UAlberta SMILES ital to the health of our communities 2016/2017 Edition
Chair’s message Oral health is our business. The School of Dentistry at the University of Alberta is vital to the health of our communities. We provide information in simple terms about the importance of keeping your oral health in good shape. And we’ve been doing it for close to 100 years. In 2017, the school will celebrate its centennial year. While we’re looking forward to that milestone, it also helps us reflect on our storied past. Until 1958, for example, our school was the only dental school in Western Canada. Today, 32 dentists and 42 dental hygienists graduate from the School of Dentistry each year. From April 2015 to April 2016, the School’s dental clinics had a total of 41,107 patient visits. Our students receive instruction from our expert faculty members, most of whom are practising dentists and dental hygienists. Others are themselves graduates of the School. Together, they are helping educate the next generation of oral health practitioners. In addition to teaching the fundamentals of dentistry, many of our faculty members also specialize in periodontics, oral surgery, pedodontics, prosthodontics, endodontics, oral pathology and oral medicine. But in simple terms remember this: your mouth is connected to the rest of your body and when you have poor oral health it can often reveal other health issues. Keep your mouth healthy by visiting your dentist or dental hygienist regularly, and don’t forget to smile!
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Design & Cover Tarwinder Rai
Writers & Photography Cheryl Deslaurier Tarwinder Rai
Table of contents A family affair .................................................................
Trigeminal neuralgia: Know the signs ...........................
Childrenâ€™s oral health can impact learning ...................
Pain you canâ€™t escape ...................................................... 10-11 When toothaches go untreated ................................
Are you afraid of the dentist? ........................................ 14-15 What your mouth can tell you ..................................
Mobilizing dental hygiene .............................................. 18-19 Oral health important in head and neck cancer ............ 20-21 Save your teeth!.............................................................. 22-23
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Keeping your teeth healthy is important. Rafael Conde (left to right), Vanessa Conde, Bryan Conde and Liza Espejo come to the School of Dentistry Clinic as a family for their check-ups.
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A family affair Your child’s first visit to the dentist
Dentists are often asked, “When should I bring my child to the dentist?” The Canadian Dental Association recommends that children should be examined within six months of the eruption of their first tooth or by the time they turn one. When parents or caregivers hear this, they often wonder, “What are dentists going to do with a child that has no teeth?” Dentists can do a lot, however they can provide a comprehensive oral exam by examining the child’s oral cavity, their gum pads, and when they are a little older, their teeth. “We can check to see if the teeth are coming in healthy,” says Ida Kornerup, a pediatric dentist at the School of Dentistry. “These dental exams also help us catch any problems earlier.” To ensure your child’s teeth come in correctly and to avoid the possible onset of tooth decay, regular visits to the dentist are important. Since baby teeth are going to last until children are 12 to 13 years of age, Kornerup says establishing good oral habits early is vital. “As parents, we play a huge role in helping keep our kid’s teeth healthy and clean,” she says. “We want to help form healthy habits early. So, in addition to educating children about how to care for their teeth, we also
address nutrition’s big role. For example, sugary snacks and drinks can get deposited on teeth. If children aren’t brushing properly, food remains trapped and cavities form.” While many dentists and parents recognize children may be apprehensive about visiting the dentist, Kornerup says early visits can help prevent more invasive treatment like needles and drilling for children as they age. Dentists can talk to the parents about the importance of a good diet, examine the child’s bite, gums, and evaluate oral habits. Form good oral hygiene habits at home early to ensure fear-free dental visit: • Choose a soft, kid-size brush. Replace the toothbrush every three months. • Use no more than a rice-size amount of toothpaste on your child’s brush. • Help your toddler brush their teeth twice a day. • Avoid starchy and sugary snacks. They stick to teeth and increase the risk of decay. • If your child is unable to brush, rinse his or her mouth with water to wash away food particles and sugar.
