Tooth Whitening Then & Now. Focus on Infection Control. Amy Melillo Doing our Profession Proud. A Special Spotlight on June Cook. the.

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1 the Tooth Whitening Then & Now Focus on Infection Control Published by the Ontario Dental Assistants Association Amy Melillo Doing our Profession Proud A Special Spotlight on June Cook the Published by the Ontario Dental Assistants Association f a l l V o l u m e 1 2 i s s u e 3

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3 ODAA Executive President Constance Steinborn HBA, CDAII, CDR President-Elect Wendy Bambridge CDA II Vice President Stephanie Davenport CDA II Executive Director Judy Melville BA Editorial board Editor Judy Melville BA Associate Editor Lana Thistle 5 27 Deadline Date for Journal Submissions December 1, 2005 (Winter 2006 Issue) The opinions expressed in this Journal are those of the writers and do not necessarily reflect those of the Ontario Dental Assistants Association. Publication of a signed editorial or of an article in The Journal does not imply endorsement of its contents by the Ontario Dental Assistants Association, or its agents, or any ODAA member. Information drawn from other published sources is the responsibility of the writers. Subscription information $40.00 Subscription (Canada) $11.00 Single Copy (Canada) $55.00 Subscription (Out of Country) $15.00 Single Copy (Out of Country) Contact ODAA Advertising Inquiries Judy Melville Tel: Ext 25 Fax: Change of Address the Members please be sure to inform ODAA Business Office of any change of name, address or telephone number. Please send us your address as well. Ontario Dental Assistants Association 869 Dundas Street, London ON N5W 2Z8 Tel: Fax: Web: Office Hours: Mon Fri 8:30 am to 4:30 pm Members: Please see the back of your membership card for our toll-free number. Have your certification or member number available when calling the Business Office. The Journal is the official publication of Ontario Dental Assistants Association. The Journal s objective is to promote the advancement of dental assisting and dental reception. 3 President s Message 4 From Judy s Desk 5 Letters to the Editor 6 Regulation Update 7 Meet Amy Melillo CDA II 9 Tooth Whitening Then & Now 15 Focus on Infection Control 17 Frequently Asked Questions 18 Announcements 19 Open Wide. A Campaign for Change in Dental Care 21 Affiliate News 25 A Special Spotlight on June Cook 27 Show your Pride with New Promotional Items 29 Home Study Programs Commercial Publication Mailed Under Agreement No Customer No

4 ODAA President Constance Steinborn, HBA, CDA II, CDR President s Message Hello everyone! Once again our summer has gone by too quickly. I hope all of you enjoyed the hot weather we had! Although summer time is usually a little quieter for ODAA, this year has definitely been the exception. We ve been doing some amazing things since our last Journal publication and we re very excited to share them with you. Project Smile is our code name for the development and launch of the ODAA s brand new professional identity, and this issue of The Journal is the official unveiling of our bold new look! You ll be seeing our new identity on our website, letterhead, membership certificates and pins later this fall. If you had the opportunity to attend our AGM back in April, then you ve already had a sneak preview of some of our promotional items with our new logo. However, if you were unable to attend, then you re in for a treat! See inside for an exciting look at our new jackets, velour vests, gym bags, water bottles and uniforms. All members will have an opportunity to order these professional promotional items in the near future. Recently, your Board of Directors approved a fall media campaign as recommended by our marketing firm back in April. While this media campaign works to raise awareness of the issues facing the dental assistant profession in Ontario, our government-relations firm will be focused on getting the message to our provincial members of parliament. Your Executive Director, Executive Committee and Board of Directors will be jointly committed to our pursuit of self-regulation. As mentioned at our AGM and in my previous report to you, our financial commitment to the government-relations firm will ensure our professional success and recognition for future self-regulation. Therefore, a small increase in membership fees will be essential in this process. The Board will be reviewing financial recommendations later this fall and will finalize a decision prior to our membership renewal period. Your voluntary membership and commitment to ODAA has been especially noticeable this year! As of July we had a record increase in membership. We are now 7,700 members strong the highest number in years! I personally wish to welcome all of our new members, and extend my congratulations to those of you who have renewed lapsed memberships with ODAA this year. Thank you! Most of you have already received your affiliate newsletters. Data retrieved from our most recent survey has been compiled and your region s wages have been published. Please use this data in your salary negotiations. Many members have reported pay increases after their employers received and reviewed ODAA s recent letter regarding Ontario wages for dental assistants. As the ODAA faces more challenges this year, I will continue to draw on your membership support and strength. Let us all step forward into this exciting new era. Together we share our pride...and shape our future! 03

5 Executive Director Judy Melville From Judy s Desk Notice anything different? At the end of 2004, we embarked on an incredible journey of change. We felt that it was time for the ODN&AA to turn a corner, to instill renewed pride and professionalism into our work, and to create a strong and sure future for dental assistants across Ontario. As of January 1, 2005, the ODN&AA became the ODAA (Ontario Dental Assistants Association). This was the first signal of change within our organization. From there, we decided to repackage ourselves, with a bold new logo and a powerful tagline, both of which grace the front cover of our new Journal. The logo represents you, the dental assistant, embraced by the support of your organization. It is contemporary, energetic and positive. The tagline, Sharing our pride. Shaping our future, gave us goosebumps when it was first presented to us at a meeting of your Board of Directors. Why? Because it captures the very essence of our organization where we ve been and where we are going. We started in the late 1920s, at a time when women in Canada were just getting the vote. Our founder, Marion Edwards, formed the association in 1927, and we incorporated in In 1929, under the Person s Act, women got the vote in Canada. Back then, Marion recognized the value of fellowship, unity and professional growth. Over the years, others have continued this work and shaped our association into what it is today. So, indeed, we are sharing our pride. Pride in professionalism, in patient care and in certification, thus ensuring our professional growth. We are now in our 71st year of being an incorporated professional association. Now it is time to shape our future. It is time for the ODAA to be the leader of dental assistants in Ontario. It is time for us to take the steps to self-determination for the profession of dental assisting. It is time for dental assistants to determine the duties or scope of practice of dental assistants, rather than allowing others to define them. Becoming a self-regulated health profession will enable us to form our own disciplining body. In Ontario, a disciplining body of a regulated health profession is called a College. The College of Dental Assistants will be governed by dental assistants and by public members. We will determine what we do and how we do it, and ensure that only formally educated and certified dental assistants perform the work of dental assistants. Advocacy, lobbying and ensuring that the profession of dental assisting is recognized and respected will shape our future. And as members of the ODAA, you will share it with us. 04

