Volume 10 • 2023 • Issue 5

2023 • Volume 10 • Issue 5 The Canadian Dental Association Magazine PM40064661 Dental Workforce Challenges Page 18 + IN THIS ISSUE CDCP: Let’s Work Together to Get it Right P. 13 Oral Care Best Practices for Preventing Pneumonia in ICU Patients P. 25 The Impact of the Pandemic and Interest Rates on Dental Practices Values P. 31

CDAMissionStatement The Canadian Dental Association (CDA) is the national voice for dentistry dedicated to the promotion of optimal oral health, an essential component of general health, and to the advancement and leadership of a unified profession. is the official print publication of CDA, providing dialogue between the national association and the dental community. It is dedicated to keeping dentists informed about news, issues and clinically relevant information. 2023 • Volume 10 • Issue 5 Head of Communications Zelda Burt Managing Editor Sean McNamara Writer/Editor Sierra Bellows Gabriel Fulcher Pauline Mérindol Publications & Electronic Media Associate Rachel Galipeau Graphic Designer Carlos Castro Advertising: All matters pertaining to advertising should be directed to: Peter Greenhough Media Partners Inc. 15 Wade Road Ancaster, ON L9G 4G1 Display or web advertising: Peter Greenhough pgreenhough@pgmpi.ca 647-955-0060, ext. 101 Classified advertising: John Reid jreid@pgmpi.ca 647-955-0060, ext. 102 Contact: Rachel Galipeau rgalipeau@cda-adc.ca Call CDA for information and assistance toll-free (Canada) at: 1-800-267-6354 Outside Canada: 613-523-1770 CDA email: publications@cda-adc.ca @CdnDentalAssoc canadian-dentalassociation CanadianDental Association cdndentalassoc cdaoasis cda-adc.ca CDA Essentials is published by the Canadian Dental Association in both official languages. Publications Mail Agreement no. 40064661. Return undeliverable Canadian addresses to: Canadian Dental Association at 1815 Alta Vista Drive, Ottawa, ON K1G 3Y6. Postage paid at Ottawa, ON. Notice of change of address should be sent to CDA: reception@cda-adc.ca ISSN 2292-7360 (Print) ISSN 2292-7379 (Online) © Canadian Dental Association 2023 Editorial Disclaimer All statements of opinion and supposed fact are published on the authority of the author who submits them and do not necessarily express the views of the Canadian Dental Association (CDA). Publication of an advertisement does not necessarily imply that CDA agrees with or supports the claims therein. The editorial department reserves the right to edit all copy submitted to CDA Essentials. Furthermore, CDA is not responsible for typographical errors, grammatical errors, misspelled words or syntax that is unclear, or for errors in translations. Sponsored content is produced by Peter Greenhough Media Partners Inc., in consultation with its clients. The CDA Essentials editorial department is not involved in its creation. CDABoardofDirectors President Dr. Heather Carr Dr. Raymon Grewal British Columbia Dr. Brian Baker Saskatchewan President-Elect Dr. Joel Antel Vice-President Dr. Bruce Ward Dr. Dana Coles Prince Edward Island Dr. Jerrold Diamond Alberta Dr. Melissa Gagnon-Grenier NWT/Nunavut/Yukon Dr. Lesli Hapak Ontario Dr. Stuart MacDonald Nova Scotia Dr. Marc Mollot Manitoba Dr. Jason Noel Newfoundland/Labrador Dr. Kirk Preston New Brunswick 3 Issue 5 | 2023 |

ADCACDA923 Stephanie Hicks, CDA Canada Territory Manager Toll-free 888.437.0032 ext 214 | shicks@garrisondental.com www.garrisondental.com © 2023 Garrison Dental Solutions, LLC 150 DeWitt Lane Spring Lake, MI USA 49456 ORDER TODAY! 888.437.0032 or contact your authorized Garrison dealer. SGR-KSH-10 contains: 1 Short Ring (blue) 1 Tall Ring (orange) 1 Wide Prep Ring (green) 50 Assorted Matrix Bands 50 Assorted Firm Matrix Bands 10 VariStrip™ 80 Assorted Wedges 12 Assorted Rally™ Polishers 1 Ring Placement Forceps (FXP01) Benefits of upgrading to the All-New Separator Rings • Lasts longer! Drawn-wire nickel-titanium holds its shape better. • Enhanced marginal ridge! Helps support the matrix band in the proper position. • Smaller size! Stays out of your way. Wide Preparation Ring • Garrison exclusive! Only Garrison helps you restore the largest preps. Full Curve Matrix Bands • Enhanced marginal ridge! Helps form this critical anatomy. • Improved emergence profile! Ideal anatomy is built right in. • Subgingival extensions! All four of the standard sizes are ready for deeper preps. • Still dead-soft and only 0.0016” thick. Ultra-Adaptive Wedges • Smooth tunnel design! Sits lower interproximally and seals deeper. • More flexibility! The Soft-Face™ overmold with fins and flexible sidewalls easily adapt to concavities and irregularities. • Stackable! Secure stacking of multiple wedges when simultaneous wedging from the buccal and lingual is desired. Dentistry’s Premier Forceps • Larger offset! Makes ring placement easier. • Double tipped! Place rings in either direction for maximum access. • Places virtually any ring from any manufacturer! all NEW

