The Canadian Dental Association Magazine 2025 • Volume 12 • Issue 3 PM40064661 Dr. Bruce Ward of Vancouver, BC New CDA President Page 9
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 3 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 or sponsored content 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 solely produced by advertisers. The CDA Essentials editorial department is not involved in its creation. CDA Board of Directors President Dr. Bruce Ward Dr. Raymon Grewal British Columbia Dr. Brian Baker Saskatchewan President-Elect Dr. Kirk Preston Vice-President Dr. Jason Noel Dr. Joy Carmichael New Brunswick Dr. Jerrold Diamond Alberta Dr. Mélissa Gagnon-Grenier NWT/Nunavut/Yukon Dr. Lesli Hapak Ontario Dr. Paul Hurley Newfoundland/Labrador Dr. Stuart MacDonald Nova Scotia Dr. Marc Mollot Manitoba Dr. Janice Stewart Prince Edward Island 3 Issue 3 | 2025 |
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Contents The Canadian Dental Association Magazine 2025 • Volume 12 • Issue 3 15 20 CDA at Work 7 Relationships Matter 9 Dr. Bruce Ward New CDA President News and Events 15 Statistics Canada Data: Human Resource Challenges, Wait Times and Plans for the Future Among Oral Health Care Providers 17 Dental Digest Issues and People 20 Big Picture: Antibiotics and Antimicrobial Resistance Classifieds 34 Offices and Practices, Positions Available, Advertisers’ Index Supporting Your Practice 26 Maxillary Sinusitis of Dental Origin: Diagnosis and Treatment 30 Difficult Conversations in the Dental Office 32 Fostering Mindfulness Did You Know 37 Peculiar Toothpaste Facts 26 30 Obituaries 38 Dr. Karen Gardner 5 Issue 3 | 2025 |
Reevaluate RinseTM It’s Time For An Evidence-Based Recommendation Systematic reviews, meta-analyses, the European Federation of Periodontology S3 level clinical practice guidelines, and a recent consensus report from global experts, support the adjunctive use of antiseptic mouth rinses.1-3 Clinically Proven Formula with Essential Oils Eliminate Germs Learn More 1. Treatment of stage I-III periodontitis. The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020 Jul;47. 2. Figuero, E., Roldán, S., Serrano, J., Escribano, M., Martín, C., & Preshaw, P. M. (2020). Efficacy of adjunctive therapies in patients with gingival inflammation: A systematic review and meta-analysis. Journal of clinical periodontology, 47 Suppl 22, 125–143. 3. Bosma, M.L., McGuire, J.A., DelSasso, A. et al. Efficacy of flossing and mouth rinsing regimens on plaque and gingivitis: a randomized clinical trial. BMC Oral Health 24, 178 (2024). https://doi.org/10.1186/s12903-024-03924-4 Always read and follow the label. © Kenvue Canada Inc. 2025
Dr. Bruce Ward president@cda-adc.ca Relationships Matter In April, when I retired after practising dentistry for 49 years, it felt bittersweet. I knew it was time, but I worried that I’d miss my patients and staff. I’d been caring for some families for four generations. As my last day neared, I realized that I wasn’t going to see them regularly anymore. Among my team, I’ve been working with my receptionist, Kim, and dental assistant, Debbie, for nearly my whole career. They’ve made my working days smooth, effective and enjoyable for nearly 45 years. More than colleagues, they became good friends. And just because I’m retired doesn’t mean I’ll lose touch with them; in fact, we all had dinner last month. It means something to work closely with people for a long time. You get to know them so well that you work together seamlessly. You trust and rely on their knowledge, technical skills and instincts. Not only do you know their character, but you also care about their well-being. Work relationships are significant. The people you see every day at the office have considerable influence on the quality of your career and your life. Putting effort into building strong relationships with my staff also contributed to the high quality of care we provided for patients. In 2018, a national survey undertaken by the Canadian Dental Assistants’ Association, the Canadian Dental Hygienists Association and CDA revealed that one of the main reasons staff leave a dental office is because of an unpleasant work environment. I’ve always tried to do my best to make my dental office a comfortable and enjoyable place to work. At my practice in Coquitlam, BC, we’d do communication exercises as a group of 26 staff members. We’d have weekly staff meetings and talk about any problems that people were experiencing interpersonally so we could try to solve them together. I worked hard to listen and to understand other staff members’ points of view. Over the years, I’ve learned that for a staff member to trust me, they need to know that I have their back, that I will support them even if they make a mistake. We’re all human— even me—and we don’t always do things perfectly. But supporting a person to address a situation ethically and improving the overall systems in the office to make sure they’re designed correctly to prevent errors allows our colleagues to grow while respecting our shared humanity. I believe that it’s the responsibility of dentists to