6 Letters to the Editor Dear ODN&AA, It is with great regret that I need to inform you of 2005 being my last year as a member of the ODN&AA, and being a certified dental assistant. It has been over ten years since I graduated and became a member. I started working as a dental assistant as soon as I graduated in a part-time position in Brantford, Ontario. Six months later, my husband and I moved back to New York, after which I started searching for work in a dentist s office. Much to my disappointment, the closest dentist was 30 minutes from my home, through rolling and winding snow-covered roads, which was not appealing. Two months after we were living there, I was offered a position with the County, which soon became permanent. We have since moved from New York, and I am again working with the County in a Sheriff s office. It is not looking as though I will ever work in a dental office again. So, after ten years of continuing education and staying current, I am going to let this year be my last one. I have enjoyed the ODN&AA immensely, and the challenging courses through the years. ODN&AA has given much to my life!! I cannot begin to thank you and everyone in your office for the kindness all of you have shown me through the years. I have never known an organization with so much kindness, courtesy and politeness. We, in the States, need to take lessons and learn from you. I have grown as a person with the knowledge of the school and the continued education. The Attitude Home Study really made an improvement in my life. So, I thank you for every way in which I have grown as a woman through the years because of the ODN&AA!! May God continue to bless you and the ODN&AA! Sincerely, Mary Jane Prospero Have a question, opinion or comment? Send your typed letters to us by to by snail mail to c/o ODAA, 869 Dundas Street, London, Ontario N5W 2Z8 or by fax to We reserve the right to edit all submissions. 05

7 Regulation Update Developing a personal relationship with a client Recently, an Ontario dental hygienist lost her Certificate of Registration because she was found to have committed an act of professional misconduct (sexual abuse) when she developed a personal and sexual relationship with a client. Sexual abuse of a client is defined in Section 1.(3) of the Health Professions Procedural Code as: a) sexual intercourse or other forms of physical sexual relations between a registrant and a client, b) touching, of a sexual nature, of a client by a registrant, or c) behavior or remarks of a sexual nature by a registrant towards a client. This hygienist was found to be having a sexual relationship with a client. As such, she had committed an act of professional misconduct. The penalty for this under the Code is a reprimand and revocation of her Certificate of Registration. In this case, she lost her ability to work as a dental hygienist for a period of five years. Sexual abuse by professionals is a serious violation of boundaries, deemed unacceptable by all regulated health professions. Should a health professional wish to engage in an intimate relationship, the professional relationship must first be terminated. The Code dictates zero tolerance because clients are generally considered vulnerable, and there is a perceived power imbalance between a health professional and a client. As well, sexual abuse tarnishes public trust in the entire profession. Though our profession is not yet regulated, one must weigh the costs of becoming involved with a client. It is certainly not advisable given the desire of dental assistants to be regarded as healthcare professionals. We would encourage our members to act as if they are regulated health professionals and refrain from engaging in activities defined by the Health Professions Procedural Code as sexual abuse of a client. the 06

8 CDA Profile Doing Her Profession Proud 07

9 AmyMelillo A highly committed dental assistant with a CDA II designation, Amy Melillo has a personal desire to inform and teach her patients as much as possible. When they ask me about dental procedures, or they need to make a decision about whitening, for example, I have to have answers for them, she says. The more knowledgeable I am, the better it is for our patients. encourages me to take extra courses to earn my 15 points each year and keep up my membership. She also takes advantage of many other exclusive benefits that come with ODAA membership. I get a lot of great information from The Journal. When it arrives, I always make a point of going through it. I even do the quizzes. In addition, Amy appreciates the discounted services she is eligible for as a member. I joined Goodlife Fitness at a special rate, and also signed up for the life insurance plan for ODAA members. For the Demarco, Panwar, Graber and Fuzy Dental Office, who employ seven dental assistants, certification has been an absolute prerequisite since the office opened 28 years ago. We hire dental assistants that have been well-trained and educated by reputable schools, and form them the way we want them to be. We surround ourselves with the best people, treat them well and they stay, says Campeau. Employees attend monthly meetings with industry speakers, and were sent to Las Vegas for training in cosmetic dentistry. It s a team approach and Clockwise: John Demarco, Hans Graber, Michelle Fuzy, Manu Panwar Left to Right: Derek Viveiros, Kathy Samson, Diane Kozachuk, Denis Campeau, Andrea Renault, Sambeth Seang, Megan Srigley, Amy Melillo, Amy Zimmerman you need your whole staff behind you. We have assistants and dental hygienists. We all have to know what the products are and what can be done. A graduate of the Dental Assisting Program at Fanshawe College, Amy joined the Ontario Dental Assistants Association in 2000 after hearing about it in a class. Her initial incentive was practical. It seemed like a good organization, and by joining I got a head start on earning my points for the year. But now Amy sees the ODAA as something more a means of helping her further her education and stay on top of her profession. The ODAA Employer support makes all the difference At the Demarco, Panwar, Graber and Fuzy Dental Office in London, Ontario, where Amy works, dental assistants receive a level of respect that is rare in the industry. Denis Campeau, the clinic s business manager, believes that dental assistants are hardworking, well-trained professionals that are undervalued in the marketplace. It s an investment that is not lost on Amy and her co-workers. They really want us to succeed and be the best at our jobs. It reflects positively on everyone. Amy feels very fortunate to be a part of a professional team committed to doing what s right for the patient. If we re properly trained and knowledgeable, our patients have more faith in us. 08

