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Publication Mail Registration No. 5383
                                                Publication Mail Agreement No. 40063878

                   Ontario Dentist

                   THE JOURNAL OF THE ONTARIO DENTAL ASSOCIATION

Looking Forward to ASM19 — Your Learning Destination
A p ril 2 0 1 9
Ontario Dentist - Looking Forward to ASM19 - Your Learning Destination April 2019 - Ontario Dental ...
Ontario Dentist - Looking Forward to ASM19 - Your Learning Destination April 2019 - Ontario Dental ...
May 9-11, 2019
       19                      Metro Toronto Convention Centre, South Building
                                         Located just outside the exhibits floor on level 800.

                             The ODA Booth is back!
                 Drop by to learn how the ODA can expand your potential
                          through our valuable member benefits.

Meet the people on the other side of the phone. ODA staff will be on hand to answer all your
 questions — and provide information you didn’t know you needed! The ODA booth is also
a great place to mingle with your Board of Directors, members of the Membership Services
                      and Programs Committee and your colleagues.

      PLUS…bring your dental team for a sneak peek of a new and innovative way to
      save on your business costs. Be the first to try out this latest member benefit.

                                      See you there!

                                   yourpotential.oda.ca

         A customized experience for dentists in practice for 10 years or less!

                          SAVE THE DATE
                         October 26-27, 2019 | Delta Toronto

                          Registration Opens May 2019
                        Learn more at: www.oda.ca/new-dentist-symposium

                                       Sponsored by:

                                                                                  April 2019 • OD   3
Ontario Dentist - Looking Forward to ASM19 - Your Learning Destination April 2019 - Ontario Dental ...
April 2019
    Volume 96 | Issue 3    Contents
                          20                                   30                                       36

                          Ideas
                          10   Letters                               16     Risk Management
                               The Future Must Matter                       Direct to Consumer
                               Dr. Brian Clark                              Dr. Lionel Lenkinski

                               How Increasing Costs Affect           18     Osseointegration
                               Services                                     The Genesis of Osseointegration:
                               Mariam Kamel                                 The Toronto Connection
                                                                            Dr. James C. Taylor
                          12   President’s Page
                               “Out of Many, One People”             20     New Care Model
                               Dr. David M. Stevenson                       Person-Centred Care
                                                                            Dr. Sanjukta Mohanta
                          14   Editorial
                               In a Boat With a Very Small
                               Paddle
                               Dr. Carlos Quiñonez

                          Analysis
                          24   Social Networking
                               Uses, Benefits and Limitations of Social Networking Sites for Dental Public
                               Health Surveillance
                               Janet Wu

                          Clinical
                          30   New Disease Classification System
                               The New Classification Scheme for Periodontal Diseases and Conditions
                               Dr. Zeeshan Sheikh, Dr. Nader Hamdan and Dr. Michael Glogauer

                          36   Case Report
                               Tooth Replacement Using a Novel Reinforced Fibre
                               Dr. Pasquale Duronio

4    OD • April 2019
Ontario Dentist - Looking Forward to ASM19 - Your Learning Destination April 2019 - Ontario Dental ...
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Ontario Dentist - Looking Forward to ASM19 - Your Learning Destination April 2019 - Ontario Dental ...
Contents

                                                 44                                            56

                      Your Practice
                      38   Practice Management                 42   Discipline Hearings
                           Suggested Fee Guide Coding and           What Dentists Need to Know
                           Dental Claims/Plans Questions            About RCDSO Discipline Hearings
                           Barbara Morrow                           Josh Koziebrocki

                      40   Employment Law
                           Taking a Bite Out of
                           Employment Law
                           Stuart Rudner and Shaun Bernstein

                      Our ODA
                      44   ASM19                               50   Dental Calendar
                           Plan to Attend the ODA’s
                           Annual Spring Meeting in            56   In Memoriam/Tribute
                           May 2019                                 Dr. Ivan (Ivica) Mus
                           Helen McDowell                           Dr. Paul Edmund McKenna
                                                                    Dr. Bernard Blackstien
                      48   Continuing Education
                           Calendar

                      Classifieds
                      58   Classified Ads                      64   Advertiser Index

6   OD • April 2019
Ontario Dentist - Looking Forward to ASM19 - Your Learning Destination April 2019 - Ontario Dental ...
Introducing
Next Generation
Colgate Total*

                                                                                                                                    Petri dish treated
                                                                                                                                   with saliva + water,
                                                                                                                                   left out overnight†

                                              Petri dish treated with
                                    New Colgate Total* formula,
                                                  left out overnight†

                                                                                                       †
                                                                                                        Bacteria growth after overnight incubation in an in vitro study.

Help patients achieve Whole Mouth Health‡
New patented Dual-Zinc combined with arginine§ formula
Fights plaque-causing bacteria on 100% of mouth surfaces¶1 for better patient outcomes:
 Significant reductions in plaque2, gingivitis2, calculus3 and malodour4

       Now with sensitivity relief
       across all variants.

Reduces bacteria on saliva, teeth, tongue, cheeks and gums; helps prevent plaque and gingivitis, protects enamel, relieves sensitivity.
‡

Arginine is a stabilizing non-active excipient that enhances the flavour of the toothpaste formula.
§

Statistically significant greater reduction of cultivable bacteria on teeth, tongue, cheeks, and gums with Colgate Total* vs. non-antibacterial fluoride toothpaste at 4 weeks, 12 hours
¶

after brushing.

    References: 1. Prasad K. J Clin Dent, accepted for publication 2018. 2. Garcia-Godoy F, et al. J Clin Dent, accepted for publication 2018. 3. Seriwatanachai & Mateo, September 2016,
    internal report. 4. Hu D, et al. J Clin Dent, accepted for publication 2018.
Ontario Dentist - Looking Forward to ASM19 - Your Learning Destination April 2019 - Ontario Dental ...
ODA Board of Directors
Ontario Dentist is the official journal of the Ontario Dental
Association, dedicated to supporting the Association’s Mission and                                President
Vision by providing members with educational information relevant                            Dr. David Stevenson
to their profession and the dental practice environment in Ontario.                                Rideau

PUBLISHER                                                                                       President-Elect
Marcus Staviss                                                                                 Dr. Kim Hansen
                                                                                                  Brockville
EDITOR
                                                                                                 Vice-President
Dr. Carlos Quiñonez
                                                                                                Dr. Lesli Hapak
                                                                                                     Essex
MANAGING EDITOR
Julia Kuipers                                                                                    Past President
                                                                                              Dr. LouAnn Visconti
CREATIVE AND GRAPHIC DESIGN SPECIALIST                                                              Timmins
Natalia Ivashchenko
                                                                                                Dr. Lisa Bentley
ASSOCIATE EDITOR                                                                                  Halton-Peel
Gilda Swartz
                                                                                               Dr. David Brown
PROFESSIONAL AFFAIRS ADVISOR                                                                         York
Roberta MacLean
                                                                                               Dr. Charles Frank
CLASSIFIEDS CO-ORDINATOR
                                                                                                     Essex
Catherine Solmes
                                                                                               Dr. John Glenny
                                                                                                West Toronto
EDITORIAL BOARD CHAIR                                                                        Dr. William Hawrysh
Dr. David Walker                                                                                 Halton-Peel

