The Canadian Dental Association Magazine 2025 • Volume 12 • Issue 1 Pushing the Boundaries of Oral Health Research Page 24 PM40064661 + IN THIS ISSUE Oral Microbiome Transplants P. 16 Oral Health and Healthy Aging P. 18 Caries Detection and AI P. 20
About CDA Founded in 1902, the Canadian Dental Association (CDA) is a federally incorporated not-for-profit organization whose corporate members are Canada’s provincial and territorial dental associations. CDA represents over 21,000 practising dentists nationwide and is a trusted brand and source of information for and about the dental profession on national and international issues. is the official print publication of CDA, providing dialogue between the national association and the dental community. It is dedicated to keeping dentists informed about news, issues and clinically relevant information. 2025 • Volume 12 • Issue 1 Head of Governance & Communications Zelda Burt Managing Editor Sean McNamara Writer/Editor Sierra Bellows Gabriel Fulcher Pauline Mérindol Publications & Electronic Media Associate Michelle Bergeron Graphic Designer Carlos Castro Advertising: All matters pertaining to Display or Online advertising should be directed to: Mr. Peter Greenhough c/o Peter Greenhough Media Partners Inc. pgreenhough@pgmpi.ca 647-955-0060, ext. 101 All matters pertaining to Classified advertising should be directed to: Mr. John Reid jreid@pgmpi.ca 647-955-0060, ext. 102 Contact: Michelle Bergeron mbergeron@cda-adc.ca Call CDA for information and assistance toll-free (Canada) at: 1-800-267-6354 or 613-523-1770 CDA Essentials email: publications@cda-adc.ca @CdnDentalAssoc canadian-dentalassociation Canadian Dental Association cdndentalassoc cdaoasis cda-adc.ca CDA Essentials is published by the Canadian Dental Association in both official languages. Publications Mail Agreement no. 40064661. Return undeliverable Canadian addresses to: Canadian Dental Association, 1815 Alta Vista Drive, Ottawa, ON K1G 3Y6 Postage paid at Ottawa, ON. Notice of change of address should be sent to: reception@cda-adc.ca or publications@cda-adc.ca ISSN 2292-7360 (Print) ISSN 2292-7379 (Online) © Canadian Dental Association 2025 Editorial Disclaimer All statements of opinion and supposed fact are published on the authority of the author who submits them and do not necessarily express the views of the Canadian Dental Association (CDA). Publication of an advertisement does not necessarily imply that CDA agrees with or supports the claims therein. The editorial department reserves the right to edit all copy submitted to CDA Essentials. Furthermore, CDA is not responsible for typographical errors, grammatical errors, misspelled words or syntax that is unclear, or for errors in translations. Sponsored content is produced by Peter Greenhough Media Partners Inc., in consultation with its clients. The CDA Essentials editorial department is not involved in its creation. CDA Board of Directors President Dr. Joel Antel Dr. Lesli Hapak Ontario Dr. Brian Baker Saskatchewan President-Elect Dr. Bruce Ward Vice-President Dr. Kirk Preston Dr. Jerrold Diamond Alberta Dr. Mélissa Gagnon-Grenier NWT/Nunavut/Yukon Dr. Raymon Grewal British Columbia Dr. Stuart MacDonald Nova Scotia Dr. Marc Mollot Manitoba Dr. Matthew Moore New Brunswick Dr. Jason Noel Newfoundland/Labrador Dr. Janice Stewart Prince Edward Island 3 Issue 1 | 2025 |
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Contents The Canadian Dental Association Magazine 2025 • Volume 12 • Issue 1 11 20 CDA at Work 7 Expanding the Science of Dentistry 9 CDA Convenes Event on Dental School Admission Tools 11 CDA Launches New Resource to Help Dentists Prepare for and Manage Risk News and Events 12 Dental Digest 15 Dentists’ Attitudes on the Communication of COVID-19 Guidelines and Protocols 16 The Potential of Oral Microbiome Transplants Issues and People 18 Q&A on Oral Health and Healthy Aging 20 Detecting Caries Using AI 24 Nanotechnology in Dentistry: From Fiction to Reality Classifieds 35 Offices and Practices, Positions Available, Advertisers’ Index Supporting Your Practice 27 Endodontics for General Dentists: Case Selection Criteria 31 Supporting a Worker with a Serious Illness 33 Social Media and Your Team: To Friend or Not To Friend? Did You Know? 37 The Neanderthal Version 27 33 5 Issue 1 | 2025 |
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Dr. Joel Antel president@cda-adc.ca Expanding the Science of Dentistry In our evidence-based profession, new research and technological change transforms what we do in our dental offices. Our dental education provides us with the skills necessary to evaluate scientific and clinical studies, so we can determine what new practices and treatments to embrace in our daily routines. During their additional time in education, dental specialists often spearhead their own research, pushing the boundaries of what we know towards what might be possible. The pace of innovation in research, and therefore in clinical practices, has risen exponentially, which is exciting because it ultimately results in better oral health for patients. It also means that as dentists, we all must continue to evolve, adapt and grow throughout our careers. In this edition of the magazine, we highlight new ideas and research related to oral microbiome transplants in animals (p.16), the association between oral health and chronic disease among seniors (p. 18), using artificial intelligence (AI) in intraoral photographic caries detection (p. 20), and the potential use of nanotechnology in orthodontics (p. 24), among others. These innovations make me think about how my own clinical practice has changed over the years. Early in my career, light cured composite resins and their applications were new; novel products and advancements in this domain arrived in the dental marketplace quickly. As a new dentist, I had faith in my training, and I wanted to make sure that I waited for conclusive evidence before adopting any new techniques too hastily. I didn’t want to be the first dentist to use a novel material, but I also didn’t want to be the last. It was a steep learning curve to determine where to land on this