SEPTEMBER 

Endodontic Instrumentation

Dental Anatomical Anomalies Journal Impressions and Working Casts

Children’s Oral Health

     CDA Journal Volume 35, Number 9 Journal september 2007

departments 601 The Editor/Health Care Reform - A Quixotic Quagmire 605 Impressions 611 Table Clinic Winners/Abstracts from first-place winners from the table clinics during the Spring Session in Anaheim. 658 Dr. Bob/Product-palooza! features 619 Disparities in Children’s Oral Health and Access to Care This paper provides an overview of oral health disparities experienced by racial and ethnic minority children based upon the socioeconomic status. Many Americans, particularly children, continue to suffer disproportionately from oral pain and disease, including minority, low-income, and/or special care populations. Lesa Paige Bentley, MHA, MBA, MBIT

625 Simplifying Endodontics With EndoSequence Rotary Instrumentation Recent advances in endodontic instrumentation have simplified the treatment process and improved long-term success. Ten years ago, the vast majority of endodontic instrumentation was being performed with hand files and reamers. Today, most practitioners providing endodontic therapy are utilizing rotary instrumentation. Gregori M. Kurtzman, DDS, MAGD

631 Dental Anatomical Anomalies in Asians and Pacific Islanders Dental anatomical anomalies having a significant impact on endodontic diagnosis and treatment are the talon cusp, tuberculated premolars, three-rooted mandibular molars, and C-shaped molars. Asian and Pacific Islander ethnic groups have the highest percentage of these dental anatomical anomalies compared with the general population. As the population of Asians and Pacific Islanders continues to grow in California and other western states, dentists should be aware of the diagnostic and treatment complexities associated with specific patient groups. Charles E. Jerome, DDS, and Robert J. Hanlon, Jr., DMD

637 Improving Decision-Making in Restorations: Evaluation of Impressions and Working Casts This report looks at the finish line consistency of 73 “clinically acceptable” impressions made by dental students and working casts poured in the laboratory section. Findings show a number of possible inaccuracies in preparations, impressions, or a combination of both. Gitta Radjaeipour, DDS Editor CDA JOURNAL, VOL 35, N 9 º

Health Care Reform — A Quixotic Quagmire

ALAN L. FELSENFELD, DDS

his is the year of health care reform for California. Maybe The surgeon general stated that oral health this is the year of health care reform. care is an integral part of total health care, and The problem, simply stated, Tand, admittedly, it is an oversimplifica- dentistry has championed that opinion. tion, is a significant segment of our population does not have the ability to receive routine health care. At least three ing theories that poor periodontal health bills and three proposals are before the dental care as an optional benefit for is related in a causative manner to many state Legislature at this time to allegedly individuals to purchase through the state systemic illnesses. Maintaining periodon- solve this problem. All of them provide purchasing pool. This might be considered tal health is essential to prevention and the ability for the uninsured and under- favorable by many of our members for control of significant problems such as insured to receive medical care as needed. financial reasons, but there is growing heart disease, stroke, diabetes, and low A Kaiser Commission study suggests that public concern about the all inclusiveness birth weight babies. Recent discoveries of only 20 percent of our state population is of any health care package. salivary markers for systemic malignan- not eligible for some form of coverage. Universal health care presents cies have improved dentist involvement This may not include the undocumented problems for dentistry. Dentists take in saving lives by simple, noninvasive immigrants, those who are eligible for pride in being health care professionals testing. Management of drug effects, as in coverage by safety net programs but do and espousing total patient care. Con- the use of antihypertensive or antiseizure not participate, and those who have cov- versely, many of us have been frustrated medications creating periodontal disease, erage but no access to care. with insurance companies and public or bisphosphonates and osteonecrosis The diverse programs and proposals programs that limit access to care, as we have integrated dentistry into the treat- include a single payer model (a statewide define it, and reimburse at less than fair ment of serious medical conditions. Truly, program for universal health care funded market value for services rendered. This dentists are achieving the conceptual goal and administered by the government) as causes confusion and unhappiness in of becoming physicians of the oral cavity. well as a mandate for employers to “pay our patients as well as frustration with Insurance reimbursement and cover- or play” (provide insurance to employees the system for patient and provider. This age for procedures has spiraled downward or put money into a state purchasing conflict between payers, patients, and over the years. This trend is not likely to pool). The Medi-Cal program is not likely providers has implications in health care be reversed absent governmental inter- to be improved, but Healthy Families, a reform with universal coverage regardless vention. But government programs are federally funded State Children’s Health of the plan. not necessarily any more user friendly, Insurance Program, eligibility criteria may The surgeon general stated that oral and reimbursements are equally poor be increased to 300 percent of the poverty health care is an integral part of total for services provided. Most of us do not level. Most of the proposals, with one health care, and dentistry has cham- desire socialized or government health exception, do not mandate dentistry as pioned that opinion. The periodontal care coverage for dentistry since the part of the program other than to include literature is replete with articles support- remuneration is likely to be significantly

SEPTEMBER 2007 601 lower and the administrative process will be convoluted with impressive impact on the bottom line of running practices with increasingly high overhead. Some practitioners may be able to opt out of the system and not accept any third-party re- imbursement, but that is not a reasonable position for many of our colleagues. It is reasonable to believe that a ne- gotiated health care program will be put into place, if not this year then in the fu- ture. Dentistry has to take a position on inclusion of dental care benefits in any plan that will be enacted. We need to be at the table to be certain that quality oral health care is allowed for all Californians. Dentistry has much to offer in the pre- vention, detection, and management of oral and systemic diseases. Our patients need the ability to receive care. We need to ascertain that coverage will allow, at a minimum, prevention and treatment of acute problems to relieve pain and treat infections. Children should be the first area of concern in any dental program. Inclusion of dentistry in a health care package will not be comfortable for many of our colleagues, but we are doctors and need to take responsibility for health care in our patients both at the local level in our practices and globally for the greater good. If dentistry is going to talk the talk, it has to be prepared to walk the walk, and that may be very uncomfortable for many of us.

REFERENCES 1. The Uninsured: A Primer — Key Facts about Americans Without Health Insurance; The Kaiser Commission on Medicaid and the Uninsured, December 2003.

Address comments, letters, and questions to the editor at [email protected].

602 SEPTEMBER 2007 Impressions CDA JOURNAL, VOL 35, N 9 º

Puffing and Snoozing Top the List of Lifestyle Factors That Impact Oral Health A study has identified that certain life- style habits have an impact on periodontal health. Among these factors are mental stress, exercise and nutrition, but the top two are smoking and sleeping. A study in the spring issue of the Jour- nal of Periodontology followed a group of 29 factory workers in Japan from 999 to 2003 in an effort to evaluate the effect of different lifestyle factors on the progres- sion of periodontal diseases. Each worker was evaluated on a list of the following lifestyle factors: alcohol consumption, eating breakfast, hours of sleep, hours worked, mental stress, nutritional balance, physical exercise, and tobacco use. At the top of these factors that impacted the progression of periodontal disease was smoking, trailed by hours of sleep. More than 4 percent of study partici- CONTINUES ON 610 Dan Hubig

Helping Patients Give Overbrushing the Brush Off The woman had There is something to the adage “too much of a good told her dentist thing.” It even applies to dental care. that, fearful of losing In an article in the Texas Dental Journal, Drs. Hiroyasu her teeth, she brushed Endo, Terry Rees, William Hallmon, Yoshiharu Kono, and Takao Kato, reported on a number of case studies showing with a hard-bristle that “excessive oral hygiene practices” can inflict serious toothbrush for more gingival injuries. than 30 minutes One of the cases presented was of a 54-year-old woman with a one-month history of three times a day. gingival problems, including bleeding and lesions. The woman had told her dentist that, fearful of losing her teeth, she brushed with a hard-bristle toothbrush for more than 30 minutes three times a day. Her dentist instructed her to use a soft-bristle brush and limit her brushing to two minutes each time. Two weeks later, the patient reported she was no longer in pain, and the dentist noted that all ulcers and other problems had disappeared. In another case, a woman who reported similar personal hygiene habits also stated she had sore gums. After receiving brushing tips from her dentist, the patient reported a week later that her gingival pain had disappeared completely. The authors concluded by warning that excessive brushing and other bad habits could be a sign of emotional disturbance.

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J Stem cells obtained from pig periodontal ligament form a single Museum Features Cutting-edge colony cluster. A Science That Could Treat Disease stimulus has caused and Grow New Teeth these cells to organize — an For thousands of years humankind example of the first has sought to replace lost teeth. Even an- step toward growing a Researchers cient Egyptians used gold wire to attach new tooth. a donor tooth to their own teeth. Now, already imagine replacing a missing tooth with have taken the a new one grown from one’s own cells? impact on our lives in years to come.” What’s more, imagining may not be too The completion of the Human Genome first steps to far from becoming an actuality. Project has enabled scientists to unlock separately grow At the Samuel D. Harris National the secrets of the genetic code, opening Museum of Dentistry, the recently opened the door to unprecedented breakthroughs the crowns and exhibit “Bioengineering: Making a New in science. Researchers already have taken roots of You” shows how researchers have taken the the first steps to separately grow the first steps to grow new teeth from adult crowns and roots of teeth from adult stem teeth from stem cells. One also can discover how this cells. They are working on growing a com- adult stem cells. emerging science works, what it means plete tooth with the correct shape and size. for the future of dentistry, and what types Researchers also are studying ways to treat of careers could help make it a reality. The oral and systemic diseases using genes. cutting-edge dental research that is being Salivary glands are being studied as an done could revolutionize ideal injection site for gene therapeutics. the way a lost or diseased “Bioengineering: Making a New You” tooth is treated, but is the latest installment of “Your Spit- could also offer the key to ting Image” series, the first museum diagnosing and treating exhibition to focus on the cutting-edge systemic disease. research that is changing the face of Engaging displays dentistry. Developed by The Dr. Samuel and hands-on experi- D. Harris National Museum of Dentistry, ments reveal the science the interactive three-part exhibition behind the breakthroughs, includes “Saliva: A Remarkable Fluid”; “Bioengineering: Making a “Forensics: Solving Mysteries”; and the New You,” which opened current “Bioengineering: Making a New June 6, traces the history You.” The series explores how emerging of tooth replacement from science will affect dentistry and overall A Careers in cellular the ancient Egyptians to today; explores well-being in the future. and molecular biology, how researchers are using adult stem cells chemistry, genetics (found in the pulp of baby teeth and adult engineering, and teeth) to begin growing natural teeth re- dentistry will help help placements; and reveals how genes inserted make bionengineered teeth a reality. into the salivary glands could be used to treat systemic disorders like diabetes. “‘Bioengineering: Making a New You’ showcases innovative research that could ultimately change the face of oral health and the treatment of systemic disease,” said Rosemary Fetter, NMD executive A director. “The National Museum of Den- Mankind has sought to Some had their teeth replace missing teeth for replaced by using gold tistry is proud to play a part in educating thousands of years. Ancient wire to attach the crown the public about these important advanc- Egyptians had access to from a donor tooth to es in dentistry that will make a significant “specialists of the teeth.” their own teeth.

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Perio Therapy May Help Baby Arrive the risk of preterm delivery to equal Right on Time that of periodontally healthy women,” According to a study published said study author Catia M. Gazolla, recently in the Journal of Periodontology, DDS. “These are important find- periodontal therapy may significantly ings that we hope all pregnant reduce the risk of delivering a preterm, women will take to their low birth weight baby for women with the dental professionals when oral disease. discussing their periodontal The study looked at 328 pregnant health.” women with periodontal disease and 22 “These findings are periodontally healthy women. Periodontal interesting, as they come on treatment was performed during the sec- the heels of another study ond trimester of pregnancy on 266 of the appearing in the May issue women with periodontal disease. Sixty- of the JOP that showed two women dropped out of treatment. the effects of high levels of Postpartum follow-up on all 450 subjects periodontal bacteria dur- showed that 79 percent of the women ing pregnancy on increased with untreated periodontal disease had risk for preterm delivery,” said delivered a preterm, low birth weight baby Preston D. Miller, Jr., DDS, presi- compared to only 7.5 percent of the peri- dent of the American Academy of odontally treated women and 4. percent Periodontology. “These studies and of the healthy women. others continue to strengthen the “Our study showed that performing idea that women should consider a periodontal therapy on pregnant women periodontal evaluation as part of their who have periodontal disease may reduce prenatal care.

