CDA Journal Volume 30, Number 10 Journal October 2002
departments 715 The Associate Editor/Nourishing Our Roots 721 Impressions/Dentistry for People With Special Needs 802 Dr. Bob/Oral Gratification Out of Control
features
731 Loma Linda University School of Dentistry -- From Dream to Reality Charles J. Goodacre, DDS, MSD
735 Reducing Bacterial Counts in Dental Unit Waterlines: Distilled Water vs. Antimicrobial Agents James D. Kettering, PhD; Carlos A. Muñoz-Viveros, DDS, MSD; Joni A. Stephens, RDH, EdS; W. Patrick Naylor, DDS, MPH, MS; Wu Zhang, MD
742 UCLA School of Dentistry: Successes, Challenges and Opportunities No-Hee Park, DMD, PhD
747 The School of Dentistry at the University of California, San Francisco: Service to Humanity Charles N. Bertolami, DDS, DMedSc
752 Implementing an Infant Oral Care Program Francisco Ramos-Gomez, DDS, MS, MPH; Bonnie Jue, DDS; and C. Yolanda Bonta, DMD, MS, MS
763 A Dental School That Serves the Practicing Profession Arthur A. Dugoni, DDS, MSD
769 Clinical Evolution of the Invisalign Appliance Vicki Vlaskalic, BDSc, MDSc, and Robert L. Boyd, DDS, MEd
777 University of Southern California School of Dentistry: Dental Education for the 21st Century Harold C. Slavkin, DDS
783 Saliva: A Fountain of Opportunity Mahvash Navazesh, DMD; Paul Denny, PhD; and Stephen Sobel, DDS Associatehead Editor cda journal, vol 30, nº 10
Nourishing Our Roots
Steven A. Gold, DDS
entists comprise a diverse glimpse at excellence, I will be forever population, yet there is one grateful to them. I believe everyone common denominator we all who is so motivated has his or her own share: We are all the products great teachers who have given similar of dental education. Dental inspiration. Dschools are the foundation of dentistry. This issue of the Journal of the They are the institutions that mold and California Dental Association is both train future dentists, and they contribute a showcase for the California dental to the body of dental knowledge through schools as well as a tribute to them. We research. They provide the community are fortunate not only to have five dental at large with valuable dental services schools in California, but also to have and improve access to dental care for a schools, administrators, and faculty that significant segment of the underserved rival the best in the world. We owe a debt population. While dental schools of gratitude to everyone who works to collectively contribute to the profession make our schools such benchmarks of at large, it is through our own personal excellence: from the deans, through the experiences that we are most closely and ranks of the faculty, and to a sometimes forever bound to those solemn halls (and forgotten group -- the staff and employees clinics and labs) of dental education. who make the day-to-day running of the True, we can readily recall the schools possible. numerous challenges we all faced during Recently, we have heard that there is that seemingly interminable creep toward a crisis looming in dental education. In graduation. Yet in spite of the hardships, fact, according to some, it is here. Schools it seems most dentists do look back report difficulty attracting enough faculty fondly on their days in dental school. I to meet the current and projected demand. believe that, although we rarely admit it, In particular, there seems to be a lack of most of us rely daily on our dental school young, career-minded dental educators education as we treat patients. We may crucial to replenishing the faculty ranks as modify our individual techniques and the more experienced teachers inch closer favorite materials throughout our careers, to retirement. There are two suspected but our formative education has etched reasons for this. First, new dentists are something more indelible on our brains. more in debt from their education than For me, it was a standard of excellence ever before; and second, salaries in private and the motivation to endlessly pursue practice are higher than for starting dental that standard that was instilled in me by school faculty positions. How then can we teachers such as Richard Kahn and Terry encourage young dentists to pursue careers Donovan. For that brief yet unforgettable in dental education?
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For starters, I will go out on a limb and project that dental school salaries will never match those that can be earned by capable private practicing dentists. At the same time, I do not believe that dentists, on the whole, enter the profession for purely financial reasons. Surely there are other careers that offer a greater return on investment for the amount of time and expense dental education demands. Dentists tend to be giving. We have a large number of dentists who volunteer time to organized dentistry and other endeavors with little to no monetary compensation. Whether serving organized dentistry or dental education, there is some degree of sacrifice involved. But being a teacher can bring the rewards of shaping and inspiring future dentists and making a tangible difference in the quality of dentistry we are able to provide our patients. There is a value and a reward gained from teaching that a paycheck can never provide. This is a message that everyone in dentistry can help promote whether inside or outside of the dental education system. It is also a message that young dentists and new graduates should heed as they consider career choices and how they would like to give back to a profession as rich with opportunity as ours. If we all work together to address our education crisis, we will continue to keep dental schools, the very roots of our profession, strong and ensure a bright future for dentistry.
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Dentistry for People With Special UOP has helped facilitate the es- out the state. Needs tablishment of eight community-based UOP also hosts a popular one-day By Collette Knittel networks that implement local oral continuing education course for interest- Efforts to expand access and improve health treatment and prevention delivery ed volunteer dentists, titled Dentistry for the delivery of dental health services to networks that link people with devel- People with Special Needs, in various cit- Californians with special needs are under opmental disabilities to locally available ies in California several times throughout way. The University of the Pacific School of dental screening, treatment, and preven- the year that are funded by the California Dentistry has selected eight regional cen- tive services. Endowment. ters as partners to expand oral health care “Because of the difficulty in accessing For information online, UOP, through programs for people with special needs. dental services, many individuals with its Center for Oral Health, has developed The project is funded in part with a $2 mil- disabilities have significantly poorer oral a resource guide for materials related lion grant from the California Endowment, hygiene and higher rates of dental disease to prevention and treatment of dental the state’s largest health foundation. than the rest of the population,” said disease for people with special needs. This “The California Endowment is commit- Paul Glassman, DDS, MA, MBA, project resource guide lists books, pamphlets, ted to expanding access to health-related co-chair and director of UOP’s advanced videotapes, prevention supplies, treat- services to persons with special needs,” education and general dentistry program. ment materials, and other resources said Marion Standish, senior program of- Without regular dental care and pre- useful in preventing or treating dental ficer with the California Endowment. “We ventive practices, people with disabilities disease for people with special needs. are pleased to support the UOP School of generally see a dentist only in emergency It is available at www.dental.uop.edu/ Dentistry in this statewide effort that will situations, when visits are not only pain- resource. Materials can be displayed for a have a significant and positive impact on ful and stressful, but also expensive and particular category, audience, subject, or the dental health outcomes for people liv- may require extensive travel to dental format. ing with developmental disabilities.” schools or local hospitals. E-News Alerts Can Bring in More There are 21 regional centers through- “With the cooperation of these centers, Patients out the state of California. A regional we are mounting a statewide effort to By Dell Richards center is a social service agency for people improve access to local dental services for Generally, there are three ways to with developmental disabilities. They are people with disabilities,” said Christine generate more profit from a dental prac- under contract with the state Department Miller, RDH, MHS, MA, project co-chair tice: Cut costs, recruit new patients, or of Developmental Services and perform and UOP’s director of community services. encourage existing patients to use more triage, referral, and advocacy services. Now finishing the second year of a services. Since many dentists already are Each center has a case manager, who is three-year grant project, a number of doing everything they can to pare down responsible for seeing that individuals goals and objectives have been imple- costs, finding ways to bring patients into receive the services they need. mented. Dental coordinators have been the office is the only alternative. UOP’s grant program, called the State- hired and trained in all eight regional cen- E-newsletters and alerts not only wide Task Force on Oral Health for Per- ters. The part-time coordinators provide cut the cost of traditional newsletters, sons with Special Needs, focuses on eight case management, assessment, and refer- but also are a perfect tool for reminding regional centers throughout the state: the rals for the clients of the regional centers. current and prospective patients how Alta California Regional Center in Sacra- The coordinators also provide oral health valuable their dental health is. Yet few mento, Central Valley Regional Center in education, dental care resource develop- dentists use them -- or any other material Fresno, East Bay Regional Center in Oak- ment, and education for professionals, -- to follow up on initial contacts. land, Lanterman Regional Center in Los caregivers, and consumers. Statistics shows that 20 percent of all Angeles, Harbor Regional Center in Long Additionally, an electronic oral health leads are never followed up on. And, 90 Beach, Inland Regional Center in San tracking system has been established in percent of businesses give up after the Bernardino, North Bay Regional Center in the eight regional centers to monitor the first attempt -- even for people who have Napa, and San Gabriel/Pomona Regional progress of clients they are serving in shown interest by contacting them. Center in Pomona. rural and urban communities through- In addition, the average response time
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between the initial contact and the first in the person’s mind, reminding them poor candidates for aggressive combina- piece of information is 58 days, with 12 per- that they would be healthier if took care tion therapy. Therefore, for more effective cent taking up to six months to respond. of their teeth better -- and came into your local and regional control of head and In 1995, Performark, a leads closing office more often. neck squamous cell carcinoma and to firm, calculated from a six-year study of The best system is to personalize the minimize systemic exposure and toxic- 10,000 marketers that the loss in adver- address and include the name of the re- ity, locally injectable therapies have been tising dollars from lack of timely follow- cipient in the heading so that it seems like investigated.” through was 82 percent. a personal letter. If you do not have that Understandably, sending out literature capability, send mass emails by blind copy. Scientists Map DNA Segment Associ- or asking staff to make phone calls is a Never list names or email addresses. ated With Oral Cancer huge expense. Brochures are costly, as are Although it may take time to motivate Researchers from the University of envelopes, postage, and mail house prices. patients and prospects to act, you will get Pittsburgh Graduate School of Public All that changed with the advent of more business if you make contact on a Health have produced the first detailed e-mail, however. Literature in the form of regular basis rather than wait for them to map of a segment of DNA associated with e-newsletters and e-news alerts can go out do so. poor outcomes in oral cancer treatment for much lower costs. Once a database is The Sacramento public relations firm and discovered a new gene they suspect set up for patient groups, the only costs Dell Richards Publicity specializes in may play a key role in cells becoming are research, writing, and “mailing” time. health care clients. malignant. To do e-newsletters, set up a template The DNA segment, known as 11q13, with your company logo at the top. Break Injectable Gel Effective inT reating Head contains at least nine different genes text into 2/3 and 1/3 columns. That way, and Neck Cancer and is “amplified” -- found in excess -- in you can get in one “feature article” and An injectable gel combining cisplatin, almost half of all head and neck cancers, a related “sidebar” with statistics -- or a chemotherapy drug, and epinephrine is the researchers said in an Aug. 6 report in another shortie. The equivalent of one effective in treating cancers of the head the Pittsburgh Post-Gazette. printed page (single-spaced) usually is and neck, according to a new study pub- Using the 11q13 map developed at enough, less than 500 words. lished in the Archives of Otolaryngology the university’s Oral Cancer Center, However, the trick is to use the “news” and Head and Neck Surgery. scientists will be able to quickly compare in newsletter. Trite, self-serving articles Squamous cell carcinoma originates the 11q13 segments that are amplified in that do not show concrete benefits to the in a particular type of cell found in many different cancers, possibly speeding the patient will only be seen as more spam, different parts of the body. Head and neck development of molecular markers to dumped faster than junk mail. squamous cell carcinoma refers to this help them diagnose cancers and choose Newsletters must have easy-to-read, type of cancer in the head or neck. proper treatments. but not chatty, content that uses current Head and neck squamous cell carcino- The researchers said they don’t yet health news as the basis for the articles. ma is diagnosed in about 40,000 Ameri- know what the newly discovered gene, Those 500 words must be chock full cans each year and more than 600,000 called TAOS1, does but its activity of facts and figures that tell the reader people worldwide. Barry L. Wenig, MD, increases with the number of copies of important information. Quirky stats also MPH, of Northwestern Medical School, 11q13. Extra copies of the 11q13 segment can work, if they fall into the “Wow, I Evanston, Ill., and colleagues investigated are associated with poor response to treat- didn’t know that” category. the use of cisplatin/epinephrine gel in- ment in oral cancer patients. Be honest with yourself on this score. jected directly into the tumor in patients The map could also prove useful for If you don’t have the time or the ability with such cancer. Cisplatin given intra- research into other cancers associated to write journalist-style news, farm it venously has been shown to be a potent with multiple copies of the DNA segment, out. There are many companies that do agent for treatment, but because it affects including breast, bladder, and esophageal e-newsletters and alerts for dentists and the entire body when given intravenously, cancers, the researchers said. other health care professionals. it can have serious adverse effects. The National Institute of Dental E-newletters generally go out more of- The authors wrote, “Therapeutic and Craniofacial Research has given the ten than traditional newsletters. Because options for advanced head and neck squa- University of Pittsburgh scientists a $1.6 e-newsletters are scanned so easily, some mous cell carcinoma are limited. These million grant to continue studying the companies send them out two or three patients generally have undergone exten- 11q13 segment. times a week. Once or twice a month, sive surgery, have received near-maximum however, is enough to keep your practice tolerated doses of radiation, and are often
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Scientists Report New Resin Matrix Passes Initial Tests Scientists report in the July issue of the Taste Receptor for Amino Acids Discovered journal Dental Materials that two synthetic Scientists recently reported the discovery of a new taste receptor that recognizes molecules designed in their laboratory to most of the 20 naturally occurring amino acids, leading them to speculate that it evolved to improve the durability of composite fillings help humans select foods rich in these essential nutrients. had acceptable strength and good biocom- patibility during initial tests. Published in Nature, the report is the latest in a series of articles resulting from a five- According to the scientists, these year collaboration between investigators jointly led by Dr. Nicholas Ryba at the National results suggest the structure of these Institute of Dental and Craniofacial Research and Dr. Charles Zuker of the Howard Hughes so-called oxirane, or epoxy, molecules can Medical Institute at the University of California at San Diego. be further refined in the laboratory to According to Ryba, “The amino acid receptor is related to the sweet taste receptor produce a nonshrinking resin matrix, the that we identified and characterized last year: Both are combinations of a family of taste chemical backbone of a composite filling. receptors referred to as T1R.” “There has been a need in restorative They made this new discovery by inserting mouse T1R genes into cells engineered dentistry for a safe, nonshrinking compos- to respond to and report receptor activation. Surprisingly, the investigators found that ite matrix,” said Dr. David Eick, a scientist different combinations of the T1R receptors resulted in either a sweet taste receptor or an at the University of Missouri at Kansas amino acid taste receptor. City and lead author on the study. “These The scientists note that in mice, the same taste receptor recognizes nearly all amino results mark a small, but important, re- search step toward meeting this need.” acids, but that the human receptor is much more specifically tuned to recognize one in To eliminate the shrinkage problem, particular -- glutamate. scientists need to improve the chemistry Glutamate occurs naturally in certain foods, such as seafood, and is often added to of the composite’s matrix backbone, the processed food as the flavor enhancer monosodium glutamate. It has a unique flavor main source of the shrinkage. One hope is known as “umami,” a Japanese word meaning delicious. According to Ryba, “the human to develop a suitable synthetic molecule, receptor is far more sensitive to glutamate than other amino acids and is very likely to be a or monomer, that polymerizes without major receptor for the umami taste.” losing volume as it forms chemical bonds There are benefits to deciphering the umami taste pathway, Ryba noted. He pointed with other monomers. out that while many associate the umami taste of MSG with processed or snack foods, According to Eick, a strong candidate some researchers are using MSG to stimulate consumption of nutritious foods by those is oxirane, which polymerizes cationically. with poor appetites, such as the elderly and people with diabetes. Its monomers open their aromatic rings and expand to form chemical bonds. Cur- rent composites are based on free-radical chemistry, in which their rings contract during bond formation, resulting in a slight loss of volume.
Travelers Guide to Safe Dental travelers avoid unnecessary risks. people can take before leaving home Care Available “In many areas, items such as gloves, to minimize the potential for a dental A new brochure designed to assist sterile instruments, disposable needles, emergency. It also offers suggestions for individuals on how to receive safe dental and safe water are not routine elements of finding a dentist, choosing medications, care when traveling outside the United dental practice,” said Dr. Jennifer L. Cleve- and assessing infection control practices States is now available from the Centers land, who manages the infection control in a dental office. A checklist provides a for Disease Control and Prevention and activities of CDC’s oral health program. series of questions for the overseas dental the Organization for Safety and Asepsis “This new resource can help international office to ensure that it uses appropriate Procedures Foundation. The Traveler’s travelers obtain safe dental care when precautions to prevent disease transmis- Guide to Safe Dental Care provides tips traveling and avoid potential situations sion. Some questions include: for people when selecting a dental pro- that could lead to exposure to microor- nnDo staff wash their hands with soap vider abroad and identifies basic infection ganisms or other contaminants.” between patients? control principles and practices that help The guide provides a series of steps nnDo staff wear gloves for all procedures?
