April Is National Oral Health Month Bonding Agents and Resin

JCDAJournal of the Canadian Dental Association Vol. 69, No. 4 April 2003

Painting by Dr. Jim Messer

April Is National Oral Health Month Bonding Agents and Resin Cements Dentin Hypersensitivity: Diagnosis and Treatment Impact of Cyclosporin and Nifedipine on Gingival Overgrowth ISO 9002 and Dental Care

Canada’s Peer-Reviewed Dental Journal • www.cda-adc.ca/jcda • Winning smile

Your smile says it all. Skilled, professional dentistry delivered with pride. And we’re happy to be part of your success. As always, Ash Temple is moving forward, working in partnership with customers, anticipating needs, developing more effective products and services. Our constant concern is to find new ways of helping Canadian dental practitioners attain their professional and business goals. When you win we win. We’d like to tell you more about the Ash Temple companies; just call 1-800-268-6497. Or visit our web site at ashtemple.com

Advancing dental practices

Supplies ● Equipment ● Design ● Repairs Financing ● Transitions JCDAJournal of the Canadian Dental Association

CDA Executive Director George Weber Editor-In-Chief Mission statement Dr. John P. O’Keefe Senior Writer/Editor CDA is the authoritative national voice of dentistry, dedicated to the Harvey Chartrand representation and advancement of the profession, nationally and Assistant Editor internationally, and to the achievement of optimal oral health. Natalie Blais Coordinator, Translation & French Staff Writer Nathalie Upton Coordinator Publications/Editorial Assistant Rachel Galipeau Editorial consultants Manager, Design & Production Dr. Catalena Birek Dr. James L. Leake Barry Sabourin Graphic Designer Dr. Jeff Coil Dr. William H. Liebenberg Janet Cadeau-Simpson Dr. Pierre C. Desautels Associate Editors Dr. Kevin E. Lung Dr. Michael J. Casas Dr. Terry Donovan Dr. Debora C. Matthews Dr. Anne Charbonneau Dr. Robert Dorion Dr. Mary E. McNally Dr. Alan R. Milnes Dr. Sebastian Saba Dr. Robert V. Elia Dr. David S. Precious All statements of opinion and supposed fact Dr. Joel B. Epstein are published on the authority of the author Dr. Richard B. Price who submits them and do not necessarily Dr. Kenneth E. Glover express the views of the Canadian Dental Dr. N. Dorin Ruse Association. The editor reserves the right to Dr. Daniel Haas edit all copy submitted to the Journal. Publica- Dr. George K.B. Sàndor tion of an advertisement does not necessarily Dr. Robert J. Hawkins imply that the Canadian Dental Association agrees with or supports the claims therein. Dr. Claude Ibbott Dr. Benoit Soucy The Journal of the Canadian Dental Associa- Dr. Gordon W. Thompson tion is published in both official languages Dr. Aleksandra Jokovic — except scientific articles which are published in the language in which they are Dr. Asbjørn Jokstad Dr. Robert S. Turnbull received. Readers may request the Journal in the language of their choice. Dr. Richard Komorowski Dr. David W. Tyler The Journal of the Canadian Dental Dr. Ernest W. Lam Dr. Peter T. Williams Association is published 11 times per year (July-August combined) by the Canadian Dental Association at 1815 Alta Vista Drive, Ottawa, ON K1G 3Y6. Copyright 1982 by the Canadian Dental Association. Authorized as CDA Executive council Publications Mail Registration No. 40064661. Postage paid at Ottawa, Ont. Subscriptions President Dr. Jack Cottrell are for 11 issues, conforming with the calen- Dr. Tom Breneman Port Perry, Ontario dar year. All 2003 subscriptions are payable in Brandon, Manitoba advance in Canadian funds. In Canada — Dr. Gérald L. Dushkin $65.42 (+ GST); United States — $95; all President-Elect Montreal, Quebec other — $118. Notice of change of address should be received before the 10th of the Dr. Louis Dubé Dr. N. Craig Fedorowich month to become effective the following Sherbrooke, Quebec month. Member: American Association of Hamiota, Manitoba Dental Editors and Canadian Circulations Vice-President Audit Board • Call CDA for information and Dr. Wayne Halstrom assistance toll-free (Canada) at: 1-800-267-6354 Dr. Alfred Dean Vancouver, British Columbia • Outside Canada: (613) 523-1770 • CDA New Waterford, Nova Scotia Fax: (613) 523-7736 • CDA E-mail: reception@ Dr. Darryl R. Smith cda-adc.ca • Web site: www.cda-adc.ca Valleyview, Alberta ISSN 0709 8936 Printed in Canada Dr. Deborah Stymiest Fredericton, New Brunswick

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 199 NEW! Now available without Muscles aprescription Out Pain * New Super Strength MOTRINibuprofen IB Relieves Acute Pain • New! 400 mg offers the convenience of a one tablet dose. • Powerful relief from the pain of inflammation:1 Minor Musculoskeletal Pain • Dental Pain • Dysmenorrhea Tension Headache • Minor Backache • Rapid onset of relief demonstrated within 15 minutes.1†

Most common side effects include occasional nausea, epigastric pain and heartburn, incidence 3 to 9%. Should not be used by persons sensitive to ASA.

† Double-blind, randomized, placebo-controlled trial, p<0.05 (n=35). Maximum OTC dosing is 1200 mg/day. Super Strong Pain Relief.

? 1 888 6-MOTRIN www.motrin.ca *Trademark CONTENTS Journal of the Canadian Dental Association

D EPARTMENTS P ROFESSIONAL I SSUES

Experience of 2 Dental Clinics Registered to ISO 9002 . . . . . 215 ...... 203 Editorial Michael J. Casas, DDS, MSc David J. Kenny, BSc, DDS, PhD President’s Column ...... 205 Douglas H. Johnston, DDS, MSc

Letters ...... 206

Advertisers’ Index ...... 207 C LINICAL P RACTICE

News...... 208 Consensus-Based Recommendations for the Diagnosis and Management of Dentin Hypersensitivity ...... 221 ...... 212 Statements by the FDI Canadian Advisory Board on Dentin Hypersensitivity Clinical Abstracts ...... 243

Point of Care ...... 249 A PPLIED R ESEARCH

New Products ...... 256 Effect of Mode of Polymerization of Bonding Agent on Shear Bond Strength of Autocured Resin Composite Classiﬁed Ads ...... 257 Luting Cements ...... 229 Cecilia C.S. Dong, DMD, BSc (Dent), MSc (Prostho) Dorothy McComb, BDS, MScD, FRCD(C) James D. Anderson, BSc, DDS, MScD Laura E. Tam, DDS, MSc The Effect of Cyclosporine with and without Nifedipine on Gingival Overgrowth in Renal Transplant Patients ...... 236 Abdol Hamid Khoori, DDS All matters pertaining to the Journal should Behzad Einollahi, MD be directed to: Editor-in-chief, Journal of the Ghassem Ansari, PhD Canadian Dental Association, 1815 Alta Vista Mohammad Bagher Moozeh, MSD Drive, Ottawa, ON, K1G 3Y6. E-mail: [email protected]. • Toll-free: 1-800-267-6354 • • Tel.: (613) 523-1770 • • Fax: (613) 523-7736 •

All matters pertaining to classiﬁed advertising should be directed to: Ms. Beverley Kirk- 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: Ms. Marg Churchill c/o Keith Health Care Inc., 104-1599 Hurontario St., Mississauga, ON L5G 4S1 • Toll-free: 1-800-661-5004 • An independent review* has concluded that oscillating- • Tel.: (905) 278-6700 • rotating technology, pioneered by Oral-B, is the most • Fax: (905) 278-4850 • effective at reducing plaque and gingivitis. *For more information, and to read the published abstract, visit the Cochrane Collaboration website at Publication of an advertisement does not www.update-software.com/toothbrush. necessarily imply that the Canadian Dental Association agrees with or supports the claims therein. Please see our advertisement opposite the Editorial page.

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 201 Yo u r p ati e n ts wa n t to kn ow which power toothbrush works best. Now you can baseyourrecommendation on 40 years of research.

oscillating

An independent research group, The Cochrane Collaboration, recently completed the most comprehensive review of power toothbrush studies ever undertaken. It concluded: “Brushes that worked with rotation oscillation action removed more plaque and reduced gingivitis more effectively than manual brushes in the short and long-term… No other powered brush designs were consistently superior.”1 The Cochrane Review clearly confirms that the oscillating-rotating technology pioneered precisely by Oral-B is superior to any other form of brushing, including manual and “sonic.” For the full Cochrane Review, visit www.update-software.com/toothbrush. For more information or to order clinical data please call 1 800 268-5217 or visit www.oralb.com.

I have also recently heard dental growing body of evidence that oral associations such as CDA described, in health and general health are inti- HEALTH regulatory circles, as advocacy organi- mately linked. The U.S. Surgeon zations for dentists — the insinuation General has stated that a person PROMOTION being that dental regulatory authorities cannot be healthy without good oral have the monopoly on looking out for health. In keeping with that state- IS OUR the public interest and that associations ment, the World Health Organization have no real business in this domain. has stated that our responsibility is to BUSINESS This flies in the face of the words in promote general health through the CDA mission statement, which improved oral health. proclaim that the organization is preoc- We can promote health through cupied as much with achieving optimal strategies designed to impact on its oral health for all as it is with advanc- principal determinants: human biol- ing the dental profession. ogy, lifestyle, accessible and cost- If we allow our professional world effective health services, and the to be framed by both of these descrip- physical, political and socioeconomic tive phrases, we become in our own environment. Through these strate- minds, and in the eyes of the public gies, we help our fellow citizens take and society’s decision-makers, a control of their own health as much as narrowly focused self-interest group. possible. This does not reflect my experience of Modern health promotion is not our profession or my concept of its simply comprised of chairside future. For me, the interests of a education or poster-and-pamphlet Dr. John P. O’Keefe successful profession never diverge far, campaigns. It includes an intensely or for long, from the public interest. political set of activities where indi- As leaders of the oral health team, vidual professionals and their repre- inguists say that language is sentative organizations show leader- we are in a position to provide a range the garment of thought. By ship and take responsibility to of public services, from guidance on this, they mean that words advance the public good. We can all L preventing disease to providing frame how we think. Conversely, we do our bit to provide accessible, cost- sophisticated rehabilitative treat- can communicate specific meaning to effective oral health care. While dele- ments. We must take these responsi- others through carefully chosen gating certain activities, we have a bilities very seriously and never leave words. Two examples of what I major impact on lifestyle choices that gaps that could be filled by others. consider to be carefully chosen affect oral and general health. Further, National Oral Health Month, language relating to the Canadian the true professional is not afraid to with its theme Oral health — good for become politically involved at the dental sector cannot, in my opinion, life, gives us an opportunity to be accepted without qualification. local level to advance the public’s pause and ask how we can be health health. Recently, in dental hygiene publi- promoters in the broadest sense. Two cations, I have seen the assertion that Once we become health promoters elements require brief comment. to the core, we will realize that we hygienists are “specialists” in health CDA now celebrates “oral” rather promotion, while dentists tend to don’t really need an oral health than “dental” health month to reflect month. All our professional activities focus on the surgical aspects of oral the fact that our profession is not and many of our everyday private care. I interpret this use of language focused solely on teeth, but on the interactions promote health. So here’s to presume a rather narrow and whole orofacial complex. This change is to individual dentists and our associa- education-based definition of health in keeping with the modern broad defi- tions as health promoters! promotion. Equally, I believe that we nition of oral health passed by CDA’s mustn’t allow ourselves to be depicted Board of Governors in March 2001 as surgeons alone, as we enter the era (see page 218). John O’Keefe of the medical management of caries Secondly, the theme reflects the 1-800-267-6354, ext. 2297 and periodontal disease. profession’s preoccupation with the [email protected]

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 203 Not if it’s Colgate Total. * 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. It attaches triclosan (an antibacterial ingredient) to teeth for protection that lasts even after eating and drinking. That’s why only Colgate Total is clinically proven to help fight gingivitis, plaque, caries, calculus buildup and bad breath — no matter what’s next on the menu.

Brush twice a day for round the clock protection. Protection even after eating and drinking.

Colgate. The choice of today’s dentists and hygienists.†

†Colgate-Palmolive independent research study on file. *TM Reg’d Colgate-Palmolive Canada Inc. President’s Column

on the inside might be tiring of the gathering and collating input from all message just as the general public stakeholders, we will develop a strat- TAILORING starts to become aware of it! egy to deal with the issue, along with Persistent delivery of certain messaging that can be used by our COMMON messages reinforces the mission state- spokespersons to relay that informa- ment in which CDA pledges to tion to our various publics. MESSAGES provide optimal oral health care for In some situations, the relaying of TO GET Canadians. It also helps our corporate that information may entail a one- sponsors, by promoting those prod- time-only request for information. RESULTS ucts that have earned CDA’s Seal of But in many instances, our approach Recognition. is multifaceted. In the case of NIHB, National Oral Health Month we were concerned by the administra- delivers a uniform message through a tive burden the program created for consistently credible source — CDA. dentists, and by the subsequent dele- We must be prepared in a similar terious effect it had on the oral health manner for each issue coming down of Canada’s First Nations and Inuit the pike that affects dentistry. How do populations. we accomplish this? The same message must be deliv- The first task is to maintain a ered to many different groups. Both databank pertaining to these breaking to be heard and to be effective, the issues. We do this partly through message must be consistent, so there is media scans. CDA staff and MP no confusion, either in our concerns contact persons keep track of devel- or in the expected outcome. We must Dr. Tom Breneman deliver the message to the various oping issues, which are formally involved stakeholders, so that they can reviewed 4 times a year and updated fully appreciate our concerns and be as required at meetings of CDA’s prepared to act with us on them. We Executive Council. This process pril is National Oral Health must at all times be singing from the ensures that all our files are current. Month. For more than 30 years, same hymnbook for maximum effec- The next step is to ensure that we A this event has served as a tiveness and to improve our odds of have appropriate messaging, when wonderful opportunity for our profes- achieving success. required. The breadth and scope of sion to focus on our mantras of This does not just happen, but the issue determine the message we prevention. This message has been results from persistence and dedica- send out. consistent with different slogans and tion to developing a common approaches through 3 decades, allow- If it is a scientific issue, we contact message, building and maintaining ing us to reach out to the general the necessary dental researchers for relationships with media and dental public and reinforce the principle of their input and expertise and develop industry personnel, so that dentistry prevention. And of course this our message accordingly. These can have a credible voice for policy- outreach also encourages visits to experts often become spokespersons makers and the public. This takes dental offices. for CDA as well. ongoing time, energy and resources The broader the pickup and the If the issue has political overtones, on the part of CDA, all with the goal more we reinforce the common we may convene a forum with repre- of providing tangible and intangible message, the greater the impact. As sentatives from all constituencies benefits for our members, corporate CDA takes the lead in targeting this to debate, as we did with the sponsors and patients. messaging to government, the media Non-Insured Health Benefits (NIHB) and other groups, we must ensure that program, the oral hygiene personnel the same messaging is reinforced shortage and challenges facing acade- provincially and locally. Only then mic dentistry. In a country as large will the visibility and effectiveness of and diverse as Canada, the percep- our message be enhanced. Or as an tions of a problem and how to Tom Breneman, DMD advertising executive once told me, we deal with it can vary greatly. After [email protected]

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 205 Letters

Editor’s Comment Credit should be given to Dr. Roy products presented a health hazard, The Journal welcomes letters from Ellis for what was truly a great step due to the vaporization of mercury, readers about topics that are relevant forward. It mattered not how perfect and the use was contra-indicated with to the dental profession. The views was the preparation and impression better understanding of the dangers of expressed are those of the author and do taken for inlays; improper mixing of such practices. not necessarily reflect the opinions or the dental (lab) alloy for the inlay Development of so-called high- official policies of the Canadian Dental die could and would negate it all. copper amalgams significantly Association. Letters should ideally be no Dr. Ellis’ instructions on how to extended the use of amalgam for longer than 300 words. If what you construct a simple electroplating posterior restorations. The American want to say can’t fit into 300 words, machine meant that accurate dies — Dental Association specification for please consider writing a piece for our which would not contaminate the final dental amalgam before 1963 limited Debate section. inlay with mercury (from the polishing copper content to no more than 6%. procedure) — became possible, with Following the work of Innes and the use of copper-plating of the impres- Youdelis, alloys were developed with A Century of Service sions instead of amalgam. particles containing between 9% and I am sure that many dentists I think that his use of a toy train 30% copper, dispersed in a conven- enjoyed the series A Century of Service. transformer, a simple rectifier and tional amalgam alloy. The strength of I almost hesitate to make a couple of several lamp bulbs as resistors was very these dispersed alloy systems was slight corrections. typical of his clarity of thought. significantly improved, along with Mention of the high-copper amal- Congratulations on the series. the creep resistance. An unexpected gam as being developed in 1963 benefit was the increased resistance Dr. Wallace F. Walford brings back memories of its being Perth, Ontario to corrosion, due to the elimination used in our clinic at the Montreal or reduction of the gamma-2 tin- General Hospital (MGH) before the Response mercury phase, responsible for the Second World War. It was reputedly Dr. Walford is confusing high- creep of amalgam alloys, as well as the less affected by moisture than silver copper amalgams with the so-called low corrosion resistance. amalgam. Its use was discontinued copper amalgams, in use 30 or 40 The date for the introduction of when this was not found to be true years earlier than the high-copper alginate impression material as 1941 and when having a meal with acid amalgams which were developed, is based on the publication date for foods, like pickles, became an electri- based on the 1963 Canadian research the patent by Wilding (US Patent fying experience. Also, if one used a of Innes and Youdelis. These copper # 2,249,694, July 15, 1941). It is utensil such as a pewter spoon, it was amalgams were an amalgam of copper possible that Dr. Walford’s recollec- a memorable event. and mercury — typically 65% to 70% tion of use of a hydrocolloid impres- The date for alginate impression mercury and 35% to 30% copper, sion material before 1941 may well material was certainly earlier than supplied as pellets, which were heated relate to the use of an agar material, 1941. The first of this group — the in an iron spoon, until the mercury in which the material is heated to trade name of which I’ve forgotten — appeared in droplets on the surface. form a solution (sol) and is then was heated to a flexible state and then The mass was then triturated with a cooled to form a gel. In the case of used in a water-cooled tray. My first pestle and mortar. These materials agar materials, intermolecular forces memory of its use was by a Dr. Ira K. were recommended for restorations in or secondary bonds hold the resulting Lowry (1936) at the MGH clinic. On deciduous teeth, since they were less gel together and the sol-gel change is that occasion, somehow or other the affected by moisture; they were also strictly related to the temperature “exit” tube for the water got blocked used in the laboratory for construct- change. The alginate materials are also and all the students, Dr. Lowry and ing dies for inlays and crowns. hydrocolloids, but the change from a the poor patient were thoroughly These copper amalgams under- sol to a gel state occurs as a result of soaked when it burst. went considerable corrosion and the formation of primary chemical The alginate was used as a were thus not suitable for so-called bonds — hence the term irreversible powder/water mix in the army dental permanent restorative procedures. hydrocolloid. clinics from the start of the war — They were still in use in 1970s-era Dr. Derek W. Jones and not always for dental purposes. restorations in deciduous teeth. These Halifax, Nova Scotia

206 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Letters

What Next for Dental making choices for the people of Finch Avenue, which is just a glorified Education? Ontario, which properly should be walk-in clinic nowadays. made by the Government of Ontario. I read with interest and general Dr. Jocelyn Zuck Since the Toronto program has also good feeling the President’s Column Toronto, Ontario trained many of the oral and maxillofa- in the January 2003 JCDA. Congratu- lations on crafting such an insightful cial surgeons now practising in and constructive message! I agree with Western Canada, this matter must also and applaud the agenda being set and be of concern to the federal govern- must comment on how quickly the ment. It cannot be that our elected Canadian practitioner and education bodies are prepared to allow a small communities have developed a starter special interest group to dictate to agenda. them who the Government of Ontario Dr. Richard W. Valachovic, execu- is and is not prepared to treat. tive director of the American Dental As you so rightly say, CDA can and Education Association (ADEA), and I must be a vocal advocate for health A D VERTISERS’ care in Canada. It cannot and (I am were honoured to attend and partici- I NDEX pate in the Dental Academic Summit. sure) will not remain silent, while this We feel that ADEA has strengthened prestigious program is jettisoned. its partnership with our Canadian As the former head of the depart- 3M ESPE ...... 235 colleagues. ADEA values greatly the ment of oral and maxillofacial surgery Ash Temple Ltd...... 198 formal and informal relationships we at the U of T, I write this letter with have with our Canadian partners. great sadness. However, my feelings Care Credit ...... 220 We feel strongly that we have much pale into insignificance when compared to learn from each other’s successes to the feelings of the residents within CDA Membership ...... 248 and failures. the program. Their condition is CDA RSP ...... 254 Very best in this important work! urgent and it seems that only a direct CDSPI ...... 214, 241, 263 Dr. David Johnsen approach to government will succeed in helping them. Who better than President, ADEA, and dean of dentistry, Colgate-Palmolive CDA to undertake this task? University of Iowa Canada Inc...... 204 Iowa City, Iowa Dr. John M. Symington Johnson & Johnson Inc. . . . .219 Hospital Discharge is Bad for Etobicoke, Ontario Dentistry McNeil ...... 200, 262 When I was a student about I agree with the message you 50 years ago in Birmingham Oral-B convey (Editorial, February 2003 Laboratories . . . . .201, 202, 247 JCDA). There are wider issues to (England), the clinical years were consider. The base hospital for the spent working in the downtown Orthodent ...... 228 Toronto residency program in oral Birmingham Dental Hospital. Since Pfizer Canada Inc...... 264 and maxillofacial surgery is the we are being kicked out of the medical-run hospitals, why doesn’t the Toronto General Hospital (TGH), Philips Oral Healthcare . . . .242 part of the University Health profession establish its own hospitals? Network. As a teaching hospital, the I don’t think the federal or provincial Polaroid Canada ...... 211 TGH has an agreement with the governments would object and you Porsche Sports Cars ...... 227 University of Toronto to provide facil- might even be able to put the arm on ities for the teaching of undergradu- them for a financial contribution. The Procter & Gamble ...... 255 ates and residents. The summary oral surgeons have the biggest interest exclusion of the oral and maxillofacial in this. What does their society have Strathcona Pharmacy ...... 241 to say? I think this subject deserves surgery residency program by the Strong Dental Inc...... 218 hospital administration may very well some investigation. result in the closure of the only In Toronto, it may be possible to University of Montreal . . . . .234 program in this discipline in the take over part of a downgraded hospi- province of Ontario. Effectively, this tal, such as the Northwestern Hospital unelected group of administrators is on Keele Street or the Branson on

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 207 News New U.S. Infection Control Guidelines for Dentistry COVER ARTIST The U.S. Centers for Disease The cover art for the April JCDA is Control and Prevention (CDC) has a painting of a deHavilland Beaver CF- released Draft Recommended Infection JAT flying over northern terrain, signed Control Practices for Dentistry — by Dr. Jim Messer. The plane is head- 2003. These would be the first major ing towards Goose Bay, Labrador, over changes in dental-specific infection Lake Melville. The vast empty land- control guidance since 1993. scape and rich, endless hues in the sky According to the CDC’s Division of were common subjects in Dr. Messer’s Oral Health, the draft recommenda- paintings. The Beaver CF-JAT was well known tions are developed “for practitioners to residents on the Labrador coast in the 1960s, says the artist’s son Murdo responsible for monitoring and Messer. “I grew up hearing about it and seeing it in the many models that preventing infections and ensuring Dad created as static displays from which to paint. In 1970, this plane that occupational health and safety developed engine trouble in flight after take-off and made a forced landing guidelines are followed in dental near St. John Island on Lake Melville. Passengers were evacuated to the health care settings.” nearby shore, but the plane sank after it was pushed against the rocks by The new guidelines are more waves and the floats were punctured. It was a close call for those on board. comprehensive than previous ones, “This painting was the last one Dad completed before he died in 1995,” updating and expanding the science Murdo Messer relates. “The original now hangs in my mother’s living base. For example, CDC recommends room. To me, it captures many things. In it, I see the beauty of flight. The that the quality of water from dental way the plane is suspended in the sky is magical. The painting captures the units not exceed 500 colony-forming forbidding beauty and vast emptiness of the Labrador landscape. The units per milliliter. While CDC’s passenger in the window makes me think of Dad — a last farewell flight of recommendations don’t have the force imagination into a brightening sky of new horizons.” of law, they could be used by agencies Born in Wemyss Bay, Scotland, in 1940, Dr. Messer graduated with a with enforcement power, such as the Bachelor of Dental Surgery from Scotland’s Glasgow University Dental U.S. Department of Labor’s Occupa- School in 1964. Emigrating to Canada, he earned his Doctor of Dental tional Safety & Health Administration Surgery from Dalhousie University’s faculty of dentistry in Halifax in (OSHA) and state dental boards. 1982. Relocating to St. John’s, Dr. Messer was chief of dental services for The comment period ended on Grenfell Regional Health Services in Newfoundland and Labrador from C March 17 and the final guidelines are 1976 to 1994. expected to be ready in May or June. For more information, visit http:// engine (at http://medinformatics. Lung, and Blood Institute (NHLBI) www.cdc.gov/oralhealth/infection_ uthscsa.edu/EviDents) addresses all of the National Institutes of Health control/guidelines/comments.htm. C dental specialty areas, including has stopped the study early. The study, implants, periodontics, orthodontics, New Search Engine for which began in 1998, was scheduled endodontics, prosthodontics and oral to run until 2005. Evidence-Based Dentistry C surgery. The multi-centre Prevention of The launch of a unique search Recurrent Venous Thromboembolism engine for evidence-based dentistry Low-Dose Warfarin Prevents (PREVENT) trial found a 64% (EBD) was announced at a January Recurrence of Blood Clots conference sponsored by The Forsyth A U.S. study of long-term, low- reduction in episodes of DVT and Institute of Boston. dose warfarin to prevent the recur- pulmonary embolism in study partic- The search engine, called rence of the blood-clotting disorders ipants taking low doses of the warfarin EviDents, is a unique electronic deep vein thrombosis (DVT) and anticoagulant, compared to those resource that allows patients and clin- pulmonary embolism resulted in such taking a placebo. Furthermore, there icians to sort through vast amounts of a high degree of benefit to the was no evidence of significant risks, information to find the best oral patients, without significant adverse such as major hemorrhage or other health evidence available. The search effects, that the National Heart, potential side effects of warfarin.