Some Straightforward Steps in Preparing to Sell Preparing a dental practice for sale involves a number of phases, said financial expert Timothy Brown in an issue of Ontario Dentist. Brown said there are five main steps one should consider before at- tempting to successfully sell a practice: ■ Confirm your premise lease renewal. Although most leases contain an option to renew, a tenant must confirm the presence of such an option before selling or risk a lot of headaches later on. Most practice buyers today demand the right to remain in the existing premises for a minimum of seven or eight years. ■ Prepare your financial records. Buyers want to understand the nature of a practice and may want to see a procedure analysis to determine if their skill set matches that of the owner vis-à-vis the financial software used in the practice. ■ Ensure that your practice is protected against employee fraud. It might be wise to hire a profes- sional fraud investigator to go over your books and computer data to shore up your practice. A clean bill of health in this area is nice to have prior to selling. ■ Review and update contracts and agreements. Purchasers demand accurate details of the con- tracts you have in place. Ask your associates, partners, and landlord for copies of your contracts and make sure they are dated and signed. ■ Consult with your accountant about incorporation. There might be substantial tax benefits to incorporating prior to a sale.

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Be Proactive Before Catastrophe practice, including all of its equipment and Strikes supplies. Don’t forget storage areas. Preparation is key in helping a dental ■ Keep a record of serial numbers and practice survive a natural or man-made replacement value for all your equipment. disaster said property-loss expert Wes ■ Make copies of all contracts and Baldwin in an issue of NYSDA News, the fi nancial records in order to determine newsletter of the New York State Dental losses caused by a disaster. Association. ■ Back up patient records, X-rays, and And, Baldwin wrote, the time to plan computer fi les. for disaster is now because one can’t fi le All of these materials, along with a claim for what one cannot prove one insurance policies, equipment manuals, owned. It is essential one complete an warranties, and deeds should be secured inventory, and document every aspect of off site. your practice, including its contents. Oth- Baldwin also advised hiring a public er considerations, according to Baldwin: insurance adjuster after disaster strikes. ■ If you own the building in which Paid a percentage of the fi nal settlement your practice is located, keep photos of from the insurance company, a public the exterior on fi le. adjuster tends to be less biased in arriving ■ Photograph the interior of your at a fi nal settlement.

Honors

Kevin D. Anderson, DDS, MAGD, of San Diego, was recently honored with the 2007 Distinguished Service Award from the Academy of General Dentistry. As former treasurer, chair of Budget & Finance, as well as the Kevin D. Anderson, DDS, John B. Featherstone, Arthur A. Dugoni, DDS, Investment Committ ee, Anderson MAGD MSc, PhD MDS provided valuable input in the es- tablishment of goals and strategic Restorative Dental Sciences. of Dentistry. Dugoni was honored direction to help grow and establish The award recognized him for for his outstanding leadership and fi nancial stability for the AGD. In two his “perseverance in investigating exemplary service to the dental years he grew the reserves of the the fi eld of cariology,” as well as his community, dental education, and Academy from $2.2 million to more groundbreaking research that “has public oral health. than $6.5 million. signifi cantly advanced scientifi c Dugoni is currently president Anderson retired from the knowledge of dental caries and of the ADA Foundation and has active practice of dentistry fi ve caries-inhibitory mechanisms, and served as president of the ADA, years ago and recently launched changed the way we treat caries the American Association of Den- a private equity partnership fund and control the underlying infec- tal Schools, the American Board of open to accredited investors of tious disease,” according to an ADA Orthodontics, and the California which many dentists are partners. press release. Dental Association. While he con- This year’s winner of the Norton The Program Advisory Com- cluded his deanship at the Arthur M. Ross Award for Excellence in mitt ee of the Edward B. Shils A. Dugoni School of Dentistry in Clinical Research is John D. B. Entrepreneurial Education Fund 2006, he continues to be involved Featherstone, MSc, PhD, profes- presented its 2007 Shils Award with the school and the university sor and interim Dean of the Univer- to Arthur A. Dugoni, DDS, MDS, as dean emeritus, professor of sity of California, San Francisco, dean emeritus of University of the orthodontics, and senior executive School of Dentistry, Preventive and Pacifi c, Arthur A. Dugoni School for development.

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“Entrepreneurship is UPCOMING MEETINGS living a few years of 2 0 0 7 your life like most

Sept. 27-30 American Dental Association 148th Annual Session, San Francisco, ada.org. people won’t, so that

Nov. 27-Dec. 1 American Academy of Oral and Maxillofacial Radiology 58th Annual Session, you can spend the rest Chicago, aaomr.org. of your life like most 2 0 0 8 people can’t.”

May 1-4 CDA Spring Scientific Session, Anaheim, 800-CDA-SMILE (232-7645), cda.org. ASPIRING BUSINESS OWNER, AS QUOTED IN Sept. 12-14 CDA Fall Scientific Session, San Francisco, 800-CDA-SMILE (232-7645), cda.org. ENTREPRENEUR MAGAZINE

Oct. 16-19 American Dental Association 149th Annual Session, San Antonio, Texas, ada.org.

To have an event included on this list of nonprofit association continuing education meetings, please send the information to Upcoming Meetings, CDA Journal, 1201 K St., 16th Floor, Sacramento, CA 95814 or fax the information to 916-554-5962.

ADA Publication Reviews Impression evaluations of eight air turbine handpiec- Materials, High-speed Handpieces es and compared traits of those hand- pieces with their electric counter- Working time for elastomeric impres- parts. Handpiece manufacturers sion materials can drop 50 percent or more whose products were reviewed once syringed around the teeth and reach were Bien-Air, Brasseler, Dental- mouth temperature, according to the sum- EZ Group, Dentsply, KaVo, and Sirona mer issue of the ADA Professional Product Dental Systems. Review. PPR is a quarterly publication “We knew that the reaction time was sent to ADA dentists along with their shorter at higher temperatures, but we issue of Th e Journal of the American were surprised some materials retained Dental Association. Th e newsletter is free only 25 percent of their working time at to ADA members and available by 35-degrees Celsius compared with working subscription to nonmembers. For time at 23 degrees,” says David Sarrett, subscription information, go to www.ada. DMD, editor of PPR. “For some materials, org or call 32-440-7735. the working time at 35-degrees Celsius was less than 0 seconds.” In addition to working time, the PPR reported on elastic recovery, stiff ness, tear Volunteers Sought for ADA’s New Forensic Standards Project strength, and other common properties. The American Dental Association Standards Committ ee on Dental Informatics is seek- Brands of impression materials tested ing volunteers for its recently approved work project on a standard for dental forensics. for this review were Affi nis, Aquasil Ultra The proposed ADA Specifi cation No. 1058 for Antemortem Forensic Dental Data Set Smart Wetting, Correct Plus, Examix will recommend forensic data standards necessary to adequately serve the dental forensic NDS, Flexitime, Genie Ultra Hydrophilic, odontology community. Impregum Penta Soft Quick Step, No guidelines currently exist for defi ning a minimal dental data set or other technical Imprint 3, Take , and VP Mix. guidelines concerning dental forensic information. This project will meet the need for a PPR, which was packaged with the July issue of Th e Journal of the American forensic dental standard of data that will aid in the determination of the identity of an Dental Association, also looked at high- unknown person. speed handpieces, both air turbine and For information about participating in the ADA standards committ ee working group electric. that will develop the standard, contact Paul Bralower [email protected] or 800-587-4129. Th is edition also featured performance

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“This study points out to patients that there DENTIST, CONTINUED FROM 605 are lifestyle factors other than brushing and pants who showed periodontal disease ing periodontal health are limited. From flossing that may affect progression from 999 to 2003 were this study, we can speculate that shortage smokers. Additionally, lack of sleep was of sleep can impair the body’s immune re- their oral health.” identified as a significant lifestyle factor sponse, which may lead to the progression PRESTON D. MILLER, JR., DDS that may play a role in the progression of of diseases such as periodontal disease.” periodontal disease. The participants who “This study points out to patients snoozed seven to eight hours exhibited that there are lifestyle factors other than less periodontal disease progression than brushing and flossing that may affect those who received six hours or less of their oral health,” added Preston D. Miller, sleep. Daily alcohol consumption and Jr., DDS, president of the American Acad- high stress levels also demonstrated sig- emy of Periodontology. “Simple lifestyle nificant impacts on periodontal disease changes, such as getting more sleep, may progression. help patients improve or protect their oral “Our findings are in line with other health,” said Miller. “It is also important studies that have identified smoking as a to keep these in mind as the body of strong lifestyle factor affecting oral health,” evidence linking oral disease with sys- said study author Muneo Tanaka, DDS. temic diseases continues to grow because “However, studies that have looked at hours ultimately these lifestyle factors might of sleep as an independent factor affect- impact a patient’s overall health.”

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Winners of the 2007 Table Clinic Competition

Each year, the California Dental Association invites dental, dental hygiene and dental assisting students and military residents from across the state to enter the Table Clinic Competition at the Anaheim Scientifi c Session. The fi rst-place fi nishers in each category receive cash awards and an invitation to write an abstract of their work to appear in the Journal of the California Dental Association.

SCIENTIFIC STUDENT WINNERS

The CDA Foundation replication and survival, to the detriment awarded a $1,000 of infected tissues. It has been postulated scholarship to the recent that mesenchymal infection is the critical winners of the Dental Assisting Student Table step in disrupting organogenesis. If so, Clinic Competition. organogenesis dependent on epithelial- Supporting promising mesenchymal interactions would be students is crucial to particularly vulnerable. In this study, we developing a competent chose to model the vulnerability by inves- work force and, therefore, the CDA Foundation is tigating the cell and molecular pathogen- committ ed to sponsoring esis of CMV infected mouse embryonic this scholarship. Ultradent submandibular salivary glands, SMGs. Products, Inc., was the METHODS: We infected E5 SMG sponsor of the table explants with mouse CMV (mCMV) clinics. Following are the winners of the 2007 table for 24 hours and cultured them clinic competition. Dr. Ron Mead, CDA Cytomegalovirus-induced in the presence or absence of ac- president, and Judy Embryopathology: Mouse tive infection for up to 2 days. Photos by Charr Crail Durrant of Ultradent Submandibular Salivary Gland RESULTS: We infected E5 SMG Products fl ank a beaming Epithelial-Mesenchymal Ontogeny explants with mouse CMV (mCMV). An online application for University of Southern the 2008 Table Clinic California dental student as a Model Active infection for up to 2 days in competition will be George Abichaker, winner Michael Melnick, George Abichaker, vitro resulted in a remarkable cell and available Oct. 1 at cda.org. in the scientifi c category Tina Jaskoll, University of Southern molecular pathology characterized of the annual table clinics California School of Dentistry; Edward by atypical ductal epithelial hyperpla- competition held during S. Mocarski, Stanford University School sia, apparent epitheliomesenchymal the 2007 Spring Session in Anaheim. of Medicine transformation, oncocytic-like stromal PURPOSE: Human studies suggest, metaplasia, β-catenin nuclear localiza- and mouse models clearly demonstrate, tion, and upregulation of Nfkb2, Relb, Il6, that cytomegalovirus, CMV, is dysmor- Stat3, and Cox2. Rescue with an antivi- phic to early organ and tissue develop- ral nucleoside analogue indicated that ment. CMV has a particular tropism for mCMV replication is necessary to initiate embryonic salivary gland and other head and maintain SMG dysmorphogenesis. mesenchyme. CMV has evolved to co-opt CONCLUSION: mCMV infection of cell signaling networks so to optimize embryonic mouse explants resulted in

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dysplasia, metaplasia, and, possibly, transformed SMG cells and the surround- anaplasia. The molecular pathogenesis ing extracellular matrix, resulting in the appeared to center around the activation nuclear translocation of β-catenin. From of canonical and, perhaps more impor- these studies, a tentative framework has tantly, noncanonical NFκB. Further, emerged within which additional studies COX-2 and IL-6 are important down- may be planned and performed. stream effectors of embryopathology. At the cellular level, there appeared to be a TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE consequential interplay between the CONTACT George Abichaker at [email protected].

