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Publication Mail Registration No. 5383
Publication Mail Agreement No. 40063878
Ontario Dentist
THE JOURNAL OF THE ONTARIO DENTAL ASSOCIATION
Looking Forward to ASM19 — Your Learning Destination
A p ril 2 0 1 9
May 9-11, 2019
19 Metro Toronto Convention Centre, South Building
Located just outside the exhibits floor on level 800.
The ODA Booth is back!
Drop by to learn how the ODA can expand your potential
through our valuable member benefits.
Meet the people on the other side of the phone. ODA staff will be on hand to answer all your
questions — and provide information you didn’t know you needed! The ODA booth is also
a great place to mingle with your Board of Directors, members of the Membership Services
and Programs Committee and your colleagues.
PLUS…bring your dental team for a sneak peek of a new and innovative way to
save on your business costs. Be the first to try out this latest member benefit.
See you there!
yourpotential.oda.ca
A customized experience for dentists in practice for 10 years or less!
SAVE THE DATE
October 26-27, 2019 | Delta Toronto
Registration Opens May 2019
Learn more at: www.oda.ca/new-dentist-symposium
Sponsored by:
April 2019 • OD 3
April 2019
Volume 96 | Issue 3 Contents
20 30 36
Ideas
10 Letters 16 Risk Management
The Future Must Matter Direct to Consumer
Dr. Brian Clark Dr. Lionel Lenkinski
How Increasing Costs Affect 18 Osseointegration
Services The Genesis of Osseointegration:
Mariam Kamel The Toronto Connection
Dr. James C. Taylor
12 President’s Page
“Out of Many, One People” 20 New Care Model
Dr. David M. Stevenson Person-Centred Care
Dr. Sanjukta Mohanta
14 Editorial
In a Boat With a Very Small
Paddle
Dr. Carlos Quiñonez
Analysis
24 Social Networking
Uses, Benefits and Limitations of Social Networking Sites for Dental Public
Health Surveillance
Janet Wu
Clinical
30 New Disease Classification System
The New Classification Scheme for Periodontal Diseases and Conditions
Dr. Zeeshan Sheikh, Dr. Nader Hamdan and Dr. Michael Glogauer
36 Case Report
Tooth Replacement Using a Novel Reinforced Fibre
Dr. Pasquale Duronio
4 OD • April 2019
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Contents
44 56
Your Practice
38 Practice Management 42 Discipline Hearings
Suggested Fee Guide Coding and What Dentists Need to Know
Dental Claims/Plans Questions About RCDSO Discipline Hearings
Barbara Morrow Josh Koziebrocki
40 Employment Law
Taking a Bite Out of
Employment Law
Stuart Rudner and Shaun Bernstein
Our ODA
44 ASM19 50 Dental Calendar
Plan to Attend the ODA’s
Annual Spring Meeting in 56 In Memoriam/Tribute
May 2019 Dr. Ivan (Ivica) Mus
Helen McDowell Dr. Paul Edmund McKenna
Dr. Bernard Blackstien
48 Continuing Education
Calendar
Classifieds
58 Classified Ads 64 Advertiser Index
6 OD • April 2019
Introducing
Next Generation
Colgate Total*
Petri dish treated
with saliva + water,
left out overnight†
Petri dish treated with
New Colgate Total* formula,
left out overnight†
†
Bacteria growth after overnight incubation in an in vitro study.
Help patients achieve Whole Mouth Health‡
New patented Dual-Zinc combined with arginine§ formula
Fights plaque-causing bacteria on 100% of mouth surfaces¶1 for better patient outcomes:
Significant reductions in plaque2, gingivitis2, calculus3 and malodour4
Now with sensitivity relief
across all variants.
Reduces bacteria on saliva, teeth, tongue, cheeks and gums; helps prevent plaque and gingivitis, protects enamel, relieves sensitivity.
‡
Arginine is a stabilizing non-active excipient that enhances the flavour of the toothpaste formula.
§
Statistically significant greater reduction of cultivable bacteria on teeth, tongue, cheeks, and gums with Colgate Total* vs. non-antibacterial fluoride toothpaste at 4 weeks, 12 hours
¶
after brushing.
References: 1. Prasad K. J Clin Dent, accepted for publication 2018. 2. Garcia-Godoy F, et al. J Clin Dent, accepted for publication 2018. 3. Seriwatanachai & Mateo, September 2016,
internal report. 4. Hu D, et al. J Clin Dent, accepted for publication 2018.
ODA Board of Directors
Ontario Dentist is the official journal of the Ontario Dental
Association, dedicated to supporting the Association’s Mission and President
Vision by providing members with educational information relevant Dr. David Stevenson
to their profession and the dental practice environment in Ontario. Rideau
PUBLISHER President-Elect
Marcus Staviss Dr. Kim Hansen
Brockville
EDITOR
Vice-President
Dr. Carlos Quiñonez
Dr. Lesli Hapak
Essex
MANAGING EDITOR
Julia Kuipers Past President
Dr. LouAnn Visconti
CREATIVE AND GRAPHIC DESIGN SPECIALIST Timmins
Natalia Ivashchenko
Dr. Lisa Bentley
ASSOCIATE EDITOR Halton-Peel
Gilda Swartz
Dr. David Brown
PROFESSIONAL AFFAIRS ADVISOR York
Roberta MacLean
Dr. Charles Frank
CLASSIFIEDS CO-ORDINATOR
Essex
Catherine Solmes
Dr. John Glenny
West Toronto
EDITORIAL BOARD CHAIR Dr. William Hawrysh
Dr. David Walker Halton-Peel
EDITORIAL BOARD Dr. Maneesh Jain
Dr. David Chvartszaid Dr. Deborah Saunders Waterloo-Wellington
Dr. Peter Copp Dr. Barry Schwartz
Dr. Michael Glogauer Dr. Shawn Steele Dr. Grace Lee
Dr. Lionel Lenkinski Dr. Susan Sutherland Ottawa
Dr. Sanjukta Mohanta Dr. Anthony Veale
Dr. Melissa Milligan
West Toronto
DISCLAIMER Dr. Brock Nicolucci
The opinions expressed in Ontario Dentist are those of the authors, and do London
not necessarily reflect the opinions of the ODA, Editor or Editorial Board.