EDITORIAL BOARD                                                                               Dr. Maneesh Jain
Dr.   David Chvartszaid                    Dr.   Deborah Saunders                            Waterloo-Wellington
Dr.   Peter Copp                           Dr.   Barry Schwartz
Dr.   Michael Glogauer                     Dr.   Shawn Steele                                   Dr. Grace Lee
Dr.   Lionel Lenkinski                     Dr.   Susan Sutherland                                  Ottawa
Dr.   Sanjukta Mohanta                     Dr.   Anthony Veale
                                                                                             Dr. Melissa Milligan
                                                                                                 West Toronto
DISCLAIMER                                                                                    Dr. Brock Nicolucci
The opinions expressed in Ontario Dentist are those of the authors, and do                          London
not necessarily reflect the opinions of the ODA, Editor or Editorial Board.
                                                                                               Dr. Roch St-Aubin
Copyright: The Ontario Dental Association.                                                          Sudbury
Reprint only by permission of the ODA.
                                                                                              Dr. Donald Young
ISSN 0300 5275                                                                                   Thunder Bay

Advertising must comply with the advertising standards of the ODA.
The publication of an advertisement or inclusion of a polybagged item               Office of the Chair, General Council
should not be construed as an endorsement of, or approval by, the ODA.                     Chair of General Council
                                                                                             Dr. Roger Howard
DISPLAY ADVERTISING INFORMATION                                                                     Ottawa
Dovetail Communications Inc
30 East Beaver Creek Road, Suite 202                                                     Vice-Chair of General Council
Richmond Hill, Ont. L4B 1J2                                                                    Dr. Blake Clemes
Tel: 905-886-6640 Fax: 905-886-6615                                                           Waterloo-Wellington

Jennifer DiIorio          Gillian Thomas
905-886-6641              905-886-6641
ext. 309                  ext. 308
jdiiorio@dvtail.com       gthomas@dvtail.com

                                                                              OD
CONTACT US
4 New Street, Toronto, Ont. M5R 1P6
Tel: 416-922-3900
                                                                                         Ontario Dentist           Coming in May:
Fax: 416-922-9005
Email: jkuipers@oda.ca
www.oda.ca                                                                    Gingival Grafts and Predictable Outcomes

8      OD • April 2019
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68.635% (w/w) Sodium Perborate
Ontario Dentist - Looking Forward to ASM19 - Your Learning Destination April 2019 - Ontario Dental ...
Ideas
 Letters
                                                                      How Increasing Costs
                                                                        Affect Services
      The Future Must Matter                                    I would like to highlight the Ontario Dentist column
                                                                titled, “Never Forget Access to Care and Patient Safety
I would like to compliment Dr. Carlos Quiñonez on               by Dr. Lionel Lenkinski (January/February 2019). I re-
his January/February 2019 Editorial, “The Future Must           ally liked the fact that Dr. Lenkinski discussed how the
Matter at All Costs.” It is well argued and supports the        increasing costs of running a practice can affect the
importance of maintaining dental programs for poor              services provided to patients and may end up affecting
and underserviced families and children in the province.        their access to care.
Even in the face of chronic underfunding and probable              It can be a challenge for dentists to achieve a bal-
austerity measures to bring the provincial deficit under        ance between taking care of patients’ basic needs and
control, it is important to maintain these programs.            performing procedures that boost revenue. I believe
                                                                this is a very important topic to discuss with dental
  Dr. Brian Clark                                               students, and I will also be posting the article on the
  Tillsonburg, ON                                               Facebook site of Schulich’s Student Professionalism
                                                                and Ethics Association. OD

                                                                  Mariam Kamel
                                                                  DDS 2021, Schulich School of Medicine
                                                                  and Dentistry
                                                                  Social Media Representative, Student Profession-
                                                                  alism and Ethics Association (SPEA) Schulich

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 10    OD • April 2019
ONE.
     One is all it takes. The frequency and size of malpractice claims are on the rise in Canada.
          In recent years, individual claims worth millions of dollars have been launched.
                         Although rare, these cases can lead to disastrous financial losses
                                    for those who aren’t adequately insured.
         The good news is that you can significantly increase your malpractice coverage with
              Excess Malpractice Insurance from CDSPI1, for just a few dollars a week.

                       Excess Coverage Options           Annual Premium (for excess coverage)2              Weekly Premium3
                                  $ 1M                                        $ 64.51                                $ 1.24
                                  $ 2M                                        $115.19                                $ 2.22
                                  $ 3M                                        $159.42                                $ 3.07
                                  $ 8M                                       $378.74                                 $ 7.28
                                  $23 M                                      $764.54                                $14.70

              You strive to provide the highest level of care, you deserve the peace of mind
                        that comes with no longer having to worry about the one.

                  To find out more about Ontario Excess Malpractice Insurance from CDSPI
                        call us at 1.800.561.9401 or email us at insurance@cdspi.com.

                                                 60 Y E A RS S ER V I N G D EN T I S T S

              1. You must be a dentist licensed to practise in Ontario and a member of the Ontario Dental Association to be eligible to apply.
Excess Malpractice Insurance for Ontario dentists is arranged for by CDSPI Advisory Services Inc. and is underwritten by Aviva Insurance Company of Canada.
    2. Based on CDSPI 2019 rates. For coverage in excess of your primary coverage of $2 million mandated by the RCDSO; CDSPI Advisory Services Inc.
                        is not affiliated with the RCDSO. 3. Based on annual premiums; weekly premium payments are not available.
                                                                                                                                                         19-873 2/19
Ideas
  President’s Page

