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oralhygiene Nove No v mber 201 0 6

WAITING TO EXHALE: Managing Sleep Apnea for the Pediatric Patient

PANDAS: A Story of Molecular Mimicry

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oralhygiene CONTENTS

PEDIATRICS Waiting to Exhale: Managing Sleep Apnea for the Pediatric Patient

Susan Woodley, RDH; Lee Somerville, RDH, MS

PANDAS: A Story of Molecular Mimicry

Anne Bosy, RDH, MEd, MSC

PATIENT MANAGEMENT Welcome to the Practice: Compliance Begins When They Walk in the Door

Leann Keefer, RDH, MSM

HEALTH Diagnosing Bulimia

Gloria Alban, DDS, RHN

Get Fit, Get Smarter!

Uche Odiatu, DMD

DEPARTMENTS Editorial

Crystal-Balling the Future of Oral Health

News

New Leadership for Canadaâ€™s Dental Hygienists

New Products

Dental Marketplace

Editorial Board Members Lisa Philp | Kathleen Bokrosssy Debra Englehardt-Nash

35 November 2016

www.oralhealthgroup.com

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EDITORIAL

Crystal-Balling the Future of Oral Health Sometimes it takes a village, sometimes a of caries and periodontal diseases marriage of powerful forces to produce and the latest industry developsomething meaningful and that is the case ments helping to improve access with the recently-released custom collaband cost-of-care in these areas. oration between Colgate and Scientific • The state of the science linking oral American Custom Media. health and other areas of medicine “The Future of Oral Health, Global and changes in the relationships Challenges, Advances and New Technolbetween the dental and medical ogies” is an important document introcommunities as they slowly de-silo duced at the ADA’s annual meetand integrate to deliver better care ing in Denver during the panel and greater access for patients. Solutions in discussion, “The Evolving • New tools being emLandscape of Global Oral ployed in diagnostics, biooral health must address Health, Its Prevention technology and digital evolving patient needs, and Treatment.” The dishealth that are advancing cussion was moderated changing global demographics, care, along with a special by Jeremy Abbate, VP look at how dentistry and and the ever-advancing and publisher of Scientific oral health will be maninnovation landscape… American and the publishaged in the future. ing director of The Future • Philosophies and techof Oral Heath. Panelists innologies that have fueled induscluded Michael C. Alfano, DMD, try changes and ways in which globPhD, Caswell A. Evans, DDS, MPH, al demographics are mandating Sharon Guynup, Thomas E. Van Dyke, more accommodating, on-demand DDS, PhD, Dipl. ABP (Periodontology) approaches to dentistry that reduce and Marko Vujicic, PhD. cost and bring care to hard-to-reach I’d love all Canadian dental hygienists as populations.” well as Canadian dentists to check out this “Solutions in oral health must address important document (see the links below) evolving patient needs, changing global and I cannot steal its thunder here but I’d demographics, and the ever-advancing inlike to include important information from novation landscape that will affect delivColgate’s Oral Health Network for Profesery methods and models of care. We are sional Education and Development on this very proud to be a part of this multifacetfascinating collection of articles. ed conversation,” says Pat Verduin, Col“The publication explores science, poligate’s Chief Technology Officer. cy and new delivery models to better understand the current and future state of https://www.scientificamerican.com/ the multifaceted oral health field. Within products/the-future-of-oral-health the issue are updates on: www.scientificamericam.com/futureoral• The oral health of a growing elderhealth ly population; global health issue

Catherine Wilson Editor

November 2016 www.oralhealthgroup.com

NEWS BRIEFS

New Leadership for Canada’s Dental Hygienists The Canadian Dental Hygienists Association (CDHA) is pleased to announce the installation of its new president, Gerry Cool, at its annual general meeting in Edmonton, Alberta, on October 22. Gerry hails from Alberta and joins president-elect Sophia Baltzis (Quebec), past president Donna Scott (Yukon, Northwest Territories, Nunavut), and directors Mandy Hayre (British Columbia), Leanne Huvenaars (Saskatchewan), Deanna Mackay (Manitoba), Beth Ryerse (Ontario), Wendy Taylor (New Brunswick), Joanne Noye (Nova Scotia), Tracy Bowser (Prince Edward Island), and Tiffany Ludwicki (Newfoundland & Labrador) on CDHA’s board of directors for 2016-2017. Gerry Cool brings 42 years of experience to the position of CDHA President. Following her graduation from the University of Alberta in 1974, Gerry worked as a dental hygienist for 10 years in Prince Rupert, British Columbia, before returning home to the family farm in Carseland, Alberta, in 1983. Since then, she has worked in private dental practices, full and part time, and has been actively involved in the College of Registered Dental Hygienists of Alberta and CDHA in a variety of leadership roles. Gerry’s straightforward approach, compassion, and commitment will serve the national association well. “I feel so privileged to be a part of the dental hygiene profession,” Gerry remarks, adding, “As CDHA president, I look forward to advocating for more accessible oral care that is responsive to each person’s oral health needs. Improved oral health means improved overall health and well-being for all.” Serving the profession since 1963, CDHA is the collective national voice of more than 28,495 registered dental hygienists working in Canada, directly representing 18,000 individual members including dental hygienists and students. Dental hygiene is the 6th largest registered health profession in Canada with professionals working in a variety of settings, including independent dental hygiene practice, with people of all ages, addressing issues related to oral health. For more information on oral health, visit: www.dentalhygienecanada.ca.

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November 2016 www.oralhealthgroup.com

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PEDIATRICS

WAITING TO

EXHALE Susan Woodley

Managing Sleep Apnea for the Pediatric Patient

RDH, began practicing dental hygiene in a general dentistry setting, though the better part of her career led her to practicing in Orthodontics. Susan enjoyed many years as a part-time faculty member with a local college both lecturing and as a clinical instructor. Susan also independently presents an all-day Oral Pathology Refresher course to Dental Professionals. She developed and presents an Orthodontic course to guide the clinician in achieving clinical excellence with orthodontic procedures. She continues to be an active member of the Ontario Dental Hygienists’ Association as well as the Canadian Dental Hygienists Association.

ave you ever experienced listening to a grandparent, a parent or a spouse snoring so loud you couldn’t sleep? No matter how hard you tried to ignore it, that’s all you could focus on. Then suddenly, sweet silence! You breathe a sigh of relief because they stopped! However, the only thing that stopped was their breathing. Then the silence was broken and the “sound show” resumed as they began frantically filling their lungs with air. The process was repeated over and over throughout the night. How many of us have shared these “snoring” stories in a social setting, ending in collective laughter? These “snoring” episodes are actually part of a disease process called Sleep Disordered Breathing (SDB) and it’s no laughing matter. SDB covers a broad spectrum of sleep disorders with Obstructive Sleep Apnea (OSA) being the most common. It is significant to note that OSA, along with Cancer and AIDS, are considered the most dangerous and destructive diseases on earth.1 Originally, OSA was believed to be directly related to increased body fat, however, more recent studies confirm there are other causative factors. They include overly relaxed throat and neck muscles due to eating or drinking too closely to bedtime, nasal or pharyngeal/laryngeal blockage as well as flabby throat and oral structures, such as a large uvula or a soft floppy palate. Exactly what is sleep apnea? SA occurs when air flow is completely stopped and diagnosed when there are five apneas (cessation

of breathing during sleep) or 10 apnea-hypopnea episodes per hour of sleep. Hypopnea is defined as airflow reduced by one-half to two-thirds. 2 Apnea alone is not a problem, except when it exceeds 10 seconds in duration. There are three types of sleep apnea to acknowledge; central, obstructive, and mixed sleep apnea. Central apnea occurs when there is no respiratory effort due to brainstem immaturity of the respiratory control. This is commonly seen in premature babies and newborns. Obstructive sleep apnea is caused by airway obstruction. In young children, the obstruction is most often due to enlarged tonsils and adenoids. With a five-fold increase in childhood obesity in Canada and the United States over the last fifteen years, we see an increasing number of children with obesity-

November 2016 www.oralhealthgroup.com

PEDIATRICS related SDB. 3,4 Mixed sleep apnea combines features of both central and obstructive causes. The Canadian Sleep Society as well as the American Sleep and Breathing Academy prove to be valuable resources relating to this topic. 5 Given the added complexity of behavioural and developmental issues that often accompany a child with SDB, our mission is to heighten the awareness for the dental professional with the purpose of earlier intervention. As co-therapists, it is important for us to have a clear understanding of our role regarding interdisciplinary management and to highlight various methodologies of treatment to broaden our scope of knowledge. Contrary to adult SDB, pediatric SDB (OSA) often presents with behavioral symptoms that can have cascading effects in many areas of their life. These may include changes in mood, misbehavior and poor school performance. Often symptoms of SDB are confused with ADHD and as such, they are treated with medications that include stimulants, non-stimulants and antidepressants. Not every child with academic or behavioral issues will have SDB, but if a child snores loudly on a regular basis and is experiencing mood, behavior or school performance issues, sleep disordered breathing should be considered. The largest and most comprehensive study to examine the effects of sleep disordered breathing symptoms on subsequent behavior from six months to seven years was conducted in the UK. The study evaluated and followed more than 11,000 children for over six years. The combined effects of snoring, apnea and mouth-breathing on the behavior of children enrolled in the Avon Longitudinal Study of Parents and Children in the United Kingdom were examined. Parents completed questionnaires about their children’s SDB symptoms at several intervals, from six to 69 months of age. At approximately ages of four and seven years old, parents filled out the Strengths and Difficulties Questionnaire

(SDQ). The SDQ rated the individual for: • inattention/hyperactivity • emotional symptoms (anxiety and depression) • peer difficulties • behavior problems (aggressiveness and rule-breaking) • pro-social behavior (sharing, helpfulness, etc.) The study controlled for 15 possible confounding factors, such as socioeconomic status, maternal smoking during the first trimester of pregnancy, and low birthweight as three examples. The study revealed children with sleep-disordered breathing were from 40 to 100 percent more likely to develop neurobehavioral problems by age seven, compared with children without breathing problems. The largest increase was seen in hyperactivity. There were however, significant increases across all five behavioral measures. Children whose SDB symptoms peaked early, at six or 18 months, were 40 percent and 50 percent more likely, respectively, to have behavioral problems at seven years of age compared with children who had normal breathing. Children with the worst behavioral problems had SDB symptoms that continued throughout the evaluation period and became most severe at 30 months.6 This shines a light on the unique opportunity for dental professionals to be on the front line of discovery for numerous oral systemic diseases. Many of our patients visit the dental office more often than any other healthcare provider. Given the severity and far reaching effects, should we not consider screening for SDB on a routine basis? The pathway to discovery begins with a clear understanding of the physical signs and symptoms of pediatric Sleep Disordered Breathing: • Abnormal breathing during sleep • Bruxism • Frequent awakenings or restlessness • Frequent nightmares • Enuresis (bedwetting)

Lee Somerville, RDH, MS, received a Master of Science in Dental Public Health from Boston University School of Graduate Dentistry. She has over 30 years in private practice experience. Lee has been an instructor at Cape Cod Community College since 1986 and has taught freshman and sophomore clinic, radiology and several didactic courses. She is a member of the American Dental Hygienists’ Association and American Dental Educator’s Association. Lee manages Professional Education for Philips North America in the Northeast. She lectures in the Northeast as well as nationally. Lee is a full-time Professional Educator with Philips North America and teaches part time at Cape Cod Community College.