Dr. Roch St-Aubin
Copyright: The Ontario Dental Association. Sudbury
Reprint only by permission of the ODA.
Dr. Donald Young
ISSN 0300 5275 Thunder Bay
Advertising must comply with the advertising standards of the ODA.
The publication of an advertisement or inclusion of a polybagged item Office of the Chair, General Council
should not be construed as an endorsement of, or approval by, the ODA. Chair of General Council
Dr. Roger Howard
DISPLAY ADVERTISING INFORMATION Ottawa
Dovetail Communications Inc
30 East Beaver Creek Road, Suite 202 Vice-Chair of General Council
Richmond Hill, Ont. L4B 1J2 Dr. Blake Clemes
Tel: 905-886-6640 Fax: 905-886-6615 Waterloo-Wellington
Jennifer DiIorio Gillian Thomas
905-886-6641 905-886-6641
ext. 309 ext. 308
jdiiorio@dvtail.com gthomas@dvtail.com
OD
CONTACT US
4 New Street, Toronto, Ont. M5R 1P6
Tel: 416-922-3900
Ontario Dentist Coming in May:
Fax: 416-922-9005
Email: jkuipers@oda.ca
www.oda.ca Gingival Grafts and Predictable Outcomes
8 OD • April 2019
68.635% (w/w) Sodium Perborate
Ideas
Letters
How Increasing Costs
Affect Services
The Future Must Matter I would like to highlight the Ontario Dentist column
titled, “Never Forget Access to Care and Patient Safety
I would like to compliment Dr. Carlos Quiñonez on by Dr. Lionel Lenkinski (January/February 2019). I re-
his January/February 2019 Editorial, “The Future Must ally liked the fact that Dr. Lenkinski discussed how the
Matter at All Costs.” It is well argued and supports the increasing costs of running a practice can affect the
importance of maintaining dental programs for poor services provided to patients and may end up affecting
and underserviced families and children in the province. their access to care.
Even in the face of chronic underfunding and probable It can be a challenge for dentists to achieve a bal-
austerity measures to bring the provincial deficit under ance between taking care of patients’ basic needs and
control, it is important to maintain these programs. performing procedures that boost revenue. I believe
this is a very important topic to discuss with dental
Dr. Brian Clark students, and I will also be posting the article on the
Tillsonburg, ON Facebook site of Schulich’s Student Professionalism
and Ethics Association. OD
Mariam Kamel
DDS 2021, Schulich School of Medicine
and Dentistry
Social Media Representative, Student Profession-
alism and Ethics Association (SPEA) Schulich
Great Smiles
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10 OD • April 2019ONE.
One is all it takes. The frequency and size of malpractice claims are on the rise in Canada.
In recent years, individual claims worth millions of dollars have been launched.
Although rare, these cases can lead to disastrous financial losses
for those who aren’t adequately insured.
The good news is that you can significantly increase your malpractice coverage with
Excess Malpractice Insurance from CDSPI1, for just a few dollars a week.
Excess Coverage Options Annual Premium (for excess coverage)2 Weekly Premium3
$ 1M $ 64.51 $ 1.24
$ 2M $115.19 $ 2.22
$ 3M $159.42 $ 3.07
$ 8M $378.74 $ 7.28
$23 M $764.54 $14.70
You strive to provide the highest level of care, you deserve the peace of mind
that comes with no longer having to worry about the one.
To find out more about Ontario Excess Malpractice Insurance from CDSPI
call us at 1.800.561.9401 or email us at insurance@cdspi.com.
60 Y E A RS S ER V I N G D EN T I S T S
1. You must be a dentist licensed to practise in Ontario and a member of the Ontario Dental Association to be eligible to apply.
Excess Malpractice Insurance for Ontario dentists is arranged for by CDSPI Advisory Services Inc. and is underwritten by Aviva Insurance Company of Canada.
2. Based on CDSPI 2019 rates. For coverage in excess of your primary coverage of $2 million mandated by the RCDSO; CDSPI Advisory Services Inc.
is not affiliated with the RCDSO. 3. Based on annual premiums; weekly premium payments are not available.
19-873 2/19Ideas
President’s Page
“Out of Many, One People”
David M. Stevenson
DDS
“O ut of many, one people” is the national
motto of Jamaica and it is inscribed on
its coat of arms. My mother was Jamai-
can and she loved these words. As I have learned more
as, at that time, military personnel moved from base to
base on a regular basis and brought their records with
them. Signatures were left in the form of occlusal anat-
omy in an amalgam, and not just in the patient’s chart.
about this side of my heritage, I have grown to appreciate But leaving our mark on our profession is bigger than
the complex vision in this simple phrase. I promise my just our clinical footprint. We leave our signatures on our
Jamaican family not to take their words, but as I reflect practices, since each situation is unique. The same base
on the meaning of the motto, I see many parallels with of patients in a different office would most likely result
the ODA and its members. in an entirely different mix of treatment. Not better or
To say that dentists come from many different back- worse, just different. The same can be said about how the
grounds is stating the obvious. But I’ll state it anyway, mix of staff, partners and associates influences a practice.
because it is important. We are all different, and I don’t What makes our practices unique is important in many
just mean from an ethnic or cultural perspective, but also ways. It is important to our patients, so they may have
in our character and our passion. We all bring something a choice in their care. It is important to our careers. It
unique to the table, which in turn brings tremendous is important to how we choose to transition out of our
value to our profession — and to each other. practice or into another. It is important to the signature
Passion was particularly evident at the ODA’s Wel- we leave on our communities; for many of us, particu-
come to the Profession Luncheon, held for students in larly those in smaller communities, our practices help
the International Dentist Advanced Placement Program define who we are as neighbours.