spectrum. I perform many root canals at my practice, and, in the past 15 years, respected thinking about the root canal has evolved. The general mindset has shifted. Originally, the idea was that we cleaned out the whole root canal system using hand filing systems, which was based on my training in dental school. The current idea is that we use our filing systems to access the root canal system so that the irrigation solutions can chemically clean out the root canals. Changing the overall goal of each step of the procedure has influenced what technology we use; rotary instruments, microscopes and cone-beam computed tomography (CBCT) radiographs have revolutionized endodontic treatment. Dentistry is more than just a professional practice; it is a science that depends on evidence-based research for its foundation. Research is undertaken at our 10 Canadian dental schools as well as in the industrial and governmental sectors. It’s to the profession’s advantage, like any science, to have a large number of research-trained professors in academia and robust resources to support their efforts. We all benefit from international research, but I’m especially proud of the researched performed here in Canada that reflects our unique population, culture and health care needs. I felt this acutely at the inaugural Canadian Oral Health Summit last June in Halifax, Nova Scotia, which brought together people from academia and the profession who were involved in oral health research. I learned about diverse and impressive Canadian research, new ways of gathering and analyzing data, and opportunities to strengthen our research capacity. I will continue to reflect on the work of our colleagues in research during my daily practise. And I remain excited to see how my skills, and my patients’ health, will evolve in the coming years. From the President 7 Issue 1 | 2025 | CDA at Work
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In November 2024, CDA held a 2-day meeting that brought together representatives from all 10 Canadian dental schools to discuss how CDA programs, most notably the Dental Aptitude Test (DAT), can continue to support the work of admissions officers at the schools in helping to identify future dentists. The meeting of the Committee on Dental School Admission Assessment Tools was co-facilitated by Dr. Benoit Soucy, CDA’s chief knowledge officer, and Dr. Steven Patterson, professor and associate chair of the faculty of medicine & dentistry at the University of Alberta, who represented the Association of Canadian Faculties of Dentistry. Dr. David Waldschmidt, senior director of testing services at the American Dental Association, made a presentation to the group about the validity of the DAT within the selection process. Dr. Waldschmidt shared research that showed that DAT scores were the best predictor of academic success in the first two years of dental school, more so than grade point average. “We had dynamic and wide-ranging conversations about the traits and skills required to become successful dentists, as well as the diversity of motivation and goals that future dentists should possess to meet the oral health (L. to r.): Isabella Yuan Yu-Ting, Dalhousie University, Vicki Koulouris, University of British Columbia, Dr. Anuradha Prakki, University of Toronto, Dr. Vanessa Swain, University of Manitoba, Rosanna Glover-Punko, University of Alberta, Chelsea Johnson, Schulich School of Medicine & Dentistry, Dr. Benoit Soucy, CDA, Dr. Caroline Nguyen, National Dental Examining Board of Canada, Dr. Walter Siqueira, University of Saskatchewan, Dr. Steven Patterson, University of Alberta, Dr. Raphaël Godue, University of Montreal, Crystal Noronha, McGill University , Dr. François Boulanger, Laval University, Fatna Moussali, CDA, Dr. Kavita Mathu‑Muju, UBC, April Carr, CDA CDA Convenes Event on Dental School Admission Tools care needs of people in Canada,” says Isabelle Gingras, CDA’s programs advisor. “It was also helpful for us at CDA to learn, in more detail, about the tools, processes and challenges that each school has in selecting their first-year class.” “The DAT program is administered by CDA in service of the 10 dental schools and for the future of the profession, so a strong relationship with the schools is very important,” says Fatna Moussali, CDA’s DAT associate who has helmed the program for over 30 years. “Understanding the complexity of the needs of the dental schools allows us to look for better and new ways to meet their needs. Also, the DAT is the first interaction that prospective dentists have with CDA, so we work very hard to make it a good beginning to a career-long connection.” We had dynamic and wideranging conversations about the traits and skills required to become successful dentists. 9 Issue 1 | 2025 | CDA at Work
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In November 2024, CDA launched a new resource created to help oral health care providers prepare for and mitigate potential risks facing dental offices across Canada. The Preparedness in a Dental Office: Building Resilience When Deviating from Business-as-Usual resource includes: z a risk inventory that lists various occurrences and events that could pose a risk to an oral health care provider z a risk assessment framework to determine the level of preparedness required z a risk mitigation section with strategies to achieve better outcomes “Unprecedented risks such as the COVID-19 pandemic that undermine our ability to provide essential oral health care can come from anywhere and at any time,” says Dr. Astha Shah, health policy advisor and scientific editor at CDA, who coordinated the project and contributed her expertise to the resource. “Although not everything can be controlled, one thing that can be done is to be better prepared for risks before they emerge. Drawing on dental professionals’ lived experiences, this step-by-step guide CDA Launches New Resource to Help Dentists Prepare for and Manage Risk will help ensure that your dental office and team is ready to tackle obstacles that come your way.” During production of this preparedness resource, CDA received valuable insights and contributions from representatives from PTDAs, the Canadian Dental Hygienists Association, Canadian Dental Assistants’ Association, CDSPI, as well as practising dental professionals from across the country. See: bit.ly/4hpoaPr 11 Issue 1 | 2025 | CDA at Work