CLINICAL STUDENT WINNERS education Web site (Blackboard). Pre- and post-tests were given on Blackboard to the Loma Linda University School of Den- tistry dental class of 2008. The post-test was only made available after the student had studied the online reference guide. RESULTS: A paired-t test at a signifi- cance level of α=0.05 showed that the post-test performance was significantly higher than the pretest, with p < 0.000. The median pretest score was 6 out of 0, and the median post-test score was 8. The percentage of students whose scores improved was 7.7 percent. CONCLUSION: Our reference guide, Loma Linda University Treatment of Common Oral Conditions Treatment of Common Oral Conditions, dental students Audrey Natalie Cochran, Audrey Mojica, Loma assisted students in accessing perti- Mojica and Natalie Cochran graciously accept Linda University School of Dentistry nent treatment information, produc- their first-place award for ABSTRACT: Common oral conditions ing a statistically significant improve- the clinical category. They are often diagnosed but left untreated ment in their test performance. are joined by Judy Durrant due to confusion and uncertainty about and Dr. Ron Mead. proper treatment. The purpose of our TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE CONTACT Natalie Cochran at [email protected] or Audrey project was to provide a concise and infor- Mojica at [email protected]. mative reference guide covering treat- ment options of common oral conditions for students and dental professionals. MATERIALS AND METHODS: Using clini- cal photos, courtesy of Dr. Susan Rich- ards, and an Apple Computer with iPhoto software, we created a reference guide in an iPhoto book format. The book was published by Apple, as well as published online in pdf format through our school’s

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RDA STUDENT WINNERS

Do You Want Your Child to Have a Brighter Smile and a Brighter Future? It All Begins at Birth! Yun Hee Chung, Sandra P. Ayala, Whitney V. Iosua, Olivia Bugarin, Ha- cienda La Puente Adult Education PURPOSE: The purpose of this pre- sentation is to increase the awareness of bacterial transmission from mothers to infants. As dental assistants, we have a diluted to 9 ml of sterile saline water, and Drs. Anthony Perez and responsibility to educate patients about it was divided into three different test Bruce Toy (far left and far the transfer of their saliva to their babies. tubes: one was control, another was for right) take a moment with RDA student winners MATERIALS AND METHODS: We gathered three drops of xylitol, and the other was Sandra P. Ayala, Olivia various articles and literature from the for six drops of xylitol. When a bacterial Bugarin, Yun Hee Chung, Journal of the California Dental Association culture was mixed with six drops of xylitol and Whitney V. Iosua of and pediatric dentistry journals. We extract, it showed significant inhibition of Hacienda La Puente discussed how the bacteria are transferred bacterial growth compared to three drops Adult Education. from mothers to their babies. Also, we of xylitol extract grown at the same period discussed how we can prevent and improve of time. The result indicated that when through patient education. We spoke to a proper amount of xylitol is consumed, pregnant women and mothers of infants recommended 6~0g of xylitol per day, from the class and explained to them xylitol helps to prevent the bacterial how they could transmit bacteria to their transmission from mothers to infants. babies. They realized the damage this action CONCLUSION: Dental caries is an infec- created and they wanted to correct their tious and transmissible disease that is behaviors. In addition, we suggested seeing caused by bacteria, mutans streptococci. their dentist during the pregnancy to start However, not many mothers and soon-to- antibacterial salivary treatment earlier so be mothers are aware of this information. they can prevent bacterial transmission. We We emphasized how important it is to produced an exemplary clinical brochure educate all mothers. We, as dental assis- that has brief information on treatments tants, need to inform our patients about and explanation of bacterial transmission. available treatments so they can prevent The mothers thought it was informa- transferring bacteria to their babies. tive and useful. There are three ways of SUGGESTION: We felt there is a lack treatment for mothers with high level of of communication between the medi- mutans streptococci: fluoride varnish, cal and dental professional. We would chlorhexadine mouthrinse, and xylitol. like to promote that the medical and Considering cost, time, and patient compli- dental professionals work together in ance, we thought chewing gum containing the future for the benefit of the patient, xylitol has the most potential. We ran a including the combination of the diag- mini-experiment to see the effectiveness nostic process becoming a team effort. of chewing gums that contained xylitol. EXPERIMENT: We prepared xylitol TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE CONTACT Yun Hee Chung at withdear@hotmail. extract from xylitol gum; 6g of xylitol was extracted to 20 ml of sterile saline water. A colony of saliva bacterial culture was

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RDH STUDENT WINNERS

for a complete comparison of all probes against each manufacturer to determine differences. The amount of pressure was standardized with a less than 2 percent variation between examiners. Data was analyzed using a Winks statistic soft- ware program. Probes were measured for variations in size and weight. RESULTS: Data analysis determined Jamie Davidson (far left) Probing Into Manufacturers’ differences from manufacturer to manu- and Candace Barclay Differences facturer were not statistically signifi- (holding blue ribbon) of Jamie Davidson and Candace Barclay, cant; however, individual comparisons Cypress College are all smiles with Judy Durrant Cypress College determined slight variances in readings and Dr. Ron Mead after the BACKGROUND: To determine the from manufacturer to manufacturer. announcement that the calibration and manufacturers’ dif- CONCLUSION: Results of the study de- students had won in their ferences of manual probes. termined a difference exists between man- category. METHODS: Six variations of periodon- ufacturers of periodontal probes. Data tal probes were obtained from different supported the need for a standardized manufacturers. Probes shared the 3, 6, probe for dentistry, millimeters are crucial 9, 2 design. A single blind study was in disease assessment and progression. conducted, N=24. First molars were TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE probed then re-probed after 30 minutes. CONTACT Jamie Davidson, P.O. Box 1658, La Mirada, Calif., Random selection of the probes allowed 90637.

MILITARY PEER-VOTE WINNERS (There was a three-way tie in the peer-voting competition; however, only one abstract was provided to the Journal.)

Immediate Loaded Implants Vinh T. Ton, DDS, LT, DC, United States Navy BACKGROUND: As dental implants become the standard of care, there has been a tremendous increase in implant treatment. Two-stage surgical implant or delayed loaded implant, DLI, protocol for “loaded free and submerged healing” was designed to maximize predictability of osseointegration. However, discomfort, inconvenience, and anxiety related to Vinh T. Ton, DDS, is shown healing time associated with this tech- with his winning entry, “Immediate Loaded nique, DLI continues to be a challenge for Implants,” in the military both the patient and the clinician. Single- peer-voting category. stage or immediate-loaded implant, ILI, protocol is designed to reduce the steps

614 SEPTEMBER 2007 CDA JOURNAL, VOL 35, N º 9

Following are the other two Military Peer-Vote winners:

Resin Modified and length of treatment time and pared to DLI. Bone quality, quantity, and Glass Ionomer, ultimately eliminate some of these bone morphology of bone to implant Resin Composite, challenges. contact postosseointegration are found Sandwich PURPOSES: The purpose of this to be similar in both ILI and DLI. Technique table clinic was to review the success CONCLUSION: This review of the litera- Spencer Wirig, DMD rate of ILI versus DLI, and discuss ture supports the use of the ILI technique the surgical, implant, host, and occlu- due to similar clinical and statistical suc- Restoring a Tooth sion-related factors that may influence cess rates between ILI and DLI. Bone and With External outcome of ILI treatment modality. quantity around ILI are found to be simi- Resorption MATERIAL AND METHODS: Review lar to those found in DLI. No significant Christopher of the literature was limited to hu- clinical difference of crestal bone loss be- Stewart, DDS man studies over the past 25 years. tween ILI and DLI were noted. Solid initial Data was organized in a table format stability of implants is considered to be to demonstrate the differences be- the most important criteria for achieving tween the success rates of ILI versus ILI success. A meticulous case selection DLI, and address factors that have a is necessary to integrate ILI treatment significant impact on implant success; modality into daily practice. Importantly, especially important in ILI treatment. surgical, host, occlusion, and implant-re- RESULTS: The success rate of ILI is lated factors should be carefully studied clinically and statistically similar to those and analyzed prior to starting treatment. found in DLI. Regardless of implant TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE type, surface coating, and design, ILI CONTACT Vinh T. Ton, DDS, LT, DC, USN 1st DenBn/NDC has similarity success rate when com- Camp Pendleton, Calif., 92055.

Socket Preservation: An Overview of MILITARY PUBLIC-VOTE WINNERS the Indications, Benefits and Tech- niques of Preserving Alveolar Bone After Tooth Extraction Alfonso Navarrete, DDS, and Matthew Burke, DDS, Veterans Administration Northern California Health Care System, general practice residency, Mare Island, Calif. OBJECTIVES: A review of the gen- eral principles, techniques, materi- als, and indications for socket pres- ervation after tooth extraction. METHODS: A literature review was conducted and specialists were consulted. RESULTS: Tooth extraction may result in alveolar ridge resorption or collapse. As part of the informed consent process, the goal of preserving bone volume for Drs. Gary Ackerman, far it is important that the potential sequella future treatment should be considered. left, and Dennis Shinbori, far right, congratulate to the surgical procedure be thoroughly There is a 25 percent decrease in width Drs. Matthew Burke and reviewed with the patient. As part of of alveolar bone in the first year and Alfonso Navarette for their this discussion, socket preservation with a 40 percent to 60 percent decrease in first-place table clinic.

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TABLE 1 Grafting Materials Osteogenesis Osteoinductive Osteoconductive Autograft Yes Yes Yes Allograft No Yes/No Yes Xenograft No No Yes the material used and is critical for the clinician to understand. Ideal charac- Alloplast No No Yes teristics of graft material are its ability to form bone and induce bone forma- width in two to three years’ postextrac- tion. Osteogenesis is the formation of tion.2-5 After multiple extractions, there new bone by cells contained in the graft. is a 4 mm decrease in height of alveolar Osteoinduction is a biochemical process bone.4,5 Th is bone loss experienced after by which molecules contained in the tooth extraction can have undesirable graft convert the neighboring cells into esthetic, hygienic, and prosthetic results. osteoblasts. Osteoconduction is the physi- Due to potential undesirable results cal eff ect by which the matrix of the graft postextraction, patients should be educat- forms a scaff old that favors outside cells ed about the indications for pocket pres- to penetrate the graft and form new bone. ervation. Indications include, but are not CONCLUSION: Key factors for suc- limited to ) prevention of or reduction of cess include proper diagnosis, treatment bone resorption postextraction; 2) pres- planning, careful extraction technique, ervation of bone contour and volume; 3) utilizing the appropriate materials and provide adequate bone for future implant methods for the patient and postop- placement; 4) maintain soft tissue esthet- erative follow-up. When extractions ics; and 5) help with the maintenance of are being considered, patients should the adjacent tooth periodontal status. be given the appropriate informa- Extraction site management includes tion to make an informed decision atraumatic tooth extraction, asepsis, and part of this would be to present removal of all granulation tissue, the possibility of socket preservation evaluation of remaining bony walls, to minimize potential bone loss and ensuring adequate blood supply, choos- optimize the area for future treatment. ing the appropriate grafting materials, soft tissue closure, and allowing for REFERENCES  1. Tischler M, Misch CE, Extraction site bone graft ing in general adequate healing time. dentistry: review of applications and principles. Dent Today Th e decision to utilize grafting 23(5):108-13, May 2004. material presents many choices to the 2. Carlsson G, Persson G, Morphologic changes of the man- dible aft er extraction and wearing of dentures. A longitudinal clinician. Autografts are taken from the clinical and x-ray cephalometric study covering 5 years. Odont patient’s own body, either from extraoral Revy 18(1):27-54, 1967. or intraoral harvest sites. Allografts are 3. Misch CE, What you don’t know can hurt you (and your patients). Dent Today 19(12):70-3, December 2000. obtained from members of the same 4. Misch CE, Contemporary Implant Dentistry, second ed., St. species (TABLE 1). Louis: Mosby Inc., 455-64, 1999. Xenografts are from a diff erent species 5. Christensen GJ, Ridge preservation: why not? J Am Dent Assoc 127(5):669-70, May 1996. such as porcine or bovine. Alloplasts are synthetic materials such as ceramics or TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE bioglass. CONTACT Matt hew Burke, DDS, at matt [email protected]. Graft selection criteria should include the following: biologic availability, pre- dictability, clinical feasibility, minimal operative hazards, minimal postopera- tive sequelae, and patient acceptance. Graft potential varies depending on

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Disparities in Children’s Oral Health and Access to Care

LESA PAIGE BENTLEY, MHA, MBA, MBIT

ABSTRACT The oral health of Americans has improved in recent years, yet considerable gaps in the provision of dental care remain according to the U.S. Surgeon General’s Report in 2000. This paper provides an overview of oral health disparities experienced by racial and ethnic minority children based upon the socioeconomic status. Many Americans, particularly children, continue to suffer disproportionately from oral pain and disease, including minority, low-income, and/or special care populations.