(IDAPP) at the University of Toronto. These students are That sense of community is also strong within our
an inspiration. Most of them have had journeys that profession. As individuals, we may be very different, but
have not been easy. How each individual arrived at this we all want the same thing — that which is best for our
point in their career is as unique as they are. However, patients. I am extremely grateful to the many in our pro-
what they shared was obvious appreciation at being in fession who choose to specialize, or practise in hospitals,
this place at this time. When listening to their stories and or embrace public health. As a GP practising in a small
dreams, which range from being new to our profession town, I am expected to provide a wide range of services
to working many years as an experienced practitioner, to my patients. But I also know when I’m in over my
or having aspirations of a private practice to careers in head — because I’ve been in over my head. And when I
research, academia and even the military, I felt I was have been there, I knew I could depend on specialists,
listening to a group of aspiring artists. hospitals or public health, not just to bail me out, but
I don’t think anyone would deny there is an art to also to help me provide better services and options for
dentistry. So we must all be artists. There are many my patients. I like to believe that as a GP in private prac-
different art forms and, as dentists, we always leave our tice I have also helped them provide better services and
signature on our work. This was first evident to me when options to their patients, because we really are all together
practising in the Royal Canadian Dental Corps. Recogniz- in the same boat.
ing another clinician’s restorations was not uncommon
12 OD • April 2019President’s Page
I am also grateful that many in our profession choose question, but I don’t think so. There are too many dif-
research to exercise their passion. These researchers play ferences among dentists and our practices, and within
an extremely important role in our dental community. our profession. That is a good thing. Our ODA has
The ODA was proud to sponsor the keynote speaker at embraced all the advantages of a voluntary association
this year’s Research Day at the University of Toronto’s that represents more than 90 per cent of dentists in
Faculty of Dentistry, and the ODA also sponsors student Ontario. The products and services we offer our members
research programs at Schulich School of Medicine and are just as varied as our membership itself. If we want to
Dentistry, Western University. Speaking as a clinician, come together at the right place, wherever that may be
I am aware that, without research, there would be no on any given issue, it won’t be because we have to but
evidence upon which to base treatment for our patients. because we want to, and we’ll bring all our opinions with
Research is the foundation upon which we can strive for us.
excellence in oral health for our communities, and the If “What is a dentist?” is not an easy question to
researcher’s vision is how we continue to build upon that answer, then “Who is a dentist?” is nearly impossible.
goal. So, I would like to say to those with a passion for Did you know there are 14 different membership cat-
making known the unknown, or making the good even egories in the ODA? “Out of many, one…” I promised
better: keep up your valuable work! I wouldn’t take the words. But I do hope you get my
I have on occasion heard members tell me that the meaning. OD
ODA should be more like a union, for then we might
have more influence on government. But that influence Dr. David M. Stevenson is the President of the ODA
is not a certainty and, by being union-like, we would for 2018-19. He practises in Carleton Place, Ont.,
give up a tremendous amount of individuality. Are we an and may be contacted at ODAPresident@oda.ca.
association that would welcome the prospect of a col-
lective bargaining agreement with a single employer
such as government? I don't know the answer to that
Gain new perspectives with numerous
networking opportunities.
We make it easier to connect with your peers and the
dental community at large to share your experiences.
Our Annual Spring Meeting, volunteer programs, and
local component dental societies give you multiple
opportunities to build new relationships and contribute
to how the profession evolves.
yourpotential.oda.ca
April 2019 • OD 13Ideas
Editorial
In a Boat With
Carlos Quiñonez
DMD MSc PhD FRCD(C)
a Very Small Paddle
I n my last Editorial (1), I spoke about the unfounded
and unscientific claims made by some regarding the
health effects of root canals, amalgam restorations,
periodontal infections and vaccinations. I highlighted
scientific basis for the medical benefit and cost-
effectiveness of orthodontic care” (2, p. 8). As with most
evidence reviews in dentistry, few high-quality stud-
ies were found, and results did not allow the German
the lack of a scientific base regarding such claims and the researchers to make definitive statements about the
real and alarming dangers that they can produce (e.g. therapeutic benefit of orthodontic care. Further, it should
unnecessary and costly dental work, infectious disease not be lost on us that this was quickly picked up by the
outbreaks, engaging in non-therapeutic and sometimes media and reported using headlines such as: “German
dangerous treatments). ministry questions benefits of braces,” “No proof dental
Yet, in dentistry, if one digs deeper, one finds that the braces work, German government report finds,” “How
evidence base in support of the benefits of many — I dare helpful are braces really? Government report questions
say, most — dental procedures is limited. This begs the benefits,” and “No evidence braces have health benefits
question: how are we to defend ourselves against “unsci- for teeth, Health Ministry report finds.”
entific” claims when the “scientific” ones are potentially For periodontal care, a recent Cochrane systematic
not supported by strong research? review aimed to determine the effects of routine scaling
The lack of evidence does matter. I have been, or am and polishing for periodontal health (3). Surprisingly,
currently, involved in government and professional com- only two studies could be included based on the quality
mittees/panels, where the search for evidence is primary of existing research, with the authors concluding:
and crucial to policy decisions about who and what to
fund. And the reaction from medical and lay colleagues “For adults without severe periodontitis who regu-
who sit on these committees/panels is surprise when they larly access routine dental care, routine scale and
learn that the evidence base in dentistry is not strong. polish treatment makes little or no difference to
What is more, the reaction from — and sobering reality gingivitis, probing depths and oral health-related
for — some of my dental colleagues on these commit- quality of life over two to three years follow-up […].
tees/panels is shock, and sometimes open resistance, as There may also be little or no difference in plaque
they learn that what is taken as a given regarding the levels over two years […]. Routine scaling and polish-
effectiveness and benefits of dental care, does not always ing reduces calculus levels compared with no routine
bear out when a review of the evidence is undertaken. scaling and polishing, with six-monthly treatments
Consider the benefits of orthodontics and routine reducing calculus more than 12-monthly treatments
periodontal care as examples. In terms of the former, over two to three years follow-up […], although the
in Germany, due to growing expenditures in orthodon- clinical importance of these small reductions is un-
tic care within that country’s health-care system, the certain. Available evidence on the [cost-effectiveness]
German government recently commissioned an evi- of the treatments is uncertain (3, p. 2).”