Dr. Lynn Tomkins of Toronto (right) was honoured by the American College of Dentists (ACD) with its 2024 Distinguished Leadership Award. This award recognizes individuals who have a record of significant and distinguished leadership in dentistry, public health, or national health policy at the national level. Dr. Tomkins served as CDA president in 2022– 23 and as president of the Ontario Dental Association in 2010–11. Dr. Tomkins has also been recognized for her outstanding contributions to dental education with the Dr. A. Bruce Hord Master Teaching Award for excellence for her work in clinical instruction at the University of Toronto’s Faculty of Dentistry. The ACD also recognized other Canadian dentists with awards in 2024. Dr. Barry Schwartz of London, Ontario, was the recipient of the ACD Ethics and Professionalism Award, given to recognize exceptional contributions by individuals or organizations in the promotion of ethics or professionalism in dentistry. American College of Dentists Award Winners Dr. Daniel Haas Appointed as Member of the Order of Canada CDCP Predetermination Updates Dr. Daniel Haas of Toronto, a professor and former dean of the University of Toronto (U of T) faculty of dentistry, was appointed as a Member of the Order of Canada in December 2024. Dr. Haas is a leading expert in dental anesthesiology and pharmacology and was recognized for his significant contributions to oral health and dental education. His research on local anesthetic risks has enhanced patient safety. As dean of the U of T faculty of dentistry and an advocate for specialty recognition, Dr. Haas has influenced dental training and practices worldwide. Created in 1967, the Order of Canada is one of the country’s highest civilian honours. It recognizes individuals whose achievements and service have had an impact on communities across Canada and beyond. Since November 2024, dentists have been able to submit Canadian Dental Care Plan (CDCP) predetermination requests for services that require prior approval. Health Canada and Sun Life are aware of some technical challenges encountered by dental offices and are working to simplify the process and provide more clarity. Some improvements have already been implemented and CDA will continue to advocate for further improvements. Tutorial videos with accompanying checklists of required documentation are being created by Health Canada, beginning with one on partial dentures, with crowns and additional units of scaling coming in 2025. The tutorial videos will explain what documentation is needed when submitting a predetermination request to CDCP and the checklists will help providers and dental office staff know what documentation should be submitted. DENTAL DIGEST Dr. Thomas Harle of Ottawa and Dr. Lance Rucker of Vancouver were the 2024 recipients of the ACD’s Outstanding Service Award, which recognizes ACD Fellows for specific, outstanding service to dentistry, the community, or humanity. See: acd.org/fellowship/awards/awardees Dr. Daniel Haas See: bit.ly/4jqfme6 See: youtube.com/watch?v=dlTK3hEAGPs Dr. Lynn Tomkins 12 | 2025 | Issue 1
In November 2024, CDA received a gold global Facilitation Impact Award in recognition of its strategic planning process, which led to the creation of CDA’s strategic plan, Forward Focus: Strategic Plan 2024-2029. The award is presented by the International Association of Facilitators, a global community of facilitators that promotes excellence in using professional group process facilitation to create engagement and impact. “CDA is honoured to receive the Facilitation Impact Award,” says Dr. Bruce Ward, CDA vice-president and former chair of the Strategic Planning Working Group. “The process of developing our strategic plan was an ‘all-hands-on-deck’ one. Together, we worked with our key stakeholders and received valuable insights from provincial and territorial dental associations, CDA staff, and our Board of Directors, and they all helped shape the plan and ensured that it aligns with the needs and expectations of those we serve.” CDA Receives Global Facilitation Impact Award In fall 2024, the federal government introduced legislation to amend capital gains legislation and the Canada Revenue Agency (CRA) has already put these changes into effect starting June 25, 2024. With the announcement that Parliament is prorogued until March 24, 2025, the capital gains tax legislation would have to be reintroduced in a new session of Parliament. However, based on administrative tax policies grounded in parliamentary convention, the CRA typically requires taxpayers to file on the basis of proposed legislation. Therefore, the proposed capital gains tax rules are still technically in effect despite prorogation, pending any further announcements, guidance or clarifications issued by the CRA in the coming months. Dentists should consult with their tax professionals for specific advice on capital gains tax issues. Prorogation of Parliament and Capital Gains Tax Proposals See: bit.ly/3Cm84r6 13 Issue 1 | 2025 |