208 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association News

“These results suggest that low- tobacco-induced oral malignancies Reduction of passive smoking is dose warfarin is a safe and effective and evidence-based approaches to important, not only for the preven- way to prevent future episodes of tobacco cessation. tion of many medical problems, but these potentially serious blood- For details, contact PTIDSociety@ also for the promotion of children’s clotting problems,” said NHLBI aol.com or visit the conference Web dental health, the authors conclude. C director Dr. Claude Lenfant. C site at http://umanitoba.ca/faculities/ dentistry/oral_biology/research/ FDA Proposes Medication Bar Two Amalgam Lawsuits conference/. C Codes Dismissed The Food and Drug Administr- Judges in New York and Georgia Passive Smoking Linked to ation (FDA) is proposing a require- recently dismissed lawsuits claiming Dental Caries ment for bar coding on all prescrip- that amalgam fillings had harmed Young children who are exposed to tion drugs, some over-the-counter plaintiffs. The American Dental second-hand smoke have a much drugs and vaccines. The adoption of Association (ADA) hopes these higher rate of tooth decay than chil- the regulation will improve patient verdicts will set precedents for similar dren who do not grow up around safety in hospital and other health care suits pending in California and smokers, according to a study settings by reducing medication Maryland. The New York suit was supported by the U.S. Agency for errors. The bar code would, at mini- brought against the ADA, New York Healthcare Research and Quality. The mum, contain the drug’s National State Dental Society and Fifth District study, entitled Environmental Tobacco Drug Code number, its strength and Dental Society. It alleged that the 3 Smoke and Risk of Caries, appears in its dosage form. More information associations deceived the public about the March 12 issue of JAMA (Journal could also be added to the bar code the health risks of amalgam, concealed of the American Medical Association) standards as information technology information about its environmental and can be accessed online at http:// progresses. impact, gagged dentists from inform- jama.ama-assn.org/issues/v289n10/ FDA estimates that the bar code ing patients about amalgam’s health abs/joc21865.html.) rule will result in a 50% increase in effects and hid an economic stake. A The study is the ﬁrst in the United the interception of medication errors New York State Supreme Court judge States to associate second-hand, or at the dispensing and administration ruled that the plaintiffs had failed to passive, smoking with tooth decay. stages. show a “cognizable cause of action.” Although the occurrence of dental For more information: www.fda. The Georgia suits brought charges cavities in children has declined gov/oc/initiatives/barcode-sadr/ against various vaccine manufacturers, dramatically in the U.S., little head- fs-barcode.html. C the ADA, Georgia Dental Association way has been made in reducing cavi- and Georgia Power Company, alleg- ties in children living in poverty, who DCF Celebrating Smiles Gala ing that a child suffered neurological generally have less access to dental The Dentistry Canada Fund effects from mercury poisoning. The care and appear to be more vulnerable (DCF) is holding a gala soirée — ADA was dismissed from the Georgia to dental decay. beginning at 6:30 p.m. on suit, but so far, not the Georgia Based on data from household Wednesday, May 7 — in the Ballroom Dental Association. C interviews and health examinations of of Toronto’s Fairmont Royal York about 4,000 children ages 4 to 11, the Hotel. The Celebrating Smiles Gala Preventing Tobacco-Induced study found that children had an will salute philanthropy within Diseases increased risk of tooth decay if they Canada’s charity for oral health and The Annual Scientiﬁc Meeting of had high levels of cotinine, a byprod- feature a gourmet meal, a silent the International Society for the uct of nicotine that is consistent with auction, awards presentations and live Prevention of Tobacco Induced second-hand smoke exposure. About entertainment. Diseases will be held September 29– 32% of the children with cotinine A highlight of the evening will be October 1 in Winnipeg. The meeting levels consistent with second-hand DCF’s first Philanthropy Awards will bring together practising medical smoke exposure had decayed surfaces ceremony, recognizing Outstanding and dental clinicians, basic and clini- in their baby teeth, compared with Philanthropist and honouring Out- cal scientists, social scientists, 18% of children with lower levels of standing Individual Service, from epidemiologists and others with cotinine. The higher risk of cavities in among dentistry professionals and the professional interests in tobacco- tobacco-exposed children persisted dental industry. related research. after controlling for other factors, “DCF’s inaugural gala is already Areas to be covered include such as poverty and frequency of ensured of being a great success, due periodontitis in tobacco smokers, dental visits. to the strong sponsorship support

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 209 News

received from industry and ticket New Dean of Dentistry at Vancouver died on November 26, 2002, at purchases by a variety of oral health Dalhousie age 69. stakeholders,” enthused DCF’s execu- Dr. Donald Moore, a founding member tive director Richard Munro. “DCF of the faculty of dentistry at the encourages donors and supporters to University of Western Ontario (UWO), attend and discover more about the passed away on March 1 after a increasing scope of worthy endeavours prolonged illness. He was 86. After grad- undertaken by your charity.” uating from the University of Toronto in Tickets are priced at $150 and 1943, Dr. Moore served with the may be purchased from DCF. For Canadian Dental Corps. He then more information about the Celebrating returned to graduate school and received Smiles Gala, contact DCF, 427 Gilmour a Diploma in Periodontics in 1947. Street, Ottawa, ON K2P 0R5; tel.: Dr. Moore practised in Toronto, Hamilton and London and taught part (613) 236-4763, ext. 2; fax: (613) 236- time at U of T. In 1967, he joined the 3935; e-mail: [email protected]; C Dr. David Precious newly established faculty of dentistry at Web site http://www.dcf-fdc.ca/. UWO as one of its first full-time U of T Class of 43 Reunion Dr. David Precious has been appointees. Dr. Moore played an important role in the design of the new facility. The University of Toronto’s dental named dean of dentistry at Dalhousie As professor and chair of the department faculty graduating Class of March University in Halifax, effective July 1. Dr. Precious has been a professor at of oral medicine from 1967 to 1972, he 4T3 will hold its 60th reunion on formulated and implemented much of May 8 at Toronto’s Metropolitan Dalhousie since 1973 and currently chairs the university’s department of the academic and clinical curricula. His Hotel. For more information, contact inﬂuence in the ﬁeld of normal and oral and maxillofacial sciences. He has Dr. Murray Hunt at (416) 221-3248 abnormal occlusion gained him interna- also served on Dalhousie’s Board of or at [email protected]. C tional stature and is underscored each Governors. Dr. Precious is a former year when the Donald S. Moore Award is president of the Nova Scotia Dental presented to a graduating senior student A PPOINTMENTS Association. He has an international at UWO. C reputation as a scholar, educator and MDA News practitioner. Dr. Precious is also an editorial consultant for JCDA. C

O BITUARIES Chevrette, Dr. Maurice: A 1966 graduate of the University of Montreal, Dr. Chevrette of Flowers Cove (Newfoundland) died in Trois-Rivières (Quebec) on January 24 at age 61. Mercier, Dr. Gérard R.: Dr. Mercier of Gatineau (Quebec) passed away on December 14, 2002, at age 73. He was a life member of CDA. Dr. Leon Stein Mitchell, Dr. Robert A.: A 1952 graduate Dr. Leon Stein of Winnipeg was of the University of Alberta, Dr. Mitchell elected president of the Manitoba of North Vancouver passed away on Dental Association in January. Dr. Stein November 30, 2002. He was 76. is a 1974 graduate of the University of Rivest, Dr. Roger (Andy): Dr. Rivest Manitoba’s faculty of dentistry. He has passed away on January 9 in St. practised general dentistry since gradu- Catharines, Ontario. He was 68. Dr. ating. A big challenge for MDA during Rivest graduated from the University of his term will be to address the shortage Toronto in 1956. of dentists, hygienists and assistants in Smith, Dr. Allan: A 1958 graduate of the Manitoba. C University of Alberta, Dr. Smith of

210 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Instant images so realistic, you may find yourself handling them with latex gloves.

Incredibly high-quality images are why so many top dentists are grabbing hold of the Polaroid Macro 5 camera with both hands. With clear, detailed images, you can instantly x1 show positive results to your patients. You can also communicate more effectively with labs and insurance companies. And because the Macro 5 camera is so easy to use, anyone in your office can be taking professional-looking photos in just five minutes. See x2 why the Macro 5 camera, and the way it can help build your business, are for real.

For more information call toll-free: 1-800-268-6970, Ext. 381, or visit our web-site at

www.polaroid.com. Available from: x3 Polaroid Macro 5 Statement by the Associations Between Oral, Cardiovascular and Cerebrovascular Health

Background: 2. These associations may not apply equally to all racial and There is a considerable body of published literature socio-economic groups. exploring associations between the prevalence and severity 3. These oral and systemic diseases share common risk of periodontal infections and cardiovascular diseases (espe- factors, such as poor diet, smoking, diabetes, and genetic cially myocardial infarction), cerebrovascular diseases (espe- predisposition. cially occlusive stroke) and birth complications (premature and underweight births). 4. There are biologically plausible mechanisms by which Research continues apace in many countries and the oral infections might contribute directly to the patho- dental and medical professions and the public show consid- genesis of some cardiac and cerebral vascular diseases. erable interest in the topic and its implications. The FDI is 5. The FDI supports more extensive, interventional, longi- aware of these implications and has asked the Science tudinal studies to explore the relationship further. Commission to keep a watching brief on developments. At 6. The primary prevention and effective treatment of peri- the time of writing, the FDI takes the following position: odontal, pulpal and periapical bacterial infections Present position: remain major goals of the dental profession. These 1. There is evidence for such associations, especially in should be pursued in the interests of the oral health of relation to heart diseases: however the literature is not our patients as well as for a likely beneﬁcial effect on consistent. general health and quality of life.

Adopted by the FDI General Assembly: 1 October 2002 - Vienna

Statement by the Action Against Illegal Dental Practice

1. One of the four FDI Mission Statements is: “To with the specific education, training and qualifications, promote optimal oral and general health for all peoples”. recognised in each country, can be entrusted with the 2. In the interest of the oral and general health of the popu- practice of dentistry. lation, dental authorities and associations should insist 4. The practice of dentistry by those not educationally and that the practice of dentistry should only be carried out legally qualified should be opposed. by those who are legally qualified to do so and after 5. The FDI recommends the competent authorities in each successful completion of appropriate dental education country: and training. •To develop and establish a legal framework for the 3. A prerequisite for achieving optimal oral health is for all entire area of the practice of dentistry people to have access to the best possible oral health care. •To control the quality of the education and training Therefore, the FDI recommends that appropriate for the practice of dentistry Governmental agencies of all countries legally regulate •To control the practice of dentistry within the estab- the practice of dentistry, based on the principles of lished legal framework self-regulation and competent authority. Only those •To identify and suppress illegal dental practice

Adopted by the FDI General Assembly: 1 October 2002 - Vienna

212 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Statement by the

The Use of Acupuncture in Dentistry

Deﬁnition and background: Recommendations: Acupuncture is one of the so-called “Complementary 1. Dentists should only attempt acupuncture on their and Alternative Medicine (CAM)” techniques used to treat patients after having attended appropriate courses and a variety of diseases and disorders. Up to one third of the having acquired the necessary skills. public in many countries have been shown to consult a 2. Acupuncture should only be employed after thorough CAM practitioner at least once a year. diagnosis of the patient’s condition and the employment Acupuncture originated in China more than 3000 years of accepted conventional therapies (e.g. infections must ago. Diseases are treated by inserting needles in different be appropriately diagnosed and treated as such). parts of the body - the acupuncture points. Ear acupunc- 3. Strict cross-infection procedures must be in place. Single ture, electro-acupuncture and transcutaneous nerve stimu- use needles must be used. lation are additional related techniques. 4. Detailed records must be kept of all indications, proce- In dentistry acupuncture is used particularly for analge- dures and outcomes when patients are treated. sia associated with dental procedures and for the manage- 5. Research into the use of acupuncture in dentistry is ment of chronic facial and myofascial pain syndromes, encouraged. This is likely to require multi-centre studies including those with a component of temporomandibular to be sufficiently powerful and should preferably be joint involvement. Acupuncture is one of the CAM conducted in association with a relevant national society approaches that literature suggests has possible beneﬁt in or an academic unit. dental pain management, although difficulties arise in the 6. Teaching and experience in acupuncture could be interpretation of efficacy studies because of problems with considered as an optional part of undergraduate, post- study design, sample sizes and the choice of placebo and graduate and continuing dental education. sham acupuncture points. Acupuncture is one of the CAM approaches regarded as having satisfactory training and regulatory procedures in a number of countries.

Adopted by the FDI General Assembly: 1 October 2002 - Vienna

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 213 The Canadian Dentists’ Investment Program Add another levelto your investments …with the CDA Seg Fund Investment Account

Registered investing can provide an excellent foundation to serve your future needs. But you may soon bump your head on the annual contribution ceiling. Consider an addition that can let your savings grow outside a registered plan: the CDA Seg Fund Investment Account.With it, you can: • build an additional retirement nest egg without any limits on your contributions or your foreign content • expand your savings for a child’s post- secondary education outside an RESP • save for big-ticket items, such as a vacation or a new car The CDA Seg Fund Investment Account offers greater potential for growth than a bank account.You gain access to the CDA investment funds, with their record of superior long-term fund performance, leading fund managers, low fees, and no-cost investment planning advice. So make your savings work for you on multiple levels… with the CDA Seg Fund Investment Account.

For more information about the CALL FOR EXPERT ADVICE Canadian Dentists' Investment Program call: Call the non-commissioned certified financial planners* at Canadian Dental Service Plans Inc. at Professional Guide Line Inc. — A CDSPI Affiliate for: 1-800-561-9401 or • Free advice on choosing investment plans to meet your goals (416) 296-9401, • A no-cost review of your overall portfolio (for CDA plan holders) extension 5020. Dial 1-877-293-9455 or (416) 296-9455, extension 5023. The Canadian Dentists' Investment Program is offered by the CDA and administered by CDSPI. * Restrictions may apply to advisory services in certain jurisdictions. 03-76 2/03 P ROFESSIONAL I SSUES

Experience of 2 Dental Clinics Registered to ISO 9002

• Michael J. Casas, DDS, MSc • • David J. Kenny, BSc, DDS, PhD • • Douglas H. Johnston, DDS, MSc •

Abstract

This paper describes the 3-year experience of managing 2 hospital-based dental clinics registered to ISO 9002:1994; it also examines the revision of previous quality management standards in 2 separate institutions to prepare for registration under the new ISO 9001:2000 standard. Daily equipment and process checks, combined with internal audits, were the backbone of the quality system at both locations. Corrective and protective actions had been underused, because of the partial duplication produced by 2 different institutionally mandated risk management and incident reporting systems. ISO 9002 registration provided both dental clinics with responsive quality systems, emphasizing patient satisfaction and providing measurable continuous quality improvement.

MeSH Key Words: dental service, hospital/standards; practice management, dental/standards; quality assurance, health/standards

he Hospital for Sick Children (HSC) and the hospital administration impose an extensive framework of Bloorview MacMillan Children’s Centre (BMCC) standards and regulations on hospital departments and T are teaching and research facilities affiliated with their health care professionals. Each regulatory body the University of Toronto, Toronto, Ontario. HSC is an requires that specific quality assurance measures be imple- acute care hospital. The dental clinic logs 15,000 patient mented to satisfy its legislative or regulatory standards. visits annually and provides a 24-hour dental emergency Hospital-based dental clinics must demonstrate compliance service. BMCC is a rehabilitation centre that provides with external standards through risk management or inci- inpatient and outpatient services for disabled children dent reporting, random compliance audits and periodic and youth. The BMCC dental clinic logs more than accreditation or departmental reviews. Managers who wish 5,000 patient visits annually. Both institutions are part of a to optimize patient satisfaction and safety will likely intro- Child Health Network that involves 20 central Ontario duce quality measures in addition to the measures that are hospitals. HSC and BMCC are the only hospitals with mandated. full-time facilities for dental treatment of children and are designated centres for the provincial Cleft Lip and Objectives for Registration under ISO 9002 Palate/Craniofacial Dental Program. The dental clinics Two objectives drove the decision to register the HSC share a common dentist-in-chief/director and cross- and BMCC dental clinics under the ISO 9002:1994 qual- appointed staff dentists and residents. HSC has a staff ity standard: quality assurance and patient/parent satisfac- turnover rate of more than one-third annually, as graduate tion. These objectives were motivated by the desire for dentists progress through their residency and training consistent administration of policies and procedures at each programs then leave for employment elsewhere. of the 2 dental clinics. A quality system that would ensure Regulation of health care practices is complex and and document consistent compliance with regulatory involves many stakeholders who have different priorities. guidelines and institutional standards was viewed as a bene- Federal, provincial and municipal governments, regulatory fit by the dentist-in-chief/director. An audited unified qual- colleges, accreditation bodies, university administration and ity system would assure hospital management, patients and

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 215 Casas, Kenny, Johnston

parents that consistent practices were carried out at all with standards. Other quality systems such as accreditation times, even when the dentist-in-chief/director was not of the teaching program and the dental service as well as present. A second motivation was the desire to consolidate hospital-wide accreditation were also in place. Although pre-existing individual quality systems and practices. A external audits were more frequent than accreditation visits third motivation was to comply with hospital-wide strate- (which take place every 3 to 4 years), the possibility of staff gic goals for excellence in care. Both hospitals expect that members improving compliance in anticipation of an exter- departments will ensure patient safety, provide excellent nal audit and then reducing compliance after a successful care and foster excellent relations with patients and their review was perceived as a risk. families.1 The final motivation was the desire to continue Preventive action reports (PAR) and corrective action to exceed the expectations of patients and parents. reports (CAR) are integral methods for assessing and main- Information acquired from patient and parent surveys taining compliance with standards in many applications of before ISO 9002 registration suggested that there was the ISO 9002 quality system. PAR and CAR empower already a high level of satisfaction with the services employees to identify a deficiency, noncompliance or provided by the clinic staff. It was anticipated that as potential risk and to report the finding along with the services improved, patients and parents would expect action taken to rectify the situation. At both clinics, these improvements as the minimum standard for subse- targeted internal audits combined with CAR were effective quent visits. Continuous quality improvement would be in improving compliance. When corrective actions were required to exceed their expectations. reported, quality procedures or ISO 9002 registration was selected as processes were modified to improve the quality system that could achieve Encouraging staff compliance. Targeted internal audits the objectives of quality improvement were undertaken after changes were and patient/parent satisfaction. to submit action reports implemented to confirm compliance This paper reports on the experience empowers them at with new processes. For example, a of managing the HSC and BMCC a higher level than they CAR identified that a weekly autoclave dental clinics for 3 years and 2 years, are accustomed to in spore test was missed. The process for respectively, after their registration to clinical practice. spore testing was therefore changed ISO 9002. During that time, the HSC and a specific person was given the underwent 5 external audits, while the responsibility for spore testing and to BMCC was twice audited externally. consolidate weekly spore testing with The paper also reports on the process of revising the other regular weekly tasks. Targeted internal audits quality management standards of the 2 clinics to register to confirmed compliance at 1, 2 and 3 months after the the new ISO 9001:2000 standard. The process of develop- process was changed. Instituting targeted internal audits ing and adapting the quality system for registration under after a process was modified made it possible to verify that ISO 9002 has been described previously.2 new changes were implemented and maintained. Although CAR were effective in identifying instances of Assessment of Compliance with ISO 9002 noncompliance, dentists and auxiliary dental staff at both Standards clinics were reticent to use CAR and PAR. The pre-existing Compliance with the quality policies, operational proce- systems of risk management and incident reporting that are dures and work instructions was assessed and documented mandatory in hospital-wide quality systems often super- using 3 methods: preventive or corrective actions, internal seded the use of PAR and CAR. It is likely that these report- audits (daily equipment and process checks and monthly ing systems cover similar areas, but PAR and CAR can be audits by clinic staff) and semi-annual independent exter- applied to a broader spectrum of concerns than those nal audits. Internal and external audits are not part of usual covered by hospital risk management and incident reports. clinical practice for Canadian dentists. Daily equipment CAR may be used to identify a variety of management and process checks, combined with internal audits, were issues (e.g., vacation scheduling, clinic supervision, patient the backbone of the quality system at both clinics. These complaints) that are beyond the scope of hospital risk daily checks provided the fastest notification of noncompli- management and incident reports. ance to clinic managers, who were then able to address vari- Encouraging dental assistants and information clerks to ances. Monthly internal audits provided feedback at a submit action reports empowers them at a higher level than slower rate, but still reinforced the compliance of the dental they are accustomed to in clinical practice. CAR and PAR assistants performing the daily equipment and process allow staff members to report variances from quality stan- checks. Although external audits confirmed overall compli- dards and to register direct feedback from patients and ance, the fact that they occurred semi-annually limited parents. This information is collected by clinic administra- their ability to demonstrate consistent daily compliance tors and used to modify policies and standards to maximize

216 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Experience of 2 Dental Clinics Registered to ISO 9002 safety and patient/parent satisfaction. For example, at the mail slots, e-mails, fan-out lists and a communication book HSC, CAR are collected for operating room and dental were integrated. The procedures supporting this new clinic time overruns. When a clinic session or operating process were included in the revised HSC manual. room runs late, a nurse or dental assistant submits a CAR The ISO 9001:2000 standard was itself revised from the that details the length of the overrun, the reasons for the ISO 9002:1994 standard to which both clinics were origi- late finish and the dentist or surgeon responsible. These nally registered. The revised 2000 standards emphasize CAR are collected, and the data tabulated and analyzed. A customer satisfaction and process-oriented objectives. The semi-annual summary is submitted to the dentist-in-chief, designation ISO 9002 was deleted in the 2000 reorganiza- who uses the information to discuss the issue with staff tion of standards. Organizations that revise their standards dentists or surgeons who repeatedly finish late, to respond for registration to the new standard are now registered as to operating room administrators who are concerned about ISO 9001. The process-based standards of ISO 9001:2000 time overruns, or to answer parent and patient concerns were designed to allow organizations to measure and about delays in the clinic and operating room. The use of demonstrate continuous quality improvement, and not CAR, in this instance, allows the clinic to meet all of its simply to demonstrate compliance with quality standards.3 motivations for registration under ISO 9002. The tabulated The HSC dental clinic achieved registration to the CAR reports allows clinic administrators to demonstrate ISO 9001:2000 standard in February 2002. The BMCC that the clinic is complying with hospital standards for clinic achieved ISO 9001:2000 registration in December operating room use, that consolidated quality assurance 2002. They are the first and only North American dental measures are in place for operating room and clinic use, that clinics to achieve the original ISO 9002:1994 and the the clinic is complying with the hospital’s strategic goals for current ISO 9001:2000 registration. The HSC and BMCC optimal patient care and that it is helping to meet the dental clinics are also the only departments within their expectations of parents and patients by minimizing operat- institutions to pursue ISO 9001 registration. ing room and clinic waiting times. Limitations of ISO 9002 Registration The Evolution of Quality Standards Not all staff members have expressed positive opinions Staff specialists and clinic managers together set the about the ISO 9002 quality system. Some members have quality policies, operational procedures and work instruc- reported that the quality system occupies an excessive tions in the quality manuals. The HSC and BMCC manu- amount of their time and effort for the perceived benefits of als have evolved since initial registration to ISO 9002. In a unified quality system. A strong emphasis on quality addition to externally mandated changes, administrative assurance and patient satisfaction before ISO registration practices also changed within the clinics. A requirement may minimize the perception, among staff, of the benefits that staff specialists request holidays and meetings 6 weeks of registration. Concerns about increased workload associ- in advance proved unworkable. The process was subse- ated with managing the quality system have been reported quently changed so that a specific coordinator was assigned in other health care practices4 registered to ISO 9002. to keep track of the off-service requests of all clinicians. In Furthermore, the quality policies, operational procedures direct consultation with the service directors, the coordina- and work instructions for registration to the ISO 9002 stan- tor was able to shorten the lead-time for such requests, yet dard have been of limited assistance in preparing for accred- ensure that clinical coverage was not compromised. itation reviews. Each accreditation body has its own unique The most recent modifications to the quality system and evolving method of assessment, so documentation were the result of procedural alterations mandated by the requirements change with each survey. The documentation hospitals, professional colleges or government legislation. required for ISO 9002 registration is differently focused The quality manual was updated to incorporate these new and more extensive in scope than that required for accredi- processes and to eliminate redundancies. Changes that tation assessments. Also, accreditation and regulatory occurred between semi-annual external audits were moni- reviews determine compliance with a minimum standard, tored internally and the relevant documentation was not a proficiency standard that may be higher than the presented to auditors at the time of the next external audit. minimum standard. ISO 9002 registration allowed both Both clinics have numerous part-time dental staff and resi- clinics to set and monitor compliance with standards before dents who are not on site every day. The requirement that the standards were included in regulatory guidelines. For clinic administrators ensure that part-time clinic members example, standards for mercury discharge in wastewater were informed of procedural changes and modifications was were in place in both clinics before they became a require- significant. Information dissemination was identified as ment under City of Toronto bylaws. Also, standards for inadequate during the review process in preparation for the waterline biofilm testing, which are not required under initial ISO 9002 registration. A number of procedures were regulatory guidelines, have been incorporated in the quality therefore instituted to ensure that a pre-existing system of systems at both clinics.

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 217 Casas, Kenny, Johnston

ISO 9002 registration has provided the dental clinics at services, Bloorview MacMillan Children’s Centre, and professor of HSC and BMCC with centralized and responsive quality dentistry at the University of Toronto, Toronto, Ontario. systems. Corrective and preventive actions, internal audits Dr. Johnston is dentist-in-chief at The Hospital for Sick Children, director of dental services at the Bloorview MacMillan Children’s and external audits have allowed the clinics to document Centre, and associate professor of dentistry at the University of compliance with institutional, regulatory and departmental Toronto, Toronto, Ontario. requirements. Departmental quality manuals were modified Correspondence to: Dr. Michael J. Casas, S524, The Hospital for Sick when original standards were unworkable or to reflect the Children, 555 University Ave., Toronto, ON M5G 1X8 E-mail: [email protected]. introduction of new external regulatory guidelines. The views expressed are those of the authors and do not necessarily In the future, use of CAR and PAR as risk analysis and prob- reflect the opinions or official policies of the Canadian Dental lem-solving tools for quality issues will be emphasized. The Association. successful move to the ISO 9001:2000 quality standard will allow detailed measurement of continuous quality improve- References ment and improved documentation of patient satisfaction. C 1. Kenny DJ, Casas MJ. ISO 9002: Maintaining quality standards for comprehensive care of children and adolescents with special needs. Medicina Oral 2000; 5(Supp 1):8. Acknowledgment: The authors wish to thank Leslie Brown, clinical 2. Kenny DJ, Conway RM, Johnston DH. The development of leader, and Mary-Lou Littleproud, coordinator of purchasing, for their comments and suggestions for the manuscript. ISO 9002 quality management standards for Canadian dental practices. J Can Dent Assoc 1999; 65(2):105–8. Dr. Casas is staff pediatric dentist at The Hospital for Sick Children, manager of the dental trauma research unit at the Bloorview 3. International Organization for Standardization. Available from URL: MacMillan Children’s Centre, and assistant professor of dentistry at http://www.iso.ch. the University of Toronto, Toronto, Ontario. 4. Rissanen V. Quality system based on the standard SFS-EN ISO 9002 Dr. Kenny is director of dental research and graduate studies at in Kuopio University Hospital. Int J Health Care Qual Assur Inc Leadersh The Hospital for Sick Children, research coordinator of dental Health Serv 2000; 13(6-7):266–72.