Trigeminal neuralgia: know the
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On what seemed like an ordinary day in 2002, Miriam Fraser, just shy of her 30th birthday, suddenly experienced something that changed her life forever. While folding laundry, she started to experience a sharp pain in her left eye. As the day wore on, the pain intensified. By the end of the day, her doctor had a diagnosis: trigeminal neuralgia (TN). She was placed on medication immediately. Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from the face to the brain. TN is caused by a blood vessel pressing on the nerve near the brain stem. If you have TN, even mild stimulation of your face such as brushing your teeth can trigger excruciating pain. “I am still unable to have a normal life,” says Fraser, who also had microvascular surgery completed to help alleviate her constant pain. “With medication it’s controlled, but eating, drinking or a slight breeze will trigger my pain. Any kind of vibration in a car or plane triggers it. I can’t even exercise.” Because of the pain, Fraser says she’s been isolated in her home for the past few years. When she’s having a good day, she does as much as she can. “I left my job that day in 2002 to see the doctor, but I never thought I wouldn’t return to work,” she says. “The pain isn’t something you can hide. It’s in your face, and it’s in your life.” TN can occur as a result of aging, or it can be related to multiple sclerosis. Some people experience TN due to a brain lesion, surgical injuries, stroke, facial trauma, an abscessed tooth or, in Fraser’s case, nothing at all. “I had no dental damage. But during my surgery in 2012, the neurosurgeon did three nerve compression spots on my brain,” she says. “But in my case, even after the surgery, the pain remained.” Fraser is now managing her pain by medication and through the help of orofacial pain clinical professor Ivonne Hernandez.
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Children’s oral health can affect learning Children with poor oral health have trouble concentrating in class, have lower self-esteem, and it can adversely affect their social interactions. A recent study shows that rates of early childhood caries (ECC) is five times higher than that of asthma – making it the most common chronic childhood disease. It further demonstrates that poor oral health has a significant impact on a child’s growth, development and overall quality of life. “We tell parents and encourage them to be the main influential factor in helping their children maintain good oral health,” says associate professor of pediatric dentistry and researcher Maryam Amin. “Regular dental visits allows for early detection and prevention of oral diseases. Parents must supervise their children’s oral hygiene.” According to the Canadian Institute for Health Information, ECC accounts for about one-third of all day surgeries performed on Canadian children between the ages of one and five. “The recommendation is to see a dentist within six months of the first tooth erupting or by the child’s
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first birthday,” says Amin. “We understand there are sometimes barriers preventing from utilizing dental care, but regular attendance teaches and forces children to think about their health.” The School of Dentistry has many programs available that focus on school-aged children. This includes a “school visit” program that offers free dental treatments to children living in underserved areas. The program has been around more than a decade. Established in 2012, SMILE is another volunteer initiative led by dental hygiene students that aims to provide oral health education by visiting schools and hospitals across Edmonton. Since 2008, the division of pediatric dentistry has also initiated an outreach program serving inner-city children and their families by providing oral health education and prevention services. Amin takes her research team into communities considered to be the most vulnerable and into immigrant populations to do dental outreach work, as well. They conduct community-based integrated workshop programs that engage these communities in oral health promotion activities for their children.
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Pain you can’t escape Can you imagine a world where your mouth feels like it’s on fire? The pain is inescapable - you can no longer eat or drink the food and beverages you once enjoyed. “Sometimes the pain is excruciating,” says Elizabeth LePage, who suffers from a condition called Burning Mouth Syndrome (BMS). “To the point where I want to throw up.” BMS is the medical term for ongoing (chronic) or recurrent burning in the mouth without an obvious cause. The discomfort may affect your tongue, gums, lips, inside of your cheeks, roof of your mouth or widespread areas of your whole mouth. BMS appears suddenly and can be severe, as if you scalded your mouth. It can be described as a neuropathic pain where the nerves in the mouth are not functioning properly. Not much is known about BMS as it’s often under-diagnosed and its management complex. Some studies show that 40 per cent of those diagnosed are elderly people, mostly postmenopausal women. They also show that people with BMS may experience a decrease in quality of life and an increase in psychological distress. LePage was originally diagnosed with Thrush―a medical condition in which a fungus called candida albicans overgrows in the mouth and throat.
After taking medication prescribed for Thrush, there were no changes in LePage’s condition. Further visits to her doctor and denturist resulted in a referral to an oral pathologist―Tim McGaw, at the University of Alberta School of Dentistry. McGaw took swabs from LePage’s tongue and top of mouth and sent them to the lab, which ruled out any persistent candidiasis. After excluding other local or systemic causes of secondary burning symptoms of the mouth, a diagnosis of BMS was rendered and a treatment plan was prescribed in November 2014. Reid Friesen, School of Dentistry, Oral Medicine program resident, is currently conducting research on a new treatment—one, he hopes, is more effective. To this day, LePage follows a regimented routine of topical clonazepam―one of the methods of treatments that is sometimes effective. She is also careful about what she eats and drinks, avoiding things like wine and spicy foods. Conditions like this demonstrate that oral health is part of people’s overall health and should not be ignored. If you think something isn’t right in your mouth, maybe not your teeth, but the inside of your mouth, go see a dentist, oral pathologist or dental hygienist. They all can prove to be a valuable resource in your health care needs.