AUTHOR he oral health of Americans ter of the children had untreated tooth has improved in recent years, decay; and some 4 percent of the kids Lesa Paige Bentley, MHA, MBA, MBIT, is a dental com- yet considerable gaps in the were sitting in the classroom in pain or pliance manager for Aetna, provision of dental care re- suffering from an abscess. The problem Inc., managing the western main, according to the U.S. Sur- is worse for the poor, Hispanics, other dental territory for all Tgeon General’s Report in 2000. The report ethnic minorities, and for the uninsured. regulatory matters. states that oral health is essential to the Barriers to dental care, including parental general health and well-being of all Ameri- financial difficulties or a lack of dental cans. There is a silent epidemic of oral insurance, can have a profound impact diseases affecting our most vulnerable cit- on their children’s dental health. About izens: poor children, the elderly, and many one-third of low-income children have members of racial and ethnic minority untreated decay compared to about groups. The report served as a wake-up one-fifth of higher income children. call against this silence and a call to action Oral diseases are cumulative and for health professionals, policymakers, progressive over time and can affect lives community leaders, insurance compa- in many ways. Oral diseases can limit the nies, the public and private business. foods one eats, affects one’s appearance, During the 2004-2005 school year, and cause significant pain and discom- the Dental Health Foundation surveyed fort. Oral health is also an integral part of more than 2,000 California children overall health and may lead to systemic in kindergarten or third grade in nearly diseases. One such disease, periodontal 200 randomly selected schools located disease, is caused by bacterial growth across the state.2 They found that by the that forms dental plaque. When plaque is third grade, more than 70 percent of the not completely removed on a daily basis, children had a history of tooth decay; at calculus forms and causes the symptoms any given moment, more than a quar- associated with periodontal disease.

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Chronic bronchitis 4.2

embarrassment of the appearance of Hay fever 8.0 flawed teeth, difficulty chewing or eating comfortably, and may be hindered from participating fully in typical childhood Asthma 11.1 activities. Prevalence increases with age. The majority (5.6 percent) of children age 5 to 9 had at least one carious lesion or filling in a primary or a permanent tooth.3 Caries 58.6 Despite progress in reducing den- tal caries, individuals in families living below the poverty level experience more 0 10 20 30 40 50 60 70 dental decay than those who are bet- ter off economically. Furthermore, the FIGURE 1. Dental caries 5-to 17-years-old. caries seen in these individuals is more Note: Data from the National Center for Health Statistics, 1996. likely to be untreated than caries in those living above the poverty level (FIGURE 2); 50 more than one-third (36.8 percent) of 45 poor children age 2 to 9 have one or more 43.6 40 untreated decayed primary teeth com- pared to 7.3 percent of nonpoor children. 35 36.8 34.4 In addition to poverty levels, the pro- 30 portion of teeth affected by dental caries 25 also varies by age and race or ethnicity. 23.4 Poor Mexican-American children age 2 20 to 9 have the highest number of primary 15 17.3 teeth affected by dental caries (a mean Percentage of people Percentage 10 11.3 of 2.4 decayed or filled teeth) compared 5 to poor non-Hispanic blacks (mean .5) and non-Hispanic whites (mean .9). 0 Among the nonpoor, Mexican-Ameri- Poor 2 to 9 5 to 17 18+ (permanent (primary teeth (primary and teeth only) can 2- to 9-year-olds have the highest Nonpoor only) permanent teeth) number of affected teeth (mean .8), followed by non-Hispanic blacks (mean Age .3) and non-Hispanic whites (mean .0).

FIGURE 2. Higher percentage of poor people untreated decayed tooth. There are also differences by race/eth- Note: Data from the National Center for Health Statistics, 1996. nicity and poverty level in the proportion of untreated decayed teeth for all age Periodontal bacteria may enter the blood- common among adults, but children are groups. Poor Mexican-American children stream to affect major organs and to stim- also at high risk for oral health prob- age 2 to 9 have the highest proportion of ulate new infections. Recent studies have lems. Dental caries by far is the most untreated decayed teeth (70.5 percent), shown a relationship between periodontal common chronic childhood disease followed by poor non-Hispanic black disease and low birth weight babies. – five times more common than asthma children (67.4 percent) (FIGURE 3). Non- Vulnerabilities to oral health may and seven times more common than poor children have lower proportions of be due to a variety of reasons includ- hay fever in children 5- to 7-years-old untreated decayed teeth, although the ing poor nutritional habits, inadequate (FIGURE 1). Children suffering from oral group with the lowest proportion (non- oral hygiene, or difficulties with access- health complications may be dealing Hispanic whites) still has an average of ing dental care. Oral disease is not only with persistent pain and/or abscesses, 37.3 percent of decayed teeth untreated.

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80

70 70.5 67.4 60 As it becomes more common knowl- 56.1 56.9 57.2 edge that oral health is an inseparable part 50 of general health, increasing emphasis 40 is being placed on addressing the issues 37.3 contributing to the poor oral health status 30 of the nation.4 According to the 200-2002 Report Card released by the collaborative 20 that are untreated per child effort of Oral Health America, the United 10 States received a national grade of C for Percentage of decayed primary teeth of decayed Percentage its status of oral health overall (TABLE 0 1). The report shows that policymakers Non-Hispanic Mexican Non-Hispanic need to place more emphasis on basic Poor Children Black American White oral health across the nation. Similarly, Nonpoor Children California received an overall grade of C. In addition, California was scored FIGURE 3. Poor children untreated decayed primary teeth. for availability of dentists, prevention Note: Data from the National Center for Health Statistics, 1996. programs, dental restorations, and pres- ence of a dental director. The availability ■ To increase the quantity of healthy Healthy People 200 initiative, estab- of dentists, for which California received living, lished goals for the current decade. The a C, showed a very high ratio of :,50- ■ To reduce health disparities among primary goals of Healthy People 200 are 2000. This grade for the availability of Americans, and to increase quality and years of healthy dentists is based on the ratio of profes- ■ To ensure access to preventive life, and eliminate health disparities. sionally active, licensed dentists to the services for the whole population. state’s population. Prevention, for which In a broad sense, the term health Recommendations California received an F, is based on the disparities refer to differences that ex- Accordingly, the Dental Health percentage of population in each state on ist among population subgroups and Foundation recommends that a means public water supplies receiving fluoridated their ability to access and receive quality to improve the socioeconomic status water. The presence of a dental director, health care. The National Institutes of of children in oral health and access to for which California received an F, is due Health has defined health disparities as care in California would be to develop to a lack of an individual in this position differences in the incidence, prevalence, a comprehensive oral health surveil- and of an oral health coalition in the state. mortality, and burden of diseases and lance system, eliminate barriers to care, In an effort to improve the health of other adverse health conditions that exist prevent disease, and establish an inte- all Americans, in 979, a national initia- among specific populations groups in grated public health infrastructure. tive was established that emphasized the United States. Disparities are com- DEVELOP A COMPREHENSIVE ORAL HEALTH coordinated and comprehensive activities monly observed among ethnic groups. SURVEILLANCE SYSTEM. At this time, Cali- in health prevention. The foundation of Minorities and persons living in rural fornia lacks any mechanism to regularly this effort was the Oral Health in America: communities suffer from higher mortal- and systematically collect data on the oral A Report of the Surgeon General in 2000, ity rates from cancer, heart disease, and health status of individuals or the avail- Healthy People and Healthy People 2000: diabetes than whites, and are less likely to ability of oral health services. Decision- National Health Promotion and Disease receive diagnostic tests and treatments. makers must have current and reliable Prevention Objectives, which resulted Two decades after the Healthy People information to establish relevant policies from the collaboration of government, and Healthy People 2000 report was an- and programs and evaluate their success. voluntary, and professional organiza- nounced, the surgeon general issued a call California needs a system to regularly as- tions, businesses, and individuals. This to action specifically to address oral health sess oral health status and services. Such report established a set of overall health care needs and disparities within the U.S. a system would require local county as- objectives for the nation. Three major population. Concurrently, the U.S. De- sessments of the oral health status, needs, goals were established for the 990s: partment of Health and Human Services, and available resources for care for chil-

SEPTEMBER 2007 621 TABLE 1 State Final Grades 2001–2002

PREVENTIONFluoridation Sealants ACCESS TOAvailability CAREdentists of Children’sdental medical programVisits– income to dentists Visits<15K– income to dentists >15KOverall visitsDental– adults insuranceDental– elderly insuranceORALLEADERSHIP HEALTHDental directorOralcoalition health ORALSTATUS HEALTHOralof health childrenUse tobaccoof spit Edentulous– income elderly Edentulous<15K– income elderly Edentulous>15Koverall elderlyOral cancer Oralmale cancer femaleSTATE GRADE ALABAMA B B B D+ D C F B C C F A A A C A D D B C C B C

