tion after removal of teeth 26 and 27. The patient’s history was embedded in the medial–superior recess (Fig. 5), as indicated that the high-speed surgical bur used for removal had been predicted by the radiographic assessment. A surgi- of the teeth had become dislodged somewhere within the cal grasper was inserted, and the bur was gently removed patient’s oral cavity. The patient had well controlled hyper- (Figs. 6 and 7). Associated inflammatory tissue was tension and bipolar disorder. debrided. The wound was irrigated copiously and closed Clinical examination identified active epistaxis and primarily. The patient was maintained on a course of post- bleeding from a patent oroantral fistula. The findings on operative antibiotics and decongestants for 10 days follow- neurological examination were unremarkable. The patient ing surgery. had no visual disturbance, and he was hemodynamically stable. Outcome The patient’s immediate and long-term recovery was Patient Management uneventful. There was minimal surgical edema. The integrity Primary treatment included local measures to achieve of the maxillary division of the trigeminal nerve was hemostasis and an attempt to locate the dislodged bur. The preserved; the patient had no complaints and testing showed bur could not be visualized clinically at that time, and the no signs of nerve injury. There were no postoperative wound was closed primarily to achieve hemostasis and close antrum-related complaints; the wounds healed completely, the oroantral fistula. Panoramic and plain film radiography and there was no residual oroantral fistula. indicated that the surgical bur was within the maxillary sinus (Fig. 1). The patient was admitted to the oral and Lessons to be Learned maxillofacial surgery service for further investigations, Special care must be taken to ensure that adjacent hard including computed tomography. This imaging confirmed and soft tissues are protected at all times from iatrogenic that the surgical bur lay within the sphenoidal recess of the injury. This case demonstrates the potential for a surgical maxillary antrum (Figs. 2 and 3). instrument to become embedded in contiguous structures. The surgical plan was to encourage closure of the In this case, a surgical bur lodged just millimetres from the oroantral fistula and then to retrieve the foreign body by an orbital contents within the ethmoidal recess of the maxil- endoscopically assisted Caldwell-Luc procedure. It was felt lary antrum. It is the authors’ opinion that the surgical bur

200 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association

Clinical Showcase

Figure 1: Preoperative panoramic Figure 2: Computed tomography (sagittal Figure 3: Computed tomography (axial radiograph. The foreign body, a surgical bur, view) demonstrates the surgical bur in the view) demonstrates the surgical bur in the appears to be lodged within the left superior aspect of the left maxillary sinus most medial and posterior part of the left maxillary sinus (black arrows). (black arrow). maxillary sinus (black arrow).

Figure 4: A 4.0-mm endoscope is passed Figure 5: Endoscopic view of the surgical Figure 6: Endoscopic view of the surgical through a modiﬁed Caldwell-Luc opening bur lodged within the left maxillary sinus. bur being removed from the left maxillary into the left maxillary sinus. sinus with a micro rongeur.

Dr. Friedlich is active staff, department of surgery, William Osler Health Centre, Ontario, associate in dentistry, University of Toronto, Toronto, Ontario, and in private practice, oral and maxillofacial surgery, Toronto and Brampton, Ontario.

Dr. Rittenberg is attending staff, department of oral and maxillofacial surgery, Mount Sinai Hospital, Toronto, Ontario, and in private practice, oral and maxillofacial surgery, Scarborough and Richmond Hill, Ontario.

Figure 7: Surgical bur after its removal from Correspondence to: Dr. J. Friedlich, 55 Avenue Rd., Suite 2100, the left maxillary sinus. Toronto, ON M5P 3E5. E-mail: [email protected]. used for removal of 2 of the patient’s teeth was not suited to the standard dental high-speed handpiece. Therefore, Further Reading care must be taken to ensure compatibility between the Buus DR, Tse DT, Farris BK. Ophthalmic complications of sinus surgery. surgical bur and the handpiece. Ophthalmology 1990; 97(5):612–9. A minimally invasive approach to retrieval of a foreign Gonty AA. Diagnosis and management of sinus disease. In: Peterson LJ, editor. Principles of oral and maxillofacial surgery. Volume I. New York: body from the maxillary antrum, as in this case, has numer- J.B. Lippincott Company; 1992. p. 245–9. ous short-term and long-term beneﬁts. In the immediate Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, and others. perioperative period the reduced exposure of the lateral Laparoscopic versus open appendectomy: outcomes comparison based maxilla required to facilitate this approach decreased on a large administrative database. Ann Surg 2004; 239(1):43–52. swelling, pain and bleeding. Over the long term, the result- Messerklinger W. Endoscopy of the nose. Urban and Schwarzenberg; 1978. ing bony defect of the lateral antral wall will be smaller than Murray JP. Complications after treatment of chronic maxillary sinus with other methods, and there will be less expression of disease with Caldwell-Luc procedure. Laryngoscope 1983; 93(3):282–4. antral inﬂammation in the overlying soft tissues. Perhaps Schon R, Gellrich NC, Schmelzeisen R. Frontiers in maxillofacial most important, this approach clearly decreases the inher- endoscopic surgery. Atlas Oral Maxillofac Surg Clin North Am 2003; 11(2):209–38. ent risk of damage to adjacent vital structures, particularly Venkatachalam VP, Jain A. Comparative evaluation of functional when retrieving a large, sharp foreign body from the maxil- endoscopic sinus surgery and conventional surgery in the management lary antrum. C of chronic sinusitis. J Indian Med Assoc 2002; 100(2):78–9, 82–3.