create a culture of respect and build an office environment that people want to work in. This environment carries over to both staff and patients. My patients appreciated that whenever they came into the office, they’d see the familiar faces of long-time staff. When you think about it from the patient perspective, a dental office is often highly charged emotionally. Patients sometimes arrive in pain and are often nervous or worried. How much better must they feel when the emotional tenor of their care providers is one of harmonious calm? Yet, we don’t learn how to manage people and create a work culture in dental school. These are skills that we must build on our own, over time. If I’ve learned one thing from my career, it is that relationships matter and nurturing and tending to them is one of our most important tasks. After my last day in April, the new practice owner asked me if I could cover for a dentist on leave. I’m actually happy to be able to go back occasionally because I’ll get to see friends, patients and colleagues that I’ve had the privilege to know for such a long time. From the President 7 Issue 3 | 2025 | CDA at Work
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Dr. Bruce Ward New CDA President Dr. Bruce Ward grew up in Granby, Quebec, an hour east of Montreal, in the Eastern Townships. The oldest of four brothers, he graduated top of his class from a small English-language high school. At age 16, he began studying botany at McGill University. “I have three younger brothers. Brian is a Rhodes Scholar who became an immunologist, Gary is a professor of cell biology at the University of Vermont, and Glen is a pediatrician who also lives in BC, so I get to see him often, which is nice because I left for university when he was 7 years old,” says Dr. Ward. After three years at university, Dr. Ward applied to dental school at McGill. “My mother was surprised because I’d always disliked going to the dentist as a child. But I think this can be attributed in part to our childhood dentist never using anesthetic,” he says. Once his dental education began, Dr. Ward found that he liked it. Dental career When he graduated from dental school at 24, Dr. Ward moved to Bermuda for his first dental practice experience. “I flew from Montreal to Bermuda in February,” he says. “I remember the warmth and fragrance of the air when I got off the plane and how it just felt like the right place to be.” His dental assistant was 19 and the receptionist was 21. “We were all just a bunch of kids really,” Dr. Ward says. After six months, the financial arrangement that he had with the practice owners proved unsustainable. Luckily, before he left Bermuda, he had the good fortune to meet his wife, Karin. “She happened to be on vacation from her home in New Jersey,” he says. The two married in 1978. (L. to r.): The Ward brothers. Dr. Brian Ward, Dr. Gary Ward, Dr. Bruce Ward and Dr. Glen Ward. 9 Issue 3 | 2025 |
In 1977, Dr. Ward moved to British Columbia and worked as an associate for almost a decade in North Vancouver. “I learned a lot from the principal dentist, Dr. George Sakata,” he says. “It was the best associateship I could’ve hoped for.” Then, along with two classmates from dental school, Dr. Rod Clarance and Dr. Scott Stewart, he purchased a practice in Coquitlam, BC, where he would work for 30 years. In 2008, he decided to shift to part-time hours at a practice close to his home in West Vancouver so that he could put more energy into volunteering, teaching and organized dentistry. This past April, Dr. Ward retired after 49 years of continuous practise. “When I officially retired last week, two of my staff had been with me for close to 45 years, almost since I started,” he says. “One of the things that I’m proudest of is my staff and how they stuck with me through thick and thin.” Dr. Ward says that every day of his career in clinical practice, he’d commute to work feeling nervous. “I always felt a little bit of trepidation about trying to meet whatever challenge presented itself chairside with both compassion and technical excellence,” he says. “I care a lot about doing a good job and about my patients and staff. So, there was always some stress to make sure that I met expectations.” However, working with students at the University of British Columbia (UBC) and his roles in organized dentistry don’t cause the same jittery nerves. “That stuff is just fun, in comparison,” he says. Organized dentistry In the early 1980s, Dr. Ward joined the ethics committee of College of Dental Surgeons of British Columbia. “Then I just kept saying ‘yes’ to everything they asked,” he says. In the years that followed, he served on committees and task forces for the college and then for the British Columbia Dental Association (BCDA). He served as president of BCDA for its 2010-11 term. For 10 years, Dr. Ward made presentations at elementary schools about oral health and dental hygiene. “I would use a puppet called Squirt. It had a big set of plastic human-like teeth, and I’d ask a volunteer to brush Squirt’s teeth,” he says. “There was a nozzle in the puppet’s mouth attached to