2024 • Volume 11 • Issue 1 The Canadian Dental Association Magazine PM40064661 Exploring the Oral Microbiome Page 24 + IN THIS ISSUE Canadian Dental Care Plan Update P. 9 Pediatric Pain Management P. 18 Trauma-Informed Care P. 30
CDAMissionStatement The Canadian Dental Association (CDA) is the national voice for dentistry dedicated to the promotion of optimal oral health, an essential component of general health, and to the advancement and leadership of a unified profession. 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. 2024 • Volume 11 • Issue 1 Head of Communications Zelda Burt Managing Editor Sean McNamara Writer/Editor Sierra Bellows Gabriel Fulcher Pauline Mérindol Publications & Electronic Media Associate Rachel Galipeau Graphic Designer Carlos Castro Advertising: All matters pertaining to advertising should be directed to: Peter Greenhough Media Partners Inc. 15 Wade Road Ancaster, ON L9G 4G1 Display or web advertising: Peter Greenhough pgreenhough@pgmpi.ca 647-955-0060, ext. 101 Classified advertising: John Reid jreid@pgmpi.ca 647-955-0060, ext. 102 Contact: Rachel Galipeau rgalipeau@cda-adc.ca Call CDA for information and assistance toll-free (Canada) at: 1-800-267-6354 Outside Canada: 613-523-1770 CDA email: publications@cda-adc.ca @CdnDentalAssoc canadian-dentalassociation CanadianDental 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 at 1815 Alta Vista Drive, Ottawa, ON K1G 3Y6. Postage paid at Ottawa, ON. Notice of change of address should be sent to CDA: reception@cda-adc.ca ISSN 2292-7360 (Print) ISSN 2292-7379 (Online) © Canadian Dental Association 2024 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. CDABoardofDirectors President Dr. Heather Carr Dr. Raymon Grewal British Columbia Dr. Brian Baker Saskatchewan President-Elect Dr. Joel Antel Vice-President Dr. Bruce Ward Dr. Dana Coles Prince Edward Island Dr. Jerrold Diamond Alberta Dr. Mélissa Gagnon-Grenier NWT/Nunavut/Yukon Dr. Lesli Hapak Ontario Dr. Stuart MacDonald Nova Scotia Dr. Marc Mollot Manitoba Dr. Jason Noel Newfoundland/Labrador Dr. Kirk Preston New Brunswick Cover Photo Courtesy of Dr. Jessica Mark Welch 3 Issue 1 | 2024 |
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Contents The Canadian Dental Association Magazine 2024 • Volume 11 • Issue 1 9 18 22 30 CDA atWork 7 Fighting for the Future of Dentistry in Canada 9 Update on the Canadian Dental Care Plan News and Events 13 A Lift to Accessibility 15 Dental Digest 18 Pain Management in Pediatric Patients Issues and People 20 Communication Skills for Behaviour Change 22 Increase in Oropharyngeal Cancers 24 A Brief History of the Oral Microbiome Classifieds 35 Offices and Practices, Positions Available, Miscellaneous, Advertisers’ Index Supporting Your Practice 30 Trauma-Informed Care in the Dental Office 33 Change is Inevitable, Growth is Optional Obituaries 38 Dr. Timothy Gould 5 Issue 1 | 2024 |
EVERY SHADE. ONE CHOICE.
Dr. Heather Carr president@cda-adc.ca Fighting for the Future of Dentistry inCanada In December, I attended the announcement of the roll-out of the Canadian Dental Care Program (CDCP) in Ottawa. At the event, Health Minister Mark Holland pledged that the CDCP would be fair to dentists. While I appreciated his promise, I want to see this reflected in the program details as they are released. CDA was there to represent the dental profession and remind the federal government that this initiative can only be successful if dentists can reasonably provide care for eligible patients. I fielded many questions from the media that day and in the following weeks, and each and every time I expressed our serious concerns with the program’s feasibility. Minister Holland arranged a follow-up meeting with me at my Halifax dental practice in January. It was hoped that a face-to-face discussion could resolve some of the outstanding issues raised by CDA and the united provincial and territorial dental associations (PTDAs). As part of a frank discussion, I explained what dentists need to ensure optimal oral health care for all Canadians, but also the concerns that could prevent dentists from participating in the CDCP. I told him that every dentist I knowwants to treat patients who do not have access to care, BUT not if it jeopardizes the sustainability of dentistry in Canada. I assured the minister that dentists want the CDCP to be a success. Although the federal government has consulted with CDA since the December 2023 announcement, the program was originally developed without incorporating many of CDA’s key recommendations. Their final program design must reflect the advice provided by CDA and the PTDAs to ensure it will help those patients who need it most. As CDA president and a practising dentist, I know it’s critical that the CDCP guarantees patient choice and respects the dentist-patient relationship. We need the CDCP to offer fair terms and reasonable processes. The administrative burden of participation must be easily managed. Over the past year, CDA, the PTDAs and other concerned dentists have been fighting for the future of dentistry in Canada. These efforts aren’t just for our contemporaries, but for new dentists, like my son, who are starting their careers with more educational debt than ever before. We are also working to protect the two-thirds of Canadians who currently receive excellent care and to help patients who need access to treatment from a robust oral health system. The issues continue to evolve rapidly and, at this time, there is still much unknown about the CDCP and how it will function, for patients and dentists. Soon, dentists will be invited by Sun Life, on behalf of the federal government, to participate in the program. Based on the limited CDCP public information, a survey was conducted with a sample of dentists across Canada, excluding Quebec. Nearly half of those surveyed said they needed more details to make an informed decision whether to participate in the CDCP. We heard very clearly from these dentists that to participate in the program, they need seamless connection to existing suggested fee guides, both in terms of procedures and customary fees. Let me share with you the same advice that I will give my son and colleagues about the CDCP as more details are released. Learn as much as possible about the program and encourage your fellow dentists to stay informed about it. Please take the time to carefully consider how participating in the program will affect your patients and practice not just this year, but into the future. There has never been a more critical time to stay informed and involved. From the President 7 Issue 1 | 2024 | CDA atWork