                                                   “Out of Many, One People”
David M. Stevenson
DDS

“O                ut of many, one people” is the national
                  motto of Jamaica and it is inscribed on
                  its coat of arms. My mother was Jamai-
can and she loved these words. As I have learned more
                                                               as, at that time, military personnel moved from base to
                                                               base on a regular basis and brought their records with
                                                               them. Signatures were left in the form of occlusal anat-
                                                               omy in an amalgam, and not just in the patient’s chart.
about this side of my heritage, I have grown to appreciate        But leaving our mark on our profession is bigger than
the complex vision in this simple phrase. I promise my         just our clinical footprint. We leave our signatures on our
Jamaican family not to take their words, but as I reflect      practices, since each situation is unique. The same base
on the meaning of the motto, I see many parallels with         of patients in a different office would most likely result
the ODA and its members.                                       in an entirely different mix of treatment. Not better or
   To say that dentists come from many different back-         worse, just different. The same can be said about how the
grounds is stating the obvious. But I’ll state it anyway,      mix of staff, partners and associates influences a practice.
because it is important. We are all different, and I don’t     What makes our practices unique is important in many
just mean from an ethnic or cultural perspective, but also     ways. It is important to our patients, so they may have
in our character and our passion. We all bring something       a choice in their care. It is important to our careers. It
unique to the table, which in turn brings tremendous           is important to how we choose to transition out of our
value to our profession — and to each other.                   practice or into another. It is important to the signature
   Passion was particularly evident at the ODA’s Wel-          we leave on our communities; for many of us, particu-
come to the Profession Luncheon, held for students in          larly those in smaller communities, our practices help
the International Dentist Advanced Placement Program           define who we are as neighbours.
(IDAPP) at the University of Toronto. These students are          That sense of community is also strong within our
an inspiration. Most of them have had journeys that            profession. As individuals, we may be very different, but
have not been easy. How each individual arrived at this        we all want the same thing — that which is best for our
point in their career is as unique as they are. However,       patients. I am extremely grateful to the many in our pro-
what they shared was obvious appreciation at being in          fession who choose to specialize, or practise in hospitals,
this place at this time. When listening to their stories and   or embrace public health. As a GP practising in a small
dreams, which range from being new to our profession           town, I am expected to provide a wide range of services
to working many years as an experienced practitioner,          to my patients. But I also know when I’m in over my
or having aspirations of a private practice to careers in      head — because I’ve been in over my head. And when I
research, academia and even the military, I felt I was         have been there, I knew I could depend on specialists,
listening to a group of aspiring artists.                      hospitals or public health, not just to bail me out, but
   I don’t think anyone would deny there is an art to          also to help me provide better services and options for
dentistry. So we must all be artists. There are many           my patients. I like to believe that as a GP in private prac-
different art forms and, as dentists, we always leave our      tice I have also helped them provide better services and
signature on our work. This was first evident to me when       options to their patients, because we really are all together
practising in the Royal Canadian Dental Corps. Recogniz-       in the same boat.
ing another clinician’s restorations was not uncommon

 12     OD • April 2019
President’s Page

   I am also grateful that many in our profession choose       question, but I don’t think so. There are too many dif-
research to exercise their passion. These researchers play     ferences among dentists and our practices, and within
an extremely important role in our dental community.           our profession. That is a good thing. Our ODA has
The ODA was proud to sponsor the keynote speaker at            embraced all the advantages of a voluntary association
this year’s Research Day at the University of Toronto’s        that represents more than 90 per cent of dentists in
Faculty of Dentistry, and the ODA also sponsors student        Ontario. The products and services we offer our members
research programs at Schulich School of Medicine and           are just as varied as our membership itself. If we want to
Dentistry, Western University. Speaking as a clinician,        come together at the right place, wherever that may be
I am aware that, without research, there would be no           on any given issue, it won’t be because we have to but
evidence upon which to base treatment for our patients.        because we want to, and we’ll bring all our opinions with
Research is the foundation upon which we can strive for        us.
excellence in oral health for our communities, and the           If “What is a dentist?” is not an easy question to
researcher’s vision is how we continue to build upon that      answer, then “Who is a dentist?” is nearly impossible.
goal. So, I would like to say to those with a passion for      Did you know there are 14 different membership cat-
making known the unknown, or making the good even              egories in the ODA? “Out of many, one…” I promised
better: keep up your valuable work!                            I wouldn’t take the words. But I do hope you get my
   I have on occasion heard members tell me that the           meaning. OD
ODA should be more like a union, for then we might
have more influence on government. But that influence                    Dr. David M. Stevenson is the President of the ODA
is not a certainty and, by being union-like, we would                    for 2018-19. He practises in Carleton Place, Ont.,
give up a tremendous amount of individuality. Are we an                  and may be contacted at ODAPresident@oda.ca.
association that would welcome the prospect of a col-
lective bargaining agreement with a single employer
such as government? I don't know the answer to that

                                                       Gain new perspectives with numerous
                                                             networking opportunities.

                                               We make it easier to connect with your peers and the
                                               dental community at large to share your experiences.
                                               Our Annual Spring Meeting, volunteer programs, and
                                                local component dental societies give you multiple
                                              opportunities to build new relationships and contribute
                                                          to how the profession evolves.

                                                             yourpotential.oda.ca

                                                                                                  April 2019 • OD     13
Ideas
    Editorial

                                                                        In a Boat With
Carlos Quiñonez
DMD MSc PhD FRCD(C)

                                                                   a Very Small Paddle

I   n my last Editorial (1), I spoke about the unfounded
    and unscientific claims made by some regarding the
    health effects of root canals, amalgam restorations,
periodontal infections and vaccinations. I highlighted
                                                               scientific basis for the medical benefit and cost-
                                                               effectiveness of orthodontic care” (2, p. 8). As with most
                                                               evidence reviews in dentistry, few high-quality stud-
                                                               ies were found, and results did not allow the German
the lack of a scientific base regarding such claims and the    researchers to make definitive statements about the
real and alarming dangers that they can produce (e.g.          therapeutic benefit of orthodontic care. Further, it should
unnecessary and costly dental work, infectious disease         not be lost on us that this was quickly picked up by the
outbreaks, engaging in non-therapeutic and sometimes           media and reported using headlines such as: “German
dangerous treatments).                                         ministry questions benefits of braces,” “No proof dental
   Yet, in dentistry, if one digs deeper, one finds that the   braces work, German government report finds,” “How
evidence base in support of the benefits of many — I dare      helpful are braces really? Government report questions
say, most — dental procedures is limited. This begs the        benefits,” and “No evidence braces have health benefits
question: how are we to defend ourselves against “unsci-       for teeth, Health Ministry report finds.”
entific” claims when the “scientific” ones are potentially       For periodontal care, a recent Cochrane systematic
not supported by strong research?                              review aimed to determine the effects of routine scaling
   The lack of evidence does matter. I have been, or am        and polishing for periodontal health (3). Surprisingly,
currently, involved in government and professional com-        only two studies could be included based on the quality
mittees/panels, where the search for evidence is primary       of existing research, with the authors concluding:
and crucial to policy decisions about who and what to
fund. And the reaction from medical and lay colleagues           “For adults without severe periodontitis who regu-
who sit on these committees/panels is surprise when they         larly access routine dental care, routine scale and
learn that the evidence base in dentistry is not strong.         polish treatment makes little or no difference to
What is more, the reaction from — and sobering reality           gingivitis, probing depths and oral health-related
for — some of my dental colleagues on these commit-              quality of life over two to three years follow-up […].
tees/panels is shock, and sometimes open resistance, as          There may also be little or no difference in plaque
they learn that what is taken as a given regarding the           levels over two years […]. Routine scaling and polish-
effectiveness and benefits of dental care, does not always       ing reduces calculus levels compared with no routine
bear out when a review of the evidence is undertaken.            scaling and polishing, with six-monthly treatments
   Consider the benefits of orthodontics and routine             reducing calculus more than 12-monthly treatments
periodontal care as examples. In terms of the former,            over two to three years follow-up […], although the
in Germany, due to growing expenditures in orthodon-             clinical importance of these small reductions is un-
tic care within that country’s health-care system, the           certain. Available evidence on the [cost-effectiveness]
German government recently commissioned an evi-                  of the treatments is uncertain (3, p. 2).”
dence review to question “whether there is a sufficient

