canadian journal of journal canadien de …...micro dentisterie restauratrice peer-reviewed –...

ISSN

1916

-7520

Dental Materials /Matériaux dentairesOral Medicine /Médecine buccalePractice Management /Gestion de cabinetMicro RestorativeDentistry /Micro DentisterieRestauratrice

PEER-REVIEWED –JOURNAL - REVUE DES PAIRS

VOLUME 1-3DEC/DÉC 2008

www.cardp.ca

Canadian Journal ofRestorative Dentistry & ProsthodonticsThe official publication of the Canadian Academy ofRestorative Dentistry and Prosthodontics

Publication officielle de l'Académie canadiennede dentisterie restauratrice et de prosthodontie

Journal canadien dedentisterie restauratrice et de prosthodontie




www.andrewjohnpublishing.com

PUBLICATIONS AGREEMENT # 40025049

3Canadian Journal of Restorative Dentistry and Prosthondontics

VOL. 1, NO. 3 • DEC/DÉC 2008

Official Publication of the CanadianAcademy of Restorative Dentistry andProsthodontics

Publication officielle de L’Académie canadienne dedentisterie restauratrice et de prosthodontie

EDITOR-IN-CHIEF/RÉDACTEUR EN CHEFHubert Gaucher

Québec City, Québec | [email protected]

ASSOCIATE EDITORS/RÉDACTEURS ASSOCIÉSEmmanuel J. Rajczak

Hamilton, Ontario | [email protected] Andrea

Chester, Nova Scotia | [email protected] Nimchuk

Vancouver, British Columbia | [email protected]

SECTION EDITORS/RÉDACTEURS DE SECTION

Occlusion and Temporo-Mandibular Dysfunctions/Occlusion et dysfonctions temporo-mandibulaires

John NasedkinVancouver, British Columbia | [email protected]

Implant Dentistry/Dentister ie implantaireDwayne Karateew

Vancouver, British Columbia | [email protected]

Esthetic Dentistry / Dentister ie esthétiqueParesh Shah

Winnipeg, Manitoba | [email protected]

MANAGING EDITOR/DIRECTEUR DE LA RÉDACTION

Scott [email protected]

CONTRIBUTORS/CONTRIBUTEURSPeter Barry | Michelle Bourassa | Glauber Vieira Duarte

Gustavo Pinheiro de FreitasAnderson Pinheiro de Freitas | Cornell H. Driessen

David J. Clark | Hubert Gaucher | Les KallosRénald Pérusse | Gildo Santos Jr.

Maria Jacinta Moraes Coelho Santos

ART DIRECTOR/DESIGN /DIRECTEUR ARTISTIQUE/DESIGN

Binda [email protected]

SALES AND CIRCULATION COORDINATOR/COORDONATRICE DES VENTES ET DE LA DIFFUSION

Brenda [email protected]

TRANSLATION/TRADUCTIONVictor Loewen / Gladys St. Louis

ACCOUNTING / COMPTABILITÉSusan McClung

GROUP PUBLISHER / CHEF DE LA DIRECTIONJohn D. Birkby

[email protected]_____________________________________________

CJRDP/JCDRP is published four times annually by Andrew JohnPublishing Inc. with offices at 115 King StreetWest, Dundas, On, CanadaL9H 1V1. We welcome editorial submissions but cannot assume respon-sibility or commitment for unsolicited material. Any editorial material,including photographs that are accepted from an unsolicited contributor,will become the property of Andrew John Publishing Inc.

FeedbackWewelcome your views and comments. Please send them to Andrew JohnPublishing Inc., 115 King Street West, Dundas, On, Canada L9H 1V1.Copyright 2008 by Andrew John Publishing Inc. All rights reserved.Reprinting in part or in whole is forbidden without express written con-sent from the publisher.

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Publications Agreement Number 40025049ISSN 1916-7520

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Content/Sommaire

ACADEMY NEWS / NOUVELLES DE L’ACADÉMIE9 CARDP–APC 2008 Scientific Meeting in Review /

Revue du congrès ACDRP – APC 2008

FEATURES/ARTICLES

4 Share your Knowledge / Mise en commun de votre savoir5 Message from the Editor-in-Chief6 Message du rédacteur en chef8 CARDP Committee Structure and Members /

Structure des comités et membres de l’ACDRP

DECEMBER / DÉCEMBRE 2008

INDICATES PEER REVIEWED/INDIQUE REVUE DES PAIRS

Dental Materials /Matériaux dentaires12 Composite Core Build-Up with

Prefabricated Posts: An In VitroStudyBy Dr. Glauber Vieira Duarte DDS,MSc; Dr.Gustavo Pinheiro de Freitas, DDS,MSc; Dr. CornellH. Driessen, DDS,MSc, PhD; Dr. Maria JacintaMoraes Coelho Santos, DDS,MSc, PhD; Dr.Anderson Pinheiro de Freitas, DDS,MSc, PhD; andDr. Gildo Coelho Santos Jr., DDS, MSc, PhD

Médecine buccale

17 Comment mettre l’eau à labouche d’un patient souffrant dexérostomie: principes générauxPar Dre Michelle Bourassa, B Pharm,MSc, DMD etDr. Rénald Pérusse DMD,MD, LMCC, FRCD(C), C.S.(ODQ)

Oral Medicine

24 Making Their Mouths Water:General Principles for TreatingXerostomia PatientsBy Dre Michelle Bourassa, B Pharm,MSc, DMD andDr. Rénald Pérusse DMD,MD, LMCC, FRCD(C), C.S.(ODQ)

Practice Management /Gestion de cabinet

28 Vital Interactions: The Chemistryof a Championship Dental TeamBy Mr. Peter Barry, CMC, RRDH

Micro Restorative Dentistry /Micro dentisterie restauratrice

35 Operating Microscopes and Zero-Defect DentistryBy Dr. David J. Clark, DDS

935 12

The cover of this issue is an image of CabotTower on Signal Hill, a Canadian NationalHistoric Site in St. John's, Newfoundland.

CJRDP Editorial Board/Le comité de rédaction JCDRP

Editor-in-Chief/Rédacteur en chef

HUBERT GAUCHERQuébec City, Québec

Associate Editors/Rédacteurs associés

EMMANUEL J. RAJCZAKHamilton, Ontario

MAUREEN ANDREAChester, Nova Scotia

DENNIS NIMCHUKVancouver, British Columbia

Section Editors/Section éditeursOcclusion and Temporo-Mandibular

Dysfunctions/Occlusion et Dysfonctionstemporo-mandibulaire

JOHN NASEDKINVancouver,British Columbia

Implant Dentistry/Dentisterie implantaire

DWAYNE KARATEEWVancouver,British Columbia

Esthetic Dentistry / Dentisterie esthétique

PARESH SHAHWinnipeg, Manitoba

V O L U M E 1 • I S S U E 3

MISE ENCOMMUN DEVOTRE SAVOIR

Chers membres,

Notre Journal vous invite à con-tribuer vos évaluations écrites afin d’of-frir une source additionnelle d’informa-tion à nos lecteurs.

Vous avez récemment fait lectured’un article ou d’un livre portant sur laMédecine dentaire et vous souhaitezpartager votre appréciation de son con-tenu et de son impact sur votre pratique?Prenez un moment pour transmettre parcourriel vos commentaires et recom-mandations à notre Rédacteur à [email protected] Partagez votre savoir.

Nous apprécions votre participation.

L’équipe éditoriale

SHARINGYOUR

KNOWLEDGE

Dear fellow Members,

The Academy’s Journal welcomesyour written contributions as an addi-tional source of information for ourreadership.

Have you recently read a professionalarticle or textbook and wish to shareyour appreciation of its content andimpact on your practice? Take a momentto e-mail your comments and recom-mendations to the Editor [email protected]. Share yourknowledge.

We look forward to your input.

The Editorial Board.




The official publication of the Canadian Academy ofRestorative Dentistry and Prosthodontics


NEW SECTION / NOUVELLE SECTION

Decembre 2008Journal canadien de dentisterie restauratrice et de prosthodontie4

Turning our sight from West to East inthis gigantic country of ours, I would

like to salute our colleagues fromCanada’s easternmost province,Newfoundland and Labrador, and informthem of our Academy’s activities as wellas our upcoming 2009 annual scientificmeeting to be held in Montréal nextSeptember 23−26.

The cover of this Issue of our Journalfeatures the capital, St. John’s. I have hadthe good fortune of becoming acquaintedwith Newfoundland and can safely say thatit is one of Canada’s best kept secrets. It isnow my pleasant mission to promote thisAtlantic province and to invite its restora-tive and prosthodontic confederates tokeep abreast of our activities andannouncements by regularly visiting ourAcademy’s website at www.cardp.ca

One of the editorial board’s mainobjectives is to circulate scientific contentto its readers as well as acquaint them withother current issues liable to be of interestand use to them. In so doing, we strive toincrease contributions and services to allCanadian dentists and to ultimately wel-come them into our Academy.

Before I introduce the articles appear-

ing in this Journal, I would like to sincerelythank our contributors for submitting theirwork, several of them for the second orthird time.

In this Issue, the third Oral Medicinearticle on xerostomia, presented by DrsMichelle Bourassa and Rénald Pérusse,focuses on related therapies including sali-vary substitutes, sialogogues, and the pre-ventive measures required to reducesequelae.

In our Practice Management series Mr.Peter Barry reminds us that our “peopleskills” are just as important as our techni-cal competence. Conflict resolution ispassé as a concept and has transitioned to“connection management,” a “proactive”tool that emphasizes teamwork.

Dr. David Clark’s second article under-lines the evolution of triage in the assess-ment of dental pathologies. Restorativedentistry now being inextricably linked toimplant dentistry, we are short changingour practice by not availing ourselves ofmicroscope technologies.

Might I beseech Dr. Clark to follow up,with a subsequent article on the practicemanagement concerns related to introduc-ing microscope technologies into a restora-

tive/prosthodontic practice?The section on Dental Materials fea-

tures Dr. Gildo Santos and his co-authors’original in vitro assessments of the effectof specific pre-fabricated posts on therelated strengths of resin composite corebuild-up. The authors recommend cautionwhen using these pre-fabricated posts inclinical cases presenting adequate soundtooth structure.

This seems an appropriate place to callupon our readers to contribute their ownexperiences with various therapies and bydoing so, jumpstart our new section: ShareYour Knowledge / Mise en commun devotre savoir. The goal is to facilitate theflow of valuable information and opinion(using e-mail) generating from your ownpractice.

As 2008 winds down, and during thehectic upcoming Holidays, let’s not forgethow very fortunate we are, and that luckhad at least something to do with our get-ting here. So many others have not been asblessed as they wrestle with economichardship or struggle to achieve peace. OurEditorial Board members join me in wish-ing you and yours a fulfilling HolidaySeason.

Dr. HubertGaucher

Editor-in-Chief

Greetings to OurEasternmost Colleagues

This past September our Academy hosted a resoundingly successful annualmeeting in Vancouver. Thanks to the meeting co-chairs, Les Kallos and AshVarna, plus numerous dedicated committees of our members, the scientificand social programs were topnotch, as were the Industry exhibits that benefitedmembers and guests alike.

MESSAGE FROM THE EDITOR-IN-CHIEF

Canadian Journal of Restorative Dentistry and ProsthondonticsDecember 2008 Canadian Journal of Restorative Dentistry and Prosthondontics 5

Decembre 2008Décembre 2008

MESSAGE DU RÉDACTEUR EN CHEF

En survolant du regard notre immensepays de l’ouest à l’est, j’aimerais saluer

nos collègues de la province canadiennela plus orientale, c’est-à-dire Terre-Neuveet Labrador, et leur communiquer lesactivités de notre Académie ainsi que denotre réunion scientifique annuelle quiaura lieu à Montréal du 23 au 26 septem-bre prochain.

Sur la couverture de ce numéro duJCDRP figure la capitale, St-John’s. J’ai eula chance de connaître Terre-Neuve et jepeux affirmer sans la moindre hésitatitonque c’est l’un des secrets les mieux gardésdu Canada. J’ai maintenant l’heureuse mis-sion de promouvoir cette province del’Atlantique et d’inviter nos acolytes endentisterie restauratrice et prosthodon-tique à se tenir au courant de nos activitésen visitant régulièrement le site de notreAcadémie à www.cardp.ca

L’un des objectifs principaux de notrecomité de rédaction est de diffuser un con-tenu scientifique à ses lecteurs et de lesmettre au diapason d’autres questions d’ac-tualité qui pourraient les intéresser et leurêtre utiles. Ce faisant, nous cherchons àaugmenter notre contribution et nos serv-ices à tous les dentistes canadiens et,ultimement, les inviter à joindre les rangs

de notre Académie.Avant de vous présenter les articles qui

paraissent dans ce numéro, j’aimeraisremercier tout particulièrement ceux etcelles qui y ont participé, certains pour ladeuxième ou troisième fois.

Donc dans ce numéro, le troisièmearticle de la médecine buccale portant surla xérostomie, rédigé par les Drs MichelleBourassa et Rénald Pérusse, accentue lestraitements qui y sont associés, notammentles substituts salivaires, les sialogogues etles mesures de prévention nécessaires à laréduction des séquelles possibles.

Dans notre série de gestion de la pra-tique, M. Peter Barry nous rappelle quenos aptitudes en relations humaines sontaussi importantes que notre compétencetechnique. La résolution de conflits estchose du passé en tant que concept et estmaintenant remplacée par la gestion deconnexion, un outil pro-actif qui favorisele travail d’équipe.

Le deuxième article du Dr David Clarkmet en évidence l’évolution du triage dansl’évaluation de pathologies dentaires.Puisque la dentisterie restauratrice estaujourd’hui indissociable de l’implantolo-gie, nous serions perdants si nous ne profi-tions pas des techniques de la microscopie.

Puis-je solliciter du Dr Clark un autrearticle sur les enjeux de la gestion de pra-tique concernant l’introduction de cestechniques microscopiques dans un cabi-net de dentisterie restauratrice et prostho-dontique?

La section sur les matériaux dentairesrédigée par le Dr Gildo Santos et ses co-auteurs discute des évaluations in vitro del’effet de pivots préfabriqués spécifiques surla force des résines composites. Les auteursrecommandent la prudence lors de l’utili-sation de ces pivots préfabriqués dans lescas cliniques présentant une structure den-taire adéquate et saine.

Voici l’endroit idéal pour demander ànos lecteurs de nous communiquer leursexpériences personnelles avec divers traite-ments et ce faisant, nous lançons notrenouvelle section : Share YourKnowledge/Mise en commun de votresavoir. Ainsi, au moyen du courrier élec-tronique, vous pourrez échanger vos avis etcommentaires et nous transmettre desrésultats obtenus dans votre propre pra-tique.

Comme nous approchons la fin de l’an-née 2008, et durant cette période des Fêtes,il ne faudrait surtout pas oublier que noussommes paticulièrement privilégiés et qu’ily a toujours une part de chance dans notrecheminement. D’autres, beaucoup moinsfortunés, se heurtent contre des obstaclespécuniaires insur-montables ou livrentbataille pour assurerla Paix. Les membresde notre comité derédaction se joignentà moi pour vous

Salutations ànos collègues de l’Est

En septembre dernier, notre Académie a tenu sa réunion annuelle à Vancouver.Grâce aux efforts concertés de Les Kallos et Ash Varna, ainsi qu’aux nombreuxcomités de membres dévoués, ce fut un succès éclatant. Les présentations sci-entifiques et les programmes d’activités sociales étaient de premier ordre.Aussi, les membres et invités ont pu profiter des expositions de très haut cali-bre de l’Industrie dentaire.

Journal canadien de dentisterie restauratrice et de prosthodontie6

COMMITTEE STRUCTURE AND MEMBERSSTRUCTURE DES COMITÉS ET MEMBRES

The main governing body is made up ofthe executive council, which consists of:The President, President Elect, PastPresident, Vice President, and SecretaryTreasurer.

This year, these positions are filled by:

PresidentDr. Stanley Blum

President ElectDr. Vernon Shaffner

Vice PresidentDr. Kim Parlett

Past PresidentDr. Michael Racich

Secretary TreasurerDr. Les Kallos

The next governing body below this is thegroup of councillors made up of represen-tatives from the different regions ofCanada.They are:Dr. Maureen Andrea representing theAtlantic Region.Dr. David Blair representing Quebec andNunavut.Dr. Kim Parlett representing Ontario.Dr. Terry Kolteck representing Manitobaand Saskatchewan.Dr. Doug Lobb representing Alberta andthe Northwest TerritoriesDr. Myrna Pearce representing BritishColumbia and the Yukon.