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Update on the Canadian Dental Care Plan The federal government announced a phased roll-out of theCanadianDental CarePlan (CDCP) inDecember 2023. But there are still many details that remain unknown about how the government programwill function. The government says that the CDCP will be reviewed regularly, based on data and evidence, to ensure that it meets the needs of Canadians. CDA remains hopeful that all key recommendations from our February2023PolicyPaper, created incollaborationwith theprovincial and territorial dental associations (PTDAs), are included in the CDCP. CDA will review the program in its entirety when more specifics are clarified in the coming months. Our focus remains that any federally funded dental care program should: z be compatible with a holistic approach to oral health that acknowledges the interconnection between oral health and general health and well-being z promote patient-centred care and a patient’s right to choose their provider z prioritize preventative care z support the delivery of care primarily through the existing network of dental offices, supplemented as needed by public clinics The CDCP should deliver optimal and barrier-free oral health care, and CDA will continue to work towards this end goal for patients and providers. As of late January 2024, the following CDCP details are what we know. What do we know about the CDCP? The federal government announced a phased sign-up process for those eligible for the CDCP, based on age. The government intends to provide coverage for Canadian residents who do not have dental benefits and have an adjusted net household annual income of less than $90,000. The first group eligible to apply for the program are seniors age 87 and older, with other age brackets and groups gradually becoming eligible throughout 2024. Eligible persons with a valid Disability Tax Credit certificate and children under 18 will be able to enrol in the CDCP starting in June 2024. The government hopes to have all remaining eligible Canadian residents able to enrol starting in 2025. The government refers to eligible members of the CDCP as “plan members.” The CDCP is a government dental benefit; it is not a free dental program. The CDCP is not intended to replace existing workplace or private dental benefits. Sun Life is the contracted service provider that will manage the CDCP on behalf of the federal government. Who is eligible? To qualify for the CDCP, patients will need to meet eligibility criteria, including: z have no access to employer/pension-sponsored or private dental insurance z have a net adjusted household annual income under $90,000 z be a Canadian resident z have filed tax returns in the previous year The Canada Revenue Agency (CRA) will now require employers to report on theirT4/T4Awhether their employees and their families had access to dental insurance coverage, including spending and wellness accounts. 9 Issue 1 | 2024 |
What treatments and services are covered? The CDCP will help cover the cost of various preventative oral health care services, as recommended by an oral health provider. Services that could be covered under the CDCP include scaling (cleaning), polishing, sealants and fluoride, as well as: z diagnostic services, including examinations and X-rays z restorative services, including fillings z endodontic services, including root canal treatments z prosthodontic services, including complete and partial removable dentures z periodontal services, including deep scaling z oral surgery services, including extractions Note that some of these services will not be available until later in 2024. How will billing, reimbursement and co-payments function? Some plan members covered by the CDCP will be required to make co-payments. In this case, the government definition of co-payment is the percentage of the government rate that will not be reimbursed by the CDCP, which plan members will pay directly to the oral health provider. Plan members with net adjusted household annual income under $70,000 will be eligible for 100% of the government rate for their CDCP-covered dental care. Plan members whose household income is between $70,000 and $79,999 are entitled to 60% of the government rate. For those between $80,000 and $89,999, the CDCP will reimburse 40% of the government rate. To limit the out-of-pocket expenses for patients, dentists who participate as service providers in the CDCP and provide oral health care services will bill the CDCP directly for reimbursement, rather than having patients seek reimbursement from Sun Life for services covered under the program. Co-payments and any other non-covered costs of care will be paid directly to the dentist by the plan member. The CDCP will only pay for oral health care services covered within the plan at the established CDCP government rates, which have not yet been announced. While Health Canada encourages dentists to bill patients based on the CDCP benefit, dentists can bill their usual and customary fees. Health Canada is advising plan members to confirm the fees with their dentist when booking their appointment. How can dentists participate in the CDCP? In early 2024, oral health providers will be able to participate on a voluntary basis. The government will launch a provider awareness campaign, with the support of Sun Life, that will invite providers to participate. Dentists who are licensed and in good standing to practise in the province or territory where the services will be given will be able to participate in the CDCP. Participation in this program remains voluntary; providers can assess whether the CDCP is right for their practice. Will the CDCP integrate with provincial or territorial dental programs? At this stage, we do not know how the CDCP will work with existing provincial government programs. The federal government has said patients can apply for CDCP if they are eligible, even if they are covered under another government program, and that they will ensure there is no duplication of coverage. Your PTDA can provide more guidance and information about how the CDCP will impact dentists in your community. Look for more details on the CDCP as they are released by the federal government at: www.canada.ca/en/services/ benefits/dental/dental-care-plan 10 | 2024 | Issue 1