CDA’S DEFINITION OF ORAL HEALTH

Oral health is a state of the oral and related tissues and structures that contributes positively to physical, mental and social well-being and the enjoyment of life’s possibilities, by allowing the individual to speak, eat and socialize unhindered by pain, discomfort or embarrassment. Approved by Resolution 2001.02 Canadian Dental Association Board of Governors March 2001

Continuing Dental Education CDA maintains a current listing of continuing dental education courses to help dentists stay informed about various learning opportunities offered to them in Canada and abroad. To view the complete calendar of CDE events, visit CDA’s Web site at www.cda-adc.ca.

218 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association An idea so simple, it’s brilliant...

Floss that whitens!

Recommend the floss patients will actually want to use. What a bright idea! The first floss that is clinically proven to remove stains between teeth. It’s a brilliant way to encourage compliance. In fact, in home-usage studies, 86% of patients using new Johnson & Johnson REACH® Whitening Floss said they BEFORE would purchase it. This unique floss is a shred-resistant, easy-to-slide, silica-coated yarn designed to gently polish away stains. Johnson & Johnson REACH® Whitening Floss is definitely an idea whose time has come.

AFTER Inc. Montréal, H1N 2G4 © Johnson & Johnson Inc. 2003 Before and after photos under Floss controlled clinical testing. Copy of clinical study available upon request: TOLL FREE 1-866-JNJ-FLOS (1-866-565-3567) A brilliant reason to floss 800-300-3046x519 www.carecredit.com C LINICAL P RACTICE

Consensus-Based Recommendations for the Diagnosis and Management of Dentin Hypersensitivity

• Canadian Advisory Board on Dentin Hypersensitivity •

Abstract

These consensus recommendations for the diagnosis and management of dentin hypersensitivity were developed by a broadly constituted board of dentists and dental hygienists drawn from general dental practice, specialist practice, academia and research from across Canada, joined by 2 international dentists with subject matter expertise. The need for consensus recommendations was made evident by the lack of clear and robust evidence in the dental literature, as well as confusion about diagnosis and management demonstrated by an educational needs assessment survey. High prevalence of the condition, underdiagnosis and widespread availability of noninvasive, efficacious and inexpensive preventive treatment further underscored the need for direction. This paper outlines the key elements of the scientiﬁc basis for the causes, diagnosis and management of dentin hypersensitivity; where such evidence is deﬁcient, the document relies on the compound experience of the board. A simple algorithm was developed to guide clinicians through the diagnostic process and assist them in determining appropriate case management. Finally, the board makes a series of recommendations to raise awareness, to improve dental education, to develop symbols for charting, to develop an index for case assessment and for further research.

MeSH Key Words: algorithms; consensus; dentin sensitivity/etiology; dentin sensitivity/therapy

entin hypersensitivity has been defined as a “short, ciencies were identified, the board developed consensus posi- sharp pain arising from exposed dentin in tions drawn from members’ own diverse clinical and acade- D response to stimuli typically thermal, evaporative, mic backgrounds. Gaps in knowledge were identified tactile, osmotic or chemical and which cannot be ascribed through an educational needs assessment survey. The board to any other form of dental defect or pathology.”1 Several brought together all its considerations into a set of consensus reviews2–4 reported that the prevalence of dentin hypersen- recommendations, including an algorithm (Fig. 1) to guide sitivity ranged from 8% to 57% in the general population practitioners through diagnosis and case management. and that strategies for managing the condition were remarkably varied. Furthermore, scientific support for vari- Data Collection — Literature Search ous therapies was variable, so it could be a challenge for a An extensive computer (MEDLINE) and hand search of practitioner to select appropriate therapy. Recognizing the literature identified original articles and reviews for the these issues, the Canadian Advisory Board on Dentin period 1966 to 2002 (see Table 1 for search terms). Because Hypersensitivity met in Toronto, Ont., in June 2002 to of space limitations, only critical findings are presented develop consensus-based recommendations on the manage- here. ment and treatment of dentin hypersensitivity. Definition Methods After full consideration of the literature the board The board considered data from 2 sources: an extensive accepted the definition proposed by Holland and others,1 literature search and a survey of knowledge and practices of with one minor change. The agreed definition was a “short, dentists and hygienists across Canada. Where scientific defi- sharp pain arising from exposed dentin in response to

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 221 Canadian Advisory Board on Dentin Hypersensitivity

SCREEN PATIENT: Does your patient suffer from twinges or stabs No treatment No of pain or sensitivity? required

Yes

OBTAIN PATIENT HISTORY •Ask patient to describe pain (look for description of pain as short, sharp) •Ask patient to identify pain-inciting stimuli (look for thermal, tactile, evaporative, osmotic, chemical) •Determine patient’s desire for treatment •Probe for intrinsic and extrinsic acids •Obtain detailed dietary history (look for excessive dietary acids: e.g., citrus juices and fruits, carbonated drinks, wines, ciders) • Probe for gastric acid reﬂux and excessive vomiting

EXAMINE PATIENT TO EXCLUDEa •Cracked tooth syndrome •Post-restorative sensitivity •Fractured restorations •Marginal leakage • Chipped teeth • Pulpitis •Dental caries •Palatogingival grooves •Gingival inﬂammation

Diagnosis inconsis- Is your patient’s examination/history consistent with dentin tent with dentin No hypersensitivity?b hypersensitivity

Yes Seek other causes

CONFIRM YOUR PATIENT’S DIAGNOSISc Treat other causes INITIATE MANAGEMENT FOR DENTIN HYPERSENSITIVITY • Educate patient to remove risk factors • Recommend removal of excessive dietary acids •Recommend tooth-brushing remote from mealtime (preferably before) •Advise against overly frequent or aggressive tooth-brushing/hygiene

FOLLOW-UP: Does your patient’s dentin hypersensitivity persist? No No further treatment

Yes a. Potentially useful diagnostic tools • Air jet INITIATE TREATMENT FOR DENTIN HYPERSENSITIVITY • Cold water jet Apply desensitizing techniques with consideration for convenience and • Other thermal tests cost-effectiveness • Dental explorer • Periodontal probe • Radiographs (if needed) NONINVASIVE INVASIVE • Percussion testing •Desensitizing toothpaste used •Mucogingival surgery • Assessment of occlusion correctlyd • Resins • Bite stress tests •Topical agents • Pulpectomy b. Deﬁnition of dentin hypersensitivity Maintain current Dentin hypersensitivity is charac- FOLLOW-UP: Does your patient’s dentin hypersensitivity still persist? therapy long-term terized by short, sharp pain (i.e., does your patient report improvement but still have pain and if so, No and review regularly. arising from exposed dentin in does your patient still desire further treatment?) Reconsider response to stimuli typically predisposing factors. thermal, evaporative, tactile, Yes osmotic or chemical and which cannot be ascribed to any other No further treatment form of dental defect or disease.1 REVIEW DIAGNOSIS TO EXCLUDE •Periodontal pain • Neuropathic pain c. Other potential diagnostic • Referred pain • Chronic pain syndrome aids • Selective anesthesia Refer patient to • Transillumination Should you continue dentin hypersensitivity treatment and patient appropriate No d. The best results are achieved education? specialist (dental or if desensitizing toothpaste is medical) applied via twice-daily brushing, Yes performed on an ongoing basis according to a regular schedule Continue dentin hypersensitivity treatment and patient education, with (not applied topically, as in ongoing reminders to alter predisposing factors “dabbing”).

Figure 1: Algorithm for diagnosis and management of dentin hypersensitivity

222 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Consensus-Based Recommendations for the Diagnosis and Management of Dentin Hypersensitivity

Table 1 Key words and search terms used in lated that the fluid flow in sensitive teeth is approximately the literature search 100 times greater than in nonsensitive teeth. The number of tubules increases toward the pulp, and this may not only Search 1 increase the probability of dentin hypersensitivity but also (clinical trial OR randomized clinical trial OR clinical evaluation) help explain any increase in symptoms as tooth wear advances AND (dentinal OR dental OR tooth OR intra-dental nerves) AND toward the pulp. (toothpaste OR dentifrice OR mouthwash) AND (hypersensitivity OR sensitivity OR desensitization) AND treatment AND (potas- Causes sium nitrate OR potassium citrate OR potassium chloride OR ferrous oxide OR sodium fluoride OR sodium monofluorophos- Two processes are essential for the development of phate OR glutaraldehyde OR strontium chloride), limited to dentin hypersensitivity: dentin must become exposed humans (lesion localization), through either loss of enamel or gingi- Search 2 val recession, and the dentin tubules must be open to both (dentinal hypersensitivity) OR (dental hygienists) AND (treatment the oral cavity and the pulp (lesion initiation). AND (conservative OR operative OR restorative OR varnishes OR Erosion,7 abrasion (or their co-effects), attrition8 and resins OR silver nitrate OR glutaraldehyde OR formaldehyde)) possibly abfraction9 lead to exposure of tubules. Both clin- NOT potassium NOT toothpaste NOT dentifrice, limited to humans ical and laboratory evidence suggests that enamel at the buccal cervical region is lost through a combination of erosion and abrasion.7,10 Enamel is resistant to abrasion by stimuli typically thermal, evaporative, tactile, osmotic or tooth-brushing, with or without toothpaste, but is particu- chemical and which cannot be ascribed to any other form larly sensitive to the effects of acid; thus, brushing of acid- of dental defect or disease” (where “disease” replaces the softened (eroded) enamel has a marked abrasive effect.10 original “pathology” of Holland and others1). This defini- As indicated in the survey results (see below), many tion challenges clinicians to consider other potential causes practitioners assume that “abrasive” toothpastes are respon- for pain associated with tooth sensitivity. Many conditions sible for lesion development. While it is possible that tooth- share the symptoms of tooth sensitivity, so a differential paste may erode dentin to some extent, the abrasivity might diagnosis is essential. also produce a smear layer, thereby reducing sensitivity.11 Mechanisms of Dentin Hypersensitivity Interestingly, toothpaste abrasives in combination with The most widely accepted mechanism of dentin hyper- detergents may remove the smear layer and open the sensitivity is the hydrodynamic theory proposed by tubules. Indeed, if predisposing factors (see below) are not Brännström,5 whereby fluid flow within dentinal tubules is eradicated, brushing with nearly any toothpaste may open altered (increased or changed directionally) by thermal, the tubules.3 Occasionally, some deposits of the abrasive tactile or chemical stimuli near the exposed surface of the from toothpastes do adhere to the tubules, but they detach tubules. This alteration would lead to stimulation of the easily later. A-δ fibres surrounding the odontoblasts. This putative Gingival recession, another factor in exposure of dentin, mechanism requires that individual tubules be open at the has recently been described as an enigma,12 and its causes dentin surface, as well as within the pulp. are not well understood. However, overzealous brushing, Dentin Morphology acute necrotizing ulcerative gingivitis, self-inflicted injury In a study to determine differences between sensitive and periodontal procedures are the major predisposing and nonsensitive teeth, Absi and others6 reported that factors. nonsensitive teeth were unresponsive to any stimuli and Data Collection — Educational Needs had very few exposed tubules. In contrast, sensitive teeth had much greater numbers of open tubules per unit area Assessment (8 times as many tubules at the root surface than nonsensi- A 66-item questionnaire was developed to determine tive teeth). Similarly, the average diameter of tubules in practitioners’ understanding and clinical management of sensitive teeth was almost 2 times greater than that of dentin hypersensitivity. Key elements included practice tubules in nonsensitive teeth (0.83 µm vs. 0.4 µm). profile, experience with patients suffering hypersensitivity, According to Poiseuille’s law, which states that fluid flow is perceptions of causes and diagnosis, and clinical manage- proportional to the fourth power of the radius, diameter ment. The questionnaire was mailed to a random sample of differences alone would indicate that the fluid flow in 5,000 dentists and 3,000 hygienists across Canada. The tubules of hypersensitive teeth should be 16 (i.e, 24) times 7% response rate (331 dentists and 211 hygienists) was greater than that of fluid in nonsensitive teeth. Combining reasonable considering the many items on the question- the increased number of open tubules with the increased naire and the method of distribution. An independent diameter of the tubules in sensitive teeth, it can be postu- research group (The Chapman Group Limited, Unionville,

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 223 Canadian Advisory Board on Dentin Hypersensitivity

Ont., unpublished data) compiled the results and convened 90% responded incorrectly that the principal action of focus groups to examine knowledge gaps more closely. desensitizing toothpastes is tubule occlusion. Potassium A total of 14 key knowledge gaps were identified, which nitrate is thought to act by interfering with the transmission were classified as relating to either the causes and diagnosis of pain, whereas strontium chloride, which is much less or the management of the condition. widely available, acts by occluding tubules. Causes and Diagnosis of Dentin Hypersensitivity 12. Although many desensitizing toothpastes offer substantial secondary benefits and are suitable for daily use, 1. Prevalence was underestimated, particularly for young misunderstanding exists. For example, 49% of dentists and adult patients. Approximately 70% of respondents indi- 40% of hygienists did not believe that desensitizing tooth- cated that most of their patients with dentin hypersensitiv- pastes were effective in preventing caries, even though most ity were between 35 and 50 years old. Yet an independent contain fluoride. research study (by The Chapman Group Limited) of 683 13. Thirty-nine percent of respondents recommended adults drawn from a nationally representative sample of the topical application (dabbing) of desensitizing toothpaste, Canadian population found that the prevalence of sensitive despite a lack of published evidence of the effectiveness of teeth was about 30% in adults throughout the 18- to 64- this method. year age band (28% for those 18–24 years of age, 22% for 14. Although most dentists (56%) and hygienists (68%) those 25–34 years of age, 30% for those 36–49 years of age believed that desensitizing toothpastes were effective in and 30% for those 50–64 years of age). preventing dentin hypersensitivity, 31% of dentists and 2. Screening is not routinely conducted, except when 16% of hygienists did not believe that desensitizing tooth- prompted by patients. pastes relieved dentin hypersensitivity. 3. Fewer than half of the respondents considered a differential diagnosis, even though dentin hypersensitivity is by Developing Consensus definition1 a diagnosis of exclusion. 4. Many respondents (64% of the dentists and 77% of Screening the hygienists) identified bruxism and malocclusion as trig- The advisory board concluded that screening of all gers of dentin hypersensitivity, even though neither has dentate patients was essential to avoid underdiagnosis and been identified as a major causative factor. undertreatment of the condition. 5. Only 7% of dentists and 5% of hygienists correctly Diagnosis identified erosion as a primary cause of dentin hypersensi- By definition,1 dentin hypersensitivity is a diagnosis of 13 tivity. Sixty percent of respondents overall incorrectly exclusion. Therefore, before proceeding to management and identified gingival recession (rather than a predisposing treatment, conditions that present with symptoms mimick- factor) as the most common cause of dentin hypersensitivity. ing dentin hypersensitivity must be ruled out16 (Fig. 1). 6. Seventeen percent of dentists and 48% of hygienists Patients with dentin hypersensitivity usually experience a failed to identify the accepted theory of dentin hypersensi- short, sharp pain in response to cold (the most common tivity (the hydrodynamic theory5). trigger), touch, evaporation, osmosis or chemical stimuli.17 7. Eighty-five percent of dentists and 94% of hygienists It is difficult to quantify dentin hypersensitivity in a clin- incorrectly cited toothbrush abrasion as a reason for contin- ical setting, and hence clinicians must rely on patient- ued tubule exposure, even though toothbrushes with or reported history. In this regard, a patient might indicate without toothpaste have no significant effect on tubule that she or he experiences pain but that it does not affect exposure.14,15 her or his quality of life (and that she or he is not seeking Management of Dentin Hypersensitivity treatment). Others might request intervention to obtain 8. About 50% of respondents reported that they lacked some relief from the pain they experience. Given the many confidence in managing their patients’ pain. variations in presentation, the board members agreed that 9. Only 50% of respondents reported that they try to objective measures of pain from air blast or thermal stimuli, modify predisposing factors. as are commonly employed in clinical trials, might not be 10. Fifty percent of dentists and 73% of hygienists capable of replicating all types of dentin hypersensitivity, reported, incorrectly, that the most popular desensitizing which would reduce the reliability of evaluating the ingredients in desensitizing toothpastes are fluoride outcomes of therapeutic interventions. Given these issues, compounds; in fact, the most widely available desensitizing the board concluded that it would be most appropriate to ingredient is potassium nitrate. rely on patients’ perception of pain following treatment; the 11. Only 10% of respondents correctly thought that board also agreed that there was a need for a universal pain desensitizing toothpastes disrupt pain transmission by index. Such an index would constitute a judgement of preventing repolarization within the nerve. The remaining global transition, meaning that the patient would indicate

224 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Consensus-Based Recommendations for the Diagnosis and Management of Dentin Hypersensitivity

that she or he feels an improvement, feels the same or feels “improvement for a majority of cases will be obtained by even worse after the intervention. In addition, the patient the recommendation of a desensitizing agent.” might indicate that she or he desires no further treatment; Follow-up in this situation and if the problem has been reduced or The members of the board endorsed the concept that resolved, further treatment would be inappropriate. follow-up was necessary. If pain persists, a review of the Management: Removal of Predisposing Factors diagnosis is mandatory to rule out other causes (Fig. 1). and Causes More invasive techniques, such as mucogingival surgery for Whenever possible, the predisposing factors should first root coverage, application of resins (to seal exposed tubules) be removed or modified. Otherwise, treatment is likely to or even pulpectomy may be necessary. In some cases the provide only short-term success. In their review, Dababneh pain may be refractory and should be referred to a special- and others2 cited reports of dentin erosion caused by many ist (ideally before pulpectomy). acidic substances derived either from the diet or from the If the pain abates after treatment but recurs thereafter, stomach. A detailed, written dietary history (and investiga- and a review of the patient’s medical history is still consis- tion into bulimia and other dietary problems, if suspected) tent with a diagnosis of dentin hypersensitivity, then can help to identify possible predisposing factors. Contrary further counselling regarding the removal of predisposing to the popular opinion demonstrated in the survey, normal factors, combined with continuous long-term desensitiza- brushing of the teeth with or without toothpaste has relation treatment, should be considered. tively little effect on erosion unless the environment has recently been acidified. The results of an in vitro study18 Educational Issues suggested that the timing of tooth-brushing should be Academic members of the advisory board (both dentists remote from meals or ingestion of acidic drinks. The board and dental hygienists) indicated that little time is allotted to considered that brushing before meals would be more dentin hypersensitivity in the curriculum. School curricula advantageous. should offer greater focus on the diagnosis and manage- Patients who brush excessively or use undue pressure ment of pain in general, and give increased emphasis to while brushing should be instructed on proper tooth- dentin hypersensitivity. Resources for and approaches to brushing techniques to avoid gingival recession, the latter teaching dentin hypersensitivity are highly variable and being a predisposing factor for both dental erosion and should be reviewed to ensure greater effectiveness. dentin hypersensitivity that is difficult to correct. Although Development of a Diagnostic Algorithm debates continue on the correct method for brushing teeth, Given the knowledge gaps identified by the educational technique has little effect on dentin hypersensitivity (apart from the effects on gingival root coverage), unless the needs assessment survey and practitioners’ expressed lack of predisposing factors for erosion are still in place. confidence in management, a systematic, structured approach to the problem of dentin hypersensitivity was Treatment developed and incorporated into an easy-reference algo- Treatment can be designed to reduce fluid flow in the rithm (Fig. 1). tubules, block the nerve response in the pulp or possibly The algorithm reflects the published science on this both. An extensive analysis of review papers that focused on topic and, where such evidence is lacking, the clinical expe- the use of desensitizing agents indicated a wide array of rience of the board members. Its framework includes the potential treatments for dentin hypersensitivity, most fundamental elements and critical steps required to increase involving attempts to interrupt neural activation and pain the likelihood of correct differential diagnosis and success- transmission with either potassium nitrate or potassium ful management of dentin hypersensitivity, and, where chloride. Fluid flow can be reduced by a variety of physical appropriate, it directs the clinician to other causes, no and chemical agents that induce a smear layer or block the further treatment or referral. This algorithm can be used to tubules. Tubule-blocking agents include resins, glass- guide the practitioner in making correct diagnostic deci- ionomer cements and bonding agents; strontium chloride sions and then in acting upon the findings in a systematic or acetate; aluminium, potassium or ferric oxalates; silica- manner. or calcium-containing materials; and protein precipitants. Although there is little evidence to determine the Consensus Recommendations superiority of one desensitizing agent over another, there Screening and Diagnosis is evidence that desensitizing toothpastes do provide benefit.4,19–21 •Screening is critical for identifying dentin hypersensitivity. The board, in considering the use of desensitizing tooth- • Conditions that have symptoms in common with dentin pastes, echoed the conclusion of Dababneh and others2 that hypersensitivity must be excluded.

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 225 Canadian Advisory Board on Dentin Hypersensitivity

•Universal symbols should be devised to indicate the References severity and extent of condition. 1. Holland GR, Narhi MN, Addy M, Gangarosa L, Orchardson R. Guidelines for the design and conduct of clinical trials on dentine hyper- •A universal index combining an analogue pain measure sensitivity. J Clin Periodontol 1997; 24(11):808–13. with the patient’s own rating of the effect of pain on 2. Dababneh RH, Khouri AT, Addy M. Dentine hypersensitivity — an enigma? A review of terminology, epidemiology, mechanisms, aetiology their quality of life should be developed. and management. Br Dent J 1999; 187(11):606–11. •A detailed dietary history assessing erosive influences is 3. Addy M. Dentine hypersensitivity: definition, prevalence, distribution essential. and aetiology. In: Addy M, Embery G, Edgar WM, Orchardson R, editors. Tooth wear and sensitivity. Clinical advances in restorative Management dentistry. London: Martin Dunitz; 2000. p. 239–48. 4. Jackson R. Potential treatment modalities for dentine hypersensitivity: •Predisposing factors and causes of dentin hypersensitiv- home use products. In: Addy M, Embery G, Edgar WM, Orchardson R, ity should be removed or modified. editors. Tooth wear and sensitivity. Clinical advances in restorative dentistry. London: Martin Dunitz; 2000. p. 326–38. • Everyday use of desensitizing toothpastes should be 5. Brännström M. A hydrodynamic mechanism in the transmission of considered and recommended as a noninvasive, inexpen- pain producing stimuli through the dentine. In: Anderson DJ, editor. Sensory mechanisms in dentine. Oxford: Pergamon Press; 1963; p. 73–9. sive, efficacious first line of treatment, without necessar- 6. Absi EG, Addy M, Adams D. Dentine hypersensitivity. A study of the ily sacrificing other benefits that patients seek (e.g., patency of dentinal tubules in sensitive and non-sensitive cervical dentine. cavity prevention, whitening). J Clin Periodontol 1987; 14(5):280–4. 7. Braem M, Lambrechts P, Vanderle G. Stress-induced cervical lesions. • Brushing with desensitizing toothpaste (at least twice J Prosthet Dent 1992; 67(5):718–22. daily) is the only clinically supported method of 8. Smith BG, Knight JK. A comparison of patterns of tooth wear with the application of such agents. There is no published etiological factors. Br Dent J 1984; 157(1):16–9. 9. Grippo JO. Abfraction: a new classification of hard tissue lesions of evidence to support topical application (dabbing). teeth. J Esthet Dent 1991; 3(1):14–9. • Depending upon the severity and extent of the condi- 10. Davis WB, Winter PJ. The effect of abrasion on enamel and dentine tion, reversible procedures should be employed before and exposure to dietary acid. Br Dent J 1980; 148(11-12):253–6. 11. Adams D, Addy M, Absi EG. Abrasive and chemical effects of denti- nonreversible procedures. frices. In: Embery G, Rolla G, editors. Clinical and biological aspects of • Follow-up is essential. dentifrices. Oxford: Oxford University Press; 1992. p. 345–55. 12. Smith RG. Gingival recession. Reappraisal of an enigmatic condition Research Needs and new index for monitoring. J Clin Periodontol 1997; 24(3):201–5. 13. Pindborg JJ. Pathology of the dental hard tissues. Copenhagen: • Long-term follow-up studies are required. Ideally, studies Munnksgaard; 1970. p. 312–21. would be randomized, placebo-controlled and double- 14. Addy M, Griffiths G, Drummer P, Kingdom A, Shaw WC. The distri- blinded. bution of plaque and gingivitis and the influence of toothbrushing hand in a group of South Wales 11–12 year-old school children. J Clin • The mechanisms underlying dentin hypersensitivity Periodontol 1987; 14(10):564–72. should be explored further; it is then conceivable that 15. Absi EG, Addy M, Adams D. Dentine hypersensitivity — the effect of toothbrushing and dietary compounds on dentine in vitro: an SEM more effective therapies can be developed. study. J Oral Rehabil 1992; 19(1):101–10. Education 16. Dowell P, Addy M, Dummer P. Dentine hypersensitivity: aetiology, differential diagnosis and management. Br Dent J 1985; 158(3):92–6. • Clinical education should provide greater focus on the 17. Dowell P, Addy M. Dentine hypersensitivity — a review. Aetiology, predisposing factors, diagnosis and management of dentin symptoms and theories of pain production. J Clin Periodontol 1983; 10(4):341–50. hypersensitivity and other forms of chronic pain. C 18. McAndrew R, Kourkouta S. Effects of toothbrushing prior and/or subsequent to dietary acid application of smear layer formation and the patency of dentinal tubules: an SEM study. J Periodontol 1995; Acknowledgments: The Canadian Advisory Board on Dentin 66(6):433–48. Hypersensitivity was funded by an educational grant from GlaxoSmithKline Consumer Healthcare Inc. 19. Kanapka JA. Over-the-counter dentifrices in the treatment of tooth hypersensitivity. Review of clinical studies. Dent Clin North Am 1990; The Canadian Advisory Board on Dentin Hypersensitivity 34(3):545–60 comprises Dr. James R. Brookfield, Dr. Martin Addy, Dr. David C. Alexander, Dr. Véronique Benhamou, Dr. Barry Dolman, Dr. 20. Silverman G. The sensitivity-reducing effect of brushing with a potas- Véronique Gagnon, Dr. K. Tony S. Gill, Ms. Marilyn J. Goulding, sium nitrate-sodium monofluorophosphate dentifrice. Compend Contin Ms. Stacy Mackie, Dr. Wayne A. Maillet, Dr. Gordon Schwartz and Educ Dent 1985; 6(2):131–3, 136. Dr. Howard C. Tenenbaum. 21. Nagata T, Ishida H, Shinohara H, Nishikawa S, Kasahara S, Wakano Y, and others. Clinical evaluation of a potassium nitrate dentifrice for the Correspondence to: Dr. James R. Brookfield, 58 Government Rd. W, treatment of dentinal hypersensitivity. J Clin Periodontol 1994; Kirkland Lake, ON P2N 2E5. E-mail: [email protected]. 21(3):217–21.

226 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association ©2003 Porsche Cars North America, Inc. Porsche recommends seat belt usage and observance of all traffic laws at all times. Specifications for comparison only.

Art not imitating anything.

Consider this bold collaboration. You and the incomparable 911 Carrera. Wrap yourself in the driver’s seat, feel the surge of the hand-assembled, rear-mounted 320-hp engine, and every twist and bend of the road becomes pure artistry. Contact us at 1-800-PORSCHE or porsche.com.

The 911 Carrera The economical way to treat “Splint Personalities.”