November 2016 www.oralhealthgroup.com

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PEDIATRICS • • • • • •

Difficulty awakening Excessive daytime sleepiness Hyperactivity/behavior problems Daytime mouth breathing Poor or irregular sleep patterns Growth impairment The screening process for the dental professional begins with a general observation of the patient. Mouth breathing and adenoidal facies (dull expression with open mouth) should be noted. Hyponasal voice (sounds like pinched nose when speaking) is a clue to nasal obstruction and a muffled voice suggests adenotonsillar enlargement. Secondly, the lateral facial profile should be examined for retrognathia, micrognathia or midfacial hypoplasia. These can all have an effect on the nasopharyngeal and oropharyngeal passages and are key diagnostic findings. The oral cavity should be observed for tongue and soft palate size and appearance. A large tongue along with or independent of a high/ low-arched or elongated palate may reveal a predisposition to SDB.7 Note their head posture. Blocked nasal breathing and jaw joint inflammation both result in forward head posture. Persistent forward head posture causes muscle contraction and results 96% of the time in occipital and forehead headaches. 8 Once we have established and documented our clinical findings, asking a series of questions contributes greatly to the screening process for SDB: 1. Does he/she snore? 2. Have you heard him/her grinding their teeth? 3. Do they appear restless and/or awaken frequently at night? 4. Do they have frequent nightmares? 5. Do they wet their bed? 6. Is it difficult to waken them in the morning? 7. Are you aware of excessive sleepiness during the day? 8. Are there any hyperactive or behavioural issues you are aware of? 9. Would you consider the child to be a mouth breather?

In keeping with an interdisciplinary approach, it is vital to share any abnormal clinical findings with the child’s physician as soon as possible. Children are in such a rapid state of cognitive development that time is of the essence to effect change. “Any alterations of health and brain function associated with SDB could permanently alter a child’s social and economic potential, especially if the disorder is not recognized early in life or treated inadequately. It is imperative that healthcare workers actively seek out symptoms of SDB in patients and educate parents and teachers about the signs and symptoms of SDB to improve early detection and treatment for prevention of long-term morbidity”.9 After a physical examination, a Polysomnogram (PSG-sleep study) should be prescribed by the physician to confirm the diagnosis of OSA in collaboration with the clinical suspicion, history and physical findings from the dental professional. Once the Polysomnogram is completed, severity is measured by the AHI (Apnea Hypopnea Index) • None/Minimal: AHI < 5 per hour • Mild: AHI > 5, < 15 per hour • Moderate: AHI > 15, < 30 per hour • Severe: AHI >30 per hour10

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November 2016 www.oralhealthgroup.com

PEDIATRICS

“Any alterations of health and brain function associated with SDB could permanently alter a child’s social and economic potential, especially if the disorder is not recognized early in life or treated inadequately”.

A vast majority of cases of OSA in children are associated with adenotonsillar hypertrophy. The peak prevalence of childhood OSA is at two to eight years, which is the age when the tonsils and adenoids are the largest in relation to the underlying airway size. An endoscopy has shown the site of collapse is most often at the level of the adenoid.11 Although research indicates variances in the success rates from tonsillectomy and adenoidectomy surgery, these procedures are often considered to be the first approach in management of pediatric SDB.12,13 CPAP (Continuous Positive Airway Pressure) is another avenue in managing pediatric OSA. From a medical point of view, this treatment option is considered to be very successful when directions for use are followed carefully. Compliance does often present a challenge with inconsistencies in wear time, variances in care giver philosophies as well as other real life situations which can impede the success rates associated with a CPAP. Orthodontic appliances are gaining traction as a viable option in orthopedic management of SDB in the young patient. These appliances can be used as a prevention tactic as well as secondary therapeutic management with other modalities. The appliances used most often involve expansion of the palate or anterior posturing of the mandible and tongue during sleep. The significance of early detection and treating the underlying craniofacial abnormalities in children at high risk for developing OSA, could in effect, prevent the disorder. Since maxillary constriction is a feature of chronic naso-respiratory obstruc-

tion,14 Rapid Maxillary Expansion (RME) has the potential to play a prominent role in a prevention strategy. The quality of sleep of these children improves after RME, regardless of the severity of their respiratory obstruction. Orthodontists who perform a comprehensive head-neck examination are uniquely positioned to identify children with malocclusion that could lead to development of SDB.15 Narrowing of the pharyngeal airway passage (PAP) and adaptations in the soft palate are common among subjects who present with a retrognathic mandible.16,17 As a result, the space between the cervical column and the mandible decreases, leading to a posteriorly postured tongue and soft palate. This increases the chances of impaired respiratory function during the day and possibly causing SDB symptoms like snoring, upper airway resistance syndrome, and obstructive sleep apnea (OSA) syndrome.18,19 A study was conducted to determine the effects of a twinblock appliance on the anatomy of the PAP. Thirty eight subjects (male and female) age range of eight to 14 years with skeletal Class II malocclusion associated with mandibular retrusion participated in the study. It was concluded that correction of mandibular retrognathism by functional appliances improved the dimensions of the upper airway. “Finding Connor Deegan” is a five minute video revealing the “human” side of a child living with SDB. It illustrates the far reaching effects SDB can have on an individual’s life and how that can all change with a proper diagnosis and management strategies. We

November 2016 www.oralhealthgroup.com

PEDIATRICS

encourage you to take a few minutes to watch this video and layer your learning experience. https://www.youtube.com/watch?v= ZX5s4WNXK3M Regardless of the treatment option(s), the individual with SDB is considered to be at high risk for dental caries and gingival inflammation. 20 As dental professionals we know scientifically that xerostomia plays a crucial part in the formation and adherence of plaque biofilm. Consistent mouth breathing and the use of functional appliances can contribute greatly to this undesirable environment. The Philips Sonicare For Kids Power Toothbrush, with 31,000 brush strokes per minute and high

amplitude, creates patented fluid dynamic action to reduce the biofilm burden. With Bluetoothconnectivity, the child can connect to an App that will help guide and coach their brushing experience in real time. Sonicare for Kids is safe and gentle for use with all appliances and removes 75% more plaque in hard-to-reach areas than a manual toothbrush in children ages seven to 10 years. 21 The collaboration of an interdisciplinary team, clinical circumstances, research and historical data all influence a customized approach to treating SDB in the young patient. As dental professionals, we want to â€œprevent more to treat lessâ€?. Implementing systematic screenings for Sleep Disordered Breathing should be routine and the standard of care in every dental practice. Evidence tells us that early interventions with pediatric SDB can have a profound effect in the formative years. We all know how it feels to save a tooth. Just imagine how great it would feel to change a life!

Footnotes 1. http://www.dentistryiq.com/articles/2010/ 06/dentistry-s-new-frontier-the-treatment-of-obstructive-sleep-apnea.htm 2. Parisi RA. Ch. 12-Respiration and Respiratory Function: Technique of Recording and Evaluation. In: Chokroverty S (ed). Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects, 2nd edition. 1999, Boston: Butterworth-Heinemann, pp. 220-221. 3. Anders TF, Eiben LA. Pediatric sleep disorders: a review of the past 10 years. J Am Acad Child Adolesc Psych 1997;36(1):9-20 4. Quality Of Life Improvement With Positive Airway Pressure Therapy For Sleep Disordered Breathing In Obese Youth Sherri L. Katz , MDCM, FRCPC, MSc 1 , Joanna MacLean , MD, PhD 2 , Lynda Hoey , CCRP 3 , Valerie Kirk , MD 4 , Glenda Bendiak , MD 4 , Nicholas Barrowman , PhD 5 , Linda Horwood , MSc 6 , Stasia Hadjiyannakis , MD 1 , Laurent Legault , MD 6 , Bethany Foster , MD 6 , Evelyn Constantin , MD 6 , http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A1222