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The lift makes dental care easier for patients, but it also makes providing treatment less physically demanding for Dr. Hundal and the other oral health professionals at the practice. A Lift toAccessibility New lift at dental practice helps patients with disabilities access care One of the patients at Dr. Simar Hundal’s practice, TranscenDental in Dartmouth, Nova Scotia, asked about the possibility of a ceiling mounted lift to help move patients from wheelchairs into dental chairs. “I have several patients who I treat in their wheelchairs, and I didn’t realize that there was a better option until my patient suggested it,” Dr. Hundal says. “He can still move from his wheelchair by himself, but he said that in a few years, he won’t be able to.” During a renovation of the clinic, an automatic lift, which cost about $10,000, was installed in one of Dr. Hundal’s patient rooms. It uses an attachable sling to lift a person into the dental chair. “One of my favourite patients used to bring his 90-year-old father, who was fully paralyzed, to me for his oral health care,” says Dr. Hundal. “I’d treat him as best I could in his wheelchair, but it was difficult for all of us. And the son would cry every time. It can be very emotional.” Providing accessible dental care for people with disabilities is important to Dr. Hundal. “My father had paralysis, so I’ve seen firsthand the challenges disability can cause in many spheres of life,” she says. “And it’s so crucial that all people have access to health care. As my patients age, I believe that having aids like this will become increasingly important.” The lift makes dental care easier for patients, but it also makes providing treatment less physically demanding for Dr. Hundal and the other oral health professionals at the practice. “The ergonomics of providing treatment to patients is always best when they are in the dental chair,” says Dr. Hundal. Dr. SimarHundal (left) and dental assistant Carolyn Deschenes (above) shown with the ceilingmounted lift at TranscenDental in Dartmouth, Nova Scotia. 13 Issue 1 | 2024 | News and Events
Join us ‘in-person’ Vancouver, BC Three days of varied and contemporary continuing dental education sessions are offered (something for your whole team) Fantastic line-up of speakers / topics to choose from in open sessions and hands-on courses, as well as the Live Dentistry Stage in the Exhibit Hall Spacious PDC Exhibit Hall with all your favorite exhibiting companies looking forward to connect with you again Lunches & Exhibit Hall Receptions (Thurs/Fri) included in the registration fee Fantastic shopping, beautiful seawall access within blocks of your hotel, and great spring skiing, golfing and cycling pdconf.com Registration and Program information at... Pacific Dental Conference March7-9, 2024 Save these Dates! in conjunction with the Canadian Dental Association Pacific Dental Conference Featured Speakers Jeff Brucia Materials/Restoration Carolyn Stern Communications Theresa Gonzales Forensics/ Pathology Peter Nkansah Dental Emergencies Ernest Lam Radiology Tija Hunter Dental Assisting Fernanda Almeida Alan M. Atlas Dani Botbyl William ‘Bo’ Bruce Mahmoud Ektefaie Derek Salisbury Rodrigo Sanches Cunha Karen Davis Amy Doneen Faraj Edher Chrissy Ford Jeffrey Hoos Nekky Jamal Carlos Quiñonez Mark Lin Brian Nový Giovanni Olivi Michael Wiseman Miles Cone Jeff Coil Bethany Valachi
DENTAL DIGEST The Canada Emergency Business Account (CEBA) program offered interest-free loans to small businesses affected by closures during the COVID-19 pandemic, through financial institutions across Canada. The repayment deadline for eligible CEBA loan holders to qualify for partial loan forgiveness (up to 33%) was extended to January 18, 2024. However, if a CEBA loan remained outstanding after that date, it would convert to a non-amortizing term loan with full principal repayment due by December 31, 2026. CEBA loan holders that submitted a refinancing loan application to their financial institution by January 18, 2024, but require a grace period to finalize the payout of their CEBA loan, may qualify for partial loan forgiveness, if the outstanding principal of their CEBA loan is repaid by March 28, 2024. According to CEBA, if a small business is unable to repay by the deadlines, CEBA will review circumstances on a case-by-case basis and try to establish a payment arrangement or repayment plan tailored to the loan holder’s ability to repay. CEBA Program Loan Repayment Deadlines SmileDirectClub Abruptly Shuts Down On December 8, 2023, the direct-to-consumer (DTC) teeth aligner company SmileDirectClub (SDC) announced it was shutting down its global operations, including in Canada. The sudden closure came a few months after SDC filed for Chapter 11 bankruptcy protection in the US. SDC’s primary business was offering DTC teeth aligners, shipped directly to customers. Existing clients were informed that SDC’s customer support line was no longer available, despite some aligners still needing adjustments or touch-ups. On its website, SDC advised: “If you wish to continue treatment outside of our platform, please consult your treating doctor or your local dentist with any questions around future aligner treatment.” For any SDC clients seeking refunds, the company said it would have more information “once the bankruptcy process determines next steps.” In a December press release, the American Dental Association (ADA) stated: “In light of recent news reports concerning a DTC manufacturer and marketer of teeth aligners, the ADA reaffirms its policy which strongly opposes offers of DTC dentistry because of the potential for irreversible harm to individuals, who are treated as ‘customers’ rather than as patients. The ADA’s primary concern around DTC dentistry has always been patient safety, first and foremost.” Any questions on the specific details of loan forgiveness eligibility, repayment options or refinancing should be directed to the financial institution that provided the CEBA loan. See ceba-cuec.ca or contact the CEBA Call Centre at 1-888-324-4201. Canada Emergency Business Account (CEBA) Repayment Deadlines 15 Issue 1 | 2024 |