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 201 The Canadian Dentists’ Investment Program FindFind outout whatwhat you’reyou’re missingmissing

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Don’t miss out on a good thing. Call today to have a Personal Investment Advisor from Professional Guide Line Inc. — A CDSPI Affiliate assigned to you and discuss your personalized strategy for investing.† 1-877-293-9455, extension 5023

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05-58 01/05 CDSPI Reports

the Program’s Office Overhead You may also wish to spell out in a ARE YOU Expense (OOE) Insurance plan — document how your practice should which covers certain office-related be operated in your absence. For READY TO costs in order to keep your practice example, it could include the name of going when a disability prevents you a colleague who would be willing to BECOME from practising. It’s important to treat your patients until a locum is DISABLED? consider obtaining this coverage even found, and who would be authorized if you share office expenses with a to pay expenses on your behalf. Once By Susan Roberts partner, since the terms of your drafted, consider discussing your professional agreement could legally disability contingency plan with your our chances are like the flip bind you to pay for your share of over- family and staff. head costs — even during a disability. of a coin: As surprising as this Know What to Expect When may sound, actuarial statistics To ensure you’re properly protected Y Filing a Disability Insurance reveal the disturbing reality that by your disability insurance coverages, dentists stand about a 50-50 chance* speak to your personal insurance advi- Claim of becoming disabled for an extended sor at Professional Guide Line Inc. for Here is an overview of the initial period at some point during their a no-cost review. steps involved should you need to file careers. a claim under your Insurance Program Given the relatively high probabil- Establish an Emergency Fund LTD and/or OOE coverage: ity of experiencing a disabling illness Before disability insurance claim First, you’ll need to contact or injury, it’s prudent for all dentists payments begin, you must first satisfy CDSPI’s Claim Support Centre — to prepare for the prospect. In doing an elimination period. During this which serves as a liaison between so, consider the following suggestions. period — beginning with the onset of claimants and the insurer (the insurer a disability — benefits are not is the sole adjudicator of your claim). Ensure Your Disability payable. Depending on the elimina- The Claim Support Centre represen- Insurance Fully Protects You tion period you chose when you tative will take some preliminary The amount of disability insurance purchased your Program LTD cover- information about your claim, inform you’re eligible to purchase depends age, it could be as long as 120 days the insurer about your intent to file a on your income. That’s why it’s crucial before payments begin. Therefore, claim, and then send you a Claim Kit to carefully review your coverage each consider establishing an emergency that includes forms you’ll need to year. If your income significantly fund that would sufficiently cover complete for the insurer. increases and you don’t alter your your living expenses until your bene- The Claim Kit will include a form coverage to reflect that change, you fits start coming in. that will need to be completed by your could suffer needless financial hard- When deciding upon how much to physician, as well as forms pertaining to ships in the event of a disability. put aside in your emergency fund, your finances to determine your benefit Additionally, the Canadian Dentists’ bear in mind that a disability could amount. You’ll also need to submit Insurance Program’s Long Term introduce new expenses into your supporting documents with these Disability (LTD) Insurance plan budget — such as the cost of expen- financial forms, which may include: offers options that can enhance your sive medication. complete copies of your personal tax disability insurance protection. For return and Notice of Assessment docu- example, the Future Insurance Grant Power of Attorney ments for your 2 most recent taxation Guarantee (FIG) Option allows you If a disability left you incapaci- years, copies of financial statements, to increase your coverage at specific tated, who would be authorized to partnership agreements, corporate tax points in your life without having to make decisions about your personal information and financial agreements submit medical information. Call to financial affairs and how your practice with management companies and learn more about FIG and other would operate in your absence? You locums. In the case of an OOE claim, options to enhance your coverage. can prepare for this contingency by you will also be required to submit a If you’re responsible for paying all granting power of attorney to some- breakdown of your office expenses in or a portion of your practice costs, one you trust. Contact your lawyer for the 3-month period prior to when your you should also consider obtaining advice. disability commenced.

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 203 CDSPI Reports

(During the claim process, you’ll common to dentists are preventable, The Canadian Dentists’ Insurance Program’s also be in contact with the insurer’s but many others are. That’s why Long Term Disability and Office Overhead claims consultant, who may request CDSPI’s Claim Support Centre Expense Insurance plans are underwritten by The Manufacturers Life Insurance Company additional financial and medical created an informative booklet called (Manulife Financial). information.) Long Term Disability and You — *Source: Commissioner’s IDA Morbidity If you become disabled, you will Reducing the Risk. It contains informa- Table, Society of Actuaries. need to supply many different types of tion specific to dentists about ways **Restrictions may apply to advisory services financial documents to the insurer to lessen the likelihood of suffering a disability. To download a free copy, in certain jurisdictions. Residents of Quebec (within 90 days of the date your disabil- and PEI, please call CDSPI at 1-800-561- click on “Loss Prevention” at www. ity commenced) at a time when you 9401, extension 5000, for insurance plan C may not find it easy to assemble these cdspi.com/claims. information. papers. Since a disability could leave you incapacitated, consider whether Information someone acting on your behalf could Susan Roberts is the service provided by supervisor for the Canadian Canadian Dental easily procure these documents — and Dentists’ Insurance Program. Service Plans Inc. perhaps create a filing system where they could be easily found. For no-cost insurance planning advice,** Takes Steps to Reduce Your speak to your personal insurance advisor at Professional Guide Line Inc. — A CDSPI Chances of Becoming Disabled Affiliate. Dial 1-877-293-9455 (toll-free) or Not all types of disabilities 416-296-9455, extension 5002.