Below this is the group of committeechairs and their committee members.The committees that exist at this point inthe academy are:CONVENTION COMMITTEE

Dr. Ash Varma, Powell River, BC andDr. Les Kallos, Burnaby, BC (Co-Chairs)

ADMISSIONS COMMITTEEDr. Mary Currie Pointe-Claire, QC(Chair)Dr. Maurice Wong, Vancouver, BCDr Myrna Pearce, Vancouver, BC

NOMINATIONS COMMITTEEDr. David Ellis, Kitchener, ON (Chair)Dr. Robert David, Montreal, QCDr. Dennis Nimchuk, Vancouver, BC

PUBLICATIONSDr. Gorman Doyle, Halifax, NS (Chair)

CONSTITUTION AND BY-LAWSCOMMITTEE

Dr. Dennis Nimchuk, Vancouver, BC(Chair)Dr. Gerald Skea, Thunder Bay, ONDr. Patrick Arcache, Montreal, QC

PHOTO-ROSTER COMMITTEEDr. Peter Woolhouse, Westmount, QC(Chair)Dr. Baxter Rhodes, Ithaca, NYDr. Les Kallos, Burnaby, BC

SPECIAL FUNDS COMMITTEEDr. E.J. Rajczak, Hamilton, ON (Chair)Dr. Andrew Tynio, Toronto, ONDr. Larry Pedlar, Burlington, ONDr. Ed McIntyre, Edmonton, AB

COMMUNICATIONS COMMITTEDr. Ian Tester, St. Catherines, ON(Chair)Dr. David Blair, St. Lambert, QCDr. Brian Friesen, Winnipeg, MB

CONTINUING EDUCATIONCOMMITTEE

Dr. Jim Donaldson, Thunder Bay, ON(Chair)Dr. Ed McIntyre, Edmonton, AB

HISTORIANDr. William Sehl, Waterloo, ON

CORPORATE LIASON COMMITTEEDr. Dennis Nimchuk, Vancouver, BC(Chair)Dr. Ed McIntyre, Edmonton, ABDr. Cary Letkemann, Ancaster, ONDr. Larry Pedlar, Burlington, ONDr. Maureen Andrea, Chester, NSDr. E.J. Rajczak, Hamilton, ON

LOCAL ARRANGEMENTS COMMITTEE(Appointed by the President)

Dr. Robert David. Montreal, PQ(Chair)

The Canadian Academy of Restorative Dentistry and Prosthodontics

CARDP consists of many volunteers that donate a lot of their time and talents. Below is an outline of the council andcommittee structure of the academy.

Décembre 2008Decembre 2008Journal canadien de dentisterie restauratrice et de prosthodontie8

ACADEMY NEWS/NOUVELLES DE L’ACADÉMIE

Canadian Journal of Restorative Dentistry and Prosthondontics

CARDP members and guests gathering for a day of kayaking.

The one that didn’t get away!

President Dr. Stanley Blum supported by President - Elect Dr. VernonShaffner (left) and Past President Dr.Michael Racich (right) at thePresident’s Gala.

December 2008December 2008

In Vancouver this past September, the Canadian Academy ofRestorative Dentistry and Prosthodontics (CARDP) was proudto host its16th annual Scientific Session –this year with the dis-tinct pleasure of also having the participation of the Associationof Prosthodontists of Canada.

Meeting Co-Chairs Drs. Les Kallos and Ash Varma put togeth-er an outstanding array of pre-conference social and academicactivities. From ocean kayaking about the Pasley Islands and stur-geon fishing on the Fraser River to a hands-on-course at theUniversity of British Columbia, opportunities to interact withother delegates abounded. Other events such as the golf tourna-ment, the Vancouver Culinary Experience, the ExperienceVancouver: Reception and Dinner, and the President’s Gala round-ed out the social possibilities.

Scientific and Clinic Chairs Drs. Ron Zokol and Myrna Pearceorganized a talented group of academicians, clinicians, and manu-facturers for a stimulating two days of learning, sharing, andexploring. The terrific line-up of speakers featured:

Dr. Harry Rosen on “The Blending of Art and Science inDentistry”

Mr. Tom Lee on “Simplified Articulation for Esthetics andFunction

Dr. Loïc Legendre on “Restoration and Prosthodontics inVeterinary Patients”

Dr. Dennis Nimchuk on “Dogma and Controversies inImplantology”

Dr. Sonia Leziy on “The Next Dimension in ImplantAesthetics: An Architectural Plan and Vision for Success:

Dr. Terry Donovan on “Evidence-Based Selection ofContemporary Ceramic Systems”

Dr. Robert Miller on “Oral Implantology: Yesterday, Today,and Tomorrow”

Dr. Yvan Fortin on “Implant Restoration of the Moderate toSeverely Resorbed Edentulous Maxilla without Bone Grafting”

Dr. Charles Goodacre on “A new Era for Occlusion: The Use of3D digital Technology to Enhance Education and Understanding”

Dr. Maxwell Anderson on “Good Plaque and Management ofDental Diseases”

Dr. Byoung Suh on “Research-Based Adhesion Dentistry”Dr. Dorin Ruse on “Adhesive Dentistry – What and How

Based on Understanding Why”Dr. Edward Lowe on “Modern Esthetic Restorative Materials –

clinical Challenges and Considerations”

Canadian Journal of Restorative Dentistry and Prosthondontics 9

CARDP–APC 2008 Scientific Meeting in Review /Revue du congrès ACDRP–APC 2008

September 10-13th, Vancouver, BC / 10-13 septembre, Vancouver, CB

Secretary-Treasurer, Dr. Les Kallos greeting one of our Montréal mem-bers, Dr. Patrick Arcache, at the President’s Dinner-Gala.

Mr. Ron Suh, Bisco Dental sharing his insights with Dr. Dorin Ruse, UBCFaculty of Dentistry.

Dr. Harry Rosen getting a warm reception from Dr.Myrna Pearce. Learning from Table Clinics.

Décembre 2008Décembre 2008Journal canadien de dentisterie restauratrice et de prosthodontie

We hope you enjoyed this year’s CARDP meeting and the exciting city of Vancouver

Nous espérons que vous avez apprécié le congrès annuel de l’ACDRP ainsi que l’excitante ville de Vancouver.

We look forward to seeing you again at next year’s CARDP meeting in the dynamic city of Montréal.

Nous espérons vous revoir lors de notre congrès annuel de l’ACDRP l’an prochain dans la dynamique ville de Montréal.

ACADEMY NEWS

10

DENTAL MATERIALS / MATÉRIAUX DENTAIRES

Strength of a Resin CompositeCore Build-Up with Prefabricated

Posts: An In Vitro StudyBy Glauber Vieira Duarte, DDS,MSc; Gustavo Pinheiro de Freitas, DDS,MSc; Cornell H Driessen, DDS,MSc, PhD;Maria JacintaMoraes Coelho Santos, DDS,MSc, PhD; Anderson Pinheiro de Freitas, DDS,MSc, PhD; Gildo Coelho Santos Jr., DDS,MSc, PhD

ABSTRACTPurpose: Determine the diametral tensile strength (DTS) of a resin composite core (Filtek Z250- 3M) bonded to glass and carbon fibre posts of varying diameter.Material and Methods: Part I, cylindrical samples of resin composite (C), measuring 6 mm ×

3 mm, were fabricated (n = 10). Another two groups consisted of 1.5 mm glass-fibre posts(Reforpost - Angelus) (GF1.5) and 1.5 mm carbon-fibre posts (Reforpost - Angelus) (CF1.5) bond-ed to the resin disks. Part II, specimens were made using 1.1 mm glass-fibre post (GP1.1), and 1.1mm carbon-fibre post (CF1.1). Specimens were light cured for 40 seconds each side, stored in37ºC distilled water for 7 days and submitted to a DTS test in a universal testing machine (EMICDL2000). Data was recorded and analyzed using ANOVA with post-hoc pairwise test. Resultsrevealed a statistically significant difference (p <.001) among the groups.Results: Part I, the mean force (MPa) required to fracture the specimens for each group was:C: 52.33 (± 5.97), GF 1.5: 33.46 (± 4.35), CF 1.5: 35.74 (± 4.49). Control Group was significantlygreater than the experimental groups but there was no difference between the two experi-mental groups. Part II, the mean force (MPa) for each group was: GF 1.1: 37.81 (± 4.46), andCF 1.1: 32.93 (± 3.53). Group GF 1.1 was significantly greater than GF 1.5 and CF 1.1, similar to GC 1.5,

12 Journal canadien de dentisterie restauratrice et de prosthodontie Decembre 2008Décembre 2008

About the AuthorsGildo Coelho Santos Jr., is assistant professor, University ofWestern Ontario, Schulich School of Medicine and

Dentistry, London, ONGlauber Vieira Duarte is with the Faculty of Dentistry, Federal University of Bahia, Brazil.

Gustavo Pinheiro de Freitas is with the Faculty of Dentistry, Federal University of Bahia, Brazil.Cornell H. Driessen is assistant professor, University ofWestern Ontario, Schulich School of Medicine and

Dentistry, London, ONMaria Jacinta Moraes Coelho Santos is associate Professor, Department of Dental Clinics, Faculty of Dentistry, Federal University of

Bahia, Brazil.Anderson Pinheiro de Freitas is associate professor, Department of Dental Clinics, Faculty of Dentistry, Federal University of Bahia,

Brazil.Correspondence may be directed to Gildo C. Santos Jr. He can be reached at: [email protected].

Cast posts have been used in restora-tive dentistry for more than 100

years.1 The main disadvantage of castposts is the high modulus of elasticity ofthe metal, which exceeds by 8 to 15 timesthe modulus of elasticity of the dentin.This leads to a high incidence of fractureof the root due to a high stress concentra-tion at the tooth-post interface.2Moreover, cast posts require more fre-quent clinical sessions, more extensiveremoval of dental structure, and maystain the adjacent root area.3

Prefabricated posts are now widelyavailable and are made of carbon, glass, orquartz fibres. These posts have a modulusof elasticity similar to the dentin and allowthe post to have the same flexion pattern

as the tooth, thereby providing a homoge-neous distribution of stress on the root andminimizing the incidence of root frac-tures.4,5

The advantages of prefabricated postsare: they involve less tooth removal,require less time to prepare, are easilyremoved, are more esthetic, are available indifferent diameters, and adhere better tothe dental structure and the crown.3,6

When non-metallic prefabricated postsare used in the restoration of endodonti-cally treated teeth, a crown restoration canbe prepared at the same appointment asthe resin core is being built and the twocomponents can be bonded together toform a single unit.7,8

Fokkinga et al.9 investigated the frac-

ture resistance and failure mode of crownsfabricated with fibre posts bonded to aresin composite core. The types of postsused were: (1) prefabricated metallic posts,(2) prefabricated fibreglass posts (3) castposts, and (4) no posts (disks of solid resincomposite). A static load was applied untilthe fracture of the samples using a univer-sal testing machine. Results were similarfor fracture resistance and failure modeamong the groups, which suggests thatposts did not decrease the fracture resist-ance of the crowns.

Heydecke et al.10 studied the fracturestrength and survival rate of endodontical-ly treated crowned maxillary incisors withproximal class III cavities and differentcore build-ups including titanium posts,

SANTOS ET AL.

13Canadian Journal of Restorative Dentistry and ProsthondonticsDecember 2008December 2008

and CF 1.1 showed a lower value statistically significant difference to CF 1.5.Conclusion: The fibre posts used in this study have a negative effect on the fracture resistanceof the resin composite material.Clinical Implications: If the tooth has adequate sound structure, the use of prefabricated postsshould be avoided.

RÉSUMÉObjectif : Déterminer la force de tension diamétrale d’un noyau de résine composite (FiltekZ250 - 3M) lié à des pivots en fibre de verre et en fibre de carbone de diamètre différent.Matériel et méthodes : Partie I, des échantillons cylindriques de résine composite (C),mesurant6 mm sur 3 mm, ont été fabriqués (n = 10). Deux autres groupes étaient composés de pivots de1,5 mm en fibre de verre (Reforpost - Angelus) (GF 1,5) et de pivots de 1,5 mm en fibre de carbone(Reforpost - Angelus) (CF 1,5) liés à des disques en résine. Partie II, les spécimens ont étéfabriqués en utilisant un pivot de 1,1 mm en fibre de verre (GP 1,1), et un pivot de 1,1 mm en fibrede carbone (CF 1,1). Les spécimens ont subi une photopolymérisation de 40 secondes de chaquecôté, ont été conservés dans de l’eau distillée à 37 ºC pendant 7 jours et soumis à un test de forcede tension diamétrale dans une machine universelle (EMIC DL2000). Les données ont étéenregistrées et analysées selon la méthode ANOVA et le test par paires a posteriori. Les résul-tats ont révélé une différence statistiquement significative (p <0,001) parmi les groupes.Résultats : Partie I, la force moyenne (MPa) requise pour entraîner la rupture des spécimens dechaque groupe était : C: 52,33 (± 5,97), GF 1,5: 33,46 (± 4,35), CF 1,5: 35,74 (± 4,49). Le groupetémoin était significativement plus important que les groupes expérimentaux,mais il n’y avaitpas de différence entres les deux groupes expérimentaux. Partie II, la forcemoyenne (MPa) pourchaque groupe était : GF 1,1: 37,81 (± 4,46), et CF 1,1: 32,93 (± 3,53). Le groupe GF 1,1 était signi-ficativement plus important que le groupe GF 1,5 et CF 1,1, semblable à GC 1,5, et CF 1,1 a démon-tré une différence statistiquement significative de valeur inférieure à CF 1,5.Conclusion : Les pivots utilisés dans cette étude ont un effet négatif sur la résistance de rupturede la résine composite.Conséquences cliniques : Si la dent a une structure solide, l’utilisation de pivots préfabriquésdevrait être évitée.

37ºC distilled water for 7 days.After seven days of distilled water stor-

age, specimens were subjected to compres-sive loading in a universal testing machine(EMIC DL2000) with a load cell of 2.000kg at 1 mm/min of crosshead speed. Eachsample was oriented horizontally on theplatform of the machine and a DTS testwas performed. Load was applied until fail-ure of the resin core specimen occurred.The force (N) needed to fracture the sampledisc was converted into megapascal (MPa).

A one-way analysis of variance(ANOVA) was used to determine whetherthere was any difference among the threegroups means (C, GF 1.5, and CF 1.5). TheTukey-Kramer test was used for pair-wisecomparisons. A p value <.05 was consid-ered to be statistically significant and a25% difference in effect size was consid-ered to be clinically significant.

Part II – Effect of Diameter of FibreIn part II, new specimens were made,using 1.1 mm diameter glass fibre post andresin composite core (Group GF 1.1), andusing 1.1 mm diameter carbon fibre postand resin composite core (Group CF 1.1)following the same procedures describedabove.

ResultsThe results of the DTS test are presented inTable 2. In part I, Group C (control group)displayed the highest mean DTS value,while Groups CF 1.5 and Group GF 1.5presented similar, but showed lower frac-ture resistance values. The fracture resist-ance of Group CF 1.5 was slightly greaterthan that of Group GF 1.5. The amount of

STRENGTH OF A RESIN COMPOSITE CORE BUILD-UP WITH PREFABRICATED POSTS

Decembre 2008Décembre 2008

zirconia posts; hybrid composite fillingpartially the root canal, and access openingrestored with resin composite. They foundthat the cementation of posts was compa-rable, but there was no evidence of advan-tageous fracture resistance when comparedto the restoration of the endodonticallytreated tooth with composite alone.

The purpose of this study was to deter-mine (1) the DTS of resin core materialwhen bonded to prefabricated posts withdifferent fibres, (2) the DTS of a resin corebonded to prefabricated posts with differ-ent diameters.

The null hypothesis is that there is nodifference in DTS of the resin compositecore material when bonded to glass fibreor carbon fibre prefabricated posts, or toposts with different diameters when com-pared to the resin core material alone.Materials and MethodsPart I – Effect of Type of FibreTwo commercial, fibre-reinforced, com-posite posts were tested. Materials used arelisted in Table 1.

Thirty disc specimens were fabricatedwith a resin composite material (FiltekZ250 – 3M/ESPE) using a two-part, stain-less steel dye. The inferior portion, meas-uring 80 mm in diameter with a centralperforation of 2 × 1 mm, was used to posi-tion the pre-fabricated posts (Figure 1).The superior portion, measuring 70 mmin diameter, had a central perforation of6 mm in diameter and 3 mm in depth. Thecentral perforation of the inferior portionallows the positioning of a prefabricatedpost into the center of the specimen that isformed in the superior portion.5 Threegroups of resin composite core specimenswere prepared with this device, each con-sisting of 10 specimens. Resin compositediscs without posts served as control group(Group C). The remaining specimens weremade using either glass or carbon-rein-forced post and resin composite core com-binations as follows: Reforpost (GlassFibre) 1.5 mm diameter glass fibre post(Group GF 1.5) and Reforpost (Carbon

Fibre) 1.5 mm diameter carbon fibre posts(Group CF 1.5).