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nnAre new needles used for each patient? nnIs sterile water used for surgical procedures? To obtain a free copy of the Traveler’s Guide to Safe Dental Care, contact OSAP at (800) 298-OSAP. To view the brochure online, go to http://www.osap.org/pa- tients/articles/travelguide.htm CDA Officer Slate Forwarded to House The Board of Trustees, acting as the Nominating Committee, has forwarded to the House of Delegates its slate of nomina- tions for Executive Committee positions. Per Bylaws Chapter IX, Section 30 B (c), this slate of officer candidates is being published to notify members of the slate at least 45 days prior to the House. The House of Delegates will be held Nov. 22 through 24 in San Diego, Calif. The slate is as follows: President Elect: Debra S. Finney, DDS Vice President: Russell I. Webb, DDS Treasurer: Dennis W. Hobby, DDS Secretary: Ronald B. Mead, DDS Speaker of the House: Matthew J. Campbell, Jr., DDS
Honors William Lundergan, DDS, MA, profes- sor and chair of the Department of Peri- odontics at the University of the Pacific School of Dentistry, has received the 2002 Pacific Distinguished Faculty Award. The award, given annually, recognizes one faculty member from the university who fulfills the highest aspirations of faculty service to students, colleagues, the profes- sion and the community.
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Loma Linda University School of Dentistry – From Dream to Reality
Charles J. Goodacre, DDS, MSD
Author n 1953, the Seventh-day Adventist Spiritual Values, Religion, Behavioral Church established Loma Linda Sciences Charles J. Goodacre, DDS, University School of Dentistry in Courses in this aspect of the curriculum MSD, is dean of the Loma Linda University School of response to a need. Seventh-day include the heritage of the Adventist Dentistry. Adventist dentists from across church and its focus upon health, personal Ithe country, who had attended many development, ethics, personal and family prestigious universities, dreamed wholeness, the art of integrative care, of establishing a dental school that interpersonal relationships, and community scheduled no classes or academic leadership. The personal development requirements on Friday night or course includes developing communication Saturday, our day of worship. The skills, managing stress, marriage and family founders also envisioned a curriculum relationships, financial management, openly incorporating spiritual values and substance abuse prevention and into the educational program. Over the management. A foundational ethics course years, students and faculty of many in the first year explores the central values faiths have found the mission of Loma that undergird the practice of dentistry, Linda University to be compatible with and a Web-based ethics course is in the their beliefs and lifestyles. Currently, process of being developed for predoctoral 27 nationalities and 28 religious faiths students in their clinical years. The are represented in the student body. University’s Faculty of Religion and Center Approximately 50 percent of the faculty for Bioethics provide strong curricular are Seventh-day Adventists and 50 support and develop practical applications percent come from other faiths. This of ethical principles. Formal coursework is diversity enhances our programs and supplemented by multiple opportunities strengthens our values. whereby students can apply their The educational process at Loma coursework through experiential activities. Linda’s dental school has always included In addition, an objective structured a special focus on spiritual values, clinical examination has been developed that religion, and the behavioral sciences. utilizes standardized patients to evaluate Therefore, when highlighting the students during phone conversations and characteristics of the School of Dentistry, personal interactions. The standardized these components of the curriculum serve patients evaluate communication skills, as an appropriate beginning. the student’s preparation for the clinical
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appointment, and interactions occurring have served in one or more of the overseas are provided with up to $20,000 per year for during the measurement of vital signs and mission clinics. five years to help pay off educational loans. completion of the medical history. In 1958, the school started a summer student outreach program in Chiapas, Clinical Education and Patient Care Service Learning Mexico, and it has grown to encompass Since the original faculty were many parts of the world. In 2000, 11 experienced practitioners who then Local Community Service summer experiences were provided to 11 made a commitment to dental education, In 1955, two years after the School of countries -- Armenia, Bolivia, Dominican substantial clinical patient treatment Dentistry opened, a program of off-campus Republic, Belize, Pakistan, Nicaragua, Peru, experience has always been one of the means community service was initiated in the Philippines, Korea, and Thailand/Burma. by which student competence is achieved. community of Mecca, Calif., near Indio, Students and faculty participated in service The School of Dentistry maintains an using mobile dental equipment. In 1998, trips. In 2001, there were 12 international active program of patient care in which a permanent clinical facility opened in service learning trips to Africa, Armenia, an average of 750 patients is seen each the Saul Martinez Elementary School in Bangladesh, Belize, Costa Rica, Fiji, Mexico, day. However, numbers of patients and Mecca; and over the past four years, School Nepal, Nicaragua, Peru, and the Ukraine numbers of experiences do not represent a of Dentistry students at this clinic have involving 70 students and 17 faculty. complete education. In addition to multiple provided approximately 2,500 children with Faculty Development clinical competency examinations, patient dental care. The initial faculty for the School of perceptions regarding the care they receive In 1966, the school established its first Dentistry were recruited using a relatively is important. A patient survey taken in 2001 permanent facility at Monument Valley, unique model. Drs. M. Webster Prince indicates that more than 70 percent of the Utah. This clinic served the needs of Native (first dean of the School of Dentistry), patients “strongly agreed” with statements Americans for the ensuing 30 years. More Claudis Ray, Al Burns, and others traveled indicating their student dentist or hygienist than 43,000 patients received dental throughout the United States in search was caring, honest, polite, cheerful, and care that otherwise would not have been of successful, experienced Seventh-day sought to produce excellent dental work. available. Adventist practitioners who were willing to Another 20 percent “agreed” with these In addition to the elementary school in make a commitment to a career in dental statements. A total of 94 percent of patients Mecca, the School of Dentistry currently education. The School of Dentistry provided “strongly agreed” or “agreed” with the provides dental care at two other local advanced education for these practitioners following statement: “I would trust my elementary schools as well as in two at multiple dental schools where special student dentist or hygienist to treat another volunteer clinics. Local service activity will be expertise was available in the various dental member of my family.” expanded this year through the addition of a disciplines. After completing graduate Treating the whole person is the most new mobile dental clinic. training, these recruits became the original important aspect of dental care, and faculty of the School of Dentistry. the School of Dentistry sees this data as International Service at LLU This tradition of developing faculty evidence that students have captured this International service has also been a through educational and professional vision. long-standing tradition of the School of growth opportunities has been sustained. Dentistry. In 1961, an alumnus from the During the 50 years of Loma Linda’s Implant Dentistry dental class of 1957 went to Seoul, Korea, existence, the School of Dentistry has Loma Linda University became the as the first missionary from the dental educated 106 faculty. Sixty-one of these first School of Dentistry to offer advanced school. In 1964, a new graduate became recruits received their advanced training education in the discipline of implant the second missionary by traveling to at other universities and 45 at Loma Linda dentistry. Dr. Robert James started this Blantyre, Malawi, and establishing a dental University. Twenty-nine of our current program in 1976. The first students observed clinic. These alumni engaged in long-term full-time faculty were educated through and assisted Dr. James as he placed mission service. The School of Dentistry this system, 15 of them within the past 10 implants. in conjunction with the Seventh-day years. Subsequently, the program transitioned Adventist Church currently operates and The Alumni Association provides the to a three-year master’s degree program in manages more than 70 mission dental school with substantial financial support which students learn both the prosthodontic clinics throughout the world. Many Loma for the specific purpose of reducing or and surgical aspects of care, including Linda students have the opportunity to eliminating the indebtedness of young advanced surgical procedures. Up to three work in some of these clinics. More than faculty who are making a commitment to a students are accepted into this program 260 graduates of the School of Dentistry career in academic dentistry. Young faculty each year. During the past 10 years,
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faculty and students from this program Other programs are in the developmental comprehensive education of students have contributed substantially to the stages. Online courses are currently used in and whole-person care of our patients. profession through research, publications, biochemistry, nutrition, caries management, nnOur students, staff, and faculty are presentations, and the development of new and orthodontics. empowered through an enabling clinical procedures that have enhanced the The Department of Orthodontics began environment that honors the dignity, quality of life for patients. the process of transitioning to a paperless, diversity, and worth of everyone. digital clinic in 1998. The modules of clinic nnOur graduates are exemplary Dental Anesthesiology management and diagnostic records were professionals and progressive clinicians In 1976, the Schools of Dentistry and completed in 2001. This year, the final of integrity. Medicine at Loma Linda University jointly phase of patient charting will be completed. nnOur Lord’s example inspires us sponsored Health Manpower Pilot Project In 2001, the first NewTom 9000 unit to to enrich our local and global #110. This legislation provided for the be installed in a dental school was placed communities through service. This is training of dentists in anesthesiology and in the Department of Orthodontics for our calling. their subsequent employment in academic the purpose of volumetric imaging. With medical institutions. In 1978, two School this unit, it is possible to obtain more Mission of Dentistry faculty members (Drs. David dimensional information about the orofacial A mission statement serves as the Anderson and Russell Scheult) completed complex with lower doses of radiation pathway to the vision describing what the a 24-month residency training program than is currently available through other organization intends to become, whom in medical anesthesiology. Their training, technologies. it is here to serve, and how it intends to along with the subsequent training of Dr. The school is committed to an ongoing serve. John Leyman, led to the establishment of a program of developing and analyzing a LLUSD seeks to further the healing and Department of Dental Anesthesiology and variety of electronic tools for providing teaching ministry of Jesus Christ wherein: the development of a graduate program in education. The goal is to develop an electronic nnStudents learn to provide high quality Dental Anesthesiology, which opened in core curriculum that will make available oral health care, based on sound 1984. Forty-four dentists have been trained curriculum time less focused on information biologic principles. thus far, and eight are currently enrolled. It is dissemination and more focused on subject nnPatients receive competent care, the largest program in the country training mastery. which is preventive in purpose and dentist anesthesiologists. comprehensive in scope, provided with Motto,V ision, and Mission compassion and respect. Information Technology The School of Dentistry’s motto, nnFaculty, students and staff value the In 1985, the School of Dentistry vision, and mission statements guide our patient relationship, respect diversity developed and implemented a computer educational focus and direct our plans for and share responsibility by working program to more effectively monitor student the future. together toward academic, professional, clinical progress, clinical experience, and spiritual, and personal growth. patient finances. In 1999, a commercially Motto nnScholarly activity and research provide a produced program replaced the initial “Service is our calling.” foundation for evidence-based learning program developed by the school. and enhance whole-person care. The first “on-line” continuing education Vision nnThe workplace environment attracts program was offered in 1998. In addition, A vision statement is about the best and retains a superior and diverse for the past two years, the third-year course that an organization can imagine becoming faculty and staff who motivate, educate, in implant dentistry has been based upon a at some point in the future. Although it is and serve. CD-ROM program developed at the School about the future, the most powerful visions nnOur communities -- local, global, and of Dentistry. This year, the CD-ROM will are written in the present tense as though professional -- benefit from our service, be made available to all dental students, we are standing at that point in the future stewardship, and commitment to advanced education students, and full- describing what we have become. It is in this lifelong learning. time faculty throughout North America sense that the School of Dentistry developed As Loma Linda University School of at no charge through an educational grant its Vision 2005. Dentistry charts its course for the future, from Nobel Biocare. Additional CD-ROM nnLLUSD is a pre-eminent health care we will endeavor to have our aspirations and programs have also been developed -- The organization seeking to represent God accomplishments exceed our limitations. Principles of Tooth Preparation and a in all we do. We are enthusiastically four-part financial management series. committed to excellent, innovative,
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Reducing Bacterial Counts in Dental Unit Waterlines: Distilled Water vs. Antimicrobial Agents
James D. Kettering, PhD; Carlos A. Muñoz-Viveros, DDS, MSD; Joni A. Stephens, RDH, EdS; W. Patrick Naylor, DDS, MPH, MS; Wu Zhang, MD
abstract Background. This study evaluated five chemical disinfectants to compare their abilities to improve dental unit waterline quality and assess their effects, if any, on the biofilm layer. Methods. Sixty new dental units, with a closed-circuit water system, were used to compare microbial levels in DUWLs treated with five antimicrobials: Listerine, Bio 2000, Rembrandt, Dentosept, and sodium fluoride to a control group of authors sterile distilled water alone over a six-week period. For all units, the waterlines were filled with solution, left overnight, and then flushed for 30 seconds with sterile distilled James D. Kettering, PhD, is professor water the following morning prior to patient treatment. Waterlines were examined for of microbiology and molecular genetics at the biofilm buildup using scanning electron microscopy and colony-forming-unit counts. Schools of Medicine and Dentistry at Loma Linda Results. The sodium fluoride and the four chemical antimicrobials reduced the microbial University. count to 200 cfu/ml or less. Only samples taken from dental units receiving the control Carlos A. Muñoz-Viveros, treatment (distilled water with no added antimicrobial) failed to meet ADA’s stated DDS, MSD, is professor and director of the Center goal. Examination of the SEMs revealed an apparent decrease in the biofilm mass but for Dental Research at LLU School of Dentistry. not elimination, despite repeated treatment with the four antimicrobial materials.
Joni A. Stephens, RDH, Conclusions. Even in a closed-circuit water system, distilled water alone cannot reduce EdS, is a professor of dental hygiene at LLU microbial contamination of dental treatment water from dental unit waterlines to School of Dentistry. the 200 cfu/ml ADA stated goal. However, water treated with Listerine mouthrinse, W. Patrick Naylor, Rembrandt mouthrinse, Bio 2000, 0.5 percent sodium fluoride, and Dentosept, it did DDS, MPH, MS, is an adjunct professor in meet microbial reduction goal. The biofilm apparently was reduced in volume, but not the Department of Restorative Dentistry at entirely eliminated. Clinical Significance. The ADA goal of a maximum of 200 cfu/ml LLU School of Dentistry. was achieved using any of five chemical antimicrobials and distilled water in a closed- Wu Zhang, MD, is an water system. Despite the successful reduction in microbial contamination of the dental assistant professor in the Department of Dental treatment water, the biofilm was not completely eliminated. Biofilm elimination and Educational Services at LLU School of Dentistry prevention would be needed through some other means.