November 2016 www.oralhealthgroup.com

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PEDIATRICS 5. https://css-scs.ca/; americansleepandbreathingacademy.com/ 6. Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years; Karen Bonuck, PhD, Katherine Freeman, DrPH Ronald D. Chervin, MD, MS, and Linzhi Xu, PhD: Pediatrics. 2012 Apr; 129(4): e857–e865. doi: 10.1542/peds.2011-1402 www.ncbi.nlm.nih.gov/pmc/ articles/PMC3313633/; 7. Role of oral health professional in pediatric obstructive sleep apnea: Sanjeev Kumar Verma, Sandhya Maheshwari, Naresh Kumar Sharma, K. C. Prabhat:Natl J Maxillofac Surg. 2010 Jan-Jun; 1(1): 35–40. doi: 10.4103/0975-5950.69162: PMCID: PMC3304178 8. Anterior Repositioning Appliance Therapy for TMJ Disorders: Specific Symptoms Relived and Relationship to Disc Status on MRI. CRANIO 2005; vol 23, no 2, 89-99. 9. Treatment Alternatives for Sleep-Disordered Breathing in the Pediatric Population Ann C Halbower, MD ; Brian M McGinley, MD ; Philip L Smith, MD; www.medscape.org/viewarticle/586396: Curr Opin Pulm Med CME. 2008; 14(6):551-558. © 2008 Lippincott Williams & Wilkins 10. http://healthysleep.med.harvard.edu/sleep-apnea/diagnosing-osa/understanding-results 11. Isono S, Shimada A, Utsugi M, Konno A, Nishino T. Comparison of static mechanical properties of the passive pharynx between normal children and children with sleep-disordered breathing. Am J Respir Crit Care Med. 1998; 157:1204–12. [PubMed] 12. http://www.sciencedirect.com/science/article/pii/S0194599809000850 13. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004500/ 14. Jureyda S, Shucard DW. Obstructive sleep apnea - An overview of the disorder and its consequences. Semin Orthod. 2004;10:63–72 15. http://pubmedcentralcanada.ca/pmcc/articles/PMC4229758/ 16. Kirjavainen M, Kirjavainen T. Upper airway dimensions in class II malocclusion. Effects of headgear treatment. Angle Orthod. 2007;77:1046–1053. doi: 10.2319/081406-332. [PubMed] [Cross Ref 17. Jena AK, Singh SP, Utreja AK. Sagittal mandibular development effects on the dimensions of the awake pharyngeal airway passage. Angle Orthod. 2010;80:1061–1067. doi: 10.2319/030210-125.1. [PubMed] [Cross Ref 18. Schafer ME. Upper airway obstruction and sleep disorders in children with craniofacial anomalies. Clin Plast Surg. 1982;9:555–567. [PubMed] 19. Ozbek MM, Miyamoto K, Lowe AA, Fleetham JA. Natural head posture, upper airway anatomy and obstructive sleep apnea severity in adults. Eur J Orthod. 1998;20:133–143. doi: 10.1093/ ejo/20.2.133. [PubMed] [Cross Ref 20. http://jcodental-uobaghdad-edu.org/index.php/jbcd/article/viewFile/216/pdf_105 21. Milleman J, Putt M, Olson M, Master A, Jenkins W, Schmitt P, Strate J. International J Pediatric Dent 2009; 19:s1 Defenbaugh J, Schmitt P, Master A, Jenkins W, Strate J. International J Pediatric Dent 2009; 19:s1 Jenkins W, Master A, Defenbaugh J, Wei J. Philips Oral Healthcare, Snoqualmie, WA; J Dent Res 89 (spec iss B); Abstract 3696, 2010

November 2016 www.oralhealthgroup.com

HEALTH

Diagnosing Bulimia Dental professionals can often be the first to recognize the signs of bulimia in their patients and can be very important in making a diagnosis. Gloria Alban, DDS, RHN Dr. Gloria Alban graduated from the University of Toronto, Faculty of Dentistry in 1978. She worked in her own dental practice in Toronto until 2001 when she retired due to health issues. As part of her healing, she became a Holistic Nutritionist in 2010. Dr Alban now works in association with the Spark Institute in Vaughan, Ontario â€“ an integrative clinic devoted to preventive medicine and the treatment of anxiety, depression, eating disorders and digestive disorders. She may be contacted at info@thesparkinstitute.com.

n the September 2016 issue of this journal, I shared information about how the dental professional can help patients with their general and oral health through the diagnosis of acid reflux, a condition that affects up to 50% of the population. In this article, I discuss bulimia, an eating disorder which in the early stages can mimic the oral manifestations of acid reflux disease. Bulimia is a very serious chronic illness affecting 1-3% of women and a lower but significant number of men. I hope that by reading this article you become more aware of this illness in your patients and also feel comfortable in knowing how to approach the topic with them.

WHAT IS BULIMIA NERVOSA (BULIMIA) Bulimia Nervosa is an eating disorder characterized by bingeing and purging. Typically, binges tend to be large quantities of food eaten in a manner that feels out of the patientâ€™s control. The patient cannot stop eating. Selfinduced vomiting is the most common method of purging although some sufferers abuse laxatives or compensate for overeating with excessive exercise. The purging behavior is used to prevent weight gain following a binge. Patients with bulimia often have a normal body weight and appear healthy. They can be fully functional, attending school or working and having what appears to be a good life. A person with bulimia may feel that she is overweight regardless of her actual weight. Her body shape and weight are often the main measure of how she feels about herself and her self-esteem.

CAUSES OF BULIMIA NERVOSA The exact causes of bulimia are extremely difficult to identify as they are a complex web of psychological, social, and biological factors that are unique to each sufferer. So cial attitudes towards body size and appearance likely contribute to the illness. Patients with bulimia may have a history of sexual or physical abuse, drug abuse, anxiety disorders, low self-esteem, perfectionism or excessive peer pressure. Binge eating may be triggered by low mood, depression, stress, hunger following dieting and anxiety. The individual uses food to reduce these negative feelings but the binge is often followed by worsening selfblame, self-hatred and depression. Suicide attempts are common and 4% of those diagnosed with bulimia will die as a result of the eating disorder. Eating disorders have the highest mortality rate of any mental illness.

SOME STATISTICS The majority of patients suffering with bulimia are female (approximately 90% of cases) but many males are affected as well (approximately 10% of cases). According to Statistics Canada, 2015, 1-3% of adolescent women will develop bulimia in their lifetime. The illness typically begins in the teenage years or early adulthood and can be chronic or intermittent, often continuing for a lifetime unless well treated. It is very common in dancers, models, competitive athletes and those who aspire to a perfect appearance. The National Association for Anorexia Nervosa and Associated Disorders (ANAD) states that eating disorders affect all races and ethnic groups. More

November 2016 www.oralhealthgroup.com

HEALTH than half of patients with bulimia have a mood or anxiety disorder and one in ten have a substance abuse disorder, often alcohol.

EXPOSING THE SECRET OF BULIMIA Dental Professionals can be the first line of defense in identifying the warning signs and symptoms of bulimia. Because there is an unbelievable amount of shame and embarrassment associated with the disorder, patients will try to keep it a secret from people in their lives. As a result, the eating disorder can go undiagnosed for many years. There are very few objective findings that would alert a medical professional to the presence of this disorder but bulimia needs to be recognized early because it can be life threatening. Dental professionals have an advantage over medical doctors in diagnosing the disease by observing oral changes.

CHANGES IN THE ORAL CAVITY AND DENTITION Changes in the dentition are characteristic of bulimia and in the beginning stage are similar to the oral changes with acid reflux. General chalkiness of the enamel, loss of lustre, decay, sensitivity and erosion are some of the first signs that can indicate bulimia. Over time, generalized erosion of the enamel, starting along the lingual surfaces of the incisors and the occlusal surfaces of the molars will become more and more severe due to the teeth being bathed in stomach acid from vom-

iting. There can also be damage and redness to the gingiva, tongue, cheeks and the throat. We have all seen the pictures of severe cases of bulimia with restorations standing higher than the teeth and complete loss of enamel of course these pictures are showing the long term, untreated effects of the disease.

SIGNS OF BULIMIA (especially in teenagers and young adults) • Tooth decay. A sudden increase in the number and size of cavities can be a red flag. • Tooth sensitivity. Erosion of the tooth enamel can lead to dramatic sensitivities. • Discolouration and yellowing of the teeth. Initially there is a chalkiness to the teeth, they lose their lustre and can become more stained. With more time, the teeth look more yellow as the protective enamel is lost. • Dry mouth and swollen cheeks. This can result from repetitive purging leading to inflammation and problems with the salivary glands. • Bad breath. The stomach acid and bile in the mouth creates halitosis. Patients may have bad breath regardless of their efforts with brushing and using mouthwash. • Sores on the hands or knuckles. There may be scars on the top surface of the hands from contact with the teeth while pushing their fingers down their throat to cause vomiting. This can be a sign of frequent purging and can help to confirm that an eating disorder may be present.

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GlaxoSmithKline Consumer Healthcare Inc., Mississauga, Ontario L5N 6L4 © 2016 GSK group of companies or its licensor. All rights reserved. * Dry mouth can disrupt the oral health environment and lead to halitosis, demineralization, and increased caries.4,5 † Mouthwash, Gel and Spray. ‡ As measured in a 28-day clinical study.6 1. GSK data on ﬁle. Biotène dry mouth growth opportunity (with Canadian U&A data). July 16, 2014. 2. Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004;38:236–240. 3. Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth, 2nd edition. Gerodontology. 1997;14:33–47. 4. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138:15S–20S. 5. Fox PC. J Clin Dent. 2006;17(Spec Iss):27–28. 6. GSK data on ﬁle 2014, RH01986.

HEALTH HOW YOU CAN HELP

Early intervention makes a big difference! By observing signs that suggest bulimia and informing your patient of what you see, you can help to eliminate the secrecy involved and help the patient get necessary treatment. Talking to a patient about eating disorders can be difficult and must be done in a careful, thoughtful manner that does not blame the patient. Instead, the discussion will be most effective if it conveys concern for the patient’s overall well-being. You may be the first person to know that a problem exists. Some patients affected can be young and even their parents may be unaware of the problem. Many patients with bulimia will not understand the damage their illness is causing to their body and their health. By educating them on the long-term effects of enamel erosion on their oral health, dental professionals can provide important eye-opening information to help them realize the importance of reaching out for help. A patient recently interviewed at the Spark Institute where we work extensively with patients with eating disorders, reported that even though she has suffered from bulimia for decades, no medical or dental professional had ever mentioned noticing any symptoms of it. She had lived with her illness in secrecy and only as a mature adult was seeking treatment. Dental professionals need to be aware of how to help these patients and be especially vigilant to the changes in the dentition in young patients.