Group C specimens were fabricated byinserting the resin composite (Filtek Z250– 3M ESPE) into the stainless steel dyeusing a spatula and then the resin waslight-cured for 40 seconds (Optilight PlusQTH unit – Gnatus – 540mW/cm2). Thesamples were removed from the dye, light-cured on the opposite surface for another40 seconds and then stored in 37ºC dis-tilled water for seven days.

Group CF 1.5 and Group GF 1.5 speci-mens were prepared using an additionalstep. Prior to their insertion into the lowerportion of the dye, the posts were cleanedwith 97% ethyl alcohol in accordance withthe manufacturer’s instructions to preventcontamination. Silane (Silane Agent –3M/ESPE) was applied to the cleaned postsfor 60 seconds, air-dried and a layer ofadhesive (Single Bond 2 – 3M/ESPE) wasapplied and gently air-dried to facilitatesolvent evaporation and light-cured for40 seconds (20 seconds in each side of thepost). The fibre post was then placed intothe central perforation of the inferior partof the dye and a resin composite was fabri-cated similar to Group C and light-curedfor 40 seconds (Figure 2). The resin discwith the fibre post was removed from themould, the bottom surface was light-curedfor another 40 seconds and then stored in

Table 1. Materials UsedBrand Composition ManufacturerREFORPOST Fibreglass post (1.5 mm and 1.1 mm) AngellusREFORPOST Carbon fibre post (1.5 mm and 1.1 mm) AngellusFiltek Z250 Composite resin – Type II 3M ESPESingle Bond Bonding agent 3M ESPESilane Silane 3M ESPE

14 Journal canadien de dentisterie restauratrice et de prosthodontie

Figure 1.Metallic matrix. Figure 2. Light-curing a sample.

SANTOS ET AL.

force required to fracture the resin discwas 31.7% less for Group CF 1.5 and 36%less for Group GF 1.5 when compared toGroup C.

The ANOVA indicated that the meanforce required to fracture the resin discwas statistically significant among thegroups (p <.001). Post hoc, pairwise com-parisons using the Tukey-Kramer testrevealed a statistically significant differ-ence in mean fracture resistance of bothGroup CF 1.5 and Group GF 1.5 comparedto the control group (p <.05). The differ-ence in mean fracture resistance betweenGroup CF 1.5 and Group GF 1.5 was notstatistically significant (p >.05). Allassumptions respecting ANOVA were sat-isfied.

In part II, the reduction of the glassfibre post diameter increased the fractureresistance of the resin core, while thereduction of the carbon fibre post diameterdecreased the final strength of the core.

The amount of force required to frac-ture the resin disc was 27.7% less forGroup GF 1.1 and 37.9% less for Group CF1.1 when compared to Group C. These dif-ferences were deemed to be statisticallysignificant.

Post hoc, pairwise comparisons usingthe Tukey-Kramer test revealed that thefracture resistance of Group GF 1.1 wassignificantly greater than that of Group GF1.5 and CF 1.1 (p >.05). The comparison ofthe mean fracture resistance betweenGroup CF 1.1 and Group CF 1.5 showed astatistically significant difference (p <.05).There were no statistical differencebetween Groups GF 1.1 and CF 1.5.

The SEM image of the surface of afragment of a specimen made with glassfibre post at 500× magnification showed acohesive failure of the post occurred, thusexposing the fibres (Figure 3). All of thespecimens bonded to a post and fracturedat the same point within the post materialadjacent to the bond between the post andthe resin core.

The scanning electron microscope(SEM) image of a fragment of a specimenmade with carbon fibre post at 500× mag-nification displays cohesive failure alsooccurred with this type of post as evi-denced by a peeling of the surface layer ofthe post occurred upon fracture (Figure 4).This image shows that the carbon fibresare relatively smaller in diameter whencompared to the glass fibres.

DiscussionDifferent mechanical tests havebeen used to evaluate the bondstrength of fibre posts whenbonded to a resin compositebuild-up core.11 The DTS is anevidence-based testing methodbecause of its simplicity, unifor-mity and reproducibility. It isconsidered an important assayfor simulating in-vitro, the tensilestress to which dental restora-tions are subjected in the oralcavity.11,12

Thermocycling was notapplied to the specimens.According to Purton et al. ther-mocycling should be given less

emphasis in tests for the retention of rootcanal posts cemented with resin cements.13

In another study investigating theeffects of pre-treatment on bond strengthbetween resin cements and various postsincluding prefabricated glass fibre postsand Interpenetrating Polymer Post (IPNpost, Stick Tech), it was found that ther-mocycling had no significant influence.14

Cho et al.15 verified the DTS of tworesin composites (XRV Herculiteand Prodigy) for core build-up.They tested samples with thesame diameter as the specimensevaluated in this study (6 mm ×3 mm) and reported average DTSvalues of 51 MPa and 55 MPa,respectively. Santos Jr. et al.5 alsoinvestigated a resin compositecore build-up material (Tetric-Ceram) and reported mean val-ues of DTS of 54 MPa. Thoseresults are similar to our studywhere the average DTS value forthe resin composite core (Z250)was 52.3 MPa.

In this study, the use of glassfibre and carbon fibre posts decreased thefracture resistance of the core build-upmaterial by 31.7% for CF 1.5 and 36.1% forGF1.5 respectively. Results demonstratedthat the resin composite core material pro-vides higher fracture resistance when usedas a solid block.

The use of carbon fibres or glass fibresto prepare the posts did not result in anydifference of strength of the samples,although there was difference in width ofthe fibreglass fibres compared to the car-bon fibres.


Figure 3. Fibre Post – 500 x original magnification showingpost and resin composite.

Figure 4. Carbon Post – 500x original magni-fication showing post and resin composite.

Table 2. Mean force (MPa) required to fracture core specimen, by groupGroup Mean SD SE % Difference from Control HGGroup (C) 52.33 5.97 1.88 aGF 1.1 37.81 4.46 1.41 -27.75% bCF 1.5 35.74 4.49 1.42 -31.70% bcGF 1.5 33.46 4.35 1.37 -36.10% cdCF 1.1 32.93 3.53 1.11 -37.08% d

HG = Homogeneous Groups – Different letters means statistic difference among groups.

Both carbon fibre and glass fibre postswith 1.5 mm diameter displayed similarbehaviour to compressive forces but differswhen 1.1 mm fibre posts where used.

The increasing on the diameter of theglass fibre post decreases the fractureresistance of samples.

AcknowledgmentWe would like to thank MeghanPerinpanayagam for her assistance to thepreparation of this manuscript.

DisclosureThe authors declare no competing finan-cial interest.

References1. Marchi GM, Paulillo LA, Pimenta LA, De

Lima FA. Effect of different filling materi-als in combination with intra-radicularposts on the resistance to fracture ofweakened roots. J Oral Rehabil2003;30(6):623–9.

2. Martinez-Insua A, da Silva L, Rilo B,Santana U. Comparison of the fractureresistances of pulpless teeth restoredwith a cast post and core or carbon-fibrepost with a composite core. J ProsthetDent 1998;80(5):527–32.

3. Campos TN, Arita CK,Missaka R, AdachiLK, Adachi EM. Influence of core materialsin the microleakage of cast crowns. CiencOdontol Bras 2005;8(4):13–7.

4. Aksornmuang J, Foxton RM,Nakajima M,Tagami J.Microtensile bond strength of adual-cure resin core material to glass andquartz fibre posts. J Dent 2004;32(6):443–50.

5. Santos Jr. GC, El-Mowafy O, Rubo JH.Diametral tensile strength of a resin com-posite core with nonmetallic prefabricat-ed posts: an in vitro study. J Prosthet Dent2004;91(4):335–41.

6. Heydecke G, Butz F, Strub JR. Fracturestrength and survival rate of endodonti-cally treated maxillary incisors withapproximal cavities after restoration withdifferent post and core systems: an in-vitro study. J Dent 2001;29(6):427–33.

7. O’Keefe KL,Miller BH, Powers JM. In vitrotensile bond strength of adhesivecements to new post materials. Int JProsthodont 2000;13(1):47–51.

8. El-Mowafy OM, Fenton AH, Forrester N,Milenkovic M. Retention of metal ceramiccrowns cemented with resin cements:effects of preparation taper and height. JProsthet Dent 1996;76(5):524–9.

9. FokkingaWA, Le Bell AM, Kreulen CM,Lassila LV, et al. Ex vivo fracture resistanceof direct resin composite completecrowns with and without posts on maxil-lary premolars. Int End J 2005;38(4):230–7.

10. Heydecke G, Butz F, Strub JR. Fracturestrength after dynamic loading ofendodontically treated teeth restoredwith different post-and-core systems. JProsthet Dent 2002;87(4):438–45.

11. Cohen BI, Penugonda B, Pagnillo MK, et al.Torsional resistance of crowns cementedto composite cores involving three stain-less steel endodontic post designs. JProsthet Dent 2000;84(1):38–42.

12. Nergiz I, Schmage P, Ozcan M, Platzer U.Effect of length and diameter of taperedposts on the retention. J Oral Rehabil2002;29(1):28–34.

13. Purton D, Chandler N, Qualtrough A.Effect of thermocycling on the retentionof glass fibre root canal posts.Quintessence Int2003;34(5):366–9.

14. Bitter K. Noetzel J. Neumann K.Keilbassa AM. Effect of silanization onbond strengths of fibre posts to variousresin cements. Quintessence Int2007;38(2):121–8.

15. Cho GC, Kaneko LM, Donovan TE,WhiteSN. Diametral and compressive strengthof dental core materials. J Prosthet Dent1999;82(3):272–6.

The reduction of the post diameter to1.1 mm (GF 1.1) increased the DTS valueswhen compared to the 1.5 mm glass fibreposts (GF 1.5). This may be explained dueto the increasing on the final volume of thecore material.

The behaviour of Groups CF 1.5 andCF 1.1 which results demonstrated that thebigger the diameter the higher the DTS(statistically significant) probably can beexplained because of the relatively smallerdiameter of the carbon fibres compared toglass fibres and the higher number of thefibres per volume.

All resin composite samples withbonded fibre posts demonstrated cohesivefailure. The failure occurs predominantlywithin the fibre-reinforced post along theinterface between the resin matrix and thepost. This finding suggests that the bondbetween the composite core material andthe post surface was stronger than thebond between the internal fibres and theresin matrix of the post.

This study showed a decrease in frac-ture resistance of resin composite corebuild up material when used in conjunc-tion with these particular glass and carbonfibre prefabricated posts. This finding indi-cates that the glass fibre or carbon fibreposts used in this study do not strengthenresin composite core build-up materials.Thus, if the tooth has adequate soundstructure, the use of prefabricated postsshould be questioned.

ConclusionThe use of carbon fibre and glass fibre pre-fabricated posts utilized in this study,bonded to resin composite core build-upmaterial decreased the fracture resistanceof resin core material by about one third.

STRENGTH OF A RESIN COMPOSITE CORE BUILD-UP WITH PREFABRICATED POSTS

Décembre 2008Decembre 2008Journal canadien de dentisterie restauratrice et de prosthodontie16

MÉDECINE BUCCALE

Comment Mettre L’eau à laBouche d’un Patient

Souffrant de Xérostomie:PRINCIPES GÉNÉRAUX

Dre Michelle Bourassa, B Pharm,MSc, DMDDr. Rénald Pérusse DMD,MD, LMCC, FRCD(C), C.S. (ODQ)

RÉSUMÉLa xérostomie est une plainte fréquemment rapportée par les patients qui consultent enmédecine dentaire. En plus de causer un inconfort, la diminution du débit salivaire a un impactnégatif sur la qualité de vie en affectant différentes fonctions dont la mastication, la dégluti-tion, l’élocution et peut être la source de nombreuses complications buccodentaires de natureinfectieuse.

Elle peut être associée à certaines conditions systémiques, principalement à caractère auto-immun, la plus fréquente étant la maladie de Sjögren ou résulter de la destruction des aciniglandulaires suite à la radiothérapie cervicofaciale.Mais la cause la plus fréquente demeure lesmédicaments pourvus d’une action anticholinergique et ceux qui modifient certaines com-posantes biologiques.

L’approche thérapeutique consiste premièrement à un examen soigneux allant à la recherchede la cause afin de la corriger lorsque possible. Dans le cas contraire, il y a lieu de recourir à des

Biographie sommaire des auteurs :L’auteure principale est détentrice d’un baccalauréat en pharmacie et d’une maîtrise en pharmacie d’hôpital.Par la suite, elle a poursuivi une formation en médecine dentaire complétée par une résidence en dentisteriemultidisciplinaire. Elle exerce en tant que dentiste généraliste en bureau privé et à l’Hôpital Laval (Institutuniversitaire de cardiologie et pneumologie de Québec), elle est dentiste consultante au sein de l’équipe desmaladies hématologiques congénitales sévères de l’est du Québec, aussi chargée d’enseignement à la facultéde médecine dentaire de Québec et dentiste bénévole à la Maison Michel Sarrazin de Québec.Elle peut être contacté à :[email protected]

Le Dr Rénald Pérusse est détenteur d’un doctorat en médecine dentaire et en médecine. Il enseigne et exercecomme spécialiste en médecine buccale à la faculté de médecine dentaire de l’Université Laval. Il est l’auteur oule co-auteur d’un volume, de trois cédéroms et de 52 publications scientifiques. Ses champs d’intérêt sont lesmanifestations orales des désordres systémiques, les urgences médicales et la pharmacologie dentaire.Il peut être contacté à: [email protected]

December 2008December 2008 Canadian Journal of Restorative Dentistry and Prosthondontics 17

Condition souvent rencontrée dans lapratique dentaire, la xérostomie est

un symptôme résultant d’une diminutionde la quantité de salive et d’une modifica-tion de sa composition.1−3 L’hyposali-vation traduit une réduction réelle dudébit salivaire alors que la xérostomie esten soi une expérience subjective desécheresse de la bouche fréquemment,mais pas toujours, associée à une réduc-tion du débit salivaire. Généralement, lespatients commencent à ressentir de la

xérostomie avec une réduction de moitiédu débit salivaire habituel.2

Dans la lancée des articles de laprésente série, celui-ci fera tout d’abordune brève révision de principes générauxrelatifs à l’étiologie de ce désordre. Par lasuite, les modalités thérapeutiques nonpharmacologiques et pharmacologiquesseront présentées. La dernière portionsuggérera des interventions ayant pourbut de prévenir ou de retarder les compli-cations qui y sont associées.

Complications associées à uneréduction du débit salivaireLa salive joue un rôle important àplusieurs égards dont entre autres, dansles fonctions gustatives, masticatoires etd’élocution, ainsi que dans la préventiondes infections des muqueuses et desdents.1,3,4 Les lecteurs désireux d’en con-naitre davantage au sujet des con-séquences possibles de la xérostomie sont


mesures palliatives et de mettre en place des mesures préventives afin de minimiser le risquede complications ou d’en retarder l’apparition.

Les premières mesures visent des éléments de la vie quotidienne et consistent à éviter les fac-teurs aggravant, à favoriser l’hydratation desmuqueuses par un apport hydrique suffisant, sansoublier l’humidification de l’air ambiant. De plus une plus grande production de salive peut êtreinduite par la prise plus fréquente de repas, la mastication de gomme à base de xylitol ou laconsommation de bonbons sans sucre. Pour certains patients le recours à un des agents deremplacement, appelé salives artificielles, peut aider à réduire l’inconfort. Dans les cas les plussévères, l’utilisation d’un sialogogue peut être bénéfique.

Dans tous les cas, un suivi très étroit de la condition du patient est indiqué. Des mesuresd’hygiène buccale strictes devraient être instaurées, accompagnées d’une diète à faible pouvoircariogène et généralement du fluor sous une forme adaptée à la situation du patient.

Algorithme du traitement de la xérostomie

Recherche de l’étiologie

Correction de la cause Cause non corrigible

Suivi étroit

Mesures palliatives :• Retrait des irritants: café, alcool• Arrêt du tabagisme• Hydratation : eau, glace

concassée, lait• Humidification de l’air ambiant• Mesures non pharmacologiques

de stimulation de la production desalive: augmentation de la fréquencedes repas, bonbons sans sucre,gomme au xylitol

Mesures pharmacologiques :• Salives artificielles :

MoiStir, Mouth Kote, Biotene.• Sialogogues :

Sialor, Salagen

Mesures préventives :• Diète non cariogène• Mesures rigoureuses

d’hygiène buccodentaire• Fluor topique (neutre)• Chlorhexidine (rince-bouche)• Antifongique si candidose

• Auto examen quotidien• Examens et nettoyages

professionnels fréquents etréguliers.

Figure 1. Algorithmedu traitement de laxérostomie

COMMENT METTRE L’EAU À LA BOUCHE D’UN PATIENT SOUFFRANT DE XÉROSTOMIE: PRINCIPES ÉNÉRAUX

19Canadian Journal of Restorative Dentistry and Prosthondontics

BOURASSA ET PÉRUSSE

December 2008December 2008

invités à consulter l’article paru dans l’édi-tion précédente de cette revue.