Caution to readers

Dental offices have contacted the Canadian Dental Association (CDA) expressing their dissatisfaction with a dental supply company named Canada Wide Dental Supplies. A sales representative for this company repeatedly telephones dental offices to solicit business, despite explicit requests to stop calling. Several offices describe the calls as “harassing” and are frustrated with the actions of this sales representative. CDA reminds readers to exercise caution by not disclosing credit card details to companies with whom they are unfamiliar. Take Action Offices can advise such harassing callers to place them on a “do not call” list. Legitimate dental supply companies should respect such a request and discontinue contact by telephone. The Canadian Marketing Association offers its Do Not Contact service free of charge (www.cmaconsumersense.org/marketing_lists.cfm). This service removes your name and telephone number from telemarketing call lists and helps reduce the number of marketing offers received by mail, telephone and fax. Bell Canada offers privacy services on most of its business or residential lines for a monthly fee (www3.bell.ca/ecare/PrsCSrvMgAc_Phone.page). These services include a Call Screening option, which can block up to 12 incoming telephone numbers. A Call Privacy option forces callers from “private” or “unknown” numbers to enter their phone number or a 10-digit number before your office phone will ring. Bell Canada also suggests compiling a list of the harassing phone calls, noting the date, time and phone number of the calls. Bell will then register and distribute this information to participating phone service providers across the country. Stay Informed CDA ﬁrst notiﬁed its members about Canada Wide Dental Supplies in a CDAlert distributed by e-mail on January 27, 2005. A complete archive of these electronic bulletins can be found on the members’ side of the CDA Web site (www.cda-adc.ca/english/members/cda_members/member_news/cdalert/default.asp). If you would like to receive future CDAlerts, contact a CDA membership services representative at 1-800-267-6354 or e-mail [email protected].

204 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association New Products The New Products section provides readers with brief descriptions of recent innovations in dentistry. Publication of this information, which is condensed from news releases provided by companies, does not imply endorsement by JCDA or the Canadian Dental Association. If you would like material to appear in New Products, send all news releases and photographs to Rachel Galipeau, coordinator, publications, at [email protected]. English- and French-language material will be given priority.

ITL Dental introduces VibraShield, a needle-capping protector. VibraShield is a simple and economical solution to recapping needles. Its large size provides for a more than adequate shield when recapping the needle and also acts as a stand for the syringe when not in use. VibraShield ﬁts most disposable dental needles. One VibraShield is used daily then discarded. The VibraShield comes in a convenient dispenser box containing 30 shields. • ITL Dental, 800-277-0073, www.itldental.com •

Sunstar Butler has announced the availability of an easy-to-use 0.5 cc syringe for dispensing PerioGlas Synthetic Bone Graft Material, a bioactive bone grafting particulate. PerioGlas is safe and biocompatible and bonds to both bone and soft tissue. PerioGlas is indicated for a variety of osseous defects, including ridge augmentation, sinus elevation, extraction sites, cystectomies and apicoectomies, and periodontal and peri-implant defects. • Sunstar Butler, 800-265-8353, www.sunstaramericas.com •

MCC offers the System 9 Series for clinicians wanting full rear delivery and support. MCC System 9 cabinets provide convenient and accessible storage and work surfaces for materials, instruments and supplies. All MCC cabinets feature built-in conveniences such as counter waste drops, glove/towel/cup dispensers, doctor and assistant sinks at optimal heights, and ample room for additional appliances. Computer integration can also be accommodated through a CPU storage area and keyboard access from doctor or assistant side. • MCC, 905-832-8311, www.mccdental.com •

Tenax Implant Inc. introduces an implant with a 7-mm intraosseous length. The inclusion of the 10X-XSW implant to Tenax’s offerings increases the implant system’s versatility while maintaining the company’s vision of the fewest steps, the fewest parts and the shortest healing period of any implant system to date. Existing prosthetic components can be used with the short implant. • Tenax Implant Inc., 888-265-1010, www.tenaximplant.com •