dence review to question “whether there is a sufficient
14 OD • April 2019Editorial
Unfortunately, there is a scarcity of quality research Again, the state of our knowledge matters because
resulting in equivocal results for systematic reviews in we are increasingly asked to rationalize ourselves by
dentistry. A simple scan of the Cochrane database for oral the public, by governments, by funders, and by our
health (4) confirms this for many clinical interventions, patients. There can be no doubt that the name of the
including: survival between bonded and non-bonded game now and into the future is and will be “evidence
amalgam restorations; chlorhexidine treatment for the and data.” Unfortunately, we may not be able to depend
prevention of dental caries in children and adolescents; on our national research-funding agencies, which have
dental cavity liners for Class I and Class II resin-based not prioritized dental research compared to research in
composite restorations; enamel matrix derivative for other areas of health care. Thus, we will have to depend
periodontal tissue regeneration in intrabony defects; on ourselves. And this will take courage: courage (from
endodontic procedures for retreatment of periapical our regulators and associations) to invest in research,
lesions; final-impression techniques and materials for and courage to rationally deal with the answers we may
making complete and removable partial dentures; full- receive from the questions we ask. OD
mouth treatment modalities for chronic periodontitis in
adults; interdental brushing for the prevention and con- REFERENCES
trol of periodontal diseases and dental caries in adults; 1. Quiñonez C. Science, Self-Regulation and the
interventions for replacing missing teeth; lasers for car- Public’s Health. Ontario Dentist. 2019;96(2):12-13.
ies removal in deciduous and permanent teeth; occlusal 2. Hoffmann A, Krupka S, Seidlitz C, Sussmann S,
splints for treating sleep bruxism; single versus multiple Sander I, Gothe H. Kieferorthopädische Behand-
visits for endodontic treatment of permanent teeth — lungsmaßnahmen. Berlin: IGES Institut, 2018.
amongst many others. 3. Lamont T, Worthington HV, Clarkson JE, Beirne
This research scarcity does not mean that our clini- PV. Routine scale and polish for periodontal health
cal interventions do not work or that they demonstrate in adults. Cochrane Database of Systematic Re-
no therapeutic benefit. It just means that there is little views 2018, Issue 12. Art. No.: CD004625. DOI:
evidence of the same (that’s the rub). 10.1002/14651858.CD004625.pub5.
Indeed, this is a complex topic that situates within 4. Cochrane Oral Health. Accessed February 28, 2019.
the nature of evidence itself, meaning: what we know Available at: https://oralhealth.cochrane.org/oral-
clinically is not always researched, and since the evi- health-evidence
dence bar is very high, much of the research conducted 5. Advisory Panel for the Review of Federal Support
does not meet that bar. The complexity is also related for Fundamental Science. Investing in Canada’s
to the state of social processes and institutions meant Future. Strengthening the Foundations of Canadian
to generate knowledge; Canada, in particular, has been Research. Canada’s Fundamental Science Review.
noted as weak in supporting research generally and lack- Ottawa: Government of Canada, 2017.
ing the commitment to secure and safeguard the research 6. Andrew-Gee E, Grant T. In the dark: The cost of
enterprise (5,6). Canada’s data deficit. The Globe and Mail. Published
We must also be aware of the nature of dentistry itself January 26, 2019, updated February 13, 2019. Ac-
in this state of affairs. Sadly, we are often disparaged as cessed February 28, 2019. Available at: https://
being a “data-free zone” by researchers and policymakers. www.theglobeandmail.com/canada/article-in-the-
We are reluctant to adopt whatever research does exist in dark-the-cost-of-canadas-data-deficit/
the form of clinical practice guidelines. And we are often
driven more by the findings of private industry than by Dr. Carlos Quiñonez is the Editor of Ontario
public science. Dentist. He may be reached at 416-864-8239,
or at cquinonez@oda.ca.
April 2019 • OD 15Ideas
Risk Management
Direct to Consumer
Lionel Lenkinski
DDS Cert. Endo
T he media has been abuzz with the latest foray in
dentistry, which concerns circumventing tradi-
tional means of service delivery. It now appears
that, for orthodontics, some hope to avoid “the middle
actual harm — and this is not to say that there is — the
proof of harm has to materialize and the risk has to be
recognized by a regulator or government. Without these
factors, very little will happen. And certainly, big busi-
person” and go straight (no pun intended) to the end ness understands the rules and will try to play within
user. This is not new in health care and is now the norm, them. They have a brand to protect, a business to run and
with “big pharma” inundating the public with adver- profits to make, and causing harm (perceived or actual) is
tisements for the latest blood thinner, or biologics for not a good strategy.
arthritis or gastrointestinal problems, and so on. The pre- In its wisdom, the ODA has issued the directive
scription eyeglass space is also replete with players using “ODA Interim Policy Position on Direct-to-Consumer
direct-to-consumer approaches. Ride-sharing platforms Dentistry.” There are good resources and links on the
have similarly disrupted the taxi business, which is also ODA member website relevant to this. But, what else can
a regulated industry. we do?
In fact, the dental profession participated in something First, we must have a direct relationship with our
similar not so long ago, when some of the larger, mostly patients. They should know who we are, what we do for
U.S.-based specialty groups started advertising directly them and, most importantly, that we act in their best
to patients. This was meant to circumvent the usual interest. Second, we have to be part of the value chain
patient referral process, and drive patient flow directly in patient care. If we are not seen as critical to the provi-
to specialists. Personally, despite being a specialist, I was sion of care, then we can be circumvented. Maybe this
never in favour of this sort of advertising, as it can have is just my simplistic view, but we need to be physically
unintended consequences, such as confused patients, present and check on treatment that has been delegated.
disruption in the continuity of care, and heightened We have to be in the middle at all times. After all, we are
competition in, as well as strain on the relationship be- ultimately responsible for the dental treatment that takes
tween general dentists and specialists. Certainly, from place in our practices, for our patients.