ALASKA D D D C+ B C F B B A C B C A C C D C B B B C C

ARIZONA F D F C- F C D B C B D A A A B A B B B B B B C+

ARKANSAS D D D D F C F C C D F A A A C A C F B C C B C-

CALIFORNIA F F D C C C D B B B C D- F D B- C B C A B B B C

COLORADO C C C C- C C D B B I F A A A C+ A D D B B B B C+

CONNECTICUT C+ B C C+ B C C A B I F B C A B A B B B B B B B-

DELAWARE C B D C- D D D B B I I B+ A B C+ C B C B B C B C+

DISTRICT OF COLUMBIA C A F C+ A D C B B I I F F DNR C- DNR B D B B F D C

FLORIDA C D B C- D C D B B I F A A A C+ C B C A B C C C+

GEORGIA C A F D+ F D F B C A F A A A C B D D B C C B C

HAWAII D F D B- B C C B B A B A A A B A B C A B C B B-

IDAHO C F A D+ D I D B C C F A A A C+ A D D B B B B C

ILLINOIS B A C C C C D B B B F A A A C+ B C C B B C B C+

INDIANA B A C C- D C D B B B F A A A C+ A C D C C B B C+

IOWA B+ A B C- C C D B B C F A A A B- A C C B B B B B-

KANSAS C D B D+ D I D B B I F C F A C F C C B B B B C

KENTUCKY C A F C- C B F B C I F A A A C A D D C D C B C

LOUISIANA D+ D C D+ D C F B C I F C F A C A C D B C C C C-

MAINE C+ C B D+ D I D B B D F B C A C+ A B F C C B B C

MARYLAND C+ A D C- C D D B B I D A A A C+ A B D B B C C C+

MASSACHUSETTS D D D C B B C B B C F D+ C D C+ F B C B B B B C

MICHIGAN B A C C C C D A B I D C+ A D C+ C C D B B B B C+

MINNESOTA C A F C C C D B B I I A A A C+ C C D B B B B C+

MISSISSIPPI F F F D F C F C C I F B C A C+ A C C C C C B C-

MISSOURI D+ B F D D D F C C I F A A A C+ A C F B C B B C

MONTANA D+ F B D+ C C D C C D F A A A C- C F D B C B C C-

NEBRASKA D C F C C B C B B I F A A A C D D F B C B A C

NEVADA C+ C B D+ F C D C C I D B C A B- A C D A B B B C

NEW HAMPSHIRE F F D C C I C B B I F A A A C+ A B D B B C C C

NEW JERSEY F F D C- B D D B B I F B C A C+ F C C A B B B C

NEW MEXICO C+ C B D+ F C D B C I F A A A C+ A C D B C B B C

NEW YORK C C C C B I D B B B F A C A B- B B D B B B B C+

NORTH CAROLINA C+ B C C- F C D B B I I A A A C+ A C D B B C B C+

NORTH DAKOTA B+ A B D D D D B C D F B C A C A D F C D B B C

OHIO B B B C- C C D B B C F B A C B- A C D B B B B C+

OKLAHOMA D+ C D D D D F C C I F A A A C A D F C C B B C-

OREGON D F C C C C D B B B F A A A B- A C C B B B C C+

PENNSYLVANIA D+ D C C- C C D B B I F A A A C A D D C C B B C

RHODE ISLAND B B B C C C C B B B F A A A C+ C B D B B B B C+

SOUTH CAROLINA A A A C- F C D B B I I A A A C- C C D B C D C C+

SOUTH DAKOTA B B B D+ D I D B C I F F F F C+ A D D B C B B C-

TENNESSEE C A F C- D C D B B I F A A DNR C DNR D F B B C B C

TEXAS D+ C D D D I F C C C F A A A B A C B A B C B C

UTAH C F A C C D C B B B F A A A B A B C B B A A B-

VERMONT C D B C C B C B B C F A A A C+ B C D B B B B C+

VIRGINIA B+ A B C C C D B B B F A A A C+ A I F B C C B C+

WASHINGTON C D B C C I D B B B F B C A B- A C D B B B B C+

WEST VIRGINIA B B B D D C F C C I F B C A C A D F C D B B C-

WISCONSIN C+ B C C C C D B B B F A A A C+ B D C B B B B C+

WYOMING C F A D+ D C D C C C F B C A C+ A D F B B A B C

UNITED STATES C C- B+ C+ C

Data from the Oral Health America, 2001. 622 SEPTEMBER 2007 CDA JOURNAL, VOL 35, N º 9

dren in preschool through high school to measures. Increase, to at least 25 percent, centers and public health facilities alone be conducted every five years. In addition, the number of preschool children served are able to provide a sufficient safety net statewide assessment of oral health status by existing programs that receive fluoride as a majority of dentists do not partici- of preschool and school-aged children varnish applications and other preven- pate in Medicaid. Children who come needs to be conducted every five years. tive services. Increase funding for state from low-income families are the ones ELIMINATE BARRIERS TO CARE. People prevention programs to add more schools, who are suffering from poor oral health fail to receive good oral health care for more grades, special education programs, and inadequate access to care as a result a number of reasons including: a lack of and to provide more resources for local of their socioeconomic status. The public, resources (insurance or money) avail- preventive programs and expansion of policymakers, and medical providers able for care; limited appreciation for preschool preventive activities. Fund den- consider oral health to be less important the importance of oral health; and little tal sealant programs and other preventive than other health needs. Barriers con- information about publicly funded pro- services in existing school-based/school- tinue to exist for children, dental disease grams. In addition, reimbursement rates linked programs, and develop new preven- is still prevalent in the United States, and for providers through California’s public tive programs at community clinics and we have fewer dentists graduating from dental insurance programs are signifi- migrant health centers. Conduct a seal dental school to provide essential cantly lower than most states and insuf- promotion campaign directed at both the preventive and restorative services. In ficient to attract any significant participa- public and dental professionals. Increase order to reverse these trends, we need to tion by most private providers. Expand financial support for capital, operations, mobilize resources, including public and programs to inform Medi-Cal, Healthy and maintenance costs of community private oral health care providers. Families and Children’s Health Initia- water fluoridation. Build the science base tive enrollees about their dental benefits by encouraging more research aimed at REFERENCES 1. U.S. Department of Health and Human Services, Oral health and the importance of early and peri- prevention and elimination of the disease. in America: A report of the surgeon general — full report. odic dental visits to prevent oral disease. ESTABLISH AN INTEGRATED PUBLIC HEALTH Rockville, Md.: U.S. Department of Health and Human Ser- Provide financial incentives to medical INFRASTRUCTURE. California lacks a suf- vices, National Institute of Dental and Craniofacial Research, National Institutes of Health, April 2000. http://www.nidcr.nih. and dental professionals to provide early ficient public health infrastructure to gov/AboutNIDCR/SurgeonGeneral/ExecutiveSummary.htm. preventive care, including counseling, meet the oral health needs of its resi- (Accessed July 12, 2007.) risk assessment, and preventive dental dents, including an adequate dental work 2. Dental Health Foundation, Mommy, it hurts to chew: The California smile survey an oral health assessment of Califor- procedures. Increase payments for preven- force focused on serving the public. This nia’s kindergarten and third-grade children, Oakland: California tive services to providers who receive requires California to create and maintain Department of Health Services, Office of Oral Health, Oral training on early childhood oral health. a state dental director position. Provide Health Access Council, 2006. 3. U.S. Department of Health and Human Services. Summary PREVENT DISEASE. Dental decay is adequate authority and resources to en- of surveys and data systems. Hyattsville, Md.: Center for largely preventable if appropriate pre- able the director to advance policies and Disease Control and Prevention, 1996. http://www.cdc.gov/ ventive measures are taken at an early programs that improve oral health status nchs/data/NCHS_Survey_Matrix.pdf. (Accessed July 12, 2007.) 4. Oral Health America, filling the gaps. Rockville, Md.: U.S. age. These measures include early care while integrating oral health to overall Department of Health and Human Services, National Institute by a dentist. Proven preventive dental health. Grow the public dental health. of Dental and Craniofacial Research, National Institutes of services such as dental sealants, fluoride Health, 2001. http://oralhealthamerica.org/pdf/2001-2002Re- portCard.pdf. (Accessed July 12, 2007.) varnishes, and the fluoridation of com- Conclusion munity water supplies are effective but Despite progress, large gaps remain. TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE are underutilized. Funding for research However, many Americans, particularly CONTACT Lesa Paige Bentley, MHA, MBA, MBIT, P.O. Box 11365, Glendale, Calif., 91226. aimed at preventing or eliminating the children, continue to suffer disproportion- disease is limited. Every child should ately from oral pain and disease, including have a dental examination and necessary minority, low-income, and/or special care treatment by kindergarten. Require all populations. A growing number of dental insurance and managed care plans children are also facing difficulties in to provide coverage for dental sealants accessing care, as states cut Medicaid and other scientifically proven preventive dental benefits. Community health

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Simplifying Endodontics With EndoSequence Rotary Instrumentation

GREGORI M. KURTZMAN, DDS, MAGD

ABSTRACT Recent advances in endodontic instrumentation have simplified the treatment process and improved long-term success. Ten years ago the vast majority of endodontic instrumentation was being performed with hand files and reamers. Today, most practitioners providing endodontic therapy are utilizing rotary instrumentation.

AUTHOR DISCLOSURE otary instruments have nEndo), also significantly increase the Gregori M. Kurtzman, DDS, Dr. Kurtzman has been allowed the instrumenta- percentage of contact within the canal MAGD, is in private general provided honoraria tion process to become wall and subsequently increase lateral practice in Silver Spring, for lecturing on easier and more produc- resistance (FIGURE 1). The greater the file’s Md., and is a former EndoSequence and has assistant clinical participated in funded tive. The introduction of lateral resistance, the greater the torque professor at the University research on Resilon/ Rgreater taper instruments has allowed required to instrument the canal. In- of Maryland School, Epiphany. the practitioner to “mill” the canals creasing the lateral resistance of a nickel Baltimore College of thereby creating shapes that are easier titanium file will increase the torque Dental Surgery, to obturate. As a result of improved requirement, making the file less efficient. Department of Endodontics, Prosthetics technology, file breakage has decreased Radial lands that increase the stiffness and Operative Dentistry. and cutting efficiency has increased along of a file decrease its flexibility in curved He earned diplomat status with improvements in file flexibility. canals. Files with essentially triangular in the International cores (e.g., ProTaper file, Dentsply Tulsa) Congress of Oral Rotary NiTi Endodontic Files will have greater flexibility than those Implantologists. In contrast to stainless steel hand with wide radial lands (K3), but may files, nickel titanium endodontic files transport the canal if they lack a cen- are not formed by twisting, but from tering device. Furthermore, those files grinding a blank. The design of the blank with a constant pitch (e.g., Profile from will influence a file’s flexibility and how Dentsply Tulsa) have a tendency to create much lateral resistance is generated when “suck-down,” particularly in larger sizes. the file is working within the canal. File Suck-down refers to the tendency of the designs that incorporate radial lands, in file to be pulled apically as it engages the an attempt to reinforce the cross sec- canal walls. File manufacturers have incor- tion of the file, and thereby decrease porated variable pitch and variable helical file separation (e.g., K3 file from Sybro- angles in an attempt to reduce suck-down.

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FIGURE 2. Comparison of a file with constant helical angle (top) and one with variable helical angle (bottom).

FIGURE 3. Graphic representation of an FIGURE 1. Graphic image demonstrating a file elliptical tear that may occur apically with a file with lands and its contact with the canal walls. that has a cutting tip.

FIGURE 4. Graphical representation of alternating However, as file speed increases, there contact point between the file is a decrease in time to cyclic failure and canal. and consequently, the files cannot be used as many times before cyclic fa- tigue is encountered and instrument separation results. Files of any design run at low speed (50 rpm to 75 rpm) have an increased tendency for instru- ment separation. This results because the files efficiency is decreased and the practitioner tends to apply greater api- cal pressure to get the file to advance. FIGURE 5. SEM demonstrating the noncutting tip of the EndoSequence file. EndoSequence Files The EndoSequence file (Real World Endo, Brasseler USA, Savannah, Ga.) addresses the concerns of previous Pitch is defined as the number of bris coronally out of the canal (FIGURE 2). file design by creating an efficient, spirals or flutes per unit length on the File tip design can be either cutting safe file with a short learning curve file. The larger the number of spirals on or noncutting. Cutting tips can lead that allows the practitioner to create a file, the greater the file’s resistance. The to transportation of the canal in less well-instrumented (milled) canals.,2 lower the resistance, the more efficient experienced hands. Additionally, should The file design employed by the the file and the smoother the instrumen- a cutting tip pass through the apex an EndoSequence instrument provides for tation process. Consequently, a reamer elliptical orifice may be created, mak- alternating contact points, ACP, along the design (triangular blank) will result in ing apical sealing more difficult (FIGURE instrument’s cutting length (FIGURE 4). a more efficient cutting instrument. 3). A noncutting tip is less aggressive The use of ACP allows the file to remain As previously mentioned, a variable and less likely to transport the canal. centered in the canal, while simultane- pitch file will decrease the tendency for Should the noncutting tip be passed ously reducing the torque requirements. suck-down, especially in files that are .06 longer than the working length (through The lack of radial lands provide a sharper taper or greater. Helical angles, defined the apex) a round orifice is more likely instrument as a result of a decreased as the angle where the flutes intersect created, which is easier to seal. thickness of metal, thereby providing the long axis of the file, determine debris Rotary speed is dependent on the a more flexible file. This is true even removal as the file moves apically. Con- torque requirements of the file system. in the greater tapers. Combined with stant helical angles may lead to debris As the torque requirement is decreased, a precision tip, the alternating contact accumulation, which increases torque file speed can be increased. The greater points provide an efficient instrument demand and can lead to file separation. the speed, the more efficient and the that will not transport the canal. Variable helical angles aid in moving de- smoother the file works in the canal. In addition to its unique ACP design,

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FIGURE 6a. SEM of file. Rough surface following FIGURE 6b. Surface following traditional polishing. FIGURE 6c. Surface following electropolishing. grinding.

FIGURE 7. Representa- FIGURE 8. The EndoSequence tion of the file contents Expeditor file. of the small, medium, and large EndoSequence file packs.

FIGURE 10. Maxillary lateral incisor (No. 7) instrumented with a medium EndoSequence pack. Final size was a 40/.06.