10 Tooth Whitening Then & Now Dr. Len Boksman D.D.S., B.Sc. F.A.D.I., F.I.C.D. Everyone wants to have a radiant smile with gleaming pearly whites and today, practically everyone can! Sales of over-the-counter whitening products have been estimated to approach $1 billion a year in North America alone. 1 Tooth whitening has become a multi-million dollar industry, and there are literally hundreds of competing products to whiten teeth, be they in-office procedures or take-home systems. The more you know about tooth whitening, the better prepared you ll be to help your patients make informed decisions about what system is right for them. How it all began The dental use of hydrogen peroxide, the basic ingredient in all tooth-whitening products, has been documented for over 80 years. Initially, hydrogen peroxide was used for periodontal treatment and wound healing, because it was proven to prevent and retard the colonization and multiplication of anaerobic bacteria. 2,3 In 1966, Schneider et al. 4 documented the use of a peroxide-containing gingival strip to apply peroxides in periodontal tissue healing. It wasn t long before an accidental side effect was observed peroxide actually whitened the teeth. Later, a pediatric dentist, Dr. Jerry Wagner, used Proxigel in custom-fitted, vacuum-formed trays specifically for whitening teeth. These were FDAapproved oral antiseptics containing 10% carbamide peroxide. 1 The concept of tooth whitening was born. How it works Hydrogen peroxide releases the oxygen that breaks down the conjugated bonds in protein chains (stains) into a single bond, which increases the absorption of colour wavelengths resulting in the reflection of little colour (i.e., a whitening effect). 5 Extrinsic staining, which affects only the enamel surface, can be caused by tea, coffee, nicotine, 09

11 chewing tobacco, blueberries, wine and natural aging. These stains are all relatively easy to treat with tooth whitening. The intrinsic stains that discolour the internal aspect of the tooth such as fluorosis, tretracycline, trauma and systemic conditions are infinitely more difficult to treat. Even though peroxides in whitening materials have been shown to permeate intact enamel in just a few seconds 6, changing the colour of the dentin requires long exposure to realize positive results. Is it safe? The safety of using hydrogen peroxide and carbamide peroxide has been documented in numerous studies. In a retrospective look at two hundred and fifty-six major medical and dental journals, Yarborough 7 states that the safety and efficacy of hydrogen peroxide is well established. Studies on the effect of hydrogen peroxide on the oral hard tissues and pulp have shown that hydrogen peroxide does not adversely affect enamel morphology or microhardness and hydrogen peroxide is not expected to inhibit pulpal enzymes. 8 Even when used for extended periods when treating tetracycline-stained teeth, no adverse effects have been noted using carbamide peroxide. 9 Tooth whitening and tooth sensitivity In some cases, tooth sensitivity may occur as a side effect of tooth whitening. Tooth sensitivity as a result of whitening teeth is dose- and time-related. The higher the dose or concentration of the whitening agent and the longer the teeth are exposed, the greater the risk of tooth sensitivity. If sensitivity occurs, the first and easiest way to address the problem is to decrease the time the patient treats the teeth or decrease the dosage of the peroxide. Many products contain water to decrease the dehydration effects of whitening, and others have fluoride and potassium nitrate to decrease the incidence of tooth sensitivity. Potassium nitrate penetrates the dentinal tubules and depolarizes the nerves, decreasing the painful stimulus. 10 Potassium nitrate gels, which can be utilized in bleaching type trays for hypersensitive root surfaces, include UltraEZ (UltraDent), Den-Mat Desensitize (Den-Mat) and Relief (Discus). Recently, Amorphous Calcium Phosphate has been added to products like Zoom 2 (Discus Dental) to address this issue. In-office tooth whitening In-office tooth whitening uses high concentrations of hydrogen peroxide. It is more expensive for the patient than take-home whitening due to the chair time required. In-office tooth whitening is best for those patients who want faster, more immediate results, or patients who need close monitoring for clinical conditions, such as extensive tissue recession or deep unrestored abfraction lesions. It is also necessary for endodontic or internal tooth whitening. Many current systems employ lightactivated bleaching. Some of these include Laser Smile (Biolase Technology) 37% hydrogen peroxide, ArcBrite (Biotrol) 30% hydrogen peroxide, BriteSmile (BriteSmile) 15% hydrogen peroxide, Rembrandt Smile (Den-Mat) 35% hydrogen peroxide, Zoom (Discus Dental) 20% hydrogen peroxide, and LumaWhite Plus (LumaLite) 35% hydrogen peroxide. Because of media coverage about lightactivated bleaching, patient demand for this process is increasing. However, CRA clinical trials repeatedly show that light and heat do not increase tooth lightening and are not necessary for vital tooth bleaching. Contact time and concentration of active ingredients are the critical factors. 11 The use of lights may impress patients, but they add cost, occupy operatory space, can cause soft-tissue burning and can increase operatory temperature. 12 All systems recommend a take-home tray as an adjunct, so the question is whether any observed benefit is due to the light or the tray. 13 Before utilizing a light-activated bleaching system, ask the patient if he/she is on any medication. Some medications can cause minor to extreme photosensitivity. These include acne medications, anti-cancer drugs, antidepressants, antihistamines, antimicrobials, antiparasitic drugs, antipsychotic drugs, diuretics, hypoglycemics and non-steroidal antiinflammatory drugs. In-office whitening systems not using light or heat include Illumine (Dentsply Professional) 15% hydrogen peroxide, Office White (Life-Like Cosmetic Solutions) 40% hydrogen peroxide, Perfecta White (Premier Dental Products) 35% hydrogen peroxide, Niveous (Shofu Dental) 25% hydrogen peroxide and Opalescence Xtra Boost (UltraDent) 38% hydrogen peroxide. Due to the negative effects on gingival tissue of these high concentrations of hydrogen peroxide, many of these systems utilize various forms of tissue protection to minimize the potential for gingival damage. The application times and number of applications vary by product. Take-home tooth whitening In March of 1989, Dr. Harald Heymann and Van Haywood introduced the concept of tooth whitening using a nightguard with a viscous gel containing a thickening agent (Carbopol), which allowed for longer bleach activation and increased retention in the tray. 14 In 1989, Dr. Dan Fischer, who created Opalescence carbamide peroxide (UltraDent), received a patent for creating the thick and sticky whitening gel formulation that is still the basis for most nighttime gels marketed today. This was the first ADA-approved system for whitening. 1 This product was developed with a high water content to minimize tooth sensitivity, a neutral ph, and a thixotropic viscosity to stay in the tray. It was designed for sustained release of the hydrogen peroxide. The degradation over time of carbamide peroxide shows that after two hours, more than 50 percent of the active ingredient is available and 10 percent is available after 10 hours. 15 Therefore, for nighttime wear, the maximum whitening effect occurs in the first two hours. Whitening agents that are recommended for nighttime use by their manufacturers include: Opalescence (UltraDent) 10%, 10