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number of reports have (Bio2000, now marketed under the name been published on the issues of BioBLUE, manufactured by Micrylium surrounding microbial Laboratories, Inc, Phoenix, Ariz.) was contamination of dental unit found to be effective in achieving the waterlines and techniques to recommended reduction of microbial Aachieve the American Dental Association contaminants to 200 cfu/ml in dental unit stated goal of 200 colony forming units waterlines while a 5.25 percent sodium for dental treatment water.1-16 Kettering hypochlorite (0.31 percent dilution of and colleagues15 demonstrated the household bleach) was not. But several critical role water source selection plays questions remained. Do differences exist in achieving this 200 cfu/ml goal. In this between antimicrobial products? If so, study, bacterial contamination of dental which products can be used for DUWL unit waterlines was affected by water treatment? What effects, if any, do these source selection (tap water vs. sterile chemical products have on the biofilm that distilled water), the system design (open forms over time in dental unit waterlines? system drawing tap water vs. a closed This study was undertaken to assess the system using bottled, sterile distilled effectiveness of sodium fluoride and four water), and whether the waterlines were commercially available materials marketed treated with chemical disinfectants.16 as antimicrobial agents. Unfortunately, the actual mechanics for consistently obtaining and Materials and Methods maintaining dental unit waterline quality Sixty new dental units with a closed- have been left to the research community circuit water system (Adec, model Decade to determine. It has even been argued 1021) were used in this study. Water that dental unit manufacturers should samples were collected from the air/water provide the profession with remedies syringe and the high-speed handpiece to meet the waterline quality standards waterlines at baseline and two, four, and rather than dental clinicians doing so.18 six weeks. Prior to the initiation of the Regardless of where the answers to this study, the dental units were used with tap problem might come from, the costs water for two weeks without any other and responsibilities for addressing this treatment. At the start of the study, the multifaceted subject remain with the end water bottle containers of each dental user -- the clinician. unit were sterilized. The day the samples Even if dental units were redesigned were collected from the waterlines, the to prevent microbial contamination of lines were flushed for 30 seconds, and dental treatment water, conversion to approximately 50 ml of water was these new systems would be both slow collected in a sterile, plastic container. and costly. So research must continue to All the samples were collected at noon. evaluate techniques and products that can When the collection was completed, provide water quality with existing dental no handpiece or syringe tip was used equipment that meets or exceeds the because the authors did not want to ADA goal. Achieving this goal reduction introduce another potential source of will not only benefit the dental profession contamination and/or variable. For all but also reassure patients as to the quality units, the waterlines were filled with and safety of dental treatment water. solution, left overnight, and then flushed In Kettering and colleagues, 16 for 30 seconds with sterile distilled water 0.12 percent chlorhexidine gluconate the following morning prior to patient
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treatment. During the day, all the dental microbiology laboratory. The specimens nnGroup 2 -- original Listerine units used sterile distilled water in the were stored at 4 degrees Celsius and mouthrinse; bottle containers. No municipal tap water cultured within 24 hours. nnGroup 3 -- 0.5 percent sodium fluoride; was used at any time during this portion The dental units were randomly nnGroup 4 -- Rembrandt mouthrinse; of the investigation. Careful attention assigned to one of the following six nnGroup 5 -- Bio2000 (Now called was paid to avoid possible contamination groups (Table 1) with 10 units in each BioBLUE) (0.12 percent chlorhexidine of the water when the samples were group: gluconate); and collected. After collection, the water nnGroup 1 -- sterile distilled water with no nnGroup 6 -- Dentosept. samples were immediately sent to the antimicrobial (control group);
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Microbial Culturing Protocol Each water container was labeled but coded so the evaluators were blind to its contents. The labeled water samples were mixed by vortexing for 30 seconds. Fifty μl of liquid was removed and added to 100 ml of sterile, deionized water (Suspension 1). One hundred μl was removed from suspension 1 and added to a second 100 milliliters of sterile water (Suspension 2). Each addition was mixed thoroughly. The 100 ml suspensions were filtered through separate 47 mm membrane filters (MicroFunnel, Gelman Sciences, Ann Arbor, Mich.), and the filter was removed aseptically to a sterile R2A agar plate (R2A Agar, Difco, Becton Dickinson Microbiology Systems, Sparks, Md.). The plates were incubated at room Figure 1. Air/Water Syringe Waterline (Colony Forming Units) temperature for five days. Bacterial colonies were counted by one investigator and dilution factors applied (20 for Suspension 1 and 2000 for Suspension 2) to obtain cfu/ml values. In an effort to evaluate the presence or absence of a biofilm, 2 cm sections of waterline were removed from two samples from each group, air dried for 24 hours, and sputter-coated with gold for viewing in a scanning electron microscope. The samples were examined in a Phillips scanning electron microscope XL30, and photomicrographs were taken at 8000x magnification.
Statistical Methods A one-way analysis of variance was performed to evaluate the change in cfu/ ml over time for each of the five treatment groups (p<0.05). When differences were found, a Student-Newman-Kuels all pairwise multiple comparison was used to identify those differences.
Figure 2. High-Speed Handpiece Waterline (Colony Forming Units) Results The study results for the comparison of outcomes for Groups 1 to 6 are presented in Table 2 and illustrated graphically in Figures 1 and 2 for the dental handpiece and the air/water syringe waterlines, respectively. All three mouthrinses
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Figure 3. Scanning electron micrograph of new tubing Figure 4. SEM of biofilm buildup in the dental unit Figure 5. Biofilm buildup in the air/water syringe prior to placement in the dental unit (8000x magnification). waterline after four weeks of use with tap water (50x waterline tubing at baseline (8000x magnification). magnification).
Figure 6. Biofilm buildup in the handpiece waterline Figure 7. Biofilm buildup in the handpiece waterline Figure 8. Biofilm buildup in the handpiece waterline tubing after six weeks of treatment with Bio 2000 (8000x tubing after six weeks of treatment with distilled water tubing after six weeks of treatment with Listerine (8000x magnification). (8000x magnification). magnification).
count for Group 1 declined substantially, There did not appear to be any but the count was well more than the correlation between the amount of ADA standard. biofilm present and the number of viable Over the course of the entire six-week microorganisms for any of the groups. All test period, all scores for the test groups the SEM indicated a significant amount were at or near zero cfu’s, except for Week 2 of biofilm in the water lines, despite and Week 4 for the Bio2000. This anomaly the reduction in colony forming units during Week 2 for the Bio2000 resulted in (Figures 3 through 9). Figure 3 illustrates a microbial count of 46,348 cfu/ml for the what the intaglio surface of new tubing Figure 9. Biofilm buildup in the handpiece waterline air/water syringe and 8,060 cfu/ml for the received directly from the manufacturer tubing after six weeks of treatment with Rembrandt (8000x handpiece after two weeks. In contrast, all should look like. At magnification of magnification). of the other samples for the other four test 8000x, this area of the tube is not smooth groups had essentially zero colony counts. but has a rather an undulating surface, (Listerine, sodium fluoride, and This outcome was believed to be due to which might contribute to biofilm Rembrandt) and the two antimicrobials a lapse in sterile technique rather than a accumulation (Bio2000 and Dentosept) reduced the breakdown of the chemical product. All bacterial count to 200 cfu/ml or less. All five treatment group samples essentially Discussion values were well within the American returned to zero bacteria counts from It is apparent that water source Dental Association recommended level of Week 3 to Week 6. selection played a vital role in achieving 200 cfu/ml (Table 1). Only samples taken Examination of the SEMs revealed an consistent disinfection of water run from dental units receiving the control apparent decrease in the biofilm mass, but through dental unit waterlines. Sterile treatment of distilled water with no added a portion of the biofilm remained intact distilled water in combination with a antimicrobial (Group 1) failed to meet the despite repeated treatment with the four chemical antimicrobial was found to be ADA goal. At the end of six weeks, the cfu chemical antimicrobials (Figures 3 through 9). an effective combination for achieving
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the ADA waterline quality goal of 200 cfu/ biofilm, long-term effectiveness of 6. A biofilm was detected in the ml or less. Results from this investigation antimicrobials, effects of these products waterline samples for all the dental units. indicated that all five products tested on restorative materials (the bond While the biofilm may have been reduced achieved the desired level of microbial strength of composite resins, color in size (volume) as a result of treatment, decrease for both air/water syringe and changes of tooth-colored restorations, it was not eliminated by any of the dental handpiece waterlines. Moreover, etc.), and the effects of routine use on antimicrobial rinses used in this study. the reductions were dramatic. Bacterial the longevity of dental handpieces and counts were maintained at the near zero ultrasonic scalers. References 1. Blake GC, The incidence and control of bacterial infection of level during this six-week period with It should be noted that the products dental unit and ultrasonic scales. Br Dent J 15:413-6, 1963. the sole exception of Week 6. The high used in these study are marketed 2. Williams JF, Johnston AM, et al, Microbial contamination colony counts in Week 2 were believed to as antimicrobial agents and not as of dental unit waterlines: prevalence, intensity and microbiological characteristics. JADA 124(10):59-65, 1993. be due to a handling error that resulted disinfectants and should be used 3. Mills SE, The dental unit waterline controversy: defusing the in the contamination of the water sample. according to the manufacturer’s intended myths, defining the solutions. JADA 131:1427-41, 2000. The source of the contamination was use and directions 4. Shearer BG, Biofilm and the dental office. JADA 127:181-9, 1996. not known, but the authors presumed 5. Miller CH, Microbes in the dental unit water. J Calif Dent that it occurred during water collection Conclusions Assoc 24(1):47-52, 1996. or because someone may have touched Based on the testing format and the 6. Kono G, The dental waterline controversy. Dent Today 15(8):82-5, 1996. the tube that goes in the bottle reservoir, materials used in this study, the following 7. Atlas RM, Williams JF, Huntington MK, Legionella accidentally contaminating the sample. conclusions were drawn: contamination of dental-unit waters. Appl Environ Microbiol These findings provide additional 1. Sterile distilled water alone cannot 61(4):1208-13, 1995. 8. Jensen ET, Giwercman B, et al, Epidemiology of support for the conclusion that water reduce microbial contamination of dental Pseudomonas aeruginosa in cystic fibrosis and the possible source selection may play a pivotal role in treatment water from dental unit waterlines role of contamination by dental equipment. J Hosp Infect the disinfection of dental unit waterlines. to the 200 cfu/ml ADA stated goal. 36:117-22, 1997. 9. Santiago JI, Huntington MK, et al, Microbial contamination It is believed that the American Dental 2. Dental units with a closed water of dental unit waterlines: short- and long-term effects of Association recommended goal of 200 system met or exceeded the American flushing. Gen Dent 48:528-44, 1994. cfu/ml can, in fact, be achieved for dental Dental Association goal of 200 cfu/ml 10. Karpay RI, Puttaiah R, et al, Efficacy of Flushing Dental Units for Different time Periods. (IADR abstract 3366) J Dent treatment water with existing dental units. when sterile distilled water was treated Res 76:434, 1997. But to consistently achieve this reduction, with any one of the following products: 11. Williams HN, Kelley J, et al, Assessing microbial three essential criteria must be met: Listerine mouthrinse, 0.5% sodium contamination in clean dental units and compliance with disinfection protocol. JADA 125:1205-11, 1994. nnThe dental unit must have a closed fluoride, Rembrandt mouthrinse, Bio 12. Kettering J, Muñoz C, et al, Comparison of methods for water system, 2000 (Now BioBLUE), or Dentosept. reducing dental unit waterline bacteria and biofilm. Abstract nnA chemical antimicrobial in conjunction 3. Microbial reduction of dental unit (AADR abstract 3371). J Dent Res 76:435, 1997. 13. Murdock-Kinch CA, Andrews NL, et al. Comparison of with sterile distilled water must be waterlines can be achieved using 100 dental water quality management procedures. JADA 128:1235- used; and percent of any of the five antimicrobial 43, 1997. nnThe closed-water system must products tested and no distilled water, 14. Meiller TF, DePaola LG, et al, Dental unit waterlines: biofilms, disinfection and recurrence. JADA 130:65-72, 1999. be properly maintained to avoid but such a protocol would be more costly 15. Kettering J, Stephens J, Muñoz CA, Use of antimicrobial contamination of the sterile distilled than one involving a dilution with sterile rinses for reducing bacterial counts in dental unit waterlines. water and the dental unit water bottle. distilled water. (AADR abstract 287). J Dent Res 77(A):141, 1998. 16. Kettering JD, Stephens JA, et al, Reducing bacterial There was no correlation between 4. Given the equivalent performance counts in dental unit waterlines: tap water vs distilled water. the amount of biofilm present and of the antimicrobial products tested in J Contemp Dent Practice Accepted for publication, summer the reduction in colony forming units. this study, strong consideration should 2002. 17. Costerton JW, Lewandowski Z, et al, Microbial biofilms. Ann Figure 3 illustrates the inside surface of be given to the cost of each product. Rev Microbiol 49:711-45, 1995. new tubing at high magnification. The 5. Additional research is 18. Christensen R, More about waterlines. Letters. J Am Dent tube is not smooth but has a rather recommended to assess patient Assoc 132:142-6, 2001. To request a printed copy of this article, please contact: James an undulating surface, which might acceptance of water taste, corrosion of D. Kettering, PhD, Loma Linda University, Loma Linda, CA contribute to biofilm accumulation. dental equipment, prevention and/or 92350, or [email protected]. Additional research is recommended elimination of the biofilm, long-term to evaluate individual commercial effectiveness of the antimicrobials, products for patient acceptance of water effects on restorative materials, and the taste, corrosion of dental equipment, impact of routine use on the longevity of prevention and/or elimination of the dental handpieces and ultrasonic scalers.
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UCLA School of Dentistry: Successes, Challenges and Opportunities
No-Hee Park, DMD, PhD
author he University of California at I am extremely proud of the No-Hee Park, DMD, PhD, Lost Angeles School of Dentistry accomplishments of our school. It is is dean of the University of has a vision to be one of the essential to note that our successes do not California at Los Angeles most respected dental schools always come easily. In this article, I have School of Dentistry. in the nation. Encompassed in highlighted some of accomplishments Tthis vision are the school’s core ideology and some of our significant internal and (core purpose and core value) and an external challenges. envisioned future. The core purpose of the UCLA School of Dentistry is to Student Admissions improve the oral health of the people On a consistent basis, the UCLA of California and the United States. We School of Dentistry admits one of the top seek to accomplish this purpose with classes academically among all 54 dental the school’s core values of integrity, schools. The Class of 2005, admitted in collegiality, care, allegiance of disciplines, September 2001, is no exception. This and academic freedom. More specifically, class had an average GPA of 3.61 and the school makes an effort to carry out scored close to the 95th percentile on the core purpose through the following the academic portion of the Dental means: Admission Test. It is important to note nnEducating and training individuals who that we do not rely on scores alone will provide the highest quality dental for our decision-making regarding care with established and new bases of admissions. We have recently reinstated knowledge; the personal interview in the admission nnConducting outstanding research into process because we believe that personal the cause, prevention, diagnosis, and interviews complement the review of an treatment of oral and craniofacial applicant’s academic record and assist us diseases and abnormalities; and in identifying the applicants most likely nnOffering services to the community to possess the personal skills required including patient care services, to successfully complete our rigorous educational programs, and expertise. educational program. Our envisioned future is that the There are a number of factors that achievements of the school with respect contribute to our success in recruiting. to teaching, research, and service be These factors include the reputation recognized for, if not synonymous with, of the School of Dentistry, reasonable excellence. tuition, excellent faculty, and the
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reputation of UCLA. Other important students. This represents a divergence advanced prosthodontics, oral biology contributing factors include our graduates’ from the traditional didactic instruction and medicine, oral and maxillofacial successful acceptance rate into excellent characteristic of most dental schools. surgery, orthodontics, combined residency/postgraduate programs and This shift in philosophy is a challenge not orthodontics-pediatric dentistry, public the achievements of our graduates, who only for our faculty (who must find the health and community dentistry, excel not only in the practice of general time to develop and implement these restorative dentistry, and the Dental dentistry, but also in varied specialties methodologies sometime between their Research Institute. The school was and in unique leadership positions. other teaching, research, and clinical pleased to attract a highly qualified and obligations), but also for our students competitive group of applicants for Student Performance who tend to be resistant to these less these positions. It is clear, however, that Throughout the four years of the traditional teaching styles and learning advancement opportunities are critical for dental education program, our students techniques. An additional barrier is retention of faculty. We are pleased that meet high standards of performance. One that problem-based and service-based we were able to promote several members measure of student performance is the learning require an increased number of of the faculty. National Board Dental Examination, the faculty members to provide appropriate Although we have been successful standard exam that provides the nation’s supervision, resulting in an increased with our efforts to recruit and retain dental schools with benchmarks of their number of required full-time-equivalent faculty, we are continually faced with the educational progress and excellence. positions. Given our limited resources, we challenge of identifying and obtaining UCLA dental students consistently rank seek the involvement of volunteer clinical adequate resources for faculty recruitment in the top five among dental schools in faculty. The students greatly appreciate and support. In particular, we must performance on the National Boards the real-world experiences shared by provide the current ladder-rank faculty Part I. In addition, UCLA graduates have these faculty members. with the resources necessary to teach and performed exceptionally well on the conduct research. A second challenge is California Dental Board exam, reflecting Financial Concerns of Students the fact that our faculty is aging. We must the clinical training they received while Debt is one of the greatest challenges identify resources to hire new faculty to students. A third indicator of the success facing our students. The average ensure an appropriate transition plan that of the academic program is our students’ indebtedness of our 2001 graduating will minimize the loss of institutional high rate of placement in residency/ class members was $78,000. Eliminating knowledge and expertise of these postdoctoral programs. For example, the students who were able to pay invaluable faculty members. Finally, we approximately 60 percent of the graduates for their schooling without loans, the face the challenge of attracting graduates from the Class of 2002 were accepted to average indebtedness was nearly $85,000. to enter academia. As mentioned above, residency/postgraduate programs; in fact, This is an insurmountable sum, which debt serves as a primary deterrent close to 90 percent of those graduates serves to limit the options of our for graduating students to pursue an who applied for such programs were graduating students. This oppressive academic career. One way we have sought accepted. This statistic is particularly debt discourages these graduates from to address these challenges is through impressive given the fact that the number pursuing careers in academia, entering the establishment of endowed chairs. We of open slots for residencies is far less solo practices, and purchasing practices of have recently implemented the Tarrson than the number of applicants. retiring dentists. Family Endowed Chair in Periodontics Although our teaching program has To alleviate our students’ debt and established the Dr. Jack A. Weichman been successful -- as demonstrated by obligations, we have increased our Endowed Chair in Endodontics and the our students’ scores, acceptances to development campaigns for various Dr. Thomas R. Bales Endowed Chair in residency/postdoctoral programs, and student scholarships, with positive results. Orthodontics. I have every intention of job placements -- we recognize that We consistently seek and communicate pursuing additional funding to increase there is a critical need to incorporate opportunities to our students regarding the number of endowed chair positions. new instructional methods and scholarships and debt forgiveness. technologies into the curriculum. The Faculty Recruitment and Retention Research and Creative Activities integration of problem-based and The UCLA School of Dentistry The UCLA School of Dentistry service-based learning methodologies continues to undertake a number of has outstanding sponsored research and clinical simulation technologies significant recruitments and academic activities. We continued to advance into the curriculum will provide an even personnel actions. Among the areas science in traditional areas and to better educational experience for our of recruitment in the past year were create new research opportunities in
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nontraditional areas of inquiry. Our and donations from friends to build the information system. This system is to be research, traditionally individually Jane and Jerry Weintraub Center for utilized for clinical management with an focused, has expanded in recent years to Reconstructive Biotechnology, a 5,000 electronic medical record feature, student multidisciplinary and interdisciplinary square foot state-of-the-art research instruction, research, and evaluation. efforts. Research currently being facility for basic, translational, and The School of Dentistry partnered with conducted at the UCLA School of clinical research. In addition to the Software of Excellence to develop and Dentistry can be categorized into six Weintraub Center, the school also has implement the first phase of the new major areas: two other research centers: the Dental management information system. nnOral cancer and carcinogenesis research Research Institute and the Center for Oral – Topics falling under this area include Microbiology Research. Community Relations early detection of head and neck cancer The UCLA School of Dentistry’s using biomarkers, mechanisms of Clinic Operations and Specialty involvement with the community is not carcinogenesis, signal transmission Training Under Graduate Medical limited to providing services at our dental studies in oral cancer, oral cancer and Education Program centers. The school has taken a leadership immunology studies, bioengineering The school operates a 200-chair dental role in a number of community-based studies in oral cancer, and gene therapy center at the Westwood campus and initiatives such as community-based for oral cancer. additional clinics at the Wilson-Jennings- screening, oral hygiene instruction, and nnOral microbiology research -- Topics Bloomfield UCLA Venice Dental Center sealant programs. falling under this area include and the UCLA Children’s Dental Center We are proud of the school’s molecular biology studies in dental at the Edward R. Roybal Comprehensive community service accomplishments caries, motility of bacteria, and the role Health Center in East Los Angeles. We are to date and hope that future state of oral bacteria in the development of known as a safety-net provider, offering budgetary constraints will not hinder our systemic diseases such as myocardial inexpensive comprehensive care to low- ability to expand our community service infarction and diabetes. income or indigent residents of Los Angeles. activities in both the Los Angeles and San nnOral health disparities research – In addition to the student clinics, Fernando Valley communities. Topics falling under this area include the school has a number of specialty minority oral health disparities with clinics that train future specialists New Academic Programs caries, orofacial trauma, and HIV through residency programs. These We recently established a combined infection. specialties include advanced education in DDS/MBA program, which is a nnBone biology, tissue engineering general dentistry, dental anesthesiology, collaborative effort with the Anderson and biomaterials research –Topics endodontics, general practice residency, School at UCLA. In this five-year program, falling under this area include the maxillofacial prosthetics, oral and students attend classes at the Anderson molecular basis for craniosynostosis maxillofacial surgery, orofacial pain School after completing three years at the and craniofacial development, the and dysfunction, orthodontics, School of Dentistry and then return to molecular basis for tissue damage and pediatric dentistry, periodontics, and dentistry to complete their fourth year. In repair processes, the mechanisms of prosthodontics. These residency programs the 2001-02 academic year, the first dental bone formation and resorption, the have operated under the Graduate student was admitted into the combined mechanisms of collagen formation, Medical Education Program for the past DDS/MBA Program. early detection of osteoporosis using seven years, providing stipends for the We are also pleased to inform you X-rays, and allergies and dental residents. In addition to the specialty that the school has just established a materials. clinics, we also have various faculty clinics, formal DDS/PhD program. Beginning nnHealth services research – Topics including faculty group dental practices in fall 2002, there will be two slots per falling under this area include research and faculty clinics specializing in hospital year for students interested in pursuing regarding outcomes, quality assurance, dentistry, maxillofacial prosthetics, oral a joint DDS/PhD. We hope this program and access to oral health care. and maxillofacial pathology, oral and will encourage the development of future nnClinical research -- Topics falling under maxillofacial radiology, oral maxillofacial faculty. this area include clinical drug trials, surgery, oral medicine, orofacial pain, and The school has also established material testing, biocompatibility periodontics. a two-year Professional Program for research, and clinical outcome studies. We have strived to bring our clinical International Dentists for graduates of The school is pleased to have secured operations into the 21st century with the non-U.S. dental schools in response to National Institutes of Health funding implementation of a new management an appeal from the California Legislature.