Journal of the Canadian Dental Association March 2005, Vol. 71, No. 3 205

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No trafficjamsand and indoorrecreation available minutes term industrialbase.Allkindsofoutdoor gram, inagreat town withasolidlong- H W BRITISH COLUMBIA -Kitimat: We P r per year, on4daysperweek. Owneris available upon request. Gross $700,000+ ment. Professional practicevaluation Ex patients andstaff, patientflow. highnew for sale.Prime location with great M indowntownopportunity Halifax. elocating outofprovince. Contact: eter, tel.(902)497-6700orcheckour quired. Please contact:Bob, fax(250) ygienist-supported recallygienist-supported andperiopro- ell-established generalpracticeforsale. odern well-established dentalpractice cellent leaseholdsandhigh-techequip- b sitewww.scotiadental.com. ac 05 o.7,N.3Journal oftheCanadianDental Association March 2005, Vol. 71,No. 3 Ex ceptional D1423 D1634 D1537 Ex- For D1636 (306) 922-9240. SK S6V6Z1;tel.(306)764-8145orfax E facilitate quicksuccessfultransition. D minutes awayfrom cottagecountry. and outdooramenitiesincluding30 with low costofliving,reasonable indoor 170 days/year. Situated inPrince Albert Gr UNITED STATES: 05733; tel.(802)247-3473. Ha staff andpatients.Please contact:Susan general practice.Long-term,dedicated dentist interested inowning anactive excellent forany financialopportunity E as oneofthetop2towns inNew best… Yankee magazinepickedBrandon practice forsale.Small-town lifeatits VERMONT, US-Brandon: Av of theseoutstanding opportunities. y All withnofinancialinvestment from equity intoyour practiceforretirement. ever thoughtpossiblewhilebuilding earningmorethis opportunity thanyou Learn more abouthow you cancapture ful practicemodelwitha30-year history. this growing, progressive, highlysuccess- o dentists whohave interest inaffiliated cases. We are currently identifying ratory, inmost enablingsamedayservice ofadedicatedon-sitedental labo- service MDI implants.Eachpracticeenjoys the and anichemarket, providing Sendax dentures, extractions,relines, repairs vidual dentist,focusonfullandpartial general practices,eachowned by anindi- practices inover halftheU.S. These tooverservices 110affiliated dental care! ACI provides practicemanagement do best...delivering high-qualitypatient more. You’re free tofocusonwhatyou marketing, payroll, humanresources and “headache” areas ofbusinessoperations, affiliate. ACI managesthetraditional practices fordentistswhochooseto v practice withnopersonalfinancialin- that allows dentiststoown adental (ACI) offersauniquebusinessmodel Affordableopportunities! Care Inc. estment. ACI develops generaldentistry ou! Iurgeyou tocallustodayfordetails wnership ofapracticemodeledafter nquiries to:Box 2194,Prince Albert, ngland. Closetoskiingandlakes.An entist motivated tosell,staffpoised ailable locations include:Minneapolis, ossing justunder$900,000working y den, 5 Carver St.,den, 5Carver Brandon, VT P ractice ownership Den D1688 D1627 tal attention: Business Manager. P professional qualitycare andservice. to detailandbecommittedproviding must possessteamspirit,payattention family-oriented practice.Applicants full-time associaterequired tojoina ALBERTA -Edmonton: to (403)271-9180. w nology andtechniqueswithan excellent, dental officeemploying the latest tech- This isaprogressive, well-established buy-in isavailable totherightcandidate. south Calgary. forfuture Opportunity re ALBERTA -Calgary: www.albertadentalimplants.com Kim. Feel free tovisitour Web site sume to(780)349-2626,attention: talimplants.com orfaxyour CV orre- please reply toe-mailkim@albertaden ofourdynamic team, become apart ofEdmonton. Ifnorth you wouldliketo and outdoorpursuits.Only 45minutes r ov your whileperfecting implant dentistry and learnabouttheexciting fieldof cosmetic andimplantdentistry. Join us with anoutstandingteamspecializingin modern surgicalandteachingfacility graduateswelcomed forasuccessful, new tion foranimplantinternship. Recent or dividual committedtocontinuingeduca- ship. We are seekingacompassionatein- ALBERTA - Westlock: [email protected]. ext. 2234,fax(252)527-7384ore-mail Alan Wallace at(800)313-3863, F T Ha Wa and Medford, Oregon; Spokane, R P Yo W M R elaxed atmosphere offersmanyrewards or more information,pleasecall opeka, Kansasand Tallahassee, Florida. hoenix and Tucson, Arizona; Chico lease faxresume to(780)414-6045, edding andFresno, California;Eugene ell-trained team. Please faxyour resume ochester andDuluth, Minnesota; quired forgeneraldentalpracticein erall dentalskills.Rural lifestylewitha ilwaukee, LaCrosse and Wausau, isconsin; Cleveland, Ohio; Utica, New r A P rt shington; Traverse City, Michigan; k, Las Vegas andReno, Nevada; ford, Connecticut; Wichita and V OSITIONS AILABLE F ull-time associate I mplant intern- Pa r t-time/ D1658 D1692 D1678 D1681 J established family practiceiscurrently ALBERTA -Cold Lake: (780) 849-6332. tel. (780)849-4477orfaxresume to contact: Jose Antony, Office Manager, graduates orexperienceddentist. Please ries. Excellent fornew opportunity W associate required forabusypractice. ALBERTA -Slave Lake: (780) 875-4222. lent staff, excellent patients.CallCraig, dentist.Excel-(6,000 patients)tonew fer manyofthecurrent patientbase patientsamonth. new Willing totrans- busy 2-dentistpractice.Averaging 80 position available Feb. 1,2005,invery ALBERTA -Lloydminster: tel. (780)477-6649. drherchen.com, fax(780)989-9649, in awell-established office.E-maildrh@ Ex needed forbusy, 4-5day/week position. ALBERTA -Edmonton: sitydentalcare.net, tel.(403)262-1581. Sp high-traffic locationbesideaStarbucks. quired, fulltime,forofficeintrendy ALBERTA -Calgary: [email protected]. 3773, fax:(403)647-3772,e-mail the Town ofMilk River, tel.(403)647- this exciting opportunity, pleasecontact Montana.northern For informationon and for clientelefrom southernAlberta are inhighdemand Dental services art. ranging from smallscaletostateofthe Large spacecanaccommodatepractices mediate dentalpracticeoccupation. available forleaseandprepared forim- River. Modern, renovated facilityis quired toestablishpracticeinMilk ALBERTA -Milk River: e-mail [email protected]. patients/month. Fax (403)259-2622 or existing practicewith30-40new w F for dynamic,experiencedfamilydentist. ciate, June 1,2005. Excellent opportunity ALBERTA -Northwest Calgary: unlo h aainDna soito March 2005, Vol. 71,No. 3 ournal of theCanadianDental Association ull-time positionwith2evenings per eek and every secondSaturday.eek andevery Large ell-established officewithsixoperato- ecial opportunity. E-mailinfo@univer cellent opportunity withgreatcellent opportunity staff Associate re- D O F Associate entist re- Associate ur well- ull-time Asso- D1632 D1652 D1644 D1635 D1621 D1613 (780) 594-5965. (780) 594-5984orfaxyour resume to information, contact:Kelly Avery, tel. this beautifullakesidecity. For further ton. You canenjoy aqualitylifestylein cated just 3 health, pleasegive usacall! We are lo- ted toproviding exceptional dental and satisfyingcareer withateamcommit- office. If you are lookingforarewarding busy, progressive, computerized family ina ing allaspectsofgeneraldentistry intraoral cameras. You willenjoy provid- completewith perio-hygiene department practice. We have a successfulaccelerated ofthisoutstanding to buyallorpart fortherightindividual is anopportunity o skills toassumeexistingpatientsasthe dentist withexcellent communication looking foracompassionate,motivated friendly teamofprofessionals. We are looking foranassociatetojoinour eral practice.Emphasis onoralsurgery busygen- needed immediatelyforavery thusiastic andhard-working associate ALBERTA -High Prairie: wner gearsdown forretirement. There hours northeast ofEdmon- hours northeast Caring, en- D1581 re ideal location.If interested pleasefax O odontal treatment anddentalimplants. No in downtown Vancouver andthe lished, progressive periodontalpractice to associateorpurchase awell-estab- O BRITISH COLUMBIA - Vancouver: Ne applicantswelcome. Contact: part-time O and buy-infortherightindividual. oriented practice.New graduateswelcome getic staff. Relaxed atmosphere. Family- and assumefullpatientload. Young, ener- tice topursuenon-dentalinterests. Step in quired isleavingprac- asfull-timepartner ALBERTA -Rural: (780) 523-4434. r experienced practitioner. Locumsona from Edmonton. Suits graduateor new be andenjoy theoutdoors.Only 4hours and implants.Be asbusyyou wantto egular basiswelcome. Fax resume to sume to(604)913-1610. nly 2hoursfrom Edmonton. Full or ur office is almost brand new andinan ur officeisalmostbrandnew pportunity for a certified periodontist foracertified pportunity il, tel.(780)484-5868. rt h Shore. We emphasize qualityperi- H elp! Associatere- 209 D1679 D1487 D1555 D1598 Classified Ads BRITISH COLUMBIA - Dawson BRITISH COLUMBIA - Vernon: Full- www.cityofrevelstoke.com; www.skirev Creek: Locum wanted. Help! Full-time time associate position available in busy, elstoke.com. For further details contact: locum required for maternity leave from well-established family practice with ex- Dick Russell, tel. (250) 837-3359 (res.) May 1 to Sept. 1, 2005. Booking 2 cellent long-term staff. Full range of den- or e-mail [email protected]. D1663 months ahead so expect a running start! tistry provided in a vibrant, rapidly grow- Five-operatory practice with 3,000 + ing community. Practice in an amazing BRITISH COLUMBIA - Kelowna: patient base. Set your own schedule. multi-season recreation area with world- Outstanding opportunity for a warm, Lots of potential for developing all your class skiing, boating, hiking, biking and caring associate to join an established skills. Possibility of associateship. New many other opportunities. Experienced practice. Long-term staff and exceptional graduates welcome! Call (250)782-4440 applicants preferred as large patient load patients. Recent major renovations. New or fax resume to (250)784-0133, e-mail available. Eventual buy-in agreement for Adec equipment. Six operatories. Oppor- tunity to buy into the practice. Reply to: information to [email protected]. D1680 the right individual. Please call (250) Dental Associate, PO Box 694, Kelowna, 545-1141 (evgs.). D1657 BC V1Y 7P4. D1628 BRITISH COLUMBIA - Castlegar: BRITISH COLUMBIA - Revelstoke: BRITISH COLUMBIA - Grand Associate required for a busy general Full-time associate required to take over Forks: Associate with desire to purchase practice. Castlegar is a wonderful caring full book from outgoing colleague. We half of my busy general practice required community. We enjoy all the seasons are looking for an enthusiastic, friendly for 4 days per week. Position starting have to offer. Just go outside your back dentist with the skills and motivation to Jan. 1, 2005. Please contact: Dr. Tracy door or travel less than 1 hour to all provide a high quality of patient care. Tambosso, tel. (250) 442-2731. D1631 activities. We have a community college, Custom-built office designed by THE of sports and pool complex and the regional Texas, full range of support staff includ- BRITISH COLUMBIA - Williams airport. New graduates welcome. Make ing visiting orthodontist and two full- Lake: Full-time associate opportunity a 1-year commitment to get some time hygienists. Our town is situated in a available for July 2005. Established asso- experience and pay off some debt. If pristine alpine setting with superb recre- ciate position with excellent earnings this is the place for you, owner would ational opportunities. This position track record going back 25 years. Large like to arrange for a future buy-in could provide an excellent career oppor- family practice with well-organized hy- or purchase of the practice. E-mail tunity for the right individual. Informa- giene department and computerized office [email protected]. D1686 tive Web sites: www.thedesign.com; support. Williams Lake is a small city