toll free, 24/7 Help is available. Thinking of suicide? 9-8-8 A new organization was launched in December 2023 to improve the collection and sharing of health workforce data in Canada. Health Workforce Canada (HWC) will operate as an independent organization with support from the Canadian Institute for Health Information (CIHI). As a stand-alone entity, HWC will work closely with CIHI and other health care system stakeholders to share health workforce data for creating practical solutions and innovative practices. “Health Workforce Canada will help us better understand the root causes of health workforce issues by understanding data gaps and supporting planning efforts for the future,” said the Honourable Mark Holland, Canada’s Minister of Health. The creation of HWC aims to address the current lack of information about Canada’s health workforce. Moving forward, this initiative should improve how such information is collected, used and shared to help with better health workforce planning across the country. A new toll-free, three-digit suicide crisis helpline launched nationwide on November 30, 2023. People having suicidal thoughts or other mental health distress can call or text 988 to reach a trained responder 24 hours a day, 7 days a week, no matter where you live in Canada. The project is funded and overseen by the Public Health Agency of Canada and is being led by the Centre for Addiction and Mental Health (CAMH). In addition to CAMH, the 988 response network will be staffed by partner mental health agencies across Canada, including Kids Help Phone and the Indigenous agency Hope for Wellness. People can access the 988 helpline in English or French, but other languages will be made available through the partner organizations. The 988 helpline expands on the Talk Suicide Canada helpline, which had a toll-free 10-digit number but did not have a 24-hour texting service. According to CAMH, “While the focus of 988 is on suicide prevention, no one who reaches out to the service will be turned away. Whoever you are, wherever you are located in Canada, by calling or texting 988 you can connect with a trained responder who’s ready to listen without judgement.” HealthWorkforce Canada 988 Suicide Crisis Helpline See: 988.ca See: healthworkforce.ca 16 | 2024 | Issue 1
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Pain Management in Pediatric Patients Dr. MarkDonaldson is a clinical professor in the Department of Pharmacy at the University of Montana inMissoula, clinical associate professor in the School of Dentistry at the OregonHealth and Sciences University in Portland, and adjunct professor at the Faculty of Dentistry at the University of British Columbia. Dr. Donaldson currently serves as associate principal pharmacy advisory solutions for Vizient. The American Dental Association (ADA) released a clinical practice guideline for the pharmacological management of acute dental pain in children in September 2023.1 “The prevalence of toothache in children from birth to 5 years is about 28%, but from age 6 through 10, the prevalence almost doubles to 52%,” says Dr. Mark Donaldson. “Clear guidelines for the appropriate management of orofacial pain in this young population were very much needed.” As the opioid abuse epidemic in the general population continues to unfold in both Canada and the US, overprescribing and mis-prescribing of opioids or narcotic-containing analgesics continues to be a threat to public health. 18 | 2024 | Issue 1
Research shows that with an initial 10-day opioid prescription, which can be fairly common amongst health care practitioners, about 1 in 5 patients become a long-term user of opioids.2 “When a patient receives a one-day opioid prescription, the likelihood that they end up using opioids for a year or longer is 6%,” says Dr. Donaldson. “So clearly we need to move away from our dependence on opioids.” Dr. Donaldson says older guidelines recommended opioids for moderate to severe oral pain in children. “The use of these kinds of analgesics for postoperative pain or toothache has been contraindicated since 2017 by the Food and Drug Administration,”3 he says. “A report that same year showed that codeine and tramadol should not be given to children.”4 The recent ADA guideline was sponsored by 31 different governing bodies in dentistry, medicine and pediatrics. It gives recommendations for the pharmacological management of postoperative pain after one or more surgical or simple tooth extractions in children and recommendations for temporary pharmacological management of children’s toothaches. “Acetaminophen is an excellent analgesic,” says Dr. Donaldson. “NSAIDs, nonsteroidal anti‑inflammatory drugs, with ibuprofen as the most ubiquitous, are also outstanding for pain management. The third medication category that is recommended in some circumstances is corticosteroids, like dexamethasone, methylprednisolone and prednisone.” The first line treatment for both postoperative pain and toothache is ibuprofen. The second best is naproxen, though not for children under age 2. For those patients for whom a NSAID is contraindicated, acetaminophen is recommended.1 “Sometimes a combination of ibuprofen and acetaminophen is the best option,” says Dr. Donaldson. “They work on Access the full JADA guideline at: bit.ly/3U4fmGk different pain receptors and appear to have synergistic effects when used together.5” Both ibuprofen and acetaminophen are available in liquid formulations too, so they can be easily administered to children via a medi-cup or oral syringe. Dosing for these medications is weight-based and the new guideline evaluates doses of acetaminophen and NSAIDs that may differ from the dosing printed on overthe-counter packages. “I encourage dentists to read the ADA guideline,” Dr. Donaldson says. “It’s short, to the point, and, most importantly, a nice refresher on the benefits of what you may already be doing.” References 1. Carrasco-Labra A, Polk DE, Urquhart O, Aghaloo T, Claytor JW Jr, Dhar V and others. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children. J Am Dent Assoc. 2023 Sep;154(9):814-825.e2. 2. Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015 CDCWeekly March 17, 2017. 66(10);265–69. 3. FDA drug safety communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. US Food and Drug Administration. April 20, 2017. 4. FDA Drug Safety Podcast: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. US Food and Drug Administration. April 20, 2017. 5. Donaldson M, Goodchild JH. Utilizing synergism to maximize therapeutic effects of postoperative analgesics. Gen Dent. 2023 Jan-Feb;71(1):6–11. Watch a video conversation with Dr. Donaldson on CDA Oasis: bit.ly/3So6qul Sometimes a combination of ibuprofen and acetaminophen is the best option. They work on different pain receptors and appear to have synergistic effects when used together. 19 Issue 1 | 2024 | News and Events