FIGURE 9. Maxillary first premolar (No. 5) instru- FIGURE 11. Mandibular second pre- mented with a small EndoSequence pack. Final size molar (No. 20) instrumented with a large for both buccal and lingual canals was a 30/.06. EndoSequence pack. Final size was 50/.06.

the EndoSequence file takes advantage nickel titanium endodontic instruments, its mirror-like finish that remains sharper of a precision tip. A precision tip is leaves microcracks in the metal that may longer and stays cleaner during use. defined as a noncutting tip that becomes propagate into fractures when the instru- In addition to its use of ACPs and lack fully engaged  mm from the tip (D-). ment is subjected to stress (FIGURE 6A). of radial lands, the EndoSequence file (FIGURE 5). This design allows the instru- Electropolishing removes the greatest utilizes variable pitch and variable helical ment to be both safe and efficient. majority of these microimperfections angles. As a result of these improved Metal treatment has long been and produces a sharper instrument with design features that reduce the torque ignored in dental applications. Recent increased cutting efficiency (FIGURES 6B, requirements, an increased rate of speed research has shown that the grind- C). The EndoSequence file undergoes (600 rpm) may be used with the EndoSe- ing process used in the fabrication of electropolishing and the result is visible in quence file. The increased rate of speed

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will result in greater tactile awareness. medium, and large) (FIGURE 7). An initial with variable pitch and helical angles, the The ideal range for the EndoSequence rotary instrument called an “Expeditor” result is greater file control that helps file is between 500 rpm and 600 rpm. is included with the system to assist in achieve precision-based endodontics. Should an audible clicking noise be determining the initial canal diameter and Endodontics has begun to take heard during instrumentation, this is which EndoSequence package to open. advantage of the scientific improvements an indication too much apical pressure The Expeditor is a size-27 file, with a touching other aspects of dental care. is being applied to the file and is not .04 taper and is 2 mm long (FIGURE 8). Precision-based instrumentation allows an indication of excessive revolutions After coronal patency has been confirmed the practitioner to create constant tapered per minute. This sound is common for with a hand file, the Expeditor is intro- shapes making obturation easier and files with a triangular cross section. duced into the canal and taken to initial more predictable. Treatment predictability The EndoSequence file system is engagement. If engagement is met within from precision-based instrumentation has available in both .04 (size 5-60) and .06 the apical half of the Expeditor’s cutting allowed a leap forward in how we provide (size 5-50) taper instruments, in lengths shank, the EndoSequence package opened endodontic therapy. of 2, 25, and 3 mm instruments. It will be a “small.” Should the Expeditor is also available in both single instru- advance to about the midway point before REFERENCES 1. Koch K, Brave D, The EndoSequence file: a guide to clinical ment packs and procedural packs (small, engagement is met, then a “medium” use. Compend Contin Educ Dent 25(10A):811-3, October 2004. package is selected and the initial file used 2. Koch K, Brave D, Endodontic synchronicity. Compend Contin in a crown down manner will be a size Educ Dent 26(3):218, 220-4, March 2005. 40. If the Expeditor does not meet any engagement, or is loose at full insertion, TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE CONTACT [email protected]. then a “large” package is utilized. The files are available in packs of individual sizes or as small (5-20-25-30); medium (25-30- 35-40); and large (35-40-45-50) packs. Precision instrumentation can be accomplished selecting which EndoSe- quence instrument pack is appropriate for that canal, based on the initial fit of the Expeditor. The canal is then en- larged using four sequential files, creat- ing a shape to the canal that will allow thorough obturation (FIGURES 9-11).

Conclusion Scientific advances in both file design and obturation materials have greatly improved the long-term success of end- odontics. The EndoSequence file system has taken advantage of electropolishing, which has been used historically in both precision medical instruments, and in high-end machining. The result is a sharper, more efficient instrument. Lat- eral resistance is also decreased with the EndoSequence file by use of its unique al- ternating contact point design. Combined

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Dental Anatomical Anomalies in Asians and Pacific Islanders

CHARLES E. JEROME, DDS, AND ROBERT J. HANLON, JR., DMD

ABSTRACT Dental anatomical anomalies having a signifi cant impact on endodontic diagnosis and treatment are the talon cusp, tuberculated premolars, three-rooted mandibular molars, and C-shaped molars. Asian and Pacifi c Islander ethnic groups have the highest percentage of these dental anatomical anomalies compared to the general population. As the population of Asians and Pacifi c Islanders continues to grow in California and other western states, dentists should be aware of the diagnostic and treatment complexities associated with specifi c patient groups.

AUTHORS ll races and ethnic groups tion. Fifty-one percent of that total

Charles E. Jerome, DDS, is Robert J. Hanlon, Jr., have some degree of dental population resides in the western United a former career U.S. Navy DMD, is a member of the anatomical variation. States that includes Alaska, Arizona, Dental Corps endodon- Executive Committ ee of Groups that have the most California, Colorado, Hawaii, Idaho, tic consultant and is a the San Diego County varied dental anatomy and Montana, Nevada, New Mexico, Oregon, member of the Journal of Dental Society and is a Aprovide the most concern for the practice Utah, Washington, and Wyoming. Endodontics Scientifi c clinical instructor in the Advisory Board. Department of Family and of endodontics are those of Asians and Asians account for 0.9 percent of Preventive Medicine at the Pacifi c Islanders. Th e widest variation in California’s total population while native University of California coronal shape, external root form, and Hawaiian and other Pacifi c Islanders San Diego School of internal canal space morphology will be account for 0.3 percent of the popula- Medicine. encountered with “Pacifi c Rim” cases. tion. Th e national Asian and Pacifi c

Drs. Jerome and Hanlon Anthropological relationships among Islander population is growing at a rate  are partners in Escondido Western Coastal Native Americans of approximately 4.5 percent per year. Endodontics. compound the occurrence of anatomi- Several diff erent anatomical variations cal variants in the Pacifi c Rim geo- occur both externally on the tooth crown graphical area because Western Native and within the root canal system. Exam- Americans share virtually all anatomical ples of anomalies seen throughout all rac- anomalies with Asian populations. es and ethnic groups are dens invaginatus, According to March 2002 U.S. Cen- dens evaginatus, shovel-shaped incisors, sus Bureau statistics, 2.5 million Asians Cusps of Carabelli, taurodonts, multiple and Pacifi c islanders lived in the United roots, and root form bifurcations. Howev- States. Th at 2.5 million represents er, the most common anatomical variants 4.4 percent of the total U.S. popula- associated with Asians and Pacifi c Island-

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FIGURE 1. Central incisor talon cusp with FIGURE 2. Caries removal in the fissured area FIGURE 3. Dens evaginatus presenting as a developmental fissure caries. resulted in a near exposure of the pulp extension. projection of the lingual cusp.

An often underestimated but impor- tant reason for studying anatomical varia- tion is for forensic value. Two anatomical variations related to cusp morphology, that may not have diagnostic or endodon- tic implications but can be significant for forensic identification, are Cusps of Carabelli and shovel-shaped incisors. The Cusps of Carabelli represents the FIGURE 4. Radiograph of Figure 3 demonstrat- FIGURE 5. Premolar example of a prominent tu- cuspal tuberosity frequently observed on ing arrested root development from the exposed bercle arising from the central groove with nonvital the lingual surface of maxillary molars necrotic pulp. pulp and arrested root development. while the shovel trait is seen as very prominent mesial and distal marginal ers that will have an impact on diagnosis is most often seen in cases of maxil- ridges on maxillary incisors. Unlike the and treatment are talon cusps, three- lary lateral incisor dens invaginatus and tuberculated premolar, Cusps of Cara- rooted mandibular molars, C-shaped maxillary and mandibular premolar dens belli do not contain a pulp horn exten- molars, and tuberculated premolars. evaginatus, also known as the tubercu- sion into the cusp. Chinese populations While some anomalies, such as lated premolar. The etiology for pulpal differ from Western Europeans groups dens invaginatus were described and disease may not be clinically apparent by having a high prevalence of the reported in the 9th century, literature since many of these cases involve unre- shovel trait on incisors and low pres- reports of some of the most com- stored teeth and there is no evidence of ence of Carabelli’s trait on molars.4 mon anatomical variants are surpris- crown fracture or history of trauma. The following material is a review ingly recent.2 For example, C-shaped Recognizing anatomical variation of characteristic anatomical varia- molars were first reported in the lit- prevents procedural errors. Treating tion that will be commonly found in erature by Cooke and Cox in 979.3 mandibular molars without angled the practice of Pacific Rim dentistry. There are several reasons for study- pretreatment radiographs can lead to ing dental anatomical variants in any missed third roots. The occurrence of Talon Cusps population. The most significant reason, three-rooted mandibular molars in Histologically, the talon cusp and in clinical terms, concerns enhanced Caucasians is only  percent to 4 percent dens evaginatus are identical. The histol- diagnosis and treatment planning. Es- compared to approximately 40 percent ogy has been described by Lau as being tablishing a diagnosis without a cause or for some Pacific Rim populations. an axial core defect of the dental germ. etiology for a disease is risky and inap- Instrumenting the thin isthmuses There is an extrusion of uncoordinated propriate. Inaccurate diagnosis quite often found in C-shaped molars can lead to tissue proliferation into the stellate leads to improper treatment planning. catastrophic strip-perforations. Instru- reticulum of the tooth germ during the Some anatomical variants can cause mentation errors can be avoided by bell stage of tooth development. This pulpal or periradicular disease that does studying radiographic characteristics proliferation of tissue is followed by a not have a very obvious cause. A prime common to C-shaped molars. Refer- preodontoblast layer of the dentin over example of this can be found with oc- ral for specialty care before procedural which the enamel is subsequently built currences of apical pathosis associated problems arise is an important as- up. The cylinder of dentin and enamel with otherwise unrestored teeth. This pect of proper treatment planning. contains a fine pulpal extension.5,6

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FIGURE 6. Radiographic verification of an MTA FIGURE 7. MTA plugs delivered by a micro-carrier. FIGURE 8. Obturation over barrier placement. apical barrier. Note that the first molar has a third root proximal to the mesial and distal roots that appears very short. 2 percent of Asian populations and In another variant, the cusp arises as a rarely in other ethnic groups. The high- tubercular projection from the center of The talon cusp occurs 90 percent est percentages within the Asian groups the occlusal surface.8,9 The fragile enamel of the time in the permanent denti- were identified in Eskimo-Inuit, Filipino, covering the cusp can be crushed dur- tion and infrequently in deciduous and Thai populations.7 A higher incidence ing an occlusion episode even before it is teeth. Talon cusps are present in overall of dens evaginatus is observed in Eski- exposed through normal wear. If recog- populations with less than  percent mos-Inuits and Native North Americans, nized early, the cusp can be reinforced frequency. Northern Indian and Malay- further evidence that there is an anthro- by placing bonded composite around it sian groups, for example, have a high pological link between Native Americans if it doesn’t interfere with occlusion.0 frequency of talon cusp occurrence.6 and other Pacific Rim ethnic groups.8 When instrumenting canal spaces as- The talon cusp contains a pulp exten- This anomaly is responsible for most sociated with dens evaginatus in premo- sion that has diagnostic and restorative cases that have nonvital pulp in unre- lars, special care must be taken to locate clinical significance. The developmental stored teeth. Nonvital pulp in tubercu- all radicular spaces. Mandibular premolars fissures around the talon are subject to lated premolars frequently occurs at such are known to have deep bifurcations that caries (FIGURE 1). Radiographically, the a young age that apical root development are not radiographically evident since the talon can mimic a superimposed me- is rarely completed. As pulp necrosis position of the bifurcation is buccolingual. siodens or a compound odontoma. Issues reaches apically to Hertwig’s epithelial The most significant endodontic with talon cusps are primarily related to root sheath, further root growth will treatment challenge with dens evaginatus pulp exposure from normal occlusion be arrested. Pulpal necrosis may occur, involves the apical management of incom- attrition or pulp exposure from fissure however, as late as the second decade. pletely formed roots. The tubercle is usu- caries (FIGURE 2). As with dens evaginatus, The histologic-embryologic genera- ally exposed from wear or crushed within the pulpal extension inside the talon is tion of dens evaginatus is the same as a short time after the tooth is in occlusion subject to exposure from occlusal wear. that for the talon cusp. However, in resulting in necrotic pulp and incom- Except for problems with fissure car- posterior teeth it is described as dens plete root development (FIGURES 4, 5). ies or possible occlusion interference, evaginatus. There is typically a bilat- Open root apices can be managed the talon cusp is not a very significant eral distribution and a predilection for with either apexification or placement anomaly. From an endodontic treat- females. The evaginated pulp contain- of an artificial barrier. Many materials ment standpoint, the canal space has no ing tubercle can be present on a cuspal such as calcium hydroxide and trical- unusual ramifications and will appear inclination, in the center of the occlusal cium phosphate, both in paste and dry as a typical tubular canal space form. surface, or simply be an enlargement of powder form, have been recommended Developmental fissures can be the buccal or lingual cusp5 (FIGURE 3). for apexifiation.,2 The disadvantage of treated with minimally invasive res- Pulpal necrosis ranges from 4 using calcium hydroxide is the neces- torations keeping in mind that the percent to 40 percent in all teeth with sity for multiple visits, patient compli- talon does contain a pulpal exten- evaginated tubercles. The tubercle arises ance, and long time periods required to sion and is subject to exposure. predominately from the lingual ridge complete the process of apexification. of the buccal cusps. The location of the A more contemporary technique Dens Evaginatus tubercle on the cuspal ridge makes it employs the use of mineral trioxide ag- Dens evaginatus has also been prone to occlusal wear in lateral excursive gregate, MTA, placed as a barrier. The described as the tuberculated premolar. movement, resulting in exposure of the procedure can be completed in two visits Dens evaginatus occurs in approximately pulp projection within the extra cusp. with obturation and immediate restora-