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“During the COVID-19 pandemic, provincial and territorial dental regulatory bodies, both those for dentists and for hygienists, communicated about COVID-19 risks in the dental office, new protocols and guidelines for patient care,” says Dr. Sreenath Madathil, a faculty member in Dental Medicine & Dentists’ Attitudes on the Communication of COVID-19 Guidelines and Protocols Dr. Sreenath Madathil Reference: 1. McLaughlin KJ, Khanna M, Allison PJ, Glogauer M, McNally ME, Quiñonez C, Rock L, Siqueira W and Madathil SA. Community Dent Oral Epidemiol. 2024 Aug;52(4):462-68. Dr. Madathil and his colleagues performed a qualitative analysis nested within a prospective longitudinal cohort study in which data were collected using online questionnaires of 644 Canadian dentists, taken at regular intervals between August 2020 and November 2021. The group also studied COVID-19 infection rates among dentists and dental hygienists, which they published separately. “During the pandemic, regulatory bodies put out COVID-19 related information on their websites and emailed dentists about appropriate PPE, updated infection prevention and control, how to screen patients, and how to use teledentistry, among other topics,” says Dr. Madathil. “Information changed quickly, which was hard but unavoidable. Also, because there are so many regulatory bodies, the information wasn’t always aligned. Do we need N95s or not? Sometimes, information was presented in very long documents that were hard to navigate.” The study findings were that dentists encountered challenges and frustrations amid the COVID-19 pandemic, grappling with diverse regulations and communications from dental bodies. Although some bodies offered helpful guidance, many participants felt the need for improved communication on such guidelines. Dentists wanted expedited, clearer and more frequent updates, and expressed that it was difficult to navigate the overwhelming information. Negative views emerged on any vague and unclear communication of COVID-19 guidelines, contributing to confusion and frustration among dentists. “Dentists responded more positively when it was clear that guidelines were evidence-based,” says Dr. Madathil. The study also suggested that greater collaboration among regulatory bodies might help dentists more easily navigate their messaging. “Trust in our regulatory institutions is an important part of effectively navigating a crisis like the pandemic,” he says. “Successful communication can increase trust.” Oral Health Sciences at McGill University and co-author of a study1 on how dentists perceived the communications from regulatory bodies during the pandemic. “We wanted to see how effective COVID-19 communications were, during a time of such distress, and how dentists felt about their usefulness.” 15 Issue 1 | 2025 |
The Potential of Oral Microbiome Transplants Dr. Peter Zilm is a researcher and associate professor at the Adelaide Dental School in Australia. Dr. Peter Zilm is a biochemist and microbiologist who has been working in oral microbiology for 40 years. “When I began, we were interested in individual bacteria that created acid, like Streptococcus mutans,” he says. “Then we studied small groups of bacteria, called biofilms. Now we are looking at the 500 to 700 kinds of bacteria in the mouth as a whole microbiome.” Some microbiomes create an acid oral environment that can lead to dental caries, but others do not. “We’ve found that there are people who have great teeth, even though they have a lot of plaque, they don’t brush or floss as often as they should, and they eat a lot of sugar in their diet,” he says. “Their oral microbiome prevents decay and disease, even when other risk factors are present. In our work, we’ve found some of these people and we call them ‘super donors.’” With a grant from the National Health and Medical Research Council in Australia, Dr. Zilm and his research team have been collecting oral microbiome samples from three groups of people: optimal donors, good donors and suboptimal donors. Using an assessment tool the team created, they rate donors’ oral health care practices and diet. They also do a clinical assessment of the oral health We’re going to do DNA sequencing so we can look at the specific genes in those bacteria to see why some produce more acid or others produce less. 16 | 2025 | Issue 1
of each donor. “An optimal donor has a poor diet and oral hygiene but good dental health. A good donor has a decent diet, regular oral hygiene, visits the dentist often and has good oral health. The suboptimal donor is someone who has had dental caries in the past but now has stable oral health.”1 A group of researchers at the Pennsylvania State University, led by Professor Laura Weyrich, is sequencing the DNA from bacteria in the oral microbiome samples that Dr. Zilm’s team collects. “We are mapping out the microbiome in these people’s mouths and that work is ongoing,” says Dr. Zilm. One of the PhD students on Dr. Zilm’s team developed the media in which they had isolated S. mutans from different donors. “We made a broth, we added sugar and measured the pH level after 30 minutes or so,” says Dr. Zilm. The experiment found a significant difference in the amount of acid made by different strains of S. mutans. “We’re going to do DNA sequencing so we can look at the specific genes in those bacteria to see why some produce more acid or others produce less,” says Dr. Zilm. Dr. Zilm and his team ran an experiment on rats to see if transplanting a microbiome from a super donor would protect teeth from caries. “There is already a well-documented rat caries model, where you feed rats a high sucrose diet,” says Dr. Zilm. During the experiment, two groups of rats received oral microbiome transplants, some from optimal donors and others from suboptimal donors. “Over 3 days, we initially washed the rats’ mouths out with chlorhexidine mouth rinse to suppress their existing microbiome and then introduced the transplant from the donors,” he says. The rats then ate a high sugar diet for 8 days. To make sure that the processes were safe, the team took blood serum to test for inflammatory markers and gut samples for histology. They also took swabs of the rats’ oral microbiomes and examined their jaws for caries. “We saw a statistically significant decrease in the caries in the rats that had the transplants, from both kinds of donors,” says Dr. Zilm. “We were a little bit surprised that it actually worked because it was such a new idea.” The team is still working with the data from the experiment to see if there was a complete shift to the introduced microbiome or if a hybrid microbiome resulted from the transplants. Dr. Zilm believes that oral microbiome transplants in humans could be an integral part of preventing caries in the future. “In a very early study, researchers just took a plaque sample from a donor dog and put it in the mouth of a recipient dog with periodontitis,” says Dr. Zilm. “We couldn’t do this in humans because it