today’s vantage point of an über-competitive dental-care The tendency to market, to the public, minimally
market (again, no pun intended), these patient-directed invasive or non-invasive medical devices for which the
advertisements did result in some of these negative out- patient/consumer is the end user, is not new. Indeed,
comes. Apart from this, though, if we ourselves have about 10 years ago, I was in the U.S. at a meeting of the
engaged in these direct-to-consumer advertisements, American College of Dentists and saw the early advertise-
why the surprise when “big business” in dental care starts ments for clear aligners on taxis. I remember thinking
engaging in similar efforts? at the time about what was then an already established
What am I missing here? Why the furor that this has business model in medical devices in the U.S., which was
not been outlawed by government? Does this really cre- to start with business-to-business sales and then move to
ate a risk of harm or actual harm to patients? For good business-to-consumer. Since consumers tend to be price
or bad, these issues are usually dealt with on a reactive conscious, the business-to-consumer part of the model
basis, meaning that if there is indeed a risk of harm or usually involves a price drop. When this happens, the
16 OD • April 2019Risk Management
businesses look for higher sales volumes. There is some- is only together, keeping the best interests of our patients
thing to notice here, though, and that is the absence of in mind, that we can maintain an appropriate voice and
the word “patient.” After all, what matters is our relation- measure what action needs to ensue. OD
ship with our patients, not our “clients” or “consumers.”
I know that this column is published in Ontario Den- Dr. Lionel Lenkinski is the Executive Director/CEO
tist, so it may not be seen by non-member dentists. Yet, of the Canadian Dental Protective Association,
I ask you: how much of the complaining about this cur- a mutual defence organization representing
rent state-of-affairs is coming from non-members, who Canadian dentists in regulatory matters. He also
only see the ODA as a vehicle for the Suggested Fee Guide maintains a private practice in Toronto in the
and/or Extended Health Care? Now, more than ever, we specialty of endodontics. Dr. Lenkinski may be contacted at
need to keep our associations strong, as outside forces llenkinski@cdpa.com.
will only affect our professional lives further over time. It
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April 2019 • OD 17Ideas
Osseointegration
The Genesis of Osseointegration:
James C. Taylor
DMD MA
The Toronto Connection
I suspect one would be hard pressed to find, in the
global oral health community, practitioners who were
not aware of Dr. Per-Ingvar Brånemark’s first observa-
tion of osseointegration in 1952, in the course of his re-
the possibility of a major Canadian replication study to
validate the theretofore very positive findings of the
Swedish study. In 1976, Dr. Zarb returned to Göteborg
with some U of T colleagues to learn the Swedish pro-
search with titanium bone chambers in a lapine model tocol and plan what would come to be known as The
or, perhaps, of his first human implant patient in 1965, Toronto Study. In 1979, they established the U of T
Gösta Larsson of Göteborg, Sweden, who passed away in Osseointegration Clinical Research Unit, funded by On-
2006 with all of his implants in full function. Or even of tario Provincial Health Research Grant #PR 882. Later
the Brånemark team’s extensive body of published clini- that year, The Toronto Study was initiated as a prospec-
cal research in this area, commencing in 1969, in the tive replication study of Dr. Brånemark’s work, the first of
Scandinavian Journal of Plastic and Reconstructive Surgery. its kind outside of Sweden.
However, perhaps less well known, even by many Cana- Meanwhile, in Boston, the Harvard-National Insti-
dian practitioners, is the essential role that the University tutes of Health — National Institute of Dental Research
of Toronto (U of T) and the province of Ontario played Consensus Development and Technology Assessment
in bringing this revolutionary treatment modality into Conference was held in June 1978. It attempted to create
global dental practice. guidelines for the use of the various types of implants
Perhaps the best place to start in the Toronto story is that were already in use in North America, through the
in the mid-70s at U of T, with a young full professor by analysis of retrospective clinical data. Root-form titan-
the name of Dr. George Zarb, who at that time was head ium endosseous implants were not considered at this
of the discipline of prosthodontics and a member of the conference, as they were not in clinical use outside the
School of Graduate Studies. Dr Zarb had long been frus- Brånemark study; nevertheless, the Brånemark team had
trated with the lack of acceptable solutions to the pre- published 10 years of clinical data the previous year.
dicament of the edentulous patient, and the failure of It must be remembered that oral implants were tra-
existing complex surgical and prosthetic interventions ditionally the subject of significant suspicion and dis-
to deliver a satisfactory outcome for these patients. Then, missal (in some cases perhaps deservedly) in the dental
one day in 1975, Dr. Henry Levant (one of Dr. Zarb’s community. Unfortunately, titanium endosseous dental
prosthodontic graduate students at that time) brought to implants were caught up in this historical perspective,
his attention some promising work going on in Sweden. even past the point where the peer-reviewed literature
As fortune would have it, Dr. Zarb was already on his clearly indicated that scientifically documented implant
way to Göteborg soon thereafter to work with Dr. Gun- systems should be an integral element of comprehensive
nar Carlsson on the first edition of their classic temporo- oral health care. I have recollections of Canadian licens-
mandibular joint text. While there, Dr. Zarb was invited ing jurisdictions where, as late as the mid-1990s, poli-
by Dr. Brånemark to visit their osseointegration clinic cies stipulated that implants were “experimental” and
and examine some recall patients from what was at that should only be attempted when “conventional” care mo-
point their 10-year clinical study. Dr. Tomas Albrekts- dalities had failed. Fortunately, the approach of the new
son joined them, and a conversation ensued regarding millennium seemingly catalysed new thinking: by 2000,
18 OD • April 2019Osseointegration
a number of Canadian jurisdictions were progressing In May 2008, U of T held a landmark conference to
toward the current position that implants are a part of celebrate the 25th anniversary of the Toronto Confer-
routine oral health care, and that not to identify them ence on Osseointegration in Clinical Dentistry. In that
as a treatment option to patients in appropriate circum- vein, one of my action items as the first Canadian
stances constituted a failure of informed consent. President of AO was to hold a collaborative event with