Communication Skills for Behaviour Change Dr. NoraMakansi is an assistant professor at the Faculty of DentalMedicine andOral Health Sciences at McGill University. How many times have you told patients that they should floss more often, but when they return to your dental office, their habits are unchanged? Dr. Nora Makansi says there are ways to talk to your patients about change that could help. “Motivational interviewing is an evidence-based approach to enable people to recognize and articulate reasons for change,” says Dr. Makansi. “By articulating these reasons, they become more motivated to commit to change.” This counseling approach can be helpful in many settings where behaviour change is needed for better health outcomes. Numerous controlled trials have shown that it is an effective approach in smoking cessation, addiction treatment, suicide prevention, vaccine hesitancy and caries prevention. According to Dr. Makansi, it provides a broad framework that enables effective conversations about change, which makes it a useful tool in dentistry. “In health care, the classic approach is to diagnose a problem, then fix it,” Dr. Makansi says. “We have a righting-reflex where we rush to tell the patient what they should do, which doesn’t always work well for behavior change.” Motivational interviewing is a person-centered counseling approach that brings 20 | 2024 | Issue 1
Dedicating time for building rapport with patients through open-ended questions and active listening is crucial. The educational videos on motivational interviewing techniques can be found at: bit.ly/4b5tzsW a patient’s values and experiences into the discussion of change. Instead of relying solely on being directive, a dentist can also take a guiding approach through an exploration of the patient’s feelings, experiences, and readiness for change. “It’s a conversational style that investigates someone’s personal reasons for and resistance to change, which can help them articulate their own motivation and plan for change,” she says. Open-ended questions encourage the patient to do most of the talking, help avoid premature judgments, and keep communication moving forward. Open-ended questions often start with words such as “how,”“what,”“tell me about,” and “describe.” In most cases, you can start with general questions and then get more specific to clarify issues and focus the discussion. Motivational interviewing helps to build a relationship of mutual trust. “We need to trust that our patients have the wisdom to identify what is good for them, while respecting where they are on a continuum of change,” she says. “And our patients soon realize that we are listening to them and understanding who they are and what they value.” In collaborationwithDr.AiméeDawson at Laval University, Dr. Makansi has created an instructional video tool to bring motivational interviewing techniques to the classroom. “The videos show exaggerated versions of different approaches to conversations about behaviour change that students can discuss in class,” she says. “But they could also be helpful refreshers for clinicians and their teams.” Dr. Makansi says that mastering motivational interviewing techniques takes some practice. Dedicating time for building rapport with patients through open-ended questions and active listening is crucial. Diagnostic questions required to fill out the medical chart, while important, should not take precedence over humanizing the patient’s experience. A motivational interviewing approach may seem to take up more time in the beginning, but it eventually pays off as patients become more committed to their self-articulated goals. This not only saves time down the line but also prevents burn out among dentists. Watch the full conversation with Dr. Makansi on CDA Oasis: bit.ly/3O4dauU CORE SKILLS OF MOTIVATIONAL INTERVIEWING Affirmations are used to validate the patient’s feelings, ideas or efforts.They also express appreciation and understanding of both difficulties and strengths in coping with problems. Affirmations promote self-confidence and efficacy for the patient, which are necessary for change. Reflective listening involves careful listening with the goal of understanding the meaning of what the patient says.A reflection can be simply reflecting the patient’s own words back at them or inferring the unspoken meaning of what was said and reflecting it back using new words or phrases. Offering reflections is a way of checking for meaning that demonstrates that you have accurately heard and understood the patient. Summarizing reinforces what has been said, shows that you have been listening carefully, and prepares the patient to move from one idea to the next. Summaries don’t have to be comprehensive; you can select what information to include, minimize, or leave out to best reinforce any conversations about change.You can also add information to help explore a patient’s feelings of ambivalence. 21 Issue 1 | 2024 | Issues and People
Increase in Oropharyngeal Cancers Statistics Canada published a report on cancer rates in Canada for 2020, the first year of the COVID-19 lockdowns. Rates were lower for many commonly diagnosed cancers, but there was a significant increase in oropharyngeal cancers. “Compared to the average rates between 2015 and 2019, it was up 13.9% in 2020,” says Dr. Firoozeh Samim. “And when you look at the last 20 years, rates are up more than 200%, which means that health care practitioners who care for the oral cavity need to be on high alert.” Dr. Firoozeh Samim is a specialist in oral medicine and oral maxillofacial pathology and assistant professor atMcGill’s Faculty of DentalMedicine and Oral Health Sciences. Oropharynx cancers include cancers found in the soft palate, base of tongue, lingual and palatine tonsils, and surrounding tissues. Dr. Samim notes that the lateral border of the tongue is often where she sees ulcers in her patients. According to Dr. Samim, the traditional risk factors of smoking and alcohol have decreased in recent years. “The rise in oropharyngeal cancer has an etiology related to the human papillomavirus (HPV),” she says. “Research shows that about 70% of these cancers are caused by a specific strain called HPV16.”