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This program is part of the phase-out of the California “bench” exam for foreign- trained dentists. The goal of this program is to graduate dentists who will possess the necessary scientific knowledge and clinical skills to provide competent comprehensive dental care as practiced within the United States. Graduates of the program will be eligible to take the dental licensing examinations throughout most of the United States. The first entering class of six students began June 24, 2002. For each year hereafter, we anticipate accepting 10 students. I hope this article has provided you with some insight regarding the activities at the UCLA School of Dentistry. As is evident from the description above, there are many successes, challenges and opportunities as the UCLA School of Dentistry continues to fulfill its mission. I am both proud and honored to serve as dean of this institution during this exciting time.
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The School of Dentistry at the University of California, San Francisco: Service to Humanity
Charles N. Bertolami, DDS, DMedSc
author UCSF defines its mission as the educational philosophy and curriculum. Charles N. Bertolami, achievement of excellence in teaching, Thus, the school’s mission is to establish DDS, DMedSc, is research, patient care, and public service. For the highest quality academic environment professor of oral and many years, UCSF has been world-renowned for development, application, and maxillofacial surgery and dean of the School of for scientific discovery and research, teaching, dissemination of knowledge necessary to Dentistry, University of and innovative delivery of health care. prevent, treat, or cure orofacial diseases California, San Francisco. However, we are not satisfied to rest on our and malformations. reputation. Our faculty and administration are both catalysts for and responsive to History and Setting scientific, social, and economic changes, and The founding of the School of are committed to preparing students for Dentistry at the University of California, careers in a rapidly changing environment. San Francisco, occurred in 1881 when -- J. Michael Bishop, chancellor Samuel W. Dennis petitioned the regents of the University of California to permit Mission the formation of a dental department. The dental profession, like the other From its inception, the School of healing arts, is best understood as a Dentistry was a component of the calling to help people in need, doing so University of California. in a highly specialized way. The lofty It patterned itself after and was assisted goal of service to humanity -- whether by the existing dental schools at Harvard through patient care, research, or teaching University, the University of Pennsylvania – remains the keystone of the dental (of which the founding dean was an programs at the University of California alumnus), and the University of Michigan. at San Francisco. After the school had been announced as an Recognizing the importance of the integral part of the university, donations dental profession in serving the public were solicited from the city’s practitioners; and promoting a healthy and humane and their generosity yielded $510 -- enough society has penetrated the school’s core to furnish the clinic, lecture rooms, library, identity and has deeply influenced our and a pathologic museum.
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Today, 121 years later, the school education unit provides cutting-edge United States for each of the past 10 is located on the UCSF campus in courses for dental professionals, both on years, with an overall research budget the Parnassus Heights region of San our home campus and in outreach venues today of approximately $25 million. This Francisco -- one of nine campuses making as well. decentralized organization is illustrated up the University of California system, Central to the school’s and the only one dedicated exclusively clinical educational to the health sciences. The campus as a and service programs whole consists of four research-intensive are its 14 dental clinics, professional schools -- dentistry, medicine, which are responsible nursing, and pharmacy -- and a graduate for more than 130,000 division. Also at the Parnassus site are patient visits per year two acute-care hospitals, a psychiatric and generate roughly $12 hospital, and one of the largest million in clinical income. ambulatory care facilities in California. Our predoctoral UCSF enterprises are distributed curriculum offers dental throughout the city, including subsidiary and dental hygiene campuses at the UCSF/Mt. Zion Medical students the opportunity Center; a Laurel Heights campus; a to become outstanding community dental clinic on Buchanan clinicians and seeks to Street; and active clinical sites at our cultivate in them the affiliated institutions, San Francisco self-identity of being General Hospital and the San Francisco men and women of Veteran’s Administration Hospital. During science. The intent is to 2002, a major new campus -- nearly the train competent dentists size of the Parnassus site -- will open in and dental hygienists the Mission Bay section of San Francisco. who understand the relationship between Academic Program: Dental Predoctoral, the craniofacial complex Postgraduate, and Graduate Academic and the rest of the The school admits 80 students per body and who see year into its four-year DDS curriculum, themselves as contributing significantly in Table 1. 18 students per year into its two-year to improving oral health by integrating In addition to programs based in our bachelor’s degree in dental hygiene basic, behavioral, and clinical sciences four departments, the internationally curriculum, 15 students per year into its for individuals and communities. Our known Center for the Health Professions unique Postbaccalaureate Program, and postgraduate and graduate academic is administered by the UCSF School of 16 students per year into its International programs aim to educate clinicians in the Dentistry. Dentist Program. Advanced educational various dental specialties as well as to Space does not permit detailing the programs (postgraduate and specialty) are become educators and scientists. plethora of research projects in which our offered in general dentistry, orthodontics, Organization and Funding of faculty are engaged, but it is important to pediatric dentistry, periodontology, Academic and Research Programs emphasize that much of this research is prosthodontics, oral medicine, dental Organizationally, the school is clinically based and aimed at improving public health, endodontics, and oral/ highly decentralized, consisting of the practice of dentistry, not only here at maxillofacial surgery. Soon, the school four departments which, in turn, are home, but abroad as well. will initiate a hospital-based General composed of 15 divisions. The structure In addition, UCSF School of Dentistry Practice Residency program. has allowed the school to be highly considers itself the research institution In collaboration with the campus’s responsive to opportunities in an with a heart, so many of our research Graduate Division, the school offers ever-changing environment. By way of projects are aimed at doing our part to try graduate academic programs such as example, the UCSF School of Dentistry to improve the human condition. the master of science and the doctor of has ranked first in overall National UCSF Dentistry’s Oral AIDS Center is philosophy degrees in oral biology. Our Institutes of Health research funding one of the word’s leading centers for the community relations and continuing among the 55 dental schools in the study of the oral manifestations of HIV
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infection. Research to fight this terrible enrollment is 12 percent. We operate a and behavioral sciences. Students are health problem is not a new commitment number of outreach and recruitment placed in research laboratories of faculty on the part of our UCSF faculty: the Oral programs designed to increase the with well-funded, highly organized AIDS Center was established in 1986 by numbers of economically disadvantaged research programs. a group of investigators and clinicians students and students from underserved The UCSF Undergraduate Mentorship who had been working together since the areas. These programs augment our Program allows undergraduate college early days of the AIDS epidemic. Director involvement in local career fairs, students, primarily from economically Dr. John Greenspan pointed out “The recruiting visits to high schools and disadvantaged backgrounds, to spend an Oral AIDS Center comprises many of the colleges, and our Dental Aptitude Test intensive seven-week summer session leading clinicians and investigators in the preparation course. working with dental school faculty on field of oral and dental aspects of AIDS; The centerpiece is the clinical and research projects. The goal of several of these people were responsible Postbaccalaureate Program -- the only the program is to target potential applicants for the discovery of hairy leukoplakia, its one in dentistry in the United States. for dental school at an early phase in their association with Epstein-Barr virus, and its Admitting 15 students per year, the undergraduate academic development, to relationship to HIV infection and AIDS.” program targets disadvantaged students foster an appreciation and understanding “Our group,” Greenspan added, who have failed to gain admission to a U.S. of the dental profession, to understand the “was among the first to describe the dental school. The one-year curriculum process of becoming a health care provider, periodontal infections associated with provides both residential and academic and to become familiar with the UCSF HIV. Also, we were the first group to experiences to increase academic School of Dentistry. The program accepts initiate a systematic study of the oral competitiveness. In the four years of 30 college students each year from targeted features of simian AIDS.” the program’s existence, 100 percent of colleges throughout the country that have In addition to the Oral AIDS Center, postbaccalaureate students successfully a partnership with the UCSF School of the UCSF AIDS Specimen Bank was gained admission to at least one U.S. Dentistry. created more than 20 years ago. Yvonne dental school. De Souza, assistant director of the Other programs include the Dental Community Service Specimen Bank, explained its function as Mentorship Program, which is designed UCSF has a history of community “a repository for tissue biopsies and serum for students who have an interest in service dating back to the 1906 specimens for investigators involved in the health professions and who wish to earthquake and fire that destroyed the search for the causative agent of this participate in career exploration activities. much of San Francisco: Dental students disease.” It provides students with limited and faculty helped care for the injured. There are many other examples hands-on experience in a clinical setting, Building on that tradition, today’s dental as well, including the school’s NIH- matching them with a faculty or dental students are active participants in funded Comprehensive Oral Health student mentor. Up to 25 students are community service activities, expressed Research Center of Discovery, directed selected to participate each academic year. most commonly through the school’s by Dr. Caroline Damsky; its new $11 The UCSF Health Sciences Enrichment consistent tradition of providing care for million Center to Address Disparities Program is a six-week residential summer the indigent. in Children’s Oral Health, under the offering designed to increase the math Inasmuch as our patients are largely direction of Dr. Jane Weintraub; its Oral and science proficiency of economically people on public assistance, people on Cancer Research Center, headed by Dr. disadvantaged high school students. This fixed incomes, and the working poor, fees Randall Kramer; and several NIH-funded is done in the hope that they will become in our student clinics are set at 50 percent research training initiatives, under Dr. more academically competitive in college to 75 percent of that of community Grayson Marshall. and, ultimately, consider applying to practitioners. Eighteen percent of our dental school. Students are recruited from overall clinical income is from DentiCal, Diversity and Outreach three UCSF partnership high schools in with some of our clinics posting DentiCal Our school strives to assemble a San Francisco and two in Oakland. income in the 36 percent to 59 percent diverse student body that accurately The UCSF Summer Research Training range. In 2001, 53 percent of DentiCal reflects the population of California. At Program is an intensive 10-week summer procedures done at all California dental present, 45 percent of DDS students experience for undergraduate college schools were done at UCSF. are women. Total minority student students designed to address the The most popular elective course in enrollment is 67 percent; total under-representation of minorities and the school is one that allows students underrepresented minority student disadvantaged students in the biomedical to take part in a clinic for the city’s
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homeless; roughly 100 dental and dental sites convenient to all neighborhoods original manuscript and for making hygiene students participate each year. of the city and are fortunate to have useful additions. Visiting citywide shelters, students have internationally renowned faculty and the opportunity to conduct screenings students who are well-experienced in and interviews for approximately 80 providing expert, sympathetic treatment to 100 patients per month. Following to patients with HIV disease. The program the screenings, selected patients are is funded under a Title I Ryan White transported to campus one night a week contract with the city of San Francisco to for operative care provided by students provide $434,000 per year of dental care supervised by volunteer faculty. There to HIV-infected city residents. is no charge for the services, since the Our Alumni and Our Mission students raise money for supplies and One of the important outcomes supervising faculty are volunteers. measures of any school of dentistry Students who provide this care do is the quality of its human product: so voluntarily. “It is hard to motivate its graduates. Our graduates evince a yourself to come to the clinic for the commitment to lifelong learning and homeless on the one Thursday night a service to others. month when I don’t have to be in the “Continuing to learn keeps us clinic for school,” said fourth-year student energized in our profession,” said Rob Gladys Lim. “But then I remember how Huntley, DDS, president-elect of the genuinely appreciative of our work these UCSF Dental Alumni Association “This people are. So I go.” tradition of learning is important to UCSF Mary Anne Baysac, a second-year Dental Alumni Association members, not student, explained that her decision to just as dental professionals, but as human attend UCSF was based partially on our beings.” school’s commitment to this Community As a public institution, the school Clinic. “I did research before I came to had a time when it relied relatively little UCSF, and one of the big reasons I am on the generosity of its alumni, patients, here is because I wanted to go to a dental and friends to support its core activities. school where I’d have a chance to be That has all changed in recent years. In involved in community service.” fact, only about 8.8 percent of the school’s Baysac is one of the student overall budget comes from state funds. coordinators at the clinic. As such, she Alumni play an ever-increasing role in has the opportunity and responsibility to providing quality education for the young be involved with the organizational and women and men who will be joining them logistical aspects of this outreach project. as UCSF graduates. Steven Silverstein, DDS, who has been With technological advances, altered supervising students at the Community disease patterns, and changing health Clinic for nearly a decade, said, “Students care delivery systems, dentistry has have a chance here to be involved not undergone substantial change in recent only with the clinical aspects of providing decades. The UCSF School of Dentistry quality dental care, but the logistical ones has embraced these changes, and it seeks as well. I’m impressed, not only with how to help lead them. In so doing, it hopes to they find the time to be here, but with the continue to contribute to the health and quality of their work.” quality of life of all Californians. UCSF School of Dentistry outreach efforts extend to a whole variety of Acknowledgments sites and diverse patient populations. The author wishes to gratefully The school is in a unique position to acknowledge the contributions of Dr. offer expert dental care to HIV-positive James Anderson and Dr. Troy Daniels San Franciscans. We have multiple in carefully reviewing and revising the
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Implementing an Infant Oral Care Program
Francisco Ramos-Gomez, DDS, MS, MPH; Bonnie Jue, DDS; and C. Yolanda Bonta, DMD, MS, MS
abstract The American Academy of Pediatric Dentistry, American Dental Association, American Public Health Association, Association of State and Territorial Dental Directors, California Dental Association, and California Society of Pediatric Dentists currently recommend that children receive their first dental evaluation within the first year
authors of life. Providing early care to children from ages 6 months to 5 years
Francisco J. Ramos- offers an opportunity to educate and inform parents about their Gomez, DDS, MSc, MPH, children’s oral health. Anticipatory guidance -- counseling of parents is an associate professor in the Department of by health providers about developmental changes that will occur in Growth and Development, Division of Pediatric their children between health visits -- for children’s dental health is Dentistry, at the University of California San Francisco an important part of preventive care. It may be the most effective and the director of Pediatric Dental Services way to prevent problems that traditional infectious disease models at San Francisco General have failed to address, such as early childhood caries. The model of Hospital. anticipatory guidance is valuable for dental professionals because it Bonnie L. Jue, DDS, is an adjunct faculty member at emphasizes prevention of dental problems rather than restorative UCSF School of Dentistry and the University of care. A comprehensive infant oral care program utilizes (1) oral health the Pacific School of Dentistry. She is part of assessment at regularly scheduled dental visits, (2) risk assessments, the research team at UCSF (3) counseling sessions with parents during either regular dental visits for the prevention of early childhood caries, and is a or additional visits scheduled if a child is deemed at risk, (4) preventive private practitioner in San Francisco. treatment such as the application of fluoride varnish or sealants,
C. Yolanda Bonta, DMD, and (5) outreach and incentives to reinforce attendance. Facilitating MS, MS, is the director of technology, global access to early and regular dental care is a crucial part of any effective professional relations, intervention strategy, and intervention techniques should be tailored to and marketing at Colgate Palmolive Company. the community being served.