The Toronto Conference on Osseointegration in Clini- U of T to continue to recognize the early and ongoing
cal Dentistry was held in Toronto in May 1982. It was co- contributions of this fine institution to the global emer-
sponsored by the University of Göteborg and U of T, and gence and evolution of osseointegration and its related
led by co-chairs Drs. Zarb and Jack Symington (who was treatment modalities. Thus, in partnership with U of T
Head of Oral and Maxillofacial Surgery at U of T at the Dean, Dr. Daniel Haas, and his team, AO will be holding
time). Invited delegates were senior university prostho- a symposium entitled, “A Tribute to the Toronto Con-
dontists and oral surgeons from across North America, ference and its Impact on Global Dentistry ” on May 4,
and the speakers were global experts in various aspects of 2019, at the U of T Auditorium. This symposium will be
osseointegration science and the Brånemark treatment introduced by Dr. Zarb himself, and involve expert AO
protocol. The goal was to subject the basic and clinical speakers describing the evolution of the various elements
research on osseointegration from Sweden to the scru- of osseointegration and implant dentistry that were pre-
tiny of the North American academia, and it represented sented at the 1982 conference, and a panel discussion of
the formal introduction of osseointegration to North the current state of the science and the future directions
America. The revelations of this conference also led to in each of these domains. I look forward to seeing you
the formation of the Academy of Osseointegration (AO) all there. OD
in 1986, and a number of the Toronto Conference speak-
ers collaborated to provide foundational articles on os- For more information, please visit:
seointegration in the inaugural issue of the International https://osseo.org/toronto-conference-2019/
Journal of Oral & Maxillofacial Implants (the AO’s journal)
later that year. Dr. James C. Taylor is currently the President of
U of T continues to provide leadership in the global the Academy of Osseointegration, the immediate
conversation on osseointegration. For example, Professor Past President of the Academy of Prosthodontics,
J.E.D. Davies has kindly accepted my invitation to lead and a Past President of both the Association
an international panel of experts regarding the current of Prosthodontists of Canada and the Atlantic
state of the science on the phenomenon of osseointe- Prosthodontists Society. His teaching and research were
gration, for the upcoming 2019 AO Annual Meeting in undertaken at Dalhousie University.
Washington, D.C. (For more information, visit: https://
ao2019.osseo.org/)
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April 2019 • OD 19Ideas
New Care Model
Person-Centred Care
Sanjukta Mohanta
BSc DDS
H
Table 1.
ealth care is undergoing an evolution in terms
Differences between the medical model and person-centred care (8)
of the way patients are cared for. Instead of
the medical model of care, there is a focus on Medical Model Person-Centred Care
person-centred care. In dentistry, embracing person- Person is passive Person asks questions
centred care has the potential to improve patients’ oral Provider decides care Person makes decisions about care
health and their care experience (1). This article discusses Person receives care Person is a partner in care
the differences between these two models, the advan-
Centred on disease Centred on quality of life
tages of person-centred care and ways that dentists can
practise it. Provider is trained in health care Provider also has training in
overall needs
Provider is the expert Person is the expert in himself/
What is person-centred care? herself
The medical model of care treats the disease, whereas the
Goal is treatment of disease Goal is optimal health
person-centred model treats the person. Person-centred
care is a partnership between a person and health-care
provider. It encompasses shared decision-making, in- Already practising person-centred care?
stead of the provider dictating care. This creates shared Most dentists provide patients with some person-
responsibility, in which the person is seen as an expert centred care by offering choices with appointment times,
in his/her own health. It focuses on getting to know the teaching home care, performing preventive procedures,
person’s beliefs, life circumstances, concerns, attitudes allowing family members in the operatory and discuss-
and goals. There is sharing of information and power, ing treatment options. Other ways to incorporate this
the provision of continuous care, and co-ordination of model are to: have quality improvement initiatives; ask
care with other providers. There is a focus on providing patients at each appointment if they have any concerns;
emotional support and physical comfort; asking about encourage feedback; involve patients in decision-making;
preferences and care experiences; and respecting auton- provide information and referrals to address other needs
omy. With this model, the clinician is working with the (medical, social, financial, etc.); and ask patients if they
person instead of on the person (2-9). have any questions (17).
A way to know if you are practising person-centred
Why should we practise person-centred care? care is if your patients indicate in a survey that they feel
There is evidence that person-centred care improves comfortable talking to you about concerns and that
health outcomes, enhances person and provider satisfac- they feel you understand them as a person and not just
tion, improves pain management and increases patient their disease. Do you want to practise more person-
compliance with provider recommendations (1,2,10). A centred care? Here’s a simple way to start: instead of
dental office is a good setting to provide person-centred asking patients what is the matter with them, ask
care, as patients can build trust with the dental team patients what matters to them (7,18). OD
through regular maintenance appointments.
20 OD • April 2019New Care Model
Examples of person-centred care (8,11,12)
• Doing patient-satisfaction surveys
• Conducting patient focus groups
• Using the results from the above to create quality-improvement initiatives
• Collaborating with other professionals to improve the care experience for the patient
• Discussing treatment options, cost, possible outcomes, most likely outcomes, and benefits and risks of treatment
• Focusing on prevention, compliance and decreasing risk factors
• Understanding the whole person: family, culture, employment, financial security, beliefs and barriers
• Involving the patient’s family, friends and other health-care providers upon the patient’s request.
Examples of questions to ask in surveys and patient focus groups (13)
• Do you have enough time with the dentist?
• Does the dentist listen to you and understand your concerns?
• Does the dentist explain things clearly?
• Are you involved in decisions about your care?
• Are you given the opportunity to ask questions?
• Does the dentist explain how you can improve your own health?
• Are you satisfied with the care provided?
• Has your health improved since becoming a patient here?