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FIGURE 9. Three-rooted mandibular molar. FIGURE 10. Angled radiographs separate the FIGURE 11. Instrument placement in a mandibular Straight on view obscures the third root. third root in the obturation view of the preop tooth first molar. Because of the radiographic angulation, the in Figure 9. third root appears very short. The third root curves back toward the buccal. FIGURE 12. Buccal view of an extracted C-shaped present, the operator may actually have mandibular second molar demonstrating the fusion to search for five orifices in total, mesio- groove. There are no coro- buccal, mesiolingual, then the distobuc- nal anomalies indicating cal, distolingual, and the orifice of the unusual root form. third root. The orifice of the third root may be relatively in the same location as the distobuccal and distolingual. The apical extent of the third root FIGURE 13. Mid- and apical sections of the tooth in frequently swings toward the buc- Figure 13 showing that the root canal spaces are eccen- cal in the same manner that the apical tric toward the fused groove. This is an example of a Melton Type I Continuous C-shape. third of a palatal root of a maxillary molar is inclined buccally. If the buc- cal curvature is not properly negotiated tion. At the first visit, the necrotic tissue low in Chinese population of 8 percent.4 it can be easily ledged (FIGURE 11). is removed and the canal space soaked The third root can present a di- Since there is a high incidence with sodium hypochlorite. Calcium agnostic problem if multiple-angled of three-rooted mandibular molars, hydroxide is then used as an intracanal radiographs are not exposed for end- dens evaginatus, and C-shaped molars medication for at least a week. At the odontic treatment planning. The aver- in Asian populations, these anoma- second visit, MTA is placed to the apical age diagnostic periapical film is usu- lies will frequently occur together. extent of the undeveloped root and care- ally exposed straight on rather than In Figures 6 and 8, note the pres- fully packed as a barrier using radiographs angled, and the third root is frequently ence of the three-rooted molar distal to verify extent and completeness of the superimposed and obscured by the to the tooth being treated for dens barrier (FIGURES 6-8). The entire canal can distal root in this view (FIGURES 9, 10). evaginatus. The third root, radiographi- be obturated with MTA or traditional If there is wide separation of the roots cally proximal to the mesial and dis- root canal obturation materials can be and the third root comes off the root trunk tal roots appears very foreshortened added over an apical barrier of MTA.3 at a 45-degree angle, the third root may radiographically (FIGURES 6, 8, 11). appear radiographically very short and Three-rooted Mandibular Molars may be difficult to visualize (FIGURES 9-11). C-shaped Molars The incidence of three-rooted man- The third root is lingual to the me- The C-shaped root canal system dibular first molars in Caucasians ranges sial and distal roots, and if not properly anatomy is now well-recognized in the from 0.9 percent to 4.3 percent. There is treated endodontically, it will present a literature. As an anatomical anomaly, it great variation across Asian populations. challenge for possible apical surgery. is a relatively late bloomer as it was first Occurrence in Aleutian ethnic groups Third roots are anatomically separate reported by Cooke and Cox in 979. is reported as high as 43 percent, while and independent from the main distal The C-shaped canal system occurs in neighboring Inuit populations are report- root but the orifice location is always mandibular first molars and maxillary ed at approximately 2.5 percent. Japa- situated in closer proximity to the distal molars but is most common in mandibu- nese and Thai populations range from 9 root orifice. This location is important for lar second molars. The incidence of C- percent to 20 percent with a comparative endodontic treatment. If a third root is shaped molars in the general population

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Typical mandibular molar orifice Type I C-shape continuous arrangement. arrangement

FIGURE 15. An example of a Type II Semicolon C- shaped orifice arrangement.

Type II C-shape semi-colon Type III C-shape orifices appear arrangement separate

Orifice locations for molars with mesial orientation appearing at the top of the illustration.

FIGURE 14. Orifice orientations for Melton’s C-shaped molar classifications.

FIGURE 16. An extracted C-shaped mandibular first molar. The flat apical area is a clue to the presence of fused roots for this anatomical anomaly. Note the thin dentin isthmus connecting the main mesial and distal roots. The isthmus was perforated during instru- mentation and obturation. FIGURE 17. This mesially inclined mandibular FIGURE 18. Instrument placement in the molar second molar is C-shaped. The canals spaces are of Figure 17 shows that the instruments are near the eccentric toward the furcation. That appearance furcation and close to a perforation. provides another radiographic clue that the internal anatomy will be of the C-shaped variety. is approximately 8 percent, but can be as tinuous crescent-shaped space without Not all teeth in this category have high as 3 percent in Asian ethnic groups.3 separate orifices. The Type 2 Semicolon conical-tapered root apices but there C-shaped molars develop when arrangement may have two connected are radiographic clues that may indi- Hertwig’s epithelial root sheath fails to orifices with a separate space, and the cate the presence of a C-shaped molar. fuse either on the buccal or lingual sur- Type 3 arrangement is represented by Frequently, the tooth will appear as a face. That fusion failure results in a groove three separate orifices that are con- typical two-rooted mandibular molar on the opposite side of the root that is nected to varying degrees throughout because the dentin isthmus connect- present coronoapically5 (FIGURES 12, 13). to body of the root (FIGURES 14, 15). ing the main mesial and distal root A classification system was proposed Diagnostic interpretation and instru- areas is very thin and not radiographi- by Melton and others that detailed the mentation modifications are required cally evident. In other instances, the external and internal anatomical and to overcome the clinical challenges roots will appear with flattened apices histological features of C-shaped molar presented by C-shaped canal systems. as this area represents the connect- anatomy.6 In a study of 5 extracted In the case of this anatomical anomaly, ing dentin isthmus (FIGURE 16). Canal teeth, they described the dentin-canal internal canal space form cannot be spaces seen radiographically in C-shaped space isthmus as occurring approximately ascertained from clinical crown shape. molars may appear unusually eccentric equally on both the buccal and lingual. In Radiographic examination, however, toward the furcation (FIGURES 17, 18). the Type  continuous form, the inter- can provide information supporting Instrument placement in the thin nal canal space is seen as a single con- the diagnosis of a C-shaped root. dentin isthmus may appear radiographi-

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FIGURE 19. The middle instrument has been FIGURE 20. Obturated C-shaped molar with Type FIGURE 21. C-shaped mandibular second molar placed in a thin connecting isthmus of this C-shaped II Semicolon arrangement. The connecting isthmus with a deep connecting isthmus. molar. The file appears to have perforated the has been appropriately debrided and obturated. furcation since the isthmus is too thin to be radio- graphically evident.

cally as a furcation perforation (FIGURE 19). throughout the United States, all health TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE CON- TACT Charles E. Jerome, DDS, Escondido Endodontics, 488 E. The dentin in this area is too thin to be care providers should be aware of diagnos- Valley Parkway, Suite 307, Escondido, Calif., 92025. radiographically opaque. Debridement tic and treatment technique modifications and flaring in this area has to be minimal required to overcome the clinical chal- to prevent strip-perforation of the thin lenges posed by various anatomical isthmus (FIGURE 16). With careful debride- anomalies. ment and soaking with sodium hypochlo- rite, the thin isthmus can be safely REFERENCES 1. Reeves T, Reeves C, The Asian and Pacific Islander Popula- debrided and obturated (FIGURES 20, 21). tion in the United States. U.S. Census Bureau, Washington, Internal fiber optic light transil- D.C., Current Population Reports, pp 20-540, March 2002. lumination can be used to enhance 2. Salter S, Warty tooth. Transactions Pathol Soc London 6:173-7, 1855. canal space anatomy when searching 3. Cooke HG, Cox FL, C-shaped canal configurations in man- for spaces. When the tip of a fiber optic dibular molars. J Am Dent Assoc 99:836-9, 1979. light is placed under the rubber dam, 4. Hsu JW, Tsai PL, et al, Ethnic dental analysis of shovel and Carabelli’s traits in a Chinese population. Aust Dent J 44:40-5, the canal space will appear as a dark line 1999. or area demarcating the pulp space. 5. Lau TC, Odontomes of the axial core type. Br Dent J 99:219, The use of thin ultrasonic tips in 1955. 6. Mellor J, Ripa L, Talon cusp: A clinically significant anomaly. isthmus areas is invaluable for safe Oral Surg Oral Med Oral Pathol 29:225-8, 1970. debridement. Warm vertical gutta- 7. Augsberger RA, Wong MT, Pulp management in dens invagi- percha compaction is an essential natus. J Endodon 22:323-6, 1996. 8. Merrill RG, Occlusal anomalous tubercles on premolars of method for complete obturation of the Alaskan Eskimos and Indians. Oral Surg 17:484-96, 1964. various internal space configurations 9. Wu KL, Survey on midocclusal tubercles in bicuspids. China presented by the C-shaped variant. Stomatol 3:294, 1955. 10. Levitan ME, Himel VT, Dens evaginatus: Literature review, pathophysiology, and comprehensive treatment regimen. J Conclusions Endodon 32:1-9, 2006. Familiarization with dental anoma- 11. Goldman M, Root-end closure techniques including apexifi- cation. Dent Clin North Am 18:297-308, 1974. lies, specifically those pertaining to 12. Roberts SC, Brilliant JD, Tricalcium phosphate as an adjunct to endodontic treatment will enable the apical closure in pulpless permanent teeth. J Endodon 1:263, 1975. provider to prevent inaccurate diagnosis 13. Shabahang S, Torabinejad M, Treatment of teeth with open apices using mineral trioxide aggregate. Pract Periodont that can potentially lead to inappropri- Aesthet Dent 12:315-20, 2000. ate treatment or procedural errors. 14. Younes SA, Al-Shammery AR, El-Angbawi, MF, Three- Some anomalies such as dens evagina- rooted permanent mandibular first molars of Asian and black groups in the Middle East. Oral Surg Oral Med Oral Pathol tus and the subsequent pathosis seen 69:102-5, 1990. with early pulp necrosis will more likely be 15. Manning SA, Root canal anatomy of mandibular second seen in children. As the Asian and Pacific molars. Part II. C-shaped canals. Int Endo J 23:40-5, 1990. 16. Melton DC, Krell KV, Fuller MM, Anatomical and histological Islander population grows in the western features of C-shaped canals in mandibular second molars. J states, and as those populations migrate Endodon 17:384-8, 1991.