12 15%, 20%, Nupro White Gold (Dentsply Professional) 10% and 15% carbamide peroxide, Nite White Turbo (Discus Dental) 6% hydrogen peroxide, Gentle White (IMDS) 35% hydrogen peroxide, and Pola Night (Southern Dental Industries) 10%, 16% and 22% carbamide peroxide. For daytime use, both carbamide peroxide and hydrogen peroxide are effective at-home bleaching agents. 16 Products that are indicated for daytime use by their manufacturers include: Opalescence (UltraDent) 10%, 15%, 20% carbamide peroxide, Rembrandt XTRA-Comfort (Den- Mat) 16%, 22%, 30% carbamide peroxide, Natural Elegance (Henry Schein) 10%, 15%, 22% carbamide peroxide, JustSmile (JustSmile Whitening Systems) 2 10% hydrogen peroxide, Perfecta Bravo (Premier Dental Products) 9% hydrogen peroxide, and Pola Day (Southern Dental Industries) 3%, 7.5%, and 9.5% hydrogen peroxide. An innovative new product by UltraDent Products is Treswhite, the first pre-molded, pre-filled, disposable tooth-whitening tray. The tray contains 9% hydrogen peroxide gel along with a gingival barrier protector gel around the sides. The thixotropic nature of the gel ensures that it stays in contact with the teeth. When it comes to tray tooth-whitening, the use of reservoirs is still an issue of debate. The reservoir technique creates a little bubble of space on the inside surface of the tray immediately adjacent to the buccal surface of the tooth. This space will trap a greater quantity of bleach than a non-reservoir technique. The increased bleach quantity will release more oxygen ions over a longer period of time in the vicinity of the tooth, creating a greater early whitening effect. 17 In a study by Matis, he states that there is no clinical difference in tooth whitening after two hours of tray use whether or not reservoirs are present, yet in his conclusions he states that bleaching with tray reservoirs produced significantly greater tooth lightening than bleaching without reservoirs. 18 The author prefers using trays with reservoirs. Companies like Proctor and Gamble and Colgate offer non-tray whitening products that have been well researched and documented. 19,20 These include Crest Whitestrips, containing a 6.5% hydrogen peroxide, many different versions of Colgate Platinum whitening toothpaste, and Colgate Simply-White Whitening Gel, a paint-on gel containing 5.9% hydrogen peroxide. 21 As a valued member of the dental team, you are in a unique position to play an active role in encouraging and educating your patient about the choices available for tooth whitening. If you have utilized a tooth-whitening system yourself, don t be afraid to talk to your patient about your experience, and proudly show them your pearly whites! Bibliography: 1. Goff S. Getting the White Right, Dental Products Report (Jan. 2005) Wennstrom J., Lindhe J. Effect of hydrogen peroxide on developing plaque and gingivitis in man, J Clin Periodontol 6(2): (Apr. 1979) the 3. Volpe AR et al. Gingival tissue oxygenation: The effect of a single application of four commercial preparations, J Periodontol 37.6 (Nov.-Dec. 1966): Schneider HG et al. Clinical experience with the peroxide-containing gingival strip from the Leipziger Arzneimttelwerk, Dtsch Stomatol (Germany East), 16.9 (Sep. 1966): L. G. Wade Jr., Conjugated Systems Organic Chemistry, 3rd ed. (Upper Saddle River, NJ: Prentice Hall; 1994): 695, R. C. Craig and J. Powers, Restorative Dental Materials, 11th ed. (St. Louis, Missouri: Mosby Inc., 2002). 7. D. K. Yarborough, The Safety and Efficacy of Tooth Bleaching: A Review of the Literature, Compendium 12.3 (Mar. 1991): G. Pugh, et al. High levels of hydrogen peroxide in overnight tooth-whitening formulas: effects on enamel and pulp, J Esthet Restor Dent 17.1 (2005): 40 45, discussion V. B. Haywood and R. H. Leonard, et al., Efficacy of Six Months of Nightguard Vital Bleaching of Tetracycline-Stained Teeth, J of Esthet Dent 9.1 (1997) R. Orchardson and D. G. Gilliam, The efficacy of potassium salts as agent for treating dentin hypersensitivity, J Orofac Pain 14 (2000): CRA Newsletter 4.4 (April 2000) 12. CRA Newsletter (November 2002) 13. G. Kugel, Is there a benefit to light-activated tooth whitening? JCDA Point of Care 71.6 (June 2005): V. B. Haywood, Nightguard vital bleaching, Quit Internat : B. A. Matis, et al., In vivo degradation of bleaching gel used in whitening teeth, JADA, 130 (February 1999) G. R. Mokhlis, et al. A clinical evaluation of carbamide peroxide and hydrogen peroxide whitening agents during daytime use, J Am Dent Assoc (Sep. 2000) Dentistry today Buyers Guide to Whitening Systems, Dentistry Today Dec 2004: B. A. Matis, et al., A clinical evaluation of a bleaching agent used with and without reservoirs, Operative Dentistry 27 (2002) R. W. Gerlach and Zhou X., Clinical trial comparing two daytime hydrogen-peroxide vital-bleaching systems, Compend Contin Educ Dent 25.8 (Suppl. 2) (Aug. 2004): P. A. Sagel and W. F. Landrigan, A new approach to strip-based tooth whitening: 14% hydrogen peroxide delivered via controlled low dose, Compend Contin Educ Dent 25.8 (Suppl. 2) (Aug. 2004): G. Gambarini et al., Efficacy and safety assessment of a new liquid tooth whitening gel containing 5.95% hydrogen peroxide, Am J Dent 17.2 (Apr. 2004):