could potentially also transmit viruses and other pathogens.” Dr. Zilm’s team takes samples from human donors and then culture them in vitro in artificial saliva on 3D-printed hydroxypatite discs, which have enamel-like properties. In future, biofilm would be sequenced, to allow the researchers to know the biofilms’ exact constituents, then the biofilm would be stored in a biobank until it was needed for use.2 “At this point, it is still theoretical, but I can imagine that, in future, a microbiome transplant is something that would happen in dental clinics.” The next step for Dr. Zilm’s team is a clinical study in humans. “We are getting a lot of interest from different groups because a microbiome transplant is a different way of looking at solving oral diseases like caries and periodontal disease,” he says. References: 1. Nath S, Zilm PS, Jamieson L, Ketagoda DHK, Kapellas K, Weyrich L. Characterising healthy Australian oral microbiomes for ‘super donor’ selection. J Dent. 2024; Oct 24:105435. 2. Ketagoda DHK, Varga P, Fitzsimmons T, Moore N, Weyrich L, Zilm P. Development of an in vitro biofilm model of the human supra-gingival microbiome for oral microbiome transplantation. J Microbiol Methods. 2024; Aug 223:106961. Dr. Peter Zilm (2nd from left) and his research team at the University of Adelaide School of Dentistry. 17 Issue 1 | 2025 | News and Events
Q&A on Oral Health and Healthy Aging Dr. Noha Gomaa, assistant professor and associate director of research at the Schulich School of Medicine & Dentistry, and her team recently published an article that considers the impact of access to oral health care on the well-being of older adults in Canada.1 The study assessed the extent of the association between suboptimal oral health and multimorbidity among middle-aged and older adults, and whether improved access to oral health care can change this relationship. Q What prompted you to conduct this study? Dr. Noha Gomaa (NG): Part of what my research group at Western University studies is characterizing the connections between oral and general health at the population level, including the impacts of oral health interventions on overall health. Aligning with the United Nations-World Health Organization Collaborative on Healthy Aging, there is a growing interest in Canada and internationally in understanding the determinants of health in older populations. However, oral health and oral health care are often left out from these discussions. We sought to investigate how oral health contributes to the burden of chronic diseases, or multimorbidity, in older adults in Canada and to further examine the role of access to oral health care in this relationship. Q Could you tell us about the data set that you used for this study? NG: We have been leveraging data from the Canadian Longitudinal Study on Aging for multiple projects in my lab that investigate the social and biological determinants of oral health around aging. This dataset enables us to look at a nationwide sample of 50,000 middle-aged and older Canadians who are followed through time. This longitudinal study We sought to investigate how oral health contributes to the burden of chronic diseases, or multimorbidity, in older adults in Canada and to further examine the role of access to oral health care in this relationship. 18 | 2025 | Issue 1
includes self-reported oral health measures and chronic disease outcomes, as well as comprehensive sociodemographic and biological variables, making it very well-suited to our research questions. Q What were your main findings? NG: As hypothesized, we found individuals with poor oral health to have multiple chronic conditions, or what the Public Health Agency of Canada collectively defines as multimorbidity. Previous research has linked individual chronic diseases—such as diabetes, cardiovascular diseases, chronic respiratory diseases and mental illnesses—to oral health conditions, but we didn’t know much about the relationship of multiple chronic diseases, or multimorbidity, to oral health. We also found the risk for multimorbidity to be greater in those who have not been able to see the dentist in the past year, and those who reported cost barriers to accessing oral health care due to financial constraints or lack of dental insurance. These findings really underscore how deeply oral health and general well-being are connected, and they shine a light on the need for policies that make oral health care more accessible for older adults with chronic diseases. Q Could you talk more about why you study access to dental care for seniors? NG: Many seniors face unique challenges. As people age, they are likely to develop more chronic conditions like diabetes and cardiovascular diseases, which we know are linked to oral health. Also, many seniors no longer have dental benefits upon retirement, making oral health care harder to afford. Yet, older adulthood is generally when oral health needs are higher, because aging physiologically affects oral tissues. In 1971, Julian Tudor Hart proposed the “inverse care law,” which states that the availability of good medical care is inversely related to the need for it in a population. This is an example of this concept; access to quality oral health care for our seniors is very important, which is why we wanted to look at how it impacts seniors’ health and well-being. Provincial dental care programs for seniors and, more recently, the Canadian Dental Care Plan are good initiatives in this area, and we’re hoping to see the impacts of these targeted interventions for this population. Q What outcomes from this study surprised you? NG: Previous studies on oral health inequalities made us expect to find connections between suboptimal oral health and multiple chronic diseases. What was interesting was that this was further exacerbated by the lack of access to oral health care and that it was particularly evident in older adults. On top of these findings, we conducted a subsequent study to investigate whether there were differences between men and women in the impact of access to oral health care on the chronic disease burden. Men are generally more likely to have poor