Dentists have an advantage because with our dental chairs and lights, we can see more of the oral cavity than most other health care professionals. Dentists have an opportunity to educate patients about HPV and to play a role in prevention and early detection of oropharynx cancer. “Because HPV is sexually transmitted, it might be a challenge at first for dentists to have conversations with patients about it,” Dr. Samim says. “I encourage dentists to include sexual activity as part of their medical history questionnaires.” Oral cancers sometimes present with pain, but not always. “Look for ulcers, redness, changes in tissue, tissue that looks different from adjacent tissue. Tissue that has red or white areas is especially concerning,” says Dr. Samim. If patients are experiencing oral pain, joint pain, sore throat, voice change, or difficulty in swallowing, these are all possible symptoms of oropharyngeal cancer. Dr. Samim adds that it is extremely important to examine the lymph nodes as part of a head and neck examination because large lymph nodes are an indicator of late-stage oropharyngeal cancer. “If anything strikes you as unusual, refer your patient to an oral and maxillofacial pathologist or an ear, nose, and throat (ENT) specialist who can do a biopsy,” she says. “Don’t wait. Early detection makes a huge difference.” To date, HPV vaccines have not been proven to prevent oropharyngeal cancer, but Dr. Samim would encourage patients to get HPV vaccines. The Centers for Disease Control and Prevention (CDC) says that the use of barrier contraceptives, such as condoms and dental dams, during oral sex reduces the risk of developing oropharynx cancers. HPV-related oropharyngeal cancer has a bimodal age pattern, occurring most often in young men and men in their 60s. It is more common among white people of high socioeconomic status. “Though a few years ago, we also noticed an increase in oral cancers among women between age 30 and 40, who had no risk factors, so I believe that screening everyone for oropharynx cancer is important,” Dr. Samim says. A comprehensive clinical examination of the oral cavity is an essential screening method. “Dentists have an advantage because with our dental chairs and lights, we can see more of the oral cavity than most other health care professionals,” says Dr. Samim. Watch Dr. Samim’s conversation on CDA Oasis: bit.ly/3SnU45e 23 Issue 1 | 2024 | Issues and People
A Brief History of the Oral Microbiome Dr. JessicaMarkWelch, PhD, is a senior scientist at the ADAForsyth Institute, which is dedicated to advancing oral health through scientific innovation and research. The first observations of bacteria, made by Antoni van Leeuwenhoek though his hand-made microscope in the 1670s, were from plaque scrapings from his teeth. Leeuwenhoek’s discoveries of what he called animalcules revealed an invisible world of living things too small to be detected by the human eye. “He made little drawings of bacteria that we can recognize today,” says Dr. Jessica Mark Welch of the ADA Forsyth Institute. “Microbiologists have been studying bacteria in the mouth since the invention of this field of study.” A community of bacteria from a sample taken from the tongue. Both the structure and the kinds of bacteria found on the tongue are different from those found on teeth. Images courtesy of Dr. Jessica Mark Welch 24 | 2024 | Issue 1
Most of that study has relied on the culture method— samples of microbes are taken in the field and then grown in agar medium in the laboratory. “But only some bacteria will grow in culture medium,” says Dr. Mark Welch. “Which means we’ve been studying a limited set of bacteria.” How limited? Only about one-tenth of 1% of microbes can be cultured using standard methods. In a soil sample that contained 1,000 different kinds of microbes, only one would grow in the lab. “This phenomenon is called the great plate count anomaly,” she says, “because we know there are more bacteria out there than we were able to count on our culture plates.” Dr. Dewhirst’s research these days is focused on how to cultivate the remaining 1/3 so we can have as complete a picture as possible of the oral microbiome.” The Mission Dr. Mark Welch’s research group works to understand the structure and function of bacterial communities in the mouth. They’re studying how different bacteria work together and how they impact human health. “It seems that certain bacteria consistently live next to other kinds of bacteria, that there is a necessary relationship between them, which may explain why some don’t grow in culture,” she says. “Oral bacteria’s natural habitat is in this enormous, complex biofilm, which is a collection of bacteria of all sorts growing together inside a matrix that they make. One kind of bacteria is probably leaking metabolites and chemicals. So, the bacteria next to it knows it can get metabolites from its neighbour, so doesn’t make them itself.” Between the 1970s and early 1990s, researchers began using gene sequencing to identify uncultivatable bacteria. “They used a gene that all organisms have, coding for ribosomal RNA (rRNA),” says Dr. Mark Welch. “Comparing these genes, researchers were able to identify bacteria that they’d never seen before.” Dr. Floyd Dewhirst, a colleague of Dr. Mark Welch at the ADA Forsyth Institute, did pioneering research into the diversity, genetic capability and pathogenic potential of organisms in the mouth. He used 16S rRNA gene sequence information for cultured and as-yet-uncultured oral microbes to