Contents The Canadian Dental Association Magazine 2023 • Volume 10 • Issue 5 9 18 27 34 CDA atWork 7 My Pride in Our Profession 9 Helping Create Healthy Smiles Across Canada 13 As Federal Efforts are Underway to Improve Access to Oral Health Care, Let’s Work Together to Get it Right News and Events 16 Dental Digest Issues and People 18 Dental Workforce Challenges Persist in the US and Canada 25 Study ExaminesTooth Brushing and Oral Care Best Practices for Preventing Pneumonia in ICU Patients Classifieds 35 Offices and Practices, Positions Available, Advertisers’ Index Supporting Your Practice 27 Know the Law: Is a Dental Team Member an Employee or Independent Contractor? 31 The Impact of the Pandemic and Interest Rates on the Value of Dental Practices in Canada 34 Building a Resilient Work Team Obituaries 38 Dr. Richard Sandilands 5 Issue 5 | 2023 |

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Dr. Heather Carr president@cda-adc.ca My Pride inOur Profession Serving as a representative of our profession in a variety of roles, I’ve met with many people outside of dentistry and tried to convey my experiences with the dentists of Canada. It can be a challenge to clearly communicate what I’ve learned over the years through countless social and working relationships with my colleagues. When meeting with the media or government, I share my firsthand knowledge of the profession and the pride I feel about the contributions we make every day that benefit the lives of Canadians. I was recently invited to speak at a White Coat ceremony at Western University in London, Ontario. It was an honour and pleasure to witness dental students taking their oath of commitment. It was also an opportunity to put into words what I know our profession to be, as I welcomed students into a long and respected history of service. The dentists that I’ve known carefully consider the needs of their patients and the greater good of society at large. They are empathetic, confident, humane and caring. They provide person-centred care based on an individual’s values, needs and aspirations. It may sound idealistic when I describe the ethical principles that form the foundation of our profession. However, my experience is that dentists embody these principles in the hundreds of small decisions they make each day in their practices. Dentists genuinely care about their patients and the members of their team; they work hard to treat them as they would want to be treated. I see this every day among my colleagues. This week, I saw a patient who I’ve been treating since she was a young child. She has special health care needs, so I do my best to provide dental care standing up while she reclines her wheelchair. During the appointment, we celebrated victories—her caregiver had been able to successfully brush her front teeth and my patient found a way to give me better access to her teeth. Each of my patients has unique needs, and I try to meet those needs to the best of my abilities—just like my colleagues across the nation. One of the partners in my practice recently suffered a serious leg injury that will keep her out of the operatory for weeks. The dentists in our practice have pulled together and colleagues in her orthodontics study club quickly volunteered to see her patients while she recovers. Her patients will be cared for while she takes some much-needed time to recover. There is a strong desire to help in our profession, not only patients but each other. At every CDA meeting, I marvel at the dentists who take time to effect positive change on issues impacting the oral health of Canadians. They show an incredible amount of compassion and effort in this work. I also have colleagues who use their days off to teach at dental schools or work at clinics for vulnerable patients. If only I could bring people outside of dentistry along with me for just one week—from my practice to a study club to a CDA committee meeting to a White Coat ceremony— they’d be able to get a better sense of what our profession truly is. I’m so proud of the dentists of Canada. We’ve contributed to the health of our fellow citizens and to the communities where we live and work. From the President 7 Issue 5 | 2023 | CDA atWork

© 2023 Align Technology, Inc. Align, Invisalignw and the Align and Invisalign logos, among others, are trademarks and/or service marks of Align Technology, Inc. | A01439 Rev-A Your patients, Your practice, Your potential advanced Accelerate your practice growth by adding Invisalign® treatment to your offerings.* With our advanced technology and ongoing expert-led support, you can treat a wide range of cases while growing your relationships with patients. Begin your journey as an Invisalign provider today * Clear aligner gross revenue per visit is 46% higher than wire and brackets. Based on data located in a database of 1,000 practicing orthodontists in North America who use any brand clear aligners and any brand conventional wire and brackets to correct a variety of malocclusion, ranging from 6 to 36 months but malocclusion types are not matched. The revenue per visit metric is based on the average difference in revenue per visit between clear aligners and wire and brackets between May 2017 and June 2018. Revenue per visit is calculated by taking the total value of contract dollars per treatment type and dividing it by the number of visits a patient completes throughout the course of treatment. Data on file at Align Technology, as of October 30, 2018.