ÉtiologieLa cause la plus fréquente de xérostomieest sans contredit la prise de médicamentspourvus d’effets anticholinergiques. Desmédicaments possédant des mécanismesd’action autres peuvent aussi induire uneréduction de la production de salive. Uneliste non exhaustive des classes pharma-cologiques d’agents ayant été associés à ceteffet secondaire est présentée au tableau1.1,5−7 Bien que la maladie de Sjögren soitfréquemment responsable de la xéros-tomie, d’autres conditions systémiques ont

aussi été reconnues pour leur potentield’induire de la xérostomie par différentsmécanismes; le tableau 2 en dresse uneliste.1,2,5,7 La destruction des acini des glan-des salivaires, conséquence fréquente de laradiothérapie de la tête et du cou, peutaussi être responsable d’une réduction dudébit salivaire possiblement sévère etirréversible dans cette situation.1,4,5,7,8Fréquemment rencontrée chez les person-nes âgées de plus de 65 ans, la réduction dela fonction salivaire ne résulterait pas del’âge en soi mais serait plutôt associée à laprésence d’un désordre systémique ou à laprise de médicaments inducteurs de xéros-tomie.1,4,6

TraitementLa première mesure consiste à tenterd’établir l’étiologie de la xérostomie, afin decontrôler la pathologie sous-jacentelorsqu’elle est identifiée, ou encore de con-sulter le médecin traitant pour modifier lamédication lorsque cette dernière est sus-pectée en tant qu’agent causal de la xéros-tomie.4,9

Dans l’éventualité où la cause ne peutêtre corrigée, l’approche prend 2 volets, lepremier étant de nature palliative afin deprocurer le soulagement des symptômes etle second visant la prévention des compli-cations buccales associées à la réduction desalive.Mesures palliativesDes mesures générales et simples peuventaider à diminuer la sensation désagréablede bouche sèche. L’eau est la salive artifi-cielle la plus fréquemment utilisée etprésente plusieurs avantages.1 Tout d’abord,un apport hydrique adéquat, un minimumde 2 litres par jour est recommandé, àmoins que le patient souffre d’une condi-tion justifiant une restriction liquidienne.7,9L’apport peut se faire, par exemple, par depetites gorgées d’eau prises fréquemmentau cours de la journée.1,5 Également, l’ac-tion de croquer ou sucer des morceaux deglace peut aider à réduire l’inconfort chezcertains patients.5,7 Au cours de la nuit, laproduction de salive étant généralementréduite, la xérostomie est ainsi souventplus marquée pour le patient et l’utilisationd’un humidificateur au chevet peut aider àréduire la sécheresse buccale et en dimin-uer l’inconfort associé.4−6 De façongénérale, une augmentation de l’humiditédes muqueuses buccales peut aider àréduire les infections opportunistes.5

De part ses propriétés physiques etchimiques, le lait peut aussi être considérécomme un bon substitut salivaire tout encontribuant à un bon apport liquidien. Soncontenu en calcium et phosphate peut con-tribuer à la reminéralisation de l’émail.D’autres bénéfices sont tirés de son pou-voir tampon pour neutraliser l’acidité de lasalive qui favoriserait la déminéralisationde l’émail et aussi de sa capacité à lubrifieret humidifier les muqueuses asséchées.1

Aussi, tout agent irritant devrait êtreévité soit : café, alcool (incluant les rince-bouches à base d’alcool) qui peuventassécher davantage les muqueuses etempirer les symptômes de xérostomie ainsi

Tableau 1 : Classes de médicaments pouvant causer de la xérostomie(adapté de 1,5-7)Classe pharmacologique ExamplesAnticholinergics Atropine, benztropine, oxybutynin,

scopolamine, trihexyphenidylAntidépresseurs

Tricycliques Amitriptyline, doxepin, desipramine, nortriptylineSélectifs de la recapture de la sérotonine Citalopram, fluoxetine, paroxetine, sertraline,

venlafaxineHétérocycliques Imipramine,mirtazapineInhibiteur de la monoamine oxydase Phenelzine,moclobemideAntidépresseurs atypiques Bupropion, nefazodone

AntipsychotiquesNeuroleptiques ChlorpromazineAtypiques Clozapine, olanzapine, quetiapine

Sédatifs et anxiolytiques Lorazepam, diazepam, alprazolam, flurazepam,temazepam, triazolam, bromazepam, clonazepam

Antihypertenseurs Captopril, enalapril, lisinopril, clonidine,methyldopa, prazosin, terazosin

Diurétiques Hydrochlorothiazide, furosemide, triamterene,spironolactone

Anti-arythmique DisopyramideBronchodilatateurs Ipratropium, salbutamolAntihistaminiques Hydroxyzine, chlorpheniramine, diphenhydramine,

loratadine, cetirizineDécongestionnant PseudoephedrineAntiémétique MeclizineAntiparkinsoniens Biperiden, selegiline, carbidopa/levodopaAnticonvulsivant Gabapentin, carbamazepineRelaxants musculaires Cyclobenzaprine, baclofen, orphenadrineAnalgésiquesOpiacés et autres agissant au SNC Codeine,meperidine,methadone,morphine,

pentazocine, propoxyphene, tramadolAnti-inflammatoires non stéroïdiens Diflunisal, ibuprofen, naproxen, piroxicam

Inhibiteurs de la pompe à protons Omeprazole, esomeprazole, lansoprazole,rabeprazole

Médicament contre l’acné IsotretinoinMédicament contre l’incontinence urinaire TolterodineProduit pour arrêt du tabagisme La gomme de nicotine

TRAITEMENT DE LA XÉROSTOMIE


que le tabagisme qui contribue à réduire laproduction de salive.1,5−7

Compte tenu que certains facteurspsychologiques peuvent contribuer ouaggraver la xérostomie, tels que le stress etl’anxiété, des interventions devraient êtreenvisagées pour aider le patient à mieuxgérer ces états psychologiques.9

Stimulation salivaireLorsque les glandes salivaires sont encore enmesure de fabriquer et de produire de lasalive, il est possible de les stimulermécaniquement ou encore chimiquement.Cette mesure est importante pour limiterl’atrophie des glandes salivaires qui a étéobservée chez des patients dont la mastica-tion était réduite.1 La prise de repas plusfréquents, la consommation de limonade oude breuvage acide, de bonbons durs sanssucre, l’action de mâcher de la gomme àbase de xylitol sont des mesures qui peuventinduire la production de salive et ainsi con-tribuer à réduire la sensation de bouchesèche chez un bon nombre de patients.1,4−6,9Le recours aux produits acides devrait êtreréservé à un usage de courte durée car lepH acide de la salive contribue à la décalci-fication de l’émail dentaire.10

Bien que certains acides organiques,

tels que l’acide ascorbique, l’acide maliqueet l’acide citrique, aient le potentiel d’in-duire une salivation réflexe leur usagefréquent et à long terme est à proscrirepuisqu’ils ont aussi un potentiel dedéminéralisation et d’érosion de l’émail quiconduit à des caries dentaires.1,6

Substituts de saliveLorsque les mesures précédentes n’ont pascontribué à améliorer la production desalive, il est possible de faire appel à desagents de remplacement. Leur principalepropriété est d’humidifier et de lubrifier lesmuqueuses. Ils procurent au patient unesensation de muqueuse buccale hydratée,réduisant ainsi l’inconfort associé à lasécheresse de la bouche mais n’affectentpas la quantité de salive produite.8 Lesoulagement obtenu est temporaire etgénéralement d’une durée limitée, soit aumieux quelques heures.1,5,8 L’administrationdoit donc être répétée au besoin. Certainspatients trouveront des bénéfices à y avoirrecours juste avant d’aller au lit ou avant deprendre la parole.5

Ces solutions aqueuses contiennentdifférents ingrédients dont des glycopro-téines ou des mucines, des enzymes sali-vaires (peroxidase, glucose oxidase ou

lysozymes) et des polymères tels que ducarboxyméthylcellulose ou de l’hydrox-yméthylcellulose.9,11 Les bénéfices obtenusproviennent de l’humidification desmuqueuses et de la gorge, de la protectiondes tissus mous et de leur capacité àenlever les débris et bactéries des surfacesdentaires.1,9,11

Les produits disponibles au Canadasont : MoiStir (solution à vaporiser),Mouth Kote (solution), Oral Balance (gel).Les 3 produits peuvent être obtenus à lapharmacie sans prescription.

Ces produits devraient être déposés surla langue ou directement sur les surfacesaffectées puis dispersés partout dans labouche. De façon générale, ils soulagentrapidement la sensation de bouche sèche etils protègeraient également contre les irri-tations et les sensations de brûlure pourquelques heures.1 Il est important d’in-former les patients de ne pas rincer labouche après l’application de ces produits.1Ils peuvent aussi être appliqués sous lesprothèses dentaires pour en faciliter l’in-sertion.9

Malheureusement, peu d’études ont étéeffectuées pour permettre de comparerleur efficacité et d’établir la supériorité d’unagent par rapport à l’autre. Le choix reposedonc actuellement sur la disponibilité duproduit et les préférences du patient.5 Leprincipe important à retenir est de choisirun produit à faible pouvoir érosif pour l’é-mail, c’est-à-dire dont le pH est le plusneutre possible.5 Les patients sont souventcontraints à en essayer plus d‘un pourdécouvrir celui qui est le plus efficace et lemieux adapté à leur situation 8.

SialogoquesLorsque les mesures citées précédemmentn’ont pas apporté les résultats souhaités ousatisfaisants, les sialogogues deviennentune solution à envisager. Les 2 agentsdisponibles au Canada sont des agonistesdes récepteurs muscariniques :Anétholtritione (SialorMD) et Pilocarpine(SalagenMD).

Le premier agent, Anétholtrithione(SialorMD) est disponible depuis de nom-breuses années. Son mécanisme d’actionn’est pas clairement élucidé mais il sembleavoir un effet cholinergique et agiraitdirectement sur les cellules sécrétoires desglandes salivaires.3 Les patients l’ayant util-isé ont rapporté au moins une améliora-tion subjective des symptômes de bouche

Tableau 2 : Conditions systémiques associées à la xérostomie(adapté de 1,2,5)Conditions systémiques ou génétiques pouvant altérer la fonction salivaireMaladie de Sjögren Dysplasie ectodermiqueArthrite rhumatoïde Thyroïdite auto-immuneLupus érythémateux Pancréatite chroniqueSclérodermie Maladie coeliaque,maladie de CrohnCirrhose biliaire primaire Fibrose kystiqueHépatite auto-immune Syndrome de DownHémochromatose Maladie de surcharge en glucocérébrosideSarcoïdose Dystrophie myotoniqueDiabète (type I et II) Syndrome de Papillon-LefèvreVIH Syndrome de Prader-WilliCytomégalovirus et virus de l’herpès Maladie de Gaucher (surcharge en glucocérébroside)Hépatite C Amyloïdose systémiqueAnxiété Transplantation de moelle osseuseDépression Réaction du greffon contre l’hôte

Conditions ou maladies causant un désordre métabolique pouvant induire de la xérostomieDéshydratationDésordres alimentaires (anorexie)Insuffisance rénale terminaleDéficits nutritionnels

BOURASSA ET PÉRUSSE


sèche.3La dose recommandée est de 25 mg à

chaque 8 heures. Les effets secondairesprincipaux affectent le système gastro-intestinal avec de la flatulence.3

Pour sa part, la pilocarpine(SalagenMD) est un agoniste muscariniqueavec une faible activité B-adrénergique.Son usage résulte en une stimulation desglandes exocrines chez l’humain.1-3,8

L’action de la pilocarpine sur les acinides glandes salivaires se traduit par uneaugmentation de la production de saliverésultant de la stimulation du débit d’eau etd’électrolytes et possiblement des autrescomposantes telles que la mucine.1−3 L’effetde ce médicament n’est démontrable ques’il reste une fonction résiduelle du tissuglandulaire.2

D’un point de vue subjectif, les patientsavec peu de fonction salivaire restante peu-vent ne pas ressentir une améliorationnotable des symptômes. Par contre, despatients avec une destruction sévère rap-portent souvent une amélioration dessymptômes et un soulagement avec uneaugmentation modeste du débit salivaire.3D’autres études ont objectivé une augmen-tation significative du débit salivaire et uneamélioration subjective de la sensation desécheresse de bouche chez des patients seplaignant de xérostomie légère à sévère.8

Dans les études cliniques, l’efficacité dela pilocarpine est reconnue pour le traite-ment de la xérostomie sévère secondaire àla maladie de Sjögren, à la radiothérapiecervicofaciale et à la transplantation demoelle osseuse.1,2,9,12

Le produit est disponible sous formede comprimé dosé à 5 mg et la dose ini-tiale recommandée est de 5 mg à prendretrois fois par jour (1 heure avant chaquerepas) ou quatre fois par jour.1−3 La dosemaximale ne doit pas dépasser 30 mg parjour. Le début d’action est d’environ 30minutes et l’effet persiste environ 2 à 3heures.1−3 Il peut s’écouler plusieurssemaines avant que les bénéfices soientperçus par le patient.1,8

D’autres formulations, telles que rince-bouche à 1% et 2%, solution 0.04% àvaporiser sous la langue, ont aussi été util-isées mais des études manquent pour sup-porter leur efficacité et décrire les réponsesobtenues.2,9 Ces formulations permet-traient l’usage topique de la pilocarpineavec possiblement moins d’effets sec-ondaires systémiques.

De par son mécanisme d’action, lapilocarpine peut altérer la conduction car-diaque. Donc, l’utilisation devrait êtreévitée chez patients atteints de maladie car-diaque ou pulmonaire significative.1,2,5 Leseffets secondaires les plus souvent rap-portés sont : sudation, « flushing », tachy-cardie, bradycardie, augmentation dessécrétions bronchiques, vision brouillée,incontinence urinaire et effets gastro-intestinaux.1,2,12 Une attention doit êtreportée aux patients avec une histoire d’ul-cère peptique.9 Parmi les contre-indica-tions à son usage on retrouve : asthme malcontrôlé, bronchite chronique, maladieobstructive pulmonaire chronique, maladiecardiaque, infarctus du myocarde, glau-come à angle étroit, uvéite, insuffisancehépatique sévère, cholélithiase,néphrolithiase et allergie à la pilo-carpine.1,3,9

Mesures préventivesEn présence de xérostomie, la préventiondes caries revêt une importance primor-diale. Une attention rigoureuse doit êtreportée à l’hygiène orale quotidienne. Deplus, les habitudes alimentaires du patientdevraient être revues de façon à établir etadhérer à une diète à faible potentiel cari-ogène.4−6,8 La mise en place de scellants depuits et fissures est également une mesureà considérer lorsque la situation s’y prête.5

Un meilleur contrôle de la plaque den-taire et de la gingivite peut être obtenuavec l’usage quotidien de rince-bouche à lachlorhexidine 0.12%.1,4,6,9

La protection des structures dentairespasse aussi par l’utilisation du fluor top-ique.1,5 Cette mesure a été prouvée efficacepour aider à la prévention des caries etpossiblement renverser la décalcificationdébutante.1,8 Le fluor est disponible sousplusieurs formes dont rince-bouche, gel,comprimé à mâcher et vernis. Les patientsdevraient être informés de brosser leursdents aux moins 2 fois par jour à l’aided’une brosse à soies souples et d’un denti-frice aux propriétés peu abrasives et à basede fluor.4,6,7 De plus, l’usage quotidien d’unrince bouche de fluorure de sodium peutaider à réduire la déminéralisation den-taire.7 La méthode la plus appropriée estl’application quotidienne de fluorure neu-tre dont la concentration peut varier de 0.4à 1.25% sous forme de gel à l’aide de gout-tières confectionnées sur mesure.6

Le type de fluor choisi devrait êtreadapté à la gravité de la condition et à l’ac-tivité carieuse du patient.1 Le fluorure desodium neutre est reconnu pour être lamesure la plus importante et la plus effi-cace pour prévenir les caries rampanteschez les patients après la radiothérapie dela tête et du cou.1,8

Les patients porteurs de prothèsessouffrant de xérostomie sont plus suscepti-bles de développer des problèmes tels quedouleurs associées à l’irritation desmuqueuses et une diminution de la réten-tion de la pièce de prothèse.1,5 Ces patientsdevraient être encouragés à retirer leursprothèses la nuit.6,7 De plus, ils sontexposés à un plus grand risque de dévelop-per de la candidose buccale, ce qui peutcontribuer à aggraver l’inconfort causé parla réduction de la salive.4 Un traitement àl’aide d’un antifongique topique donnegénéralement de bons résultats. Le recoursaux antifongiques systémiques devrait êtreréservé aux patients dont la candidose estréfractaire au traitement topique et auxpatients immunocompromis.4 À ne pasoublier que les prothèses sont générale-ment colonisées par Candida albicans etrequièrent également un traitement partrempage dans une solution d’eau con-tenant un antifongique ou par l’applicationd’une crème antifongique.4

Autres mesuresSelon les études disponibles, le recours àl’acupuncture a donné des résultats incon-stants et conflictuels.2,8,13 Présentement iln’existe pas d’évidence pour supporter l’effi-cacité de l’acupuncture pour le soulage-ment de la xérostomie.