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ental caries is a transmissible, age of 3.5 years than children in whom many caretakers and providers may not infectious, chronic, preventable those risk factors are not present.9 ECC understand the necessity of regular dental disease. It is five times more patients are difficult to manage in the care for primary teeth or the importance common than asthma and dental chair and are often impossible to and timing of a child’s first dental visit. seven times more common treat under normal Dthan hay fever in children.1 Therefore, clinical conditions there is an increasing trend toward without the aid of providing dental care to children before conscious sedation or the age of 3 years. The rationale for general anesthesia. early dental intervention with infants All of these factors and parents includes determining the make this disease infant’s risk status based on information expensive to treat, from parents and performing a dental and many of the examination before potential dental patients’ parents problems have a chance to manifest cannot afford to and become more complex and costly follow the dentist’s to treat.2,3 The purpose of an infant recommendations. oral health programs is to improve A recent study access to care, to provide counseling and concluded that ECC anticipatory guidance for children age 6 is a preventable Figure 1. The dentist takes a young patient’s health history. months to 5 years, and to prevent early condition that may childhood caries. Most importantly, begin as an infant’s such programs are meant to make the teeth erupt.10 Caretakers and providers may also be dental team more proactive in preventive Because of the scarcity of funds, lack unaware that they can be the cause of dentistry rather than reactive with full- of insurance, and difficulty in gaining their child’s ECC, which has been found to mouth rehabilitation.4 Many children access to dental providers, the population be a very common infectious disease.13-15 seeking emergency dental treatment have most in need of medical and dental By facilitating access to dental care ECC, also known as baby bottle tooth care for ECC does not receive it. In the and improving parents’ knowledge of decay or nursing caries. Its prevalence United States, more than 108 million ECC and other dental problems, dental varies from 5 percent to 72 percent, children and adults do not have dental professionals can improve oral health for depending on diagnostic criteria, age, insurance, which is more than 2.5 times these patients. race, and population.5 More than 40 the number of those who do not have percent of children in the United States medical insurance. Children in this group Prenatal Care Intervention Programs have tooth decay by the time they reach are 2.5 times less likely than insured for Pregnant Women kindergarten.6 The symptoms of ECC children to receive dental care.7 Yet, the The earliest and probably best include severe pain, infection, abscesses, children lacking dental insurance are opportunity to provide education about chewing difficulty, malnutrition, three times more likely to have dental infant oral health is during pregnancy. gastrointestinal disorders, and low self- needs than those with either public or Outreach to pregnant women through esteem.7 Decay of primary teeth can affect private insurance. These statistics reflect prenatal programs effectively improves children’s growth, lead to malocclusion the urgent need to address this disparity, infant oral health.16 Women are highly by adversely affecting the alignment of especially for children with special health motivated to give their child the best the developing permanent dentition, care needs, who are nearly six times more possible care, and the likelihood of and cause poor speech articulation. ECC likely to have unmet dental treatment better health for the child and reduced may be associated with future decay of concerns than their insured peers.11 The future dental costs can motivate parents. the permanent dentition.8 According prevention and treatment of ECC are Because poor maternal periodontal health to Nowak and Warren, infants who are complicated by medical, physical, social, has been associated with pre-term birth of low socioeconomic status, whose or psychological situations; and children and low birth weight, dental care and mothers have a low education level, who affected by the condition tend to have prenatal counseling for mothers may consume sugary foods, or who have high more dental disease and more missing result in better pregnancy outcomes.17 salivary Streptococcus mutans levels are teeth than the general population.12 Prenatal counseling programs should also 32 times more likely to have caries at the To further complicate matters, educate parents about healthy feeding
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Figure 2a. The dentist shows a young patient a toothbrush to observe his behavior. Figure 2b. The dentist starts to examine the child.
Figure 3. The “knee-to-knee” position allows the dentist to examine a young child with Figure 4. Counseling parents is an important part of the dental visit. the parent’s help. habits for their children, including the caries in children.18 Another study of children when teeth erupt and will avoidance of using food to comfort them found that pregnant women who had continue until the children are 3 years or modify their behavior. dental visits every six months beginning old. The cariogenic threshold levels of Several studies have shown that sometime before they gave birth reduced S. mutans and Lactobacilli are lower in reductions in S. mutans in pregnant the incidence of caries and of S. mutans younger children and toddlers than older women may result in delayed or colonization in their children.19 children, and consequently infants and diminished transfer of caries-inducing A new University of California at San toddlers are at greater risk.10 San Ysidro, bacteria to infants. Brambilla and Francisco program based at San Ysidro Calif., is a low-socioeconomic-status area colleagues showed that a low-cost program Community Health Center will work with with a large migrant Hispanic community of dietary counseling, dental prophylaxis pregnant women beginning in the second who engage in agricultural work and and instruction, and appropriate use of trimester of pregnancy to proactively are affected by border health issues. systemic and topical fluoride and topical manage S. mutans levels. The intention is Successful preventive efforts there would chlorhexidine during pregnancy could to educate the mothers-to-be about the provide a valuable model for decreasing delay or prevent S. mutans infection infectious nature of ECC and to monitor disparities in the availability and delivery in children of infected mothers, which their S. mutans levels. Fluoride varnish of dental care in other disadvantaged resulted in lower overall rates of dental treatments will begin for a subgroup communities.
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Intervention Programs for Children a dental examination, the dental team the eruption of primary molars, and the For too long, “intervention” has should establish a positive relationship formation of permanent teeth.21 Dentists occurred only after dental disease with the patient and the parents. To should show oral anatomic landmarks to has been detected. The infection can initiate an effective connection with the parents during the examination of the be present before carious lesions are child, the examiner can introduce himself infant and discuss oral stimulators, such observed clinically. Thus, the treatment to the child and parent with a toothbrush as pacifiers. It is also important to review of caries through the use of fillings and observe the child’s behavior patterns of eruption and teething facts and other interventions does not take (Figure 2a). The clinician may begin the and myths. Parents need to be educated place until after the child’s mouth has examination procedure by placing the about the important role primary teeth already been damaged. The focus of the child in the dental chair or, in the case of play in biting and chewing for healthy intervention strategies outlined below is very young children, in the “knee-to-knee” nutrition, and speaking clearly to to prevent the initial formation of dental position. In this position, the examiner promote self-esteem and education. For caries by counseling caregivers on proper and parent sit face to face with their parents of 12- to 24-month-old children, dental hygiene and by treating the mouth knees touching to make a comfortable understanding completion of the primary with antibacterial and tooth-protecting support for the young infant (Figure dentition, concepts of occlusion and arch substances. 2b). Then the child, facing the parent, length and spacing, and formation of Children should be screened and wraps his or her legs around the parent’s permanent teeth are important.22 The actively recruited for prevention waist and lies down across the laps of the dentist should discuss the importance programs. Every child, starting at 1 year examiner and parent (Figure 3). In this of space maintenance and the effects of of age, should have a dental evaluation position, the examiner can look directly bruxism, and review molar, canine, and encompassing comprehensive preventive into the patient’s mouth and evaluate the incisal positions with parents during care at least twice a year. Evaluations teeth. The handle of the toothbrush can examination. By the age of 6 years, should include four primary components: then be used as a mouth prop or mouth children will undergo the exfoliation of oral health/risk assessment, counseling, opener to prevent sudden closure. The primary teeth and the eruption of the preventive treatment, and outreach and child’s oral condition may be assessed first permanent teeth.23 Molar occlusion incentives. with a dental mirror, and the findings and healthy gums are important issues recorded. Relevant information, as well as to discuss at this time. The dentist Risk Assessment Visit recommendations for follow-up, is passed should review patterns of eruption, Risk assessment should be part of a along to the parent. discuss permanent molar occlusion with regular, thorough oral-health assessment parents, point out permanent molar visit. Risk assessment is based on the Counseling Visit occlusal anatomy, and describe healthy recommendations of the American Academy Based on the same recommendations periodontal tissues. of Pediatric Dentistry for anticipatory as those for risk assessment, counseling guidance in pediatric dental care.20 It entails of parents entails additional visits if the Fluoride several visits to a dentist, from the first year child is at high risk (Figure 4). Counseling Topical fluoride use is not of life to age 5 years. Risk-assessment visits visits should cover oral development, recommended until after the age of 6 should also include a diet evaluation survey, fluoride intake, oral hygiene/health, months. However, systemic fluoride as well as a survey about parental knowledge, habits, diet and feeding practices, and intake may be beneficial from birth, attitudes, and behavioral practices including injury prevention. All of these issues although there is controversy regarding oral health status of siblings and parents, depend upon the age of the child, with this approach. Some researchers suggest and socioeconomic status (Figure 1). Patients specific recommendations for different systemic fluoride from birth may not be from underserved communities are at higher ages. The following guidelines for as beneficial as topical applications and risk for dental decay. Anticipatory guidance counseling topics and risk assessment its excess could lead to fluorosis. Children could include checks of S. mutans and issues are organized by major topics with should be assessed at all visits for fluoride Lactobacilli levels, particularly if a more cost- age-specific concerns highlighted in the need based on dental status and sources of effective means of testing becomes available. text. fluoride (water and food inside and outside Other checks may include examinations of the home). Dentists should be aware of of calcium, phosphate, and fluoride levels Oral Development community water fluoridation, or the lack in saliva, ECC development, and effects of Oral development issues for 6- to of it, in the region where their patients drug-induced caries. 12-month-old children include eruption live. If fluoride use is indicated, it should Before infants or toddlers undergo of the first primary tooth, planning for be administered in an age-appropriate
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Figure 5 thorough 9. Figures 5 through 9. Early appointments also consist of Figure 6. preventive measures.
Figure 7. Figure 8.