oral health, but we were surprised to find older women to be more affected by issues of lack of access to oral health care than men. When you think about it, it makes sense because women generally face more socioeconomic barriers and are more likely to have lower and fixed incomes in older age, which impacts their access to oral health care. Q What further research questions did this study bring up for you? NG: So far, our research has been able to indicate associations quite well. We want to further understand whether there are causal links between oral and overall health. Importantly, we want to “break the cycle” by determining the impact of oral health interventions. My team has recently received a catalyst grant from the Canadian Institutes of Health Research that will enable us to further establish the longer-term impacts of improved access to oral health care on the oral and overall health of older Canadians and look at the broader structural and geographic determinants of health. This is work in progress, and we look forward to sharing our results soon. Reference: 1. Limo L, Nicholson K, Stranges S, Gomaa N. Suboptimal oral health, multimorbidity, and access to dental care. JDR Clinical & Translational Research. 2024;9(1_suppl):13S-22S. Men are generally more likely to have poor oral health, but we were surprised to find older women to be more affected by issues of lack of access to oral health care than men. 19 Issue 1 | 2025 | Issues and People
Detecting Caries Using AI A group of researchers led by Dr. Mohammad Moharrami, a PhD student and dental public health resident at the University of Toronto, published a systemic review to evaluate the performance of artificial intelligence (AI) models in detecting dental caries from intraoral photographs.1 The review found that AI may assist with oral health screening, clinical decision-making and facilitate communication between patients and clinicians, as well as teledentistry. In terms of clinical decision-making, the review suggests that AI models might perform better at detecting primary caries compared to secondary caries, likely due to the variability in the clinical presentation of secondary caries and the smaller number of labeled secondary caries in the data sets. Furthermore, studies that used AI that included professional and intraoral camera images as the source of data collection performed better than those that used smartphone images. However, further research is needed in this area, with a focus on implementing more robust study designs, employing standardized metrics, larger datasets and addressing the severity of caries lesions. CDA brought together some of the researchers—Drs. Michael Glogauer, Sonica Singhal and Mohammad Moharrami—to discuss the study as well as the larger implications of the potential use of AI in dentistry. The conversation has been edited for length and clarity. 20 | 2025 | Issue 1
Dr. Michael Glogauer (MG): To start with a big picture perspective, I think there’s this fear in every realm of the economy that AI could replace people. But I don’t think that’s what will actually happen. Instead, people who use AI will replace people who don’t use AI. I’ve witnessed how much the Internet has changed almost every aspect of our daily lives. AI will do the same, but in a larger order of magnitude. AI could be wonderful for dentistry from technological and educational standpoints. Dr. Mohammad Moharrami (MM): As a PhD student, when I started exploring research in the application of AI in dentistry, I observed that dentistry is following in the footsteps of medicine regarding data sources and algorithms, but obviously focusing on different outcomes. Some commercial applications have been built that use AI to help with diagnosis using radiographs, but there wasn’t much research that used oral photographs as a source of data. And oral photographs could be a great source of data if we want to focus on prevention and democratize the use of this technology for both clinicians and the public. Dr. Sonica Singhal (SS): Dental caries is the most prevalent chronic disease globally, resulting in a significant burden. Enhancing the treatment and prevention of this common condition has the potential for improving the quality of life for literally billions of people. We believe that using AI with a large data source of oral photographs could be a very powerful public health tool for oral health care providers. It has the potential to enhance preventive care and improve oral health outcomes on a population scale through early detection, remote assessment, and education through personalized feedback. I use the word “tool” intentionally; while AI cannot replace the work of oral health care providers, it can serve as a valuable resource. Our systematic review aimed to assess the effectiveness of photographs in detecting dental caries. How reliable is it? Does it generate false positives? With AI, the quality of the tool is dependent on the quality of the data it is trained on. MG: In dentistry, there’s a rich source of non-invasive data that’s both professionally procured and made by patients themselves. And if you’re able to harness these photographic images, you can generate tools for screening for dental caries that could be of incredible value, especially for people who can’t access dentistry as readily as others. This kind of tool could be very beneficial to public health. MM: We screened more than 3,000 studies as a part of this review and selected 19 papers that met the criteria of being directly pertinent to using AI for detecting dental caries from oral photographs. Some used smartphone photos as their main source, while others used professional or intraoral cameras. Compared to the annotated images by dentists, the experts who made the diagnosis in the first place, AI models’ performance was acceptable according to the reported metrics. AI that used images from intraoral cameras were better than those from professional cameras, which in turn were better than smartphones. This makes sense because the quality of the photos is simply better. As a dentist, too, we prefer to look at the highest quality image. When it comes to AI algorithms, readers should note the distinction between one-stage and two-stage algorithms. Two-stage models take longer to train and provide inference but are generally more accurate. They also need more computational power and resources, so it isn’t something usually deployed on portable devices such as smartphones, at least at the time of our article publication. Most studies trained AI models using image annotations based solely on dentists’ diagnoses from images, not In dentistry, there’s a rich source of non-invasive data that’s both professionally procured and made by patients themselves. And if you’re able to harness these photographic images, you can generate tools for screening for dental caries that could be of incredible value. 21 Issue 1 | 2025 | Issues and People