Helping Create Healthy Smiles Across Canada Learn more about the Canada Dental Benefit and the upcoming Canadian Dental Care Plan Guest article by: MarikaNadeau, Director General, Engagement and FPTRelations, Dental Care Task Force, Health Canada, Government of Canada As oral health care professionals, you see firsthand the positive impact that dental care has on Canadians. Access to quality dental care is an important part of overall health, yet, one-third of Canadians are financially unable to visit an oral health professional because they do not have dental insurance. To help address this issue, the Government of Canada launched the Canada Dental Benefit (CDB) in 2022 that provides families with direct payments of up to $650 per eligible child under 12 for out-of-pocket expenses paid for dental care services. The first benefit period was a great success During the first benefit period, from October 1, 2022 to June 30, 2023, the CDB helped 323,000 children access the dental care they need to develop healthy, bright smiles. Through close partnership with organizations like the Canadian Dental Association (CDA), we were successfully able to reach Canadians from coast to coast to coast to spread the news about the benefit. The successful impact of the CDB was made possible thanks to the support of the CDA and dentists across the country. As dental care professionals, you are transforming the lives of your patients every day. Thank you for everything you do to deliver the high-quality dental care that Canadians depend on. Let’s keep the momentum going during the second benefit period. Applications for the second period are now open Applications for the second benefit period opened on July 1, 2023, and applications will be accepted for eligible dental expenses until June 30, 9 Issue 5 | 2023 |

Guest article courtesy of Dental Care Task Force, Health Canada 2024. To be eligible, families need to meet all the following conditions for each child they apply for: z Have a child or children under 12 as of July 1, 2023, who does not have access to private dental insurance (employer-based or purchased through the applicant or other family member); z Have an adjusted family net income under $90,000 per year; z Be the parent (or legal guardian) who receives the Canada Child Benefit for that child; z Have filed their 2022 tax return; and z Have or will incur out of pocket expenses for their child’s dental care services between July 1, 2023, and June 30, 2024, for which the costs have not been fully reimbursed under another federal, provincial or territorial government program. Eligible families can continue to quickly, easily, and securely apply for the CDB via Canada Revenue Agency’s My Account. For more information on how to apply, please visit canada.ca/dental. Please help spread the word If you are looking for ways to promote the current CDB to your patients or potential patients, we have resources that can help. Check out our toolkit at canada.ca/DentalToolkit, which includes: z shareable social media materials z information sheets in 12 languages, including Punjabi, Arabic, Hindi, Simplified & traditional Chinese, Spanish, Tagalog, Somali, Michif-Cree and Ukrainian z a poster z a short explanatory video Together, we can keep spreading the word about the CDB and help eligible children access the dental care services they may need. What’s next? The Canadian Dental Care Plan The Government of Canada is working to make access to dental care more affordable to uninsured Canadians who have an annual adjusted family net income of less than $90,000, with no co-payments for those with a family net income under $70,000. The Canadian Dental Care Plan will begin rolling out by the end of 2023 with the goal of full implementation by the end of 2025. Let’s continue to work together We sincerely appreciate your dedication to your work and recognize the difference that you are making in the lives of Canadians every day. Together, let’s continue to improve the oral health of all Canadians. 10 | 2023 | Issue 5

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As Federal Efforts are Underway to Improve Access to Oral Health Care, Let’s Work Together to Get it Right In Canada, an estimated 2.26 million school days are missed each year due to dental-related illness, and tooth decay accounts for onethird of all day surgeries performed on young children. Only 47% of adults between age 60 and 79 have dental benefits. In fact, one-third of Canadians are unable to visit an oral health professional because they do not have access to dental benefits. This makes access to dental care critical for these families. The following article by Dr. Heather Carr, CDA president, was distributed to media outlets in September 2023. The oral health landscape across Canada is incredibly complex and varied, with each part of the country starting at a different place when it comes to public oral health programs and resources. Any path forward must take these different realities into account, in addition to the six comprehensive recommendations outlined by CDA in its policy paper Bridging the Financial Gap in Dental Care (see: bit.ly/3EZV6gD). In that paper, CDA recommends that in tandem with investment in access to care, the federal government should develop a comprehensive federal oral health strategy to address the broader set of challenges Canadians are facing. 13 Issue 5 | 2023 |