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When toothaches go untreated Has a tooth been bothering you? A few aches and pains? Too busy to have it checked out? You may want to head to the dentist’s office before letting it fester any longer – the longer you wait, the more detrimental it could be to your health. “A local dental infection can quickly become a major health issue,” says Reena Talwar, oral and maxillofacial surgeon and associate professor at the University of Alberta School of Dentistry. “Where there is dental pain, there is a problem. What would be a common tooth extraction or filling can easily become infected and spread throughout the entire mouth if treatment is delayed for too long.” As an oral surgeon, Talwar says patients are often assessed for treatment and do not complete it. Leaving an abscess untreated not only leads to more intense pain and swelling, but tooth loss can occur if too much of the bone is damaged. She’s seen patients leave abscesses untreated and end up in the intensive care unit because of it. “One patient with a long standing toothache and repeat infection kept on taking antibiotics and postponing treatment. They ended up in the hospital with a breathing tube and several teeth removed,” says Talwar. “When something like this happens, it not only changes the patient’s life, but it affects their family and friends.” Ma Micah, who is a patient of orofacial pain clinical professor Ivonne Hernandez, agrees with this. Experiencing pain in her mouth for almost three years, she put off seeing a dentist. “I thought it was my wisdom teeth. The pain would last three or four days and then go away. To be
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honest, I thought it was normal,” she says. It wasn’t until a bump developed on her cheek — inside and outside with yellow discharge — that she decided to seek medical advice. Her doctor diagnosed it as a cyst that would need to be removed. However, the surgery didn’t solve her problem. She went to her dentist. After a dental exam, she was told she needed a root canal. The cyst she had was actually a fistula — the result of a tooth abscess. A fistula is an abnormal passage from the apical periodontal area of a tooth to the surface of the oral mucous membrane, permitting the discharge of inflammatory or suppurative material. Within three days of having the procedure, her cheek started to heal. “If you have pain in your mouth, get it checked by a dentist. I have a scar on my cheek now, but I’m glad I got it done,” says Micah. Talwar says when people feel discomfort or pain, they should see a dentist as soon as possible. Infections, especially in the mouth, spread much faster than in other parts of your body. “Children and elderly who have infections need to be treated within 24 hours,” she says. “The longer treatment is prolonged, the harder it is to get anesthetics to work, the cost of procedure can go up, sedation may be required or a specialist needed.” If your dentist is not available, remember hospitals have emergency dentists on call.
Are you afraid of the dentist?
Hypnosis may be the solution
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It might be the oldest form of anesthetic out there. Hypnosis, not just meant for entertainment, can help alleviate a lot of pain and anxiety when it comes to visiting a dental office. David Kelner, a practising dentist and associate clinical professor at the School of Dentistry, offers it to his patients. He is a certified hypnotherapist and serves as the educational chair for the Canadian Federation of Clinical Hypnosis — national body and Alberta Division. “There’s a misconception about hypnosis that people will say and do things they don’t want to, but it’s not true,” says Kelner. “In dentistry, hypnosis is a very effective evidence-based adjunctive procedure for anxiety and pain control.” According to him, modern medicine is slowly starting to integrate hypnosis as a modality into patient treatment. “Hypnosis helps those patients who are extremely apprehensive about having any kind of dental treatment.” While under hypnosis, the patient is in an induced state of heightened consciousness and they become highly responsive to therapeutic suggestions. This means escaping the fear that comes from dental procedures is possible. Kelner, who’s been a practising certified hypnotherapist for 20 years, says on average it takes two to three appointments for routine dental procedures. Rapid induction can also be obtained for immediate pain or anxiety control as well. “Hypnosis acts on the brain’s emotions. It’s the body that must be treated so the mind can go anywhere,” he says. “I’ve had patients who are afraid of having their teeth cleaned, needles, any type of dental work done.” Kelner says he’s helped many patients overcome these fears. “I have many patients who are now comfortable enough and more willing to come back for follow-up appointments,” he says. “Every patient is different, and hypnosis isn’t for everyone. We demonstrate to our dental students that hypnosis is available as an option.”