    14   OD • April 2019
Editorial

   Unfortunately, there is a scarcity of quality research       Again, the state of our knowledge matters because
resulting in equivocal results for systematic reviews in      we are increasingly asked to rationalize ourselves by
dentistry. A simple scan of the Cochrane database for oral    the public, by governments, by funders, and by our
health (4) confirms this for many clinical interventions,     patients. There can be no doubt that the name of the
including: survival between bonded and non-bonded             game now and into the future is and will be “evidence
amalgam restorations; chlorhexidine treatment for the         and data.” Unfortunately, we may not be able to depend
prevention of dental caries in children and adolescents;      on our national research-funding agencies, which have
dental cavity liners for Class I and Class II resin-based     not prioritized dental research compared to research in
composite restorations; enamel matrix derivative for          other areas of health care. Thus, we will have to depend
periodontal tissue regeneration in intrabony defects;         on ourselves. And this will take courage: courage (from
endodontic procedures for retreatment of periapical           our regulators and associations) to invest in research,
lesions; final-impression techniques and materials for        and courage to rationally deal with the answers we may
making complete and removable partial dentures; full-         receive from the questions we ask. OD
mouth treatment modalities for chronic periodontitis in
adults; interdental brushing for the prevention and con-      REFERENCES
trol of periodontal diseases and dental caries in adults;     1.   Quiñonez C. Science, Self-Regulation and the
interventions for replacing missing teeth; lasers for car-         Public’s Health. Ontario Dentist. 2019;96(2):12-13.
ies removal in deciduous and permanent teeth; occlusal        2.   Hoffmann A, Krupka S, Seidlitz C, Sussmann S,
splints for treating sleep bruxism; single versus multiple         Sander I, Gothe H. Kieferorthopädische Behand-
visits for endodontic treatment of permanent teeth —               lungsmaßnahmen. Berlin: IGES Institut, 2018.
amongst many others.                                          3.   Lamont T, Worthington HV, Clarkson JE, Beirne
   This research scarcity does not mean that our clini-            PV. Routine scale and polish for periodontal health
cal interventions do not work or that they demonstrate             in adults. Cochrane Database of Systematic Re-
no therapeutic benefit. It just means that there is little         views 2018, Issue 12. Art. No.: CD004625. DOI:
evidence of the same (that’s the rub).                             10.1002/14651858.CD004625.pub5.
   Indeed, this is a complex topic that situates within       4.   Cochrane Oral Health. Accessed February 28, 2019.
the nature of evidence itself, meaning: what we know               Available at: https://oralhealth.cochrane.org/oral-
clinically is not always researched, and since the evi-            health-evidence
dence bar is very high, much of the research conducted        5.   Advisory Panel for the Review of Federal Support
does not meet that bar. The complexity is also related             for Fundamental Science. Investing in Canada’s
to the state of social processes and institutions meant            Future. Strengthening the Foundations of Canadian
to generate knowledge; Canada, in particular, has been             Research. Canada’s Fundamental Science Review.
noted as weak in supporting research generally and lack-           Ottawa: Government of Canada, 2017.
ing the commitment to secure and safeguard the research       6.   Andrew-Gee E, Grant T. In the dark: The cost of
enterprise (5,6).                                                  Canada’s data deficit. The Globe and Mail. Published
   We must also be aware of the nature of dentistry itself         January 26, 2019, updated February 13, 2019. Ac-
in this state of affairs. Sadly, we are often disparaged as        cessed February 28, 2019. Available at: https://
being a “data-free zone” by researchers and policymakers.          www.theglobeandmail.com/canada/article-in-the-
We are reluctant to adopt whatever research does exist in          dark-the-cost-of-canadas-data-deficit/
the form of clinical practice guidelines. And we are often
driven more by the findings of private industry than by                 Dr. Carlos Quiñonez is the Editor of Ontario
public science.                                                         Dentist. He may be reached at 416-864-8239,
                                                                        or at cquinonez@oda.ca.

                                                                                                April 2019 • OD   15
Ideas
  Risk Management

                                                                       Direct to Consumer
Lionel Lenkinski
DDS Cert. Endo

T        he media has been abuzz with the latest foray in
         dentistry, which concerns circumventing tradi-
         tional means of service delivery. It now appears
that, for orthodontics, some hope to avoid “the middle
                                                                actual harm — and this is not to say that there is — the
                                                                proof of harm has to materialize and the risk has to be
                                                                recognized by a regulator or government. Without these
                                                                factors, very little will happen. And certainly, big busi-
person” and go straight (no pun intended) to the end            ness understands the rules and will try to play within
user. This is not new in health care and is now the norm,       them. They have a brand to protect, a business to run and
with “big pharma” inundating the public with adver-             profits to make, and causing harm (perceived or actual) is
tisements for the latest blood thinner, or biologics for        not a good strategy.
arthritis or gastrointestinal problems, and so on. The pre-        In its wisdom, the ODA has issued the directive
scription eyeglass space is also replete with players using     “ODA Interim Policy Position on Direct-to-Consumer
direct-to-consumer approaches. Ride-sharing platforms           Dentistry.” There are good resources and links on the
have similarly disrupted the taxi business, which is also       ODA member website relevant to this. But, what else can
a regulated industry.                                           we do?
   In fact, the dental profession participated in something        First, we must have a direct relationship with our
similar not so long ago, when some of the larger, mostly        patients. They should know who we are, what we do for
U.S.-based specialty groups started advertising directly        them and, most importantly, that we act in their best
to patients. This was meant to circumvent the usual             interest. Second, we have to be part of the value chain
patient referral process, and drive patient flow directly       in patient care. If we are not seen as critical to the provi-
to specialists. Personally, despite being a specialist, I was   sion of care, then we can be circumvented. Maybe this
never in favour of this sort of advertising, as it can have     is just my simplistic view, but we need to be physically
unintended consequences, such as confused patients,             present and check on treatment that has been delegated.
disruption in the continuity of care, and heightened            We have to be in the middle at all times. After all, we are
competition in, as well as strain on the relationship be-       ultimately responsible for the dental treatment that takes
tween general dentists and specialists. Certainly, from         place in our practices, for our patients.
today’s vantage point of an über-competitive dental-care           The tendency to market, to the public, minimally
market (again, no pun intended), these patient-directed         invasive or non-invasive medical devices for which the
advertisements did result in some of these negative out-        patient/consumer is the end user, is not new. Indeed,
comes. Apart from this, though, if we ourselves have            about 10 years ago, I was in the U.S. at a meeting of the
engaged in these direct-to-consumer advertisements,             American College of Dentists and saw the early advertise-
why the surprise when “big business” in dental care starts      ments for clear aligners on taxis. I remember thinking
engaging in similar efforts?                                    at the time about what was then an already established
   What am I missing here? Why the furor that this has          business model in medical devices in the U.S., which was
not been outlawed by government? Does this really cre-          to start with business-to-business sales and then move to
ate a risk of harm or actual harm to patients? For good         business-to-consumer. Since consumers tend to be price
or bad, these issues are usually dealt with on a reactive       conscious, the business-to-consumer part of the model
basis, meaning that if there is indeed a risk of harm or        usually involves a price drop. When this happens, the