For Canadians who currently lack adequate access to dental care, their oral health needs are diverse and sometimes complex. An effective program needs to be flexible enough to meet these varied needs. Part of removing barriers to access means ensuring individuals can visit their dentist and get the care they need without worrying about a bill. The program needs to fully cover services and visits for these populations. Dentists like myself want to focus their time caring for our patients, so the federal program needs to be designed to avoid additional administrative burdens that impact or delay the provision of care. The program should promote the delivery of dental care primarily through the existing network of dental offices, take advantage of teams led by oral health experts and not disturb current private coverage plans. Canada’s dentists see firsthand the impact that poor oral health can have on a person’s overall health. We understand the challenges our patients face. By sharing our frontline expertise, we can help ensure this program will serve those who need it most. Over the past year, CDA has been actively engaging with Health Canada, former Minister of Health Jean-Yves Duclos, and current Minister Mark Holland, to ensure their understanding of the needs of these populations and the reality of the care needed to close the gaps in access to dental care. We also stressed the critical importance of minimizing disruptions for those Canadians who already have dental benefits. The level of openness and engagement has been highly appreciated andwe look forward to continuing this collaboration. Indisputably, this program represents an important investment from the Government of Canada, and we all have a shared responsibility to ensure it is sustainable and supports Canada’s healthcare system. We are hopeful that this program will have an enormous impact on healthcare outcomes and prevention, and we look forward to our continued involvement. CDA wants to see the government make this important project a success. In turn, this will have a positive impact on the oral health of vulnerable Canadians. Let’s work together and get this right. Last February, the federal government took steps in the 2023 budget by adding $7 billion and raising its total commitment to $13 billion in total over the next five years, and projecting $4.4 billion ongoing for the Canadian Dental Care Plan (CDCP). For our most vulnerable populations, this additional commitment increases the potential to make long-term gains in oral health. CDA has long advocated for targeted investments to improve access to oral health care, but cautioned the government on its initial cost estimates, which didn’t seem to consider the many needs of those who have lacked access to essential, preventative dental care. The Parliamentary Budget Officer also warned the government last summer that its estimates would likely fall short. The program should promote the delivery of dental care primarily through the existing network of dental offices, take advantage of teams led by oral health experts and not disturb current private coverage plans. 14 | 2023 | Issue 5 CDA atWork

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DENTAL DIGEST The British Columbia Dental Association (BCDA) appointed Quinn Mathiesen Newcomb as its CEO in September 2023. Mathiesen Newcomb has a background in leading government and stakeholder relations as well as strategy management functions. He most recently served as a senior executive at Genome BC. “Quinn’s track record of building strong relationships with diverse stakeholders, delivering successful initiatives that serve and advocate for an organization’s mandate, strategy management, and culture will enable him to effectively lead BCDA staff and support our members,” said Dr. David Lim, BCDA president, in a statement. “His commitment to service, respect, integrity, creativity, and collaboration aligns with our shared values, and he is dedicated to leading us through a new era for the profession.” Mathiesen Newcomb takes over the CEO role previously held by Jocelyn Johnston, who is retiring as CEO but will assist in the transition by remaining involved and supporting BCDA in the coming months. In early September, Jean-Yves Duclos, the Minister of Public Services and Procurement, and Mark Holland, the Minister of Health, announced that an Early Work Agreement had been awarded to Sun Life Assurance Company of Canada (Sun Life) for the Canadian Dental Care Plan (CDCP), while details of the main contract were still being finalized. As part of the announcement, the federal government indicated that up to $15 million would be provided to Sun Life to launch pre-contractual work to ensure the timely launch and successful operation of the CDCP. This includes initiating activities in such areas as recruitment, information technology and business planning. The main contract is expected to be awarded later in 2023, pending further approval. More details on the CDCP, which is expected to begin rolling out by the end of 2023, will be announced by Health Canada later this year. Quinn Mathiesen Newcomb Appointed New BCDA CEO Sun Life Awarded Contract for CDCP Groundwork ADA Clinical Practice Guidelines for the Pharmacologic Management of Acute Dental Pain in Children A panel convened by the American Dental Association (ADA) Science and Research Institute conducted a systematic review and meta-analyses to produce evidence-based recommendations for the pharmacologic management of acute dental pain after 1 or more simple and surgical tooth extractions. The guidelines also cover the temporary management of toothache (i.e., when definitive dental treatment is not immediately available) associated with pulp and furcation or periapical diseases in children under age12. The ADA Science and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania panel generated 7 recommendations and 5 good practice statements across conditions. Inits report, thegroupconcludedthat therewasasmallbeneficial net balance favouring the use of nonsteroidal anti-inflammatory See: bit.ly/48dSJUz Quinn MathiesenNewcomb drugs (NSAIDs) alone or in combination with acetaminophen compared with not providing analgesic therapy. They found no available evidence regarding the effect of corticosteroids on acute pain after surgical tooth extractions in children. In its conclusions, the panel stated that nonopioid medications, specifically NSAIDs like ibuprofen and naproxen alone or in combination with acetaminophen, were recommended for managing acute dental pain after 1 or more (simple and surgical) tooth extractions and the temporary management of toothache in children. Available at: jada.ada.org/article/S0002-8177(23)00390-2/fulltext 16 | 2023 | Issue 5