a clinical exam, which is fine for epidemiological screening. The issue is that if you don’t build your AI database on diagnoses from clinical examinations, you are more prone to false positives. What may appear carious is, in reality, not an active lesion. This could lead to overtreatment, which was one of the concerns that came out of our research. SS: I’d like to reinforce what Dr. Moharrami just mentioned. For these tools to be effective in a dental office, they must be based on a diverse range of source materials, with dental caries in the training photos diagnosed through clinical examinations. While the AI tools used in these studies may be beneficial in a public health setting such as school screening, they are not yet suitable for use in a dental office. As a quaternary prevention principle, one needs to be cautious that any tool, such as AI, should not lead to over treatment. MM: There is still a lot to explore in this field of study, and the literature documented other applications of AI in oral photographs, such as screening of precancerous lesions and certain orthodontic outcomes. For the next projects, I’m interested in looking at whether AI and oral photographs could be effective at detecting dental plaque and gingivitis. We are also exploring the idea of original research using data from our clinic at the U of T faculty of dentistry. Dentistry hasn’t been able to leverage AI as quickly as medicine, partly because we don’t have the same levels of readily available data in oral health. The biggest studies that we included in our review had only about 1,000 oral photographs, which is relatively small compared to other fields. To build effective AI tools, we need to collect more high-quality data and make it more accessible. If I could advocate for something as a researcher, it would be that we simply need more data in oral health. SS: With the launch of the federal government’s Canadian Dental Care Plan, there is great potential for progress. Dentists across Canada, providing care to millions of people eligible under the plan, are doing clinical examinations, taking radiographs and oral photographs, and making diagnoses. The funding agency, the plan administrator, and dental associations can join hands to develop a databank of anonymized data, which could serve as a significant resource for further enhancing this kind of AI tool. MM: At this point, a lot of the hard work has already been done. AI infrastructure and algorithms exist, and nowadays, we have the computational power to train and deploy AI models. Now, it’s all about having the right data so that we can build tools that will be useful in improving people’s oral health. Reference 1. Moharrami M, Farmer J, Singhal S, Watson E, Glogauer M, Johnson AEW, Schwendicke F, Quiñonez C. Detecting dental caries on oral photographs using artificial intelligence: A systematic review. Oral Dis [Internet]. 2023;30(4):1765-83. There is still a lot to explore in this field of study, and the literature documented other applications of AI in oral photographs, such as screening of precancerous lesions and certain orthodontic outcomes. 22 | 2025 | Issue 1 Issues and People
Nanotechnology in Dentistry: From Fiction to Reality Nanotechnology has garnered significant attention across various professions and industries and is now becoming more integrated in dentistry. This innovative technology, which involves the manipulation of matter on an atomic, molecular, and supramolecular scale, holds great potential for the future of dental care. Dr. Normand Bach, associate professor in orthodontics at the University of Montreal, provides an overview of how this technology is being integrated into dental practices, particularly within orthodontics. Nanotechnology refers to the branch of science and engineering devoted to designing, producing, and using structures, devices and systems by manipulating atoms and molecules at nanoscale. In the context of dentistry, nanotechnology has been described as the “synthesis of bioactive materials,” says Dr. Bach. These materials include glass ionomers, composite resins, and other biocompatible products that are engineered to release various ions, such as calcium and phosphorus, when used intraorally. According to Dr. Bach, nanotechnology’s potential uses in dentistry include remineralization, preventing demineralization, and antibacterial properties of nanoparticles. “Many applications can be used with this new generation of materials currently being synthesized and researched at the moment,” he says. Restorative materials are benefiting from the advancements in nanotechnology. Traditional dental restorations degrade over time due to wear, shrinkage, and bacterial infiltration. Nanotechnology can improve materials on a molecular scale. “Adding specific nanoparticles to certain restorative materials and adhesive systems may enhance their mechanical and physical properties like reducing polymerization shrinkage,” explains Dr. Bach. These improvements should result in more durable and esthetically pleasing restorations. Dr. Normand Bach is an associate professor in orthodontics at the faculty of dental medicine at the University of Montreal. 24 | 2025 | Issue 1