Suivi étroitDes examens fréquents sont indiqués pourpermettre la détection précoce des compli-cations buccales. Les patients devraienteux-mêmes procéder à un examen métic-uleux quotidien de leur cavité buccale pourdéceler les ulcères, lésions ou caries et con-sulter dès l’apparition de signesinhabituels.4,6 Les examens dentairesdevraient être prévus au moins à tous les6 mois et des radiographies aux 12 moispour la détection précoce des caries.4

ConclusionLa xérostomie est un symptôme fréquem-

TRAITEMENT DE LA XÉROSTOMIE

ment rencontré et a effet négatif surplusieurs aspects de la qualité de vie despatients ainsi que sur leur santé buccale.Une diminution de la production salivairepeut souvent être un effet secondaire d’unmédicament, une manifestation d’une mal-adie de Sjögren ou d’une autre maladie, ouencore une complication de la radio-thérapie. L’identification de la causedemeure une étape clé vers un traitementefficace. Lorsque la cause n’est pas corrige-able, jusqu’à présent le traitement se limiteprincipalement à une intervention pallia-tive. Quelques patients peuvent bénéficierde la stimulation salivaire à l’aide desagents cholinergiques.

Tous les patients devraient être sensi-bilisés à adhérer à des mesures d’hygiènebuccale très méticuleuses et des auto-exa-mens réguliers de leurs dents et tissusmous. Les suppléments de fluor demeurentdes aides précieuses dans la prévention descaries. Des traitements quotidiens sontindiqués pour réduire la prévalence descaries rampantes après des traitements deradiothérapie.

L’examen dentaire approfondi et le net-toyage professionnel sont à prévoir

régulièrement et à intervalles rapprochéspour permettre des interventions précoceset limiter les complications associées à laxérostomie.

Bibliographie1. Cassolato SF, Turnbull RS, Xerostomia:

Clinical Aspects and Treatment.Gerodontology 2003;20:64–77.

2. von Bültzingslöwen I, Sollecito TP, Fox PC,et al. Salivary dysfunction associated withsystemic diseases: systemactic review andclinical management recommendations.Oral Surg Oral Med Oral Pathol OralRadiol Endod 2007;103(suppl1):S5,e1 S57,e15.

3. Grisius MM. Salivary gland dysfunction: Areview of systemic therapies. Oral SurgOral Med Oral Pathol Oral Radiol Endod2001;92:156–62.

4. Turner MD, Ship JA. Dry mouth and itseffects on the oral health of elderly peo-ple. J Am Dent Assoc 2007;138:15S–20S.

5. Guggenneimer J,Moore PA, Xerostomiaetiology, recognition and treatment. J AmDent Assoc 2003;134:61–9.

6. Gupta A, Epstein JB, Sroussi H,Hyposalivation in elderly patients. J CanDent Assoc 2006;72:841–6.

7. Scully C, Felix DH. Oral medicine-update

for the dental practitioner, dry mouth anddisorders of salivation. Br Dent J2005;199:423–7.

8. Shiboski CH, Hodgson TA, Ship JA, et al.Management of salivary hypofunctionduring and after radiotherapy. Oral SurgOral Med Oral Pathol Oral Radiol Endod2007;103(suppl 1):S66.e1 S66.e19.

9. Silvestre-Donat FJ,Mirailles-Jordà L,Martinez-Muu V. Protocol for the clinicalmanagement of dry mouth.Med Oral2004;9:273–9.

10. WisemanM,The treatment of oral prob-lems in the palliative patient. J Can DentAssoc, 2006;72:453–8.

11. OH DJ, Lee JY, Kim YK, et al. Effects of car-boxymethylcellulose (CMC)-based artifi-cial saliva in patients with xerostomia. IntJ Oral Maxillofac Surg 2008;1–5.

12. Davies AN, Shorthose K,Parasympathomimetic drugs for thetreatment of salivary gland dysfunctiondue to radiotherapy, Cochrane Databaseof Systematic Reviews 2007;Issue 3:1–17.

13. Jedel E. Acupuncture in xerostomia – asystematic review. J Oral Rehabil2005;32:392–6.


ORAL MEDICINE

Canadian Journal of Restorative Dentistry and ProsthondonticsDecember 2008December 2008

About the Authors:The principal author holds a BA in Pharmacy and a master’s degree in Hospital Pharmacy. She has furthered

her training in dental medicine through a residency session in multidisciplinary dentistry. She practises generaldentistry in a private firm and at Hôpital Laval (Heart and Respiratory Institute). She also acts as dentist advi-sor for the severe congenital hematological diseases team in East Quebec, teaches in the Québec Faculty of

Dental Medicine, and volunteers dental services at Maison Michel Sarrazin de Québec.She can be reached at:[email protected]

Dr. Rénald Pérusse holds a Doctorate of Dental Medicine and a Doctorate of Medicine. He teaches and practis-es as an oral medicine specialist at Université Laval, Faculty of Dental Medicine. He has authored or co-

authored one volume, three CD ROMs, and 52 scientific articles. His fields of interest are the oral manifesta-tions of systemic disorders,medical urgencies, and dental pharmacology.

He can be reached at: [email protected]

23

Making Their MouthsWater:GENERAL PRINCIPLES FOR TREATING

XEROSTOMIA PATIENTSDr.Michelle Bourassa, B Pharm,MSc, DMD

Dr. Rénald Pérusse, DMD,MD, LMCC, FRCD(C), C.S. (ODQ)

ABSTRACT

Xerostomia is a complaint frequently reported by patients of dental medicine. In addition tocausing discomfort, the reduction of salivary secretion has a negative impact on quality of lifeas it affects various functions including mastication, deglutition, and diction and causes manyinfectious oral complications.

Xerostomia may also be associated with some systemic, primarily autoimmune, conditions, themost frequent one being Sjögren’s syndrome. It can also result from the destruction ofglandular acini by cervico-facial radiotherapy. Yet the most frequent cause continues to beanticholinergic medication and the medications that modify certain biological components.

Therapy first involves a careful examination to determine the cause so the condition can be cor-rected, if possible. If it cannot be corrected, mitigative and preventive measures should beimplemented to minimize the risk of complications or delay them.

The primary therapeutic measures focus on elements of the patient’s day-to-day life and aredesigned to eliminate aggravating factors and stimulate mucosa hydration through adequatefluid intake and the humidification of ambient air. In addition, saliva production may be stimu-lated by eating more frequently, chewing xylitol gum, or eating sugar-free candies. For somepatients, the use of saliva substitutes, called artificial salivas,may help to reduce discomfort. In

TREATMENT OF XEROSTOMIA

Acondition often encountered in den-tistry, xerostomia is a symptom of

reduced saliva production and of alteredsaliva composition.1−3 Hyposalivationrefers to the objective reduction of sali-vary secretion, while xerostomia is a sub-jective experience of dry mouth that isfrequently, but not always, associated withreduced salivary secretion. In general,patients begin to notice xerostomia whentheir usual salivary secretion is halved.2

As a continuation of the series of arti-cles on xerostomia, this article first brieflyreviews the general etiological principles ofthis disorder. It then presents the pharma-cological and non-pharmacological thera-pies. The last section suggests measuresdesigned to prevent or delay the complica-tions associated with xerostomia.

Complications Associated withReduced Salivary SecretionSaliva plays an important, varied role inthe taste, chewing, and speech functionsand in the prevention of mucosa and teethinfections.1,3,4 Readers wishing to knowmore about the possible consequences ofxerostomia are invited to consult the relatedarticle in the previous issue of this journal.

EtiologyThe most frequent cause of xerostomia isunquestionably the taking of anticholiner-gic medication. The action mechanisms ofother medications can also lead to reducedsaliva production. Table 1 provides a non-exhaustive list of the pharmacologicalclasses of agents associated with this sideeffect.1,5−7 Although Sjögren’s syndrome is afrequent cause of xerostomia, other sys-temic conditions are also known to bepotential causes through various mecha-nisms; they are listed in Table 2.1,2,5,7 Thedestruction of the salivary gland acini, afrequent outcome of head and neck radio-therapy, can also cause a severe, possiblyirreversible reduction of salivarysecretion.1,4,5,7,8 Although frequentlyobserved in patients over 65 years of age,reduced salivary function has nothing to

do with age but is associated instead withthe presence of a systemic disorder or theuse of medications that cause xerosto-mia.1,4,6

TreatmentThe first step in treatment is to try toestablish the etiology of the patient’s xeros-tomia with a view to controlling the under-

lying pathology once it is identified, or toconsult the referring physician to change amedication suspected to be the cause(Figure 1).4,9

If the cause cannot be corrected, treat-ment follows a twofold approach, the firstbeing mitigative to relieve the symptomsand the second being preventive to fore-stall the oral complications associated withsaliva reduction.

24

the most severe cases, use of a sialogogue may be advantageous.

In all cases, very close monitoring of the patient’s condition is indicated. Strict oral hygienemeasures should be instituted, accompanied with a low cariogenic diet and, generally, a fluo-rine application in a form suited to the patient’s situation.

Table 1. Classes of medications that can cause xerostomia(adapted from 1,5 7)Pharmacological class ExamplesAnticholinergics Atropine, benztropine, oxybutynin,

scopolamine, trihexyphenidylAntidepressants

Tricyclic antidepressants Amitriptyline, doxepin, desipramine, nortriptylineSelective serotonin reuptake Citalopram, fluoxetine, paroxetine, sertraline,inhibitors venlafaxine

Heterocyclic antidepressants Imipramine,mirtazapineMonoamine oxidase inhibitors Phenelzine,moclobemideAtypical antidepressants Bupropion, nefazodone

AntipsychoticsNeuroleptics ChlorpromazineAtypical antipsychotics Clozapine, olanzapine, quetiapine

Sedatives and anxiolytics Lorazepam, diazepam, alprazolam, flurazepam,temazepam, triazolam, bromazepam, clonazepam

Antihypertensives Captopril, enalapril, lisinopril, clonidine,methyldopa,prazosin, terazosin

Diuretics Hydrochlorothiazide, furosemide, triamterene,spironolactone

Anti-arrhythmics DisopyramideBronchodilators Ipratropium, salbutamolAntihistamines Hydroxyzine, chlorpheniramine, diphenhydramine,

loratadine, cetirizineDecongestants PseudoephedrineAntiemetics MeclizineAntiparkinsonians Biperiden, selegiline, carbidopa/levodopaAnticonvulsants Gabapentin, carbamazepineMuscle relaxants Cyclobenzaprine, baclofen, orphenadrineAnalgesics

Opiates and other drugs acting on Codeine,meperidine,methadone,morphine,the central nervous system pentazocine, propoxyphene, tramadol

Non-steroidal anti-inflammatories Diflunisal, ibuprofen, naproxen, piroxicamProton pump inhibitors Omeprazole, esomeprazole, lansoprazole, rabeprazoleAcne treatments IsotretinoinUrinary incontinence medication TolterodineSmoking cessation products Nicotine gum

Journal canadien de dentisterie restauratrice et de prosthodontie Décembre 2008


Mitigative MeasuresSome general, straightforward measurescan help lessen the discomfort caused bydry mouth. Water is the most frequentlyused artificial saliva, and it has severalbenefits.1 First, adequate fluid intake (aminimum of 2 litres per day) is recom-mended, unless the patient has a condi-tion that calls for a fluid restriction.7,9Fluid intake can include, among otherthings, sipping water frequently duringthe day.1,5 Also, chewing or sucking on icecubes may help reduce discomfort insome patients.5,7 Because saliva produc-tion is usually reduced when a personsleeps, which can aggravate xerostomia,the use of a bedside humidifier may helplessen dry mouth and its discomforts.4−6In general, increasing the moistness oforal mucosa can help counter opportunis-tic infections.5

Given its physical and chemical prop-erties, milk may also be both a good sali-va substitute and a good contributor tofluid intake. Its calcium and phosphatecontent may help to remineralize toothenamel. Its other benefits derive from itsbuffering capacity for neutralizing thesalivary acidity that would otherwisedemineralize enamel and also from itscapacity for lubricating and moistening

dry mucosas.1Also, all irritants should be avoided,

such as coffee and alcohol (includingalcohol-based mouthwashes), which can

aggravate mucosa dryness and worsen thexerostomia; tobacco use too contributesto reduced saliva production.1,5−7

Because stress, anxiety and other psy-

BOURASSA AND PÉRUSSE

Xerostomia Treatment Algorithm

Establish etiology

Correct the cause Cause cannot be corrected

Close monitoring

Mitigative measures• Eliminate irritants: coffee, alcohol• Smoking cessation• Hydration: water, crushed ice, milk• Humidification of ambient air• Non-pharmacological stimulation

of saliva production: increase mealfrequency, sugar-free candies,xylitol chewing gum

Pharmacological treatment• Artificial salivas:

MoiStir, MouthKote, Biotene• Sialogogues:

Sialor, Salagen

Preventive measures• Low cariogenic diet• Strict buccodental hygiene• Topical fluorine application (neutral)• Chlorhexidine (mouthwash)• Antifungal if oral candidiasis

• Daily self-examination• Frequent and regular professional

examinations and cleaning

Table 2. Systemic conditions associated with xerostomia(adapted from 1,2,5)Systemic or genetic conditions that can alter salivary functionSjögren’s syndrome Ectodermic dysplasiaRheumatoid arthritis Autoimmune thyroiditisLupus erythematosus Chronic pancreatitisScleroderma Coeliac disease, Crohn’s diseasePrimary biliary cirrhosis Cystic fibrosisAutoimmune hepatitis Down syndromeHemochromatosis Glucocerebroside overloadSarcoidosis Myotonic dystrophyDiabetes (types I and II) Papillon-Lefèvre syndromeHuman immunodeficiency virus Prader-Willi syndromeCytomegalovirus and herpes Gaucher’s disease (glucocerebroside overload)Hepatitis C Systemic amyloidosisAnxiety Bone marrow transplantDepression Graft-versus-host reaction

Conditions or diseases causing a metabolic disorder that can induce xerostomiaDehydrationFood disorders (anorexia)End-stage renal failureNutritional deficit

Figure 1: XerostomiaTreatment Algorithm

Décembre 2008Decembre 2008Journal canadien de dentisterie restauratrice et de prosthodontie

improvement in their symptoms. However,patients with a severe destruction oftenreport an improvement in their symptomsand some relief thanks to a modestincrease of salivary secretion.3 Other stud-ies have objectivised a significant increaseof salivary secretion with a subjectiveimprovement of the dry mouth feelingamong patients presenting slight to severexerostomia.8

Clinical studies recognize the efficacyof pilocarpine for treating severe xerosto-mia secondary to Sjögren’s syndrome, cer-vico-facial radiotherapy, and a bone mar-row transplant.1,2,9,12

The product is available in 5-mgtablets, and the initial recommended doseis 5 mg three times daily (1 hour beforeeach meal) or four times per day.1−3 Themaximum dose must not exceed 30 mg perday. The medication begins to take effectafter about 30 minutes and is effective forabout 2 to 3 hours.1−3 Several weeks mayelapse before the patient perceives anybenefits.1,8

Other formulations, such as a 1% or2% mouthwash, or a 0.04% solution that issprayed under the tongue, have also beenused, but there are no studies available toindicate their effectiveness or results.2,9These formulations apparently make itpossible to use pilocarpine topically withpotentially fewer systemic side effects.

Pilocarpine’s action mechanism canalter cardiac conduction. Its use shouldtherefore be avoided by patients with sig-nificant heart or lung disease.1,2,5 The mostcommonly reported side effects are sweat-ing, flushing, tachycardia, bradycardia,increased bronchial secretions, blurredvision, urinary incontinence, and gastroin-testinal effects.1,2,12 Attention must be givento patients with a history of peptic ulcer.9Its use is contraindicated in the presenceof, among others: poorly controlled asth-ma, chronic bronchitis, chronic obstructivepulmonary disease, heart disease, myocar-dial infarction, narrow-angle glaucoma,uveitis, severe hepatic insufficiency,cholelithiasis, nephrolithiasis, and allergicreaction to pilocarpine.1,3,9

Preventive MeasuresBecause caries prevention is of vital impor-tance for xerostomia patients, they must bescrupulous in their daily oral hygiene. Theirdietary habits must also be reviewed andreshaped so they can follow a low cario-

at a drugstore without a prescription.These products are placed on the

tongue or are applied directly to the affect-ed areas and then dispersed throughoutthe mouth. In general, they quickly relievethe dry-mouth feeling and also preventirritations and burning sensations for a fewhours.1 It is important to warn patients notto rinse their mouths after applying theseproducts.1 They can also be applied to den-tal prostheses to facilitate insertion.9

Unfortunately, few studies have beendone to compare and rank their effective-ness. The choice therefore now depends onproduct availability and the patient’s pref-erences.5 An important principle to keep inmind is to choose the product least likelyto erode tooth enamel, i.e., its pH must beas neutral as possible.5 Patients often haveto try different products to determinewhich one is the most effective and bestsuited to their situation.8

SialogoguesIf the above-mentioned measures do notobtain the desired results or have unsatis-factory results, sialogogues have to be con-sidered. The two agents available inCanada are muscarinic receptor agonists:anetholtrithione (Sialor) and pilocarpine(Salagen).