WHAT TO SAY TO A PATIENT WHO HAS SIGNS OF BULIMIA Because of the shame and secrecy experienced by patients with bulimia, the method for opening this conversation is important. Here is a suggested plan shared by Dr. Natalie Mulligan, ND, a practitioner at the Spark Institute who specializes in the treatment of eating disorders. 1) Clearly describe your findings to your patient (eg. erosion of enamel beyond what would be considered normal for their age) 2) Explain the possible causes of these findings (eg. excessive amounts of sugar, carbonated beverages, citrus fruits, acid reflux or excessive vomiting)

3) Reemphasize the importance of protecting tooth enamel for long term oral health and the irreversible dental complications of the problem 4) Explain that there are resources and treatments available for all of these issues. 5) Have information available that the patient can access privately for eating disorders. Realize that it is unlikely that a patient would admit to being bulimic and that it is best not to use labels such as “eating disorder” or “bulimia” in your discussion.

HOW TO PROCEED If the patient is not receptive to your concerns, it may be best to refer her to her doctor to deal with the issues causing the changes in the mouth. The patient may feel more comfortable discussing her medical and psychiatric issues with her medical doctor. If the patient is very receptive to your information and questions, you may want to ask more directed questions regarding vomiting and the patient’s understanding of the issues you have noticed. A referral to an eating disorder treatment program would be the ultimate goal. With young patients, it is important to alert the parents to the problems you detect and the possible causes. A referral to the family doctor (along with a phone call) may be the best way to proceed. Watching for continuing changes in the teeth over future visits would be very important to ensure that the bulimia was being treated effectively.

TIPS ABOUT EATING DISORDERS FOR PARENTS • It is important to realize that eating disorders are often a sign of a mental health issue that needs to be treated. Avoid focusing on food or eating habits only. • Forcing someone to change their eating habits or trick them into changing is not an effective strategy. • Avoid reacting to a loved one’s body image talk or trying to reason with statements that seem unrealistic to you. • Seek support for yourself and your family to deal with bulimia.

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HEALTH

IMMEDIATE DENTAL SUGGESTIONS FOR PATIENTS WITH BULIMIA • Immediately after vomiting, rinse your mouth with a teaspoon of baking soda mixed into a cup of water to neutralize the acid. • Brushing after vomiting will remove softened enamel so patients should wait at least an hour or more to brush. Use a manual, soft bristled brush only. • Use a baking soda toothpaste with fluoride. Rub a dab over your teeth with your finger and then rinse with water several times a day. • Rinse with a fluoride mouthwash or use a fluoride gel daily (consider custom made trays). • Avoid eating acidic and sugary foods- drink pop or fruit juice sparingly or use a straw. • Use a tongue cleaner to help remove trapped acid that remain in the papillae and can continue to bathe the lingual tooth surfaces for long periods of time. • Drinking water throughout the day can help to flush acidic residue from the oral tissues. Drinking Alkaline water can help to neutralize the pepsin that may irritate tissues. • Have regular dental checkups, X-rays and cleanings. • Consider a nightguard to protect teeth from further wear due to bruxism.

Realize that none of these recommendations will work and advanced restorative treatments will fail without effective treatment of bulimia. TREATMENT OF BULIMIA A multidisciplinary approach, either outpatient or inpatient, works best to treat bulimia. A combination of individual therapy, family therapy, behaviour modification, nutritional rehabilitation as well as lifestyle changes to manage stress and anxiety are all necessary for long term health. As an example, at the Spark Institute in Vaughan, Ontario, patients are seen on an outpatient basis. They have between one and seven appointments a week- these include psychological counselling, family counselling, medical appointments, nutrition counselling, lifestyle advice, stress management techniques, meal planning and food preparation advice. It would be helpful to know of some good resources in your area for your patients to consider. I hope this article has alerted you to another way you can make a big difference in someone’s life. There is no doubt, with the number of patients suffering with bulimia, a few of them are being treated in your practice each month. By using some of the suggestions made in this article, you can help them to get the treatment they need to recover from their illness, improve their health and save their teeth as well!

References:

Canadian Mental Health Association website: http://www.cmha.ca/mental_health/facts-about-eatingdisorders/#.V-wxNfArLIU Statistics Canada: http://www.statcan.gc.ca/pub/82-619-m/2012004/sections/sectiond-eng.htm#a2, 2015 ANAD: http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/ Restoring Our Bodies, Reclaiming our Lives; Amy Liu, Trumpeter Books, Boston, 2011 The Spark Institute Website: http://thesparkinstitute.com/ http://www.dentistryiq.com/articles/2010/06/dental-professioinals-can-be-the-first-line-of-defense-ineating-disorder-diagnosis.html http://www.rdhmag.com/articles/print/volume-31/issue-1/columns/bulimia-decreasing-the-damage-toenamel.html

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PATIENT MANAGEMENT

WELCOME TO THE Leann Keefer, RDH, MSM

In her role as Director of Education for Crosstex International, Ms. Keefer works to advance Crosstex’s thought leadership among influential dental care professionals. She proactively identifies trends in the fields of oral care and infection prevention, developing and implementing the corporation’s long-term strategies relating to education and professional relationships.

Compliance Begins When They

he first touch-point for patients is the reception area and it is critical to make a positive and lasting impression. Patients expect a dental office to maintain high standards of cleanliness and safety, which starts from the moment they enter the door. Is the room inviting, comfortable, organized and well maintained? Or does the room have stained furniture, empty drink cups, worn carpeting, and year-old magazines? And it’s even more important to consider cleaning and sanitizing what your patients cannot see. For instance, cold viruses have been shown to survive on indoor surfaces for more than seven days. Flu viruses capable of being transferred to hands and causing an infection can survive on hard surfaces for 24 hours. Flu viruses can also survive as droplets in the air for several hours and low temperatures increase their survival in the air. As patients await their appointment time, they are a captive audience with ample opportunity to make observations about the area and will take note of things they might have missed if just passing through. While microorganisms can’t be seen, patients can note dust, cobwebs, fingerprints, and dirt. Sticky surfaces can be felt and drink ‘rings’ noticed. Invest ten minutes, sit down, and carefully view the reception area through the eyes of a patient. Perceptions of the quality of care and treatment can be impacted by the appearance and environment of the reception room. Making a concerted effort to create a feeling of wel-

come, safety, and security for patients is critical to practice success. While most dental practices hire a cleaning service for weekly and scheduled maintenance, the reception area sees ongoing patient traffic, which requires daily cleaning and maintenance, with emergency cleanups as needed. Use of appropriate personal protective equipment during cleaning and maintenance is recommended. The proper level ASTM face mask (Level 1), safety eye protection, and heavy-duty utility gloves should be selected and donned/doffed appropriately. Hand hygiene should be performed immediately after doffing PPE. Create a consistent cleaning and organizing pattern around the room – clockwise or counterclockwise, it doesn’t matter, just be consistent. Clean from high to low and back to front to avoid dust/debris falling back onto the surface. Durable washable surfaces which are not only manufactured for commercial use, but healthcare grade will result in easier maintenance. Clean first then use of an appropriate level of sanitizer or disinfectant as indicated based on the surface being treated. The friction of cleaning removes most germs and exposes any remaining germs to the effects of a sanitizer or disinfectant used later. Sanitizing reduces germs on inanimate surfaces to levels considered safe by public health codes or regulations. Disinfecting destroys or inactivates most germs on inanimate objects with

November 2016 www.oralhealthgroup.com

PATIENT MANAGEMENT

PRACTICE:

Walk in the Door the exceptions of bacterial spores and prions. It is important to follow the manufacturer’s instructions for use and maintain the Safety Data Sheet binder for any cleaning materials/ products used in the office. Microfiber cloths and flat mop heads are recommended due to its ability to pick up and hold dirt as well as efficiently absorbing liquid. The absorbency of microfiber is up to seven times their own weight in liquid, which is great for cleaning glass without leaving streaks or for cleaning up spills. It is recommended to have color-coded microfiber cloths for each purpose. Use of machine washable microfiber cloths will cut cost of disposable cleaning products like paper towels. By folding the microfiber cloth into thirds lengthwise and then in half provides multiple clean surfaces during cleaning and dusting. It’s better to spray a cleaning/disinfecting product directly onto the cloth as opposed to the surface to reduce aerosol and respiratory hazards.

TOP TEN DAILY ACTIVITIES: • Windows, Doors, Walls and Mirrors Using a microfiber cloth, damp wipe vertical surfaces and ledges, paying particular attention to smudges and fingerprints; use cleaning agents as needed.

• High Touch Surfaces Including, but not limited to, door handles, cabinet knobs, light switches, remote controls, phones, and sink faucets should be

cleaned and disinfected daily with an EPA approved disinfectant. If high-touch surfaces become visibly dirty, clean and disinfect immediately.

• Furniture In addition to the carpet, vacuum any upholstered items. Regular vacuuming will remove most germs and keep your furniture looking great. Spot clean any fabric and use appropriate solutions for vinyl and leather surfaces. Dust light bulbs and replace any burned out bulbs. Remember to use plug protectors in electrical outlets to keep little fingers safe.

• Tables and Wood Dust the wood trim on furniture and any tables. A mixture of one-cup olive oil and onequarter-cup white vinegar will nourish the wood to leave it shining. The vinegar is a natural germ killer that will also clean the wood. Remember to scrub down the furniture legs, the front of the reception desk and other surfaces.

• Interactive Toys Toys, games, play equipment are easily wiped clean. Selecting toys with fewer parts, smooth flat surfaces and washable are best. Disinfect washable colorfast plastic toys with a solution of a half-cup of bleach per gallon of water. Soak for five minutes, rinse and air dry.

• Electronic Equipment TVs, monitors and cords should be wiped

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PATIENT MANAGEMENT

with a dry microfiber cloth that is approved for electronics and no scratch surfaces. Judicious use of disinfecting wipes over the entire surface of remote controls, keyboards, and mouse while paying particular attention to buttons to reduce cross contamination. Alternatively, use surface barriers for protection of electronics.