  16    OD • April 2019
Risk Management

businesses look for higher sales volumes. There is some-        is only together, keeping the best interests of our patients
thing to notice here, though, and that is the absence of        in mind, that we can maintain an appropriate voice and
the word “patient.” After all, what matters is our relation-    measure what action needs to ensue. OD
ship with our patients, not our “clients” or “consumers.”
   I know that this column is published in Ontario Den-                     Dr. Lionel Lenkinski is the Executive Director/CEO
tist, so it may not be seen by non-member dentists. Yet,                    of the Canadian Dental Protective Association,
I ask you: how much of the complaining about this cur-                      a mutual defence organization representing
rent state-of-affairs is coming from non-members, who                       Canadian dentists in regulatory matters. He also
only see the ODA as a vehicle for the Suggested Fee Guide                   maintains a private practice in Toronto in the
and/or Extended Health Care? Now, more than ever, we            specialty of endodontics. Dr. Lenkinski may be contacted at
need to keep our associations strong, as outside forces         llenkinski@cdpa.com.
will only affect our professional lives further over time. It

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                                                                                                     April 2019 • OD     17
Ideas
    Osseointegration

                                    The Genesis of Osseointegration:
James C. Taylor
DMD MA

                                            The Toronto Connection

I  suspect one would be hard pressed to find, in the
   global oral health community, practitioners who were
   not aware of Dr. Per-Ingvar Brånemark’s first observa-
tion of osseointegration in 1952, in the course of his re-
                                                                the possibility of a major Canadian replication study to
                                                                validate the theretofore very positive findings of the
                                                                Swedish study. In 1976, Dr. Zarb returned to Göteborg
                                                                with some U of T colleagues to learn the Swedish pro-
search with titanium bone chambers in a lapine model            tocol and plan what would come to be known as The
or, perhaps, of his first human implant patient in 1965,        Toronto Study. In 1979, they established the U of T
Gösta Larsson of Göteborg, Sweden, who passed away in           Osseointegration Clinical Research Unit, funded by On-
2006 with all of his implants in full function. Or even of      tario Provincial Health Research Grant #PR 882. Later
the Brånemark team’s extensive body of published clini-         that year, The Toronto Study was initiated as a prospec-
cal research in this area, commencing in 1969, in the           tive replication study of Dr. Brånemark’s work, the first of
Scandinavian Journal of Plastic and Reconstructive Surgery.     its kind outside of Sweden.
However, perhaps less well known, even by many Cana-               Meanwhile, in Boston, the Harvard-National Insti-
dian practitioners, is the essential role that the University   tutes of Health — National Institute of Dental Research
of Toronto (U of T) and the province of Ontario played          Consensus Development and Technology Assessment
in bringing this revolutionary treatment modality into          Conference was held in June 1978. It attempted to create
global dental practice.                                         guidelines for the use of the various types of implants
   Perhaps the best place to start in the Toronto story is      that were already in use in North America, through the
in the mid-70s at U of T, with a young full professor by        analysis of retrospective clinical data. Root-form titan-
the name of Dr. George Zarb, who at that time was head          ium endosseous implants were not considered at this
of the discipline of prosthodontics and a member of the         conference, as they were not in clinical use outside the
School of Graduate Studies. Dr Zarb had long been frus-         Brånemark study; nevertheless, the Brånemark team had
trated with the lack of acceptable solutions to the pre-        published 10 years of clinical data the previous year.
dicament of the edentulous patient, and the failure of             It must be remembered that oral implants were tra-
existing complex surgical and prosthetic interventions          ditionally the subject of significant suspicion and dis-
to deliver a satisfactory outcome for these patients. Then,     missal (in some cases perhaps deservedly) in the dental
one day in 1975, Dr. Henry Levant (one of Dr. Zarb’s            community. Unfortunately, titanium endosseous dental
prosthodontic graduate students at that time) brought to        implants were caught up in this historical perspective,
his attention some promising work going on in Sweden.           even past the point where the peer-reviewed literature
   As fortune would have it, Dr. Zarb was already on his        clearly indicated that scientifically documented implant
way to Göteborg soon thereafter to work with Dr. Gun-           systems should be an integral element of comprehensive
nar Carlsson on the first edition of their classic temporo-     oral health care. I have recollections of Canadian licens-
mandibular joint text. While there, Dr. Zarb was invited        ing jurisdictions where, as late as the mid-1990s, poli-
by Dr. Brånemark to visit their osseointegration clinic         cies stipulated that implants were “experimental” and
and examine some recall patients from what was at that          should only be attempted when “conventional” care mo-
point their 10-year clinical study. Dr. Tomas Albrekts-         dalities had failed. Fortunately, the approach of the new
son joined them, and a conversation ensued regarding            millennium seemingly catalysed new thinking: by 2000,