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What your mouth can tell you Tobacco, alcohol and recreational drugs may impact the health of your teeth. These addictions increase your risk for gum disease, cavities, tooth loss and oral cancer. And for patients suffering from an eating disorder like bulimia, the constant purging of food causes the acid from their stomach contents to erode tooth surfaces. “People who have severe addictions often neglect their health and may not come in for dental care until they experience pain or disability. They may self-medicate, which can make their oral health much worse,” says dental hygiene professor Barbara Gitzel, “Oral health and the perception of risk is not at the front of their mind. “Oral health is vital to general health. A decrease in self-care for those with long-term addictions increases oral disease,” she continues. “People using stimulant drugs may clench their jaws, grind their teeth and have dry mouth. They may have a high intake of carbonated drinks so cavities and gum infections are common.” In the School of Dentistry, students learn how to motivate patients to ‘kick’ unhealthy habits. They also learn to talk empathetically with patients who have eating disorders. “Our students are educated to support patients with dependencies and eating disorders. We try to make the patient feel as comfortable as possible,” says Gitzel. “Using an empathetic approach, we look for health answers. If the patient is willing, we refer them to programs or specialists. We connect them with healthcare and community resources.” If you suffer from an addiction, there are signs that may suggest it’s time to see a dentist: • • • •
Sores in the mouth Lesions that don’t heal Gums are red or bleeding Dry mouth
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Mobilizing dental hygiene As Canada’s population ages, the issues of older adults become more pervasive. One of these concerns is oral health. Age-related oral and dental concerns increase the risk of poor oral health and can lead to more severe oral conditions without proper care. Some possible complications include aspiration pneumonia, discomfort, malnutrition, poor chronic disease outcomes, and an overall lower quality of life. Despite these consequences, poor oral status is more common in long-term care facilities and few older adults utilize private practice dental care. As the whole body implications from poor oral health become more apparent, dental hygienists must contemplate the ramifications of not improving access to dental services. As health care professionals it is our responsibility to reduce the barriers that impede our clients. For older adults, especially those who are homebound or that reside in long-term care facilities, lack of transportation is an obstacle to treatment. Mobile equipment directly relieves this restriction and provides a new opportunity for dental hygienists. The continual innovation in the field of dentistry means mobile equipment is no longer an impediment to our practice. The field units donated to the University of Alberta by A-dec, the dental equipment company, include high and low volume suction, air-water syringes, polish capabilities, and more. As there are portable ultrasonic units as well, hygienists’ can still provide scaling with lavage in alternative care settings. These developments ensure that high-quality dental hygiene treatment is possible out of the dental office. The University of Alberta has embraced mobile dental hygiene and applies these practices in external rotations. Students provide oral health assessments and full dental hygiene services in continuing care facilities during their third and fourth years of study. This training develops the skill set required to manage the specific challenges that the residents are more likely to experience. For instance, the development of a co-operative patient-provider relationship is essential to effectively care for dementia
patients. Patience, eye contact, smiling, touching, hands-on interaction, and minimizing distractions are key strategies for achieving a successful appointment. Dentists have reported that lack of training is one factor that prevents themselves from practicing in long-term care facilities. This addition to the curriculum averts a similar issue in dental hygiene graduates’ futures. Furthermore, service-learning increases the likelihood that dental professionals will pursue specialized care. The students’ exposure to continuing care facilities develops clinicians that are aware of and sensitive to the discomfort and lowered quality of life experienced by many residents. This manner of training future dental hygienists will create a workforce that is more capable of and comfortable treating an aging population. The changes required to improve accessibility will only be possible with interdisciplinary co-operation. The direct interaction that occurs through mobile practice improves the understanding of the roles of each health care provider. Doctors, nurses, and health care aides all have distinct abilities and placements that would prove invaluable in improving older adults’ oral health. For example, when dental hygiene students collaborated with nursing students at a long-term care facility, both gained a more thorough understanding of how psychological and oral health factors that affect their respective treatments. These experiences reinforced that oral health awareness is an impactful part of care for all of those who take part in enhancing peoples’ wellbeing. Continued expansion of mobile dental hygiene will promote access to care for older adults, as well as rural communities, hospitalized patients, and school-aged children. This is an opportunity for dental hygienists to step outside of conventional practice and assist the vulnerable populations who are otherwise unable to acquire our services. Aurelia Pantalone has a Bachelor of Science with a dental hygiene specialization in the community module at the University of Alberta. Reprinted with permission from the Canadian Dental Hygienists Association (Oh Canada! magazine, Spring 2016 page 54)