• Trash and Recycle Containers Loose trash should be picked up throughout the day and disposed of properly. Check the trash bin mid-day for emptying; never reach into or push on the trash liner to compress trash; leave liner in container, close the top, twist and tie a knot in the top of the bag. Carry the bag away from your body to dispose in trash container. Sharps used by patients (i.e. syringes) should be disposed of in an approved sharps containhttp://www.health.state.mn.us/ ht http t tp:/ ttp p:// :///www //w w ww w.hea hea ealt lth lt th.sta sttate aatte.m mn.us m us / er. Broken glass be picked up using a handhygiene/how/clean8.pdf dustpan and brush/broom or tongs; it should not be picked up by hand, even if wearing heavy-duty utility gloves. Wipe all surfaces of the trash container with a surface disinfectant wipe and allow air-drying before replacing with a new liner.

• Flooring Carpets should be vacuumed daily using a HEPA filter low decibel vacuum cleaner and spot cleaned as needed; a regular carpet cleaning is suggested every three months. Hard flooring should be cleaned using a broom or dust mop followed by flat-head mop for light cleaning. Use of a string or sponge mop for cleaning up spills is recommended. http://www.health.state.mn.us/divs/ tpp:/ :// //ww //www w ww w w.hea hea eallt ealt lth.st lth .sttat ate te.mn mn.u mn .uus/ s/d /d idepc/dtopics/infectioncontrol/cover/

• Odors

Odors can be particularly offensive to patients and staff alike. A good ventilation system with charcoal filters can help minimize unpleasant odors. Cautionary use of disinfectant/deodorant sprays is recommended as patients may be allergic or have respiratory concerns.

• PEEP: Place for Everything and Everything in its Place Complete a visual check throughout the day for items that are out of place. Organize items in containers, baskets or files to keep them corralled. Clear plexiglas holders and wall mounts keep pamphlets and magazines orderly. Placing office policies in plastic sleeves kept in a three-ring binder is better than posting on the wall. Keep current book titles and issues of magazines available. While studies have shown low fomite contamination of the glossy pages, some offices are removing magazines from the reception area and asking patients to bring their own reading materials and children’s toys to reduce the risk of cross contamination.

PATIENT FRIENDLY SPACE Boxes of facial tissue and pump bottles of alcohol based hand rub should be appropriately placed for patient use in the reception area. Post respiratory etiquette and hand hygiene signs as a reminder about the proper practice. The “red” cover your cough poster for health care facilities asking people to cover their cough and clean their hands. This poster is available for download in twenty-six languages. The 11x17 “blue” poster shows the six steps for washing hands with soap and water, or for cleaning with alcohol-based hand sanitizers.

DO YOU REALLY WANT TO KNOW? If you really want to know what patients think about your reception area, why not just ask them? They can complete a short anonymous survey while they wait. The rate of return is usually high and patients appreciate being asked their opinion. Clinical care and staff patient relationships are key to having patients return, but don’t underestimate the power of how your office presents itself to patients, after all these patients are putting their trust to keep them safe and healthy.

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HEALTH

GET FIT GET SMARTER! Y

our three-pound brain is the CEO of your whole body’s operation. It’s the playmaker, manager and overseer. It keeps 2000 gallons of blood surging through your heart each day and throughout 63,000 miles of blood vessels. It has you place one foot in front of the other as you walk from patient to patient and let’s you know when you need to eat lunch. It stores and retrieves memories from this morning and all the way back to the day you graduated from hygiene school. Seems powerful, doesn’t it? It is and it isn’t. It’s the center of your world and one of the most powerful processing machines in the universe. But it can’t live more than four minutes without oxygen. Did you know our brains reach their maximum size as teenagers and maintains that youthful volume until our late 20’s? Much of the atrophy as we age is not from neuronal death but from dendritic pruning as stale “same old same old” information comes through the system. Yes, we get stuck in our old routines and ahhhh, routine lulls your brain gently to sleep. How can you keep your memory sharp so you can remember details about patient histories? How can you keep your ability to learn new things and embrace change? Can you decrease your chances of dementia (Alzheimer’s being the most common form of this this horrible condition) and enjoy treating patients into your 60’s and possibly your 70’s with ease? How about maintaining your reaction time and hand eye coordination to keep pace with the new grads in your town? I say YES, YES, YES. I am going to reveal to you FIVE things you can work on to main-

tain your brain power and possibly grow it more powerful as you live a long healthy life.

Dr. Uche Odiatu

SLEEP QUALITY

is an NSCA certified trainer, a Holistic Lifestyle Coach, the co-author of The Miracle of Health ©2009 and Fit for the LOVE of It! ©2002, & a professional member of the America College of Sports Medicine. He maintains a dental practice in Toronto and has inspired audiences at the largest dental conferences in the world. He has appeared on over 400 radio and TV shows including ABC 20/20 and Canada AM. Contact him www.facebook.com/ Odiatu www.DrUche.com

A good night’s sleep is very important to support body repair, regenerate and heal. The physical body is obvious, but much less so is sleep’s influence on the brain. Many of us try to burn the candle at both ends for exams, deadlines, etc., but new research shows the short term gains may lead us to long-term disaster. Mary O’Brien, MD, in her book, The Healing Power of Sleep said, “Over extended periods, these disruptions of normal function may push a vulnerable organ system over the edge to disease.” The brain during sleep consolidates memories, processes emotion, and balances neurotransmitters. Genius (and what dental hygienist wouldn’t want a little more ingenuity?) has been known to erupt out of sleep. From Keith Richards waking up with the song Satisfaction coming out of his consciousness, to August Kekule and the chemical formula for benzene. With recent surveys showing that half the population has sleep difficulties, it appears obvious that it’s attained epidemic proportions. With the critical relationship of quality sleep, learning and memory, it is clear 50% of the population may not be performing at their best due to lack of sleep. I know you are aware of the prevalence of sleep apnea. But it’s much more than that. It’s making the mistake of having that glass of wine close to bedtime (which disrupts your sleep cycle). It’s having a night-light on in the bedroom (prevents you form getting into deep stage four

DMD

November 2016 www.oralhealthgroup.com

HEALTH

sleep). It’s watching TV right up the second of going to bed (spikes your waking hormone cortisol). We all need to learn new sleep habits if we want to be the best health care provider. Research has shown that there are drugfree ways to helping with more than 70 categories of sleep disturbances, of which insomnia is number one. Progressive muscle relaxation, Cognitive Beahvioural Therapy and similar techniques are being used very successfully.

MANAGE STRESS If there is one way to upset your brain and cause you to be less than 100%, it’s to have poor stress management strategies. Can we get rid of stress? No. Can we learn to reframe it? Yes. Can we learn to change our personal destructive tension relieving methods? Yes. Chronic unrelenting stress is a killer of the body and the brain. Jay Olshansky, a PhD from the University of Illinois, calls unrelenting emotional stress an aging accelerator that will shorten your life. Besides the physical disturbances, what does it do to your brain? Experts report that stress causes physical changes to you brain.

“We are not disturbed by things but our perceptions of things” ~ Epicticus

Evening is the worst time to be preoccupied with negative thoughts and feelings. It boosts cortisol – a hormone that every of your 100 trillion cells and vital organs can’t ignore. And it screams, “Something isn’t right. You can’t rest. There’s an enemy some-

where in the vicinity.” Your primitive lifepreserving cycle kicks into gear and the hypothalamus sends messages to your pituitary gland and it in turn tells your adrenals to kick out adrenaline and cortisol. Can you see the cycle we create for ourselves? When this is going on – and for many it is happening from eight o’clock until midnight – your brain will not prepare your body brain and spirit for rejuvenating slumber. Your agitated body steals life force energy away from your digestive system and immune systems, redirecting it toward a predator that is not physically present. Anxiety steals serotonin from your hippocampus, which needs serotonin to help sort out and file away memories. Chronic stress and resulting anxiety over extended periods of time shrinks this vital part of your brain. Naturally, about the size of your fingernail, this part of your brain has shrunk to half its size by the time Alzheimer’s is first diagnosed. Have I created a sense of urgency in you to manage stress and save your brain from imminent danger? A recent study with elderly subjects 80 years of age plus, saw those who managed stress well also had thicker overall cerebral cortex and a well-formed anterior cingulate gyrus. The normal shrinking of the cortex was not evident in the people with healthier lifestyle habits. Take a look at some of Herbert Benson’s work from Massachusetts General Hospital. He showed that circulating levels of all the destructive stress hormones decreased with a regular meditation habit. It’s not just for Ti-

November 2016 www.oralhealthgroup.com

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HEALTH

“All things held equal. If you have two people of equal ability and skills, the person who is an exerciser will always outperform the non-exerciser” betan monks. North American dentists can benefit from closing their eyes in the evening and focusing on their “in breath and out breath” and observing their thoughts with detachment. Ommmm…..

EXERCISE Dementia and its precursor, MCI or Mild Cognitive Impairment, involve loss of brain function that influences language, memory, thinking, judgment and behavior. All the current research points to lifestyle as a key influence on mental sharpness as we age. People suffering with dementia often share the same lifestyle factors as those experiencing cardiovascular disease and diabetes: such as inactivity, overeating, sedentary living and smoking. People who are obese are twice as likely to be diagnosed with some form of dementia. Diabetics have a 65% more likely to develop Alzheimer’s, which some researchers are calling Type III diabetes. The same things that make your cardiovascular system work poorly also make the brain work poorly. Remember that the brain uses 20% of your oxygen intake even though it weighs three pounds. Yes, it is an oxygen hog. And how do you boost the cardiac capacity and oxygen utilization of your body? Exercise. Besides the enormous vascular needs of the brain, it has another relationship with exercise. Neuroplasticity. Neuroplasticity is brain remodeling. Yes, your brain can renovate and improve itself if it has certain ingredients and a specific environment set up. Exercise boosts a key ingredient – BDNF. BDNF is Brain Derived Neurotophic Factor. BDNF facilitates neuronal survival, protection, remodeling, and dendritic growth. Long words but allimportant parts of keeping your brain healthy and youthful.

An fMRI study by Burdette in 2010 as reported in Aging Neuroscience Journal discovered that a four month aerobic workout regimen in a group of healthy older adults who were sedentary resulted in boosted cerebral blood flow and connectivity in the hippocampus (remember, I said this area is devastated in the person with Alzheimer’s).