COMFORT BITE SPLINTS™

NEW EXTRA COMFORT HARD/SOFT Soft 1mm inner layer with 3mm outer co-polyester layer HARD Co-polyester bonds with acrylics

Providing bruxing and clenching splints can be one of the most rewarding treatments in •Guaranteed against dentistry today. You’ll get your patients out of breakage for 12 months. pain quickly and reduce further tooth destruction. This sparkling clear, co-polyester splint is •Storage case included with designed to be the first step in the treatment each splint. of bruxism, and is made with a flat occlusal plane and slight opposing cusp indentation. •Four days in lab. Erkodur splints are durable, will not discolor and are thermoformed to provide superb fit.

For more info & nationwide pick-up

800-267-8463 311 Viola St., Oshawa, ON L1H3A7 Serving Dentists Since 1988 www.ortho-dent.com A PPLIED R ESEARCH

Effect of Mode of Polymerization of Bonding Agent on Shear Bond Strength of Autocured Resin Composite Luting Cements

• Cecilia C.S. Dong, DMD, BSc (Dent), MSc (Prostho) • • Dorothy McComb, BDS, MScD, FRCD(C) • • James D. Anderson, BSc, DDS, MScD • • Laura E. Tam, DDS, MSc •

Abstract

Purpose: There have been anecdotal reports of low bond strength with autocured resin composite materials, particularly when light-cured bonding agents that combine primer and adhesive in a 1-bottle preparation are used. The objective of this study was to determine if the mode of polymerization of the bonding agent influences the strength of the attachment of autocured resin composite luting cements to dentin. Methods: The shear bond strength of 2 resin luting cements, Calibra and RelyX ARC, polymerized by autocuring, in combination with 4 different bonding agents, Scotchbond Multipurpose Plus, Prime & Bond NT, IntegraBond and Single Bond, polymerized to bovine dentin by light-curing, autocuring or dual-curing, was determined. The pH of each bonding agent and its components was measured. Two-way analysis of variance was used to test the effect of cement and adhesive on shear bond strength. For each bonding agent, the adhesive variable combined the factors product brand and mode of polymerization. With significant interaction among the above variables, the least square means of the 16 combinations of resin cement and adhesive were compared. Results: There was no consistent relationship between shear bond strength and mode of polymerization of the bonding agent. Significant differences in bond strength were specific to the proprietary brand of bonding agent. The pH of the bonding agent depends on the manufacturer’s formulation, and low pH may contribute to low bond strength. Conclusions: The low in vitro bond strength occurring with some combinations of bonding agent and resin cement could be clinically significant.

MeSH Key Words: dental bonding/methods; dentin-bonding agents/chemistry; resin cements/chemistry

he placement of all-ceramic restorations to meet Such cements provide better retention for short crown3 and the esthetic demands of patients has increased. This short post4 preparations in vitro when adjunctive retentive T has led to greater use of adhesive resin cements to design features are inadequate. Resin luting cements also provide strength for all-ceramic restorations and to ensure exhibit low solubility. Numerous proprietary resin cements secure attachment to the tooth.1,2 Cements with adhesive and bonding agents are available, and in vitro assessment is properties have a distinct advantage because of their poten- essential to determine optimal performance. tial to reduce microleakage and associated sequelae. There have been anecdotal reports5,6 of low bond Porcelain veneers, ceramic inlays and onlays, and adhesive strength with autocured (AC) resin composite materials, ﬁxed partial dentures became predictable treatment options particularly when light-cured (LC) bonding agents that only with the development of resin cements. The retention combine primer and adhesive in a 1-bottle preparation are of conventional indirect restorations and ﬁxed prostheses used. These reports led to speculation that some bonding can be improved with the use of adhesive resin cements.3,4 agents and resin cements may be incompatible and

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 229 Dong, McComb, Anderson, Tam

prompted further research7–11 in this area. Because of the significance of inadequate polymerization at the adhesive chemical similarities between these materials, problems interface includes decreased retention, increased marginal encountered with the use of resin composite core buildup leakage, negative pulpal response and reduced longevity of materials may also apply to resin composite luting cements. the restoration. Better adhesion resulting from precuring One in vitro study found that different modes of primer the bonding resin must be balanced with the potential risk polymerization affected the bond strength of each resin of excessive film thickness and incomplete seating of the 10 cement differently. However, little is known about the indirect restoration. efficacy of the attachments between resin cements and The purpose of this study was to determine if the mode bonding agents achieved with different methods of of polymerization of the bonding agent influences the polymerization. strength of the attachment of AC resin luting cements to Both resin cements and bonding agents can be formu- dentin. lated to allow LC, AC or dual-cure polymerization.12 LC polymerization occurs when a diketone photoinitiator, such Materials and Methods as camphoroquinone, absorbs light in the 400- to 500-nm The 2 resin luting cements, Calibra (Dentsply/Caulk, range and interacts with an organic amine accelerator, such Milford, Del.) and RelyX ARC (3M Dental Products, as N,N-dimethylaminoethylmethacrylate, producing free St. Paul, Minn.), were selected because they can be subjected radicals that initiate the polymerization. AC or self-curing to AC polymerization. Calibra has high AC ability.14 polymerization is possible when a peroxide initiator and a tertiary amine accelerator are combined; their reaction Table 2 Protocol for various bonding agents produces free radicals at room temperature. Dual-cure formulations consist of reagents for both AC and LC Bonding agent Protocol polymerization. Scotchbond It is critical that all the components at the adhesive inter- Multipurpose Plus face are able to undergo maximum polymerization to Light cure • Apply 2 coats primer, then wait ensure optimal bond strength, as well as maximum physical 20 seconds before air drying • Apply 1 coat adhesive, then and biological properties. The degree of conversion of wait 20 seconds before air drying monomer to polymer is defined as the percentage of carbon • Light cure for 10 seconds double bonds that are consumed. In clinical situations poly- Autocure • Apply 1 coat activator, then wait merization is seldom complete, and the degree of conver- 5 seconds before air drying sion ranges from 50% to 70%.12 Conversion depends on • Apply 2 coats primer, then wait 20 seconds before air drying the resin composition and the quantity of free radicals for •Apply 1 coat catalyst polymerization that are generated. The degree of conversion Prime & Bond NT from monomer to polymer is comparable between LC and AC resin composites with the same monomer formulations, Light cure • Apply 1 coat adhesive, then wait 20 seconds before air drying provided that effective LC polymerization is achieved. • Light cure for 10 seconds Clinicians often encounter situations in which the resin Autocure • Apply 1 coat adhesive plus cement must undergo AC polymerization because of inac- activator mixture, then wait cessibility to the visible LC source. However, the bonding 20 seconds before air drying agent is always accessible to light, and it has been demon- Dual cure • Apply 1 coat adhesive plus strated in vitro that separate LC polymerization of the activator mixture, then wait bonding agent leads to greater bond strength.13 The clinical 20 seconds before air drying • Light cure for 10 seconds Table 1 Bonding agents used in a study of IntegraBond shear bond strengh with autocured Light cure • Apply first coat, then wait 20 seconds before air drying resin luting cements • Light cure for 20 seconds • Apply second coat, air dry, then Manufacturer Bonding agent light cure for 20 seconds 3M Dental Products Scotchbond Multipurpose Plus Autocure • Apply 2 coats adhesive plus St. Paul, Minn. Single Bond activator mixture Dentsply/Caulk Prime & Bond NT • Air dry each coat separately Milford, Del. Prime & Bond Self Cure Activator Single Bond • Apply 2 consecutive coats, wait Premier IntegraBond 20 seconds, then air dry King of Prussia, Penn. IntegraBond Auto-Cure Activator • Light cure for 10 seconds

230 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Effect of Mode of Polymerization of Bonding Agent on Shear Bond Strength of Autocured Resin Cements

RelyX ARC is promoted by the manufacturer as allowing force was applied with a knife-edged rod attached to an easy removal of excess cement. Instron universal testing machine (model 4301, Instron, The bonding agents used in this study are listed in Canton, Mass.) at a crosshead speed of 1 mm/min. The Table 1. Scotchbond Multipurpose Plus (3M Dental shear bond strength was calculated by dividing the peak Products), Prime & Bond NT (Dentsply/Caulk) and failure loads by the bonding area (17.34 mm2). Mode of IntegraBond (Premier, King of Prussia, Penn.) were selected failure was determined by visual examination. Visible frac- because they are available in both LC and AC formulations. ture of the dentin or resin cement was recorded as cohesive Single Bond (3M Dental Products) is formulated for LC failure. All other failures were recorded as adhesive failure. polymerization only and is a 1-bottle preparation made by To determine if pH might affect the bond strength of the same manufacturer as Scotchbond Multipurpose Plus. the bonding agent – resin cement combinations, the pH of Bovine teeth, stored frozen in distilled water before the the bonding agents was measured with a Ag/AgCl reference study and refrigerated in distilled water during the study, electrode (catalogue no. 13-620-83, Fisher Scientific were mounted in AC polymethyl methacrylate using Canada, Nepean, Ont.) and an Accumet pH meter (model moulds 2.5 cm in diameter and 2.0 cm in depth. Before 620, Fisher Scientific Canada). The pH meter was cali- bonding, the buccal superficial dentin was exposed by brated with solutions of pH 7.0 and 4.0. The pH of the grinding with 180-grit silicon carbide paper mounted on a cured and uncured bonding agents as well as that of the grinding wheel under running water. Each tooth was individual components was measured by dispensing the polished manually on wet 600-grit silicon carbide paper15 bonding agent onto a mixing pad and bringing the elec- and rinsed just before the bonding procedure. After prepa- trode into direct contact. Measurements for set LC and AC ration and analysis with the first cement, the teeth were materials involved placing a drop of distilled water between reused for testing the second cement by manually polishing the material and the electrode. The pH of all AC bonding the dentin surface with wet 320-grit silicon carbide paper agents was measured after 6 minutes. The pH of all LC followed by wet 600-grit silicon carbide paper. bonding agents was measured 1 minute after curing the Manufacturers’ instructions were used as guidelines in material for 20 seconds. pH measurements were made in the bonding protocol for each agent (Table 2). A 35% triplicate. phosphoric acid conditioner (3M Dental Products), used for all treatment groups, was applied to the broad dentin Statistical Analyses surface with a brush tip, left for 15 seconds and rinsed thor- Two-way analysis of variance was used to test the effect oughly. If the manufacturer’s instructions did not state that of cement and adhesive on shear bond strength. For each the 2 coats of bonding agent were to be applied consecu- bonding agent, the adhesive variable combined the factors tively, the first layer was air-dried before application of the product brand and mode of polymerization. With signifi- second coat. If bald spots were observed on the dentin cant interaction among the above variables, the least square surface, additional bonding agent was applied. Where means of the 16 combinations of resin cement and adhesive applicable, the bonding agent was subjected to LC poly- were then compared. The computer program SAS version merization with a conventional quartz halogen LC unit 8.2 (SAS Institute Inc., Cary, NC) was used for all statisti- (Spectrum 800, Dentsply/Caulk) with a light intensity of at cal analyses. least 500 mW/cm2. The adhesive area was demarcated by a coni-snap #4 natural-snap gelatin capsule (Wiler Fine Results Chemicals Ltd., London, Ont.) supported by an impres- The mean bond strengths (with standard deviations and sion putty mould. Equal amounts of catalyst and base standard errors) for combinations of bonding agent and pastes were mixed within 10 seconds. The resin cement was resin cement are listed in descending order of shear bond loaded into the gelatin capsule with a ball burnisher to a strength for the Calibra cement in Table 3 and for the height of 2–3 mm. The Calibra cement was allowed to RelyX ARC cement in Table 4. There were significant cure for 10 minutes and the RelyX ARC cement for 20 interactions among the 16 combinations of bonding agent minutes before immersion in distilled water. The RelyX and resin cement (p < 0.001). ARC cement was allowed to cure for a longer period The frequency of cohesive failure in dentin was higher in because the surface was still tacky after 10 minutes. The pairs with high bond strengths (Tables 3 and 4). Similarly, specimens were stored for 24 hours at 37ºC in distilled the depth at which cohesive failure in dentin occurred was water before being subjected to the shear bond strength greater with increasing bond strength. test. Ten specimens were prepared for each of the 16 combi- The pH of uncured and cured bonding agents and their nations of bonding agent and resin cement. components are listed in Table 5. The pH values reflect the The method for testing shear bond strength followed presence of acidic components in the bonding agent 1994 ISO Technical Specification No. 11405.16 The shear formulations.

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 231 Dong, McComb, Anderson, Tam

Table 3 Mean bond strength and cohesive failure rate for dentin and resin cement for teeth prepared with Calibra resin luting cement

Bond strength (MPa) Cohesive failure (%) Bonding agent Mean* SD SE Dentin Resin cement Scotchbond Multipurpose Plus, autocure 13.15 a 2.83 0.90 90 0 Single Bond 10.53 b 1.83 0.58 40 10 IntegraBond, light cure 10.52 b 3.26 1.03 50 0 Scotchbond Multipurpose Plus, light cure 8.13 c 1.03 0.32 50 50 Prime & Bond NT, dual cure 5.46 d 1.31 0.41 50 0 IntegraBond, autocure 4.41 d,e 2.35 0.74 20 0 Prime & Bond NT, autocure 3.77 d,e 0.79 0.25 0 0 Prime & Bond NT, light cure 3.11 e 1.37 0.43 10 0 SD = standard deviation, SE = standard error. *Means followed by different letters are signiﬁcantly different (p < 0.001).

Table 4 Mean bond strength and cohesive failure rate for dentin and resin cement for teeth prepared with RelyX ARC resin luting cement

Bond strengh (MPa) Cohesive failure (%) Bonding agent Mean* SD SE Dentin Resin cement Scotchbond Multipurpose Plus, light cure 12.99 a 3.77 1.19 90 0 Prime & Bond NT, dual cure 11.33 a,b 4.22 1.33 50 10 IntegraBond, light cure 11.20 a,b 2.66 0.84 50 20 Single Bond 9.24 b 3.64 1.15 50 10 Scotchbond Multipurpose Plus, autocure 9.24 b 2.24 0.71 30 0 IntegraBond, autocure 6.89 c 2.86 0.90 10 0 Prime & Bond NT, light cure 4.43 d 3.31 1.05 10 0 Prime & Bond NT, autocure 2.97 d 1.30 0.41 0 0

SD = standard deviation, SE = standard error. *Means followed by different letters are signiﬁcantly different (p < 0.001). Discussion bonding agents in combination with resin composite Numerous methods are available for evaluating the adhe- restorative materials. Scotchbond Multipurpose has consis- sion of dental materials to teeth. In vitro measurement of tently performed well during in vitro studies,18–22 as it did bond strength is the most common method of evaluating in this study. This agent was used here as a control material the presence and extent or value of the adhesive bond. The in which the primer and adhesive are provided separately. shear bond strength test involves loading the adhesive The 3 other bonding agents were formulated with the surface in shear until fracture occurs. The advantage of this primer and adhesive combined in one bottle. The fact that test method is that it is relatively simple with respect to the 1-bottle and 2-bottle variants from a single manufac- specimen preparation, equipment required and test setup. turer yielded similar bond strength suggests that the prob- The main criticism is that it measures the cohesive strength lem of low bond strength between the bonding agent and of the material being bonded or the substrate (or both), the resin cement cannot be attributed to the manner of rather than the bond strength of the adhesive interface.17 delivery of the bonding agent. This is a problem because failure in this situation does not Some combinations of bonding agent and resin cement simulate the clinical mode of failure (i.e., failure of the yielded low bond strength (Tables 3 and 4). Application of adhesive between the restoration and the tooth). Cohesive the Prime & Bond NT and IntegraBond agents is sensitive failure in the dentin was observed in this study and is to technique: the dentin should not be too wet or too dry.23 recognized as a limitation of the study; however, the shear Both of these bonding agents contain acetone as the solvent bond strength test was used to screen for potentially large for the hydrophilic resins. The strong air blast recom- differences among the combinations of bonding agent and mended by the manufacturer of IntegraBond probably resin cement. further aggravated the technique sensitivity of this material Although there is a lack of literature on the bond by desiccating the dentin and creating bald spots on the strength of adhesives used with resin luting cements, bonding surface. Water-based primers are less sensitive than numerous studies have measured the bond strengths of acetone-based primers to the degree of dentin moisture,23–25

232 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Effect of Mode of Polymerization of Bonding Agent on Shear Bond Strength of Autocured Resin Cements

Table 5 pH of uncured and cured compo- the binary peroxide-amine catalytic components often nents and mixtures of bonding agents present in AC resin composites. Attachment to tooth structure appears to depend on the pH ± SD formulation of the bonding agent. The different chemical Bonding agent Uncured Cured formulations of proprietary bonding agents probably Scotchbond Multipurpose Plus contributed to the differences in bond strengths observed Primer 3.8 ± 0.04 NA in this study. In a previous study, low shear bond strengths Light-cure adhesive 5.9 ± 0.24 5.6 ± 0.49a of an autopolymerizing core buildup composite bonded to Activator 6.6 ± 0.23 NA dentin with 9 dentin bonding agents were attributed to Catalyst 3.7 ± 0.08 NA 7 Activator, primer and 4.1 ± 0.00 4.0 ± 0.29a material incompatibilities. In another recent study, 2 of catalyst combined 5 bonding agents tested with an AC resin composite 11 Prime & Bond NT produced low bond strengths. One study of adhesion of Light-cure component 2.1 ± 0.31 1.7 ± 0.20a resin composite core materials to dentin8 concluded that Autocure component 7.1 ± 0.08 NA low bond strengths observed with certain combinations of Light-cure and autocure 4.2 ± 0.19 2.8 ± 0.14a components combined bonding agent and resin composite might have been due to the incompatibility of components of different manufac- IntegraBond Light-cure component 5.5 ± 0.08 5.3 ± 0.16a turers’ resins; alternatively, it was suggested that the air- Auto-cure component 4.2 ± 0.07 NA inhibited layer of the bonding agent might have Light-cure and autocure 4.9 ± 0.15 4.3 ± 0.24a contributed to inadequate polymerization at the interface components combined between resin core and bonding agent. Differences in Single Bond 4.2 ± 0.04 3.4 ± 0.47a formulation might also include type of solvent, film thick- (light cure only) ness, degree of oxygen inhibition, proportion of SD = standard deviation, NA = not applicable. hydrophilic to hydrophobic components and efficiency of aValues for the bonding agent when it was used with the resin luting cement. the initiator system. AC polymerization of IntegraBond produced low bond strengths with both resin cements, even as demonstrated with Scotchbond Multipurpose and Single though this bonding agent was not unusually acidic, so the Bond. efficiency of the AC component must be questioned. Insight into the formulation of the bonding agents was Although the studies available so far do not provide data gained by measuring the pH of the individual components to inform clinicians about the clinical performance of most of each bonding agent system. There has been speculation26 combinations of bonding agent and resin cement, making that the acidity of the bonding agent may affect the degree clinicians aware of potential clinical problems and encour- of conversion of the bonding agent or the AC resin cement. aging prudence in the selection of dental materials are the The dipentaerythritolpentaacrylate phosphate ester first steps in achieving predictable long-term clinical results. (PENTA) molecule used in Prime & Bond NT is an obvi- Conclusions ous difference in chemical composition between this agent No consistent relationship was found between shear and all the other bonding agents in this study. The known bond strength of dentin and mode of polymerization of acidity of the PENTA molecule was confirmed by the low bonding agents when AC resin luting cements were used. pH of the Prime & Bond LC component (Table 5). The Similarly, no relationship was found between shear bond bond strength of the Prime & Bond NT dual-cure compo- strength of dentin and type of bonding agent (separate or nent was higher than that of other Prime & Bond versions, combined primer and bonding agent application) when AC despite the fact that it has the same formulation as the resin luting cements were used. However, there were signif- Prime & Bond AC mixture. This suggests that the effi- icant differences in bond strength specific to the propri- ciency of the AC activator and pH may affect dentin bond etary brand of bonding agent. Prime & Bond NT and strength, because LC polymerization was necessary to IntegraBond in combination with either Calibra or RelyX increase bond strength. A microtensile bond strength study ARC cement produced the lowest mean bond strengths. showed that the bond strengths of all 4 LC 1-bottle bond- Finally, the acidity of the bonding agent and the efficiency ing agents in combination with an AC composite produced of AC polymerization may be associated with low bond significantly low bond strengths.9 There was a positive strengths when AC resin cements are used. C correlation between the acidity of the bonding agents and resulting bond strength with the AC composite. Acknowledgments: Statistical analyses were performed by Mary Ultrastructural observations provided evidence to support Cheang, biostatistical consultant, University of Manitoba, Winnipeg, the authors’ hypothesis that the residual acidic resin Manitoba. This research was conducted to satisfy the requirements for a Master of Science (Prosthodontics) degree at the University of monomers from the 1-bottle bonding agent interacted with Toronto, Toronto, Ontario.

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 233 Dong, McComb, Anderson, Tam

Dr. Dong is assistant professor, department of restorative dentistry, 11. Swift EJ Jr, Perdigao J, Combe EC, Simpson CH 3rd, Nunes MF. University of Manitoba, Winnipeg, Manitoba. Effects of restorative and adhesive curing methods on dentin bond strengths. Am J Dent 2001; 14(3):137–40. Dr. McComb is professor and head, restorative dentistry, University of Toronto, Toronto, Ontario. 12. Anusavice KJE. Phillips’ science of dental materials, 10th edition. Philadelphia: W.B. Saunders Company; 1996. Dr. Anderson is professor of prosthodontics, University of Toronto, 13. McCabe JF, Rusby S. Dentine bonding — the effect of pre-curing the and director, craniofacial prosthetic unit, Sunnybrook and Women’s bonding resin. Br Dent J 1994; 176(9):333–6. College Health Sciences Centre, Toronto, Ontario. 14. El-Mowafy OM, Rubo MH, el-Badrawy WA. Hardening of new resin Dr. Tam is associate professor, restorative dentistry, University of cements cured through a ceramic inlay. Oper Dent 1999; 24(1):38–44. Toronto, Toronto, Ontario. 15. Pashley DH, Tao L, Boyd L, King GE, Horner JA. Scanning electron Correspondence to: Dr. Cecilia Dong, Department of Restorative microscopy of the substructure of smear layers in human dentine. Dentistry, University of Manitoba, D226D-780 Bannatyne Ave., Arch Oral Biol 1988; 33(4):265–70. Winnipeg, MB R3E 0W2. E-mail: [email protected]. 16. International Organization for Standardization. ISO/TS 11405/CD 1 The authors have no declared ﬁnancial interests in any company Dental Materials - Testing of adhesion to tooth structure 2000-02-28. manufacturing the types of products mentioned in this article. Geneva, Switzerland. 17. Tantbirojn D, Cheng YS, Versluis A, Hodges JS, Douglas WH. Nominal shear or fracture mechanics in the assessment of composite- References dentin adhesion? J Dent Res 2000; 79(1):41–8. 1. Kramer N, Lohbauer U, Frankenberger R. Adhesive luting of indirect 18. Barkmeier WW, Erickson RL. Shear bond strength of composite to restorations. Am J Dent 2000; 13(Spec No):60D–76D. enamel and dentin using Scotchbond Multi-Purpose. Am J Dent 1994; 2. Burke FJ, Fleming GJ, Nathanson D, Marquis PM. Are adhesive tech- 7(3):175–9. nologies needed to support ceramics? An assessment of the current 19. Cardoso PE, Braga RR, Carrilho MR. Evaluation of micro-tensile, evidence. J Adhes Dent 2002; 4(1):7–22. shear and tensile tests determining the bond strength of three adhesive 3. El-Mowafy OM, Fenton AH, Forrester N, Milenkovic M. Retention of systems. Dent Mater 1998; 14(6):394–8. metal ceramic crowns cemented with resin cements: effects of preparation 20. Mason PN, Ferrari M, Cagidiaco MC, Davidson CL. Shear bond taper and height. J Prosthet Dent 1996; 76(5):524–9. strength of four dentinal adhesives applied in vivo and in vitro. J Dent 4. El-Mowafy OM, Milenkovic M. Retention of paraposts cemented with 1996; 24(3):217–22. dentin-bonded resin cements. Oper Dent 1994; 19(5):176–82. 21. Swift EJ Jr, Bayne SC. Shear bond strength of a new one-bottle dentin 5. Clinical research associates. Core buildup and adhesive incompatibility. adhesive. Am J Dent 1997; 10(4):184–8. CRA 2000; 24(6):1–2. 22. Wilder AD Jr, Swift EJ, May KN, Waddell SL. Bond strengths of conventional and simplified bonding systems. Am J Dent 1998; 6. Miller MB, editor. Dental adhesives. Reality Now October 2000; 126. 11(3):114–7. 7. Hagge MS, Lindemuth JS. Shear bond strength of an autopolymeriz- 23. Tay FR, Gwinnett JA, Wei SH. Micromorphological spectrum from ing core buildup composite bonded to dentin with 9 dentin adhesive overdrying to overwetting acid-conditioned dentin in water-free acetone- systems. J Prosthet Dent 2001; 86(6):620–3. based, single-bottle primer/adhesives. Dent Mater 1996; 12(4):236–44. 8. O’Keefe KL, Powers JM. Adhesion of resin composite core materials to 24. Jacobsen T, Soderholm KJ. Effect of primer solvent, primer agitation, dentin. Int J Prosthodont 2001; 14(5):451–6. and dentin dryness on shear bond strength to dentin. Am J Dent 1998; 9. Sanares AM, Itthagarun A, King NM, Tay FR, Pashley DH. Adverse 11(5):225–8. surface interactions between one-bottle light-cured adhesives and chemi- 25. Swift EJ Jr, Wilder AD Jr, May KN Jr, Waddell SL. Shear bond cal-cured composites. Dent Mater 2001; 17(6):542–56. strengths of one-bottle dentin adhesives using multiple applications. 10. Swift EJ Jr, May KN, Wilder AD. Effect of polymerization mode on Oper Dent 1997; 22(5):194–9. bond strengths of resin adhesive/cement systems. J Prosthodont 1998; 26. Suh BI, Schiltz MY. Effects of pH of single-bottle adhesive on shear 7(4):256–60. bond strength http://www.bisco.com/rp/research_article13.asp. 2001.