identify oral bacteria and place them into a taxonomy, an organized biological classification system. Dr. Dewhirst became the first curator of the Human Oral Microbiome Database, which now includes approximately 700 species of human oral bacteria. “The database includes the rRNA sequence and a name for all the bacteria, so that when you see it, you can recognize it. Once a bacterium has a stable name, you can study it,” says Dr. Mark Welch, who now also curates the database. “About 2/3 of these bacteria are culturable. Oral bacteria’s natural habitat is in this enormous, complex biofilm, which is a collection of bacteria of all sorts growing together inside a matrix that they make. Antoni van Leeuwenhoek made these drawings in the 1670s of the tiny creatures he saw through his microscope when he observed plaque scrapings from teeth. 25 Issue 1 | 2024 | Issues and People
The CLASI-FISH method reveals the bacterial community in dental plaque, which Dr. Mark Welch nicknamed “the hedgehog” because of the clusters of bacterial filaments. The core of the filament structure is composed of Corynebacterium (tagged purple). What kind of communities do oral bacteria live in? In the 1970s, electron microscopy was used to make images of bacteria, including that of dental plaque. “There are beautiful electron micrographs of dental plaque structures that were described as looking like corn cobs, because there were little spherical bacteria called cocci and longer filamentous bacteria that got clumped together,” says Dr. Mark Welch. At the time, researchers could trace channels of liquid through the biofilm, and they noticed that filament rich areas of the biofilm produced more calculus. “Then the inquiry sort of got dropped because they’d done all they could with the limits of electron microscopy. That’s where we came in,” she says. To create useful microscopy images, Dr. Mark Welch and her colleague Dr. Gary Borisy needed different kinds of bacteria to appear as different colours. Since the 1980s, researchers have been using short pieces of synthesized DNA with a fluorescent molecule attached to it to tag bacteria for microscopy. “You drop a short piece of DNA, like 20 bases or so, and it finds the ribosomal RNA it matches and attaches to it and then your bacterium has a fluorescent label,” says Dr. Mark Welch. “A standard fluorescence microscope can see about 3 or 4 different colours at once: red, green, blue, maybe also far red.” As the research team began their work, cell biology was using advanced microscopy imaging that could discriminate between colours with very similar spectra. Drs. Mark Welch and Borisy decided to see what they could discover if they applied this advanced tool to microbial ecology. “With this new tool, we could use up to 16 different fluorescent labels and tell them apart,” says Dr. Mark Welch. “Then we thought: What if we use the different fluorescent labels in combination? Then we could visually differentiate more than a thousand different kinds of bacteria in a single image. Wouldn’t that be cool?” Dr. Dewhirst and his team are using this idea to try to culture formerly unculturable bacteria by growing two kinds of bacteria together that are proximal inside the microbiome. “The idea is that if one bacterium has given up the gene it needs to make the metabolite that its neighbour makes, then they need each other to culture,” says Dr. Mark Welch. Drs. Mark Welch and Borisy’s innovative imaging method revealed that dental plaque has highly organized, complex bacterial structures that they called “hedgehogs.” 26 | 2024 | Issue 1 Issues and People
Corynebacterium (tagged purple) start at the base of the biofilm and grow all the way out. Other bacteria live within the Corynebacterium structure and streptococci (tagged green) live around the outside. The Findings It took about a decade to develop the idea, which became the CLASI-FISH imaging method.1 Dr. Mark Welch takes samples of dental plaque with a toothpick and fixes it, a process of preserving a biological specimen by terminating biochemical reactions so it doesn’t spoil, which kills the bacteria but preserves the spatial structure of the bacterial community. “We apply the fluorescent labels and then we do our fancy microscopy,” she says. bacteria transforms into nitrite. Our bodies can convert nitrite into nitric oxide, which dilates blood vessels and lowers blood pressure. “There have been studies that show that if you use anti-bacterial mouthwash during the time that your body is secreting the nitrate through your saliva, it can kill the bacteria that do this work that our bodies can’t do,” says Dr. Mark Welch. “They come back, of course, but it stymies the process.” When people eat leafy greens and absorb nitrate into the blood stream, the body concentrates the nitrate into saliva ten-fold so it can wash over the oral bacteria before returning to the alimentary canal. Oral microbiologists have known for the past 50 years that different bacteria live in different parts of the mouth. Oral microbiologists have known for the past 50 years that different bacteria live indifferent parts of the mouth. “We’ve known for a long time that if you want to find Strep salivarius , you have to look on the tongue,” says Dr. Mark Welch. Drs. Mark Welch and Borisy’s innovative imaging method revealed that dental plaque has highly organized, complex bacterial structures that they called “hedgehogs” because of the spiny appearance of the structures’ characteristic clusters of bacterial filaments.2 On samples