squeeze bottle of water and I’d squirt the volunteer and then all the other kids would want to come up to take a turn as well.” In 2012, Dr. Ward became chair of the BCDA Dental Mentorship Program. “It’s difficult to design a mentorship program that’s effective in initiating long-term relationships where people feel they can actively ask their busy mentors or their mentees for their time and energy,” he says. BCDA’s program provides a list of mentors on its website and a dentist who wants a mentor, no matter what stage in their career they are in, can request a mentor that has expertise or experience that interests them. “Our mentorship program is self-motivated and made up of virtual or in-person meetings organized by the two people. It’s a great way for people to learn about our professional culture,” he says. Dr. Ward has several casual mentees who are internationally trained dentists that he met through Vancouver’s Eastside Dental Clinic where he volunteers. “They would spend time at the clinic, learning how we did things,” he says. “Now they’ve been practising for almost 10 years, but they still call when they have questions or concerns.” Usually, the questions aren’t about the technical part of dentistry, he says, but rather about how to build strong relationships with patients and staff. Dr. Ward has run 26 marathons in Canada and abroad. A fishing trip with Dr. Ward and his brothers. Front row: Gary and Glen (with fish). Bruce (l.) and Brian in the back. CDA President 2025–26 10 | 2025 | Issue 3
Dr. Ward credits the principal dentist at his first associateship, Dr. Sakata, as being an early and important mentor. Jocelyn Johnson, the executive director of BCDA before her retirement in 2023 after more than 30 years of service to BC dentists, was a mentor for Dr. Ward in organized dentistry. “I also have trusted colleagues who are specialists who I could call up all the time to ask questions or talk about my concerns related to patients,” he says. “There’s an oral surgeon and an endodontist whose advice has been very valuable over the years. I’d send them an X-ray. Ask if a root canal requires a specialist. Ask if they’d do a biopsy. That kind of advice.” In 2015, Dr. Ward became chair of the organizing group for the Pacific Dental Conference (PDC), the biggest dental meeting in Canada. “I love everything about it. I love the people I work with, putting it on for colleagues, looking for speakers, selling space to exhibitors and handling their issues,” he says. “It’s an incredible opportunity for networking and for building proficiency in new skills. We’ve turned it into the largest dental meeting in the country, and it’s arguably one of the best in North America.” In 2025, the PDC hosted close to 15,000 attendees. Dr. Ward joined the CDA Board of Directors as the BCDA representative in 2017 and was officially installed as CDA president at the AGM in May 2025. Teaching and volunteering For three years in the early 1980s, Dr. Ward taught in the Department of Restorative Dentistry at the UBC dental school. “Though I’ve just retired, I’ve kept my license because I’d like to be a sessional instructor again; I enjoyed it so much,” he says. Since 2012, Dr. Ward has been a lecturer in the UBC Professionalism and Ethics Program and coordinator of the First Year UBC Ethics Scenario Program. “I talk with students about the kind of problems they’ll face and how they might react to them,” he says. “What happens when you break a file in a root canal? What do you do? What do you say to the patient? There are so many things that can happen in dentistry that can be handled ethically and professionally, rather than handled poorly.” Dr. Ward volunteers at the Eastside Dental Clinic, which serves people living in the Downtown Eastside of Vancouver who cannot afford dental care. The neighbourhood is one of the city’s oldest and Canada’s poorest. Services at the clinic are provided by volunteer dentists and support staff. Between 2008 and 2015, Dr. Ward served on the advisory board of the clinic and has volunteered his dental expertise there for almost 20 years. “Before I started there, I was a little anxious about it,” he says. “But very quickly, I realized how gracious the people who live in Eastside are. It’s a vibrant community and the patients we treat are always grateful for our help.” In one of Dr. Ward’s first memories of the clinic, he was at the reception desk when a man came in carrying most of his possessions in a cardboard box. Dr. Ward helped the man fill in the intake form. “He said that he was 39 years old, slept under the Granville Street Bridge and had HIV, HEP B and C, but he felt great except for a toothache,” Dr. Ward says. The man had a carious lesion in his upper left first molar that was under a gold crown. “He wanted to save the tooth if he could, so the dentist on duty that day started a root canal,” he says. Person-centered care, which values a patient’s unique needs and life experience, is an integral part of the clinic. Dr. Ward and his long-serving team members enjoying a staff trip to Seattle, Washington. Bruce and Karin at a vineyard in France.