Tenure Track Faculty Position in Community Dentistry/Public Health GENERAL DENTIST College of Dentistry University of Saskatchewan Grenfell Regional Health Services invites applications for the position of Classified Ads The College of Dentistry invites applications from qualified individuals for a faculty permanent general dentist on a full-time basis for northern Newfoundland position in community dentistry/public health. The College of Dentistry is implementing and southern Labrador, effective April 1, 2005. This is a challenging and an active program of curriculum renewal, faculty renewal, research intensification, and interesting area where dental services are provided from regional bases in community outreach. The successful candidate will be an integral part of this process. Newfoundland and travelling clinics on the south Labrador coast. The Responsibilities will include teaching and coordination of the undergraduate academic travelling requirement is approximately 1/3 of the total working time. program in community oral health in all its aspects. A significant part of this position will be devoted to the development of outreach programs that will include provision of oral Salary for this position is on an 11 point government scale of $75,433- health care but will include the development of a total community awareness initiative $94,916. Initial placement on this scale will be dependent on years of that will provide students with an in depth understanding of the community that each experience. An isolation bonus payment ranging from $5,000-$10,000 will practitioner will ultimately serve. This outreach engagement will also include international programs that have been part of the college for over 25 years. There will be ample be payable upon the completion of 1 full year of service. Currently, a scope within this appointment to engage in and initiate active research programs within retention incentive of $10,000 annually, payable bi-weekly, is also in effect. the college and the interdisciplinary health sciences. Participation in the Masters of Public Health graduate program now under development at the university is encouraged. Fringe benefits include 6 weeks paid leave in a 12 month term. Assistance The candidate should have significant and successful experience in community health or with relocation and continuing education costs are available. oral health programs and initiatives and bring to the college an enthusiasm for furthering Accommodations are available at a reasonable rate. and enhancing the role and profile of the college in the community. The candidate should have an advanced degree in dental public health or equivalent at the Masters or Applicants must be eligible for registration with the Newfoundland and PhD level. Rank and salary will be commensurate with experience and qualifications. Labrador Dental Board. Preference will be given to applicants who are The university is committed to employment equity. Members of designated groups agreeable to working for a minimum 24 month term. Experience in oral (women, Aboriginal people, people with disabilities and visible minorities) are surgery is desirable. Experience in general dentistry is essential. encouraged to self-identify on their applications. All qualified candidates are encouraged to apply; however, Canadians and permanent residents will be given priority. Further Successful applicant will be required to submit a Certificate of Conduct. information about our college and its programs is available at www.usask.ca/dentistry. Interested individuals are requested to submit resumes, along with names A letter of application, accompanied by a curriculum vitae, professional credentials, a and addresses of referees, stating competition number, 05.03, to: statement of teaching and research interests, and the names of three referees should be sent to: Scott Smith Dr. James E. Stakiw Manager, Human Resources College of Dentistry University of Saskatchewan Grenfell Regional Health Services 105 Wiggins Road, Saskatoon, Saskatchewan S7N 5E4 St. Anthony, NL A0K 4S0 Tel (306) 966-5122 • Fax (306) 966-5132 Canada E-mail [email protected] Tel. (709) 454-0347 Applications with complete documentation will be accepted until April 30, 2005 or until a Fax (709) 454-3301 suitable candidate is found. E-mail [email protected] D1671 D1664