scraped from the tongue, they discovered entirely different, but equally complex, bacterial communities that Dr. Mark Welch calls “bacterial high-rises, little microbial apartment buildings that these bacteria build on your tongue.”3 In the mouth, bacterial communities build enormous, complex structures and each bacterium is most influenced by the bacteria that are closest to it, one or two body lengths away, at most.4 Other bacteria will intercept any nutrients or other chemical from farther away. “Each bacterium is secreting all sorts of stuff into the saliva, and then in turn our bodies secrete stuff into saliva that influences how the bacteria behave,” says Dr. Mark Welch. “We secrete urea in our saliva, for example, which turns into ammonium, which raised the pH, which is good because it discourages the bacteria’s tendency to produce acid that eats away at enamel.” Our bodies also secrete nitrate, a chemical compound common in leafy greens and beets, into saliva, which oral 27 Issue 1 | 2024 | Issues and People
“We’ve known for a long time that if you want to find Strep salivarius, you have to look on the tongue,” says Dr. Mark Welch. With genetic sequencing, methods became more precise, and researchers found that specific bacteria can be found at different sites such as on the tongue, teeth, and gums. “There’s some that only live on the roof of the mouth, for example,” she says. The Hedgehog The standard model for plaque formation, as explained by Drs. Paul Kolenbrander and Robert Palmer, postulates that when people brush their teeth, enamel is clean and barren of microbial life. Within seconds, enamel is coated with salivary pellicle, a glycoprotein, as the mucins in the saliva bind to the enamel. The salivary pellicle has proteins and carbohydrates to which certain bacteria can then bind. “You can think of it as what happens to an ecosystem after a forest fire, where a few plants start to re-colonize the land, then other plants can come in,” says Dr. Mark Welch. “The bacteria that can bind directly to salivary pellicle are the early colonizers and most of those are streptococcus and actinomyces. Then other bacteria bind to the early colonizers and build up in succession.” The standard model suggests that there are early colonizing bacteria, a bridging bacterium called Fusobacterium nucleatum, and then late colonizers that can cause periodontitis. “But what we saw was a different bacterium providing much of the structure,” says Dr. Mark Welch. The hedgehog structure that her images capture has a key bacterium, Corynebacterium, that makes up the core of the enormous bush of filaments. “Corynebacterium seemed to start at the base of the biofilm and grow all the way out to the tips and other bacteria were stuck to its tips,” she says. Fusobacterium nucleatum created an intermediate layer but it didn’t have structural continuity. Other bacteria live within the Corynebacterium structure and streptococci live around the outside. The hedgehog structure seems to be typical. “We saw these hedgehog structures in every person that we sampled more than once,” says Dr. Mark Welch. As well, the bacteria in the hedgehog structure are all intertwined. In plaque samples from healthy people, there are never big clusters of only one kind of bacteria. “They need each other,” she says. “In a healthy mouth, the bacteria live in balance, like in any ecosystem.” The Oral Microbiome in Dental Practice During a dental exam, Dr. Mark Welch was given a ridged plastic tongue scraper and told she had a furry tongue. “Then, of course, I felt compelled to look at what was on the tongue with our microscopy method,” she said. “And we found these amazing structures that are completely different from dental plaque.” On the filiform papillae of the tongue, there is a core of human epithelial cells, then bacteria grow out from them in columns, triangles, and pyramids. There are hypotheses that tongue bacteria may have an influence on the transformation of nitrate. Dr. Gena Tribble has published research that suggests that the microbiome of people who clean their tongues, at least occasionally, are different from those who never do.5 “Tongue cleaning does seem to shift the structure of the microbiome, probably in a positive direction,” says Dr. Mark Welch. There are more than 700 different bacteria in the oral microbiome database, but a sample of bacteria from any one person’s mouth will likely include only about 150 different types. “The general pattern is that we all have pretty much the same species of bacteria,” says Dr. Mark Welch. “And among them, there are some really major players that are almost always there, and each of them makes up like 2% or 5% of the community.” Though people have the same types of bacteria in their mouths, each person has their own strains. “You can tell people apart by their oral microbiomes,” says Dr. Mark Welch. “If I tested everyone at a party, and then tested them a year later, I’d be able to identify who was who by the strains, their abundance, and the proportion of different bacteria. It’s quite stable over time.” Dr. Mark Welch did a study where she sampled the oral bacteria of people who had been married for 10 years or longer. “We didn’t tell the person analyzing our data who Therearemore than700different bacteria in the oral microbiome database, but a sample of bacteria from any one person’s mouth will likely include only about 150 different types. 28 | 2024 | Issue 1 Issues and People
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