fashion. The dentist should be certain Oral Hygiene and Health health attitudes.27,28 For children of all to educate parents about the benefits of The frequency of dental visits should ages, regular dental care is important. systemic fluoride action, which primarily be based on risk assessment, and the Appropriate oral hygiene techniques vary involves fluoridation of the family’s importance of these visits should be with the age of the child. water supply or, if necessary, fluoride discussed with parents. This allows the For infants 6 to 12 months of age, supplements for the child, prescribed health care provider to customize a dental microflora acquisition from maternal or by the pediatrician or dentist. For the prevention program for the individual caregiver sources should be explained to 12- to 24-month-old child, proper use of patient; some patients may need exams parents; and the dentist should review topical fluoride depending on method of every six months, while others may oral hygiene techniques for infants with administration, such as fluoride-containing benefit more from three-month recall the caregiver, using a soft brush and dentifrices, can be introduced as long as appointments. One of the most frequent pea-sized amount of dentifrice or no the child is able to spit out the substance variables in caries risk assessment models dentifrice. Parents of children 12 to 24 thoroughly. The issues of fluoride toxicity is past caries experience.25,26 Other risk months of age should be educated about and safety and management of accidental indicators may include socioeconomic the type of brush to use with the child, ingestion should always be discussed with factors, such as income, race or ethnicity, the role of a dentifrice in oral hygiene and the parents or caretakers.24 and psychosocial factors, such as health, the roles of the child and parent in
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should include the role of the mouth in susceptibility to caries.35 Parents should infantile exploration, pacifier use (safety also be encouraged to develop plans for and hygiene issues), and the effects of oral trauma management for children in digit-sucking and breast-feeding on the preschool and child care. Children in the mouth. Visits for 12- to 24-month-old 2- to 6-year-old age group may sustain oral children should include a discussion and dental injuries from sports activities or review of nonnutritive sucking and (such as bicycling or skating) or car the safe use of a pacifier. Discussions accidents. Injuries at this age may affect with parents about how to stop habitual not only primary but also permanent thumb-sucking behavior in 2- to 6-year- teeth. Dentists should encourage the old children are warranted. use of protective sports equipment (helmets, pads, and mouthguards) when Diet and Feeding Practices appropriate and review differences When the baby is 6 months of age, between primary and permanent teeth the mother should ask her pediatrician with parents during examination.36 or dentist about fluoride supplements Parents should again be encouraged to for the baby, especially if the family lives prepare a plan for home and school for in a community where the water is not oral injury and treatment options, and to fluoridated. The importance of putting keep children in car seats during travel as the baby to bed without a bottle should required by law. also be stressed in this early phase of the baby’s life to prevent the habit from Preventive Treatment Figure 9. forming. ECC can develop if the baby is Preventive treatment (Figures 5 allowed to suck on a bottle containing through 9) includes the application sweetened liquid during the night, as of fluoride varnish such as Duraphat sugars can cling to teeth and initiate the (Colgate), Duraflor (Pharmascience), or brushing, and the frequency and setting decay process, unless the content of the CavityShield (OMNI). A semi-annual of oral hygiene. The dentist should review bottle is water. application of varnish has been tested home oral care procedures and compliance most often.37,38 Other studies have and work with parents to solve problems. Injury Prevention shown that an intensive treatment of From the ages of 2 to 6 years, the child’s Oral trauma can be a problem at any three applications of Duraphat in one role in maintaining his or her own age. Dentists should give parents of 6- to week per year (over three to four years) oral health becomes more important; 12-month-old infants information about may reduce caries by 46 percent to 67 and dentists should review home oral what to do if an infant experiences oral percent in proximal surfaces.39,40 The care procedures and compliance and trauma and contact numbers in case of regimen of Twetman and colleagues, recommend that the child begin brushing emergency. As children become older which consists of varnish applications at with parental supervision and assistance. and more mobile (12 to 24 months), three-month intervals, reduces caries by By the time the child’s first permanent electrical cord injuries and trauma to 40 percent to 51 percent among children molar erupts, the parents should be primary teeth are more likely injuries. age 4 to 5 years.41 Furthermore, fluoride informed of the benefits of dental Dentists should review normal dental varnish treatments can also inhibit sealants, as they play an important role in and oral anatomy with parents during carious lesions in pit and fissure surfaces caries prevention.29 This is also the time the examination. Parents should be by up to 50 percent to 70 percent.42,43 to explain dental radiographs and discuss provided with information on home Additionally, brushing or swabbing parental separation or presence at dental child-proofing, electrical cord safety, use the teeth with a very small amount of visits and normal child anxiety.24,30-32 of car seats, and prevention of chemical chlorhexidine solution can decrease S. substance ingestion, including exposure mutans and Lactobacilli in the mouths Habits to lead. Recent studies have shown that of babies at risk. Other studies have Certain sucking behaviors can be salivary gland function is impaired by shown that swabbing with Betadine deleterious to dental health.32 Early prenatal exposure to lead, which is a (povidone iodine) can also reduce the discussion of these habits with parents or serious problem in many low-income levels of these pathogens.19,44 Recent guardians of 6- to 12-month-old infants inner-city families and may increase clinical studies support findings that
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suggest that the replacement of sucrose behaviors of pregnant and parenting contrast, a program based on anticipatory with sorbitol and xylitol may significantly teens. Many of the participants cited a care guidance would seek to shift the decrease the incidence of dental caries. general need for improvements in the focus to the prevention of caries in Subjects using these sugar substitutes delivery of care by health professionals, children (Table 1). had a 30 percent to 60 percent decrease including better oral health teaching From birth to 6 months of age, before in dental decay. The xylitol or sorbitol was methods, better appointment and the baby’s first teeth erupt, it is essential used as the sugar substitute in chewing reminder systems, and shorter waiting for the mother to maintain her oral health. gum or toothpaste, in which the xylitol times for appointments. New mothers should see a dentist for demonstrated the highest rate of caries These concerns can be addressed regular dental exams and cleanings, usually reduction.45 Another study, involving by the dental office or clinic staff by every three to six months. These visits Head Start preschool students, suggests incorporating the following guidelines have the important benefit of reducing that chewing xylitol gum is well-accepted into their regular protocol. By setting the amount of bacteria in the mother’s by children.46 Furthermore, it has been their next appointments even before mouth, which can adversely affect the concluded that mothers who regularly they leave the office, the patients may dental health of the child. The baby’s gums used xylitol chewing gum prohibited feel more accountable for the next visit. should be cleaned daily with a clean, damp the transmission of S. mutans to their The patients should be called a few days washcloth or piece of gauze starting within children, thereby preventing dental caries or the day before their appointment to the first few days of birth. Gently wiping from forming.47 However, this mode of confirm the date and time; this process the gums and tongue after feedings keeps delivery is not feasible for most infants may greatly reduce the number of missed the baby’s mouth clean and helps the child and toddlers; therefore, the “Fall-Asleep appointments and unproductive clinic become accustomed to regular dental Pacifier,” a slow-release administration time. In addition, the appointment maintenance at an early age. device, was studied as a prophylactic should include time for counseling the Primary teeth may begin to erupt measure against oral infection with S. patient and parents. This should be around the age of 6 months. Parents mutans and dental caries in 1-year-old done in a culturally and linguistically should be instructed in how to gently children. The results were beneficial, sensitive manner. This practice allows clean the teeth and gums with a soft, possibly because of the advantages of the practitioner more time to educate the child-sized toothbrush or a clean, damp the prolonged intraoral bioavailability parents on dental health care without washcloth. Between 5 and 12 months, of the NaF-xylitol-sorbitol preparation falling behind schedule. Advocacy and babies should be introduced to drinking administered via the pacifier.48 counseling by the hygienist was helpful from a training cup. At 12 to 18 months, Children should be followed in the Spokane Partnership Program in babies should be weaned off the bottle or prospectively for at least three years, Spokane, Wash.49 from nursing. and their oral health should be assessed Incentives may include dental By 18 to 24 months of age, the toddler routinely. Thereafter, the goal should care products, such as toothpaste or should be off the bottle or nursing and be to keep the child as regular patient toothbrushes, and age-appropriate toys. the family should be in the habit of taking in the office to receive and maintain The incentives should be contingent on the child to the dentist for regular check- ongoing care as part of a regular dental increases in the assessed knowledge of ups, about twice a year. The dentist might home. Treating patients from an early age the caregiver (e.g., not putting a child to ask about the child’s eating patterns and has an unexpected benefit on behavior sleep with a bottle) and favorable results warn about risks from constant snacking. modification: It desensitizes them to of risk assessment. Achievement charts The baby’s teeth should be brushed in dental environment and the dental can be monitored at home as a game with the morning and before bedtime, and experience. It is wonderful to see young the child. the child can begin to learn how to hold children jump into the dental chair and the toothbrush at this age. However, the eagerly await their treatment. Conclusion child will need assistance in brushing the ECC is a significant dental disease teeth for years to come, as most children Outreach and Incentives that can have devastating effects do not develop the coordination to brush Outreach and incentives are on both the primary and secondary effectively by themselves until they are 6 intended to reinforce attendance at the dentition. The burden of this disease is to 8 years old. One study has determined assessments and to reinforce habits disproportionately carried by low-income that children who brush their teeth recommended in the counseling visits. and other underserved children. For too themselves are more likely to have visible The surgeon general’s oral health report long, the model of treatment has been to plaque after brushing than children whose cited factors affecting oral health seeking address an already diseased dentition; in teeth are cleaned by their parents.50
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patients, while attracting new patients. In Table 1. Counseling Visit Time Table addition, adopting a preventive approach Prenatal to dental care may decrease the need for Mothers should take care of their own oral health. costly restorative procedures, which could Mothers should know that periodontal disease is associated with prematurity and low birth also deliver a corresponding savings for weight. the public health sector. It is a “win-win” Infancy situation for all involved by making Babies should begin regular visits to a dentist when the first tooth appears, no later than 12 months of age. healthy babies healthier. The dentist will: • Examine the child’s mouth, check for cavities and potential problems with teeth and gums. Acknowledgments • Teach parents how to care for the child’s teeth and gums. The authors thank all the staff and • Explain how diet and feeding patterns can cause decay. faculty of the UCSF Family Dental • Help parents understand the child’s oral development. Center at San Francisco General Hospital • Check to be sure the child gets proper amount of fluoride and of the Chinatown Health Center • Schedule a continuing care/recall visit based on the child’s oral health needs. Dental Clinic for their support and Dr. Parents should: Jane Weintraub, Dr. Bob Isman, Helen • Prepare baby for brushing by cleaning mouth, gums, and tongue with gauze or a washcloth MacDiarmid, and Stephen Ordway for before teeth appear. editorial assistance. • Brush teeth at least twice a day: after breakfast and before bed. • Use a child-sized toothbrush; brush with only a smear-sized amount of fluoride tooth- References paste. 1. US Department of Health and Human Services, Oral Health • Know that signs of a healthy mouth include pink gums, white teeth, and no mouth sours. in America: A Report of the Surgeon General. US Department of Health and Human Services, National Institute of Dental • Know that good oral hygiene is especially important for babies with special needs. and Craniofacial Research, National Institutes of Health, Early Childhood Rockville, MD, 2000. Twenty baby teeth will have come in by approximately 30 months of age. Young children 2. Nowak AJ, Casamassimo PS, Using anticipatory guidance to should be in the habit of visiting the dentist at least twice a year for regular check-ups. provide early dental intervention. J Am Dent Assoc 126:1156- 63, 1995. The dentist will: 3. Ramos-Gomez FJ, Shepard DS, Cost-effectiveness model • Conduct a thorough exam and risk-assessment, similar to infancy exams. for prevention of early childhood caries. J Calif Dent Assoc • Reinforce concepts discussed in infancy exams. 27:539-44, 1999. 4. Brown LJ, Wall TP, Lazar V, Trends in total caries experience: • Help address problems like prolonged digit-sucking and pacifier use after age 4. permanent and primary teeth. J Am Dent Assoc 131:223-31, Parents should: 2000. • Begin teaching preschooler to brush by gripping the brush for the child and guiding it 5. Kaste LM, Marianos D, et al, The assessment of nursing around the mouth. caries and its relationship to high caries in the permanent dentition. J Public Health Dent 52:64-8, 1992. • Continue helping child brush until at least age 6 years. 6. Pierce KM, Rozier RG, Vann WF Jr, Accuracy of pediatric • Increase toothpaste to pea-sized amount as child learns to spit after brushing. primary care providers’ screening and referral for early • Coach brushing until age 11, when most children can brush on their own. childhood caries. Pediatrics 109(5):E82-2, 2002. 7. US Department of Health and Human Services, Oral health in Source: Based on recommendations by the American Academy of Pediatric Dentistry America: a report of the surgeon general -- executive summary. U.S. Department of Health and Human Services, Rockville, MD, 2000, pp 1-13. 8. Almeida AG, Roseman MM, et al, Future caries susceptibility in children with early childhood caries following treatment So, even though children should be dental practitioners to greatly reduce oral under general anesthesia. Pediatr Dent 22(4):302-306, 2000. encouraged to try brushing their own infections among affected populations. 9. Nowak AJ, Warren JJ, Infant oral health and oral habits. Pediatr Clin North Am 47:1043-66, 2000. teeth after the age of 2, the parents or Providing oral health education and 10. Ramos-Gomez FJ, Weintraub JA, et al, Bacterial, behavioral caretakers must still continue to take an counseling to pregnant women in a and environmental factors associated with early childhood active role in the child’s brushing and culturally and linguistically sensitive caries. J Clin Pediatr Dent 26:165-73, 2002. 11. Manski RJ, Edelstein BL, Moeller JF, The impact of insurance flossing routine. manner may also be an effective means coverage on children’s dental visits and expenditures, 1996. J This proactive approach -- including of reducing both the risk of adverse Am Dent Assoc 132:1137-45, 2001. services and education that emphasizes pregnancy outcomes and the incidence 12. University of the Pacific School of Dentistry, Practical protocols for the prevention of dental disease in community risk assessment, regular dental of ECC in their young children. By settings for people with special needs -- 2002 consensus appointments, counseling sessions, establishing an infant oral care program protocol. preventive treatment, and outreach in their practices, dentists can provide 13. Smith DJ, Anderson JM, et al, Oral streptococcal of infants. Oral Microbiol Immunol 8:1-4, 1993. and incentives -- makes it possible for a much needed service to their existing 14. Berkowitz RJ, Jones P, Mouth to mouth transmission of the
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bacterium Streptococcus mutans between mother and child. radiographic study. Caries Res 25:70-3, 1991. Arch Oral Biol 30:377-9, 1985. 40. Skold L, Sundquist B, et al, Four-year study of caries 15. Li Y, Caufield PW, The fidelity of initial acquisition of mutans inhibition of intensive Duraphat application in 11-15-year-old streptococci by infants from their mothers. J Dent Res 74:681-5, children. Community Dent Oral Epidemiol 22:8-12, 1994. 1995. 41. Twetman S, Petersson LG, Pakhomov GN, Caries incidence 16. Casamassimo PS, Maternal oral health. Dent Clin North Am in relation to salivary mutans streptococci and fluoride varnish 45:469-78, 2001. applications in preschool children from low- and optimal- 17. Dasanayake AP, Poor periodontal health of the pregnant fluoride areas. Caries Res 30:347-53, 1996. woman as a risk factor for low birth weight. Ann Periodontol 42. Petersson LG, On topical application of fluorides and its 3:206-12, 1998. inhibiting effect on caries. Odontologisk Revy S34:1-36, 1975. 18. Brambilla E, Felloni A, et al, Caries prevention during 43. Seppa L, Tuutti H, Luoma H, Three-year report on caries pregnancy: results of a 30-month study. J Am Dent Assoc prevention of using fluoride varnishes for caries risk children in 129:871-7, 1998. a community with fluoridated water. Scand J Dent Res 90:89- 19. Slavkin HC, Streptococcus mutans, early childhood caries 94, 1982. and new opportunities. J Am Dent Assoc 130:1787-90, 1999. 44. Lopez L, Berkowitz, et al, Topical antimicrobial therapy in 20. Journal of the American Academy of Pediatric Dentistry, the prevention of early childhood caries. Pediatr Dent 21(1):9-11, Pediatric Dentistry. Special Issue: Reference manual 23(7), 1999. 2001-2. 45. Hayes C, The effect of non-cariogenic sweeteners on the 21. Kohler B, Andreen I, Influence of caries-preventive measures prevention of dental caries: a review of the evidence. J Dent in mothers on cariogenic bacteria and caries experience in their Educ 65:1106-9, 2001. children. Arch Oral Biol 39:907-11, 1994. 46. Auto JT, Court FJ, Acceptance of the xylitol chewing gum 22. Jenkins S, Addy M, Newcombe R, Evaluation of a mouthrinse regimen by preschool children and teachers in a Head Start containing chlorhexidine and fluoride as an adjunct to oral program: a pilot study. Pediatr Dent 23:71-4, 2001. hygiene. J Clin Periodontol 20:20-5, 1993. 47. Isokangas P, Soderling E, et al, Occurrence of dental decay in 23. Aaltonen AS, Tenovuo J, Association between mother-infant children after maternal consumption of xylitol chewing gum, a salivary contacts and caries resistance in children: a cohort follow-up from 0-5 years of age. J Dent Res 79:1885-9, 2000. study. Pediatr Dent 16:110-6, 1994. 48. Aaltonen AS, Suhonen JT, et al, Efficacy of a slow release 24. Zickert I, Emilson CG, Krasse B, Effect of caries preventive device containing fluoride, xylitol, and sorbitol in preventing measures in children highly infected with the bacterium infant caries. Acta Odontol Scand 58:285-92, 2000. streptococcus mutans. Arch Oral Biol 27:861-3, 1982. 49. Milgrom P, Hujoel P, et al, Making Medicaid child dental 25. Abernathy JR, Graves RC, et al, Development and application services work: a partnership in Washington state. J Am Dent of a prediction model for dental caries. Community Dent Oral Assoc 128:1440-6, 1997. Epidemiol 15:24-8, 1987. 50. Habibian M, Roberts G, et al, Dietary habits and dental health 26. Beck JD, Weintraub JA, et al, University of North Carolina over the first 18 months of life. Community Dent Oral Epidemiol Caries Risk Assessment Study: comparisons of high risk 29:239-46, 2001. prediction, any risk prediction, and any risk etiologic models. To request a printed copy of this article, please contact/ Community Dent Oral Epidemiol 20:313-21, 1992. Francisco J. Ramos-Gomez, DDS, MS, MPH, UCSF School of 27. Powell LV, Caries risk assessment: relevance to the Dentistry, 707 Parnassus Ave., Room D1021, Box 0753, San practitioner. J Am Dent Assoc 129:349-53, 1998. Francisco, CA 94143-0753. 28. Gillcrist JA, Brumley DE, Blackford JU, Community socioeconomic status and children’s dental health. J Am Dent Assoc 132:216-22, 2001. 29. Dennison JB, Straffon LH, Smith RC, Effectiveness of sealant treatment over five years in an uninsured population. J Am Dent Assoc 131:597-605, 2000. 30. Berkowitz RJ, Turner J, Green P, Primary oral infection of infants with Streptococcus mutans. Arch Oral Biol 25:221-4, 1980. 31. Li Y, Caufield PW, The fidelity of initial acquisition of mutans streptococci by infants from their mothers. J Dent Res 74:681-5, 1995. 32. Rogers AH, The source of infection in the intrafamilial transfer of Streptococcus mutans. Caries Res 15:26-31, 1981. 33. Berkowitz RJ, Turner J, Hughes C, Microbial characteristics of the human dental caries associated with prolonged bottle- feeding. Arch Oral Biol 29:49-51, 1984. 34. Falco MA, The lifetime impact of sugar excess and nutrient depletion on oral health. Gen Dent 49(6):591-5, 2001. 35. Bowen WH, Response to Seow: biological mechanisms of early childhood caries. Community Dent Oral Epidemiol 26 (Suppl 1):28-31, 1998. 36. Ranalli DN, Prevention of sports-related traumatic dental injuries. Dent Clin North Am 44(1):35-51, 2000. 37. Seppa L, Studies of fluoride varnishes in Finland. Proc Finn Dent Soc 87:541-7, 1991. 38. de Bruyn H, Arends J, Fluoride varnishes -- a review. J Biol Buccale 15:71-82, 1987. 39. Petersson LG, Arthursson L, et al, Caries-inhibiting effect of different modes of Duraphat varnish reapplications: a 3-year
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A Dental School That Serves the Practicing Profession
Arthur A. Dugoni, DDS, MSD