Chirurgie buccale et maxillo-faciale La Faculté de médecine dentaire recherche :

> un(e) professeur(e) de chirurgie buccale et maxillo-faciale à plein temps. > Fonctions Les personnes intéressées doivent acheminer leur L’enseignement et la recherche sont les composantes principales de la tâche. curriculum vitæ, accompagné de deux lettres de recommandation, au plus tard le 1er mai 2003 à : > Exigences 1. Détenir un certiﬁcat de spécialiste en chirurgie buccale et maxillo-faciale ; Prof. Monique Michaud, directrice 2. Détenir une maîtrise dans un domaine dentaire ou médical, Département de stomatologie ou une maîtrise équivalente ; Faculté de médecine dentaire 3. Détenir, ou s’engager à obtenir, un permis d’exercice de l’Ordre des C.P. 6128, succ. Centre-ville dentistes du Québec ; Montréal QC H3C 3J7 4. Maîtriser la langue française. [email protected] Conformément aux exigences prescrites en matière d’immigration > Traitement au Canada, cette annonce s’adresse en priorité aux citoyens L’Université de Montréal offre un salaire concurrentiel canadiens et aux résidents permanents. L’Université de Montréal jumelé à une gamme complète d’avantages sociaux. souscrit à un programme d’accès à l’égalité en emploi pour les femmes et au principe d’équité en matière d’emploi. > Date d’entrée en fonction 1er octobre 2003. Pour de plus amples informations, veuillez consulter notre site web : www.umontreal.ca

234 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association

A PPLIED R ESEARCH

The Effect of Cyclosporine with and without Nifedipine on Gingival Overgrowth in Renal Transplant Patients

• Abdol Hamid Khoori, DDS • • Behzad Einollahi, MD • • Ghassem Ansari, PhD • • Mohammad Bagher Moozeh, MSD •

Abstract

Purpose: This investigation was performed to evaluate the effect of cyclosporine alone and in combination with nifedipine on gingival overgrowth. Methods: One hundred and nineteen patients who had undergone renal transplantation at least 12 months previously were selected for the study. The patients were divided into 2 groups according to whether they had received cyclosporine alone (group 1, n = 98) or cyclosporine with nifedipine (group 2, n = 21). Periodontal and pharmacological characteristics were assessed for all patients. Results: Marked gingival overgrowth was seen in 11 (52%) of the patients in group 2 but just 6 (6%) of those in group 1. In addition, the gingival overgrowth index was signiﬁcantly greater for patients who had received both nifedipine and cyclosporine (Mann–Whitney U-test, p < 0.001). However, there were no signiﬁcant differences between groups with higher and lower gingival overgrowth index in terms of age, sex, cyclosporine dose, nifedipine dose or level of cyclosporine in the serum. Conclusion: The combination of cyclosporine and nifedipine may increase the incidence as well as the severity of gingival overgrowth in renal transplant patients. Among patients who had received both drugs, there was a clear relationship between gingival overgrowth and duration of cyclosporine and nifedipine use.

MeSH Key Words: calcium channel blockers/adverse effects; gingival overgrowth; immunosuppressive agents/adverse effects; kidney transplantation

yclosporine is the ﬁrst-choice immunosupressant hypertension as well as its effects in reducing cyclosporine- for preventing allograft rejection in patients who induced nephrotoxicity.3 C have received organ transplants. This drug has The aim of this study was to compare the effects of reportedly also been used for treatment of pemphigus, cyclosporine alone and in combination with nifedipine on psoriasis, type 1 diabetes mellitus and rheumatoid arthri- the gingival tissue of patients who had previously under- tis.1 However, cyclosporine can cause side effects, and gone renal transplantation. gingival overgrowth is one of the most important problems Materials and Methods associated with the use of this drug.2 The hypertension that This study involved a clinical oral examination of typically occurs in renal transplant patients is routinely patients referred to the Renal Transplant Unit at Labaﬁ treated with calcium-channel blockers. For patients receiv- Nejad Hospital, Tehran, Iran, during the year 2000. ing cyclosporine, nifedipine is the most frequently used Patients who had undergone renal transplantation at least calcium-channel blocker because of its direct effect on 12 months earlier and who had received either cyclosporine

236 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association The Effect of Cyclosporine with and without Nifedipine on Gingival Overgrowth in Renal Transplant Patients alone or cyclosporine in combination with nifedipine Table 1 Criteria for gingival overgrowth indexa throughout the intervening period were considered for inclusion. Pregnant women were excluded, to avoid any Score Criteria changes caused by hormonal effects. None of the patients 0No overgrowth, feather-edged gingival margin reported any systemic disease (e.g., diabetes, cardiovascular 1 Blunting of gingival margin; only interdental papilla involved 2 Moderate gingival overgrowth (< 1/3 of crown length) disease or epilepsy) that would affect their gingival status. 3Marked gingival overgrowth (> 1/3 of crown length) Patients were also checked to ensure that they did not have a Reprinted from McGaw and others6 with permission from Elsevier. any dental caries, crowns, fixed or removable partial dentures or crowding (any of which could lead to plaque Table 2 Demographic and pharmacotherapy retention) or any periodontal disease. At least 10 teeth in characteristics for 119 renal transplant each arch (4 anterior teeth and 3 teeth on each side of the patients posterior segment) were checked and examined. Of 317 potential patients who were examined, 119 met Group; median (and range)a the inclusion requirements. Patients were divided into Cyclosporine only Cyclosporine and 2 groups: those who had taken cyclosporine alone (group 1, Characteristic (n = 98) nifedipine (n = 21) n = 98) and those who had taken cyclosporine and nifedipine (group 2, n = 21). One dentist, who had been calibrated Sex 62:36 13:8 (ratio males:females) for his periodontal assessment skills, performed all of the Age (years) 21.2 (16–58) 21.6 (16–54) examinations. The examiner was not aware of what type of Cyclosporine therapy medicine the patients had taken. Dose (mg/kg) 3.6 (1.62–5.72) 2.6 (2.11–4.76) A whole-blood sample was obtained from each patient Duration (months) 56.0 (14–124) 57.0 (14–111) Nifedipine therapy on the day of the dental examination, before the morning Dose (mg/kg) NA 0.36 (0.15–0.60) dose of cyclosporine. A radioimmunoassay technique4 using Duration (months) NA 41.0 (13–111) a Diasorin kit (DiaSorin S.A., Antony, France) was aExcept where indicated otherwise. employed to assess the cyclosporine level in serum. Periodontal Assessment confirmed, and the Mann–Whitney U-test was employed The lingual and labial surfaces of all teeth were scored for other comparisons. Differences were considered signifi- according to the Turesky–Gilmore–Glickman modification cant at p < 0.05. of the Quigley–Hein plaque index.5 Gingival overgrowth was evaluated according to the gingival overgrowth index Results of McGaw and others.6 A score for gingival overgrowth The demographic characteristics and pharmacotherapy (ranging from 0 to 3; Table 1) was assigned for all of the history of the 119 patients who participated in this peri- upper and lower buccal and lingual gingival units, each of odontal screening are shown in Table 2. There was no which ranged from the buccal or lingual midpoint of the statistically significant difference between the 2 groups in mesial papilla to the midpoint of the distal papilla of every terms of sex ratio (p = 0.90). Gingival overgrowth index tooth. For further classification of patients, each group was showed no significant differences between male and female divided into 2 subgroups on the basis of gingival over- patients (p = 0.64). Similarly, there was no statistically growth: patients with heavy gingival overgrowth (HGO) significant difference in mean age between HGO and were those with at least 1 tooth with a score of 3 (Table 1) MGO patients within group 1 (p = 0.13) (Table 3) or or with more than 2 teeth with a score of 2 and patients within group 2 (p = 0.97) (Table 4). There were no signifi- with minimal gingival overgrowth (MGO) were those who cances in age between groups 1 and 2 (p = 0.85) (Table 5) or between all HGO patients and all MGO patients had no gingival overgrowth (score = 0 and score = 1) or 2 (p = 0.44) (Table 6). teeth or less with a score of 2. Gingival overgrowth appeared in 55 (56%) of the 98 Mean values for gingival overgrowth score were obtained patients in group 1 (cyclosporine only) and 19 (90%) of the for each sextant of the mouth (sextant I = teeth 18 to 14, 21 patients in group 2 (cyclosporine and nifedipine), for sextant II = teeth 13 to 23, sextant III = teeth 24 to 28, a total of 74 (62%) of the entire study population. Marked sextant IV = teeth 38 to 34, sextant V = teeth 33 to 43 and gingival overgrowth (HGO patients) was observed in sextant VI = teeth 44 to 48). 6 (6%) of group 1 and 11 (52%) of group 2 (p < 0.001), for Statistical Analysis a total of 17 (14%) of all patients. The Kolmogorov–Smirnov test was employed to assess There was no statistically significant difference between the normal distribution of results for each group. Student’s groups 1 and 2 in terms of dental plaque index (p = 0.55) t-test was used in cases where a normal distribution was (Table 5). Similarly, the difference in dental plaque index

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 237 Khoori, Einollahi, Ansari, Moozeh

Table 3 Differences in medical, periodontal and pharmacological variables between patients with heavy gingival overgrowth (HGO) and those with minimal overgrowth (MGO) within group 1 (cyclosporine only)

Group; mean ± SDa HGO MGO Variable (n = 6) (n = 92) p value Sex (ratio males:females) 3:3 59:33 Age (years) 26.33 ± 8.20 31.55 ± 8.32 0.13b Dose of cyclosporine (mg/kg) 4.14 ± 0.86 3.61 ± 0.81 0.14c Duration of cyclosporine therapy (months) 45.33 ± 28.04 56.76 ± 37.31 0.56c Plaque index 2.21 ± 0.87 2.07 ± 0.92 0.62c Overgrowth index 0.33 ± 0.10 0.07 ± 0.10 < 0.001c

SD = standard deviation. aExcept where indicated otherwise. bStudent’s t-test. cMann–Whitney U-test.

Table 4 Differences in medical, periodontal and pharmacological variables between patients with heavy gingival overgrowth (HGO) and those with minimal overgrowth (MGO) within group 2 (cyclosporine and nifedipine)

Group; mean ± SDa MGO HGO Variable (n = 11) (n = 10) p value Sex (ratio males:females) 6:5 7:3 Age (years) 31.69 ± 10.57 31.53 ± 10.66 0.97b Dose of cyclocporin (mg/kg) 3.54 ± 0.86 3.63 ± 0.59 0.94c Duration of cyclosporine therapy (months) 86.27 ± 27.07 25.84 ± 11.07 0.001c Plaque index 13.24 ± 34.42 2.18 ± 0.82 0.13c Overgrowth index 0.65 ± 0.29 0.13 ± 0.10 0.001c Dose of nifedipine (mg/kg) 0.33 ± 0.79 0.41 ± 0.14 0.95b Duration of nifedipine therapy (months) 59.54 ± 30.72 21.66 ± 6.95 < 0.01b

SD = standard deviation. aExcept where indicated otherwise. bStudent’s t-test. cMann–Whitney U-test.

between HGO and MGO patients within group 1 (Table 4). The level of cyclosporine in the serum did not (p =0.62) (Table 3) and within group 2 (p = 0.13) differ significantly between HGO and MGO patients in (Table 4) was not significant. However, among all 119 the whole population (p = 0.46) (Table 6). patients, the difference in dental plaque index between HGO The distribution by sextant of the mean values and MGO patients was significant (p = 0.03) (Table 6). (± standard deviation) for gingival overgrowth score in the With regard to duration of cyclosporine therapy, there HGO patients was as follows: sextant I, 0.4 ± 0.49; sextant was no significant difference between HGO and MGO II, 0.9 ± 0.55; sextant III, 0.3 ± 0.53; sextant IV, 0.3 ± 0.59; patients within group 1 (p = 0.56) (Table 3) or overall sextant V, 0.9 ± 0.46; sextant VI, 0.4 ± 0.64. Among these (p = 0.30) (Table 6), but the difference was significant sextants, the highest scores occurred in sextants II and V. within group 2 (p = 0.001) (Table 4). The gingival overgrowth score in sextant V was higher on The dose of cyclosporine was not significantly different the labial surface than the lingual surface (data not shown). The differences among sextants in the gingival overgrowth between groups 1 and 2 (p = 0.87) (Table 5). Similarly, the score were highly significant (p < 0.002). differences in cyclosporine dose between HGO and MGO patients were not significant within group 1 (p = 0.14) Discussion (Table 3) or group 2 (p = 0.94) (Table 4). Gingival overgrowth is a proven side effect induced There was a significant difference between HGO and by the combination of cyclosporine and nifedipine. In this MGO patients within group 2 in terms of duration of study, mean gingival overgrowth score in group 2, which had nifedipine therapy (p < 0.01) (Table 4), but the dose of this received both cyclosporine and nifedipine (0.40 ± 0.34), was drug did not differ between these subgroups (p = 0.95) significantly higher than the corresponding score for group 1,

238 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association The Effect of Cyclosporine with and without Nifedipine on Gingival Overgrowth in Renal Transplant Patients

Table 5 Differences in medical, periodontal and pharmacological variables for the 2 study groups Group; mean ± SDa Cyclosporine only Cyclosporine and nifedipine Variable (n = 98) (n = 21) p value Sex (ratio males:females) 62:36 13:8 0.90b Age (years) 31.23 ± 8.36 31.61 ± 10.34 0.85c Dose of cyclosporine (mg/kg) 3.64 ± 0.82 3.57 ± 1.73 0.87d Duration of cyclosporine therapy (months) 56.06 ± 36.79 48.04 ± 29.9 0.32d Plaque index 2.08 ± 0.91 7.98 ± 2.54 0.55d Overgrowth index 0.09 ± 0.12 0.40 ± 0.34 < 0.001d SD = standard deviation. aExcept where indicated otherwise. bChi-square test. cStudent’s t-test. dMann–Whitney U-test.

Table 6 Differences in medical, periodontal and pharmacological variables between patients with heavy overgrowth (HGO) and those with minimal overgrowth (MGO) Group; mean ± SDa HGO MGO Variable (n = 17) (n = 102) p value Sex (ratio males:females) 9:8 66:36 Age (years) 29.81 ± 9.89 31.55 ± 8.51 0.44b Dose of cyclosporine (mg/kg) 3.75 ± 0.88 3.61 ± 0.79 0.42c Duration of cyclosporine therapy (months) 60.17 ± 28.73 53.72 ± 36.75 0.30c Plaque index 9.35 ± 27.75 2.08 ± 0.91 0.03c Overgrowth index 0.54 ± 0.28 0.08 ± 0.1 0.001c Serum level of cyclosporine (ng/mL) 179.20 ± 92.52 194.10 ± 75.22 0.46b SD = standard deviation. aExcept where indicated otherwise. bStudent’s t-test. cMann–Whitney U-test. which had received cyclosporine only (0.09 ± 0.12) In a recent study, nifedipine-treated men were 3 times (p < 0.001). According to previous reports, gingival over- more likely to experience gingival overgrowth than growth occurs in about 30% of cyclosporine-treated women.11 However, several other studies have shown no patients,5 with prevalence ranging from 6% to 81%.7,8 The correlation between sex and gingival overgrowth.7,12 In the combination of cyclosporine with nifedipine is accompanied present study, there was no significant difference in gingival by greater gingival overgrowth, with a reported prevalence of overgrowth index between men and women, although there 48% to 60%.3,9 Thus, gingival overgrowth is more frequent was a higher incidence of gingival overgrowth in women. and more severe when cyclosporine and nifedipine are This result could be due to the difference in measuring combined.3,9,10 methods or devices for the HGO patients and the effect of individual predispositions in fibroblastic function.6 It is believed that the pharmacodynamics of cyclosporine Some authors have stated that gingival overgrowth is and nifedipine is based on calcium regulation, as well as the dependent on drug dose.3,8 In animal studies, the dose of synthesis and release of collagenase. Other metallopro- nifedipine alone had a clear effect on gingival overgrowth, teinases are derived from fibroblasts, a process that depends but this was not the case when nifedipine and cyclosporine on calcium level.9 Any changes in the synthesis or release of were used together.13 The results of the current investigation collagenase from fibroblasts may lead to destruction of colla- agree with those of other authors14–16 in not supporting a gen. Lack of balance in the production and destruction of role for dose dependency of the drugs alone or together. collagen is one of the main mechanisms of gingival over- It has been stated that dental plaque has a fundamental growth.9 The combination of cyclosporine and nifedipine role in gingival overgrowth induced by cyclosporine has a more disruptive effect on collagen degradation because intake,17 and other studies have reported a significant corre- it is accompanied by the increasingly inhibitory effects of lation between plaque or gingivitis and the prevalence and both drugs on collagenase (which is calcium dependent). severity of gingival overgrowth.7,9 In contrast, some The collagen level in the connective tissue may then rise, researchers have found no correlation between plaque or which in turn leads to more severe gingival overgrowth. gingivitis and gingival overgrowth.8 A recent study showed

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 239 Khoori, Einollahi, Ansari, Moozeh

that dental plaque had no role in gingival overgrowth, responses of these cells to drugs that induce gingival over- but that gingivitis might have a predisposing effect.18 In growth to clarify the correlation between duration of ther- the study reported here, the role of dental plaque was apy and gingival overgrowth. assessed among patients with marked and less significant In conclusion, the combination of cyclosporine and gingival overgrowth. There was no significant difference nifedipine may increase the incidence as well as the severity within group 1 (cyclosporine only; Table 3) or group 2 of gingival overgrowth. Dental plaque does not play a (cyclosporine and nifedipine; Table 4), but the difference major role in gingival overgrowth during therapy with was significant when the results for all patients were cyclosporine or cyclosporine combined with nifedipine. analyzed together (p = 0.03) (Table 6). This analysis However, the role of other factors in predisposition or exac- suggests that dental plaque has a predisposing role in gingi- erbation of tissue overgrowth cannot be ruled out by the val overgrowth, such that when this factor was considered results of the present study. There was a relationship in groups 1 and 2 separately, it was overshadowed by other between gingival overgrowth and duration of cyclosporine factors, such as drug dose or duration of drug therapy, and and nifedipine intake in the group taking both of these no significant correlation could be seen. However, when the drugs. Individual variations in cyclosporine metabolism or larger population was evaluated, the effect of plaque on response of the gingival fibroblast subpopulation to gingival overgrowth could be detected more easily, and the cyclosporine or its metabolites might also be important C correlation was statistically significant. The plaque index causative factors. was higher in patients with marked gingival overgrowth. Therefore, poor oral hygiene due to gingival overgrowth Acknowledgments: The authors wish to express their thanks for the support and help of Mr. A. Azargashb, Dr. M. Nafar, and may be the main cause of plaque accumulation, and Dr. A. Firoozan throughout the preparation of this work. increasing plaque index is secondary to severe gingival over- Dr. Khoori is a graduate dentist from the Shahid Beheshti University growth. However, it would appear that dental plaque, even of Medical Sciences, Tehran, Iran. if necessary, is not sufficient to account for development of Dr. Einollahi is assistant professor, department of kidney transplant, the gingival response in patients receiving cyclosporine. In Baghiatollah University of Medical Sciences, Tehran, Iran. Dr. Ansari is associate professor, department of child dental health, the present study, several patients in the MGO group dental school, Shahid Beheshti University of Medical Sciences, exhibited a high dental plaque score but displayed no Tehran, Iran. evidence of gingival overgrowth. Data from cross-sectional Dr. Moozeh is a professor of periodontics, department of periodontol- studies such as these, however, should be evaluated with ogy, dental school, Shahid Beheshti University of Medical Sciences, Tehran, Iran. caution, and further long-term studies are necessary to clar- Correspondence to: Dr. Abdol H. Khoori, PO Box 49175-331, ify this issue. The role of local and pharmacological para- Gorgan, Iran. E-Mail: [email protected]. meters in the pathogenesis of cyclosporine-induced gingival The authors have no declared financial interests. overgrowth remains unclear. A significant inverse correlation between the duration of References cyclosporine therapy and gingival overgrowth was reported 1. Bach JF. Lessons for transplant immunosuppression from the usage for a group of cardiac transplant patients.19 Some authors of cyclosporin in autoimmune diseases.Transplant Proc 1994; have reported a relationship between gingival overgrowth 26(5):3077–81. 20 2. Seymour RA, Thomason JM, Ellis JS.The pathogenesis of drug- and duration of nifedipine intake. Animal studies have induced gingival overgrowth. J Clin Periodontol 1996; 23(3Pt1):165–75. shown that cyclosporine-induced, nifedipine-induced and 3. Margiotta V, Pizzo I, Pizzo G, Barbaro A. Cyclosporin- and nifedipine- phenytoin-induced gingival overgrowth is related to the induced gingival overgrowth in renal transplant patients: correlations duration of drug therapy.12 However, other authors have with periodontal and pharmacological parameters, and HLA-antigens. J Oral Pathol Med 1996; 25(3):128–34. reported no significant correlation between the duration of 4. Henry GB, Davey FR, Herman CJ, McPherson RA, Pincus MR, therapy and gingival overgrowth.6,7 Comparison of the Threatte GA, and other. Clinical diagnosis and management by labora- HGO and MGO patients within group 2 of this investiga- tory methods. Philadelphia: W.B. Saunders; 2001. p. 354–6. tion showed a significant correlation between gingival over- 5. Newman MG, Carina FA. Carranza’s clinical periodontology. Philadelphia: Saunders; 1990. p. 125–48. growth and duration of cyclosporine and nifedipine ther- 6. McGaw T, Lam S, Coates J. Cyclosporin-induced gingival overgrowth, apy (Table 4). Individual susceptibility could be considered correlation with dental plaque scores, gingivitis scores and cyclosporin the cause, as the reaction of gingival fibroblasts to the over- levels in serum and saliva. Oral Surg Oral Med Oral Pathol 1987; 64(3):293–7. growth inducers might vary according to ethnic back- 7. King GN, Fullinfaw R, Higgins TS, Walker RJ, Francis DM, ground.9 Other factors, including mean duration of ther- Wiesenfeld D. Gingival hyperplasia in renal allograft recipients receiving apy, dose of drug and measuring techniques, could also cyclosporin-A and calcium antagonist. J Clin Periodontol 1993; account for differences in results that have been reported in 20(4):286–93. 8. Hefti AF, Eshenaur AE, Hassell TM, Stone C. Gingival Overgrowth in the literature. Further investigations are suggested to define cyclosporin-A treated multiple sclerosis patients. J Periodontol 1994; different types of gingival fibroblasts and differential 65(8):744–9.

240 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association The Effect of Cyclosporine with and without Nifedipine on Gingival Overgrowth in Renal Transplant Patients

9. Thomason JM, Seymour RA, Rice N. The prevalence and severity of cyclosporin- and nifedipine-induced gingival overgrowth. J Clin Our Pharmacy Team Can Help You Periodontol 1993; 20(1):37–40. 10. Pan WL, Chan CP, Huang CC, Lai MK. Cyclosporin-induced gingi- Save On Your Dental Preparations ! val overgrowth. Transplant Proc 1992; 24(4):1393–4. Our pharmacy team can 11. Ellis JS, Seymour RA, Steele JD, Robertson P, Butter TJ, Thomason JM. Prevalence of gingival overgrowth induced by calcium channel block- custom compound dental ers: a community-based study. J Periodontol 1999; 70(1):63–7. preparations for your 12. Nishikawa S, Nagata T, Morisaki I, Oka T, Ishida H. Pathogenesis of drug-induced gingival overgrowth. A review of studies in the rat model. practice. We have the J Periodontol 1996; 67(5):463–71. knowledge, expertise, and 13. Chiu HC, Fu E, Chiang CY, Liu D. Does nifedipine aggravate cyclosporin-induced gingival overgrowth? An experiment in rats. equipment to compound a J Periodontol 2001; 72(4):532–7. variety of preparations 14. Thomason JM, Seymour RA, Ellis JS, Kelly PJ, Parry G, Dark J, and other. Iatrogenic gingival overgrowth in cardiac transplantation. including: antibiotic rinses / gels, bleaching JPeriodontol 1995; 66(8):742–6. agents, chelating agents, dry socket 15. Barclay S, Thomason JM, Idle JR, Seymour RA. The incidence and severity of nifedipine-induced gingival overgrowth. J Clin Periodontol preparations, desensitizing agents, etches, 1992; 19(5):311–4. hemostatic agents, and much more. If a 16. Cebeci I, Kantarci A, Firatli E, Carin M, Tuncer O. The effect of vera- pamil on the prevalence and severity of cyclosporin-induced gingival over- dental preparation has been discontinued, growth in renal allograft recipients. J Periodontol 1996; 67(11):1201–5. commercially unavailable, or overly expensive, 17. Seymour AR, Jacobs DJ. Cyclosporin and the gingival tissues. J Clin Periodontol 1992; 19(1):1–11. our pharmacy team may be able to help. For 18. Miranda J, Brunet L, Roset P, Berini L, Farre M, Mendieta C. more information, please contact Strathcona Prevalence and risk of gingival enlargement in patients treated with nifedipine. J Periodontol 2001; 72(5):605–11. Prescription Centre to speak to a 19. Montebugnoli L, Bernardi F, Magelli C. Cyclosporin-A induced compounding pharmacist. gingival overgrowth in heart transplant patients. A cross-sectional study. J Clin Periodontol 1996; 23(9):868–72. 20. Tavassoli S, Yamalik N, Caglayan F, Caglayan G, Eratalay K. The clin- Call Toll Free Today Will Leung ical effects of nifedipine on periodontal status. J Periodontol 1998; 69(2):108–12. 1 (888) 433-2334 B.Sc. Pharmacy STANDARD AUTOMATIC

SHIFT TO AN EASIER WAY TO LEASE THE CANADIAN DENTAL AUTO LEASING PROGRAM You could take the standard approach to vehicle leasing by doing everything yourself. Search everywhere for the car you want. Arrange test drives. Face the prospect of nerve-racking negotiations. Handle all the paperwork. But why deal with that stress when you can have all of these things done automatically by a leasing professional? Just call the Canadian Dental Auto Leasing Program. You’ll speak with a leasing expert who will take care of all the details on your behalf. You’ll also benefit from highly competitive lease rates and terms that suit your exact needs, and a virtually unlimited selection of vehicles. Call the Canadian Dental Auto Leasing Program toll-free today: 1-877-88-CDALP (1-877-882-3257) Available exclusively to dental professionals and their families,the Canadian Dental Auto Leasing Program is an Affinity Service of CDSPI,operated by Cardel Leasing Limited. 03-250 02/03

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 241

Clinical Abstracts

The Clinical Abstracts section of JCDA features abstracts and summaries from peer-reviewed dental publications. It attempts to make readers aware of recent literature that may be of interest to oral health care workers. It is not intended to provide a systematic review of the topic. This month’s selection provides an update on some aspects of endodontic treatment. The articles were chosen by Dr. Jeffrey M. Coil, assistant professor and chair of the division of endodontics at the faculty of dentistry, University of British Columbia.