The clinic is part of the Vancouver Aboriginal Health Society and serves many Indigenous people in the community. “A number of our patients have had traumatic experiences with dentists in Residential Schools,” says Dr. Ward. “At the clinic, we are very intentional about creating a safe space where the patient has agency.” Dr. Ward says that although he’s considered doing international volunteer work, he likes that he can make a difference in the city where he lives. Outside of dentistry Dr. Ward became a long-distance runner in the mid1980s and has run 26 marathons in Canada and abroad. He volunteered at the YMCA of Greater Vancouver Marathon Clinic until 2004. “I led the 8-and-a-halfminute mile group, and we’d run two marathons a year,” he says. “The last one was in France where we ran through 19 of the world’s greatest vineyards. It was a great way to toast the end of my running career.” Every Sunday, Dr. Ward goes hiking in and around Vancouver with a group of regulars. He enjoys spending time with friends, but cherishes his time with Karin and their 3 dogs. “I love living in Vancouver, it is such a beautiful place and a dynamic city,” he says. There is a lecture on professional ethics that Dr. Ward gives to dental students. At the beginning of the session, he asks them to imagine that they’re about to retire. How can they tell if they’ve had a successful career? A big house? A boat? “I tell them if you can retire after 40 years in practice with the respect of three groups—your patients, your staff and your peers—then you probably were a successful dentist,” Dr. Ward says. “It’s like a three-legged stool. If you only have two legs on a stool, it’ll fall over. For me, that’s the measure of an ethical professional. I think it’s a worthy goal for people to have when they first start out, rather than trying to make up for it later on.” Fun Facts • During his years in dental school, Dr. Ward worked as a phlebotomist in Montreal. • For his 50th birthday, Dr. Ward’s staff threw him a surprise party. He does not like surprises. • Dr. Ward and Karin were featured on an episode of the TV show Love it or List it: Vancouver in 2014. • Dr. Ward and Karin have three miniature wire‑haired dachshunds named Karma (17 years old), Doobie (8) and Zippy (4). Bruce (Count Dracula) and his team used to dress up every Halloween. CDA President 2025–26 12 | 2025 | Issue 3
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In March 2025, Statistics Canada released results from the Survey of Oral Health Care Providers, which was Canada’s first national survey of this group, specifically owners or operators of oral health care practices. The survey asked questions about the previous fiscal year between April 1, 2023, and March 31, 2024, and business intentions for the 24 months following the survey. The survey will be conducted every two years. Human Resource Challenges, Wait Times and Plans for the Future Among Oral Health Care Providers Eighty percent of oral health care practices reported having at least one staffing or human resources challenge. Dentist offices were most likely to report having at least one staffing or human resources challenge (82%), followed by independent dental hygienist (71%) and denturist (53%) offices. Difficulty recruiting skilled employees was the most cited human resources challenge with 64% of dentist, 50% of independent dental hygienist and 37% of denturist offices. Three in four oral health care practices (75%) reported facing at least one operational challenge. Administrative, Statistics Canada Data financial, and operational-related reasons (42%) were the most reported operational challenge felt by oral health care providers, particularly among dentist offices (43%). Despite this, almost all (96%) oral health care practices were accepting new patients. Over half (52%) of oral health care practices were able to provide nonemergency dental care appointments for their existing patients from one week to less than one month from the time of booking, while one-quarter (25%) were able to do so in less than one week. Wait times for new patients was very similar. 15 Issue 3 | 2025 |
See the Statistics Canada release here: bit.ly/44oeEsO Among all oral health care practices, 59% planned on maintaining their operation over the 24 months following the survey, 31% indicated they planned on expanding their operation, and 4% indicated they planned to cease or reduce their operation. A higher percentage of independent dental hygienist offices planned to expand their operations over the 24 months following the survey (44%) compared with dentist (32%) or denturist (26%) offices. Among oral health care practices who reported planning to expand their operation, the most common method was to increase their staff (70%). This method of expansion was reported by 80% of independent dental hygienist, 70% of dentist and 67% of denturist offices. Statistics Canada says that the survey results will help evaluate the impact of the Canadian Dental Care Plan on the oral health system and the delivery of oral health services in Canada. According to Statistics Canada information about the survey, its results are “crucial in helping governments devise policies that support access to dental care, improve oral health outcomes for Canadians, and provide a safe and efficient work environment for oral health care workers.” 16 | 2025 | Issue 3