    18   OD • April 2019
Osseointegration

a number of Canadian jurisdictions were progressing                                                             In May 2008, U of T held a landmark conference to
toward the current position that implants are a part of                                                      celebrate the 25th anniversary of the Toronto Confer-
routine oral health care, and that not to identify them                                                      ence on Osseointegration in Clinical Dentistry. In that
as a treatment option to patients in appropriate circum-                                                     vein, one of my action items as the first Canadian
stances constituted a failure of informed consent.                                                           President of AO was to hold a collaborative event with
   The Toronto Conference on Osseointegration in Clini-                                                      U of T to continue to recognize the early and ongoing
cal Dentistry was held in Toronto in May 1982. It was co-                                                    contributions of this fine institution to the global emer-
sponsored by the University of Göteborg and U of T, and                                                      gence and evolution of osseointegration and its related
led by co-chairs Drs. Zarb and Jack Symington (who was                                                       treatment modalities. Thus, in partnership with U of T
Head of Oral and Maxillofacial Surgery at U of T at the                                                      Dean, Dr. Daniel Haas, and his team, AO will be holding
time). Invited delegates were senior university prostho-                                                     a symposium entitled, “A Tribute to the Toronto Con-
dontists and oral surgeons from across North America,                                                        ference and its Impact on Global Dentistry ” on May 4,
and the speakers were global experts in various aspects of                                                   2019, at the U of T Auditorium. This symposium will be
osseointegration science and the Brånemark treatment                                                         introduced by Dr. Zarb himself, and involve expert AO
protocol. The goal was to subject the basic and clinical                                                     speakers describing the evolution of the various elements
research on osseointegration from Sweden to the scru-                                                        of osseointegration and implant dentistry that were pre-
tiny of the North American academia, and it represented                                                      sented at the 1982 conference, and a panel discussion of
the formal introduction of osseointegration to North                                                         the current state of the science and the future directions
America. The revelations of this conference also led to                                                      in each of these domains. I look forward to seeing you
the formation of the Academy of Osseointegration (AO)                                                        all there. OD
in 1986, and a number of the Toronto Conference speak-
ers collaborated to provide foundational articles on os-                                                     For more information, please visit:
seointegration in the inaugural issue of the International                                                   https://osseo.org/toronto-conference-2019/
Journal of Oral & Maxillofacial Implants (the AO’s journal)
later that year.                                                                                                       Dr. James C. Taylor is currently the President of
   U of T continues to provide leadership in the global                                                                the Academy of Osseointegration, the immediate
conversation on osseointegration. For example, Professor                                                               Past President of the Academy of Prosthodontics,
J.E.D. Davies has kindly accepted my invitation to lead                                                                and a Past President of both the Association
an international panel of experts regarding the current                                                                of Prosthodontists of Canada and the Atlantic
state of the science on the phenomenon of osseointe-                                                         Prosthodontists Society. His teaching and research were
gration, for the upcoming 2019 AO Annual Meeting in                                                          undertaken at Dalhousie University.
Washington, D.C. (For more information, visit: https://
ao2019.osseo.org/)

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                                                                                                                                                        April 2019 • OD       19
Ideas
  New Care Model

                                                                  Person-Centred Care
Sanjukta Mohanta
BSc DDS

H
                                                                                          Table 1.
         ealth care is undergoing an evolution in terms
                                                               Differences between the medical model and person-centred care (8)
         of the way patients are cared for. Instead of
         the medical model of care, there is a focus on               Medical Model                    Person-Centred Care
person-centred care. In dentistry, embracing person-           Person is passive                    Person asks questions
centred care has the potential to improve patients’ oral       Provider decides care                Person makes decisions about care
health and their care experience (1). This article discusses   Person receives care                 Person is a partner in care
the differences between these two models, the advan-
                                                               Centred on disease                   Centred on quality of life
tages of person-centred care and ways that dentists can
practise it.                                                   Provider is trained in health care   Provider also has training in
                                                                                                    overall needs
                                                               Provider is the expert               Person is the expert in himself/
What is person-centred care?                                                                        herself
The medical model of care treats the disease, whereas the
                                                               Goal is treatment of disease         Goal is optimal health
person-centred model treats the person. Person-centred
care is a partnership between a person and health-care
provider. It encompasses shared decision-making, in-           Already practising person-centred care?
stead of the provider dictating care. This creates shared      Most dentists provide patients with some person-
responsibility, in which the person is seen as an expert       centred care by offering choices with appointment times,
in his/her own health. It focuses on getting to know the       teaching home care, performing preventive procedures,
person’s beliefs, life circumstances, concerns, attitudes      allowing family members in the operatory and discuss-
and goals. There is sharing of information and power,          ing treatment options. Other ways to incorporate this
the provision of continuous care, and co-ordination of         model are to: have quality improvement initiatives; ask
care with other providers. There is a focus on providing       patients at each appointment if they have any concerns;
emotional support and physical comfort; asking about           encourage feedback; involve patients in decision-making;
preferences and care experiences; and respecting auton-        provide information and referrals to address other needs
omy. With this model, the clinician is working with the        (medical, social, financial, etc.); and ask patients if they
person instead of on the person (2-9).                         have any questions (17).
                                                                  A way to know if you are practising person-centred
Why should we practise person-centred care?                    care is if your patients indicate in a survey that they feel
There is evidence that person-centred care improves            comfortable talking to you about concerns and that
health outcomes, enhances person and provider satisfac-        they feel you understand them as a person and not just
tion, improves pain management and increases patient           their disease. Do you want to practise more person-
compliance with provider recommendations (1,2,10). A           centred care? Here’s a simple way to start: instead of
dental office is a good setting to provide person-centred      asking patients what is the matter with them, ask
care, as patients can build trust with the dental team         patients what matters to them (7,18).      OD

through regular maintenance appointments.

  20    OD • April 2019
New Care Model

Examples of person-centred care (8,11,12)
 •   Doing patient-satisfaction surveys
 •   Conducting patient focus groups
 •   Using the results from the above to create quality-improvement initiatives
 •   Collaborating with other professionals to improve the care experience for the patient
 •   Discussing treatment options, cost, possible outcomes, most likely outcomes, and benefits and risks of treatment
 •   Focusing on prevention, compliance and decreasing risk factors
 •   Understanding the whole person: family, culture, employment, financial security, beliefs and barriers
 •   Involving the patient’s family, friends and other health-care providers upon the patient’s request.

Examples of questions to ask in surveys and patient focus groups (13)
 •   Do you have enough time with the dentist?
 •   Does the dentist listen to you and understand your concerns?
 •   Does the dentist explain things clearly?
 •   Are you involved in decisions about your care?
 •   Are you given the opportunity to ask questions?
 •   Does the dentist explain how you can improve your own health?
 •   Are you satisfied with the care provided?
 •   Has your health improved since becoming a patient here?