Ways for practitioners and institutions to
improve the practice of person-centred care collaboration
(3,5,14-16) • A common electronic-management record among
• Training at dental schools and through continu- health-care providers that will allow for co-
ing education ordinated care, inter-professional collaboration
• Training as a dental team and data collection
• Having mission, vision and values that focus on • Use of data to: discover risk factors, identify high-
the patients, not on the practice risk groups, plan oral health promotion, design
• Understanding how social determinants of publicly funded oral-health programs, measure
health affect oral health health outcomes, and evaluate patient and pro-
• Redesigning the health-care system to allow vider satisfaction
person-centred care • More research on relationships between oral
• Focusing on behaviour modification, lifestyle health and overall health
changes, preventive intervention, removing • Technology that patients can use to track their
barriers to health and alternative treatment own health
modalities • Payment based on health outcomes instead of
• Changing the design and delivery of health care treatment
to integrate oral health into overall health
• Practice models conducive to inter-professional REFERENCES
April 2019 • OD 21New Care Model
education for PSWs in the home, community and long-term
care sectors. Saint Elizabeth and Yee Hong Centre for
Geriatric Care.2013 October. Available from: https://
www.saintelizabeth.com/getmedia/3b053be0-3313-
45e5-8aea-872781c0b76d/Practical-Guide-for-Imple-
menting-PCC-Education-for-PSWs-October-2013.pdf.
aspx
9. Snowdon A, Schnarr K, Alessi C. “It’s All About Me”:
The Personalization of Health Systems. Odette School of
Business:University of Windsor. 2014 February. Avail-
able from: http://worldhealthinnovationnetwork.
com/images/publications/summaries/AllAboutMe-
ThePersonalizationofHealthcareSystems_Executive-
Summary.pdf
10. Delaney, LJ. Patient-centred care as an approach to
improving health care in Australia. Collegian. 2018
Feb 1;25(1):119-23.
11. Royal College of Dental Surgeons of Ontario. Patient
1. Poochikian-Sarkissian S, Sidani S, Ferguson-Pare centred care — A dentist’s paramount responsibility.
M, Doran D. Examining the relationship between Dispatch 2012;26(3):22-23.
patient-centred care and outcomes. Journal of Neuro- 12. Patient-centred care and the business of dentistry.
science Nursing. 2010;32(4):14-21. College of Dental Surgeons of British Columbia. 2015
2. What is person-centred care and why is it important? December.
Health Innovation Network South London 2016 13. Mercer SW. PCM 10Q. Talking Mats.NHS Scotland
July. Available from: https://healthinnovationnet- 2004. Available from: http://www.caremeasure.org/
work.com/system/ckeditor_assets/attachments/41/ CAREENG10p.pdf
what_is_person-centred_care_and_why_is_it_impor- 14. Valuing people. What is person-centred care? Dementia
tant.pdf Australia. Available from: https://valuingpeople.org.
3. Walji MF, Karimbux NY, Spielman AI. Person- au/the-resource/what-is-person-centred-care
centered care: Opportunities and challenges for 15. Santana MJ, Manalili K, Jolley RJ, Zelinsky S, Quan
academic dental institutions and programs. Journal of H, Lu M. How to practice person-centred care: A
Dental Education. 2017;81(11):1265-1272. conceptual framework. Health Expectations. 2018
4. Person-centred care made simple. The Health Founda- Apr;21(2):429-40
tion. October 2014. Available from: http://personcen- 16. Lee H, Chalmers NI, Brow A, Boynes S, Monopoli M,
tredcare.health.org.uk/sites/default/files/resources/ Doherty M, et al. Person-centred care model in den-
person-centred_care_made_simple_1.pdf tistry. BMC Oral Health 2018;18(1):1.
5. National Ageing Research Institute. What is person- 17. Practice Advisory 2018 June. Maintaining a profes-
centred health care? A literature review. Published by sional patient-dentist relationship. Royal College of
the Victorian Government Department of Human Dental Surgeons of Ontario. Available from: https://
Services, Melbourne, Victoria, Australia. April 2006. az184419.vo.msecnd.net/rcdso/pdf/practice-adviso-
6. Poochikian-Sarkissian S, Wennberg R, Sidani S. Ex- ries/RCDSO_Practice_Advisory_Maintaining_Profes-
amining the relationship between patient-centred sional_Relationship.pdf
care and outcomes on a neuroscience unit: a pilot 18. Starfield B. Is patient-centred care the same as person-
project. Canadian Journal of Neuroscience Nursing focused care? The Permanente Journal 2011:15(2):63-9.
2008;30(2):14-19.
7. Biddy R, Griffin C, Johnson N, Larocque G, Messersmith Dr. Sanjukta Mohanta is a graduate of the University of
H, Moody L, et al., and the Person-Centred Care Guideline Toronto’s Faculty of Dentistry, 1999. She is the
Expert Panel. A Quality Initiative Endorsed by Cancer Care Chair of the ODA Dental Benefits Committee. Dr.
Ontario in Partnership with the Program in Evidence-Based Mohanta practises general dentistry at Wellfort
Care (PEBC) Person-Centred Care Guideline. 2015 May. Community Health Centre and is on the Editorial
Available from: https://www.cancercareontario.ca/en/ Board of Ontario Dentist.
guidelines-advice/types-of-cancer/38631
8. A practical guide for implementing person-centred care
22 OD • April 201919 The Exhibits Floor features more than 600 booths
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Some outstanding speakers to look forward to in 2019:
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Restorative Periodontics
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Edentulism: The All-on-Four®
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OntarioDentalAssociation @ONDentalAssn
April 2019 • OD 23Analysis
Social Networking
Uses, Benefits and Limitations of
Janet Wu
BSc
Social Networking Sites for Dental
Public Health Surveillance
I n 2016, 82 per cent of Internet users in the United
States reported using social networking sites (SNS)
such as Facebook and Twitter (1). Worldwide, Face-
book and Twitter have more than 1.23 billion (2) and 313
Uses of SNS
The two types of public health surveillance are passive
surveillance and active surveillance. Passive surveillance
involves the routine collection of data without health
million active users (3) respectively. SNS have become agencies actively seeking reports. Active surveillance
increasingly popular, allowing users to quickly share per- involves requesting information from health-care pro-
sonal information with large public audiences. Interest- viders and patients through surveys and other methods
ingly, the abundance of real-time data on Facebook and (7). Active surveillance is typically more expensive, but
Twitter provides an opportunity for researchers to survey provides a more complete report of health problems. It
public opinion and monitor public health challenges. appears that 15 studies have used SNS for active and pas-
The accessibility of SNS has encouraged researchers to sive dental public health-related surveillance (Table 1).