The federal government launched public consultations in September for the second legislative review of the Tobacco and Vaping Products Act (TVPA). This review is part of the government’s overall goal of reducing the number of people in Canada who smoke cigarettes and use other tobacco products to less than 5% of the population by 2035. For the recent consultations, the federal government is looking to hear from a range of voices including health professionals, public health advocates, Indigenous peoples and people who smoke or have smoked to help inform the second legislative review of the TVPA. The first legislative review of the TVPA prompted the government to introduce Vaping Products Reporting Regulations to help improve its understanding of the vaping product market. The information gathered through both reviews will help establish a baseline assessment of the TVPA and further track progress towards reducing tobacco use in Canada. Seeking Input on the Reduction of Tobacco Use Feedback can be submitted via email until November 3 at: legislativereviewtvpa.revisionlegislativeltpv@hc-sc.gc.ca

Dental Workforce Challenges Persist in the US and Canada The American Dental Association (ADA) Health Policy Institute conducted a survey about its dental workforce in 2022. It collected data from thousands of dental assistants, dental hygienists, anddentists fromacross theUS.“It found that one-third of dental assistants and dental hygienists are expecting to retire in the next 5 years or less,” says Costa Papadopoulos, CDA’s principal health policy advisor. “That’s a significant number. Especially considering that 40%of dental offices are recruiting for dental assistants and hygienists, and 80% of those are experiencing challenges because there simply aren’t enough applicants.” Costa Papadopoulos, CHE, MHA is CDA’s principal health policy advisor. 18 | 2023 | Issue 5

The ADA survey also found that factors related to workforce retention included good work-life balance, positive workplace culture, and the ability to help patients on a daily basis. Conversely, factors associated with attrition included negative workplace culture, lack of growth opportunities, inadequate benefits and feeling overworked. Approximately half of both dental assistants and dental hygienists had received a pay raise in the previous year, in the 1% to 3% range. Most of these workers also receive dental benefits, paid holidays, paid vacation, and retirement savings. Among this group, health insurance, paid sick time, paid leave, and professional development were more rare. Oral health care team members said that these benefits matter when it comes to both recruitment and retention. Common Challenges Throughout Health Care Like the US, a significant number of Canadian dental assistants are also planning to retire in the next five years. “These trends are what we need to pay at tention to, because it speaks to the future of the dental workforce,” says Papadopoulos. “But dentistry isn’t alone in facing changing workforce conditions. There are shortages throughout health care. Burnout, stress, and depression levels are high among nurses and physicians and that is causing some people to exit these professions.” A recent survey of Canadian physicians revealed that 60% felt their mental health was worse than before the pandemic and 80% reported a lack of professional fulfillment. Half of physicians screened positive for depression. “There are problems throughout the entire health care sector that existed before the pandemic, but that have been made worse by it,” says Papadopoulos. “These challenges aren’t going away anytime soon and need to be addressed by governments.” Papadopoulos says that there are trends in the labour market at large that indicate that people value flexibility more than ever before. “Health care doesn’t of fer a lot of flexibility, or remote work opportunities, for that mat ter,” he says. Forty health care organizations, including the Canadian Medical Association and the Canadian Nurses Association, “In 2019, a survey of dental assistants in Canada had pretty similar findings,” says Papadopoulos. That survey found that 36% of dental practices in Canada had unfilled dental assisting positions and that 80% of dentists in Canada had a difficult or extremely difficult time filling open assisting positions. “Push and pull factors were also similar here in Canada,” says Papadopoulos. “Insufficient pay was a top reason for leaving a practice in Canada and so was a negative workplace environment.” Comparing the two surveys, it appeared that oral health care workers in the US are more likely to have benefits than those in Canada. “For dental assistants in particular, there are two different ways to think about retention,” says Papadopoulos. “There is retention at a particular dental office, but maybe more significant is retention in the dental field in general. People are making career changes and leaving the dental field altogether in search of work that offers more flexibility, better work-life balance, remote work, and opportunities for advancement that dental assisting may not offer them.” 36% of dental practices in Canada had unfilled dental assisting positions and 80% of dentists inCanadahadadifficult or extremely difficult time filling open assisting positions. 19 Issue 5 | 2023 | Issues and People