210 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association J fax (204)256-8381. T the principal.Please contact:Dr. Ron wouldcomplement perio ororalsurgery surroundings. Aspecialinterest inpedo, relaxed incomfortable, quality dentistry right individualtopractise high- and there isgreat potentialforthe to abrandnew, facility state-of-the-art family practice. We have recently moved join ourprogressive, well-established motivated, quality-mindeddentistto a fantasticopportunity! We are seekinga looking foranassociateposition,here is MANITOBA - Winnipeg: [email protected]. vidual. Tel. (250)342-0776, e-mail Pr built officeatathrivingresort town. established familypracticeinanewly ultimately leadingtopartnership. Well- summer. Full-time associaterequired, V in thewinteratPanorama Mountain on theLake: BRITISH COLUMBIA -Invermere (604) 792-0021(bus.). BC V2P 1P2;tel.(604)795-9818(res.), 102-45625 Hodgins Ave., Chilliwack, ship. Reply to:Dr. Michael Thomas, the area. There ispotentialforpartner- associate hasbusypracticeandisleaving east of Vancouver, mildclimate.Present ing skiing,boating,hiking,etc.,100km Area offersyear-round recreation includ- education/excellence inpatientcare. to dentistcommittedcontinuing F BRITISH COLUMBIA -Chilliwack: [email protected]. please call(250)374-4544ore-mail the rightcandidate.Interested applicants staff.wonderful Buy-in anoptionfor practice. anda Wide rangeofdentistry Associate required forabusygeneral BRITISH COLUMBIA -Kamloops: shaw.ca, fax(250)398-8633. 398-9085 (evgs.),e-mailvitoratos@ 7161 (days),(250)398-2615or Dr P town livingandmakeagoodincome. toenjoyThis isanopportunity small skiing, golfing,hiking,etc.,allcloseby. great familytown withmountainbiking, in theinteriorofBritish Columbia.It isa unlo h aainDna soito March 2005, Vol. 71,No. 3 ournal of theCanadianDental Association ull-time associatepositionavailable ough, tel.(204) 253-1834(evgs.)or lease callDr. AllistairMenzies or illage andenjoy thelakein omising opportunity forrightindi- omising opportunity . Perry Vitoratos collect,(250)398- Lifestyle inparadise!Ski If you are you If D1620 D1561 D1553 D1596 D1690 addresses ofthreereferees to: of researchpublications, and thenames,addresses,internet submit aletterofapplicationwithCurriculumVitae, uptothree reprints Review ofapplicationswillbegininJanuary, 2005. Applicants should the world. graduates tomakesignificantcontributionsourregion, Canada,and learning opportunities.We inspireourstudents,faculty, staff, and with diverse,challengingacademicprogramsand career-oriented world. We provideauniqueinteractiveandcollaborativeenvironment high-achieving, motivated,andengagedstudents from aroundthe Dalhousie, partofthevibrantHalifaxcommunitysince 1818,attracts presented byourbroadrangeofeducationalandresearch activities. recognized foroutstandingacademicqualityandthe opportunities Dalhousie UniversityisoneofCanada'sleadinguniversitieswidely disability, raciallyvisiblepersons,andwomen. encourages applicationsfromqualified Aboriginal people,personswith an EmploymentEquity, Affirmative Action employer. The University and permanentresidentswillbegivenpriority. DalhousieUniversityis All qualifiedcandidatesareencouragedtoapply;however, Canadians Private practiceprivilegesforpatientcarewillbenegotiable. The successfulapplicantmustbeeligibleforlicensureinNovaScotia. program arealsoinvitedtoapply. Individuals currentlyenrolledinanaccreditedgraduate,endodontic and experiences. administration. Salaryandrankwillbecommensuratewithqualifications demonstrated experienceinresearch,undergraduateteaching,and degree.Itisexpectedthatthesuccessfulapplicantwillhave master’s Applicants shouldhavegraduateeducationinendodonticsanda available. other Divisions,Departments,andFaculties.Start-upfundsmaybe The successfulcandidatewillhaveanopportunitytocollaboratewith to candidateswithanestablishedteachingand/orresearchrecord. of aplanforgraduateendodonticprogram.Preferencewillbegiven The successfulcandidatewillalsoberesponsibleforthedevelopment depending onthesuccessfulapplicant’s credentialsandexperience. research, continuingeducationandassociatedadministrativeduties, Responsibilities willincludeundergraduateteaching,collaborative position ifgranted. term positionmaybefullycreditedtothetimeframeoftenuretrack Department ofDentalClinicalSciences. The timeassociatedwiththe to tenuretrackfacultyposition,intheDivisionofEndodontics seeking applicationsfora2-yearfull-timelimitedterm,possiblyleading The FacultyofDentistry, DalhousieUniversity, Halifax,NovaScotia,is Dr. HelenRyding,Chair, SearchCommittees Faculty ofDentistry, DalhousieUniversity Halifax, NSB3H3J5 Sciences Department ofClinical Division ofEndodontics Faculty Position 211