LIMIT JUNK FOOD Every cell in your body is influenced by every morsel of food you eat and digest. From the Pop Tart, to the muffin, to the donut, to the beer, it all has an influence on your waistline – as well as your brain. The challenge of consuming loads of high glycemic treats and junk food is that it overloads your body’s Krebs Cycle (remember that from biochemistry?). After every overstuffed meal, a negative state is set up. It's called Postprandial Dysmetabolism. The body’s biochemistry is turned upside down by the abundant grams of sugar, trans fats and salt. The oxidative stress caused by excess poor quality nutrients not only disrupts fat burning and makes your pancreases work hard, your brain is also overloaded. A brain that has become insulin resistant will not work well. Its delicate environment needs ideal nutrients to play its “A game.” The high blood sugar - low blood sugar roller coaster completely disrupts your thinking processes. Ever been groggy after a lunch meeting of pasta and muffins? Ever been annoyed and irritable after a long morning where you worked through your break and found yourself snapping at the rest of the team?

LEARN NEW THINGS Last but not least, one of the most important things you can do to keep your brain fresh

November 2016 www.oralhealthgroup.com

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and youthful is to keep learning. Your brain over a lifetime is forever pruning and reshaping. New knowledge and activities makes your brain work harder and like a challenging personal trainer, it stimulates your brain and keeps it young. Perls et al. in a 1999 study reported that learning to play a new instrument, going to a new vacation spot, taking new courses and reading new varieties of books appear to expand and build neuronal networks. Numerous recent studies have shown that ongoing learning and keeping your brain busy dramatically reduces your likelihood of developing Alzheimer’s. The challenge is on. Learn new things, visit new vacation spots, run a half marathon, stop overeating at buffets, breathe deep ten times each day, sleep deeply and enjoy renewed professional and personal success.

Alberts et al “It Is Not About the Bike, It is About the Pedaling: Forced Exercise and Parkinson’s Disease” Vol 39 No 4 October 2011 American College of Sports Mediicne Deep Sleep 101 Blue Marble © 2001 Dispenza Joe. Breaking the Habit of Being Yourself © 2012 Hay House Harrison et al. J International Neurological Society. 2012 (Nov): 18(6) Perls et al Living to 100: Lessons in Living to Your Maximum Potential at any Age New York. Basic Books © 1999 Ratey John, Spark: The Revolutionary New Science of Exercise & the Brain © 2007 Richards Keith. Life © 2010 Little Brown & Company Salter Jenny “Exercise and Dementia: Exercise Programming for Dementia and Mild Cognitive Impairment” CanFitPro Magazine March/April 2013

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PEDIATRICS

PANDAS A Story of Molecular Mimicry BACKGROUND PANDAS is an acronym for Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections. This is a condition that affects a small group of children resulting in a sudden and abrupt onset of Obsessive Compulsive Disorder (OCD) symptoms. In the late 1990's, investigators at the US National Institutes of Mental Health, during a study of childhood onset of OCD, observed that some of the children had an unusually sudden onset of symptoms that differed from the typical cases where symptoms began gradually. These children presented with obsessive thoughts, compulsive behaviors and motor or vocal tics that appeared overnight and worsened rapidly within a day or two. Neuropsychiatric symptoms included irritability and aggressive behavior, anxiety attacks, extreme mood swings, temper tantrums, baby talk, handwriting changes as well as problems with school subjects such as math and reading. The investigators discovered that in this particular group of children, symptoms appeared after streptococcal infections Bacteria implicated in this disease are Streptococcus pyogenes (group A beta-hemolytic streptococcal bacteria). We associate these bacteria with a common ailment among both children and adults â€“ a very painful condition called strep throat or acute pharyngitis. Scarlet fever, rheumatic fever, Streptococcal Toxic Shock Syndrome and impetigo are

also caused by S. pyogenes. This ancient and clever organism survives through a system called molecular mimicry. It hides from the immune system by putting protein molecules on its cell wall that resemble those found in the brain tissues, heart, joints and skin. These molecules are eventually recognized as foreign and the body produces antibodies. Unfortunately, because of the molecular mimicry, the antibodies not only react with S.pyogenes but also with the human molecules that were mimicked. In the case of PANDAS, it appears that the human molecules that are attacked are tissues in the brain, particularly the basal ganglion. These attacks alter the dopamine transmissions, including the release of excess dopamine leading to neuropsychiatric symptoms of tics and OCD. One of the problems associated with PANDAS is the diagnosis of this streptococcal infection. PANDAS symptoms may follow an asymptomatic and unnoticed infection, thus the neuropsychiatric symptoms may be the first sign of this hidden infection. A child who has strep throat infection usually exhibits fever with sore throat. The asymptomatic child or carrier of the bacteria does not have symptoms and may not be tested to confirm the presence of S.pyogenes. Children and adolescents suffering from PANDAS rarely present with sore throats and therefore often go unrecognized or are misdiagnosed as having a mental illness and prescribed psychiatric

Anne Bosy, M.Sc, M.Ed, RRDH is the Senior Vice President, Scientific Affairs and a founding partner at Oravital Inc. Her experience in education includes that of professor at George Brown College as well as clinical instructor at the University of Toronto. She is a published researcher and has presented on her work for many international organizations including the American Dental Association, the Yankee Dental Congress, IADR and International Society of Breath Odor Research.

November 2016 www.oralhealthgroup.com

PEDIATRICS

medications as an attempt to manage symptoms. In the case of PANDAS, children may have an improvement but if they get another streptococcal infection, the symptoms become dramatically worse.

DIAGNOSTIC CRITERIA Five criteria were established by the US National Institute of Mental Health group as guidelines to diagnose PANDAS: 1. The presence of OCD, tics or Attention Deficit Hyperactivity Disorder (ADHD); 2. Abrupt onset of symptoms 3. Association with neurological abnormalities including motor hyperactivity and abnormal movements, anxiety, bedwetting and other regressive behaviours such as temper tantrums, personality changes and deterioration in math skills and handwriting 4. Onset of symptoms from age three to puberty 5. Associated with group A beta-hemolytic streptococcal infections. This could be verified through a throat culture or evidence of infections such as scarlet fever or by laboratory test evidence, for example the ASO titer. It is essential to distinguish PANDAS from Touretteâ€™s syndrome, which is a common tic disorder, and from Sydenham chorea, a movement disorder caused by Strepotococcus and associated with rheumatic fever. To complicate matters further, PANDAS is a subgroup of a disorder called PANS or Pediatric Acute-Onset Neuropsychiatric Syndrome. This is described as a treatable autoimmune condition that could be triggered by infections other than strep including B.burgdorferi (Lyme disease) herpes simplex, the common cold and other viruses.

TESTS FOR PANDAS Streptococcal antibody titers are used to determine if the child has had a previous strep infection. Two strep tests are commercially available: Antistreposysin O (ASO) titer and the Antistreptoccocal DNAse B (AntiDNA-

ase-B) titer. These tests show if there are molecules in the blood that indicate an infection that the child may have had in the last few months and molecules to fight the strep infection have been created. A throat culture can also be done to check if for the presence of S.pyogenes in the oropharynx. If the throat culture is negative, strep infection in the sinus, anus, vagina or penis, although rare, have been known to trigger PANDAS symptoms. If the culture is positive, antibiotic treatment will eliminate the strep infection and PANDAS symptoms will decrease or be eliminated. A commercial polymerase chain reaction (PCR) based test for the detection of S.pyogenes has been developed and has excellent sensitivity and specificity. This may be the test of choice in the future.

TREATMENT OPTIONS If the disease is recognized as PANDAS, these patients respond well to antibiotic treatment and improvement is seen within a few days. Beta-lactam antibiotics such as penicillin, amoxicillin, and cephalosporins have been shown effective in the treatment of PANDAS. Other antibiotics that have been used with some success are erythromycin, azithromycin and clindamycin. Some resistance has been identified and if there is no improvement, the antibiotic should be changed. There is some indication that S.pyogenes can exist in oral biofilm and it has been isolated from tooth surfaces and gutta percha in endodontically treated teeth. In discussions with parents whose children have PANDAS, they have identified a connection to exfoliation of teeth. The child will have an increased intensity of symptoms during exfoliation and eruption. Further, S. pyogenes can persist on surfaces of soft toys, books, cribs and other hard surfaces for an extended period of time. This increases the possibility of exposure and re-infection with these bacteria. Since S.pyogenes is transmissible in the same manner as periodontal pathogens, after an episode, the replacement of toothbrushes by children who suffer from PANDAS would be very beneficial to prevent reinfection.

November 2016 www.oralhealthgroup.com

June 2 & 3, 2017

TIDE is proud to present the ﬁrst annual

IMPLANT COMPLICATIONS & INNOVATIONS SYMPOSIUM Implant dentistry provides a viable tooth replacement treatment modality and is considered as mainstream prosthetic dentistry. The beneﬁts and advantages of dental implants for our patients are now being provided by clinicians of diverse disciplines, backgrounds and experiences. However, clinical realities and scientiﬁc literature have provided evidence of various modes of implant complications and failures. Complications and failures in implant dentistry can range from minor to major, reversible to irreversible and problematic to detrimental outcomes. As a result, these clinical problems can cause frustrations and disappointments for our patients and the dental professionals. Taking the time to avoid complications, rather than spending time management them with compromised outcomes will be the main focus of this symposium. This symposium will consist of 2 full days of didactic and hands-on programs. On day 1, two concurrent simultaneous sessions will take place with didactic presentations from distinguished speakers and dental specialists. The “Clinicians Session” has been structured with various speakers from the specialties of Prosthodontists, Oral Surgeons and Periodontists. The “Team Session” has been structured with various expert speakers with the respective topics and dental specialists.