The first agent, anetholtrithione(Sialor), has been available for many years.Its action mechanism is not fully knownbut it seems to have a cholinergic effectand to act directly on the secretory cells ofthe salivary glands.3 Patients who haveused it have reported at least a subjectiveimprovement of their dry mouth symp-toms.3

The recommended dose is 25 mg every8 hours. The most common side effects arerelated to the gastrointestinal system,including flatulence.3

As for pilocarpine (Salagen), it is alow-level b-adrenergic muscarinic agonist.It is used to stimulate a patient’s exocrineglands.1−3,8

The action of pilocarpine on the sali-vary gland acini increases saliva produc-tion through the inducement of water andelectrolyte flow and possibly other compo-nents, such as mucin.1−3 This drug has ademonstrable effect only in patients withresidual glandular function.2

From a subjective point of view,patients with little residual salivary func-tion will not necessarily feel a noticeable

chological factors can contribute to oraggravate xerostomia, treatment shouldbe designed to include helping the patientbetter manage these factors.9

Salivary StimulationSalivary glands that are still able to pro-duce and secrete saliva can be stimulatedmechanically or even chemically. Salivarystimulation is important for limiting thesalivary gland atrophy observed in patientswith limited chewing function.1 For manypatients, eating more frequently, drinkinglemonade or some other acidic beverage,eating hard sugar-free candies and chew-ing on xylitol gum are ways to induce sali-va production, and reduce the discomfortsof dry mouth.1,4−6,9 The consumption ofacidic products should be restricted tobrief periods of time because an acid salivapH is a factor in the decalcification oftooth enamel.10

While some organic acids, includingascorbic acid, malic acid, and citric acidcan potentially stimulate the salivaryreflex, they should not be used frequentlyin the long term because they too can con-tribute to the demineralization and erosionof enamel and the ensuing caries.1,6

Saliva SubstitutesIf the mitigative measures do not improvesaliva production, patients can turn to sali-va substitutes. They serve mainly to mois-ten and lubricate mucosa. By providing thepatient with the feeling that the oralmucosa is hydrated, they reduce the dis-comfort associated with dry mouth, butthey have no effect on the quantity of sali-va produced.8 The relief they offer is tem-porary, of a limited duration, and generallylasts a few hours at most.1,5,8 They musttherefore be used repeatedly as required.Some patients find it helpful to use thembefore going to sleep or before speaking.5

These watery solutions contain a vari-ety of ingredients, including glycoproteinsor mucins, salivary enzymes (peroxidase,glucose oxidase, or lysozymes) and car-boxymethylcellulose or hydroxymethylcel-lulose polymers.9,11 They help by moisten-ing the mucosae and throat, protecting softtissue, and removing debris and bacteriafrom tooth surfaces.1,9,11

The products available in Canada are:MoiStir (moisturizing spray), MouthKote(solution), and Oral Balance (moisturizinggel). All three products can be purchased

TREATMENT OF XEROSTOMIA

26

December 2008December 2008 Canadian Journal of Restorative Dentistry and Prosthondontics

BOURASSA AND PÉRUSSE

References1. Cassolato SF, Turnbull RS, Xerostomia:

Clinical aspects and treatment.Gerodontology 2003;20:64–77.

2 von Bültzingslöwen I, Sollecito TP, Fox PC,et al. Salivary dysfunction associated withsystemic diseases: systematic review andclinical management recommendations.Oral Surg Oral Med Oral Pathol OralRadiol Endod 2007;103(suppl 1):S5,e1–S57,e15.

3. Grisius MM. Salivary gland dysfunction: Areview of systemic therapies. Oral SurgOral Med Oral Pathol Oral Radiol Endod2001;92:156–62.

4. Turner MD, Ship JA. Dry mouth and itseffects on the oral health of elderly peo-ple. J Am Dent Assoc 2007;138:15S–20S.

5. Guggenneimer J,Moore PA, Xerostomiaetiology, recognition and treatment. J AmDent Assoc 2003;134:61–9.

6. Gupta A, Epstein JB, Sroussi H,Hyposalivation in elderly patients. J CanDent Assoc 2006;72:841–6.

7. Scully C, Felix DH. Oral medicine-updatefor the dental practitioner, dry mouth anddisorders of salivation. Br Dent J2005;199:423–7.

8. Shiboski CH, Hodgson TA, Ship JA, et al.Management of salivary hypofunctionduring and after radiotherapy. Oral SurgOral Med Oral Pathol Oral Radiol Endod2007;103(suppl 1):S66.e1–S66.e19.

9. Silvestre-Donat FJ,Mirailles-Jordà L,Martinez-Muu V. Protocol for the clinicalmanagement of dry mouth.Med Oral2004;9:273–9.

10. WisemanM,The treatment of oral prob-lems in the palliative patient. J Can DentAssoc 2006;72:453–8.

11. OH DJ, Lee JY, Kim YK, et al. Effects of car-boxymethylcellulose (CMC)-based artifi-cial saliva in patients with xerostomia. IntJ Oral Maxillofac Surg 2008;1–5.

12. Davies AN, Shorthose K,Parasympathomimetic drugs for thetreatment of salivary gland dysfunctiondue to radiotherapy, Cochrane Databaseof Systematic Reviews 2007;Issue 3:1–17.

13. Jedel E. Acupuncture in xerostomia – asystematic review. J Oral Rehabil2005;32:392–6.

Other MeasuresAccording to the available studies, the useof acupuncture has inconsistent and con-flicting results.2,8,13 There currently is noevidence demonstrating the effectivenessof acupuncture for relieving xerostomia.

Close MonitoringFrequent examinations are indicated topermit the early detection of oral compli-cations. Patients themselves should metic-ulously examine their buccal cavity daily todetect ulcers, lesions, or caries and consultas soon as any unusual signs appear.4,6Dental examinations should be scheduledat least every 6 months, with radiographiesevery 12 months, for the early detection ofcaries.4

ConclusionXerostomia is a frequently encounteredsymptom. It has a negative effect on manyaspects of a patient’s quality of life and oralhealth. Reduced saliva production canoften be a side effect of a drug, a manifes-tation of Sjögren’s syndrome or anotherdisease, or even a complication of radio-therapy. Identifying its cause continues tobe a key step for effective treatment. Whenthe cause cannot be corrected, the current-ly available treatment options are mainlymitigative. Some patients may benefit fromcholinergic agents that stimulate salivaryproduction.All xerostomia patients must be madeaware of the importance of very strict oralhygiene and regular self-examination oftheir teeth and soft tissue. Fluorine supple-ments are still valuable aids in caries pre-vention. Daily applications are indicatedfor reducing the prevalence of rampantcaries after radiotherapy treatments.Thorough dental examinations and profes-sional cleaning must be regularly sched-uled at close intervals to permit early treat-ment and to limit the complications asso-ciated with xerostomia.

genic diet.4−6,8 The application of pit and fis-sure sealants is another measure to be con-sidered when the situation lends itself to it.5

A better control of plaque and gingivi-tis can be achieved through the daily use ofa 0.12% chlorhexidine mouthwash.1,4,6,9

Dental structures can also be protectedthrough a topical fluorine application.1,5This measure has been proven effective inhelping caries prevention and possiblyreversing first-stage decalcification.1,8Fluorine is available in several forms,including mouthwash, gel, chewable tablets,and varnish. Patients must be told to brushtheir teeth at least twice daily with a soft-bristle brush and a mildly abrasive fluorinetoothpaste.4,6,7 The daily use of a sodiumfluoride mouthwash can help to reducetooth demineralization.7 The most appro-priate method involves the daily applicationof a gel with a concentration of neutral fluo-ride ranging from 0.4 to 1.25% by means ofa made-to-measure tray.6

The type of fluorine chosen should bebased on the severity of the patient’s condi-tion and caries activity.1 Neutral sodium flu-oride is recognized as being the mostimportant and most effective measure forpreventing rampant caries in patients whohave received head and neck radiotherapy.1,8

Xerostomia patients with prosthesesare more likely to develop problems suchas painful irritation of the mucosa andweakened prosthesis retention.1,5 Thesepatients should be encouraged to removetheir prostheses before they sleep.6,7 Theyare also at greater risk of developing oralcandidiasis, which can aggravate the dis-comfort caused by reduced saliva produc-tion.4 Treatment with a topical antifungalagent generally gives good results.Systemic antifungals should be used onlywith patients whose candidiasis does notrespond to the topical treatment and withimmunocompromised patients.4 It must bekept in mind that prostheses are generallycolonized by Candida albicans and musttherefore be treated by soaking in an anti-fungal solution or by the application of anantifungal cream.4

27

PRACTICE MANAGEMENT / GESTION DE CABINET

Vital Interactions:The Chemistry of a Championship Dental Team

By Mr. Peter Barry, CMC, RRDH

ABSTRACTIt has been stated by many in history who are known for their wisdom that the quality of yourlife is determined by the quality of your “RELATIONSHIPS.” Low quality relationships lead to alow quality of life! High quality relationships lead to a high quality of life! The quality of yourrelationships in turn is determined by the quality of your “COMMUNICATION.” This correlationbetween our communication, our relationships, and our overall satisfaction in life is powerfulyet it very often it doesn’t get the attention it deserves. Most human resource experts will tellyou that “happiness in the workplace”has a huge impact on your overall effectiveness and suc-cess as a team. Just think; the average dentist spends 8–10 of his or her waking hours eachwork-day at the office. This can be extrapolated to mean that for the average clinician most ofyour non-sleeping timeMonday to Friday is actually spent with your co-workers/employees. Asa result; the quality of your relationships with these people is going to have a dramatic impacton your overall personal happiness and professional effectiveness. This article will examinestrategies for minimizing and managing conflict as a means to strengthen team harmony andsuccess.

RÉSUMÉIl a été mentionné dans l’histoire par plusieurs personnes qui étaient reconnues pour leurgrande sagesse que la qualité de vie est déterminée par la qualité de nos « RELATIONS ». Desrelations de mauvaise qualité engendrent une qualité de vie médiocre! Des relations d’excel-lente qualité entraînent une meilleure qualité de vie! Par contre, la qualité de nos relations estdéterminée par la qualité de notre « COMMUNICATION » avec les autres. Cette corrélation entrela communication, les relations et la satisfaction générale est puissante mais très souvent ellen’attire pas toute l’attention qu’elle devrait avoir. La plupart des experts en ressources


About the AuthorPeter Barry is a speaker, writer, Practice Mastery Coach™, and founder of Successful Practice Architects. He is thecreator of “The Dental Olympics Advantage™ Growth & Development Programs.”He is also a member of the

Academy of Dental Management Consultants and Speaking Consulting Network. Peter coachesdental teams through the implementation of successful and highly profitable systems of patientcare and business operation. He provides customized group and one-on-one personal develop-

ment success training. He can be reached at: [email protected]/416-568-5456


It is extremely important to get alongwell with the people you spend most ofyour time with because how you feelwhile you are around these people notonly impacts your performance at work,it also impacts other areas of your life.Some might say that they can leave workat work and home at home. But is thisreally possible? For example; when youare in love with someone can you fileyour love for them away when you arriveto work in the morning and by the sametoken when you experience a humandynamic tension at work can you sudden-ly eject those feelings and keep them fromcoming home with you? No way! Yourfeelings follow and stick to you like glue.Your heart stays in your chest where everyou go. Our intellectual mind might tellus otherwise. But at the core of ouressence we are human and contrary topopular belief human beings are not real-ly intellectual logical creatures. Humanbeings are “EMOTIONAL CREATURES”who use logic and intellect to justify andunderstand their emotions. This conceptis also true of our patients when theymake buying decisions in our practice.Patients shop with emotions (theirhearts). They then use logical reasoningto justify their buying decision. This iswhy it is important to develop and nur-ture a positive emotional climate in ourworkplace. Emotions are powerful.Emotions are infectious. Emotions affecteveryone including our patients. How wefeel while we do what we do is at the coreof our effectiveness. Emotions affect ourability to lead, to sell, and to feel unitedand passionate about our service. Formost dentists, however; the concept of“leading people and keeping them emo-tionally united and aligned” was notsomething they signed up for whenapplying to dental school. Many clientstell me they wish for workplace harmonybut they just don’t have the time, theenergy, or the patience to babysit theemotional climate in their practice.

I guess it would help to look at teamchemistry as more than just “babysitting”emotions. Dentistry is not only a medicalprofession that serves the human conditionit is also a business where influencing cus-tomer’s decisions and profitability are anecessity. Your team’s level of unity plays ahuge factor in their ability to collectivelyinfluence customers. Imagine coming toyour office in the morning and feeling likeyou are surrounded by a bunch of enthusi-astic confident positive people who likeeach other, support each other and are allworking together on behalf of a future theyhave all committed themselves to. Is thispossible? If it is already happening in yourpractice, can it happen at a higher level? Itis my experience that it can. At the end ofthe day everything we experience in life isrelated to people in one way or another.Relationships in the dental office can be asource of daily misery and frustration orthey can be a beautiful thing that fills yourheart and soul on a daily basis. Just thinkof a very emotional time in your life whereyou felt a strong emotion such as happi-ness, sadness, anger, or fear. If you look atit carefully the situation probably hadsomething to do with or involved otherpeople. People affect people in a big way.The Greek philosopher Plato said that thegreatest need of the human soul is theneed to feel heard, understood, and appre-ciated by others.

Now let’s examine the emotional cli-mate in your practice for a moment. Areteam conflict and egos getting in the wayof your goals? Are differences and self-centredness dividing your team and caus-ing you headaches? Are tensions andadversity weakening your team and its per-formance? Leading organizations today arerealizing that it’s difficult to achieve thelevel of teamwork needed to really excel asa business unless you first deal with the alltoo common destructive behaviours thatfuel unresolved conflicts in the workplace.

Far too many people trade their life, and abit of their soul, for a paycheque. They tol-erate endless hours of meaningless work,disappointing relationships, conflicts, gos-sip, and frustration so they can have funon the weekend and during their two-weekvacation. Similar frustrations hold true formanagers and practice owners; far toomany go home at night feeling frustratedand disappointed because of the conflictsat work, the lack of creativity and produc-tivity, and the loss of progress and profits.For many in the game of dentistry this iswhat they endure and live with each day atthe office. Keep in mind these conflicts donot just exist at an adversarial level. Youcan like a co-worker and still experienceunmet expectations or little discourtesiesthat fester and build frustration into yourwork environment over time.

Things don’t have to be this way. Feelingconnected and getting along is the mostimportant ingredient on the path to func-tioning as a high performing team thatachieves collective results. Before game 1 ofa recent 7 game NBA finals series theannouncer, in an interview with retired bas-ketball legend the great “Doctor J” JuliusIrving, asked him his pick to win the seriesand what he felt the keys to victory wouldbe. Doctor J’s response was compelling. Inan impassioned and spirited pre-game tonehe said either team can win the series, “thekey to victory will be 10 players who playin sync with each other, in sync with thecoach, in sync with the organization andwith one goal.” Wow; is this requirementany different when we are playing thegame of dentistry with our coworkers?Whenever we come to work, we’re in asense, suiting up and stepping on a playingfield with our teammates. Each person inthe practice plays an important role in thebig picture of what we are trying to achievefor our patients and as a business in ourcommunity. Our collective level of unityand connection will have a tremendous

humaines vous diront que « le bonheur au travail » a un impact considérable sur votre efficac-ité et votre réussite en tant qu’équipe. Réfléchissez un peu : le dentiste moyen passe entre 8 et10 heures chaque jour à son cabinet. Ce qui signifie que le clinicien moyen passe la plus grandepartie de son temps du lundi au vendredi avec ses collègues ou ses employés. Le résultat : laqualité de nos relations avec ces personnes aura un impact extraordinaire sur le bonheur per-sonnel et l’efficacité professionnelle. Cet article passera en revue les stratégies pour gérer lesconflits dans le but de faire régner l’harmonie et d’assurer le succès de l’équipe.

BARRY

THE CHEMISTRY OF A CHAMPIONSHIP DENTAL TEAM


impact on our effectiveness as a team.Connection in the workplace will signifi-cantly affect a team’s morale, stress, andthe level of fulfillment people draw fromtheir role in the practice.