have been calling for decisive action on staff burnout and shortages in public position statements, initially sounding the alarm bells in 2021. These health organizations say that it is necessary to create a robust data source for health human resources (HHR) in Canada, to implement a multidisciplinary nationwide HHR strategy, and to commit to transforming Canada’s health care system for the needs of the future. With the recent federal funding for dental care, dentistry has become more integrated into this sectorwide situation. Impact of Staffing Challenges Dental staff challenges have resulted in an increase in the use of temp agencies to fill positions and a reduction in the number of available appointments. An Abacus Data survey conducted for CDA revealed that approximately 500,000 dental appointments had been canceled due to staffing unavailability over the previous two-month period. “That data equates to roughly 3 million cancellations per year and approximately 100 to 120 cancellations per dentist,” says Papadopoulos. “It’s concerning because that could have a significant negative impact on the oral health of the public.” other factors,” says Papadopoulos. “My concern is that we may see longer wait times for access to care and, to some extent, significant wait times depending on the region, which is something that most people are not used to in Canada for dental care.” Papadopoulos cites economic uncertainty, high interest rates and practice staffing challenges making alternative dental practice models more attractive to newer, less established dentists. “Coming out of their dental education with high debt loads, more new dentists will look to become an associate with larger, established practices to insulate themselves from economic risk,” he says. “To me, all of this suggests that there is a need for coordinated HHR planning for the entire oral health care sector, which includes health providers like nurses and others.” This doesn’t just mean trying to figure out how to get more dental assistants in the system for the typical dental practice. But rather to look at the whole situation with a larger policy lens for the future. A broad policy lens requires that dentistry considers bigger questions about demographic changes in Canada. With our aging population, how are we going to provide oral health care in long-term care (LTC) facilities and for independent seniors in the community? What are provincial governments and the private sector doing to innovate models of delivery for general health care for seniors? Telehealth may work for many medical care services, however it may not always be appropriate for dental care because of the hands-on nature of many treatments. Looking Towards Solutions In the short term, the dental workforce needs to be better supported to retain existing workers. “To help dentists right now, we need to be talking about how to retain the people who are working in dental offices already,” says Papadopoulos. “Compensation and benefits are important. And, from the surveys, it has become increasingly clear that a well-managed, positive workplace that offers a good work-life balance can also make a real difference.” A recent Canadian study found that, on average, it costs $41,000 to replace an employee who leaves. As well, two-thirds of companies agree that employee turnover places a heavy burden on the existing employees. “Working toward high levels of communication and respect in the workplace, giving employees the authority to make their own decisions, and offering continuing education or training opportunities not only make everyone happier, they also make financial sense,” says Papadopoulos. “Invest in the team you have right now.” Papadopoulos says that increased federal funding for dental care will increase the number of Canadians who have access to dental care, which will, in turn, increase the workload in dental offices. “I’m concerned about increased demand exacerbating the staff shortage issue. Workloads will increase not just in the private oral health care sector, but also in public hospitals and community health care,” says Papadopoulos. “Each sector will be impacted differently based on their resources and staffing at the time, but there is a real concern about capacity issues.” Regional differences and the rural-urban divide already influence the capacity of the oral health care system. “I think this trend will continue to be true and some places will have a harder time finding and retaining staff depending on policy mechanics, uptake of the federal dental plan, and Abacus Data survey conducted for CDA revealed that approximately 500,000 dental appointments had been canceled due to staffing unavailability over the previous two-month period. 20 | 2023 | Issue 5 Issues and People

 40% of dental offices have recently or are currently recruiting for dental assistants and dental hygienists.  Of those recruiting and having challenges finding dental hygienists, about 80% indicate the reason is that there are not enough applicants.  Dental service organizations (DSOs) had the lowest satisfaction rankings for dental assistants, hygienists and even dentists, even though DSOs offered much higher levels of benefits. Public health had the highest satisfaction rankings.  About 50% of dental offices had given raises to dental hygienists and dental assistants within the last year, the majority having a pay raise of between 1% and 3%.  Unhealthy workplace culture was reported frequently.  The most common reasons among dental hygienists for leaving the workforce were negative workplace culture, lack of growth opportunity, and inadequate benefits.  The most common reasons among dental assistants for leaving the workforce were insufficient pay, negative workplace culture, and feeling overworked. A 2022 survey by TELUSHealth (formerly LifeWorks) found that 55% of working Canadians value flexible work arrangements over career progression. The same survey found that one-third of respondents felt that providing greater flexibility was the most important action their employer took to support their mental health. Almost half of respondents (48%) said enjoying the work they do was the reason they stay with their employer, while 34% cited health and wellness benefits and 33% reported being well paid. “Flexibility now consistently ranks as one of the top recruitment and retention factors,” says Papadopoulos. “It’s challenging in the dental office, but there may be innovative ways to operate with greater flexibility.” Compensation and benefits are important. But it has become increasingly clear thatawell-managed,positive workplace that offers a good work-life balance can also make a real difference. 2022 American Dental Association survey on dental workforce shortages: 21 Issue 5 | 2023 | Issues and People