Straight Talk about Endodontic Treatment Commentary Jeffrey Coil, DMD, MSD, PhD, FRCD(C)

This month’s selection of articles was chosen to provide tions that is effective? Which ones have the most morbidity? evidence to guide the practitioner in the diagnosis, instru- When treatment is completed, which access ﬁlling material mentation or restoration of endodontically treated teeth. gives the best seal? Doesn’t every material leak over time? It Each article deals with one particular aspect of endodontic has been found that IRM placed as a temporary material in management, providing answers to questions commonly the access cavity leaked more than CAVIT or Dyract. asked by practitioners. Several factors must be considered Once a tooth undergoes endodontic treatment, the next during clinical treatment: Should CO2 snow be used or will step is to plan for the restoration of that tooth. Should a Endo-Ice suffice for performing a cold test? What speed metal post be used or a resin-ceramic post? Which post and and torque do I need for root canal instrumentation with core system gives rise to less vertical root fracture? One nickel-titanium rotary ﬁles? What level of experience do I should always preserve tooth structure when performing need before performing instrumentation this way? What is restorative treatment. It is always desirable to retain as the best antibiotic to use for patients exhibiting signs of much coronal dentin as possible when preparing a coronal endodontic infection? Is there a combination of medica- restoration retained by a post and core. C

Which cold test methods are more effective in evaluating pulp health? Jones VR, Rivera EM, Walton RE. Comparison of carbon dioxide versus refrigerant spray to determine pulpal 1 responsiveness. J Endod 2002; 28(7):531–3. Background design on 2 separate occasions. Responsiveness or nonre- Clinicians use a variety of cold tests to evaluate pulp sponsiveness to cold was recorded and the time interval health. The materials used include carbon dioxide dry ice from application to response was measured. (CO ), dichlorofluoromethane refrigerant spray (RS), ethyl 2 Results chloride and ice water. Studies seem to indicate that CO 2 Regardless of tooth category and degree of restoration, tests are more effective than the latter 2. This study aimed both methods of cold testing were equally effective in to compare the effectiveness of CO and RS in eliciting a 2 producing a pulpal response. RS elicited a response more patient response from various types of teeth with different quickly than CO . This difference was statistically signifi- degrees of restoration. 2 cant (p < 0.05). Methods Clinical Significance Fifteen human subjects participated in the study. In each There was no clinically significant difference between quadrant, 3 teeth (an anterior tooth, a premolar and a the 2 agents. Patients were indifferent to the type of mater- molar) were identified and the restoration type recorded. ial used. C The teeth of blindfolded subjects were tested with either CO2 (Odontotest) or RS (Hygenic Endo-Ice) in a crossover

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 243 Clinical Abstracts

Can instrument deformation and separation be avoided with a crown-down technique? Yared GM, Dagher FE, Machtou P, Kulkarni GK. Influence of rotational speed, torque and operator proficiency on 2 failure of Greater Taper files. Int Endod J 2002; 35(1):7–12.

Background speed was 150 rpm. Each set of instruments was used in a Instrument deformation and separation are undesirable maximum of 10 canals. The number of locked, deformed when performing endodontic therapy. This study evaluated and separated instruments was recorded for each group. the impact of rotational speed, torque and operator profi- Results ciency on the incidence of locking, deformation and sepa- In the rotational speed evaluation, instrument deforma- ration of instruments with Greater Taper Ni-Ti rotary tion and separation did not occur. Instrument locking instruments (GT) used in extracted human molar teeth. occurred at 350 rpm only. There was no separation, defor- Methods mation or locking at the different torque values. There was For this 3-part study GT rotary instruments were no statistical difference between the 3 operators in terms of used with a crown-down technique on test subgroups of instrument separation, even though the untrained clinician 100 canals. For the rotational speed evaluation, speeds of experienced 2 separated instruments. The instruments of 150, 250 and 350 rpm (at a torque of 20 Ncm) were used. the untrained clinician deformed and locked considerably more often than those of the experienced operators. For the torque evaluation, torque was set at 20, 30 and 55 Ncm (at 150 rpm). In the evaluation of operator Clinical Significance proficiency, 3 clinicians with different levels of experience It is important to get pre-clinical training in the use of (an endodontist and a GP trained in the technique, as well the GT rotary instruments for use with a crown-down as a GP without training) were also compared. For this technique. The less experienced operator should probably portion of the experiment, torque was set at 20 Ncm and use the instruments at lower rotational speeds. C

Which antibiotics are effective against endodontic infections? Baumgartner JC, Xia T. Antibiotic susceptibility of bacteria associated with endodontic abscesses. J Endod 2003; 3 29(1):44–7.

Background cillin + clavulanic acid, clindamycin, metronidazole, and The choice of antibiotic agent to treat an endodontic clarithromycin. infection is usually based on evidence from published liter- Results ature and clinical experience. There is, however, growing Thirty-three strains of bacteria were facultative anaer- concern that more bacteria are developing resistance to obes and 65 were strict anaerobes. The percentages of currently prescribed antibiotics. From the endodontic susceptibility for the 98 species were: penicillin V, 85%; perspective, it is particularly worrying that gram-negative amoxicillin, 91%; amoxicillin + clavulanic acid, 100%; bacteria, often found in endodontic infections, are becom- clindamycin, 96%; and metronidazole 45%. ing increasingly resistant to penicillin. The aim of this study Metronidazole had the greatest amount of bacterial was to measure the antibiotic susceptibility of a range of resistance; however, if used in combination with penicil- bacteria (98 strains) isolated from 12 endodontic abscesses. lin V or amoxicillin, susceptibility for the combination Methods increased to 93% and 99%, respectively. Clarithromycin The bacterial samples in this study were aspirated with a seems to be an effective antibiotic for this type of lesion, needle from the endodontic abscesses. Bacteria were culti- but it is still considered an antibiotic under investigation in vated, and species were identified. Each of the 98 species of this circumstance. bacteria identified was tested for antibiotic susceptibility to Clinical Significance 5 individual antibiotics and 1 combination of 2 antibiotics. Antibiotics should only be prescribed as an adjunct to The antibiotics used were penicillin V, amoxicillin, amoxi- clinical treatment when the patient has systemic symptoms

244 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Clinical Abstracts

associated with the endodontic infection, that infection is amoxicillin + clavulanic acid are indicated for immuno- progressing or the patient is immunocompromised. The compromised patients and those with the most serious authors believe that penicillin V is still the antibiotic of infections. Clindamycin is a good choice for patients aller- choice for most endodontic infections. Amoxicillin and gic to penicillin. C

Do post and core systems improve the fracture resistance of endodontically treated teeth? Pontius O, Hutter JW. Survival rate and fracture strength of incisors restored with different post and core systems and 4 endodontically treated incisors without coronoradicular reinforcement. J Endod 2002; 28(10):710–5.

Background was intermittently loaded and thermocycled before under- The restoration of endodontically treated teeth presents going stress tests. a particular challenge because of their predisposition to Results fracture. While posts don’t strengthen endodontically Survival rates after 1.2 million cycles in the simulated treated teeth, they are sometimes necessary to support cores oral environment were 90% (group A), 80% (group B), and restorations. Clinicians have considerable choice 60% (group C) and 100% (group D). Statistically signiﬁ- among post systems. The purpose of this in vitro study was cant differences were found between all groups (except A to measure the survival rate and fracture resistance of upper and B). Samples in group A demonstrated more vertical central incisors restored with 3 different post and core root fractures, while those in groups C and D tended to systems. fracture horizontally at the cementoenamel junction. In Methods group B, neither the zirconia post nor the root tended to The systems investigated were a prefabricated precious fracture. metal post with a cast core (group A), a zirconia post with Clinical Signiﬁcance a prefabricated bonded ceramic core (group B) and an The preservation of tooth structure is very important experimental resin-ceramic composite post with a prefabri- when restoring endodontically treated teeth. Resin cements cated bonded ceramic core (group C). In the control group can be recommended for the cementation of posts as a (D), which did not have reinforcement of the post, the means of preventing coronal microleakage. C access cavity was closed with a light-cured composite in combination with a dentin bonding agent. Each specimen

Does the retention of coronal dentin strengthen teeth restored with partial post and cores? Al-Wahadni A, Gutteridge DL. An in vitro investigation into the effects of retained coronal dentine on the strength of a 5 tooth restored with a cemented post and partial core restoration. Int Endod J 2002; 35(11):913–8.

Background Methods Whenever a post and core restoration is indicated, it is Forty extracted single-rooted human teeth were used for imperative to preserve as much tooth structure as possible this experiment. They were divided into 4 groups in which to reduce unnecessary stresses and maintain the seal of the there was either no retained coronal dentin (group A), root treatment. Evidence indicates that retained coronal 3 mm of retained buccal coronal dentine (group B), 4 mm dentin can increase post length, improve retention and (group C), or 5 mm. A post channel and shoulder were reduce post rotation. prepared, and cast post (9 mm in length) and core were Experts are divided as to whether retaining coronal cemented with zinc phosphate cement to simulate clinical dentin has an impact on the strength of teeth restored with conditions. post and core restorations. This study aimed to examine The distance from the shoulder to the top of the core was the fracture resistance of teeth restored in this manner 5 mm. The “restored” teeth (no crowns were placed) were and supported by different amounts of coronal tooth tested to failure with an Instron Universal Testing Machine. structure. Patterns of failure were recorded photographically.

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 245 Clinical Abstracts

Results Clinical Significance A significantly greater mean force was required to cause It is desirable to retain a portion of the coronal dentin fracture in group B (271 N) than in the other 3 groups. when preparing a coronal restoration retained with post and There was no significant difference between groups A core. If this dentin is too thin the portion of the die replicat- (209 N), C (238 N) and D (239 N). ing it may break, leading to inaccuracy in core fabrication. C

Which temporary restorative materials prevent coronal microleakage after root canal treatment? Balto H. An assessment of microbial coronal leakage of temporary ﬁlling materials in endodontically treated teeth. 6 J Endod 2002; 28(11):762–4.

Background in the access cavities of the 8 control teeth (4 positive and It is imperative to place a high quality restoration subse- 4 negative). The access cavity and the apical foramen of the quent to obturating a root canal system. There is evidence negative control were sealed with nail polish. that apical periodontitis, consequent to coronal microleak- Each tooth was placed in a tissue culture plate and age, occurs far less frequently when a good coronal restora- embedded in a broth and agar solution. Marker organisms tion is placed. were placed in the access cavity, and microbial leakage was To date there had been no study examining coronal deemed to have occurred if there was an increase in the microleakage associated with various temporary restorative turbidity of the broth. materials used to seal access cavities. This in vitro study Results evaluated the microbial leakage associated with Cavit, IRM With both microbiological markers, IRM leaked within and Dyract (with bonding agent) when used in this clinical 10 days, while Cavit and Dyract leaked at 14 days. All posi- situation. tive control teeth leaked within 7 days. None of the nega- Methods tive controls had leaked by the end of the experimental period (30 days). Coronal leakage was measured using 2 microbiological markers. For each marker, the root canal systems of 15 Clinical Significance maxillary premolars were prepared and obturated with In this study, Dyract and Cavit performed better than gutta-percha. In each subgroup of 5 teeth, a layer (3.5 mm IRM in preventing coronal microleakage. The use of the thick) of one of the 3 temporary filling materials was bonding agent may have been an important factor explain- inserted in the access cavities. No filling material was placed ing the performance of Dyract. C

246 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Hold it!

And experience the comfort, control and precision of the NEW Interdental Brush System from Oral-B.®

Get a better handle on grips provide increased comfort and interdental cleaning maneuverability while a sliding “hinge” Newly redesigned with a more comfortable system provides easy access to molars and dual-material grip, the Oral-B Interdental interproximal areas, and an adjustable Brush offers increased control, even when brushhead allows for better reach. wet. And thanks to a more ergonomic handle and sleek, contemporary styling, it also encourages patient compliance. The Oral-B Compact Interdental Brush What’s more, the oval shape provides better roll, allowing your patients to Recommend the Interdental easily manipulate the brush 360 degrees. Brush System from Oral-B. Call our preferred Oral-B Dental Distributors or And for your patients on the go friendly Customer Service Representatives The Oral-B Compact Interdental Brush at 1 800 268-5217 to take advantage of is designed to fit easily into a purse or our “Buy 2 Boxes Get 1 Free” promotion pocket and combines convenience with available on all interdental products, exceptional control. Ribbed, rubber thumb including our new Patient Starter Kit.

The NEW Oral-B Interdental Brush www.oralb.com

A big advantage of joining CDA is that members are entitled to special discount rates for CDA and FDI World Dental Federation conferences

Several events hosted by CDA and FDI are coming up:

• CDA is co-hosting the 2003 Jasper Dental Congress with the Alberta Dental Association and College. The event will take place May 22–25 at the Fairmont Jasper Park Lodge and other venues in this scenic community. The congress features a world-class program of speakers targeted at the entire dental community, as well as special programs for spouses, partners and children. There will be a different social activity each day, from the opening night “Shake (or Stir) it up!” welcoming reception to the “Survivor Saturday!” ﬁnal social event on the congress’ closing night.

• CDA will co-host the 2004 Paciﬁc Dental Conference with the Association of Dental Surgeons of British Columbia. This national conference will take place March 4–6 at the Vancouver Convention & Exhibition Centre. Top-ﬂight speakers will be on hand and the latest dental products and services displayed at 350 exhibit spaces.

• FDI’s 2003 World Congress will be held September 18–21 at the Convention and Exhibition Centre in Sydney, Australia. The scientiﬁc program will feature sessions on new developments in infection control, saliva as a diagnostic tool, periodontal chemotherapy, the art and science of adhesive restorative dentistry, improving patient compliance, sleep apnea, sports injuries, and much more. Post-congress excursions to Ayer’s Rock, the Great Barrier Reef and New Zealand are optional.

• FDI 2004 World Dental Congress will be held September 10–13 at the Pragati Maiden Conference Centre in New Delhi, India. Over 9,000 delegates from FDI’s 182 member-associations (including CDA) are expected to attend this event in India’s beautiful and ancient capital city.

For information on membership in CDA,contact Bernadette Dacey, Manager, Membership Promotion, Canadian Dental Association, 1815 Alta Vista Drive, Ottawa, ON K1G 3Y6 Tel.: (613) 523-1770, ext. 2229, e-mail: [email protected]. Point of Care

The Point of Care section of JCDA answers everyday clinical questions by providing practical information that aims to be useful at the point of patient care. The responses do not purport to set forth standards of care or clinical practice guidelines. Readers are encouraged to do more reading on the topics covered. If you would like to submit or answer a question, contact editor-in-chief Dr. John O’Keefe at [email protected].

What is the best way to prevent paresthesia when placing root-form implants intended for Question 1 overdenture retention?

Background to the Problem Even though the anterior mandible is the most accessible In Brånemark’s original studies of treatment of eden- part of the mouth for surgery and even though it has no tulism, he placed 1 mandibular midline implant and 2 vital structures, which makes it the safest area for implant implants on either side of the midline implant, between the placement, transient alteration in sensation after surgery is mental foramina, for a total of 5 implants. A ﬁxed, retriev- common. In one retrospective study 37% of the patients reported altered sensation after implant surgery, and long- able prosthesis was then attached to the implants after the term changes occurred in 13%. In more than 60% of symp- appropriate healing period. tomatic patients the onset was within 1 week of the surgery To simplify implant treatment of mandibular edentulism and involved the distribution of the mental nerve. researchers and clinicians have developed successful Resolution usually occurred within 6 months. protocols with 4, 3, 2 and even a single implant for the The mandibular nerve courses inferior and anterior to stabilization and retention of the overdenture. The risk of the mental foramen, then loops superiorly and posteriorly sensory disturbance of the lower lip is a possible complica- to exit, as the mental nerve, through this opening. The tion of such surgery, and patients must be made aware of anterior extension of the resulting nerve loop is located this possibility before treatment. mesial to the mental foramen, often by as much as 10 mm.

Figure 1: A typical panoramic view such as Figure 2: A midline releasing incision with Figure 3: Good visual access allows this one does not show the mental foramina a midcrestal incision extending to the preparation of the planned osteotomies. clearly. cuspid area is safe.

Figure 4: The last of 3 press-ﬁt implants is Figure 5: The patient is ready for ﬂap Figure 6: Postoperative panoramic radio- seated. closure around the one-surgery implants. graph taken at follow-up.

(Tenax implants [Tenax Implant Inc., Collingwood, Ont.] were used in the example illustrated here.)

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 249 Point of Care Because of its position, there is risk of surgical trauma to 3. In accordance with the manufacturer’s instructions, this loop. place the implants into the osteotomies (Fig. 4). Management of the Problem 4. Close the incisions with preferred suture material (Fig. 5). Even though standard panoramic radiographic views 5. Complete the postsurgical follow-up as usual (Fig. 6). seldom show the mental foramina clearly (Fig. 1) and large With elimination of the midline implant, the above marrow spaces often mimic the mental foramina in appear- steps can be applied to the common protocol of placing ance, proper treatment planning allows placement of 2 implants, 1 in each of the cuspid areas. Paresthesia will implants in the anterior mandible with minimal risk of occur in some patients for a week or 2, as a result of injury to the mental nerve. (Tomograms and computed pressure on the mental nerves from postsurgical swelling. tomography scans interpreted by trained radiologists are However, with the steps described above, physical trauma reliable, but access to these types of imaging is limited in to the nerve is unlikely. C many parts of the country.) It is important to keep in mind that the mental foram- Further Reading ina are located just apical to and between the bicuspids. Ellies LG. Altered sensation following mandibular implant surgery: a retrospective study. J Prosthet Dent 1992; 68(4):664–71. The author favours the following approach: Wismeijer D, van Waas MA, Vermeeren JI, Kalk W. Patients’ perception 1. Make a midline releasing incision and then a midcrestal of sensory disturbances of the mental nerve before and after implant incision that extends laterally to the cuspid area on both surgery: a prospective study of 110 patients. Br J Oral Maxillofac Surg 1997; 35(4):254–9. sides (Fig. 2). Raise a ﬂap to allow good visualization of Walton JN. Altered sensation associated with implants in the anterior the osseous architecture. mandible: a prospective study. J Prosthet Dent 2000; 83(4):443–9. 2. In accordance with the implant manufacturer’s instructions, prepare a midline osteotomy followed by another Dr. Milan Somborac is coinventor of the Tenax Dental Implant osteotomy on each side of the ﬁrst one, just mesial to the System and a shareholder in Tenax Implant Inc. He maintains a cuspid areas (Fig. 3). private practice in Collingwood, Ontario.

Can the clinician proceed with planned immediate placement of an implant if, on raising a ﬂap, Question 2 he or she ﬁnds that the buccal wall has been destroyed?

Background to the Problem Management of the Problem Immediate implant placement is becoming preferred In the recent past, any tooth with a vertical root fracture over the traditional implant surgery protocol whereby a would have been removed and the site grafted in anticipa- healing period of 3 to 6 months is allowed after tooth tion of implant treatment. The implant would have been extraction. Recently, both animal1 and prospective human2 placed after a healing period of 3 months. This approach is studies have shown that the clinical outcome and degree of still appropriate in cases of extensive bone destruction, osseointegration are the same with either approach. The where primary implant stability is impossible to achieve. major advantage of immediate placement is that it helps to However, if primary implant stability is possible, then plac- maintain the bony crest and preserve the alveolar anatomy, ing the implant at the time of extraction is an option. in addition to shortening the treatment period. The objective is absolute stability of the implant and full Achieving primary implant stability is one of the basic coverage of the intraosseous aspect of the implant with principles of osseointegration. In many cases of long- autogenous bone or a mix of autogenous bone and graft standing vertical root fracture in maxillary anterior teeth, material. The author adheres to the following protocol: the thin buccal wall of bone is destroyed by the disease 1. Make releasing incisions designed to preserve the papil- process (Fig. 1), which makes stabilization a challenge. lae adjacent to the implant site. To do so, design all Furthermore, the bony void created by the destruction is incisions so as not to raise the papillae mesial and distal often so large that the intraosseous part of the implant body to the surgical site (such incisions are visible in all figures sits within the void rather than within bone. On healing, showing surgery). Raising a flap that includes the adja- some of the intraosseous aspect of the implant may be in a cent papillae results in gingival healing apical to the flap’s supragingival position. The intraosseous part of all implant original position. If crowns are present on adjacent teeth systems is rough and hence becomes a plaque trap if their margins become exposed and compromise the exposed in this way. esthetic appearance. The flap base should be wider than

250 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Point of Care

Figure 1: Vertical root fracture of tooth 11 is Figure 3: The implant is stable, but some of associated with destruction of the buccal the intrabony aspect is within the void. wall.

Figure 2: Dotted line shows direction for ideal placement of the implant.

Figure 4: A 1:4 mix of autogenous bone and Figure 5: The mucosa is sutured with 4-0 Figure 6: Image of the healed site shows a a bioactive glass ceramic is placed over the chromic gut material. Inset: Postoperative transfer coping in the implant. The patient is defect. periapical image. ready for the prosthetic phase of treatment.

(In the example illustrated here, the surgery was completed by Dr. Dilshad Hirji and a Tenax implant and PerioGlas [John O. Butler, Guelph, Ont.] bioactive glass ceramic were used.)

its free end to ensure a good blood supply. It should be 6. Close the incisions with preferred suture material (Fig. 5). sufficiently apical to allow good visualization of the site. 7. When the implant has healed (see manufacturer’s Occasionally, to enhance visualization, a similar flap recommendation for timing), start the prosthetic treat- must be raised palatally. ment (Fig. 6). C 2. Following the implant manufacturer’s instructions, References prepare the osteotomy using an osseous coagulum trap 1. Schultes G, Gaggl A. Histologic evaluation of immediate versus to vacuum up and save any bone particles resulting from delayed placement of implants after tooth extraction. Oral Surg Oral Med the drilling process. Direct the osteotomy to take full Oral Pathol Oral Radiol Endod 2001; 92(1):17–22. 2. Polizzi G, Grunder U, Goene R, Hatano N, Henry P, Jackson WJ, and advantage of available bone (Fig. 2). others. Immediate and delayed implant placement into extraction sock- 3. Place the implant into the osteotomy, ensuring that it is ets: a 5-year report. Clin Implant Dent Relat Res 2000; 2(2):93–9. stable (Fig. 3). 3. Cordioli G, Mazzocco C, Schepers E, Brugnolo E, Majzoub Z. Maxillary sinus floor augmentation using bioactive glass granules and 4. If the bone-harvesting procedure performed in step 2 autogenous bone with simultaneous implant placement. Clinical and does not produce enough material to overfill the void, histological findings. Clin Oral Implants Res 2001; 12(3):270–8. then mix the harvested autogenous bone with up to 4 times as much bioactive glass ceramic moistened with Dr. Milan Somborac is coinventor of the Tenax Dental Implant normal saline or platelet-rich plasma (Fig. 4). A bioac- System and a shareholder in Tenax Implant Inc. He has no financial interest in PerioGlas. Dr. Somborac maintains a private practice in tive glass mixed in a 4:1 ratio with autogenous bone Collingwood, Ontario. yields sufficient quality and volume of mineralized tissue Dr. Dilshad Hirji has no financial interest in either Tenax Implant for a predictable outcome.3 Inc. or PerioGlas. She maintains a private practice in Thornhill, Ontario. 5. Overfill the void with the mix created in step 4. Some of this material will resorb, but no exclusion membranes will be needed.

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 251 Point of Care

Question 3 I think my patient needs a splint. What is the best option?

Oral appliances are widely used. Well- recognized varieties include the protective sport guard and the occlusal splint appliance. Not as well recognized, but increasingly common, are oral devices for patients in whom a sleep specialist has diagnosed either primary snoring or mild to moderate obstructive sleep apnea. Although the exact mechanisms of Figure 1: Occlusal splint appliance. Figure 2: Occlusal splint appliance in place. action remain unclear, occlusal splint appliances have demonstrated efficacy and are used as an academic training and expertise to guide you and your adjunct to treatment of orofacial pain. Over the years, patient in decision making. If an occlusal splint is chosen numerous splint designs and construction materials have as a treatment adjunct, the authors recommend a custom- been advocated, and the proposed benefits of specific made hard acrylic appliance (Fig. 1) with full occlusal designs, materials and modes of therapeutic action have coverage incorporating gnathological principles (Fig. 2), been described. This range of information has led to and close, long-term follow-up. C confusion on the part of practitioners who want to provide an appropriate standard of care. In responding to this ques- Dr. Norman Thie, clinical director of the Temporomandibular tion, the authors do not want to add to the confusion. Disorder/Orofacial Pain Clinic, department of dentistry, University of Alberta, Dr. Ivonne Hernandez, a clinical instructor of the clinic, Rather, they believe that readers should critically review the and Dr. Pablo Kimos, resident of the clinic, provided the information literature, starting with the list of further reading at the for this response. The authors would like to thank Linda Hlus for her end of this article. Such critical review will allow them assistance in preparing the manuscript. to make more confident treatment recommendations for their uninformed patients. It should be noted that Further Reading although there may be diagnostic similarities among Okeson JP. Orofacial pain. Guidelines for assessment, diagnosis and patients with orofacial pain, there are no “cook books” for management. Chicago: Quintessence Publishing Co, Inc.; 1996. Major PW, Nebbe B. Use and effectiveness of splint appliance therapy: treatment; each patient is unique and requires an individu- review of literature. Cranio 1997; 15(2):159–66. alized treatment approach, which may entail long-term Dao TTT, Lavigne GL. Oral splints: the crutches of temporomandibular follow-up and perhaps modifications to the original treat- disorders and bruxism? Crit Rev Oral Biol Med 1998; 9(3):345–61. ment plan. Lund JP, Lavigne GJ, Dubner R, Sessle BJ. Orofacial pain: from basic science to clinical management. Chicago: Quintessence Publishing Co, The authors urge practitioners not to experiment with Inc.; 2001. treatment, since the inadequate diagnosis and incomplete Kreiner M, Betancor E, Clark GT. Occlusal stabilization appliances, understanding of the nature of a particular problem(s) evidence of their efficacy. J Am Dent Assoc 2001; 132(6):770–7. implied by such experimentation will lead to treatment fail- Kato T, Thie NMR, Montplaisir JY, Lavigne GJ. Bruxism and orofacial ures. Instead, become (and stay) well informed about movements during sleep. Dent Clin North Am 2001; 45(4):657–84. Okeson JP.Management of temporomandibular disorders and occlusion. evidence-based approaches. Also, become knowledgeable 5th ed. St. Louis: Mosby, Inc.; 2003. about and avoid outdated approaches (e.g., the concept of “recapturing” discs) and be cautious in using any marketed devices or medications supported by no more than single reports of efficacy with inadequate controls and lack of randomization, blinding and placebos. For more thorough experience, consider enrolling in programs, residencies and study clubs devoted to treating patients with temporomandibular disorders and orofacial pain. Oral appliances should not be used indiscriminately; doing so will lead to treatment failure, frustration, the patient’s loss of confidence and the potential for serious iatrogenic results. If there is any doubt about the diagnosis or treatment, search for a specialist with the appropriate

252 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Point of Care

Question 4 At what age should a child’s ﬁrst oral exam be scheduled?