DENTAL DIGEST In February 2025, the Canadian Institute for Health Information (CIHI) released new data about the health workforce in Canada that included supply and demographic data about more than 30 different groups of health care professionals. Some notable findings are that the supply of dental assistants fell by 1.4% between 2022 and 2023, although CIHI says that because the profession is unregulated in some provinces, the count is not as reliable as other professions. Women represented more than 75% of selected health care professionals in Canada in 2023, including dental assistants (98% female) and dental hygienists (96% female). Dentists were 56% male. “Good data about the oral health professions is an important step in planning a robust and sustainable workforce for the future,” says Costa Papadopoulos, CDA’s principal health policy advisor. “These numbers also help National Numbers: Oral Health Workforce us substantiate trends that we have been observing in other workforce information.” See: bit.ly/42PRavx Canadian dentistry is shaped by internal and external factors such as the economy, workforce, legislation and technology. CDA’s 2024 Environmental Scan for Dentists reviews pressures and opportunities, covering social and political trends, legislative changes and data to guide future decisions. This resource is available at the link below and through your provincial and territorial dental associations (PTDAs). CDA Environmental Scan for Dentists NDEB Video Library The National Dental Examining Board of Canada (NDEB) launched a collection of short videos to provide candidates with information and guidance about how to navigate its exam and certification processes. The new video library features four main themes: Exam Orientation, 90 Seconds to a Better Experience, How to Apply and Information Sessions. Created by an Act of Parliament, NDEB has been given the mandate to establish a single national standard for general dentists in Canada and to develop and administer examinations to confirm individuals who apply for registration as dentists have met the national standard. See: bit.ly/4jG0qYY See: ndeb-bned.ca/video-library 17 Issue 3 | 2025 |
DENTAL DIGEST Dr. Leigha Rock Dr. Anil Kishen Dr. Anil Kishen was appointed dean of the University of Toronto’s (U of T) faculty of dentistry as of July 1, 2025, for a five-year term. Dr. Kishen is an associate scientist in the department of dentistry at Mount Sinai Hospital and associate dean of graduate education at U of T. He is an expert in oral microbiology and immunology, with research areas focused on bioactive nanobiomaterials and phototherapeutics to fight oral infections. “I am tremendously honoured to be appointed dean of the faculty of dentistry,” said Dr. Kishen, who joined U of T in 2009 and holds the Dr. Lloyd and Mrs. Kay Chapman Chair in Clinical Sciences and a Canada Research Chair in Oral Health Nanomedicine. “It is a privilege to have the opportunity to lead such an exceptional community of faculty, students and staff in advancing dentistry scholarship, practice and community engagement.” Dr. Kishen has received many awards including the National Dental Research Award from the Canadian Association for Dental Research (CADR) and the Association of the Canadian New Dean of U of T Faculty of Dentistry Faculties of Dentistry (ACFD), the WW Wood Award from ACFD and the Louis I Grossman Award from the American Association of Endodontics (AAE). Dr. Kishen is also a pastpresident of CADR and contributed to the development of Canada’s first-ever National Oral Health Research Strategy. See: bit.ly/4krLcGT Dr. Leigha Rock was inducted as president of the Canadian Association for Dental Research (CADR) for a 2-year term, during the annual meeting of the American Association for Dental, Oral, and Craniofacial Research (AADOCR) in New York. Dr. Rock is currently director of the School of Dental Hygiene at Dalhousie University and is the first dental hygienist to become CADR president in the organization’s history. In her new role with CADR, Dr. Rock says she is committed to fostering an environment of inclusivity, collaboration and innovation. “Together, we will ensure that our research is not only advancing knowledge but also making a tangible difference in people’s lives,” she said in a speech delivered at the AADOCR event in March 2025. Dr. Rock was also co-chair, with Dr. Paul Allison of McGill University, of the 2024 National Oral Health Research Strategy (NOHRS), officially launched at the Canadian Oral Health Summit in Halifax, Nova Scotia, in June 2024. The NOHRS is intended to galvanize the oral health community into action Dr. Leigha Rock is New CADR President See: cihr-irsc.gc.ca/e/52773.html to build up the sector’s research workforce and infrastructure, and to generate new knowledge to help improve the oral health of people living in Canada. 18 | 2025 | Issue 3
The federal government announced the next phase of the Canadian Dental Care Plan (CDCP), expanding eligibility to uninsured Canadians aged 18 to 64. Applications opened throughout May 2025, with coverage beginning June 1, 2025. Eligibility opened by age groups: May 1 (age 55 to 64), May 15 (age 18 to 34) and May 29 (age 35 to 54). This expansion is an important milestone for oral health in Canada, as it will allow many uninsured Canadians to access dental care. However, CDA is concerned about the accelerated timeline, given its original recommendation of a phased 10-month rollout to help dental offices manage increased patient demand. With many regions already facing workforce shortages (particularly in rural and remote areas) a rapid influx of new patients may create further strain on dental offices. CDCP Expansion See: bit.ly/4jcnIox CDA will continue to engage with the federal government to advocate for sustainable access to oral health care. Heated water Wireless foot control Two-joint head rest The most digitally advanced chair in its class! 36-month lease-to-own at 0% interest 5-year parts warranty 3-year service warranty www.hiossenimplantcanada.ca info@hiossen.ca 1.855.912.1112