Expert Speakers

Workshops

Dr. Mark Lin Prosthodontist, Moderator

1 | Aesthetic smile designs

Dr. Lesley David Oral Surgeon Dr. Jon Suzuki Periodontist Dr. Izchak Barzilay Prosthodontist Dr. David Chvartszaid Periodontist / Prosthodontist Dr. Goth Siu Prosthodontist Dr. Tina Kokosis Periodontist

2 | Implant prosthetics for the surgical specialist 3 | CPR recertiﬁcation 4 | Powerful Treatment Consultation Inspire Your Patients - Empower Their Lives 5 | Immediate anterior and posterior implant dentistry with anterior provisionalization

+ HST

AGD members get $50 discount

CE Credit 7 per day Cancellation must be received 21 days prior to the course for refund

Day 2

Please call for exact workshop rates WORKSHOP ATTENDANCE IS LIMITED

Location BMO, 3550 Pharmacy Ave Sign-In 8:00am to 8:30 am Lecture 8:30am to 5:30pm

8 | Botox applications in implant dentistry

Dr. Romeo Paculanan Prosthodontist

10 | Soft tissue augmentation in implant dentistry

per team member (please enquire for group rate)

Early Bird Discount 50 for Registration before March 31, 2017

7 | Implant overdentures and digital dentures 9 | Surgical implant precision utilizing Dynamic Guided concept

per doctor

Toronto Institute for Dental Excellence is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 5/1/2016 to 4/30/2019. Provider ID# 217983

6 | Teeth In a Day treatment concept, treatment planning, surgical parameters and prosthetics

Dr. Joseph Fava Prosthodontist

Peter Barry CMC, RRDH

895 $ 495

Day 1

11 | Dental photography hands-on workshop

To register contact Gina Mazza at 416.825.3500/gina@tideinc.ca

www.tideinc.ca/implant-symposium

TORONTO INSTITUTE FOR DENTAL EXCELLENCE

DISCUSSION Recently, a documentary on PANDAS was aired on the program W5 and featured Dr. Wendy Edwards, a physician in Chatham, Ontario who has been treating PANDAS. Several parents whose children exhibited abnormal behavior and who were subsequently diagnosed and treated for PANDAS discussed their experiences. One of the parents described the behavior of her seven-year old son who had been normal, well adjusted and athletic. When playing hockey one day, he suddenly began hopping like a rabbit. Within a week he developed other compulsive behaviours, including angry outbursts such as smashing his head against tables and walls. She read about PANDAS but found it difficult to find a physician who would test her son for strep. Eventually he was tested and found positive for strep. A dose of antibiotics prescribed for seven days subsided the symptoms almost immediately. Unfortunately, after the antibiotics ran out, the rages and other symptoms returned. Retreatment with antibiotics followed by immune system boosting and dietary changes resulted in elimination of the symptoms and a return to normal. Since individuals can be non-symptomatic carriers of S.pyogenes, this makes a very difficult scenario if one of the children has PANDAS and the other is a carrier. Both children must be treated if the one with the condition is to improve. Suggestions provided for parents and caregivers are to check throat cultures on family members to make sure that none are strep carriers. In a longitudinal study of 100 school-aged children who were followed for a period four years, fiftythree percent were carriers of S.pyogenes

PEDIATRICS

PANDAS has been misunderstood and confusing to doctors. Controversy about treatment and the skepticism in accepting the condition as an infection contributes to the reluctance to prescribe antibiotics. Since the child’s symptoms return upon re-exposure to S.pyogenes and antibiotics are required on a regular basis is another factor. Doctors prefer to treat symptoms with psychiatric medications like Prozac or Zoloft, drugs used for obsessive-compulsive disorders. Unfortunately despite increased doses of these drugs there is little change in the child’s behavior.

at some point in the study. There is an ongoing search for a safe and effective vaccine to prevent S.pyogenes infections. Considering that S.pyogenes has been studied intensely, it is surprising that such a vaccine is still not available. If developed, this vaccine would have a significant and positive impact on the treatment of PANDAS. Lastly, as a response to a couple of physicians, Oravital Inc. is currently working to develop several antibiotic rinses that may help to control S.pyogenes and decrease the amount of systemic antibiotic intake. Since children respond to different antibiotics, this complicates the formulations. However, there has been some success especially in the treatment of those children who are carriers thus decreasing exposure to S.pyogenes and reducing the number of episodes experienced by the PANDAS child.

References Swedo S.E. et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. The American Journal of Psychiatry 1998: 155(2):264-271. Cox C. et al. Antineuronal antibodies antibodies in a heterogeneous group of youth and young adults with tics and obsessive-compulsive disorder. Journal of Child and Adolescent Psychopharmacology 2015;25(1):76–85. [PubMed: 25658702] Spellerberg B. Brandt C. Laboratory diagnosis of streptococcus pyogenes (Group A streptococci) in Streptococcus pygenes: Basic Biology to Clinical Manifestations. 2016; Eds. Ferretti JJ et al. Orefici G et al. Pediatric autoimmune neuropsychiatric disorders associated with Streptococcal infections. Basic Biology to Clinical Manifestations. 2016: Eds. Ferretti JJ et al. Mink J, Kurlan R. Acute postinfectious movement and psychiatric disorders in children and adolescents. Journal of Child Neurology. Feb 2011;26(2):214-217. Takemura N et al. Single species biofilm-forming ability of root canal isolates on gutta-purcha points. European Journal of Oral Sciences. 2004;112(6): 523-529 www.ctvnews.ca/.../w5-investigates-possible-linksbetween-common-infection-and-psychiatric and neurological disorders in children. https://www.nimh.nih.gov/labs-at-nimh/

November 2016 www.oralhealthgroup.com

PRODUCT PROFILE

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November 2016 www.oralhealthgroup.com

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‘‘

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• In the US alone, 234 new titles made their debut, up 21% from 2013. (Guide to New Magazines, USA) • FOLIO Magazine’s annual survey of US city and regional magazines said 2015 featured more new launches than any year since 2009.

Publications Serving Niche Markets (like B2B) Provide Unique Content Readers Cannot Get Anywhere Else.* * Skip Zimbalist, chairman and CEO of Active Interest Media (AIM), which publishes titles like Backpacker, Black Belt, Arts & Crafts Homes, Better Nutrition, Ski Magazine, Vegetarian Times, Power & Motor Yacht, and Yoga Journal, told FOLIO’s recent Growth Summit that AIM is investing in circulation marketing including direct mail. “We have not found declining yields in mail over the last 10-15 years,” he said.

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DENTAL MARKETPLACE

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

HYGIENISTS

NORTHERN MANITOBA

ASSOCIATESHIPS

SAULT STE. MARIE, ON HYGIENIST WANTED

Looking for two energetic hygienists to work in dental clinic in Northern Manitoba, very good income can be made. To apply please e-mail: chris.p1933@yahoo.com

Love your career at Northern Dental Care! Full time position available. Send CV to ashlee@ northerndentalcare.com

PRACTICES & OFFICES

CAREERS

EMERYVILLE, ON

GENERAL ANESTHESIOLOGIST

Available December 1, 2016 Existing Dental office for lease in Emeryville, Ontario. Approximately 12 minutes from Windsor. Spacious suites, modernized and well decorated with hardwood flooring and ceramic tile. Also has ample parking. Growing area with new developments. Building also has a busy cosmetic surgeon. Opportunity for cross promotion. Contact Cate at 519-670-3138 or cate@coleclinic.com

ONTARIO We are in need of a general anesthesiologist in several of our practices in Ontario. Our greatest need is in our Hamilton practice, which has a waiting list of patients. We need someone as soon as possible to fill this need. This clinic has already been performing GA so it already has it facility permit and an experienced support staff. E-mail: trish.carere@teethfirstdental.com

ASSOCIATESHIPS

MISSISSAUGA, ON FULL TIME Dental Hygienist wanted immediately for a large busy dental practice in Central Mississauga. Minimum 2 years experience preferred. Apply in confidence to ddsmississauga@yahoo.com

FORT MCMURRAY, AB

FULL TIME ASSOCIATE REQUIRED

Fantastic opportunity in a busy mall practice. If you want exceptional Income with freedom and time off come join us.

MULTIPLE LOCATIONS IN ONTARIO Exciting full and part time associate opportunities available for Barrie, Mississauga, Stoney Creek, Etobicoke and Scarborough. We are also looking for an orthodontist. E-mail: yourdentaldream@gmail.com

November 2016

TORONTO, ON Full time dental associate needed immediately for busy group practice in downtown Toronto. Seeking dentist who is comfortable with a fast paced environment. Excellent earning potential. Please forward your resume to: dentistrywithcare15@gmail.com

15 MIN. NORTH OF PICKERING, ON Associate Dentist Wanted. Part-time leading to full time. Potential Buy in. 2 days to start. Digital Xrays and Paperless Office. Contact: 289 818 1538 or email CV to associatedentaljobs@gmail.com

WINDSOR, ON Part-time associate wanted - 2 days a week. Family friendly office with great staff. Contact: Dr. G. W. Hanaka T: 519-258-5271, ghanaka@aol.com

SOUTH CALGARY, AB We are now accepting resumes for our full time, Wednesday to Saturday Associate position. Our busy assignment clinic, located in south Calgary, currently provides all aspects of family and general dentistry including general and advanced cosmetic dentistry, “Invisalign”, digital x-rays, Velscope to name just a few of our services and all are supported by a highly skilled and happy team. We also offer reserved patient parking for our 6 days a week clinic which includes 1 evening. Only Dentists with a minimum of 3 years experience will be considered and Invisalign, Cerec plus Dentrix knowledge preferred. Please forward your cover letter and resume including references to airlies@shaw.ca.