Background to the Issue treatment, and anticipatory guidance. Preventive strategies This issue has been a challenging one for our profession. may start prenatally by targeting the mother, and include While postponing the first oral exam until such time as a modification of diet and use of chewing gum with xylitol. child will accept examination may result in delayed diagno- Preventive strategies are effective in improving the mother’s sis and treatment, a hasty and premature exam may prove oral health and in delaying the transfer of Streptococcus to be insignificant and worthless. Unless a child needs to be mutans to the infant. Modification of the child’s diet and seen for a systemic or pathologic condition, the first oral use of fluoride varnishes are beneficial in intercepting the exam is primarily aimed at assessing oral hygiene and caries process when diagnosed early. For medically compro- dietary habits that may render the child prone to early mised children who may be at higher risk of developing childhood caries (ECC). dental dysplasia and caries, anticipatory guidance may be ECC is one of the most common chronic diseases of the most effective preventive strategy. infancy and childhood, with potentially adverse effects on Health professionals must be aware that all national the general health of children. Treatment of ECC is the regulatory bodies strongly recommend that the first oral main reason for children undergoing general anesthesia in exam be conducted within 6 months after the eruption of most regions of North America. ECC is preventable and the first tooth or by the age of one year. If treatment is easily manageable when diagnosed early. required, reasonable options for managing the disease Early evaluation of children with ECC will allow for should be offered to the parent. timely intervention, in the form of interceptive or definitive Purpose of the Examination Table 1 Diagnosis, treatment and prevention The purpose of the first oral examination is to diagnose, of early childhood caries treat and prevent ECC (Table 1). C

Diagnosis Dr. M-Reza Nouri is a pediatric dentist practising with the 1. Assess the medical history and associated events that may have PDG Pediatric Dental Group in Greater Vancouver, B.C. oral implications. 2. Complete the clinical oral examination and appropriate diagnostic tests to assess oral growth and development or Further Reading pathology. Gunay H, Dmoch-Bockhorn K, Gunay Y, Geurtsen W. Effect on caries 3. Assess oral hygiene and feeding practices. experience of a long-term preventive program for mothers and children 4. Determine fluoride exposure and dietary intake. starting during pregnancy. Clin Oral Investig 1998; 2(3):137–42. 5. Diagnose developing and existing dental caries and anomalies. Ismail AI. The role of early dietary habits in dental caries development. Treatment Spec Care Dentist 1998; 18(1):40–5. Karn TA, O’Sullivan DM, Tinanoff N. Colonization of mutans 1. Refer for further medical assessment when indicated. streptococci in 8- to 15-month-old children. J Public Health Dent 1998; 2. Remove stains and deposits as indicated. 58(3):248–9. 3. Treat caries lesions: Nowak AJ, Casamassimo PS. Using anticipatory guidance to provide • topical fluoride for incipient lesions early dental intervention. J Am Dent Assoc 1995; 126(8):1156–63. • caries control for early lesions Soderling E, Isokangas P, Pienihakkinen K, Tenovuo J, Alanen P. • restorative care for moderate to advanced lesions. Influence of maternal xylitol consumption on mother-child transmis- 4. Remove infected teeth and provide space maintainers when sion of mutans streptococci: 6-year follow-up. Caries Res 2001; indicated. 35(3):173–7. 5. Take appropriate actions following abnormal and pathologic Weerheijm KL, Uyttendaele-Speybrouck BF, Euwe HC, Groen HJ. findings. Prolonged demand breast-feeding and nursing caries. Caries Res 1998; Prevention 32(1):46–50. 1. Provide anticipatory guidance to the parents on the oral implications of any significant medical history. 2. Provide oral hygiene and dietary counselling. 3. Counsel parents on the appropriate use of fluoride supplements. 4. Provide counselling on non-nutritive oral habits (digit, pacifiers, etc.). 5. Provide age-related preventive counselling for orofacial trauma. 6. Counsel parents on behaviour modification. 7. Provide anticipatory guidance relating to dental anomalies (e.g., dysplasia). 8. Determine interval for periodic recall examinations.

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 253 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 Seg Fund Investment Account and CDA RESP.

CDA Fund Performance (for period ending February 28, 2003)

MER 1 year 3 years 5 years 10 years

CDA CANADIAN GROWTH FUNDS Aggressive Equity Fund (Altamira) up to 1.00% -8.7% -6.5% -1.4% n/a Common Stock Fund (Altamira) up to 0.99% -17.5% -11.0% 1.8% 6.1% Canadian Equity Fund (Trimark)†1 up to 1.65% -14.3% 2.9% 2.4% 8.7% Special Equity Fund (KBSH)†2 up to 1.45% -18.0% -24.4% -0.6% 15.8% TSX Composite Index Fund (BGI) up to 0.67% n/a n/a n/a n/a CDA INTERNATIONAL GROWTH FUNDS Emerging Markets Fund (KBSH) up to 1.45% -14.8% -16.3% -0.4% n/a European Fund (KBSH) up to 1.45% -39.5% -26.6% -6.8% n/a International Equity Fund (KBSH) up to 1.45% -31.8% -27.3% -3.9% n/a Paciﬁc Basin Fund (KBSH) up to 1.45% -21.3% -37.1% -6.2% n/a US Equity Fund (KBSH)†3 up to 1.20% -28.8% -18.3% -1.0% 9.4% Global Fund (Trimark)†4 up to 1.65% -18.5% 4.8% 4.1% 11.7% Global Stock Fund (Templeton)†5 up to 1.77% -27.8% -10.5% n/a n/a S&P 500 Index Fund (BGI)†† up to 0.67% -29.0% -13.6% -2.8% 9.9% CDA INCOME FUNDS Bond and Mortgage Fund (Elantis) up to 0.99% 5.1% 6.4% 5.2% 6.9% Fixed Income Fund (McLean Budden)†6 up to 0.97% 6.0% 7.4% 5.7% 7.9% CDA CASH AND EQUIVALENT FUND Money Market Fund (Elantis) up to 0.67% 2.0% 3.5% 3.9% 4.3% CDA GROWTH AND INCOME FUNDS Balanced Fund (KBSH) up to 1.00% -10.1% -6.0% 2.1% 7.0% Balanced Value Fund (McLean Budden)†7 up to 0.95% -8.3% 2.3% 4.3% 8.3%

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 this fund. 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.

254 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association

New Products With this issue, JCDA introduces a New Products section, providing readers with brief descriptions of recent innovations in dentistry. Publication of this information does not imply endorsement by JCDA or the Canadian Dental Association. If you would like material to appear in JCDA’s New Products listing, send all news releases and photographs to Rachel Galipeau, coordinator, publications, at [email protected]. English- and French-language material will be given priority.

Lares Research announces Ultra-Access, a high-speed handpiece with a head size smaller than any other handpiece currently available. At 9.7 mm length and 8.5 mm diameter, the head is over 25% smaller than the average “small” head high-speed, yet Ultra-Access delivers cutting power equivalent to many larger-head handpieces. Ultra- Access provides increased visibility and better access, making it easier to perform precision cavity preparations in difficult locations within the oral cavity. • Lares Research, 800-347-3289, ext. 1, www.laresdental.com •

The Pulpdent Embrace WetBond Pit and Fissure Sealant is the first pit and fissure sealant and small lesion restorative that can be applied in a wet field. Unlike traditional sealants, Embrace chemically bonds to the tooth, integrating with the tooth structure to create a strong, margin-free bond that virtually eliminates microleakage. Embrace WetBond Pit and Fissure Sealant is formulated from an improved dental resin that is wet bonding for easier application. The product is self-priming, self-bonding and requires no mixing. • Pulpdent, 800-343-4342, www.pulpdent.com •

Dent-Line of Canada Inc. introduces the exchangeable VKS-OC/SG attachment stud, developed by Bredent. The stud is made of biocompatible titanium, whereas the threaded retainer is composed of a gold/palladium alloy. The exchangeable stud is used with plastic retention sleeves that provide a secure anchorage through 3 levels of retention. When the retention sequence is exhausted and the stud wears, a new exchangeable stud can be screwed in place intraorally and a new plastic retention sequence can commence. • Dent-Line of Canada Inc., 800-250-5111, www.dent-line.com •

Nu Radiance, Inc. has released Forté, the first calcium peroxide-based teeth whitener. Forté combines calcium peroxide (in a water base) with carbamide peroxide (in a glycerin base) at the time of whitening. The non-acidic pH provides etch-free whitening, while the calcium helps to prevent decalcification and promote re-calcification. Forté is also virtually sensitivity-free, as it uses water-based calcium peroxide to optimize the release of whitening, while providing water to prevent tooth desiccation — the cause of tooth sensitivity. Nu Radiance Forté is also available in patient take-home kits. • Nu Radiance, Inc., 866-899-3207, [email protected] •

256 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association Classified Ads Guaranteed access to Canada’s largest audience of dentists

$500,000 on 185 days, 6 hours/day. O FFICES & To place your ad, contact: Area has all forms of recreation available P RACTICES - a great place to live! One-quarter ownership in 9,000 sq. ft. building also Beverley Kirkpatrick or ALBERTA - Foothills/Rockies: Three- available. I am flexible. Tel. (250) 338- Deborah Rodd operatory clinic with extra operatory 6080 (private line). D1330 c/o Canadian Medical Association plumbed. Beautiful design with modern 1867 Alta Vista Dr. equipment. Computerized with intra- Ottawa, ON K1G 3Y6 BRITISH COLUMBIA - Victoria: oral cameras. The area offers a wide vari- Tel.: 800 663-7336 or Practice for sale. Retiring from family/ ety of outdoor recreation and beautiful (613) 731-9331, ext 2127 residential long-established practice. scenery. Furthering studies. Tel. (780) or 2314 Broad patient base (approximately 2,000 405-7032. D1291 Fax: (613) 565-7488 active charts). Grossing $460,000/year on E-mail: [email protected] 60% leisurely work time. Three operato- ALBERTA - Grande Prairie: Do not ries - ADEC equipment in shared newer read this ad unless you want to buy a building. Brian Williams, tel. (250) Placement of ads by telephone not busy established dental office. An excep- 479-1388 after 6 p.m. Pacific Time or accepted. tionally high gross and net income. Suit- [email protected] D1323 able for 2 or 3 dentists. Grande Prairie is Deadline Dates a hot spot in Alberta for growth. Call BRITISH COLUMBIA - Vancouver Christina, (780) 539-3079 or e-mail Issue Closing Date Island: Two successful practices for sale [email protected] D1273 June May 9 in beautiful Vancouver Island. Gross July/August June 20 ALBERTA: Busy, modern dental prac- $800,000 each, 180 days/year; 3-1/2 tice for sale in a growing city of over operatories each. Motivated staff, 2 hy- Send all box number replies to: 20,000 only 2 hours drive from Ed- gienists. Nice patients, high proportion Box ... JCDA monton. Net annual income consis- insured. Beautiful office, plenty of 1867 Alta Vista Dr. tently in the $200,000 - $220,000 range natural light. Owners going to graduate Ottawa, ON K1G 3Y6 school. Interested in one or both, please on a 4-day week. Excellent staff in place Classified Ads e-mail [email protected] D1304 The names and addresses of advertis- with new leaseholds and state-of-the-art ers using box numbers are held in equipment. Will assist with smooth BRITISH COLUMBIA - Vancouver: strict confidence. transition. Owner returning to school. Priced at $275,000. Reply to: CDA Urban sophisticate wanted. Downtown Classified Box # 2829. D1234 Vancouver waterfront practice grossing Display Advertising Rates $1.1 million, net $500,000 on 4-day 1 1 page 1,640 ⁄3 page 590 ALBERTA - Northeastern: Excep- week - 10 weeks holidays. Beautiful new 2 1 ⁄3 page 1,165 ⁄4 page 515 tional opportunity, full-time general 4-chair office with spectacular views (20- 1 1 ⁄2 page 875 ⁄6 page 405 practice. High net income with 50% year lease) and top-of-the-line equipment 1 ⁄8 page 275 overhead; 4 operatories and 1,900 active including digital and lasers. Practice has patients. Beautiful 2,500 sq. ft. building been established over 60 years. Ideal for 1 Regular Classified Rates with excellent lease agreement. Please or 2 dentists, you must like crown and $85 for the first 50 words or fewer, call (780) 853-4704 or e-mail neslo bridge and routine cosmetic dentistry. each additional word 75¢. Reply box @silvercrest.ab.ca D1195 Owner will associate back for limited numbers $20 (first insertion only). period of time to assist transition. BRITISH COLUMBIA - Courtenay Associate to purchase or purchasing 1 1 Special Display (2 ⁄8˝ x 2 ⁄8˝) $200. (Vancouver Island): Practice for sale. 1/2 of practice possible. Price and terms I want to transition out completely or are flexible, if you are dedicated to qual- All advertisements must be prepaid. partially - someone to carry on what ity and gentle dentistry - continuous I’ve built up - wonderful patients and learning a must. Please send your CV wonderful staff. Building and equip- and a covering letter outlining your 10% discount to CDA members. ment 10 years old, 6 operatories, practice philosophy and goals to Mr. J. 2,200 sq. ft., 1,600 active charts, mid Leland, fax (604) 629-0759. D1280

Journal of the Canadian Dental Association April 2003, Vol. 69, No. 4 257 BRITISH COLUMBIA - Prince Owner retiring; will stay for transition. strictly confidential. Fax (780) 474-6308, George: Thriving, well-managed general Good potential for growth. Call (416) e-mail [email protected] D1328 practice in a friendly central B.C. 762-1201 or (416) 769-7488. D1320 university city (UNBC). Owner look- ALBERTA - Calgary: Full-time, experi- ing to relocate for family reasons. ONTARIO - Ottawa: Busy, growing enced associate (5 + years) required for $750,000 + in 2002 while taking lots of dental practice for sale. Five operatories; TLC Dental Care starting June 1. Ap- vacation time. Bright, popular, fully gross revenues of $1.5 million. Owner proximately 2,000 patients with 30-40 loaded (computerized, panorex, intra- returning to school. Will assist in transi- new patients per month. Some evenings oral cameras, 4 operatories, etc.) office tion. Call Tess at (613) 834-6336. D1325 and alternate Saturdays required. Contact: with fantastic team members and Dr. John Tamminen, e-mail Ejtamm@aol “Grade A” patients. Best of all, there is a .com or fax (403) 259-2622. D1327 wonderful “opposite-partner” to take ONTARIO - Ottawa South: Well- care of emergencies (while you take time established, 4-operatory general practice off) and to share some of the overhead. set in ideally located house. Suitable for ALBERTA - Edmonton (South): Please call Vicki, (250) 565-7767 or 1-2 dentists. Owner will stay for transi- Exciting and fulfilling associate opportu- tion. Above-average gross. Excellent nity available immediately. Position is e-mail [email protected] D1319 growth potential. If interested please call full time in an established, fast-paced (613) 859-1876. D1313 BRITISH COLUMBIA - Okanagan family practice. We are seeking an indi- Valley: Periodontal practice for sale or vidual who is enthusiastic, motivated partnership with eventual sale. Very ONTARIO: Are you selling your practice? and looking to complement a great attractive Okanagan Valley location. Experienced dentist seeks to purchase team. Please call (780) 465-0994 or fax Large referral base. Unparalleled 4-seasons practice or associate with intent to in confidence (780) 463-3691. D1326 lifestyle. Good potential for growth. Tel. purchase. Within 1.5 hours of Toronto. If (250) 764-4775. D1213 you are considering selling your practice, ALBERTA: Associate positions available contact me in total confidence. Reply to: immediately at busy, relaxed and BRITISH COLUMBIA - Kamloops: CDA Classified Box # 2833. D1281 dental office. Excellent energetic Well-established family practice. support staff. Just quick 2 hours west of Downtown location. Three operatories, ONTARIO - Downtown Toronto: Bay Edmonton. Great family-oriented town. 1,300 active patients. Gross $650,000+. Street, newly renovated building. Excellent opportunity for a self-moti- Low overhead, very profitable. Nice Suitable for medical/dental/optical and vated, conscientious individual. New office, staff and patients. Tel. (250) 851- other professional uses. New cabinets, graduates welcome. Also open for 8901 (evgs. and weekends). D1090 reception, counter and displays. Entire purchase option. For more information, floor, 3,003 sq. ft., dividable; tax, main- tel. (780) 779-0030 (res.), (780) 778- BRITISH COLUMBIA - Nelson: Very tenance, insurance at $17.50/sq. ft. 4646 (bus.), (780) 706-6142 (cell). D1321 successful, family practice. Beautiful free- includes utilities and janitorial service. Classified Ads standing office. Four Adec operatories. Call Betty, (416) 543-1300. D1248 Best lifestyle anywhere. All transitions ASSOCIATE considered. Details: tel. (250) 825-9932, QUEBEC – Îles de la Madeleine: Calgary, Alberta e-mail [email protected] D1044 Dental clinic for sale. Diversified practice established for 9 years. Two-storey Oral and maxillofacial surgery NEW BRUNSWICK - Grand Falls: premises (1,850 sq.ft.) with 4 operato- practice requires a full-time associate Well-established family practice, with ries, a sterilization unit and Triangle to assist in well-established busy 6,000 plus patients. Computerized office furniture. Ideal practice for 1 practice. Must be eligible for a licence to practise in Alberta. Excellent modern equipment with intraoral dentist, or a couple, in a marvelous cameras. Superb building, 6,200 sq. ft., opportunity with great earning setting. Visiting orthodontist and potential. shared with 2 general practitioners. maxillofacial surgeon (minor surgery Touristic town, bilingual with 80% fran- and implantology). For information, Please reply to: CDA Classified Box cophones, 1 hour and 15 minutes from please call (418) 839-8293 or visit 2813. D991 Rivière-du-Loup. Lots of entertainment http://www.cliniquedelarchipel.cjb. and activities such as a golf course, a bike net D1277 path and a sports centre. Close to a U.S. ALBERTA - Rural: Full-time associate- airport. Call Marium, after 7 p.m., at ship available. Established family prac- (506) 473-9805 or e-mail mlking@nb P OSITIONS tice. Relaxed atmosphere. Ideal for the .sympatico.ca D1332 A V AILABLE caring, patient-oriented dentist. Great family town with a myriad of outdoor ONTARIO - Toronto: Established 2- ALBERTA - Edmonton: Associate recreation opportunities; 3 hours from operatory dental practice set in a house dentist required for very pleasant office in Edmonton. Tel. Constantin, (780) 753- for sale. Steps to subway, High Park area. West Edmonton. Full time. All replies 7901 or (780) 753-6676. D1296

258 April 2003, Vol. 69, No. 4 Journal of the Canadian Dental Association J unlo h aainDna soito April2003, Vol. 69,No. 4 ournal of theCanadianDental Association To E-mail [email protected]

604-803-6133 Advertisements arealso at noadditionalcharge Renting your vacation (www.cda-adc.ca/jcda) Beverley Kirkpatrick or place your CDA classiﬁed Vancouver Buying equipment? F Selling apractice? Leasing anoffice? fo Appraisals time time Waiti to In have atypicallifespan ofto 5years.1 a professional,and comprehensive appraisal. Appraisals decisions.almostareof aid Practiceswiththesoldalways bank, the accountants andthe lawyersmake to informed owner. The appraisal will assist you,purchaser, the the The a ax (613)565-7488 Web: www.roicorp.com E-mail: roi@ Phone: 905-820-4145 published online

(800) 663-7336 r afree copy ofour Practice Preservation package.

e th Deborah Rodd have anappraisalwithyour valuabledocuments. xt. 2127/2314 e ad contact: of ne of ng for a complete appraisal to be performed in this To ppraisal has becomean essential tool for thepractice property? event ofsudden a death disability,or importantitis ll-free at Practice Preservation ed can decrease the saleprice ofyourpractice. can beupdat roicorp.com CORPORATION 888-ROI-4145 Appraisal Calgary ed quickly at little or no cost. Call . professionals whoarededicatedtotheAppraisal Over 3,000ofyourcolleagueshavesince1974 & Saleofyourpractice.Ifyouareconsidering ROI Corporationisthelargestassemblyof call yourROICorporationassociatefirst. a strategicchangewithinyourpractice, 905-820-4145 Stand Ms.Dorothy For moreinformationregarding applicationforthispositioncontact: teaching hospitals.Ithasavacancy inPediatricDentistrybeginningJuly1orJune15. This 1-yeardentalresidencyprogramme isoffered inconjunctionwithUniversity-affiliated Fax (604)822-3562 Mrs. Viki Koulouris,[email protected]. (604)822-4486/ For moreinformationregardingapplicationtotheaboveprogrammes contact: specialties combined. based, stipendedresidencyinoneofthreepathways:OralMedicine, Pathology, or both conjunction withUniversity-affiliated teachinghospitals.Itconsistsofa3or4-yearhospital- This postgraduateresidencytraininginOralMedicineandPathology isoffered in Association. Itisalsorecognizedbythe American Dental Association. Periodontics. The 3-yearprogrammeiscerti This programmeoffers anM.Sc.degreeandpostgraduateclinicalspecialisttrainingin various oralanddentalsciences. Ph.D. degreerequiresaminimumof3yearsforcompletion.Bothoffer researchtrainingin M.Sc. degreenormallyrequires2yearsfull-timestudy, andcanalso betakenparttime. The These graduateprogrammesareresearch-oriented,anddonotincludeclinicaltraining. The ORAL MEDICINEANDPATHOLOGY POSTGRADUATE PROGRAMME Toronto WHAT ATEAM! Applications areinvitedforadmissiontothefollowinggraduate COMBINED M.Sc(DENTAL SCIENCE)andDIPLOMAPROGRAMME Þ eld, [email protected] Tel (604)822-0345/Fax822-3562. H NVRIYOFBRITISHCOLUMBIA THE UNIVERSITY GRADUATE/POSTGRADUATE STUDIES 19Wsro al acue,BC,Cnd VT1Z3 2199 Wesbrook Mall,Vancouver, B.C.,CanadaV6T GENERAL PRACTICERESIDENCY PROGRAMME . M.Sc. andPh.D.inDENTAL SCIENCE 613-226-5775 TOPICS: 1. Tips for buying and sellinga practice. ra We

F future plans, oryour unique circumstances. so you make arrangements for an after-hours appointment Ca is team10associat of

and postgraduateprogrammes:

nging from the establisheddentist to therecent graduate.

CLYOFDENTISTRY ACULTY

Ottawa a

n t

vai

hat ada widedozenshaveweOur of practices sale.for

have over 25seminarsin 2003, suitable foreveryone

abl

we maybetter understand practice,youryour

2.Exiting ownershipprofitably. 3.Locum Lifestyle™–Part-Time Dentistry

e for private consultations. We suggest that IN PERIODONTICS

for lifewith freedom from ownership.

Seminars es (5 of (5 es Þ Brokerage ed andfullyaccreditedbytheCanadianDental 514-697-2383 . Montreal

whom are licence 902-657-1175 d Halifax entis ts) D1100 D1236 259

Classified Ads Classified Ads 260 accommodations available Comfortable boating, fishing andsnowmobiling. and great golfcourseswithgoodaccessto J town of about 1hournorth Winnipeg. lifestyle isavailable inthisfriendlyrural MANITOBA -Pine Falls: 699-6969, fax(250)699-6679. (160 days/year) andrising. Tel. (250) work “dentist’sfor part-time choice” educated patients. The gross is$337,000 Pr forasingledentist. small apartment conditioned building,2,000sq.ft.,hasa will assistintransition.Great staff. Air- Owner wishestoretire after24years and Three operatoriesandroom for3more. fice andbuildingforsaleinCentralB.C. associate required, buy-inpossibility. Of- O BRITISH COLUMBIA -Central: 374-4643. (250) 374-3499orcallSue at(250) Ne for fantasticyear-round recreation. is locatedclosetomountainsandlakes an easy-going,friendlyatmosphere and attend graduateschool.Kamloopshas r position withgoodearningstrack J ing Fri r B BRITISH COLUMBIA -Kamloops: 655-4244. r thrive inthissuperior West Coastenvi- A personable,client-centred dentistwill andqualityorientedclients. support We ted toexcellence, continuestogrow. O charming oceansidetown near Victoria. Ex BRITISH COLUMBIA -Sidney: 5868 (evgs.). from Edmonton. Tel. Neil, (780)484- r family town withamyriadofoutdoor dentist. New graduatewelcome. Great I energetic staff. Relaxed atmosphere. Established familypractice. Young, ALBERTA -Rural: ust minutesawayfrom Grand Beach une 2003. Well-established associate deal forthecaring,patient-oriented ecreation Quick 2hours opportunities. onment. Dr. Harold Prussin, tel.(250) equires associate4days/week includ- ecord. Current associateleavingto usy, family-orientedgroup practice nly dentalofficeintown. Experienced ur non-assignmentpractice,commit- eventive-orientated officewithwell- ceptional career inour opportunity w graduateswelcome. Fax resume to

have strong labandspecialist days andSaturdays, starting pi 03 o.6,N.4Journal oftheCanadianDental Association April 2003, Vol. 69, No.4 Associate required. An awesome D1128 D1267 D1297 D1014 Sm D send resume to:Dr. Hill, Fort Smith 5813, [email protected] or T future and/orsuccession. partnership for compensation package.Opportunity established patientbaseandanexcellent This isafull-timepositionofferingan ideal locationifyou love theoutdoors. the Slave River rapids,Fort Smith isan of located besideworld-classwhitewater for Wood Buffalo National Park and skilled andexperiencedstaff. The centre modern, well-equipped clinicwith range ofyour skillsworking inour Sm 367-2208 formore information. 4587, Attn: Heather orcallusat(204) r and earnincredible income.Please fax graduatetoincreasenity foranew speed on site,ifdesired. Anexcellent opportu- quired forgroup practice.Excellent op- ONTARIO -London: P busy practiceestablishedfor 13 years. timeorfulltime,inamodernand part treal andOttawa). Associateshipavailable, ONTARIO -Eastern: CDA ClassiﬁedBox #2828. expectations, to: including CVandsalary tion package.Please send application andcompensa- ritories. Attractive salary the cityof Yellowknife, Northwest Ter- dontic labtechniciantolive andwork in lowknife: NORTHWEST TERRITORIES-Yel- Fo NORTHWEST TERRITORIES- y at (506)458-9584. We to lookforward r busy immediately. Please faxyour excellent clinicalandpersonalskills.Be astic individualwithhighenergyand potential. We are lookingforanenthusi- lished practiceof18years withbuy-in modern operatories. This isalong-estab- Ve dentist forourgeneraldentalpractice. We NEW BRUNSWICK -Fredericton: esume to:Dr. AlanGrant, (204)367- esume to(506)458-9481,orcallLynne our reply. lease faxCVto(613)632-8396. el. (867)872-2044,fax872- ental Clinic,POBox 1047,Fort ry rt ith Dental Clinic.Utilize thefull ith, NTX0E0P0.

are currently seekinganassociate busy officewithafamilyfocus.Five Sm ith: S eeking experiencedortho- Associate dentistforFort (Between Mon- Associate re- D1322 D1131 D1309 D1216 D1191 (613) 794-5594. friendly environment. Please callBen at cated tocomprehensive dentalcare ina modern work environment thatisdedi- ofourteamina invited tobepart and highlymotivated associatesare nation’s capital.Experienced, energetic of ourgrowing patientbaseinthe our practicetoaccommodatetheneeds ONTARIO -Ottawa: @mac.com (613) 722-3636ore-mailingmaris the practice.Contactusby telephoneat tobuyinto hours andgoodopportunity established endodonticpractice.Flexible associate positionavailable inbusy, ONTARIO -Ottawa: Classiﬁed Box #2835. In operatories, laser, estheticscentre, etc. facility. instate-of-the-art portunity Ten W, 1738 orwriteto: 1201ColonizationRd. (evgs. andweekends), fax(807)274- (807) 274-5365(days), 274-5549 and goodqualitydentistry. Please call lifestyle. Emphasis oncaringattitude for personwithanoutdoor, active border Ontario. innorthwestern Ideal ing conditions.Practice on American gross, high net.Excellent staffandwork- booked 6monthsinadvance. High ily dentalpractice.Dentist andhygienists associate neededforextremely busyfam- ONTARIO -Fort Frances: 201, [email protected] D Dr O minutes toKingstonand60 access tolargecitycentres. Only 30 of the1000Islands region witheasy town atmosphere andthescenicbeauty lished, busypractices.Enjoy asmall- associate required for1of2well-estab- ONTARIO -Brockville: 384-4337. Lorrie, tel.(613)384-4224,fax be available July 2003.Please contact M Pr busygroupquired practice. forvery ONTARIO -Kingston: ental Canada,tel.(416)785-1828,ext. ttawa. For more informationcontact: terest inperioanasset.Reply to:CDA esent associateisrelocating to aritimes inJune 2003.Position will . George Christodoulou,Altima