Dr. Susan Sutherland Chief of dentistry at Sunnybrook Health Sciences Centre and president of the Canadian Association of Hospital Dentists. Big Picture: Antibiotics and Antimicrobial Resistance The discovery of penicillin has been called one of the greatest achievements of modern medicine. Antibiotics have saved millions of lives in the past century and extended the average human lifespan by 23 years.1 Not only do antibiotics cure infectious diseases, but they have also made many life-saving medical procedures possible, including cancer treatments, caesarean sections, organ transplants and open-heart surgery. But with the prevalent use of antibiotics, disease-causing bacteria have evolved to become resistant to them. They are no longer as effective at treating infections. Antimicrobial resistance is increasing worldwide and threatens to undo the progress of the last 100 years. The Golden Era In 1928, Scottish bacteriologist Alexander Fleming’s plates of Staphylococci were exposed to the air during laboratory work and contaminated by a mold. The bacteria began to die. When he tested the same mold in cultures of Meningococcus and Diphtheria bacillus, he observed the same effect. Fleming hypothesized that the mold excreted a compound that inhibited the bacteria, and, in 1929, he was able to isolate the active molecule and named it “penicillin,” the first antibiotic. In 1945, penicillin became widespread as a treatment for bacterial infections, first among soldiers and then the public. Penicillin’s effectiveness and limited side effects in humans ushered in a new era of biomedical research and discovery, during which new classes of antibiotics were found in soil bacteria, fungi and other natural sources. More than 150 antibiotics and 20 classes have been discovered since penicillin, but no new classes have been found for nearly the last 40 years. 20 | 2025 | Issue 3
Staphylococcus aureus, a type of spherical gram-positive bacteria. French microbiologist René Dubos isolated tyrothricin, a mixture of gramicidin D and tyrocidine, from the soil bacteria Bacillus brevis, which effectively inhibited a whole class of bacteria. It is toxic to humans if ingested, so can only be used topically. In the 1940s, American microbiologist Selman Waksman conducted a systematic study of the antimicrobial behaviour of soil bacteria, especially Streptomyces spp. He created a framework to showcase bacterial species with antagonistic relationships and, using it, discovered 15 major antibiotics and antifungals, including actinomycin, neomycin and streptomycin, which was the first effective treatment for tuberculosis. resistance became endemic in the U.S., reaching 29% of hospitalized S. aureus-infected patients. Strains of S. pneumoniae also became resistant to penicillin in 1967. Between 1979 and 1999, the percentage of cases associated with antibiotic-resistant pneumococcus tripled.2 In 1976, penicillinase-producing gonococci were found in England and the U.S. During the 10-year period after the first introduction of penicillin to treat gonorrhea, the prevalence of penicillin-resistant strains reached its peak.3 In 1983, an outbreak of gonorrhea in North Carolina proved to be caused by a bacterial strain that didn’t respond to penicillin because of a mutation not related to penicillinase. These events led to the prohibition of penicillin as the first-line drug for gonococcus treatment. The patterns of other antibiotics were similar: drugs that were effective became less effective with use. Streptomycin was an effective treatment for tuberculosis for a few years, but then a combination of antibiotics was required. Researchers sought to understand how resistance developed and whether the antibiotics themselves played a role in their declining efficacy. Using methods like Waksman’s, several pharmaceutical firms began to use rational screens for the development of new molecules using knowledge of antibiotics’ mechanisms of action. Several new antibiotic groups were found: tetracyclines in 1948, macrolides in 1952, nitrofuran in 1953, quinolones in 1960, and oxazolidinones in 1987. More than 150 antibiotics and 20 classes have been discovered since penicillin, but no new classes have been found for nearly the last 40 years. Antimicrobial resistance The first signs of antimicrobial resistance to penicillin were documented before the antibiotic was widely released. In 1940, two scientists reported that an E. coli strain was able to deactivate penicillin by releasing an enzyme called penicillinase that breaks it down. By 1942, four Staphylococcus aureus strains were found to be resistant to penicillin in hospitalized patients. During the next few years, the proportion of infections caused by penicillin-resistant S. aureus rose, spreading from hospitals to communities. By the late 1960s, more than 80% of all strains of S. aureus were penicillin resistant. Thankfully, a semisynthetic antibiotic called methicillin, the first penicillinaseresistant penicillin, was released around that time. The respite was short lived; about 20 years later, methicillin 21 Issue 3 | 2025 | Issues and People
geneticist, demonstrated that antibacterial resistance arose spontaneously in bacterial cultures due to random genetic mutations, which occurs quickly in bacteria. The mutations were not a direct result of antibiotic exposure per se, but exposure to antibiotics allowed the mutated resistant bacteria to outcompete the bacteria susceptible to antibiotics. Antimicrobial resistance was an unavoidable consequence of the nature of microbes themselves. But several factors increased the speed of antimicrobial resistance. The quick development of several types of antibiotics within a brief period resulted in a general overuse in humans. In industrial farming, antibiotics were used prophylactically in livestock to increase growth rates and prevent illness. Early research seemed to demonstrate the potential for resistant bacteria to spread from livestock to humans, yet the use of clinically important antibiotics in agriculture persists. Since the 1970s, antibiotic research has stalled, and the pipeline of new antibiotics has gone dry, with very few in clinical trials. Why has antibiotic research stalled? Only 5 of the 20 pharmaceutical firms that participated in antibiotic exploration in the 1980s are still active in the field.4 Most large pharmaceutical companies have abandoned antibiotic discovery, and this responsibility has since been taken up by smaller firms, universities, start-ups, and biotechnology companies. But what is the reason for this shift? As death rates from cancer and heart disease rose and those from infectious diseases fell, there were slimmer economic margins for developing new antibiotics. The rate of discovery