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Improving Decision- making in Restorations: Evaluation of Impressions and Working Casts

GITTA RADJAEIPOUR, DDS

ABSTRACT The success of a crown greatly relies on its margin. An ill-fi tt ed crown with an open margin will be susceptible to leakage and recurrent decay. If it remains undetected, it will eventually cause serious problems. This report looks at the fi nish line consistency of 73 “clinically acceptable” impressions made by dental students and working casts poured in the laboratory section. Findings show a number of possible inaccuracies in preparations, impressions, or a combination of both.

AUTHOR arginal integrity is an tion are to be duplicated from a working

Gitt a Radjaeipour,DDS , important element in cast, an essential element is ensuring the is an assistant professor, evaluating a restoration; presence of a detectable and well-defi ned University of the Pacifi c, however, there is no fi nish line on a tooth prior to making an Arthur A. Dugoni School of general agreement about impression. One of the most frustrating Dentistry, Department of Mthe defi nition of a clinically acceptable problems associated with impression- Restorative Dentistry, San Francisco, and in private margin. A good quality impression is taking is the fact that an impression may practice in San Jose, Calif. a prerequisite to the fabrication of a look perfect but is actually distorted. Much well-fi tting laboratory-made restora- time is wasted in making the crown, tion. With regard to the evaluation scheduling the patient, trying to seat of preparations, Rosentiel, Land, and the crown, and remaking the impression.4 Fujimoto indicated, “the impression may still be acceptable when a small defect Methodology is present in noncritical area (e.g., away Student cases for crowns and bridges from the margin of a prepared tooth). are evaluated through two steps of quality Careful judgment must be exercised.”2 control at the University of the Pacifi c, When making an impression of a Arthur A. Dugoni School of Dentistry. crown, capturing the margin becomes the An impression taken by the students most signifi cant part when evaluating is initially evaluated by the faculty and whether an impression is acceptable or students in the clinic. Additionally, the not. Th e restoration can survive in the poured-up working casts are evaluated biological environment of the oral cavity in the lab to assure the quality of the only if the margins are closely adapted to prostheses to be delivered to the patients. the cavosurface fi nish line of the prepara- Th e intent of this study was specifi cal- tion.3 When the margins of a cast restora- ly to reevaluate the poured-up casts and

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obtain rationales or a line of reasoning for attempts are made prior to producing an surfaces of 73 tooth preparations for vari- unacceptable impressions and working acceptable impression. Only one impres- ous cast restorations. The variety finish casts. Identifying the most common prob- sion maybe submitted to the lab for line designs included chamfer and 90- or lems found in impressions, that taken by fabrication of a crown. In this study, 73 20-degree porcelain shoulders. All 73 im- dental students in restorative procedures. impressions were evaluated. Data were pressions had been examined microscopi- When making impressions, students collected randomly from the cases sub- cally by clinic floor faculty and passed as are challenged to produce clinically accept- mitted by second- and third-year dental “clinically acceptable,” using a high-power able impressions. In some cases, several students. The assessment included 292 stereoscope X 0 model BM40455. In the

TABLE 1

Classification of Errors in the Margins of the Prep on the Study Casts and on the Impressions

Finish Line of Prep Type of Error Description

On the working cast None existing or light Finish line fades from the prep to the tooth; there is no margin (FIGURE 5) or it is too light (FIGURE 1). Not continuous Finish line does not go all around the tooth; it looks like a zigzag or stepped margin (FIGURE 2). Double or several finish lines There are two or several finish lines on top of each other (FIGURE 4). Rough finish line Finish line has many scratches or nicks from the bur; it is not a sharp or well-defined line (FIGURES 6, 7). Fuzzy finish line It is not possible to tell the difference between the finish line and the prep (FIGURE 5). Finish line not appropriate Finish line design not correct for the requested type of prosthesis (FIGURE 6). On the impression Bubble on finish line Small bubbles are easily identified; large bubbles on the finish line are harder to identify (FIGURE 8). Folding of impression This occurs when there is saliva or too much moisture in the sulcus. Moisture on finish line. Tear This occurs if the impression is removed prior to complete setting or if the impression cuts in the cord. Cord on the finish line An impression of the cord has been picked up with the impression and is on or next to the finish line (FIGURE 3). Distortion of impression Separation of material from the tray due to inadequate tray adhesive. Different setting time of light/heavy body impression material.

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laboratory, a total of 29 percent of these laboratory point of view will be beneficial scope is easier than evaluating a prepara- cases were rejected and they were not for practitioners to look for potential tion in the mouth or an impression. accepted for cast fabrication. The same errors early on. At the same time, calibra- high-powered scope was used for reevalu- tion of dentists, faculty, lab technicians, Summary ation; the working casts and working dies and students will reduce the number of The outcome showed inaccuracies were evaluated in a laboratory environ- remakes. It should also be noted that could occur in three categories: ) er- ment as opposed to evaluating impres- when assessing a case, the operating envi- rors in the preparations alone; 2) errors sions and preparations in patient’s mouth. ronment in clinic is more challenging than in the impressions alone; and 3) errors Establishing guidelines and requirements the laboratory environment. Evaluation of in both preparations and impressions. for an acceptable working die from the the finish line on a die under a high-power Results included: 8 percent of the er- rors were on finish lines of the prepared teeth; 8 percent of the errors were in

FIGURE 1. Light FIGURE 2. the impressions; and 4 percent were in finish line. Finish line not both the impression and the prepared continuous. tooth. Seventy percent of the die stones were determined acceptable for fabri- cation of the requested prostheses. In general, flaws in cast restora- tions could be visible or invisible flaws. Most visible flaws can be identified by the technician. Invisible flaws are dis-

FIGURE 3. Cord FIGURE 4. FIGURE 5. Un- on finish line. Double identifiable finish line. finish line.

FIGURE 6. FIGURE 7. Rough FIGURE 8. Preparation finish line. Bubble and impression on unacceptable. impres- sion.

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covered at the time of placement of the restoration. The most common visible flaw is the lack of a visible finish line. Such defects are usually the result of inadequate gingival management.5

Results The results of this study are shown in TABLE 1 and have been divided into two categories: evaluation of the finish lines of the preparations on the casts; and on the impressions. The classifica- tion of errors (TABLE 1) is based on the cases evaluated and visible flaws.

Discussion The scope of this study was limited to the evaluation of the margins of the preparations and the impressions by dental students. It is necessary to point out there could be other problems, which might not be related to the margins and that might cause a case to be rejected. These problems might include errors in prescription, errors with casts, errors in mounting, errors in the articulator itself, and others.

REFERENCES 1. Millar B, How to make a good impression (crown and bridge). Br Dent J 191(7):402-3, 405, October 2001. 2. Rosenstiel SF, Land MF, Fujimoto J, Contemporary fixed prosthodontics. 4th ed., Missouri, Mosby, chapter 14, p. 461, 2006. 3. Shillingburg, HT, Hobo S, Whitsett L, Fundamentals of fixed prosthodontics, Chicago, Quintessence Publishing Co., Inc., p. 90, 1981. 4. Hamilton J, Troubleshooting impression material problems: University of the Michigan, School of Dentistry, Cariology, restorative sciences and endodontics, 1996. 5. Wassell RW, Barker D, Walls AW, Crowns and other extra- coronal restorations: Impression materials and technique. Br Dent J 192(12):679-84, 687-90, June 2002.

TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE CONTACT Gitta Radjaeipour, DDS, University of the Pacific, Arthur A. Dugoni School of Dentistry, 2155 Webster St., San Francisco, Calif., 94115.

640 SEPTEMBER 2007 Dr. Bob CDA JOURNAL, VOL 35, N º 9

Product-palooza!

Even the most beef-witted con- sumer is well aware that toothpaste, for example, is no longer a modest adjunct to keeping ones’ teeth rea- sonably clean.

The companies should The practice of dentistry has ad- ■ Toothache kit? Yes. vanced so much in recent years that it is ■ Temporary cement? You bet! devote some thought to now impossible for a dentist not to find ■ Tooth whitening paraphernalia? something wrong with you. Teeth that Take your pick. the frequent unsettling have hitherto appeared to be shining ■ Bad breath? Paste, liquid or gel; no examples of Nature’s finest effort, are problem. tableau wherein a customer, revealed by laser devices as candidates for ■ Mirrors, explorers, tongue scrapers, the endodontist. Anterior teeth that have Quik-fix repair kits? Of course! moaning piteously, lies appeared only yesterday to be in lovely ■ Implant kits? Coming. prostrate in the aisle juxtaposition, suddenly require the wiz- Even the most beef-witted consumer ardly applications of porcelain to prevent is well aware that toothpaste, for example, unable to decide. their owner from immuring herself in a is no longer a modest adjunct to keeping nunnery. ones’ teeth reasonably clean. Dentistry is To keep pace with dentistry’s advanc- beholden to public-spirited conglomerates , Robert E. es, the pharmaceutical industry has prov- like Colgate and Crest, among others, who Horseman, en itself to be no slacker when assigned enjoin the public via the media to spend the task of formulating cures, palliative less time worrying about the state of the DDS and prevention drugs and devices. Short world and pay more attention to its oral ILLUSTRATION of an instant fix for a major maxillofacial health. In reality, the companies should BY CHARLIE O. catastrophe, such as one might encounter devote some thought to the frequent HAYWARD in a face-off with a Peterbilt truck, your lo- unsettling tableau wherein a customer, cal supermarket’s formidable dental aisle moaning piteously, lies prostrate in the has every imaginable answer to most of aisle unable to decide between Crest’s dentistry’s problems. Whitening Expressions Refreshing Vanilla CONTINUES ON 657

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DR. BOB, CONTINUED FROM 658 Mint Liquid Gel and Colgate’s Baking a task better assigned to an interior ing — if he’s honest — “Whatever the Soda & Peroxide Whitening Oxygen decorator. An ineffective solution, I feel, company reps give me as samples.” To Bubbles Frosty Mint Striped Gel. compared to my attention-grabbing paraphrase King Lear, “How sharper This dental bonanza is like a mul- alternative. than a serpent’s tooth to be an ungrate- tiple-choice test with a hundred possible When Oral-B offers a baker’s dozen of ful recipient!” King Lear, by the way, was answers. The consumer’s strategy is lim- manual toothbrushes and Colgate coun- edentulous and lived the last years of his ited to eenie, meenie, minee, mo despite ters with as many or more, to say noth- life entirely on gruel. the fact that companies devote media ing of those of other brands of brushes, It behooves us as professional oral campaigns to bind him in lifetime loyalty what’s a poor consumer to do? health persons responsible for the costing more than the total assets of “Ask your dentist,” is the advice fre- popular Flossing for Dummies manual, many Third World countries. A mind-bog- quently proffered to bewildered patients to become acquainted with even the gling scrolling of their Web sites confirms when confronted with a 00-foot long lesser-known of these products if we are that Colgate, for instance, offers at least aisle of dental products in the super- to make intelligent recommendations. three dozen types of toothpastes. Crest, market. Splendid idea, like asking your Smug and irritating as it is, sound advice not to be outdone, proudly displays its physician what to do about age spots on such as “You are required to floss only multiple choices of toothpastes and gels. the back of your hands. the teeth you want to keep” should do There are now enough toothbrush types “What do you use?” the dentist much to reduce the confusion of runaway for the conscientious brusher to have a hopes they don’t ask. The answer be- multiple choices. different configuration for each of his or her 32 teeth. I don’t recall there ever being a public clamor for so many options. IRATE CUSTOMER TO CLERK: Hey, how come there’re only 0 kinds of toothpaste here? This is a supermarket? CLERK (cowering): I’ll call the manager! The average patient, unless driven by some obscure dental angst encountered in a Krafft-Ebing 9th century textbook, is quite content with one flavor of tooth- paste and one serviceable toothbrush he fondly believes should last him upward of a year. He selfishly has other fish to fry, so all this competition for the consumer’s attention is immense. One of life’s tough decisions is when to discard a toothbrush. I once had a con- cept of a new type brush that announced its demise by harmlessly exploding when the bristles sagged 5 degrees out of vertical, much on the order of a trick exploding cigar. In deference to the com- panies that have done so much for us, I demurred in favor of their submission of bristles that gradually change color when a certain amount of time has passed. This requires the brusher to make a subjec- tive analysis of hue and color saturation,

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