13 Le blanchiment Dentaire Alors et Maintenant Tous veulent un sourire éclatant avec des dents d un blanc perle et aujourd hui, pratiquement tout le monde le peut! On estime les ventes de produits de blanchiment disponibles en comptoir à près de 1 milliard de dollars par année, en Amérique du Nord seulement. 1 Le blanchiment des dents est une industrie qui rapporte des millions de dollars, et on retrouve littéralement des centaines de produits compétitifs pour blanchir les dents, tant bien par procédures en clinique que par des systèmes pour utilisation à domicile. Plus vous en connaissez sur le blanchiment des dents, mieux vous pourrez aider vos patients à prendre une décision avertie sur le système qui leur convient le mieux. Comment tout cela a commencé Depuis plus de 80 ans la documentation existe sur l utilisation dentaire du peroxyde d hydrogène, l ingrédient de base dans tous les produits de blanchiment dentaire. Initialement, le peroxyde d hydrogène était utilisé pour le traitement parodontal et la guérison des lésions, parce qu il était prouvé que le peroxyde d hydrogène peut prévenir et retarder la colonisation et la multiplication des bactéries anaérobiques. 2,3 En 1966, Schneider et al. 4 documentaient l utilisation d une bande gingivale contenant du peroxyde pour application de peroxyde dans le traitement des tissus parodontaux. Très vite on observa, par accident, un effet secondaire le peroxyde actuellement blanchissait les dents. Plus tard, un pédodontiste, le Dr Jerry Wagner, utilisa Proxigel dans des gouttières confectionnées sur mesure spécialement pour le blanchiment des dents. Celles-ci étaient des antiseptiques oraux contenant 10% de peroxyde de carbamide approuvés par la FDA. 1 Le concept du blanchiment dentaire venait de naître. Comment cela fonctionne Le peroxyde d hydrogène libère l oxygène qui brise les liens conjugués dans les chaînes de protéines (taches) en lien singulier, ce qui amène une plus grande absorption de la longueur d ondes de couleur résultant dans la réflexion de peu de couleur (p. ex. un effet de blanchiment). 5 Les taches extrinsèques, qui n affectent seulement que la surface de l émail, peuvent être causées par le thé, le café, la nicotine, le tabac à chiquer, les bleuets, le vin et le vieillissement naturel. Ces taches sont toutes relativement faciles à traiter avec le blanchiment dentaire. Les taches intrinsèques qui décolorent l aspect interne de la dent comme la fluorose, la tétracycline, un traumatisme et des conditions systémiques sont beaucoup plus difficiles à traiter. Même si le peroxyde dans les matériaux de blanchiment a clairement démontré qu il peut pénétrer l émail intact en quelques secondes seulement, 6 altérer la couleur de la dentine requiert une exposition prolongée pour affecter la couleur. Est-ce sécuritaire? L utilisation sécuritaire du peroxyde d hydrogène et du peroxyde de carbamide a été très souvent documentée dans de nombreuses études. Après un regard rétrospectif à deux cent cinquante-six revues médicales et dentaires, Yarborough 7 déclare que la sécurité et l efficacité du peroxyde d hydrogène sont bien établies. Les effets du peroxyde d hydrogène sur les tissus durs et la pulpe ont été évalués dans plusieurs études. Le peroxyde d hydrogène n affecte pas d une façon adverse la morphologie ou la micro consistance de l émail et il n est pas anticipé que le peroxyde d hydrogène gênera les enzymes pulpaires. 8. Même durant des périodes prolongées d usage de peroxyde de carbamide, lors de traitement de dents tachées par la tétracycline, aucun effet nocif n a été noté. 9 Le blanchiment dentaire et la sensibilité dentaire Dans certains cas, une sensibilité épisodique résultant du blanchiment dentaire peut se manifester comme effet secondaire. Cette sensibilité est reliée à la dose et au temps d exposition. Plus la dose ou la concentration d agent de blanchiment est grande et plus longtemps les dents sont exposées, plus grand est le risque de sensibilité dentaire. Si la sensibilité se produit, la façon première et facile d adresser le problème est de diminuer le temps de traitement ou de diminuer la dose de peroxyde ou de peroxyde de carbamide. Plusieurs produits contiennent de l eau, ce qui diminue les effets de déshydratation du blanchiment, et certains ont du fluor et du nitrate de potassium pour diminuer l incidence de sensibilité dentaire. Le nitrate de potassium pénètre les tubulures dentaires et dépolarise les nerfs, diminuant ainsi la douleur. 10 Les gels de nitrate de potassium qui peuvent être utilisés dans les gouttières de blanchiment pour surfaces de racine hypersensibles comprennent UtraEZ (UltraDent), Den-Mat Desensitize (Den- Mat) et Relief (Discus). Tout récemment pour adresser ce problème, du phosphate de calcium amorphe a été ajouté aux produits comme Zoom 2 (Discus Dental). 12