Ways for practitioners and institutions to
improve the practice of person-centred care                      collaboration
(3,5,14-16)                                                  •   A common electronic-management record among
 •   Training at dental schools and through continu-             health-care providers that will allow for co-
     ing education                                               ordinated care, inter-professional collaboration
 •   Training as a dental team                                   and data collection
 •   Having mission, vision and values that focus on         •   Use of data to: discover risk factors, identify high-
     the patients, not on the practice                           risk groups, plan oral health promotion, design
 •   Understanding how social determinants of                    publicly funded oral-health programs, measure
     health affect oral health                                   health outcomes, and evaluate patient and pro-
 •   Redesigning the health-care system to allow                 vider satisfaction
     person-centred care                                     •   More research on relationships between oral
 •   Focusing on behaviour modification, lifestyle               health and overall health
     changes, preventive intervention, removing              •   Technology that patients can use to track their
     barriers to health and alternative treatment                own health
     modalities                                              •   Payment based on health outcomes instead of
 •   Changing the design and delivery of health care             treatment
     to integrate oral health into overall health
 •   Practice models conducive to inter-professional      REFERENCES

                                                                                               April 2019 • OD     21
New Care Model

                                                                        education for PSWs in the home, community and long-term
                                                                        care sectors. Saint Elizabeth and Yee Hong Centre for
                                                                        Geriatric Care.2013 October. Available from: https://
                                                                        www.saintelizabeth.com/getmedia/3b053be0-3313-
                                                                        45e5-8aea-872781c0b76d/Practical-Guide-for-Imple-
                                                                        menting-PCC-Education-for-PSWs-October-2013.pdf.
                                                                        aspx
                                                                  9.    Snowdon A, Schnarr K, Alessi C. “It’s All About Me”:
                                                                        The Personalization of Health Systems. Odette School of
                                                                        Business:University of Windsor. 2014 February. Avail-
                                                                        able from: http://worldhealthinnovationnetwork.
                                                                        com/images/publications/summaries/AllAboutMe-
                                                                        ThePersonalizationofHealthcareSystems_Executive-
                                                                        Summary.pdf
                                                                  10.   Delaney, LJ. Patient-centred care as an approach to
                                                                        improving health care in Australia. Collegian. 2018
                                                                        Feb 1;25(1):119-23.
                                                                  11.   Royal College of Dental Surgeons of Ontario. Patient
1.   Poochikian-Sarkissian S, Sidani S, Ferguson-Pare                   centred care — A dentist’s paramount responsibility.
     M, Doran D. Examining the relationship between                     Dispatch 2012;26(3):22-23.
     patient-centred care and outcomes. Journal of Neuro-         12.   Patient-centred care and the business of dentistry.
     science Nursing. 2010;32(4):14-21.                                 College of Dental Surgeons of British Columbia. 2015
2.   What is person-centred care and why is it important?               December.
     Health Innovation Network South London 2016                  13.   Mercer SW. PCM 10Q. Talking Mats.NHS Scotland
     July. Available from: https://healthinnovationnet-                 2004. Available from: http://www.caremeasure.org/
     work.com/system/ckeditor_assets/attachments/41/                    CAREENG10p.pdf
     what_is_person-centred_care_and_why_is_it_impor-             14.   Valuing people. What is person-centred care? Dementia
     tant.pdf                                                           Australia. Available from: https://valuingpeople.org.
3.   Walji MF, Karimbux NY, Spielman AI. Person-                        au/the-resource/what-is-person-centred-care
     centered care: Opportunities and challenges for              15.   Santana MJ, Manalili K, Jolley RJ, Zelinsky S, Quan
     academic dental institutions and programs. Journal of              H, Lu M. How to practice person-centred care: A
     Dental Education. 2017;81(11):1265-1272.                           conceptual framework. Health Expectations. 2018
4.   Person-centred care made simple. The Health Founda-                Apr;21(2):429-40
     tion. October 2014. Available from: http://personcen-        16.   Lee H, Chalmers NI, Brow A, Boynes S, Monopoli M,
     tredcare.health.org.uk/sites/default/files/resources/              Doherty M, et al. Person-centred care model in den-
     person-centred_care_made_simple_1.pdf                              tistry. BMC Oral Health 2018;18(1):1.
5.   National Ageing Research Institute. What is person-          17.   Practice Advisory 2018 June. Maintaining a profes-
     centred health care? A literature review. Published by             sional patient-dentist relationship. Royal College of
     the Victorian Government Department of Human                       Dental Surgeons of Ontario. Available from: https://
     Services, Melbourne, Victoria, Australia. April 2006.              az184419.vo.msecnd.net/rcdso/pdf/practice-adviso-
6.   Poochikian-Sarkissian S, Wennberg R, Sidani S. Ex-                 ries/RCDSO_Practice_Advisory_Maintaining_Profes-
     amining the relationship between patient-centred                   sional_Relationship.pdf
     care and outcomes on a neuroscience unit: a pilot            18.   Starfield B. Is patient-centred care the same as person-
     project. Canadian Journal of Neuroscience Nursing                  focused care? The Permanente Journal 2011:15(2):63-9.
     2008;30(2):14-19.
7.   Biddy R, Griffin C, Johnson N, Larocque G, Messersmith       Dr. Sanjukta Mohanta is a graduate of the University of
     H, Moody L, et al., and the Person-Centred Care Guideline              Toronto’s Faculty of Dentistry, 1999. She is the
     Expert Panel. A Quality Initiative Endorsed by Cancer Care             Chair of the ODA Dental Benefits Committee. Dr.
     Ontario in Partnership with the Program in Evidence-Based              Mohanta practises general dentistry at Wellfort
     Care (PEBC) Person-Centred Care Guideline. 2015 May.                   Community Health Centre and is on the Editorial
     Available from: https://www.cancercareontario.ca/en/                   Board of Ontario Dentist.
     guidelines-advice/types-of-cancer/38631
8.   A practical guide for implementing person-centred care

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                                                                                            April 2019 • OD   23
Analysis
    Social Networking

                                         Uses, Benefits and Limitations of
Janet Wu
BSc

                                       Social Networking Sites for Dental
                                               Public Health Surveillance