of new antibiotics slowed, and those few specialized drugs that were developed to overcome antimicrobial resistance were expensive to use. The latest antimicrobials are often only available in high-income countries, while low- and Resistant bacterial infections kill an estimated 1.27 million people every year across the globe. In 2018, about 1 million bacterial infections were reported in Canada, a quarter of which were resistant to first-line antibiotics. Antibiotics are a type of antimicrobial, which is a broader term that includes a variety of drugs that treat infections caused by microbes. Antibiotics are used to treats bacterial infections, while other antimicrobials are used to treat infections caused by viruses, fungi, and parasites. An antibiotic class is a group of antibiotics that share similar chemical structures and properties. Antibiotics can be categorized by chemical structure, mechanism of action, or spectrum of activity. First-line treatment for a given disease is the one that most prescribers will give to previously untreated patients, usually due to a combination of high effectiveness and low comparative risk. If that therapy is ineffective, prescribers will move on to a second-line treatment. What causes antimicrobial resistance? Microbes are living organisms that adapt over time. Like all living things, they replicate, survive, and spread as rapidly as possible. Microbes adjust to their surroundings and evolve to continue their existence. Waksman defined an antibiotic as “a compound made by a microbe to destroy other microbes.” Louis Pasteur, the French chemist and pharmacist who discovered the principles of vaccination, microbial fermentation, and his namesake pasteurization process, proposed that microbes could secrete material to kill other bacteria, back in the 19th century. Microbes co-exist in every environment on earth and compete for resources. Sometimes they create symbiotic relationships with other microbes. Other times, they seek to destroy each other using enzymes or chemicals. Scientists like Waksman found ways to use these compounds to the advantage of humans. Researchers sought to understand how resistance developed and whether antibiotics themselves played a role in their declining efficacy. In the years just after WWII, Milislav Demerec, a Croation-American 22 | 2025 | Issue 3 Issues and People
middle-income countries bear the heaviest burden of deaths from infectious disease. What about Canada? Resistant bacterial infections kill an estimated 1.27 million people every year across the globe. In 2018, about 1 million bacterial infections were reported in Canada, a quarter of which were resistant to first-line antibiotics.5 Resistant infections were directly responsible for about 5,400 deaths in Canada at a cost to the health care system of more than $2 billion, according to a Council for Canadian Academies (CCA) report from 2019 called When Antibiotics Fail. The report explains that in a world where antibiotics are less effective, everyone will be at greater risk of illness and death from infectious diseases. By 2050, if resistance to all first-line antimicrobials reaches 40%, a scenario the report considers highly plausible, 13,700 people in Canada would die each year from resistant bacterial infections, and cumulatively Canada’s population decline would reach almost 400,000 by 2050. Role of dentistry Historically, dentists have prescribed antibiotics for tooth pain. However, this practise is not supported by evidence because most tooth pain cases could be better managed with a dental procedure and/or pain medication.6 In 2022, dentists accounted for almost 10% of all antibiotic prescriptions in Canada. There is an opportunity for dentistry to contribute to the fight against antimicrobial resistance. “Antibiotics are very important drugs in dentistry,” says Dr. Susan Sutherland, chief of dentistry at Sunnybrook Health Sciences Centre and president of the Canadian Association of Hospital Dentists. “We really need them, and we really need them to work when there are patients that have infections.” She acknowledges that dental infections were a leading cause of death a few centuries ago. “But research has shown that up to 80% of antibiotics prescribed by dentists may be unnecessary,” says Dr. Sutherland. Choosing Wisely Canada, an organization that advocates for reducing unnecessary tests and treatments, recommends that dentists don’t prescribe antibiotics for toothaches or a localized dental abscess. Toothaches occur when the dental pulp is damaged due to decay, trauma, or large fillings. The How to Influence Antibiotic Use in Dentistry Overuse of antibiotics is rarely addressed publicly or scientifically in dentistry, in contrast to general medicine.1 Reasons cited by dentists for prescribing antibiotics is a desire to avoid clinical complications, the fear of losing patients and perceived patient pressure. “Prescribers of antimicrobial drugs have dual, somewhat contradictory responsibilities,” according to an article in Virulence.2 “On the one hand they want to offer optimal therapy for the individual patient under their care; on the other hand, they have a responsibility to the same and other patients in the future and to public health to preserve the efficacy of antibiotics and minimize the development of resistance.” The authors suggest that antimicrobial resistance and appropriate antibiotic use should be included at every level of education for prescribers. A small study in the US showed that after training in antibiotic stewardship by infectious diseases experts, dentists optimized their antibiotic prescribing.3 A Canadian study of antibiotic prescribing for respiratory tract infections and urinary tract infections found that educational intervention with prescribers was fairly effective and suggests CE courses in antibiotic stewardship would be helpful for all prescribers.4 References 1. Löffler C, Böhmer F. The effect of interventions aiming to optimise the prescription of antibiotics in dental care—A systematic review. PLoS ONE. 2017. 12(11): e0188061. 2. Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices. Virulence. 2013 Feb 15;4(2):192-202. 3. Goff DA, Mangino JE, Trolli E, Scheetz R, Goff D. Private Practice Dentists Improve Antibiotic Use After Dental Antibiotic Stewardship Education From Infectious Diseases Experts. Open Forum Infect Dis. 2022 Jul 25;9(8):ofac361. 4. Leis JA, Born KB, Ostrow O, Moser A, Grill A. Prescriber-led practice changes that can bolster antimicrobial stewardship in community health care settings. Can Commun Dis Rep. 2020 Jan 2;46(1):1-5. 23 Issue 3 | 2025 | Issues and People