14 Blanchiment dentaire en clinique Le blanchiment dentaire en clinique utilise une forte concentration de peroxyde d hydrogène. Le coût est plus élevé que le blanchiment à domicile dû à l occupation de la chaise. Ce type de blanchiment est recommandé pour les clients qui désirent un effet rapide, des résultats immédiats et pour ceux qui requièrent une surveillance due à des conditions cliniques comme par exemple une récession extensive de tissus ou des lésions abfractaires profondes non-restaurées. Il est aussi requis en endodontie ou pour le blanchiment intérieur dentaire. Plusieurs systèmes actuels utilisent le blanchiment activé par la lumière. Certains de ceux-ci comprennent le Laser Smile (Biolase Technology) 37% de peroxyde d hydrogène, ArcBrite (Biotrol) 30% de peroxyde d hydrogène, BriteSmile (BriteSmile) 15% de peroxyde d hydrogène, Rembrandt Smile (Den-Mat) 35% de peroxyde d hydrogène, Zoom (Discus Dental) 20% de peroxyde d hydrogène et Luma White Plus (LumaLite) 35% de peroxyde d hydrogène. La demande croissante par les clients, du procédé de blanchiment activé par la lumière, est due à sa publicité par les médias. Cependant, les essais cliniques effectués par le CRA montrent constamment que la lumière et la chaleur n augmentent pas l éclaircissement dentaire et ne sont pas nécessaires pour le blanchiment de la dent vivante. Le temps de contact et la concentration des ingrédients actifs sont les facteurs importants. 11 L utilisation des lumières peuvent impressionner les clients, mais elles augmentent le coût et le temps d occupation de la salle de traitement, elles peuvent causer des brûlures aux tissus mous ainsi que l augmentation de la température dans la salle de traitement. 13 Tous les systèmes recommandent une gouttière comme supplément à domicile, donc la question reste; est-ce que le bénéfice découle de la lumière ou de la gouttière? 13 Avant de procéder à l utilisation du système de blanchiment activé par la lumière, demandez au patient s il prend des médicaments. Certains médicaments peuvent causer une photosensibilité allant de mineure jusqu à l extrême. Ceux-ci comprennent les médicaments contre 13 l acné, contre le cancer, les antidépresseurs, les antihistaminiques, les antimicrobiens, les antiparasites, les antipsychotiques, les diurétiques, les hypoglycémiques et les anti-inflammatoires non-stéroïdes. Les procédés pratiqués en clinique qui n utilisent par la lumière ou la chaleur comprennent Illumine (Dentsply Professional) 15% de peroxyde d hydrogène, Office White (Life-Like Cosmetic Solutions) 40% de peroxyde d hydrogène, Perfecta White (Premier Dental Products) 35% de peroxyde d hydrogène, Niveous (Shofu Dental) 25 % de peroxyde d hydrogène et Opalescence Xtra Boost (UltraDent) 38% de peroxyde d hydrogène. Dû aux effets négatifs que ces grandes concentrations de peroxyde d hydrogène ont sur le tissu gingival, plusieurs systèmes utilisent des protections variées pour le tissu afin de minimiser le dommage gingival potentiel. Le temps et le nombre d applications varient selon le produit. Blanchiment dentaire à domicile En mars 1989, les Drs Harald Heymann et Van Haywood introduisaient le concept d emploi d un protecteur buccal de blanchiment contenant un gel visqueux renfermant un agent d épaississement (Carbopol), qui allouait un temps d activation plus élevé et une meilleure rétention de la gouttière. 14 En 1989, le Dr Dan Fischer, qui créa Opalescence peroxyde de carbamide (UltraDent) recevait un brevet pour la création d une formule de gel de blanchiment épais et adhérant qui est encore le principe de base employé dans la plupart des gels de nuit sur le marché actuel. Ce fut le premier système de blanchiment approuvé par ADA.1 Ce produit fut développé avec une grande concentration d eau pour minimiser la sensibilité dentaire, conserver un ph neutre et appliquer une viscosité thixotropique pour demeurer dans la gouttière. Il fut conçu pour libérer une quantité soutenue de peroxyde d hydrogène. Après un certain temps, la dégradation du peroxyde de carbamide se résume à ceci, après deux heures, on ne retrouve qu un peu plus de 50 pour cent de l ingrédient actif et seulement 10 pour cent s y retrouve après 10 heures.15 Donc pour le port de la gouttière durant la nuit, on en déduit que le maximum effet de blanchiment se produit au cours des deux premières heures. Les agents de blanchiment recommandés pour la nuit par les manufacturiers sont: Opalescence (UltraDent) 10%, 15%, 20%, Nupro White Gold (Dentsply Professional) 10% et 15% de peroxyde de carbamide, Nite White Turbo (Discus Dental) 6% de peroxyde d hydrogène, Gentle White (IMDS) 35% de peroxyde d hydrogène, et Pola Night (Southern Dental Industries) 10%, 16% et 22 % de peroxyde de carbamide. Pour une utilisation durant le jour, le peroxyde de carbamide et le peroxyde d hydrogène sont tous les deux efficaces comme agents de blanchiment à domicile.16 Les produits qui sont indiqués pour l usage durant le jour par les manufacturiers sont: Opalescence (UltraDent) 10%, 15%, 20% de peroxyde de carbamide, Rembrandt XTRA-Comfort (Den-Mat) 16%, 22%, 30% de peroxyde de carbamide, Natural Elegance (Henry Schein) 10%, 15%, 22% de peroxyde de carbamide, Just Smile (JustSmile Whitening Systems) 2-10% de peroxyde d hydrogène Perfecta Bravo (Premier Dental Products) 9% de peroxyde d hydrogène et Pola Day (Southern Dental Industries) 3%, 7.5% et 9.5 % de peroxyde d hydrogène. Un produit innovateur d UltraDent Products, le Treswhite, est la première gouttière pré-moulée, remplie et jetable. La gouttière contient 9% de peroxyde d hydrogène en gel ainsi qu une barrière de gel protectrice sur les côtés. La nature thixotropique de ce gel assure qu il reste en contact avec les dents. L utilisation de réservoirs, dans le blanchiment dentaire utilisant une gouttière, est encore débattue. La technique du réservoir est qu une petite bulle est créée sur la surface intérieure de la gouttière, immédiatement adjacente à la surface buccale de la dent. Cet espace retiendra une plus grande quantité de décolorant que dans la technique sans réservoir.