author he School of Dentistry at the graduate programs. Our professional University of the Pacific is a development program emphasizes Arthur A. Dugoni, DDS, MSD, is dean and bridge between one of the hands-on skill-building courses. The professor of orthodontics great private universities research we conduct focuses on clinical at the School of Dentistry, in the West and one of the applications to the practice of dentistry. University of the Pacific. Tnation’s most respected professions. We have initiated new programs in oral The mission of Pacific is to provide a and maxillofacial surgery and dental superior, student-centered learning hygiene in response to needs identified environment integrating liberal arts and by the profession. Our clinics provide professional education, and preparing safety-net services to population groups individuals for lasting achievement and such as the medically compromised responsible leadership in their careers and transient and disadvantaged and communities. Among its core values communities the profession cannot are academic distinctiveness, building easily reach. And Pacific continues to relationships with our communities, provide its share of exceptional leaders and using outcomes data for continuous for the profession. improvement. This makes it a unique home for educating competent Competency-Based Education beginning dental practitioners in a It is no surprise that competency- humanistic environment. Pacific may based professional education began be the only dental school in the United at Pacific. Competency means the States that is not part of a research- capability to begin independent intensive university or a major health professional practice and acceptance sciences campus with their emphases of responsibility for continuous on medicine, basic science research, and professional development. This replaces cost recovery through tertiary care. Our the old model where the curriculum was environment is the world of the private driven by a desire of the faculty to tell practitioner. everything they know. There are three It is the purpose of the School of problems with that older view. With a Dentistry to serve the needs of the big enough faculty and an exploding dental profession. Our graduates are knowledge base, the curriculum would competent to begin modern private expand beyond reasonable limits. There practices and remain current throughout is always the danger that what teachers their careers or to enter the best find interesting and important may not
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Figure 1. Dr. Phil Oppenheimer, dean of the Thomas J. Long School of Pharmacy; Dr. Donald Figure 2. Sohail Saghezchi, class of 2002, presents his senior research project on gene DeRosa, president of the University of the Pacific; and Dr. Arthur Dugoni, dean of the UOP School of therapy in human oral cancer cells to faculty at UOP School of Dentistry’s annual Research Day. Dentistry, help break ground at UOP’s new $21 million Health Sciences Learning Center and Clinics on the Stockton campus. The facility will house a state-of-the-art clinic for the dental school’s new hygiene program and its expanded Advanced Education in General Dentistry program in the Central Valley. efficiently match what practitioners is also beginning to appear in other actually expanded. Pacific students need. And finally, learners should be professional programs such as nursing, are among those in the top half dozen given the opportunity and ultimately dietetics, law, and business. But Pacific in the country in clinical experiences, full responsibility for being able to direct remains the only dental school that consistently performing 10 percent their own professional growth. drives its educational program based to 15 percent more dentistry than the Competency-based professional entirely on the needs of practitioners. national average, and doing so with education begins by identifying the For example, we are the only dental one fewer year of overall education. skills, understanding, and supporting school that completes the four-year Pacific was a pioneer in the early 1970s values required to begin practice. The predoctoral program in 36 months. That of the comprehensive patient care faculty at Pacific has identified 59 is possible because we have eliminated model of clinical education. This is an such competencies. Among these are the activities that do not directly essential foundation for competency- “evaluate the range of available dental support initial competence. This has based education because dentists must therapies for individual patients’ dental, required careful differentiation of what learn to integrate a wide repertoire of medical, and personal situations, is essential compared with what is nice skills, understanding, and values in including advantages, disadvantages, to know and awareness of how the realistic settings. Novices are very good and risk-benefits rations,” “perform profession is changing. The faculty has at doing what the faculty tells them to simple and surgical tooth and root also developed the perspective that the do, and beginners are good at getting extractions,” “function as a patient’s curriculum belongs to the whole faculty requirements (doing what they need to primary and comprehensive oral health and is not a collection of disciplines that do). Only competent practitioners are care provider,” and “think critically, solve fight for clock hours. good at doing what is in the patient’s problems, and base dental decisions Competency-based education views best interest. on evidence and theory.” If this sound learning as a 10- to 15-year journey Not all learners achieve competence more like what practitioners do than through the predictable stages of novice, on the same time schedule. Years schoolwork for students, that is as it beginner, competent, proficient, and ago, to break the traditional lock- should be. Competencies, not numerical mastery or expertise. The first three step sequencing of the dental school requirements, drive the graduation stages are accomplished in dental school. curriculum, we introduced “breathing decision. The four-academic-years-in-36-months spaces” at key points where students The competency approach to curriculum at Pacific is accomplished who needed tutorial assistance could get curriculum design is now practiced in by dramatically shortening the novice it. It turns out that this also provided all U. S. and Canadian dental schools. stage and somewhat telescoping the the opportunity for a rich array of It is a requirement of the accreditation beginner stage. Clinical education, selective courses throughout the three process. Competency-based education where competency is achieved, is years. In some years, a few students are
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retained at the end of three years for additional clinical experiences. Last year, we added enrichment experiences in the final quarter for nine students who were deemed competent before the nominal graduation date. The proof of the competency- based approach to dental education is in the performance of our graduates. Table 2 shows the four-year yield of our program since 1993. This is not the pass rate on state boards; it is the proportion of students who first enter the program and are qualified to practice independently four years later. The two or three percent who do not achieve competency include those who have difficulties with state or national boards, are extended for further training by Humanism and Leadership Humanism and leadership are the faculty or who repeat, and those I have frequently stated that we have not optional at Pacific. Among the who are dismissed, change their career the privilege of educating outstanding competency statements developed by goals, or experience severe illness or young men and women at Pacific, and the faculty are “establish and maintain other personal problems. Our three-year along the way they become doctors. A patient rapport” and “participate yield, the proportion that is qualified to large part of being a professional is who in organized dentistry.” We feel the practice in 36 months, has now reached one is, not just how smart or talented profession expects and deserves this of 87 percent. one happens to be. It will not do just to the young people entering the dental By focusing on the needs of train the head and hands and leave out profession. practicing professionals rather than the heart. Although we teach modalities Humanism is a major part of the academic disciplines, Pacific has proven that are state of the art; the care that culture of the dental school. Over the that dental education can be effective our graduates provide must be state of years, faculty and administrators have and efficient. the heart. learned how to challenge and motivate
Figure 3. CDA Speaker of the House and Pacific Alumnus Dr. Sig Abelson, ’69, with his Figure 4. UOP School of Dentistry Dean Dr. Arthur A. Dugoni congratulates Courtney wife, Teri Abelson, receives a thumbs up from their son, Dr. Michael Abelson, ’89, for receiving Inada, class of 2004, as she receives her white coat and certificate during the White Coat the School of Dentistry’s prestigious Medallion of Distinction Award at the 103rd Annual Alumni Ceremony at the Herbst Theatre in San Francisco. The ceremony focuses on the importance Association Meeting. of professionalism, ethics, and responsibility to the community as the second-year dental students begin their new roles as health care providers.
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some form of community outreach. This patient-centered, comprehensive, quality program -- called SCOPE, for Student care in an efficient clinical model that Community Outreach for Patient demonstrates the highest standards of Education -- is run by students as a service achievable.” Our clinic mission way of instilling the values of “giving statement affirms, “The mission of the something back to the community.” The school’s clinics is to provide patient- profession should be proud of this level centered, quality oral health care in a of involvement. humanistic educational environment.” The values of humanism and We are working to move away from leadership learned in dental school the model of compensating patients Figure 5. Student volunteers from UOP’s Student continue through one’s professional for the inconvenience we impose and Community Outreach for Public Education organization provide dental screenings and oral health education to adults careers. They affect the way dentists toward reducing that inconvenience and children at the annual Chinatown Community Health Fair think of themselves and how they to a minimum. The competency-based in San Francisco. interact with their patients and staff. approach and humanism both require These values also influence involvement this. We have cut the time required from students to excel, how to correct in the profession. Two ADA presidents initial screening to first therapeutic problems in patient care, and even in recent years were Pacific faculty procedure in half and decreased “redos” how to take criticism from students members (Drs. Arthur Dugoni and by 40 percent in the past five years. in ways that preserve students’ self- Burton Press). Seventeen percent of Recalls are up, and chart audits show a respect and individuality. There has the dentists practicing in California are significantly improved quality of care. been a self-selection for these traits. graduates of Pacific. A count from the We truly seek to model appropriate and The students’ view matters. In regular Leadership Directory of the California comprehensive patient care rather than meetings, students meet with the Dental Association reveals that 41 focus on isolated technical procedures. administration and faculty on a regular percent of the state and component Because of our location in San basis to discuss how the program can be society officers in this state are Pacific Francisco, Pacific has been a long-time improved. All student suggestions are graduates. The contributions of talent, and active participant in the Ryan White taken seriously, investigated, and acted time, and treasure to the profession and program. This is a national program upon if appropriate; and then students the school speak volumes regarding the that reimburses health care providers are told what happened. Students are satisfaction our alumni feel with their for the extra expenses involved in active members of all committees, careers. Humanism and competency treating HIV-positive and AIDS patients. including the faculty appointment, together are a powerful mix and a For the past five years, the clinics at promotion, and tenure committees. strong foundation for the future of the Pacific have provided more than 5,000 Participation, including funding for profession. professional visits for these patients per attendance at national meetings, is year. Our Advance Education in General encouraged for student representatives Helping Meet the Needs of Special Dentistry program has a national to the American Dental Association, the Patient Populations reputation for its work with patients American Student Dental Association, Every dentist cannot provide care for who have developmental, emotional, the California Dental Association, the every type of patient. But the profession and other disabilities. We are currently American Dental Education Association, as a whole needs to provide this broad in the second year of a program funded and several research associations. range of services to retain the public’s by the California Endowment to Student government is active and trust. Each of the dental schools in establish regional treatment centers currently includes 12 percent of the California helps provide such “safety- and train dentists and other health entire student body. net” coverage, and Pacific has its own care professionals to provide care to Students in all dental schools have special niches. patients with special needs in their own been active in community service and Dental schools have traditionally communities. outreach. Screenings, foreign missions, been clinics where patients traded time Pacific has a tradition of establishing and fund-raising activities are typical for money: They pay a little less because partnerships with the profession examples. At Pacific, the emphasis the care takes a little longer. We are for bringing care to underserved has been on full participation. For the not satisfied with that arrangement communities. Our Union City Dental past two years, 100 percent of each at Pacific. One of the elements in our Care Center was built to serve a group graduating class has participated in overall mission statements is to “provide of patients in the East Bay by gifts
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from our alumni in 1976 and remodeled dentists become proficient and then they who were taught these techniques in in 2002. We are currently building become experts. Pacific has begun to school and their older colleagues who a treatment facility to bring care to offer help here as well. learned the techniques themselves. underserved patients in San Joaquin We have intensively studied our (Recall that part of the definition of County. For the past two years, Pacific graduates during the first 12 years competency is to assume responsibility has received more scholarships for of practice. For example, we have for one’s continued professional establishing dental practices in areas discovered that they borrow almost 1 1/2 development.) with low dentist-to-population ratios times as much to start their practices as One skill our recent graduates than the other California schools they did for their dental education. They identified as being an increasing combined. We also rotate students also pay back their loans in from seven concern is the blizzard of new product through clinics in Northern California to 10 years, at about 10 percent of their claims. Never before has the profession that have been created by component practice income, and their default rate been subjected to so many and such dental societies and communities to is among the lowest of all professionals quickly changing messages about reach the underserved. In this way, -- less than 0.2 percent. how to practice. In response, we have dental students learn first-hand about Recent graduates feel competent added in each curriculum year material the sense of responsibility that the in a broad range of procedures and and even whole courses designed to profession must demonstrate to serve gradually reduce the variety of develop competency in critical thinking. the underserved and provide access to techniques performed (through referral) Although we teach the traditional care. to customize a practice in which they material on research design and Another example of helping the can become true experts. Beginning statistics, our true focus is on how to profession provide the full range of care practitioners are outstanding learners. read an ad, use the Internet to find out to patients is the creation of a hygiene They use a blend of formal continuing what the patient is learning, and how program. In the fall of 2002, we will education, journals, peers, observation to think through product claims as accept the first class of 32 students in the of their own outcomes, and other independent professionals. nation’s first three-year baccalaureate sources to remain current. And they Table 2 shows that Pacific graduates dental hygiene program. This will be are current. There is no difference in tend overwhelmingly to become a joint program on the campus of our the frequency of using newly developed independent owners of their own parent university in Stockton. Students techniques (such as implants, veneers, practices. The 96 percent ownership level will complete 18 months of general cosmetic approaches) between those within a decade of graduation compares education and prerequisites in the biomedical sciences with the university faculty and then finish with 18 months of clinical training in clinics that are currently under construction on the campus. Not only will this help address the critical shortage of hygienists for practice, it will also ease the even more critical shortfall of educators for hygiene programs. This program has had the guidance, endorsement, and financial support of the San Joaquin, Fresno- Madera, Stanislaus, and Sacramento District dental societies.
Competence to Mastery We have served the profession incompletely if we only graduate competent beginning dentists. Two of the stages in professional development occur following graduation. With practice, and certain kinds of help,
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favorably with the national average of require that all students spend more period during the first 12 years following just more than 80 percent in a dentist’s time getting ready to practice, we believe graduation. lifetime. Although Pacific graduates are the profession is better served by laying Practitioners are drawn to Pacific more likely to start a “scratch” practice a strong foundation in the shortest to share some of what they have or to associate and less apt to work as possible time and allowing practitioners learned with the next generation of employees than are graduates of other to choose the direction and depth of their colleagues and to be part of the schools, many also specialize before additional formal training they desire. inquiring environment of a dental starting practice. Graduate programs Becoming an expert in dentistry school. Scholarship -- disciplines, peer- are an excellent way to accelerate the requires years of experience and reviewed generation of new and useful proficiency stage of the learning curve. constant searching for improvement. ideas -- is expected of every faculty In the days of the College of Pacific’s approach to professional member. This includes adjunct faculty Physicians and Surgeons, we had most development is designed to strengthen members who are invited to join ongoing graduate programs, but amalgamation the profession this way. We recognized teams. Pacific is even developing the with the University of the Pacific about 10 years ago that the lecture concept of the “scholarship of practice,” required consolidation where we could update courses with big-name speakers systematic improvements in the practice demonstrate strength. From 1967 to belonged to organized dentistry and of dentistry. 1990, we offered graduate training that we should fill a niche that no one Each dental school in the United only in orthodontics, with a two-year else was adequately covering. What States is unique or nearly so. What makes program leading to the master of science practitioners told us they needed Pacific special is its determination to serve in dentistry degree in addition to the were hands-on extended clinical the practicing profession. certificate. Our Advanced Education experiences -- something like the in General Dentistry program -- with old study club approach. Currently, emphasis on special-needs patients -- Pacific offers multiweek, laboratory has been in place for 12 years. A special and clinical, participation courses in feature of this program is its emphasis endodontics, anesthesia, periodontics, on distance learning. Next year, we will prosthodontics, implants, surgery, and have three campuses in this program -- esthetic dentistry. In some of these San Francisco, Union City, and Stockton disciplines, the participation programs -- all connected by videoconferencing are sequenced in as many as three levels for didactic instruction and live of difficulty to form learning continua. consultation. The program is part of a national network that has already Blurring the Line been sharing course materials and The best practitioners are always engaging in seminars with simultaneous learning; the best educators are always participation from residents in states practicing. Lines between education such as New York and Arizona. and practice have been drawn more Our most recent graduate program distinctly than they need to be or than is in oral and maxillofacial surgery. The is helpful to the profession. Of the 319 Highland Hospital program in Alameda faculty members currently at Pacific, Country has become part of Pacific. nine are full-time administrators, nine This program has two residents in are biomedical scientists, and 46 are full- each of four years and a distinguished time. Most of those who are qualified tradition of training hands-on oral and to do so practice one day a week. We maxillofacial surgeons. The innovative, have 114 one-, two- and three-day per three-year baccalaureate dental hygiene week faculty members and 152 adjunct program has already been described. (volunteer) faculty members. Virtually These four independently accredited all of these continue to practice, and programs represent Pacific’s response many are among the best-known to the growing needs for advanced and most highly respected in their training in dentistry. Rather than add communities. Among recent graduates, years to the undergraduate program and an average of 8 percent teaches for some
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Clinical Evolution of the Invisalign Appliance
Vicki Vlaskalic, BDSc, MDSc, and Robert L. Boyd, DDS, MEd
abstract The Invisalign System of tooth movement has been available to orthodontists since 1999 and has now become available to the entire dental profession. This paper explores the role of this system within the dental armamentarium and describes the clinical evolution of the appliance, based on a feasibility study initiated at the University of the Pacific in 1997.