I    n 2016, 82 per cent of Internet users in the United
     States reported using social networking sites (SNS)
     such as Facebook and Twitter (1). Worldwide, Face-
book and Twitter have more than 1.23 billion (2) and 313
                                                                  Uses of SNS
                                                                  The two types of public health surveillance are passive
                                                                  surveillance and active surveillance. Passive surveillance
                                                                  involves the routine collection of data without health
million active users (3) respectively. SNS have become            agencies actively seeking reports. Active surveillance
increasingly popular, allowing users to quickly share per-        involves requesting information from health-care pro-
sonal information with large public audiences. Interest-          viders and patients through surveys and other methods
ingly, the abundance of real-time data on Facebook and            (7). Active surveillance is typically more expensive, but
Twitter provides an opportunity for researchers to survey         provides a more complete report of health problems. It
public opinion and monitor public health challenges.              appears that 15 studies have used SNS for active and pas-
   The accessibility of SNS has encouraged researchers to         sive dental public health-related surveillance (Table 1).
utilize SNS to investigate a wide spectrum of topics. For            In active surveillance, SNS have been used to recruit
example, Twitter messages, or “tweets,” are now used for          participants for studies, distribute online surveys and
earthquake monitoring, political polling and epidemic             directly request data from users. Three studies used SNS
tracking for influenza (4). Recently, Heaivilin et al. evalu-     to recruit participants for studies by targeting specific
ated the efficacy of Twitter as a tool for public health          groups. Participants were targeted based on age (8) and
surveillance of dental pain in real time (5). Since public        participation in previous surveys (9). SNS were also used
health surveillance involves the “continuous, systematic          to inexpensively recruit new participants to existing
collection, analysis and interpretation of health-related         studies (10).
data” (6) and is used to evaluate the effectiveness of pub-          In four studies, social media platforms allowed re-
lic health policies, its use is essential for efficiently using   searchers to distribute surveys online while targeting
public health resources. Innovative methods for health            specific groups such as dentists (11), dental students (14),
data collection, such as the use of SNS, may thus sup-            and scuba divers (12). One study surveyed dental profes-
plement, and possibly replace, traditional methods in an          sionals and the public about dental surgical procedures
effort to streamline the surveillance process.                    (13). Another survey estimated the prevalence of dental
   Traditionally, surveillance data sources include reports       health issues among susceptible groups (12). In addition,
from health-care professionals, health records and sur-           social media platforms can be programmed or structured
veys (7). However, collecting these records is labour-            to streamline the data-collection process. Parsons et al.
intensive and expensive, making the processing power              used Twitter as an “online diary” for participants to share
of SNS an attractive potential alternative to traditional         information and discuss their oral pain conditions using
methods. SNS may help identify patients and their                 tweets that followed a specific format (15), allowing for
contacts, estimate the severity of health issues and stimu-       even faster data collection and greater efficiency in den-
late research to inform public health policy.                     tal pain data analysis.
   However, SNS have only recently been used for dental              Seven studies used SNS for passive surveillance. For
public health surveillance. And the quality, ethics and           example, SNS can provide insight on how the flow of
reliability of this method of data collection remains             oral health information is diffused (16). The thoughts
largely unexplored. The objective of this paper is thus           of dental professionals and patients are important when
to investigate the uses, benefits and limitations of SNS          surveying oral health issues, and SNS provide platforms
as a tool for dental public health-related surveillance.          for researchers to target both groups when trying to im-

    24   OD • April 2019
Social Networking

                                                              Table 1.
                                   Uses of SNS as a tool for public health surveillance in 15 studies

                   Active Surveillance       Recruitment (n=3)                    Khatri et al. (2015) [8],
                                                                                  Macluskey et al. (2015) [9],
                                                                                  Motoki et al. (2017) [10]
                                             Online survey (n=4)                  Kim et al. (2017) [11],
                                                                                  Ranna et al. (2016) [12],
                                                                                  Vohra et al. (2015) [13],
                                                                                  Abdelkarim et al. (2014) [14]
                                             Structured data collection (n=1)     Parsons et al. (2015) [15]

                   Passive Surveillance (n=7)                                     Seymour et al. (2015) [16],
                                                                                  Ahlwardt et al. (2014) [17],
                                                                                  Chan et al. (2017) [18],
                                                                                  Gao et al. (2013) [19],
                                                                                  Heaivilin et al. (2011) [5],
                                                                                  Song et al. (2013) [20],
                                                                                  Henzell et al. (2014) [21]

                                                                                                     Table 2.
prove patient outcomes (11, 17, 20, 21). What is more,                 Benefits of SNS as a tool for public health surveillance in 15 studies
adolescents may be unreachable through conventional
methods, such as phone surveys through landlines,                       Quantity (n=6)                   Macluskey et al. (2015) [9],
but Twitter and YouTube can be effective alternatives                                                    Ahlwardt et al. (2014) [17],
for gaining insight into adolescent dental treatment                                                     Chan et al. (2017) [18],
                                                                                                         Gao et al. (2013) [19],
experiences (18, 19). Keywords can narrow down spe-                                                      Heaivilin et al. (2011) [5],
cific aspects of patient-related oral health topics such as                                              Song et al (2013) [20]
dental pain (17, 5), orthodontic treatment (18, 21), and                Low-cost (n=4)                   Motoki et al. (2017) [10],
dental fear (19), to allow researchers to focus on particu-                                              Macluskey et al. (2015) [9],
lar areas of concern.                                                                                    Khatri et al. (2015) [8],
                                                                                                         Vohra et al. (2015) [13]
Benefits of SNS                                                         International reach (n=4)        Macluskey et al. (2015) [9],
From these 15 studies, 10 main benefits can be ascer-                                                    Vohra et al. (2015) [13],
tained in the use of SNS for dental public health-related                                                Heaivilin et al. (2011) [5],
                                                                                                         Henzell et al. (2014) [21]
surveillance (Table 2). The most cited benefit is the quan-
tity of real-time data available on SNS (5, 9, 17-20) due               Passive Surveillance (n=7)       Macluskey et al. (2015) [9],
                                                                                                         Ranna et al. (2016) [12],
to a high level of engagement from users. The low cost                                                   Abdelkarim et al. (2014) [14],
of accessing data on SNS makes it an attractive method                                                   Parsons et al. (2015) [15]
as well (8-10, 13). SNS reach people across international               Eliminates observation           Gao et al. (2013) [19],
borders (5, 9, 13, 21), which further allows for data col-              bias (n=3)                       Song et al. (2013) [20],
lection from a more diverse sample.                                                                      Henzell et al. (2014) [21]
   SNS also allow for faster data collection (9, 12, 14, 15).           Distribute superior              Macluskey et al. (2015) [9],
Traditionally, collecting responses through mail and                    electronic resources (n=2)       Kim et al. (2017) [11]
inputting data by hand requires time. Using SNS for pas-                Target demographic (n=2)         Motoki et al. (2017) [10],
sive health surveillance also eliminates observation bias                                                Kim et al. (2017) [11]
(19-21), since data collected from SNS are candid mes-                  Only method of reaching          Parsons et al. (2015) [15],
sages left by subjects who were not actively influenced                 participant (n=2)                Chan et al. (2017) [18]
by interviewers. Researchers also found that they were                  Privacy policies give            Parsons et al. (2015) [15],
able to distribute superior electronic resources through                researchers consent (n=2)        Chan et al. (2017) [18]
SNS compared to traditional methods (9, 11). Kim et al.                 Adequate randomized              Motoki et al. (2017) [10]
included an interactive slider in a survey, which would                 sample (n=1)

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