15 La hausse de la quantité de décolorant dégagera plus d ions d oxygène au cours d une plus longue période de temps dans les environs de la dent, créant ainsi un effet supérieur de blanchiment plus rapidement. 17 Dans l étude conduite par Matis, il rapporte qu il n y a pas de différence clinique dans le blanchiment d une dent après deux heures d utilisation d une gouttière avec ou sans réservoir, encore ajoutet-il dans ses conclusions que le blanchiment avec une gouttière à réservoirs produit un effet blanchissant plus grand que sans les réservoirs. 18 L auteur préfère utiliser les gouttières avec réservoirs. Les compagnies comme Proctor & Gamble et Colgate offrent des produits de blanchiment sans gouttière qui ont fait l objet de recherche et d une bonne documentation. 19,20 Ceux-ci comprennent Crest Whitestrips contenant un peroxyde d hydrogène de 6.5%, plusieurs versions de dentifrices blanchissants Colgate Platinum sont disponibles et un gel que l on peut appliquer avec un pinceau, le gel blanchissant Colgate Simply-White Whitening Gel contenant un peroxyde d hydrogène 5.9%. 21 En tant que membre important de l équipe dentaire, vous êtes dans une position unique pour jouer un rôle actif en encourageant et en éduquant votre patient dans les choix qui se présentent dans le blanchiment dentaire. Si vous utilisez un système de blanchiment dentaire, ne craignez pas de parler à votre patient de votre expérience et soyez fière de mettre en évidence vos dents blanc-perle! Bibliographie: 1. Goff S. Getting the White Right, Dental Products Report (Jan. 2005) Wennstrom J., Lindhe J. Effect of hydrogen peroxide on developing plaque and gingivitis in man, J Clin Periodontol 6(2): (Apr. 1979) Volpe AR et al. Gingival tissue oxygenation: The effect of a single application of four commercial the preparations, J Periodontol 37.6 (Nov.-Dec. 1966): Schneider HG et al. Clinical experience with the peroxide-containing gingival strip from the Leipziger Arzneimttelwerk, Dtsch Stomatol (Germany East), 16.9 (Sep. 1966): L. G. Wade Jr., Conjugated Systems Organic Chemistry, 3rd ed. (Upper Saddle River, NJ: Prentice Hall; 1994): 695, R. C. Craig and J. Powers, Restorative Dental Materials, 11th ed. (St. Louis, Missouri: Mosby Inc., 2002). 7. D. K. Yarborough, The Safety and Efficacy of Tooth Bleaching: A Review of the Literature, Compendium 12.3 (Mar. 1991): G. Pugh, et al. High levels of hydrogen peroxide in overnight tooth-whitening formulas: effects on enamel and pulp, J Esthet Restor Dent 17.1 (2005): 40 45, discussion V. B. Haywood and R. H. Leonard, et al., Efficacy of Six Months of Nightguard Vital Bleaching of Tetracycline-Stained Teeth, J of Esthet Dent 9.1 (1997) R. Orchardson and D. G. Gilliam, The efficacy of potassium salts as agent for treating dentin hypersensitivity, J Orofac Pain 14 (2000): CRA Newsletter 4.4 (April 2000) 12. CRA Newsletter (November 2002) 13. G. Kugel, Is there a benefit to light-activated tooth whitening? JCDA Point of Care 71.6 (June 2005): V. B. Haywood, Nightguard vital bleaching, Quit Internat : B. A. Matis, et al., In vivo degradation of bleaching gel used in whitening teeth, JADA, 130 (February 1999) G. R. Mokhlis, et al. A clinical evaluation of carbamide peroxide and hydrogen peroxide whitening agents during daytime use, J Am Dent Assoc (Sep. 2000) Dentistry today Buyers Guide to Whitening Systems, Dentistry Today Dec 2004: B. A. Matis, et al., A clinical evaluation of a bleaching agent used with and without reservoirs, Operative Dentistry 27 (2002) R. W. Gerlach and Zhou X., Clinical trial comparing two daytime hydrogen-peroxide vital-bleaching systems, Compend Contin Educ Dent 25.8 (Suppl. 2) (Aug. 2004): P. A. Sagel and W. F. Landrigan, A new approach to strip-based tooth whitening: 14% hydrogen peroxide delivered via controlled low dose, Compend Contin Educ Dent 25.8 (Suppl. 2) (Aug. 2004): G. Gambarini et al., Efficacy and safety assessment of a new liquid tooth whitening gel containing 5.95% hydrogen peroxide, Am J Dent 17.2 (Apr. 2004):

16 Dean Swift BSc, FADM Focus On Infection Control Five key concepts to consider in improving asepsis in the Dental Laboratory Receiving One area of the lab should be designated for receiving impressions and prosthetics. This area should have surfaces that are easy to clean and disinfect. Impressions and trays should be sprayed or immersed with a quality non-toxic disinfectant that kills in one minute in the presence of blood and saliva. To prevent disolution or distortion, never exceed one-minute exposure, then rinse the impression lightly and pour the model immediately. Prosthetics and models are then sent to the appropriate department. The laboratory benefits from this procedure as staff are protected from incoming disease. In addition, some disinfectants have surfactants that act as an inexpensive debubblizer for the plaster. Ensure that the surfactants in the disinfectant are not part of the toxic alkyl or nonyl phenol ethoxylate family (NPE s). 2. Plaster Sink AND Trap The area for plaster mixture should have easily cleanable and disinfectable surfaces with a sink for rinsing. Remember that the minerals in plaster and stone are nutrients for bacteria. At the end of each week, rinse expired Ultrasonic disinfectant solution down the trap. The trap will smell much more pleasant. When the trap is cleaned, use disinfectant spray wait one minute then wipe with disposable towels. The laboratory benefits as staff are protected and the plaster trap smells better. 3. Pumice AND Polishing This area of the lab is often neglected. Water that sits over the weekend in pumice trays is a perfect environment for the multiplication of bacteria. Use diluted non-toxic/minimal taste disinfectant instead of water to lubricate pumice to prevent the growth of moulds or fungi. 4. Pens AND Paper Often the receiver of impressions and prosthetics will wear gloves to protect themselves. A problem arises when the same pair of gloves opens up several cases of impressions that have blood or saliva on them. Infection can be transferred to the prescription, or the pen and from one case to another. It is therefore recommended to disinfect all of the cases first. Ensure that the gloves are rinsed and disinfected between cases. Then, when all of the disinfecting is complete, the paperwork can be done with the assurance that infectious bacteria are not being transferred between cases or around the lab with a shared pen. 5. Circle of Infection Most important in the understanding of infection control principles is the sense that the circle of infection is effectively broken. Whenever there is a possibility for the transfer of infectious material, it is necessary to disinfect. Living in a bubble is not necessary, neither is a sterile lab. Quite simply - just Break the Circle of Infection! Reprinted with permission. Journal of Dental Technology, Feb 2000, pp66. the