Osseointegration is crucial for successful dental implants and nanotechnology can enhance this process by improving the surface properties of the implant, making it more conducive to bone growth and reducing the risk of implant failure. Nanoparticles can also coat implants with antimicrobial agents, reducing infection risk and improving outcomes. Nanotechnology in Orthodontics For Dr. Bach, the potential uses of nanotechnology in orthodontics fall into three areas: oral biofilm control, friction reduction and bone tissue engineering. Control of Oral Biofilm Dental plaque is always a concern in orthodontics, especially for patients with braces or aligners. “Nanomaterials are currently being tested to be used either as coatings on the surface of orthodontic appliances (brackets, wires, aligners) or it can be incorporated inside the orthodontic bonding system or cement,” says Dr. Bach. By employing nanoparticles (titanium dioxide, silicon dioxide and silver nanoparticles), these coatings may decrease caries and white spot lesions caused by brackets and appliances. Integrating nanoparticles like chlorine, fluoride, and zinc oxides into dental cements and resins used in bonding orthodontic appliances could also prevent demineralization and promote oral health during orthodontic treatment, reducing bacterial metabolism and acid production. “Elastomeric ligatures and power chains harbour a lot of bacteria. Scientists are testing silver nanoparticles in association with elastomeric ligatures to reduce dental biofilm and demineralization of enamel caused by bacterial plaque accumulation,” Dr. Bach explains. Reduction of Friction Friction can delay treatment by hindering tooth movement. Dr. Bach says, “A good percentage of the orthodontic force used to achieve the desired dental movement is lost due to the friction force.” Reducing this friction could significantly enhance the effectiveness of orthodontic treatments. Coated orthodontic wires, developed using nanotechnology, may offer a solution. “It’s been proposed that coating orthodontic arch wires with a film containing nanoparticles would be one possible solution,” Dr. Bach says. Molybdenum disulfide and tungsten disulfide could shorten orthodontic treatments by reducing friction and improving tooth movement. Friction during treatment is influenced by bracket design, torque, slot size and ligation type. Minimizing friction allows orthodontists to apply precise forces, resulting in predictable outcomes and a comfortable experience for patients. Bone Tissue Engineering Creating an artificial environment can facilitate bone regeneration and growth. “Nanoparticles can be used in a bone graft to deliver bioactive materials, growth factors, and genetic materials, or as a scaffold to enhance stability and cellular attachments,” explains Dr. Bach. Nanoparticles can be used in a bone graft to deliver bioactive materials, growth factors, and genetic materials, or as a scaffold to enhance stability and cellular attachments. This potential use is applicable to orthodontic treatment requiring tooth movement through bone regeneration. The use of nanoparticles in bone grafts can enhance the healing process and improve the overall outcomes of orthodontic treatments. For example, when moving a tooth into the space from an extracted tooth, the surrounding bone may need reinforcement to support the tooth’s new position. Nanotechnology can provide the necessary scaffolding and bioactive materials to encourage bone growth, ensuring the stability and longevity of the treatment results. 25 Issue 1 | 2025 |
Nanotechnology’s Future in Dentistry For Dr. Bach, a future where nanorobots–robots measured on the scale of nanometers–play a role in dental care is possible. “Tooth movements using nanorobots are some anticipated applications and may be closer to reality than we think,” he says. These nanorobots have the potential to revolutionize health care in areas such as drug delivery and diagnostics. In orthodontics, future scenarios include where a nanorobot could potentially remove necrotic and degenerative tissues, enhance faster tooth movement, and even prevent root resorption, a common concern in orthodontics. “The dream would be orthodontic nanorobots being injected directly in sites on the tooth to manipulate cellular structures in periodontal tissue and bone to remove the necrotic and degenerative tissues or enhance faster move tooth movements or even prevent root resorption,” Dr. Bach explains. These advancements could shorten treatment time, reduce discomfort, and enhance patient satisfaction. Nanorobots could also deliver drugs precisely in the oral cavity, minimizing side effects and maximizing efficacy. Nanosensors could also be developed to detect early signs of oral diseases, such as caries or periodontal disease, potentially allowing for earlier intervention and better outcomes. Challenges and Concerns The development and production of nanomaterials is expensive, which may limit their widespread adoption in dental practices, particularly in regions with limited health care resources. The properties that make nanoparticles effective in combating microorganisms can also pose risks to human cells. “Toxicity is the greatest limitation of these products, of this material, of the nanotechnology,” Dr. Bach warns. Due to their small size, nanoparticles can penetrate the body’s natural filtration systems and reach vital organs, including the brain. “They may also bring damage to normal cells by oxidation, by damaging the cellular membranes, thus damaging the DNA, which could affect cellular division, metagenes, and intracellular transport,” he says. Given these potential risks, more extensive research and rigorous testing are necessary before nanotechnology can be fully integrated into dental practice. “A lot of study, a lot of research has to be done, and caution must be exercised to assure the safety of this kind of technology,” Dr. Bach says. A nanorobot could potentially remove necrotic and degenerative tissues, enhance faster tooth movement, and even prevent root resorption, a common concern in orthodontics. Watch an interview with Dr. Bach on nanotechnology and orthodontics on CDA Oasis at: bit.ly/4gdpswb 26 | 2025 | Issue 1 Issues and People
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