D1687 Classified Ads MANITOBA - The Pas: Looking to be (905) 791-0644 indicating which days cost sharing options available. French more busy or for a change? Come work available. D1693 speaking an asset. Call Jocelyne, for us in a busy general practice clinic (613) 748-8266 D1668 where you can be as busy or relaxed as ONTARIO/QUEBEC: Looking for you want. We pay a high guaranteed bilingual associate for 5 mature and busy ONTARIO - Amherstburg/Windsor commission on top of your regular per- practices, south-west Quebec and/or Area: Full-time dentist wanted to associ- centage. Your accommodation and Cornwall, Hawkesbury, Ontario area. ate in our busy, well-established dental travel are reimbursed as well. Work full Full schedule (crown/bridge, endodon- practice in Amherstburg, Ontario. Our time or in terms with extended holi- tics, etc.). Stability, flexibility and respect office is just a 20-minute drive from days. Flexibility, high net income and assured. Possible sale. Seeing is worth be- Windsor. Presently retain over 6,000 best of all no hassles. Call for details, lieving. Luc, tel. (450) 370-7765. D1674 active charts and growing. Looking for a (204) 623-1494 or fax resume to (204) kind, active, professional and highly ONTARIO - Cambridge: Part-time 623-6162. D1647 motivated individual. Offering up to associate required for 2-3 days in a 9- 50% compensation. Excellent opportu- NORTHWEST TERRITORIES - In- year-old, fast-growing, family-oriented, nity for any associate willing to commit uvik: Replacement for 3 weeks. Looking multilingual general dental practice. themselves to long-term relationship for a dentist from Mar. 21 to Apr. 8, Please fax resume to (519) 622-3608, and future growth in this wonderful e-mail [email protected]. D1682 2005. Other dates also available. Sched- community. Tel. (519) 980-4073. D1639 ule already booked, excellent remunera- ONTARIO - Northwestern: Associate- tion, accommodations included. Come ONTARIO - West of Toronto: Full- ship available immediately. Full-time as- experience the far North. Please contact: time associate position in a well-estab- sociateship with option to purchase. Nancy or Lynda , tel. (867) 777-3008 or lished practice, replacing associate who Busy family practice located in North- e-mail [email protected]. is returning to school for graduate stud- western Ontario, conveniently located D1650 ies. Your schedule will be booked from on Trans-Canada Highway. Twenty- day 1 and you will have the opportunity NORTHWEST TERRITORIES - Yel- eight-year-old, well-established clinic, to be exposed to all aspects of dentistry lowknife: Associate needed to join an 2 full-time hygienists, 4 operatories. such as cosmetics, implants and much established, very busy, modern dental Excellent opportunity for someone who more as we have a team of specialists clinic (6 dentists) in a thriving commu- enjoys the outdoors and a low-stress working alongside of us! If you are a nity - the diamond capital of North enjoyable work situation with flexible team player and are looking for a posi- America. The clinic offers all modern hours and vacation time. Reply to: tive working environment, fax to equipment including intraoral cameras, CDA Classified Box # 2846. D1684 (905)846-5593. D1641 abrasion units, etc., with an excellent ONTARIO - Niagara Region: Full- and friendly support staff, providing ONTARIO - Brockville and Morris- time dental associate position available very high-quality dentistry, with the burg: Experienced associate required for for a family-oriented, well-established Classified Ads emphasis on quality rather than quan- 1 of 2 well-established, busy practices. practice. Please fax your resume to (905) tity. This is an excellent opportunity for Enjoy a small-town atmosphere and the 871-3977. D1689 anyone wishing to enjoy a wonderful scenic beauty of the 1000 Islands region lifestyle whilst practising dentistry at its ONTARIO - Lake Huron: We are with easy access to large city centres. best. Please send resume to: Administra- looking for a full-time associate to join Only 30 minutes to Kingston and tion, PO Box 1118, Yellowknife, NT our practice. If you are interested in 60 minutes to Ottawa. For more X1A 2N8; tel. (867) 873-6940, fax being fully scheduled, want to work with information contact: Dr. George (867) 873-6941. D1159 an experienced staff and think you Christodoulou, Altima Dental Canada, NUNAVUT - Iqaluit: Associate posi- might enjoy life in a beautiful resort tel. (416) 785-1828, ext. 201, e-mail tion(s) available for immediate start. Es- town, we have the position you are [email protected]. D1269 tablished clinic offers generous package looking for. Our modern office is fully QUEBEC - Abitibi: Rouyn-Noranda. and full appointment book to associates. equipped with 6 operatories, intraoral Our family practice offers you a unique All round clinical skills are your ticket to cameras and computers. We have opportunity to join our team for a re- a wide range of recreational activities! No recently replaced our charts, re-vamped placement during a maternity leave travel required and housing available in our hygiene program and routinely starting mid-April for a period of six Canada’s newest and fastest growing capi- attend continuing education courses. months. Very busy practice, booked over tal city. Please apply to: Administration, Buy-in option would be available for two months in advance, full-time posi- PO Box 1118, Yellowknife, NT X1A the right candidate. This would be an tion guaranteed thereafter. Excellent 2N8; or tel. (867)873-6940, fax (867) excellent investment opportunity for a work schedule; 4 days/week Monday to 873-6941. D1497 new graduate. Please call Michael Thursday, no weekends. Very nice area, Walden at (519) 396-2641. D1654 ONTARIO - Brampton: Part-time and with lakes and forests nearby for the na- full-time dental associates required for ONTARIO - Ottawa east: Associate- ture lover. For more information, please Brampton office. Please fax resume to ship full time. Very busy practice. Buy-in, contact Aline at (819) 762-1972. D1659