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18 Frequently Asked Questions What steps are Level II dental assistants able to perform with the ZOOM Bleaching System? Dentists can only authorize Level II assistants to administer bleaching agents generally available to the public without prescription (or equivalent). Health Canada limits for tooth-whitening products available over the counter are 3% hydrogen peroxide or 10% carbamide peroxide. This means that the tooth-whitening agents used for in-office bleaching systems, such as ZOOM, can only be applied by a dentist or a dental hygienist. The Royal College of Dental Surgeons of Ontario (RCDSO) advises that only dentists or dental hygienists apply the liquid dam because of the risk of injury to the soft tissue from the bleaching agent. Anybody can hold the light once the bleaching agent has been applied. Dentists can authorize a Level II assistant to take impressions for study models and for the fabrication of bleaching trays for at-home use. The dentist must assess the suitability of the models for the fabrications of the trays and must be present in the office when the impressions are being taken by the Level II assistant. Are Level II dental assistants allowed to take alginate impressions for the purpose of making orthodontic appliances, such as space maintainers and lingual arch? Also, are Level II assistants allowed to take alginate quadrant impressions for the fabrication of temporary crowns? The taking of working impressions for orthodontic appliances and for the fabrication of temporary crowns are controlled acts under the Regulated Health Professions Act and dentists cannot delegate these duties to dental assistants. Therefore a Level II assistant can t take these types of impressions regardless of the impression material that would be used. Can dental assistants do denture adjustments outside the mouth? A dental assistant can do lab procedures under the supervision of the dentist. Lab work not supervised by a dentist must be done by an RDT (Registered Dental Technician). Laboratory work can be taught in office. Some assistants may have a lab background and not require in-house training. An assistant cannot deal directly with the patient and provide an adjustment. If a patient presents for a denture adjustment, the dentist must examine the patient and determine what adjustment is required. If that involves a lab procedure, such as removing some acrylic, an assistant can perform this task as directed by the dentist (extra-oral). The dentist must return to examine the completed lab work and deliver the denture to the patient to insure that a satisfactory result was achieved. the 17

19 Announcements ARE YOU INTERESTED IN THE GOVERNANCE OF YOUR ASSOCIATION? We are now ready to take applications for Board Directors. For more information, contact Judy Melville, Executive ext. 25, or call the toll-free number on the reverse side of your membership card. GoodLife Fitness Program As an ODAA member you are eligible to obtain a GoodLife Gym Membership at more than 50% off the regular rates. For more information, please contact Lana Thistle at the ODAA business office. or download the enrollment form from: NDAEB Level II Examination Dates Exam: December 10, 2005 Application Deadline: October 28, 2005 Exam: March 25, 2006 Application Deadline: February 1, 2006 Exam: June 24, 2006 Application Deadline: May 12, or call ODAA Level I Certification ExamINATION Dates Exam: June 3, 2006 Application Deadline: April 28, 2006 Exam: November 4, 2006 Application Deadline: September 29, 2006 Call to receive information or to download an application form. (Use the toll-free number listed on the reverse side of your membership card.) TORONTO ACADEMY OF DENTISTRY WINTER CLINIC Friday November 4, 2005 Metro Toronto Convention Centre, North Building Members will receive 5 continuing-education credits for attendance. Sign-in for credits is required at the ODAA Membership Booth on the exhibit floor. INFECTION CONTROL WORKSHOPS 9:00 am 12:00 pm Members will receive three credits for attendance Saturday, October 15, 2005 London Saturday, October 22, 2005 Niagara-on-the-Lake Saturday, November 12, 2005 Oakville Saturday, November 26, 2005 Kitchener Contact Lynne Brandon for more information and registration, ext 22 or (Use the toll-free number listed on the reverse side of your membership card.) Congratulations to the ODAA A new image and a new era for dental assistants in Ontario. Saskatchewan Dental Assistant s Association 18

20 Open Wide Campaign for change in dental care I am tired of having my teeth decay and fall apart in pieces over time. I haven t been to the dentist in eight years to have my teeth cleaned. I do not see being able to go anytime in the future. I worry that my children will also end up with teeth like mine. Parent, Lindsay, Ontario Family Dental Health Scrapbook, 2004 Dental disease is largely an invisible problem in Ontario. When people with financial problems face the choice whether to spend their precious dollars on buying groceries, paying rent or seeking treatment at the dentist, food and rent will always win. The first steps toward fixing the problem are raising awareness among people who can make a difference and working together to support the change in current policies for dental care for low -or no-income families. The effects of dental disease can last a lifetime from childhood through adulthood. Children who have a toothache are unable to eat and therefore may not get the proper nutrients for a growing body. This may lead to lack of concentration in school, affecting their ability to learn. The pain and discomfort they experience may also limit their interaction with other children. An adult s quality of life can also be affected by dental disease. Poor oral health can influence an adult s social interactions. They may avoid laughing and smiling, and restrict conversations with others. An adult s employability may also be in jeopardy many businesses will not hire someone for a position that involves customer relations, face-to-face sales, or presentations if they have discoloured or missing teeth. Unfortunately, assistance for those without dental insurance is limited. Programs like CINOT (Children in Need of Treatment), Ontario Works, 19

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