If we call unity the engine of team’spotential, then communication would bethe fuel. As a practice mastery coach themost common desire I hear from owners,managers, and team members alike is that“we need to be more united … more con-nected.” It is relationships and communica-tion challenges that seem to be a commonrecurring theme that people wish to devel-op within their business. Today people arerealizing more and more that to reallyaccelerate the growth of your business youmust first grow the people within yourbusiness; then together as a more synchro-nized united team you can take your busi-ness anywhere. In my day-to-day coachingpractice, my new clients and I go througha discovery consultation where we exploretheir circumstances, opportunities, anddesires for growth and development. Thenprior to beginning the implementationprocess I candidly interview each memberof the team to discover what is going on inthe hearts and minds of the people whowill be at the centre of all positive changeinitiatives. As soon as I begin the inter-views an often hidden world begins toreveal itself. The underlying team dynam-ics, relationship issues, and communica-tion challenges begin to surface. These dis-coveries often come as a surprise to peopleespecially to practice leaders and man-agers. I frequently hear things like … “I

had no Idea this was going on” or “I hadno idea they felt this way.” Sometimes it’sjust one person who is bringing down themorale and operational ability of the entireteam but more often it’s a series of cliquesand subgroups that have evolved and arefragmenting the team’s effectiveness; themost common one being clinical team ver-sus business team.

The question we must explore is “whydo these conflicts occur in the first place?If we know they fragment the team intosub-groups, reducing cooperation andunity; why do we let them happen?”People often say to me “we are all reallygood caring people who like each other yetwe experience these co-worker interper-sonal issues.” It is important for us tounderstand that you don’t have to be a badperson or have bad intentions to getcaught up in a conflict. The dental practiceby design is a very intimate setting wherepeople with diverse backgrounds andunique personalities are required to com-municate and work together at a veryinterdependent level. The things we do thethings we don’t do and the way we dothem have a significant impact on ourcoworkers ability to perform their jobssmoothly and at a high level. The majoradvantage a team has over an individual isits diversity of knowledge, skills, views,and ideas. Unfortunately with this diversitycomes potential for conflict. Conflict arisesfrom our differences. When highly skilledindividuals come together at work to play ateam game their differences can contributeto the creation of conflict. This conflictimmediately begins to emotionally hijack,fragment, and divide the team. However,we must understand that this so calledconflict in work teams is not necessarilydestructive or a bad thing. It can lead toinnovative new ideas and approaches tooperational processes and challenges.Conflict, in this sense, can be consideredpositive, as it facilitates the surfacing ofimportant issues and provides opportuni-ties for people to strengthen their connec-tions while developing their communica-tion and interpersonal skills. Conflict onlybecomes negative if it is left to fester andescalate to a point where people begin tofeel defeated, combative and territorial (myjob-your-job).

It is my observation that conflicts usu-ally arise from communication failureswhich include poor listening skills; insuffi-

cient sharing of information; differences ininterpretation and perception; and nonver-bal cues being ignored or missed. It isimportant to understand that regardless ofthe scenario conflict is not an external setof events that we have the misfortune ofbeing exposed to. It is more of an internalprocess that is driven by our thoughts andattitude. We “Fuel” conflict. People createconflict based on how they choose tointerpret a situation and based on theapproach they choose to take when dealingwith it. It has been said that “the greatestgap in nature is the gap between one man’sthinking and another man’s thinking.” Ithink the problem arises when we begin toattach our diverse needs and alternateviewpoints to our emotions and then beginto judge others accordingly. People can dothis to a point where they become adver-sarial towards anyone with viewpoints thatdeviate from theirs.

It’s easy to win or dominate a disagree-ment at the expense of team unity andconnection; especially if you hold a posi-tion of authority! All you have to do is notlisten and communicate more stronglythan the other person and you win. But doyou really win in the grander scheme ofthings? The key to connecting positivelywith others is rooted in being willing toexplore beyond our personal points ofview so as to better understand how othersare experiencing a particular situation. Thequestion we should all ask ourselves is “doyou want to be right or do you want to behappy.” If your goal is to be right then yourapproach will be to shame, blame, label,and prove the other person wrong. If yourgoal is to be happy then your approach willbe to express your needs and viewpointwhile sincerely attempting to understandthe needs and viewpoint of the person youare dealing with. The problem is that mostpeople, especially when they are stressed;tend to get caught up in their favouritesubject (themselves). This personal biashinders meaningful productive conversa-tion with others and leads to the polariza-tion of hearts and minds. Our personalbias causes us to “judge people by theirbehaviour; meanwhile we are judging our-selves by the intentions of our behaviour”without fully understanding its actualimpact on others. If you really want tosolve a difficult situation you must take thetime to listen and to acknowledge theother persons intentions and view point.

BARRY


Be flexible on the road you take to happi-ness!

When a situation arises with anemployee or peer it requires fuel before itcan become a conflict. That fuel source isenergy, time and attention. Let’s look at asimple 10 step process we can follow inorder to resolve conflicts quickly therebypreserving our energy, time and attentionand for the purpose of doing more positiveand productive things.1. Ask yourself, what meaning have I

attached to this … could this meansomething else?

2. Ask the person for their help.3. Ask the person for permission to dis-

cuss your concerns with them.4. State the situation as you see it with-

out using destructive labels to describetheir behaviour. Describe the actionyou have issues with without labellingthe behaviour (i.e., you are lazy/youare inconsiderate).

5. Explain their behaviours’ impact onyou while showing show respect fortheir intentions. “This affects me by_________.I understand this is notyour intention because I know whoyou are.”

6. Ask them to help you understand andsolve this situation.

7. Listen deeply and acknowledge theirviewpoint. Even if you don’t agree, youare merely acknowledging not agree-ing. In most cases the more heard andunderstood you make them feel themore deeply they will receive andaccept your viewpoint.

8. When these steps are followed youcreate a stage on which to discuss asolution; if a solution is necessary. Inthe very least you can walk awayunderstanding each other betterwhich usually causes people to behavein ways that are more supportive ofeach other’s needs.

9. If specific resolution is required con-tinue on by making a win-win behav-iour modification agreement.a. Define the heart/root of the prob-lem not the surface

b. Brainstorm ideasc. Eliminate ideas either party feelswon’t work

d.Clarify remaining idease. Iron out details …

who/when/what/where/howf. Evaluation … revisit this in thefuture

10. Thank each other for caring enoughto give feedback and to listen andunderstand each other.

Example/Sample Process1. You: I need your help with something!

Can we talk? When you _________ Ifeel ________. It affects myrole__________. I know that is notyour intention because I know whoyou are! Can you help me understandor solve this?

2. Them: I’m sorry that is not my inten-tion…I don’t mean_______. I do thatbecause________. I didn’t real-ize__________.

3. You and Them:Walk away under-standing each other better or discussand resolve follow up behaviouralmodifications required to improvethings for both parties.

4. Them: ”Thanks for letting me know.”5. You: “Thanks for listening!”

Now let’s look at 17 very powerful gen-eral guidelines for dealing more positivelywith a co-worker issue.1. Speak only to that person and discuss

issues privately, not publicly.2. Address issues as soon as possible.3, Do not address issues while either

person is in an emotionally chargedstate.

4. Communicate your concerns openlyand honestly without sugar-coating ornursing a silent personal agenda.

5. Avoid being defensive. “LISTEN” toeach other and acknowledge eachother’s views even if you don’t agree.

6. Don’t get personal. Avoid characterlabels and name calling … i.e., “youare lazy,” “you don’t think,” “you don’tcare.” Focus on the behaviour not theperson.

7. Speak to one issue at a time. Don’toverload the person.

8. Deal only with actions the person canchange − asking the impossible onlybuilds frustration into your relation-ship.

9. Once you’ve made your point don’tkeep repeating it.

10. Avoid sarcasm. Sarcasm signals youare angry at people not their actionsand may cause them to resent you.

11. Avoid playing “gotcha” type games.12. Avoid generalizations like

“ALWAYS/NEVER.” They usuallydetract from accuracy and make peo-ple defensive.

13. Present criticisms as suggestions orquestions if possible.

14. Don’t forget the complements.15. Don’t apologize for the confrontation-

al meeting. Doing so detracts from it


and indicates you are not sure you hadthe right to express your concerns.

16. Be able to forgive! Release yourselfand your emotions from the burden ofchronic dissatisfaction and frustrationby practicing the art of forgiveness ona daily basis.

17. Finally and most importantly; beaware of how you interpret situations.Always ask yourself, “what meaninghave I attached to this … a positive oneor a negative one?” “Could this meansomething else?” “Do I have all theinformation?” Be prepared to listen.Instead of “Conflict Resolution Skills” I

prefer to call these “ConnectionManagement Guidelines” since there is no“CONFLICT” until we begin applying thedestructive behaviours that reduce impor-tant issues to a personal and adversariallevel. The ultimate question we mustalways ask ourselves before a confrontationis “do I want to be right or do I want to behappy.” If your goal is to be happy thenfocus on staying connected. Communicatewith a core desire to build cooperation intoyour relationship by learning more abouteach other. Connection Management is aproactive way of growing your business bystrengthening the teamwork and unity ofyour people.

Bibliography1. Harper G. (2004). The Joy of Conflict

Resolution. Gabriola Island: BC: NewSociety Publishers

2. Alessandra T, O’Connor MJ,Van Dyke J.(1995). People Smarts. San Francisco:Jossey-Bass Pfeiffer.

3. Sanders T. (2005). The Likeability Factor.New York: Random House.

4. O’Neill M. Transform Stress & Conflictinto Growth & Change. (Audio CD).Available at: http://www.maryoneill.com/audio-seminar-series.html.

5. Goleman D. (1998).Working withEmotional Intelligence. New York: BantamBooks.

6. Goleman D. (2007).Social Intelligence.New York: Bantam Books

7. Shapiro S, Schefdore R. Better ServiceBetter Income Better Dentistry.

8. Homoly P.(2006).Making it Easy forPatients to Say Yes. Charlotte, NC: Author.

9. Lund P. (1997). Building the HappinessCentred Business. Brisbane, Australia:Solutions Press.

10. Jameson C. (1999). Great CommunicationEquals Great Production, 2nd Ed. Tulsa,OK: PennWell Publishing.

THE CHEMISTRY OF A CHAMPIONSHIP DENTAL TEAM


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Canadian Journal of Restorative Dentistry andProsthodontics

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MICRO RESTORATIVE DENTISTRY / MICRO DENTISTERIE RESTAURATRICE


Operating Microscopes andZero-Defect Dentistry

David J. Clark, DDS

ABSTRACTOperating microscopes are celebrating their 25th anniversary in dentistry. Initially resisted byendodontists andmainstream dentists, there has been a recent surge of interest inmicroscope-enhanced dentistry. In endodontics, the microscope is becoming standard equipment.This article discusses a change in the endodontic-restorative protocol and highlights a clinicalcase that demonstrates the tremendous advantage of advanced magnification when marriedwith other forward-thinking techniques. It concludes with an exploration of the rationale andscience of zero-defect restorative dentistry, dentinal caries removal, and finally a review of thescience of microscope-enhanced dentistry.RÉSUMÉLes microscopes opératoires célèbrent leur 25e anniversaire en médecine dentaire. Initialementboudés par les endodontistes et les dentistes, on constate maintenant un intérêt grandissantpour la médecine dentaire de pointe et l’utilisation du microscope. En endodontie, le microscopeest maintenant un instrument courant.Cet article traite d’un changement apporté dans le protocole de l’endodontie et de la médecinedentaire restauratrice et expose un cas clinique qui démontre l’avantage du grossissement com-biné à d’autres techniques avant-gardistes. En conclusion, on aborde l’analyse raisonnée et la sci-ence de la médecine dentaire zéro-défaut, l’enlèvement des caries de la dentine et finalement onfait une revue de la science de la médecine dentaire de pointe et l’utilisation du microscope.

About the AuthorDr. David Clark, DDS, is the founder of the Academy of Microscope Enhanced Dentistry, an internationalassociation formed to advance the science and practice of microendodontics,microperiodontics,micro-prosthodontics, and microdentistry. He is a course director at the Newport Coast Oral Facial Institute in

Newport Beach, California. Dr. Clark served Clinical Research Associates in the “Update Series” lectures and asan interim Dentist/Researcher from 2005 to 2007.

Dr. Clark authored the first comprehensive guide to enamel and dentinal cracks based on 16-powermagnification in the Journal of Esthetic and Restorative Dentistry. He has written numerous articles relating to minimally

invasive dentistry, biomimetic endodontic shaping, and the role of advanced magnification in modern dental practice.

Dr. Clark has developed new techniques and materials, including the endo-restorative casting; a new shape for the class IIcomposite, the “Clark Class II”; and a matrix and interproximal management system, the Bioclear Matrix System, that promises a

real advancement for both bonded porcelain and direct composites. He has helped pioneer the concept of biomimeticmicro-endodontics, which is a significant departure from Schilderean shaping.

cians can assess the likely outcome and usethis information in decision making.Today’s finished case should be sealedexquisitely, pleasing esthetically, andaccompanied by regenerated papillae. Withadvanced magnification, the additionalvisual information afforded to the clinicianwith the benefit of shadowless, coaxiallight combined with infinity correctedoptics enhances the clinician’s ability tocreate clean, caries free margins, which, in

Operating microscopes are celebratingtheir 25th anniversary in dentistry.

Initially resisted by endodontists andmainstream dentists, there has been arecent surge of interest in microscope-enhanced dentistry. In endodontics, themicroscope is becoming standard equip-ment (Figure 1). At a recent opinionleader’s forum, the question was posed:“Should microscopes be required for allendodontic treatment?” This incredibleswing in endodontic opinion also is beingfelt in general dentistry. As dental schoolsbegin to integrate the microscope into thecurriculum, two new frontiers in den-tistry will be realized: minimally traumat-ic dentistry and zero-defect dentistry.

This brief article discusses a change inthe endodontic-restorative protocol andthen highlights a clinical case that demon-strates the tremendous advantage ofadvanced magnification when marriedwith other forward thinking techniques.The article concludes with an explorationof the rationale and science of zero-defectrestorative dentistry, dentinal cariesremoval and finally a review of the scienceof microscope-enhanced dentistry.

Modern Decision Making for theCompromised ToothImplants have raised the bar to the pointwhere heroic attempts to restore the com-promised tooth should generally beaccompanied with a conversation thatincludes the option for implant replace-ment.

An argument can also be made that thepredictability of implants places additionalpressure on the restorative dentist; the lossof a restored tooth after a 5-year lifespanmay have been acceptable in 1960, but maybe unacceptable in 2008.

Microscope-enhanced dentistry ischanging the endodontic-restorative proto-col, altering the thought process whendetermining when to save or extract atooth. Microscopes offer additional meth-ods for caries assessment and endodontictherapy, moving the profession closer tozero-defect restorative dentistry.

The decision to “extract or save” is aconstantly evolving art form. In micro-scope-enhanced dentistry, the thoughtprocess in the endodontic-restorative pro-tocol is often inversed. Rather than“endodontics then restorative,” it is often“restorative, then endodontics” as clini-

turn, can create an optimal restorative seal.Clinicians also can assess the actual inva-sion of the biologic width and potential forhealthy and esthetic soft-tissue contours.1For example, in the case presented, cariesremoval, margin identification, and thepotential for papilla regeneration could beverified by restorative investigation.“Restorative investigation” is an importantconcept that is defined as “The clinicalpractice of prosthodontic disassembly,

Figure 1. The author at work with his microscope, a G6 Global surgical microscope.


OPERATING MICROSCOPES AND ZERO-DEFECT DENTISTRY


CLARK

restoration removal, caries excavation,microsurgical access, and tissue retraction;the goal of which is to assess the trueextent of dental pathology combined con-current with the long term restorativepotential of the tooth.”2 After these issues

are deemed satisfactory, then, and onlythen, is the pulp chamber re-accessed andendodontic therapy initiated. This evolu-tion in triage has the potential to becomethe standard of care in the modern era ofdentistry.

Case SummaryThe patient, a 56-year-old woman, wasvacillating between treatment plans for herupper arch: a full immediate upper dentureor restorative reconstruction. While thetreatment for the lower arch was proceed-ing, she began to experience pain with theupper right central incisor (Figure 2). Shehad a class reunion that was a week away.She desperately wanted to attend thisimportant function without pain and witha smile that did not embarrass her.

Implants were not an option for theupper arch for financial reasons. She wasfaced with a decision of either removingthe tooth and receiving a temporary partialdenture, or initiating restorative treatmentcombined with endodontic therapy. Thepatient chose the latter because it allowedfor retention of the tooth as an interimtreatment until a final decision wasreached for the maxillary arch.