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Oral health important in head and neck cancer Pam Hofmann is a head and neck cancer survivor. She was diagnosed in 2001 with squamous cell cancer. She had a lump on the side of her neck that was about the size of a loonie. This lump would change her life forever. Hofmann is not a smoker or a drinker and never has been, but she did have trouble with allergies. Outside of her allergies, she was a very healthy individual. She even enjoyed going to the dentist and dental hygienist. With only six cavities in her life, her oral health was in great condition. Hofmann was doing all the right things, but that didn’t prevent her from getting cancer. Luckily, since she was healthy, her treatment ended on a positive note. “I play a role in my own health care by taking responsibility to do what I can to maximize the results,” she says. “It’s something I feel I’ve been doing all my life.” Treatment for squamous cell cancer may require surgery, radiation or both. Hofmann had two surgeries over two years as well as 30 radiation cycles within seven weeks. One month prior to her treatment, she had an oral evaluation―many people don’t realize this is a requirement before receiving any cancer treatment. Because Hofmann had good oral health, the doctors were able to proceed with treatment without delay. Others may not be so lucky. In some cases, teeth may need to be extracted and treatment delayed. Dental treatment after radiation can be complicated by slow healing and the risk of infection. Chemotherapy and radiation wreak havoc on many areas of a person’s body including their teeth and gums; the soft, moist lining of the mouth; and the glands that make saliva (spit). More than one-third of people treated for cancer develop complications that affect the mouth. Hofmann did okay. Her oral health complications were mild, but she continues to suffer from dry mouth, TMJ, sensitive teeth, thrush and loss of taste. Hofmann has good days and bad days. When she has a bad day, or can’t do something, she doesn’t say, “not ever” or “not never.” Instead she says “not today.” Her positive attitude has contributed greatly to her recovery. Cancer has changed her life forever, but Pam is a survivor. Dentists and dental hygienists never want to downplay the severity of any type of cancer, but good oral health can help reduce the impacts associated with cancer-related treatment. See your dentist or dental hygienist regularly! They are an important part of your health care team.
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Save your teeth! Oksanna Dawson was in her early 20s when she started seeing a periodontist. A periodontist specializes in the prevention, diagnosis and treatment of periodontal disease, and in the placement of dental implants. They are also experts in the treatment of oral inflammation – otherwise known as mouth sores. Dawson had signs of gum disease. This included bleeding when she brushed and flossed her teeth and, on occasion, red and swollen gums. “I’ve had gum disease for many years,” says Dawson. “When I was working, I had a dental plan and went for regular treatments to keep it under control.” Now in her mid-60s and retired, Dawson says she recognizes the importance of maintaining a solid cleaning routine. She also realizes that alone isn’t enough. “When I retired, I put off getting treatments because of cost. Unfortunately, my condition worsened,” she says. Dawson started looking around for other options and came across a newspaper ad for the School of Dentistry. “At the School, I recently had surgery on my top left gums,” she says. “I also go for deep cleanings which involves freezing. It’s worth it because I am aware of the consequences and I want to keep my teeth for as long as I possibly can.” Some people may not realize the dangers of periodontal disease and oral inflammation. More and more research is showing that oral inflammation causes and increases inflammatory disease, such as heart attack, stroke, diabetes, rheumatoid arthritis, kidney disease, sleep apnea, Alzheimer’s disease, dementia, pneumonia, preterm births and birth defects, to name a few. Dawson has had periodontal disease for over 30 years now. She follows a regimented treatment of regular dental visits, the use of special wooden toothpicks, toothpaste for sensitivity, and regular tooth brushing. While this is very much a normal routine, if not followed diligently the disease can quickly worsen. “Prevention, early detection and proper treatment of periodontal diseases should be a priority not only for saving teeth but also for promoting general health,” says Liran Levin, the division head of periodontology at the School of Dentistry. “The earlier we start treating and preventing the disease from progression, the easier (and cheaper) the treatments will be.”
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Celebrating in 2017
Kaye Edmonton Clinic 8th Floor, 11400 University Avenue Edmonton, Alberta T6G 1Z1
Edmonton Clinic Health Academy 5th Floor, 87 Avenue NW Edmonton, Alberta T6G 1C9
Katz Group Centre for Pharmacy and Health Research Office: 7-020H Edmonton, Alberta T6G 2E1
ital to the health of our communities