Fo rt

F rances, ONP9A 2T6. We Fu ll- orpart-time

are expanding Associate re- E xperienced Fu ll-time D1223 D1269 D1293 D1289 D1301 D1310 J to: CDAClassified Box # 2834. patient care apriority. Confidentialreply skilled, personableandwho considers anticipated fortherightindividual whois Pr established, solo,bilingual practice. associaterequiredfacial surgery forwell- QU (819) 777-2902. Se needed formaternityleave, mid- Q (819) 825-2204. T three dentists.Establishedpatientbase. Associate neededtoreplace oneofthe Q Classified Box #2776. purchase. Please reply to: CDA O associate for2-3daysperweek tostart. area. We are lookingforaperiodontistto specialty practiceintheNorth Toronto dontist wanted. We are aperiodontal ONTARIO -North Toronto: ONTARIO - Windsor: or Judith, tel.(705)745-9632. please contactSusan, tel.(705)749-0133 available May 2003.For information friendly andknowledgeable. Position staffthatis strong, competentsupport only, noevenings orweekends. We have a accounts receivable. Office hoursare days non-assignment practicewithlow terminals andintraoralcameras. This isa equipped operatoriesincludingcomputer r present associateisrelocating outwest to assume afull-timepatientload. The O still have acloseproximity to Toronto. lake country, withallithastooffer, but forthosewhoenjoytional opportunity ONTARIO -Peterborough: [email protected] 0985, fax(519)734-8853ore-mail to: Dr. Joe Multari, tel.(519)252- partnership. Please reply inconfidence nity. Associateshippositionleadingto ally rewarding private practiceopportu- illofacial surgery. Full-scope, profession- unlo h aainDna soito April2003, Vol. 69,No. 4 ournal of theCanadianDental Association ejoin family. We have 6modernly rained staff. Contact:Johanne, tel. UEBEC - Val-d’or (Abitibi area): ur busyofficerequires anassociateto UEBEC -Hull: pportunity forfuturepportunity partnership/ ogression tobuyinandrole reversal ptember 2003. Very busyclinic. Tel. EBEC -Montreal: Or Locum dentist O al andmaxillo- ral andmax- An excep- P erio- D1279 D1300 D1331 D1329 D1268 D492 .cjb.net or visithttp://www.cliniquedelarchipel information, pleasecall(418)839-8293 Av practice withstableandqualifiedstaff. and multi-talentedformultidisciplinary time dentistwanted.Serious, dynamic, Q In interested inalong-termrelationship. and committed toqualitydentistry clinic. We are lookingforaperson Associate required for a5-chairdental YUKON TERRITORY- Whitehorse: 2H6; tel./fax(780)436-0732. Wi MD Health Management Inc., 224 tiated. Please sendresume orcontact: v inourmission,visionand to participate sincere, enthusiasticandwillbewilling health care. This associatewillbe ongoing questforexcellence inoral our is seekinganassociatetofurther opportunity. Our patient-centred clinic SASKATCHEWAN -Regina: dence to(306)752-5994. 752-5960 (evgs.),orfaxresume inconfi- Carlson, tel.(306)752-2266(days), Contact: Dr. Tom Carlson orMrs.Raylene Do just1-3/4hoursfrom thecity.atchewan, officeinMelfort, Sask-7-operatory 5,000 plussurrounding area. Modern limit. We are theonlyofficeintown of $150,000 your firstyear, theskyis time associatewanted.Make atleast SASKATCHEWAN -Melfort: [email protected] ment. Tel. (514)931-2551ore-mail areas thepartners phasingintoretire- There potential isdefinitepartnership three periodontistsandfive hygienists. bec. The practicepresently consistsof periodontal practiceinMontreal, Que- an associateforabusy, well-established Q Q time. Please call(819)281-1741. maternity leave, owner returning part- leave. Possible following partnership needed forreplacement duringmaternity in medicalanddentalsetting.Associate alues. Salary andschedulingtobenego- alues. Salary UEBEC -Gatineau: UEBEC -Montreal: UEBEC –ÎlesdelaMadeleine:

ailable starting Marchailable starting 2003.For the new year wethe new willrequire ahighly ndermere Dr., Edmonton, AB T6R n’ t missoutonthisopportunity. We F amily practice

are seeking Associate F F D1278 D1295 D1312 D1302 ull- ull- D981 (evgs.) orfax(301)603-0861. plus beneﬁtspaid.Call(202)966-5357 + commission.Malpractice insurance excellent US$75,000 clinicalskills.Salary working, full-timegeneraldentistwith CANADA: Ma rapidly growing practiceinSilver Spring, MARYLAND, US-Silver Spring: 667-6824. w motivated, patient-orientedhygienistas [email protected] lead tobuy-inorpartnership. E-mail locums orassociateshipinCanada.Could w personal availability onthisuserfriendly available personnel;listavacancy or jobs.Searchand short-term forjobsand personnel interconnect here withlong- hygienists, CDAs,andallotherdental www.dentaljobs.ca: eb site. ell. Tel. (867)668-6077,fax P S P S r yland, U.S.A.,isseekingahard- OUGHT ERVICES RO OSITIONS P FESSIONAL ediatric dentistavailable for D entists, dental 261 D1230 Our D1318 D1324 D592 Classiﬁed Ads usually should not be administered along with acetaminophen or acetylsalicylic acid. Post-ingestion blood levels may be useful to confirm a diagnosis and to quantify the degree of exposure Patients with any serious medical condition should consult a physician before using MOTRIN* IB as an but otherwise have not been helpful in predicting clinical outcome. Generally, full recovery can be analgesic or antipyretic. expected with appropriate symptomatic management. IBUPROFEN Pain Reliever/ Muscles TABLETS USP Fever Reducer Out Pain Drug Interactions: The platelet inhibiting effects of ibuprofen, although less potent and of shorter The following cases of overdose have been reported. A 19 month old child, 1-1/2 hours after the PRESCRIBING INFORMATION duration than those induced by acetylsalicylic acid, warrant cautionary supervision by a physician before ingestion of seven to ten 400 mg tablets of ibuprofen presented apnea, cyanosis and responded only to MOTRIN* IB Tablets, Caplets and Gelcaps co-administration of MOTRIN* IB and anti-coagulants. painful stimuli. After treatment with O2, NaHCO3, infusion of dextrose and normal saline, the child was Ibuprofen Tablets USP 200 mg Coumarin Type Anticoagulants: Several short-term controlled studies failed to show that ibuprofen responsive and 12 hours after ingestion appeared completely recovered. Blood levels of ibuprofen reached 102.9 µg/mL, 8-1/2 hours after the accident. Two other children weighing approximately 10 kg, Extra Strength MOTRIN* IB Tablets significantly affected prothrombin time or a variety of other clotting factors when administered to had taken an estimated 120 mg/kg. There were no signs of acute intoxication or late sequelae. In one Ibuprofen Tablets USP 300 mg individuals on coumarin-type anticoagulants. However, bleeding has been reported when ibuprofen and other NSAID agents have been administered to patients on coumarin-type anticoagulants. The use of child the ibuprofen blood level at 90 minutes after ingestion was approximately 700 µg/mL. A nineteen Super Strength MOTRIN* IB Tablets year old male who ingested 8000 mg of ibuprofen reported dizziness and nystagmus was noted. He Ibuprofen Tablets USP 400 mg MOTRIN* IB in patients who are taking anticoagulants should therefore be avoided because of the possibility of enhanced GI bleeding or an additive effect due to ibuprofen’s reversible anti-platelet actions. recovered with no reported sequelae after parenteral hydration and 3 days of bed rest. NAME OF DRUG For perspective, a single 200 mg oral dose study in 6 fasting healthy men produced a peak plasma MOTRIN* IB Acetylsalicylic Acid: Animal studies show that ASA given with NSAID agents, including ibuprofen, yields a net decrease in anti-inflammatory activity with lowered blood levels of the non-ASA drug. Single dose concentration of 15.0 µg/mL at 0.75 hr. Another study using a single oral 400 mg dose in humans Ibuprofen Tablets USP produced a peak serum level of 31.9 + 8.8 µg/mL 0.5 hour after ingestion, and at 16 hours serum 200 mg (MOTRIN* IB) tablets, caplets, gelcaps bioavailability studies in normal volunteers have failed to show an effect of ASA on ibuprofen blood levels. Correlative clinical studies have not been done. concentrations had dropped to 1 µg/mL. 300 mg (Extra Strength MOTRIN* IB) tablets Other Anti-Inflammatory Agents (NSAIDs): The addition of MOTRIN* IB to a pre-existent prescribed Management of Overdose: Appropriate interventions to decontaminate the gastrointestinal tract may be 400 mg (Super Strength MOTRIN* IB) tablets NSAID regimen in patients with a condition such as rheumatoid arthritis may result in increased risk of beneficial within the first four hours after ingestion. Routine symptomatic and supportive treatment is THERAPEUTIC CLASSIFICATION adverse effects. then recommended. Physicians should contact the Regional Poison Control Centre for additional Analgesic antipyretic agent Diuretics: Ibuprofen, because of its fluid retention properties, can decrease the diuretic and anti- guidance about ibuprofen overdose management. INDICATIONS AND CLINICAL USE hypertensive effects of diuretics, and increased diuretic dosage may be needed. Patients with impaired DOSAGE AND ADMINISTRATION MOTRIN* IB ibuprofen is indicated for fast and effective relief of headaches, menstrual pain, renal function taking potassium-sparing diuretics who develop ibuprofen-induced renal insufficiency Adults: toothache (dental pain), pain due to arthritis, minor aches and pains in muscles, bones and joints, such might be in serious danger of fatal hyperkalemia. MOTRIN* IB 200 mg: as sprains or strains, backache, the aches and pain due to the common cold and influenza and for the Acetaminophen: Although interactions have not been reported, concurrent use with MOTRIN* IB is not 1 to 2 tablets, caplets or gelcaps as required every 4 hours, not to exceed 1200 mg (6 tablets, caplets reduction of fever. advisable. or gelcaps) in 24 hours unless directed by a physician. CONTRAINDICATIONS Other Drugs: Although ibuprofen binds to a significant extent to plasma proteins, interactions with other Extra Strength MOTRIN* IB 300 mg: MOTRIN* IB ibuprofen should not be used in patients who have previously exhibited hypersensitivity protein-bound drugs occur uncommonly. Nevertheless, caution should be observed when other drugs 1 tablet as required every 4 to 6 hours, not to exceed 1200 mg (4 tablets) in 24 hours unless directed to it or in individuals who are known to have a sensitivity (manifested as asthma, bronchospasm, also having a high affinity for protein binding sites are used concurrently. Some observations have by a physician. hypotension, angioedema, laryngeal edema, swelling, shock or urticaria) to acetylsalicylic acid or other suggested a potential for ibuprofen to interact with digoxin, methotrexate, phenytoin and lithium salts. Super Strength MOTRIN* IB 400 mg: non-steroidal anti-inflammatory drugs. However, the mechanisms and clinical significance of these observations are presently not known. 1 tablet as required every 4 to 6 hours, not to exceed 1200 mg (3 tablets) in 24 hours unless directed MOTRIN* IB ibuprofen should not be used during pregnancy (see Use in Obstetrics below). Ibuprofen Patients taking other prescribed medications should consult a physician before using MOTRIN* IB to by a physician. levels in breastmilk are extremely low and are unlikely to affect a nursing infant, however because its assure its compatibility with the other medications. Children: It is recommended that children under 12 years of age be treated using Children’s MOTRIN* safety under these conditions has not been established consult a doctor before use in nursing mothers. ADVERSE REACTIONS formulations. MOTRIN* IB ibuprofen is contraindicated in patients with Systemic Lupus Erythematosus as an Experience reported with prescription use of ibuprofen has included the following adverse reactions. Do not take for pain for more than 5 consecutive days or fever for more than 3 days unless directed by anaphylaxis like reaction with fever may occur, particularly when ibuprofen has been administered Note: Reactions listed below under Causal Relationship Unknown are those where a causal relationship a physician. If the painful area is red or swollen, if condition deteriorates or new symptoms occur, consult previously. Aseptic meningitis has also been reported. could not be established; however, in these rarely reported events, the possibility of a relationship to a physician. MOTRIN* IB ibuprofen should not be used in patients with acute peptic ulcer or gastrointestinal ibuprofen also cannot be excluded. The adverse reactions most frequently seen with ibuprofen therapy bleeding. involve the gastrointestinal system. PHARMACEUTICAL INFORMATION WARNINGS Gastrointestinal: Drug Substance: Ibuprofen is described chemically as 2 - (p-isobutylphenyl) propionic acid. It has a Anaphylactoid reactions have occurred after administration of ibuprofen to patients with known Incidence 3 to 9%: nausea, epigastric pain, heartburn molecular weight of 206.28 and the following structural formula. CH acetylsalicylic acid or other NSAID sensitivity manifested as asthma, swelling, shock or hives. Incidence 1 to 3%: diarrhea, abdominal distress, nausea and vomiting, indigestion, constipation, 3

Gastrointestinal side effects to ibuprofen have been reported including dyspepsia, heartburn, nausea, abdominal cramps and pain, gastrointestinal tract fullness (bloating or flatulence) OH CH vomiting, anorexia, diarrhea, constipation, stomatitis, flatulence, bloating, epigastric pain, abdominal Incidence <1%: gastric or duodenal ulcer with bleeding and/or perforation, gastrointestinal hemorrhage, 3 pain. Peptic ulceration with GI bleeding or perforation has been reported and has been associated with melena, hepatitis, jaundice, abnormal liver function (SGOT, serum bilirubin and alkaline phosphatase) O a fatal outcome. MOTRIN* IB ibuprofen should therefore be given only under close supervision to The generally modest elevations of serum transaminase activity that has been observed are usually patients with a history of upper gastrointestinal tract disease. without clinical sequelae but severe, potentially fatal toxic hepatitis can occur. H3C PRECAUTIONS Central Nervous System: Occasionally serious gastrointestinal side effects have been associated with the anti-inflammatory uses Incidence 3 to 9%: dizziness Ibuprofen is a white crystalline powder with a characteristic odour and slight taste. It is very slightly of ibuprofen (See Warnings). Minor gastrointestinal complaints have also been reported during the Incidence 1 to 3%: headache, nervousness clinical use of ibuprofen at analgesic doses. The administration of MOTRIN* IB with food or milk is soluble in water and very soluble in alcohol and other common organic solvents. The apparent pKa of Incidence < 1%: depression, insomnia ibuprofen is 5.2 and its melting point is 75˚C to 75.5˚C. recommended since occasional and mild heartburn, upset stomach or stomach pain may occur with its Also reported but with unknown causal relationship: paresthesias, hallucinations, dream abnormalities, Composition: use. Patients should be advised to seek the consultation of a physician if gastrointestinal side effects aseptic meningitis has been reported in patients with systemic lupus erythematosus or other connective occur consistently, persist, or appear to worsen. tissue disease, aseptic meningitis and meningioencephalitis, in one case accompanied by eosinophilia MOTRIN* IB 200 mg tablets and caplets include ibuprofen 200 mg and the following non-medicinal MOTRIN* IB ibuprofen, like other non-steroidal anti-inflammatory agents, can inhibit platelet in the cerebrospinal fluids, has been reported in patients who took ibuprofen intermittently and did not ingredients in alphabetical order: carbon black, carnauba wax, colloidal silicon dioxide, cornstarch, aggregation but the effect is quantitatively less than that seen with acetylsalicylic acid. Ibuprofen has been have any connective tissue disease, cognitive dysfunction has been observed in elderly patients who hydroxypropyl methylcellulose, pharmaceutical glaze, propylene glycol, stearic acid and titanium dioxide. shown to prolong bleeding time (but within the normal range) in normal subjects. Because this took ibuprofen. MOTRIN* IB 200 mg gelcaps include ibuprofen 200 mg and the following non-medicinal ingredients in prolonged bleeding effect may be exaggerated in patients with underlying haemostatic defects, Dermatologic: alphabetical order: calcium disodium EDTA, castor oil, cellulose, colloidal silicon dioxide, corn starch, MOTRIN* IB ibuprofen should be avoided by persons with intrinsic coagulation defects and by those on Incidence 3 to 9%: rash (including maculopapular type) FD&C yellow no. 6, gelatin, hydroxypropyl methylcellulose, magnesium stearate, parabens, povidone, propylene glycol, sodium lauryl sulfate, sodium propionate, sodium starch glycolate, synthetic black iron anticoagulant therapy. Incidence 1 to 3%: pruritis oxide, and titanium dioxide. Tinnitus, blurred and/or diminished vision, scotoma, and/or changes in colour vision have been reported. Incidence < 1%: vesiculobullous eruptions, urticaria, erythema multiforme Extra Strength MOTRIN* IB 300 mg caplets include ibuprofen 300 mg and the following non-medicinal If a patient develops such complaints while taking MOTRIN* IB, the drug should be discontinued. Also reported but with unknown causal relationship: alopecia, Stevens-Johnson Syndrome. Patients with any visual disturbances should have an ophthalmologic examination. ingredients in alphabetical order: carbon black, carnauba wax, colloidal silicon dioxide, cornstarch, FD&C Special Senses: yellow no. 6, hydroxypropyl methylcellulose, polydextrose, polyethylene glycol, pregelatinized starch, Advanced age, hypertension, use of diuretics, diabetes, atherosclerotic cardiovascular disease, chronic Incidence 1 to 3%: tinnitus renal failure, cirrhosis and conditions which may be associated with dehydration appear to increase the sodium cyclamate, stearic acid, and titanium dioxide. Incidence < 1%: amblyopia (blurred and/or diminished vision, scotomata and/or changes in colour Super Strength MOTRIN* IB 400 mg caplets include ibuprofen 400 mg and the following risk of renal toxicity. MOTRIN* IB should therefore be used with caution when these risk factors are vision). Any patient with eye complaints during ibuprofen therapy should have an ophthalmological non-medicinal ingredients in alphabetical order: carbon black, colloidal silicon dioxide, cornstarch, FD&C present. examination. yellow no. 6, hydroxypropyl cellulose, hydroxypropyl methylcellulose, polyethylene glycol, pregelatinized Patients taking MOTRIN* IB should be cautioned to report to their physician signs or symptoms of GI Also reported but with unknown causal relationship: conjunctivitis, diplopia, optic neuritis. intolerance and/or bleeding, blurred vision or other ocular symptoms, skin rash, tinnitus, dizziness, starch, propylene glycol, sodium cyclamate, stearic acid, and titanium dioxide. Metabolic: Stability and Storage Recommendations: weight gain, edema or respiratory difficulties. Incidence 1 to 3%: decreased appetite, edema, fluid retention Tablets and Caplets: Store away from heat and direct light. If MOTRIN* IB is taken in conjunction with prolonged corticosteroid therapy and it is decided to Fluid retention generally responds promptly to drug discontinuation. Gelcaps: Store in tightly closed container at room temperature; avoid high humidity and excessive heat discontinue steroid therapy, the corticosteroid should be tapered slowly to avoid exacerbation of disease Hematologic: (40°C, 104°F). or adrenal insufficiency. Incidence < 1%: leukopenia and decreases in hemoglobin and hematocrit Particular caution should be observed in elderly patients taking MOTRIN* IB ibuprofen, as they are more Also reported but with unknown causal relationship, rare cases of: hemolytic anemia, thrombocytopenia, DOSAGE FORMS likely to be taking other medications or have pre-existing disease states which can increase the likelihood granulocytopenia, bleeding episodes (e.g., prupura, epistaxis, hematuria, menorrhagia), auto-immune MOTRIN* IB ibuprofen 200 mg tablets are available as white, film-coated biconvex tablets, with of the complications that have been associated with ibuprofen. Elderly patients appear to be more hematological anemia occurred in one patient taking 400 mg of ibuprofen three times a day for ten days, “Motrin IB” printed in black ink, in bottles of 10, 24, 50, 100 and 150. susceptible to the central nervous system reactions; cognitive dysfunction (forgetfulness, inability to fatal aplastic anemia was reported in one patient who took 600 mg per day for eight months. MOTRIN* IB ibuprofen 200 mg caplets are available as solid, white, film-coated capsule-shaped concentrate, a feeling of separation from the surroundings) in such patients has been reported. Cardiovascular: tablets, with “Motrin IB” printed in black ink, in bottles of 24 and 50. Use in Obstetrics: No evidence specifically identifies exposure to analgesic doses Incidence < 1%: congestive heart failure in patients with marginal cardiac function, elevated blood MOTRIN* IB ibuprofen 200 mg gelcaps are available as solid, capsule-shaped tablets with white of ibuprofen as a cause of harm to either mother or fetus during pregnancy. pressure gelatin on one end and orange gelatin on the other end, with “Motrin IB” printed in grey ink, in trial sizes Non-steroidal anti-inflammatory drugs in general, however, are known to affect the action of Conditions such as congestive heart failure and hypertension may be aggravated by sodium retention of 2 and in bottles of 20 and 40. prostaglandin synthetase which could alter a variety of the physiological functions of prostaglandins or and edema caused by ibuprofen in such patients. Extra Strength MOTRIN* IB ibuprofen 300 mg tablets are available as solid, light orange-coloured, platelets during delivery such as facilitating uterine contraction in the mother, closure of the ductus Also reported but with unknown causal relationship, rare cases of: arrhythmias (sinus tachycardia, sinus round, biconvex, film-coated tablets, with ‘MOTRIN 300 mg’ printed in black ink, in bottles of 20 and 65. arteriosus in the fetus, and platelet-related haemostasis. Patients should therefore be advised not to use bradycardia, palpitations). MOTRIN* IB during pregnancy without the advice of a physician, particularly during the last trimester. Super Strength MOTRIN* IB 400 mg tablets are available as solid, orange-coloured, round, biconvex, Allergic: Clinical information is limited on the effects of ibuprofen in pregnancy. film-coated tablets, with ‘MOTRIN 400 mg’ printed in black ink, in pouches of 1 and in bottles Incidence < 1%: anaphylaxis (see CONTRAINDICATIONS) of 16 and 50. Use in Nursing Mothers: Pharmacokinetic studies indicated that following oral administration of Also reported but with unknown causal relationship, rarely: fever, serum sickness, lupus erythematosus ibuprofen 400 mg the level of drug which appeared in breast milk was below detection levels of 1 µg/mL. syndrome. Reference: 1. Schatchel BP and Thoden WR. Onset of ibuprofen in the treatment of muscle-contraction The amount of ibuprofen to which an infant would be exposed through this source was considered Endocrine: Also reported but with unknown causal relationship, rare cases of: gynecomastia, headache. Headache 1988;28:471-474. negligible. However, since the absolute safety of ibuprofen ingested under these circumstances has not hypoglycemic reaction, menstrual delays of up to two weeks and dysfunctional uterine bleeding been determined, nursing mothers should be advised to consult a physician before using MOTRIN* IB occurred in nine patients taking ibuprofen 400 mg three times a day for three days before menses. (Arthritis Advisory Committee; 1983). The Product Monograph is available to doctors, dentists and pharmacists upon request from: Renal: Also reported but with unknown causal relationship: decreased creatinine clearance, Patients with Special Diseases and Conditions: Several medical conditions which can predispose polyuria, azotemia. patients to the adverse effects of non-steroidal anti-inflammatory drugs in general may be applicable to Like other non-steroidal anti-inflammatory agents, ibuprofen inhibits renal prostaglandin ibuprofen. synthesis which may decrease renal function and cause sodium retention. Renal blood flow MOTRIN* IB should be used with caution in patients with a history of cardiac failure or kidney disease glomerular filtration rate decreased in patients with mild impairment of renal functions who took because of the possibility of aggravating pre-existing states of fluid-retention or edema. Mild impairment 1200 mg/day of ibuprofen for one week. Renal papillary necrosis has been reported. A number of renal function (decreased renal blood flow and glomerular filtration rate) can occur at maximal doses of factors appear to increase the risk of renal toxicity (See PRECAUTIONS). of ibuprofen. Renal papillary necrosis has been reported. SYMPTOMS AND TREATMENT OF OVERDOSE Also, patients with underlying medical or pharmacologically-induced haemostatic defects could Clinical Features: A clear pattern of clinical features associated with accidental or intentional experience further prolongation of bleeding time through the inhibition of platelet aggregation induced overdose of ibuprofen has not been established. Reported cases of overdose have often been to varying degrees by this class of drugs. complicated by co-ingestions or additional suicidal gestures. The range of symptoms observed Long-term ingestion of combinations of analgesics has been associated with analgesic nephropathy. It has included nausea, vomiting, abdominal pain, drowsiness, nystagmus, diplopia, headache, is therefore appropriate that patients be discouraged from long-term, unsupervised consumption of tinnitus, impaired renal function, coma and hypotension. A review of four fatalities associated analgesics, particularly in combination. Patients should therefore be directed to consult a physician if with ibuprofen overdose indicates other contributing factors co-existed so it would be difficult their underlying condition requires administration of MOTRIN* IB for more than 5 days. MOTRIN* IB to identify the toxicity of ibuprofen as a specific cause of death. *Trademark 1-888-6MOTRIN For Matters of Life and Debt

Basic Life,Term 100 Life,Dependents’Life and Partner Insurance from the Canadian Dentists’Insurance Program

Current debts, mortgage costs, and even everyday living expenses could EXPERT ADVICE IS AT YOUR become too much for your family to handle if you died unexpectedly. That’s FINGERTIPS why it’s vital that you obtain sufficient life insurance to protect your family A professional review of your insurance portfolio and others who rely on you and your income. can help you determine whether you have the The Canadian Dentists’ Insurance Program provides a range of superior life right coverage for your needs and even show insurance plans to help safeguard the financial interests of those who depend you how to save money on insurance. To obtain on you, including plans to protect families and key business partners. a review of your insurance portfolio over the phone — at no cost to you — contact a The Program’s life insurance plans offer comprehensive coverage, lump sum non-commissioned,licensed benefits, very affordable premiums, and lower rates for those in excellent health. insurance advisor at So, don’t delay. Secure your family’s financial future with life insurance from Professional Guide Line Inc.* the Canadian Dentists’ Insurance Program. Call Professional Guide Line Inc. — Call 1-877-293-9455 or A CDSPI Affiliate at 1-877-293-9455 or (416) 296-9455, extension 5002 to (416) 296-9455, request an application or more information.* extension 5002. * Restrictions may apply to advisory services in certain jurisdictions.Quebec and PEI residents,call CDSPI at 1-800-561-9401,extension 5000.

The Canadian Dentists’ Insurance Program’s life insurance plans are underwritten by The Manufacturers Life Insurance Company (Manulife Financial). 03-65 02/03