dentists. As a profession that champions human health and relies on having antibiotics that work, I have great confidence that dentistry will do its part to combat this problem,” she says. What does the future hold? Changing how antibiotics are used and prescribed will help slow antimicrobial resistance. Preventing the spread of infectious disease will, too. New antibiotics need to be discovered or created; bacteria will continue to evolve to protect themselves from both old and new antibiotics. Researchers believe that only a very small percentage of soil bacteria have been sampled and suggest that bacteria in the marine environment are mostly unknown to science. In 2003, the marine bacteria genus Salinospora proved to have many medically useful natural products, including one that became a drug to treat glioblastoma. Many bacteria are difficult to culture in lab settings. But new approaches have succeeded in growing previously hard-to-culture bacteria. New tools such as CRISPR/Cas9mediated genome editing, a precise method of altering DNA that is used in many areas of research and medicine, are available to exploit new discoveries in nature. In the CCA report When Antibiotics Fail, its expert panel concluded that “the most effective approach to addressing antimicrobial resistance is globally coordinated, multifaceted, and combines elements of four mitigation strategies—surveillance, infection prevention and control, stewardship, and research and innovation.” The CCA report also says that Canada is “in the middle of the pack” among high-income countries when it comes to antibiotic use, antibiotic efficacy, and mitigation efforts. “Modeling suggests an alarming future if we do not aggressively address antimicrobial resistance,” says Dr. Sutherland. “It is incredibly important work and there is still a lot of work to be done.” intense pain is caused by inflammation of the dental pulp and the tissue surrounding the root, not by bacterial infection. Thus, antibiotics aren’t useful. In the case of an acute dental abscess (a localized infection that occurs due to an untreated infection of the dental pulp) root canal therapy or extraction of the tooth, along with drainage of the abscess, is required to remove the infected tissue. Antibiotics are of no additional benefit, unless the patient also has systemic complications, such as fever, lymph node involvement, or a spreading infection. In such cases of spreading infection, source control to remove the cause of the infection is key, with antibiotics used as an adjunct to treatment. “There have been great efforts in medicine to reduce antibiotic overuse, and we’ve seen about a 25% decrease in the past five years or so,” says Dr. Sutherland. “Using antibiotics as judiciously as possible so that they continue to work when we really need them requires a culture shift. Some patients just expect them from their doctors and References: 1. Hutchings MI, Truman AW, Wilkinson B. Antibiotics: past, present and future. Curr Opin Microbiol. 2019 Oct:51:72-80. 2. Lobanovska M, Pilla G. Penicillin’s Discovery and Antibiotic Resistance: Lessons for the Future? Yale J Biol Med. 2017 Mar 29;90(1):135-45. 3. Uddin TM, Chakraborty AJ, Khusro A, Redwan BM, Zidan M, et al. Antibiotic resistance in microbes: History, mechanisms, therapeutic strategies and future prospects. J Infect Public Health. 2021 Dec;14(12):1750-66. 4. Hunt D, Kates OS. A Brief History of Antimicrobial Resistance. AMA J Ethics. 2024; 26(5): E408-17. 5. The Canadian Council of Academies. When Antibiotics Fail: The Expert Panel on the Potential Socio-Economic Impacts of Antimicrobial Resistance in Canada, 2019. Available: https://cca-reports.ca/reports/the-potential-socio-economic-impacts-of-antimicrobial-resistance-in-canada/ 6. Suda KJ, Calip GS, Zhou J, Rowan S, Gross AE, et al. Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015. JAMA Netw Open. 2019;2(5):e193909. Watch a CDA Oasis conversation with Dr. Sutherland about antimicrobial resistance: bit.ly/40Vdymm Taking the Bite Out of Tooth Pain A toolkit on using antibiotics wisely for managing tooth pain in adults Choosing Wisely Canada created a toolkit for dentistry reviewed and supported by the Canadian Dental Association, the Canadian Association of Hospital Dentists, and the Royal College of Dental Surgeons of Ontario. Access the toolkit at: bit.ly/3FeDMbl 24 | 2025 | Issue 3 Issues and People
Protect Your Livelihood Disability Insurance Created Exclusively for Dentists 1 in 4 Dentists who become disabled are unable to practice dentistry for two years or longer.* With CDSPI DisabilityGuard™ insurance you get: 4 Non-Cancellable Coverage and Guaranteed Rates Lock in rates until age 65, with guaranteed coverage until age 75. 4 Own Occupation Coverage Receive full benefits even if you transition to a new career due to disability. CDSPI is a not-for-profit created by dentists for dentists. Over 5,000 Canadian dentists and dental students trust us for their disability protection. Let’s get started – call 1.800.561.9401 or visit cdspi.com/disability. DisabilityGuard™ Insurance is underwritten by The Manufacturers Life Insurance Company (Manulife) PO Box 670, Stn Waterloo, Waterloo, ON N2J 4B8.A full description of DisabilityGuard™ coverage and eligibility, including restrictions and limitations is contained in the certificate booklet, which sets out all the coverage terms and conditions. * Manulife claims data on file. A Benefit of Membership
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