Figure 3 demonstrates the tooth aftercaries removal was thought to be complete.Although the dentin did not stain withcaries-indicator solution, in the author’sexperience the use of high magnificationto evaluate hardness is the ultimate test ofsound dentin. Magnification (16×)revealed that gross caries was still present.Figure 4 demonstrates exploration of thedeepest layer of “noodle dentin.” Finalevaluation of the nuances of sound dentinis demonstrated in Figure 5. A coarse dia-mond can be used to assess dentin becauseat 20–24× magnification the scratches canbe used as clues to assess dentin hardness.3Carr has shown that the unaided eye cannotdistinguish between two lines that are closertogether than 200 microns. With the micro-scope, 20 micron assessment is possible.

To create an ideal embrasure form, aBioclear matrix (Tacoma, WA) was used(Figure 6 and Figure 7). This anatomicallyshaped matrix encourages the papilla toregenerate.4

The composite was cured, then shapedand polished. Modern porcelain polishers,such as the D♦Fine™ (Clinician’s Choice,New Milford, CT) or Jazz™ series (SSWhite Burs, Inc, Lakewood, NJ), yield afinish that is absolutely breathtaking(Figure 8).

After the patient and clinician wereconfident that the tooth was a good invest-ment, delicate endodontic access (Figure 9)was created and endodontic therapy wascompleted in a more sterile environment.5,6

Figure 2. Preoperative view of deep caries on mesial aspect of upper right central incisor.

Figure 3. Initial caries removal. Application of caries-indicator solution did not stain the dentin.Extremely soft dentin often does not allow penetration of the dye, creating a false negativecaries assessment (original magnification 8x).

2

3

tory for minimally traumatic dentistry, andfor the patient, an elevated commitment tolifestyle changes and improved home care.This case also highlights a key factor inmany restorative cases, the emotional stateof patients that influences decision makingand how one small success can turn thetide of decision making.

Zero-Defect Restorative DentistryCaries removal is a fundamental task oftraditional dentistry. Unfortunately, thecommercially driven focus of bleaching,veneers, lasers, and implants has distractedsome away from the topic of cariesremoval. The basic preparation tool (car-bide and diamond burs) of dentistry isvery similar to what it was generations ago.

tion and improper asepsis. Introduction ofuntoward bacteria into the canal systemsboth during and after endodontic therapy8–12 has been shown in multiple studies tocontribute to endodontic failure.13–16Additionally, there are reports of failingendodontic therapy with multiple failedendodontic re-treatments that were inef-fective until a well sealed coronal restora-tion was placed.17 Other cross sectionalstudies have shown that a good coronalseal is at least as important as a good rootfilling.18

The patient was so impressed with theresult (Figure 10) that this one event creat-ed the excitement and optimism to retainrather than extract her upper natural den-tition. Accompanying this decision is a vic-

In the traditional approach, endodontics isperformed first with either no restorativeseal in the interproximal area of caries or amarginally sealed temporary restoration.Bacterial strains such as Enterococcus fae-calis that are commonly cultured from theroot canal systems of endodontic failuresare rarely cultured from the pulp spaces ofcases of irreversible pulpitis (no radi-ographic lesion, partially or fully vitalpulp) such as the featured case.7 The logi-cal conclusion discussed by the endodonticcommunity is that these problematic bac-teria can only gain access into the canalsand periapical areas through coronal leak-age after endodontic therapy, in betweenendodontic appointments, or duringendodontic therapy from inadequate isola-



Figure 4. Soft dentin being teased with an explorer (original magnifica-tion 16x).

4

Figure 5. Complete caries removal confirmed by scratch marks from acoarse diamond bur. Softer, infected dentin does not exhibit this type ofsurface texture (original magnification 24x).

5

6 7

Figure 6 and Figure 7. The anatomically shaped Bioclear matrix in position. The aggressive cervical curvature encourages the static pressure andscaffold needed to stimulate the regeneration of the papilla.

CLARK


removal should be terminated once theaffected dentin has been reached, in the40 to 50 Knoop hardness range.Microscopic evaluation at extreme levelsof magnification provides additional visu-al information to assess the texture andhardness of dentin that can augment thetraditional tactile approach to dentinhardness (Table 2).Maintaining areas of affected dentin thatmay be discoloured will not compromisethe tooth-restoration complex.25 However,some studies have shown a compromisedlong term resin bond to discoloured,affected, and amalgam contaminateddentin.26 In these cases, the use of a glassionomer sandwich technique is an option,

Table 1. Traditional clinicaldentinal caries assessment• Radiographs• Dentinal color• Dentinal hardness (spoon excavator or

explorer)• Uptake of caries-indicator dye• Laser Fluorescence (Diagnodent)

The presumption that healthy dentinis “harder” is supported by extensiveresearch.23 The most predictable clinicalindicator of sound versus unsound dentinis hardness.24 The Knoop hardness scaleof infected dentin ranges from 0 to 30,affected dentin from 30 to 70, and healthydentin from 70 to 90. Ideally, dentin

Traditional burs can in no way differenti-ate between healthy and unhealthy toothstructures. The only known selective hard-ness cutting instruments are Smartburs™(SS White Burs, Inc.), which are not readi-ly available. The tactile differences betweendecayed dentin (soft) and healthy dentin(hard) is the single most common tool thatis employed by practitioners in the deter-mination on of which structures toremove.19 Although there are many ways inwhich a clinician can assess carious dentin,today’s most common approaches includeradiographs, caries-indicator dye, spoonexcavator or explorer tip (tactile hardness)tests, and laser fluorescence detection20–22(Table1).

8a 8b

Figure 8. A, Preoperative view of deep caries on mesial aspect of upper right central incisor. B, Immediate postoperative view. The long, infinity-edgemargin allowed an ideal esthetic result – a heroic composite restoration that is as smooth as the contralateral tooth that has a porcelain crown.This exceeds all expectations of what we can do with composite.

9 10

Figure 9. Endodontic access with a conical carbide is less traumatic thanwith fissure burs or round burs. Pictured is a prototype CK endodonticaccess bur from SSWhite Burs, Inc. (original magnification 4x).

10

Figure 10. At 4 weeks, there was partial papilla regeneration. Thepatient had very little postoperative discomfort and was ecstatic aboutthe esthetic result.



which can have a more stable long termbond (glass ionomer-dentin interface) tocompromised dentin.27 Alternatively anenhancement of other more predictablesurfaces (i.e., creating longer enamel mar-gins or dentinal undercuts) could be uti-lized in lieu of a glass ionomer sandwich.Dentin colour is one of the least pre-dictable indicators of sound dentin, i.e.,black, brown, and green dentin in previ-ously restored teeth is often non-cariousand should not be removed.28 Conversely,normal coloured dentin can be soft andgrossly infected but appear normal at lowmagnification. In these cases, caries-indi-cator dye often can give a “false negative”to stain uptake. In other words, the dentincan have a normal colour, and yet be sosoft that no absorption of caries-indicatorsolution occurs. A study comparing differ-

ent diagnostic approaches to occlusalcaries assessment found that visual tech-niques without advanced magnificationwere only correct 53% of the time andcaries disclosing dyes were only accurate43% of the time.29 While laser fluorescencecan be very accurate,30 its use in mostpractices is for initial diagnosis. Use ofinstruments such as a Diagnodent for on-the-fly diagnosis during cutting of thetooth is both impractical and non specific(a positive reading of 20 or above indicatesthat caries are present but not preciselywhere the carious and non carious toothstructures are). In the case presented, thedentin in Figure 2 was treated with caries-indicator dye and had no stain uptake. It ismy opinion that without the microscope Icould have easily been lulled into a falsesense of security that caries removal was

Table 2. Visual clues of tooth hardness observed by the author under themicroscope1. “Wet sponge” reaction to explorer pressure 8x magnification2. Dentin-enamel microgapping at dentino-enamel junction 16x magnification3. Diamond bur scratching 20–24x magnification

complete. Leaving gross residual caries atthe margin areas contradicts many restora-tive principles could doom this case to pre-mature failure.

Clinical Microscopes: Luxury orNecessity?The operating microscope is not just sim-ply higher magnification than oculars(loupes). It is bettermagnification. Ocularshave been very helpful and may alwayshave a role in dentistry, but the optics arecrude when compared to the InfinityCorrected Optics of a stereoscopic micro-scope (Figures 11–14). When combinedwith the shadowless coaxial light source,they transform the clinician’s potential foraccuracy of nearly every aspect in the dif-ferent disciplines in dentistry.

Increasing levels of magnification pro-duce a squared, not linear relationship tovisual acuity. In other words, a clinicianworking at 3.5× sees 10 timesmore visualinformation, 10× magnification allows thehuman retina to acquire 100 timesmoreinformation, and 20× allows 400 times thevisual information31 (Table 3).

Improved Outcomes?Improved outcomes from the use of mag-nification have been well documented inthe medical literature, and scientific vali-dation in dentistry is beginning toemerge.32–40 There are no legal require-ments in Canada or the United Statesmandating that dentists use magnification.However, most dental schools today eitherrecommend or require the use of magnify-ing loupes for both pre-clinical and clinicaltraining. In 1999 the American Associ-ation of Endodontists mandated thatmicroscopes be implemented into all USgraduate endodontic residency programs.There are scant studies conducted at thehighest level as randomized, controlled,and double blind in any field of dentistryto prove or disprove most of what we do inprivate practice. To prove without questionthat magnification or microscopic magnifi-cation provides better clinical outcomeswill be as difficult and pointless, in myopinion, as proving that using a brightoperatory light is better than a dim light.In spite of this, the “magnification escala-tion” continues in most nations around theworld as even third world countries suchas Chile now boast Societies of Microscope

Figure 11. Oculars (loupes) rely on convergent vision that essentially requires an overlap of twoimages. This form of magnification creates increasing problems and eye strain as magnificationpower increases. The clinical microscope utilizes a more refined optical system (original magnifi-cation 16x).

11

CLARK


Dentistry. Once the bar is raised to allow a new level of diagnostic sensi-tivity, it is unlikely that a regression toward a lesser capability will occur.

There are many studies that have shown that magnification plays animportant role in clinical accuracy, such as the ability to access andshape complex root canal anatomy. In a compelling study, the use of amicroscope enabled the author, an endodontist, to improve his ability tofind a fourth canal system from 73 to 93% in maxillary first molars.41,42Sadly, most general dentists and endodontists who do not use micro-scopes rarely report finding four canal systems in maxillary first molars.There are studies showing that use of an operating microscope can leadto less postoperative discomfort.43 In periodontics, the microscopeenhances the surgeon’s visual acuity44 allowing better manipulation andmore accurate suturing of the soft tissues.45 Low tissue trauma, excellentflap control, and a micro-suturing technique that allows primary woundclosure may be responsible for improved clinical success.46,47 Reducedoperator mistakes in endodontics have been reported as a benefit of clin-ical microscopes.48 The ergonomics of the microscope clinician’s properposture have shown a remarkable reduction in back pain and disability, apriceless benefit to the practitioner for a pervasive and serious problemthat can destroy our health and diminish the daily enjoyment of ourcraft.49–51

ConclusionOwning and using a microscope does not make one dentist better thananother. Experience, training, commitment, and ability are the key traitsthat distinguish the good from the great. Excellence in dentistry is both achoice and a journey, and magnification can be a powerful asset forthose who seek absolute clinical accuracy. The testimony of doctors whouse the microscope daily in their practices confirms its value; an over-whelming majority affirms that it has improved their clinical skills. Themicroscope, with instantaneous magnification from 2.5× to 24×, novisual noise, and shadowless coaxial light, offers the best means forachieving complete visual information in dentistry. It can nurture greatconfidence, healthier posture, and better and surer hands for the clini-cian. And in the end, the excellent visual information it offers can helpthe doctor to create more precise, more healthful, and more estheticallypleasing dentistry.

DisclosureDr. Clark has no financial interest in any microscope company. Dr. Clarkhas a financial interest in the Bioclear Matrix System. He is also the co-developer of the CK endodontic access burs.

References1. Clark DJ, Kim J. Optimizing gingival esthetics; a microscopic perspective.

Oral Health 2005; April:116–26.2. Clark DJ, Sheets CG, Paquette JM. Definitive diagnosis of early enamel and

dentinal cracks based on microscopic evaluation. J Esthet Restor Dent2003;15(special issue):7:391–401.

14

Figure 14. The figure represents the same case seen with a clinicalmicroscope at 24x original magnification featuring infinity correct-ed optics. There is no eye strain and no visual noise. Loupes magni-fication at 8x (original magnification) and beyond becomes excru-ciating for most clinicians. For advanced magnification, the micro-scope is a superior and healthier choice.

12

Figure 12. The figure features 8x convergent magnification withloupes and a representation of the two images that the brainreceives as the eyes begin to focus.

13

Figure 13. The figure shows a common occurrence of the incom-plete merging of the images seen through a pair of loupes. BothFigure 12 and Figure 13 demonstrate the visual noise (blurryperiphery) of loupes optics.

Table 3. Magnification and visual informationMagnification 1x 2x 4x 10x 16x 25xInformation 1x 4x 16x 100x 256x 625xcontentPicture 660 2,640 10,560 66,000 168,960 412,500element



3. Carr GB,Magnification and illumination inendodontics. In: Hardin JF. Clark’s ClinicalDentistry. Vol 4. New York, NY:Mosby:1998:1–14.

4. Clark DJ. Restoratively driven papilla regen-eration. Can J Rest Dent Prosthodont2008;1–2: 40–46.

5. Lovdahl PE, Gutmann JL. Periodontal andrestorative considerations prior toendodontic therapy. Gen Dent1980;28(4):38–45.

6. Naoum HJ, Chandler NP. Temporization forendodontics. Int Endod J 2002;35(12):964–78.

7. Sunde PT, Olsen I, Debelian GJ, Tronstad L.Microbiota of periapical lesions refractoryto endodontic therapy. J Endod.2002;28(4):304–10.

8. Beach CW, Calhoun JC, Bramwell JD, et al.Clinical evaluation of bacterial leakage ofendodontic temporaray filling materials. JEndodoont 1996;22:459–62.

9. Beckham BM, Anderson RW,Morris CF. Anevaluation of three materials as barriers tocoronal microleakage in endodonticallytreated teeth. J Endodont 1993;19:388–91.

10. Trope M, Chow E, Nissar R. In vitro antitox-in penetration of coronally unsealedendodontically treated teeth. EndodontDent Traumatol 1995;11:90–94.

11. Cruz EV, Shigetan Y, IshikawaM,Goodis HE.A laboratory study of coronal microleakgeusing four temporary restorative materials.Int Endodont J 2002;35:315–320.

12. Balto H, Al-Nazhan S, Al-Mansour K, et al.Microbial leakage of Cavit, IRM, and TempBond in post-prepared root canals usingtwomethods of gutta-percha removal: anin vitro study. J Contemp Dent Pract2005;6(3):53–61.

13. SaundersWP, Saunders EM. Coronal leak-age as a cause of failure in root-canal ther-apy: a review. Endod Dent Traumatol1994;10:105–108.

14. Swanson K,Madison S. An evaluation ofcoronal microleakage in endodonticallytreated teeth. Part I. Time periods. J Endod1987;13(2):56–9.

15. Madison S, Swanson K, Chiles SA. An evalu-ation of coronal microleakage in endodon-tically treated teeth. Part II. Sealer types. JEndod 1987;13(3):109–12.

16. Madison S,Wilcox LR. An evaluation ofcoronal microleakage in endodonticallytreated teeth. Part III. In vivo study. J Endod1988;14(9):455–8.

17. Chong BS. Coronal leakage and treatmentfailure. J Endod 1995;21(3):159–60.

18. Hommez GM, Coppens CR, De Moor RJ.Periapical health related to the quality ofcoronal restorations and root fillings. IntEndod J 2002;35(8):680–9.

19. Freedman G. Polymer preparation instru-ments: New paradigm in selective dentinremoval.Minimally Invasive Dentistry –

The Management of Caries (Contributor)Polymer Cutting Instruments section p.109–110.

20. 9/6/08 interview with Dr. RellaChristiansen of CR (formerly CRA) and theTRAC institute.

21. Chong MJ, SeowWK, Purdie DM, et al.Visual-tactile examination compared withconventional radiography, digital radiogra-phy, and Diagnodent in the diagnosis ofocclusal occult caries in extracted premo-lars. Pediatr Dent 2003;25(4):341–9

22. Magid KS. Caries diagnosis: the necessityfor a new standard of care. Review. AlphaOmega 1996;89(3):6–10.

23. Hosoya Y,Marshall SJ,Watanabe LG,Marshell GW,Microhardness of cariousdeciduous dentin. Oper Dent 2000;25:81–9.

24. Meredith N, Sherriff DJ, Swanson SAV.Measurement of the microhardness andYoungs’s modulus of human enamel anddentin using an indentation technique.Arch Oral Biol 1996;41:539–45.

25. Terashima S,Watanabe M, Kurosaki N,Kono A. Hardness of dentin remainingafter clinical excavation of soft dentin.Japanese J Conserv Dent 1969;11:115–120.

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