utilize SNS to investigate a wide spectrum of topics. For In active surveillance, SNS have been used to recruit
example, Twitter messages, or “tweets,” are now used for participants for studies, distribute online surveys and
earthquake monitoring, political polling and epidemic directly request data from users. Three studies used SNS
tracking for influenza (4). Recently, Heaivilin et al. evalu- to recruit participants for studies by targeting specific
ated the efficacy of Twitter as a tool for public health groups. Participants were targeted based on age (8) and
surveillance of dental pain in real time (5). Since public participation in previous surveys (9). SNS were also used
health surveillance involves the “continuous, systematic to inexpensively recruit new participants to existing
collection, analysis and interpretation of health-related studies (10).
data” (6) and is used to evaluate the effectiveness of pub- In four studies, social media platforms allowed re-
lic health policies, its use is essential for efficiently using searchers to distribute surveys online while targeting
public health resources. Innovative methods for health specific groups such as dentists (11), dental students (14),
data collection, such as the use of SNS, may thus sup- and scuba divers (12). One study surveyed dental profes-
plement, and possibly replace, traditional methods in an sionals and the public about dental surgical procedures
effort to streamline the surveillance process. (13). Another survey estimated the prevalence of dental
Traditionally, surveillance data sources include reports health issues among susceptible groups (12). In addition,
from health-care professionals, health records and sur- social media platforms can be programmed or structured
veys (7). However, collecting these records is labour- to streamline the data-collection process. Parsons et al.
intensive and expensive, making the processing power used Twitter as an “online diary” for participants to share
of SNS an attractive potential alternative to traditional information and discuss their oral pain conditions using
methods. SNS may help identify patients and their tweets that followed a specific format (15), allowing for
contacts, estimate the severity of health issues and stimu- even faster data collection and greater efficiency in den-
late research to inform public health policy. tal pain data analysis.
However, SNS have only recently been used for dental Seven studies used SNS for passive surveillance. For
public health surveillance. And the quality, ethics and example, SNS can provide insight on how the flow of
reliability of this method of data collection remains oral health information is diffused (16). The thoughts
largely unexplored. The objective of this paper is thus of dental professionals and patients are important when
to investigate the uses, benefits and limitations of SNS surveying oral health issues, and SNS provide platforms
as a tool for dental public health-related surveillance. for researchers to target both groups when trying to im-
24 OD • April 2019Social Networking
Table 1.
Uses of SNS as a tool for public health surveillance in 15 studies
Active Surveillance Recruitment (n=3) Khatri et al. (2015) [8],
Macluskey et al. (2015) [9],
Motoki et al. (2017) [10]
Online survey (n=4) Kim et al. (2017) [11],
Ranna et al. (2016) [12],
Vohra et al. (2015) [13],
Abdelkarim et al. (2014) [14]
Structured data collection (n=1) Parsons et al. (2015) [15]
Passive Surveillance (n=7) Seymour et al. (2015) [16],
Ahlwardt et al. (2014) [17],
Chan et al. (2017) [18],
Gao et al. (2013) [19],
Heaivilin et al. (2011) [5],
Song et al. (2013) [20],
Henzell et al. (2014) [21]
Table 2.
prove patient outcomes (11, 17, 20, 21). What is more, Benefits of SNS as a tool for public health surveillance in 15 studies
adolescents may be unreachable through conventional
methods, such as phone surveys through landlines, Quantity (n=6) Macluskey et al. (2015) [9],
but Twitter and YouTube can be effective alternatives Ahlwardt et al. (2014) [17],
for gaining insight into adolescent dental treatment Chan et al. (2017) [18],
Gao et al. (2013) [19],
experiences (18, 19). Keywords can narrow down spe- Heaivilin et al. (2011) [5],
cific aspects of patient-related oral health topics such as Song et al (2013) [20]
dental pain (17, 5), orthodontic treatment (18, 21), and Low-cost (n=4) Motoki et al. (2017) [10],
dental fear (19), to allow researchers to focus on particu- Macluskey et al. (2015) [9],
lar areas of concern. Khatri et al. (2015) [8],
Vohra et al. (2015) [13]
Benefits of SNS International reach (n=4) Macluskey et al. (2015) [9],
From these 15 studies, 10 main benefits can be ascer- Vohra et al. (2015) [13],
tained in the use of SNS for dental public health-related Heaivilin et al. (2011) [5],
Henzell et al. (2014) [21]
surveillance (Table 2). The most cited benefit is the quan-
tity of real-time data available on SNS (5, 9, 17-20) due Passive Surveillance (n=7) Macluskey et al. (2015) [9],
Ranna et al. (2016) [12],
to a high level of engagement from users. The low cost Abdelkarim et al. (2014) [14],
of accessing data on SNS makes it an attractive method Parsons et al. (2015) [15]
as well (8-10, 13). SNS reach people across international Eliminates observation Gao et al. (2013) [19],
borders (5, 9, 13, 21), which further allows for data col- bias (n=3) Song et al. (2013) [20],
lection from a more diverse sample. Henzell et al. (2014) [21]
SNS also allow for faster data collection (9, 12, 14, 15). Distribute superior Macluskey et al. (2015) [9],
Traditionally, collecting responses through mail and electronic resources (n=2) Kim et al. (2017) [11]
inputting data by hand requires time. Using SNS for pas- Target demographic (n=2) Motoki et al. (2017) [10],
sive health surveillance also eliminates observation bias Kim et al. (2017) [11]
(19-21), since data collected from SNS are candid mes- Only method of reaching Parsons et al. (2015) [15],
sages left by subjects who were not actively influenced participant (n=2) Chan et al. (2017) [18]
by interviewers. Researchers also found that they were Privacy policies give Parsons et al. (2015) [15],
able to distribute superior electronic resources through researchers consent (n=2) Chan et al. (2017) [18]
SNS compared to traditional methods (9, 11). Kim et al. Adequate randomized Motoki et al. (2017) [10]
included an interactive slider in a survey, which would sample (n=1)
April 2019 • OD 25You can also read