212 March 2005, Vol. 71, No. 3 Journal of the Canadian Dental Association J unlo h aainDna soito March 2005, Vol. 71,No. 3 ournal of theCanadianDental Association until asuitablecandidateisfound. Applications withcompletedocumentationwillbeaccepteduntil April 30,2005or referees shouldbesentto: tials, astatementofteachingandresearchinterests,thenamesthree Al programs isavailableat residents willbegivenpriority. Further information aboutourcollegeandits candidates areencouragedtoapply;however, Canadiansandpermanent minorities) areencouragedtoself-identifyontheirapplications. All qualified designated groups(women, Aboriginal people,peoplewithdisabilitiesandvisible qualifications. The universityiscommittedtoemploymentequity. Membersof institutions. Rankandsalarywillbecommensuratewithexperience candidate isexpectedtobecomeinvolvedwithprogramsandinitiativesinthese College ofMedicineareadjacenttotheDentistryandsuccessful private practiceprivilegesareavailable. The RoyalUniversityHospitaland TMD, anesthesia,implantology, pathologyandtraumamanagement.On-site program withsignificantexperienceindentoalveolarandorthognathicsurgery, candidate willbefromaCDA/ADA-approvedoral/maxillofacialsurgeryresidency advanced degreeisdesirable. The MDdegreewouldbeanasset. The ideal FRCD(C) orequivalentlevelandresearchexperience.Possessionofan applicant musthaverelevantpostgraduateandclinicalqualificationsatthe surgery, anongoingresearchcommitment,andcollegeadministration. The didactic andclinicalinstructionofundergraduatestudentsinoral/maxillofacial or whenasuitablecandidateisfound.Responsibilitiesanddutiesinclude tensification. This positionisakeypartofthatprocess.StartdateJuly1,2005 active programofcurriculumrenewal,facultyandresearchin- faculty positioninoral/maxillofacialsurgery. The collegeisimplementingan The CollegeofDentistryinvitesapplicationsfromqualifiedindividualsfora To etter ofapplication,accompaniedbya

place your CDA Classiﬁedadcontact: (800) 663-7336ext. 2127/2314 Renting your vacation property? 105 Wiggins Road,Saskatoon,SaskatchewanS7N5E4 E-mail [email protected] Advertisements arealso at noadditionalcharge (www.cda-adc.ca/jcda) Beverley Kirkpatrick or Te F Buying equipment? T l (306)966-5122•Fax966-5132 Selling apractice? ax (613)565-7488 Leasing anoffice? enure Track FacultyPositionin published online E-mail [email protected] www.usask.ca/dentistry University ofSaskatchewan University ofSaskatchewan Deborah Rodd Oral/Maxillofacial Surgery T College ofDentistry Dr. JamesE.Stakiw oll-free at College ofDentistry curriculum vitae . , professionalcreden- .

D1672 r candidates are encouraged toapply; however, Canadians andpermanent McGill University iscommittedtoequityinemployment. All qualified 2005 oruntilasuitablecandidateisfound. Applications withcompletedocumentationwillbeaccepteduntil April 15, names ofthreerefereesshouldbesentto: credentials, astatementofteachingandresearchinterests,the Al available at given priority. Furtherinformationaboutourcollegeanditsprogramsis aged toapply;however, Canadiansandpermanentresidentswillbe self-identify ontheirapplications. All qualifiedcandidatesareencour- people, peoplewithdisabilitiesandvisibleminorities)areencouragedto employment equity. Membersofdesignatedgroups(women, Aboriginal with experienceandqualifications. The universityiscommittedto initiatives intheseinstitutions.Rankandsalarywillbecommensurate successful candidateisexpectedtobecomeinvolvedwithprogramsand College ofMedicineareadjacenttotheDentistryand practice privilegesareavailable. The RoyalUniversityHospitaland general anestheticservicesarecurrentlyavailable.On-siteprivate undergraduate students,researchprogramsandadministration.Pediatric experience. Responsibilitieswillincludedidacticandclinicalinstructionof (FRCD(C) preferred),andthesuccessfulcandidatewillhaveresearch orPhDlevelwithrelevantclinicalqualifications dentistry attheMaster’s of thisprocess. Applicants willhavepostgraduatetraininginpediatric research intensification. The successfulcandidatewillbeanintegralpart menting anactiveprogramofcurriculumrenewal,facultyand a facultypositioninpediatricdentistry. The CollegeofDentistryisimple- The CollegeofDentistryinvitesapplicationsfromqualifiedindividualsfor r teaching interests, andthenames,postal e-mailaddresses ofthree A an outstandingclinical-trackcandidate. r equivalent degree andtheabilitytoconductindependentresearch ina The additionalrequirements forthetenure trackincludeaPhD or I administration. Aworking knowledge ofFrench willbeadvantageous. R and experience. willbecommensuratewitheducation prosthodontics. Rankandsalary andspecialtytrainingin undergraduate degree indentistry of AssistantorAssociateProfessor. Candidatesmusthave completedan tenure-track andclinical-trackpositionsinprosthodontics atthelevel The Faculty ofDentistry, McGill University, invitesapplicationsfor eferees, shouldbesenttothefollowing address by April 15,2005. esidents willbegiven priority. elevant field. AnAmbrose ClinicalProfessorship maybeawarded to ntramural private practicefacilitiesare available. pplications, includingacurriculumvitae,statementofresearch and esponsibilities willincludeundergraduateandgraduateteaching etter ofapplication,accompaniedbya 105 Wiggins Road,Saskatoon,SaskatchewanS7N5E4 www.usask.ca/dentistry F Te PROSTHODONTICS aculty ofDentistry, McGill University E-mail [email protected] 1650 CedarAvenue, Room A3.132 l (306)966-5122•Fax966-5132 M T E-mail [email protected] ontreal, QC,Canada H3G1A4 enure Track FacultyPositionin University ofSaskatchewan Chair, Search Committee University ofSaskatchewan F College ofDentistry Dr. JamesE.Stakiw ax (514)934-8352 Dr McGill University College ofDentistry Pediatric Dentistry . Jeffrey Myers . curriculum vitae , professional 213

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