PARRY SOUND, ON FULL TIME ASSOCIATE wanted for established state of the art dental practice. Located in friendly Parry Sound on beautiful Georgian Bay! We are looking for a full time / 4 days per week Associate, no evenings or weekends at this time. A great opportunity! Please send resumes to: Lisa Tait, Office Manager lisa@dentistryonthebay.ca

Contact Dr Jones at 1-780-940-7251

EDMONTON, AB

FULL TIME Associate required for a busy General practice. Large established patient base, great staff in place. Office hours from 8am – 5pm NO Saturdays or evenings. Excellent long term opportunity. Please Email resume to: smiledoctors1@hotmail.com

CORNWALL, ON Part-Time position available in sophisticated office with excellent staff and team environment. Must be compassionate and maintain the highest quality standard of care for all patients. Hours: 2 days per week with growth opportunities. E-mail: dralma@dentistryatcornwall.ca

DENTAL ASSOCIATE SASKATOON, SK Campus Dentist University of Saskatchewan in Saskatoon is currently looking for an energetic, friendly, outgoing, enthusiastic individual for a very unique opportunity in a modern university setting. Please email us: marzena@campusdentist.com

RECRUITING This is a unique opportunity to join a very progressive and modern dental practice in an affluent neighbourhood in Toronto. We are seeking a dentist with a minimum of 10 years experience to join as a part-time associate working traditional hours of the week. This practice also employs restorative dental hygienists which permit the associate to focus on comprehensive treatment planning and more sophisticated procedures, as opposed to performing traditional restorative dental work. We offer a lucrative compensation package, consistent with a qualified dentist with experience. Interviews will commence in October of 2016. Please email your resume to Oral Hygiene Box 46 – karen@newcom.ca

www.oralhealthgroup.com

H E T T L H L I A N GS F O YOUR PATIENTS MAY TAKE TO BED

THEIR DENTURES SHOULDN’T BE ONE OF THEM. 1-5

Though your patients may take comfort in keeping their dentures in at night, the consequences can be severe, from increased odour to fungal infections to increased caries.1–5 Guiding your patients through the best nighttime routine could be one of the most important conversations you have with them. That means removal and gentle, antibacterial cleaning with Polident®.6

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The thin transparent 5% Sodium Fluoride Varnish in a non-messy new delivery system Easy non-messy Single Dose delivery system Transparent color without yellow discoloration of the teeth ) TGCV VCUVKPI ƃ CXQTU YKVJQWV CP WPRNGCUCPV aftertaste Contains no Saccharin, Aspartame or Gluten Available in both adult and child dose Contains Xylitol

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Révélez tout Enfin, vos patients peuvent voir une image claire de leurs habitudes de brossage. Philips Sonicare FlexCare Platinum Connected à utilisation facile révèle les habitudes de vos patients et les aide à établir une meilleure routine d’hygiène buccale.

Sonique

Brosse à dents sonique la plus recommandée au monde

•

Technologie de capteur intelligent: Des capteurs de position, de frottement et de pression assurent le suivi de brossage du patient en temps réel pour améliorer la technique et la couverture de nettoyage

•

La technologie 3D de carte de la bouche permet l’analyse postbrossage pour aider les patients à se concentrer sur les zones présentant des problèmes

•

La fonction Personalized TouchUp encourage les patients à retourner aux endroits qu’ils ont manqués pour obtenir un nettoyage plus complet

Composez le 1-800-278-8282 ou contactez votre représentant commercial pour plus d’informations.

Désolé sensibilité, c’est trois contre un*. Nous proposons toute une gamme de produits Sensodyne®, car nous savons que l’hypersensibilité dentinaire peut avoir plusieurs causes. Cela vous permet aussi de choisir un produit qui répond aux besoins de vos patients qui seront ainsi sur la bonne voie.

* Dans le cadre d’un brossage 2 fois par jour ou selon les directives. GlaxoSmithKline Soins de santé aux consommateurs Inc. Mississauga, Ontario L5N 6L4 ©2016 Le groupe d’entreprises GSK ou son concédant. Tous droits réservés.

AUCUNE DENT NÉGLIGÉE Brossette ronde CrossAction unique

Système de suivi de la pression du brossage

Contrairement aux brossettes rectangulaires, la brossette ronde ORAL-B® inspirée des outils prophylactiques enveloppe chaque dent pour un meilleur contact avec les soies.

Seul Oral-B® offre un système de contrôle de la pression triple aﬁn de détecter un brossage excessif et procure au patient une alerte visuelle de l’anneau intelligent 360°.

La brosse à dents Oral-B® GENIUS™ CrossAction nettoie mieux que la brosse à dents Sonicare DiamondClean*

Innovation : Détection de la position

L’action de pulsation oscillo-rotative de

Oral-B® Pro CrossAction

Mouvements latéraux de

Sonicare DiamondClean

Parlez de Oral-B® GENIUS™ à vos patients aﬁn qu’ils ne négligent aucune surface.

* Selon des études cliniques portant sur plusieurs semaines. Sonicare est une marque déposée de Koninklijke Philips N.V.

ORAL-20485

L’application pour téléphone intelligent aide le patient à améliorer sa technique de brossage en lui montrant les surfaces qu’il néglige.

Une personne sur quatre en souffre . 2

Plusieurs l’ignorent . Elles peuvent aussi en ignorer les conséquences sur leur santé buccodentaire*. Elles attendent vos conseils.

La bouche sèche est un problème de santé buccodentaire qui affecte surtout les personnes prenant plusieurs médicaments3. Pourtant, certaines personnes qui souffrent de bouche sèche ne savent pas qu’il s’agit d’un problème courant2. Parlez à vos patients de la bouche sèche et du soulagement que Biotène peut aider à procurer†. ®

www.biotene.ca

GlaxoSmithKline Soins de santé aux consommateurs Inc. Mississauga, Ontario L5N 6L4 © 2016 Le groupe d’entreprises GSK ou son concédant. Tous droits réservés. * La bouche sèche peut perturber l’environnement de santé buccodentaire et causer la mauvaise haleine, la déminéralisation et l’augmentation de la carie4,5. † Rince-bouche, gel et vaporisateur. ‡ Tel que mesuré dans le cadre d’une étude clinique de 28 jours6. 1. Données internes de GSK. Occasion de croissance de Biotène pour la bouche sèche (incluant les données U&A canadiennes). 16 juillet 2014. 2. Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004;38:236-240. 3. Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth, 2e édition. Gerodontology. 1997;14:33–47. 4. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007;138:15S–20S. 5. Fox PC. J Clin Dent. 2006;17 (numéro spécial):27-28. 6. Données internes de GSK 2014, RH01986.

L’ADVERSAIRE DE L’ACIDE. Crest® Pro-Santé Avancé contient du ﬂuorure stanneux pour des dents plus saines et plus fortes.

1. Le ﬂuorure stanneux reminéralise l’émail aﬀaibli.

2. Le ﬂuorure stanneux forme une micro pellicule de protection pour prévenir l’érosion causée par l’acidité et soigner la sensibilité dentaire.

3. Le ﬂuorure stanneux freine de façon importante la production d’acides liés aux bactéries responsables de la plaque.

avec SHMP

Fluorure stanneux stabilisé Non traité

SANS BILLES DE POLYÉTHYLÈNE NE TACHE PAS

ORAL-20443

un soin continu après votre visite chez le dentiste PRO-SANTÉ

Pour vous,

cela représente une bouche saine. Pour vos patients,

cela représente la confiance totale. De la part des spécialistes en hygiène buccale de Sonicare, Philips Zoom peut dévoiler un sourire sain qui renforce la confiance de vos patients. • Efficacité en clinique – blanchit jusqu’à 8 teintes en 45 minutes1 • Des résultats à domicile – les formules les plus avancées en matière de blanchiment à la maison Faites connaître à vos patients le traitement de blanchiment sain et fiable de Philips Zoom.

Philips Zoom WhiteSpeed

La marque de blanchiment

la plus utilisée par les professionnels en soins dentaires

Philips Zoom DayWhite Doux

Philips Zoom Stylo de blanchiment

Appelez dès maintenant pour obtenir votre essai gratuit au (800) 278-8282 ou consultez le site www.philips.com/ZoomPortfolio 1 Avec Philips Zoom WhiteSpeed. N’inclut pas le temps de préparation.

Votre rendez-vous de 16h...

Le vernis de l’heure

Vous avez beso besoin so d’un vernis blanc qui s’applique sans effort. Duraflor Halo simplifie les matinées et les après-midi depuis des années. Sa consistance lisse et soyeuse ne forme pas de grumeaux, de e sorte que son application est toujours sans effort. votre journée, Duraflor Halo est si lisse, qu’elle À la fin de v surpasse toute toutt concurrence... un sourire à la fois! Pour vos échantillons échan an gratuits, visitez medicom.com dès aujourd’hui!

Duraflor Halo ®

Vernis blanc au fluorure de sodium à 5 %

Un sourire à la fois

PLUS RAPIDE, PLUS FACILE, PLUS DOUX…

BeautiSealant Libération de fluor et système d’étanchéité pour fissures

Dites adieu aux étapes de mordançage et rinçage pour toujours! Q Relâche et recharge du ﬂuor biodisponible Q Force de liaison supérieure en seulement en 30 secondes Q Matériel de remplissage radioopaque cariostatique Q Lisse, sans formation de bulles Q Propriétés préventives antibactériennes Q Sans BPA et HEMA

SNBS2F-1014

Visitez www.shofu.com ou téléphonez au 800.827.4638

Shofu Dental Corporation • San Marcos, CA

VOS PATIENTS PEUVENT DORMIR AVEC

E S T D R E O S C H S E O T S U E O S T

MAIS LA PROTHÈSE DENTAIRE EN EST UNE DE TROP. 1-5

Vos patients peuvent trouver réconfortant de garder leur prothèse pendant la nuit, mais les conséquences peuvent être graves et englobent la mauvaise haleine, les infections fongiques et les caries plus nombreuses1-5. Guider vos patients à adopter de bonnes habitudes avant de se coucher pourrait être la plus importante conversation que vous aurez avec eux. Ces habitudes consistent dans le retrait de la prothèse et un nettoyage doux et antibactérien grâce à Polident®6.

Quelle réaction voulez-vous?

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Le vernis transparent et mince au Fluorure de Sodium à 5% dans un système de livraison propre et sans gâchis Système de livraison “Single Dose” sans Transparent sans décoloration jaunâtre des dents Agréable saveurs sans arrière goût Ne contient aucune Saccharine, Aspartame ou Gluten Disponible en dose adulte ou enfant Contient du Xylitol

Contactez 1-888-658-2584

VOCO Canada · sans frais 1-888-658-2584 · Fax 905-824-2788 · infousa@voco.com · www.voco.com