In the long term, there are more systemic issues that the dental profession will need to address to support a robust oral health workforce. “Not only do we need to retain the people who are currently working in dental offices, we’ll need to make sure that enough people are training to be the dental assistants and dental hygienists of tomorrow,” says Papadopoulos. CDA has been working closely with the Canadian Dental Assistants’ Association for several years and partnered to submit a project to Employment and Social Development Canada as part of their sectoral workforce solutions program. “This program is designed to address the many factors impacting the attrition of dental assistants by providing mental health andwellness training for dental office staff, providing health human resources training for dentists and office managers, increasing access to certified dental assisting programs through the development of an online curriculum, as well as developing action plans to address interprovincial labour mobility and better integration of recent immigrants into the dental workforce,” says Papadopoulos. “The labour force in Canada is changing in a broad-based way, and it is affecting every sector of the economy, so we need to partner with others, especially in health care, to make sure that we can provide optimal oral health care to a growing number of Canadians.” Listen to a podcast with Costa Papadopoulos on the dental workforce on CDA Oasis: bit.ly/3pz7nEz  10% are currently unemployed due to mental health illness or issues.  31% reported there is often a lack of staff to complete work.  53% reported having too much work to complete all their assigned tasks well.  28% reported dissatisfaction with their current job.  25% reported it is likely they will seek a new job within the next 12 months.  62% felt anxious at the workplace all or most of the time.  17% felt depressed most of the time.  The average effective hourly wage of dental hygienists across all provinces and territories has risen slightly each year since 2013.  Dental hygiene baccalaureate degree holders report higher average wages.  The approximate unemployment rate for dental hygienists remained at 1%,which was below the Canadian unemployment rate of 6.7% as of October 2021.  94% of respondents work in clinical dental hygiene and 75% work for a single employer.  More than three-quarters (86%) of dental hygienists receive employee benefits.  88% of respondents have decision-making authority over implementing dental hygiene services.  Respondents working in specialty practices work most often in periodontics (44%) and orthodontics (31%).  Independently practising dental hygienists continue to report high levels of satisfaction.  14% of respondents working in clinical practice are employed by a dental corporation. 2019 Canadian Dental Assistants’Association survey on work and mental well-being: 2021 Canadian Dental Hygienists Association job market and employment survey: Not only do we need to retain the people who are currently working in dental offices, we’ll need to make sure that enough people are training to be the dental assistants and dental hygienists of tomorrow. 22 | 2023 | Issue 5 Issues and People

As a dentist, you understand the value of a regular dental checkup. It’s true for your finances as well. Your ability to achieve healthy financial outcomes can be impacted by the passage of time or a milestone such as: Starting or buying a practice Getting married or divorced Welcoming a new member to your family Buying a vacation home or income property Receiving an inheritance Selling your practice Retiring Plan More and Worry Less. Book your checkup today. Is it Time for a FINANCIAL CHECK-UP? 1.800.561.9401 cdspi@cdspi.com One of the benefits of dental association membership is a complementary financial checkup with an Advisor at CDSPI Advisory Services Inc.

Dentists protect oral health. CDA SECURESEND protects patient data. Mobile App As easy as email. Live support at 1-866-788-1212. Secure and confidential. Share files with dentists, labs, specialists and patients. Save on your bottom line. Free with provincial dental association and affiliate CDA membership. DOWNLOAD NOW! Dentsply Sirona launches the new X-Smart Pro+ endodontic motor The powerful X-Smart Pro+ portable motor is designed to optimize the performances of Dentsply Sirona file systems, including WaveOne Gold, ProTaper Ultimate, and TruNatomy. With an integrated apex locator and Dynamic Accuracy technology, the motor delivers optimal performance in both rotary and reciprocating modes—delivering up to 7.5 Ncm and 3,000 rpm. The X-Smart Pro+ provides superior visibility and access, with a 10-lumen integrated LED, a mini contraangle with a 360° adjustable position, and a fully autoclavable handpiece sheath. The large easy-to-clean touchscreen interface includes a full file library of preset settings for Dentsply Sirona, and up to 30 customizable file sequences. SureSmile® Simulator: Let the Smile Do the Talking Introducing the SureSmile Simulator powered by DS Core.* With the SureSmile Simulator, patients can preview their new smile before they start treatment, giving clinicians and patients even more reasons to choose SureSmile® Clear Aligners. Designed for chairside visualization and treatment acceptance, the SureSmile Simulator provides custom 3D visualizations of a patient’s possible new smile following SureSmile Clear Aligner treatment. This powerful tool can provide dentists with the opportunity to educate their patients and show them the potential esthetic and oral health benefits of treatment illustrating the value of their investment. *Requires user to have a DS Core subscription and Primescan IOS. Displayed results are a simulation of potential aligner treatment and not a prescribed treatment plan, which must be directed by the dentist and complied with by the patient. Actual treatment outcomes may differ substantially. Visit: dentsplysirona.com/Xsmart Visit: dentsplysirona.com/suresmile 24 | 2023 | Issue 5 Sponsored Content The Product Spotlight section features innovations from the dental industry. Learn more about these products below.

Study ExaminesTooth Brushing and Oral Care Best Practices for Preventing Pneumonia in ICU Patients A significant body of research demonstrates that the oral microbiome changes dramatically when people are admitted to the hospital, particularly those treated with invasive mechanical ventilation in the intensive care unit (ICU). For the last two decades, this disruption in bacterial homeostasis, called dysbiosis, has been treated with chlorhexidine gluconate rinse applied topically to the patient’s mouth several times a day to control overgrowth of gram-negative oral bacteria and prevent the formation of a biofilm microbial community of pathogenic microorganisms. Topically applying antimicrobial rinse as a pneumonia prophylaxis has been widely adopted. An estimated 70% of ICUs are regularly using this treatment worldwide. Dr. Craig Dale, RN, PhD, is a clinician scientist and an associate professor at the Lawrence Bloomberg Faculty of Nursing at the University of Toronto and clinical scientist in oral health at Sunnybrook Health Sciences Centre. “Topically applying antimicrobial rinse as a pneumonia prophylaxis has been widely adopted,” says Dr. Craig Dale, an author of a study of the de-adoption of antimicrobial rinses.1 “An estimated 70% of ICUs are regularly using this treatment worldwide. Recently, systematic reviews and metaanalyses have explored evidence regarding 25 Issue 5 | 2023 |

the safety and efficacy of chlorhexidine oral care. The results are surprising,” says Dr. Dale. Antimicrobial rinse has limited to no effect in preventing pneumonia among ICU patients.2 More concerning, there’s an excess mortality signal (i.e., more die than statistically expected) among patients exposed to the treatment. “We can’t quite explain the mortality signal, but certainly it gave us pause to think about whether or not we should continue with this treatment,” says Dr. Dale. Given the risks and the limited benefits of chlorhexidine oral care, Dr. Dale and his colleagues wanted to stop using the rinse in their ICUs. “However, we know that abrupt interruption of a long-standing practice can have unintended consequences,” he says, “so we opted to conduct a rigorous, de-adoption trial to study this process.” Dr. Dale and his colleagues conducted a stepped wedge cluster randomized controlled trial with an embedded process evaluation in 6 ICUs in the Toronto area. In each ICU, the staff stopped using chlorhexidine oral care and began using a standardized oral care bundle, including tooth brushing, moistening the mouth and deep suctioning. “To accomplish this, we conducted frontline staff education, including point-of-care training and monthly audit and feedback to support this practice change over the study period.” The study’s primary research aim was to measure the impact of chlorhexidine de-adoption on mortality in mechanically ventilated patients. The second goal was to measure the impact of chlorhexidine de-adoption and implementation of a standardized oral care bundle on time to infection, procedural oral pain and objective measures of oral health dysfunction. One goal was to measure the impact of chlorhexidine de‑adoption and implementation of a standardized oral care bundle on time to infection, procedural oral pain and objective measures of oral health dysfunction. “We found that swapping the two kinds of care did not change mortality, time to infection, time on the ventilator or procedural pain for our patients,” says Dr. Dale. “However, we did see improvement in oral health dysfunction scores after the rinse was de-adopted. In short, oral health improved.” The investigators also found an increase in oral care delivery during the trial. “Oneway to interpret the findings is that we did not see any advantage of chlorhexidine rinse over a standardized oral care bundle. Since tooth brushing should be happening anyway in hospitalized patients, this should really be the default form of oral care and pneumonia prophylaxis,” says Dr. Dale. The study has led to new guidelines for oral care in hospitals endorsed by multiple infection control bodies including the Centers for Disease Control and Prevention. “These guidelines move oral care from the background to the foreground,” says Dr. Dale. “This will impact every patient admitted to hospital, both on wards and in ICUs. Tooth brushing is now considered an essential practice, which will improve patient outcomes.” References: 1. Dale CM, Rose L, Carbone S, Pinto R, Smith OM, Burry L, et al. Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients in the intensive care unit (CHORAL): a multi-center stepped wedge cluster-randomized controlled trial. Intensive Care Med. 2021 Nov;47(11):1295-1302. 2. Klompas M, Speck K, Howell MD, Greene LR, Berenholtz SM. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med. 2014 May;174(5):751-61. Watch a conversation with Dr. Dale on CDA Oasis: bit.ly/44QhGlW 26 | 2023 | Issue 5 Issues and People

The views expressed are those of the author and do not necessarily represent the opinions and official policies of CDA. KNOWTHE LAW Is a DentalTeamMember an Employee or Independent Contractor? Inna Koldorf is a partner in the Employment and Labour Law Group at KPMG Law LLP in Toronto. Her work includes helping employers with managing their workforce, providing advice, representing employers in litigation and conducting workplace investigations. As a general rule, businesses often prefer to classify workers as independent contractors because it createsmoreflexibility around managing both people and costs. Workers, on the other hand, typically prefer to be classified as employees because they benefit from legal protections and benefits that aren’t provided to independent contractors. “These competing interests can create a push-and-pull situation, which needs to be balanced carefully, between small businesses and workers,” says Inna Koldorf. “Business owners need to know the benefits and costs of each classification as well as how they are defined under the law.” In the broadest terms, an employee’s work serves and is controlled by the business they work for, while an independent contractor is a person who is in business on their own account. “A worker’s status determines the business’ obligations to the worker and how taxes are paid for that worker,” says Koldorf. 27 Issue 5 | 2023 |