authors ocumented use of vacuformed appliance as a retainer and an active removable appliances to move orthodontic appliance.3-5 Vicki Vlaskalic, teeth has been available since The main feature that distinguishes the BDSc, MDSc, is an the 1940s, and their use in Invisalign System from those before it is assistant professor in the Department of the dental office may have 3-D computer software, which dramatically Orthodontics at the Doccurred even earlier.1-7 Kesling first increases the ability to manipulate teeth University of the Pacific described the movement of teeth via a via a series of precise, small, directional School of Dentistry. tooth positioner, which is often used movements. As a result, the treatment Robert L. Boyd, DDS, today to refine the occlusion after fixed of significant malocclusions requiring a MEd, is professor and chairperson of appliance treatment.1 In 1964, Nahoum greater magnitude of change is viable.8 the Department of published a thorough article describing Other notable departures from the Orthodontics at UOP his “vacuum formed dental contour traditional active, vacuformed appliance School of Dentistry. appliance.”2 Unlike his colleagues who systems include the loss of direct control by used home vacuum cleaning systems to the clinician in creating these movements, Disclosures The study described in create an appliance over a modified study as well as the highly commercial nature this article was supported cast, Nahoum used a laboratory vacuum of Align Technology, the company that by a grant from Align system to create appliances that were produces the Invisalign System. Although Technology, Inc., Santa subsequently used to treat significant standard orthodontic consultation and Clara, Calif. malocclusions. He applied elastics and treatment planning is required to use Dr. Boyd has a financial utilized attachment systems that are still this system to provide optimal occlusal interest in Align being used today in what is erroneously outcome, many clinicians believe that the Technology, Inc. considered to be a revolutionarily new transformation of the clinician’s treatment tooth movement system. In the 1990s, plan to a 3-D computer image by employees Sheridan popularized the “Essix” overlay of the company means a loss of control
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Figure 1a. Phase 1 case ex ample: Class I mild maxillary Figure 1b. Pretreatment right buccal occlusion. Figure 1c. Pretreatment left buccal occlusion. and mandibular spacing. Pretreatment frontal occlusion.
Figure 1d. Pretreatment maxillary occlusal. Figure 1e. Pretreatment mandibular occlusal. Figure 1f. Posttreatment frontal occlusion.
Figure 1g. Posttreatment right buccal occlusion. Figure 1h. Posttreatment left buccal occlusion. Figure 1i. Posttreatment maxillary occlusal.
Figure 1j. Posttreatment mandibular occlusal.
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over treatment. While direct-to-consumer antero-posterior discrepancies. All subjects current 0.25 mm maximum in many cases marketing is commonplace in the medical were offered $200 for their participation led to ill-fitting aligners. This meant that in scene, it is relatively new to the world and the guarantee of treatment with most cases, new impressions were required of orthodontics. These characteristics fixed appliances if they were unhappy to continue treatment. Actual active combine to embody this novel and with the clinical results obtained with the treatment time in this sample is similar controversial appliance, whose ultimate system. Of the 40 subjects recruited, two to that of fixed appliances, as physiology place within the dental armamentarium is patients in Phase III did not proceed with rather than the appliance system largely at this stage unclear. treatment, resulting in a final sample size dictates the speed of tooth movement. The development of the Invisalign of 38. Figures 1a through j depict an example System began in 1996, with the formation Records collected included patient of one of the first cases treated in this of a small team of computer engineers history, intra- and extraoral photographs, study. The subject was diagnosed with skilled in 3-D digital technology. By 1997, a panoramic or FMX radiographs, and lateral Class 1 mild upper and lower anterior crude technique had been established that cephalometric radiographs. In addition, each spacing. This spacing was consolidated would allow the fabrication of vacuformed subject completed a patient questionnaire by the treatment. The patient wore 15 “aligners,” based on a stereolithographic while in treatment. Patients were reviewed maxillary and 11 mandibular aligners, with resin model created from a computer- on a four-week schedule. Progress records a total treatment time (including inactive programmed laser. Align Technology including intra- and extraoral photographs treatment) of 22 months. Since this patient approached the University of the Pacific were taken at approximately six-month was treated, tooth movement increments to conduct a feasibility study to test and intervals. End-of-treatment records have become automated within the suggest improvements for its system. included study casts, intra- and extraoral software program used to create aligners. photographs, and panoramic and lateral A finding that should have been Materials and Methods cephalometric films. anticipated was the creation of a posterior The University of the Pacific contracted open bite in some patients. This was with Align Technology to conduct a Results pronounced in patients who had thicker feasibility study that would test the system The results of this feasibility study are aligners, who were clenchers, or who had in vivo and suggest any improvements that represented by the clinical advancements little freeway space. Because many of might lead to increased clinical efficiency. that occurred during treatment of the the patients in the study tested aligners The protocol involved the recruitment of subjects. These are summarized in Table 1. of different material and thickness, not 40 subjects, who were added in groups The Phase I subjects were diagnosed all developed this open bite. The study according to malocclusion severity. More with Class I mild crowding or spacing utilized aligners of thickness ranging than 120 subjects were screened, many of malocclusions. The average treatment time from 0.030 inch to 0.040 inch. Currently, them dental students. Subject selection was 20 months. This was measured as aligners are 0.030 inch thick, and this criteria included fully erupted permanent the time from the first polyvinylsiloxane dimension seems to cause a posterior open dentition discounting third molars, impression to the time of delivery of the bite less frequently than was originally dental health with no immediate need retainer. This treatment time is excessive observed. Patients who developed open for restorations, availability for evening considering the mild malocclusions within bites wore final aligners trimmed to cover appointments, and a desire to comply with this group. These subjects, however, were the anterior teeth only, so that in a few orthodontic treatment. The subject age initiated in late 1998 and early 1999 when days the posterior teeth re-erupted. range was 14 to 52 years. Some subjects the manufacturing process was unrefined. The need for overcorrection in the had been treated previously with fixed It took an average of 4.8 months from the virtual 3-D treatment plan, or “Clincheck,” appliances. date of impression taking to the delivery also became apparent. This is likely due The first 10 subjects fell into the “mild” of the aligners to the patient. In addition, to the amount of elastic “give” in the malocclusion category. These categories the aligners delivered did not always fit aligner material, so that there is a slight were selected via subjective determination. the patient, or additional impressions difference between the position of a tooth These were largely incisor crowding, were taken due to treatment plan change on the 3-D setup and the clinical position spacing, and alignment cases. Once or case refinement. At this early stage, of the tooth. This became most obvious evidence of feasibility was established, the optimum duration of wear of each when treating incisor rotations, though two groups of 15 subjects with successive aligner was unknown, and many patients overcorrection is currently recommended malocclusion severity were recruited. These changed aligners weekly. This rapid pace not only for rotations but also for subjects included those with crossbites, combined with programmed increments of extrusion and root position. posterior rotations, severe crowding, and tooth movement that were larger than the The sophistication of the 3-D Clincheck
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Figure 2a. Phase II case example: Class I moderate Figure 2b. Pretreatment extraoral profile. Figure 2c. Pretreatment extraoral profile smile. maxillary and mandibular crowding. Pretreatment extraoral smile.
Figure 2d. Pretreatment frontal occlusion. Figure 2e. Pretreatment right buccal occlusion. Figure 2f. Pretreatment left buccal occlusion.
Figure 2g. Pretreatment maxillary occlusal. Figure 2h. Pretreatment mandibular occlusal. Figure 2i. Pretreatment overbite -- overjet.
Figure 2j. Posttreatment frontal occlusion. Figure 2k. Posttreatment right buccal occlusion. Figure 2l. Posttreatment left buccal occlusion.
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Figure 2o. Posttreatment overbite -- overjet.
Figure 2m. Posttreatment maxillary occlusal. Figure 2n. Posttreatment mandibular occlusal.
III malocclusions with mild to moderate exist. The benefit to patients of a virtual crowding and anterior crossbite. The extraction was that they would not have average treatment time was 27.2 months, to wait for aligners while retaining the with an average time of 3.6 months edentulous space for an extended period between initial PVS impression and aligner of time. insertion. Figures 2a through p depict a Class For three Phase II patients, the I moderate maxillary and mandibular treatment plan called for mandibular crowding case. The 33-year-old subject incisor extraction. This treatment required presented with a chief complaint of crooked Figure 2p. Cephalometric superimposition. significant control of the root position teeth. She had no previous orthodontic from the appliance system. As the treatment and was not interested in clinicians struggled to obtain this control, extraction treatment, despite a protrusive software, which allows the clinician to the demands on the properties of the profile, gingival recession, and lack of view the setup and each increment of aligner material increased. The material adequate attached gingiva effecting the movement, has greatly improved during of choice was EX 30-30, a polyurethane mandibular dentition. The treatment plan the progression of this study. Initially, sheet of 0.030 inch thickness. This material included resolution of crowding via dental the teeth were poorly defined, and the provides better control and comfort than arch expansion and interproximal reduction. ability of the clinician to accurately assess others that were tested. In a continued Total treatment time (including inactive alignment and occlusion was limited. effort to obtain root control, composite treatment) was 37 months, with a total of The software has evolved not only in buttons, or attachments, were bonded 41 maxillary and 43 mandibular aligners. resolution, but also in terms of additional onto the labial surface of teeth requiring Two sets of PVS impressions were needed to diagnostic features such as the use of movements that were less predictable complete her treatment. Note the posterior calibrated grids and superimposition of to achieve. These movements included open bite in the immediate post-treatment dental changes. Future advancements rotation of cylindrical shaped teeth, photographs. The patient’s maxillary under investigation by the team of the extrusion, and intrusion. They were also aligners were cut distal to the first bicuspids craniofacial research laboratory at the introduced on teeth adjacent to extraction to allow re-eruption of the posterior teeth. University of the Pacific include the sites. The shape and size of these Cephalometric superimposition showed addition of individualized root form attachments appeared to influence clinical slight proclination of the maxillary and and condyle position and accurate efficiency, so many designs were tested. mandibular incisors, with no accompanying determination of dental change within the It was also unclear whether the PVS increase of the mandibular plane angle. jaws, made possible by the latest digital impression should be taken before or Subjective determination of vertical control radiographic scanning techniques. after the clinical extraction of a tooth, as appears favorable with this system, likely The Phase II subjects were diagnosed it was possible to do either. Allowing the related to the control of tooth extrusion and with malocclusions comprising computer programmers to virtually extract posterior bite-block effect. Class I moderate crowding, posterior the tooth before the clinical extraction The Phase III patients were diagnosed crossbite, and lingually impacted took place turned out to be the method of with malocclusions including Class I and II mandibular premolars, as well as Class choice, although both options currently severe crowding. As a result, the treatment
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plan for most of these patients called This highlights the benefit of sustainable The likely outcome of the availability of for extraction therapy and, later, buccal periodontal health to the patient.10 the system to other dental disciplines will segment correction via distalization of the be the use of the system to perform other, maxillary buccal segments. The average Discussion more limited tooth movement needs such treatment time of those subjects who have This study was designed to determine as augmenting bridge, implant, or veneer completed treatment was 31.5 months, the feasibility of abstracting data from a preparation. This system has been used in with an average time of 3.3 months patient, transferring it to a 3-D computer orthognathic surgical cases to replace the between PVS and aligner insertion. format, manipulating the image according pre- and postsurgical fixed appliance phase The biggest clinical challenge with this to the clinician’s treatment plan, and of the treatment plan. It should be stressed group of patients was bodily extraction manufacturing a series of therapeutic, that these cases are not routine, and their space closure. Initially, they experienced custom-made appliances based on the outcome in comparison to traditional tooth tipping because they either had no resulting 3-D program. At the advent of the techniques is largely unknown. attachments or had small suboptimal ones. study, many of the systems in place were It is clear that that many of the Currently, UOP clinicians use at least one 5 still under development. Phase I of this questions and concerns that the specialty x 1 x 1 mm long vertical attachment for root study demonstrated that the cumulative and the entire dental profession raise control, and they overcorrect root position error involved in the entire process was regarding this appliance system have not on the virtual set-up. Esthetics was also a within clinically acceptable limits. Phase yet and will not be addressed in a definitive major concern for these bicuspid extraction II demonstrated that judicious planning manner by this continuing feasibility study patients. In those cases, the virtual pontic was required of the clinician to ensure alone. Thousands of patients are currently space that is created where the extracted the system of appliances would create being treated in practices across the United tooth existed is now filled with a tooth- the desired result. Considerations such States, Europe, and Asia with this system; colored PVS material that sticks to the as overcorrections and bodily control of and resulting case reports are providing aligner. The virtual pontic system also aids individual teeth, as well as strategies for valuable anecdotal clinical information. controlled movement of adjacent teeth as it retention and less predictable movements Although this study has helped refine provides a wall of semi-rigid material for the such as extrusion needed to be addressed and improve the system that is now teeth to move against, rather than a thinner before appliance manufacturing. In this commercially available, outstanding issues span of plastic that tended to flex in the study, the clinician had the luxury of such as the clinical efficacy, occlusal quality, extraction space. taking new impressions and refining and iatrogenic effect compared to the “gold When surveyed, 100 percent of the treatment to achieve an ideal result and to standard” of fixed appliances will require subjects claimed that they would select test novel approaches. This creates longer prospective, controlled clinical trials with the Invisalign system over regular fixed overall treatment duration but allows the adequate sample size, increased record appliances. Even early in the study when achievement of results comparable to fixed base, and the use of objective assessment subjects often spent more time waiting appliance treatment. methods such as occlusal indices to for aligners than wearing them, after Phase III patients in this study are evaluate outcome. As the Invisalign multiple PVS impressions and testing those with malocclusions that fall largely System has undergone rapid and continual many different materials, the subjects outside current commercial guidelines for evolution and refinement, it has been tolerated the aligners well and compliance the system. While most of these cases have impractical to undertake such a controlled was not an issue. Sample decay occurred finished with good clinical results, buccal study up to this time. (5 percent), particularly in the first phase segment distalization and large edentulous The paucity of such objective of subjects since these were largely mild space closure remain less predictable. This information on this new product has malocclusions, the system of treatment study will continue to investigate methods induced justified clinician frustration and was not as refined as it is today, and many to make these movements more predicable. suspicion. As a profession, it is prudent of the subjects graduated dental school The use of occlusal indices, such as the PAR to treat new products in such a manner and moved away. Loss and breakage were Index, to objectively determine subject and to embrace them with caution in an not the problem that was anticipated, groupings via malocclusion severity would effort to protect patients from inexpedient perhaps due to the largely adult population not have enhanced the resulting data of this treatment. While this system has provided of the group and relatively short duration feasibility study. However, future studies an alternative to the mechanically more (10 to 14 days) of wear of each aligner. investigating the clinical efficiency of this complicated fixed appliance system, it When asked whether oral hygiene was system utilizing larger sample size would has not replaced the need for thorough easy to maintain while using the system, enhance their value from the application of dentofacial diagnosis and treatment- 100 percent of subjects replied that it was. such measurement tools. planning expertise. For those clinicians
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appliance. Am J Orthod 31:297-304, 1945. who choose to utilize this current 2. Nahoum H, NY State Dent J 30; 9:385-90, 1964. system, sound knowledge in orthodontic 3. Sheridan, JJ, Ledoux W, McMinn R, Essix retainers: Fabrication treatment planning and biomechanics and supervision for permanent retention. J Clin Orthod 27:37-45, 1993. as well as experience in new skills such 4. Rinchuse DJ, Rinchuse DJ, Active tooth movement with essix as manipulation and diagnosis via 3-D based appliances. J Clin Orthod 31:109-12, 1997. images are imperative to provide patients 5. Lindauer SJ, Shoff RC, Comparison of Essix and Hawley retainers. J Clin Orthod 32:95-7, 1998. with quality outcomes. The orthodontists 6. Ponitz RJ, Invisible retainers. Am J Orthod 59:266-72, 1971. treating patients in this study experienced 7. McNamara JA, Kramer KL, Juenker JP, Invisible retainers. J Clin a steep learning curve with this system, so Orthod 19:570-8, 1985. 8. Boyd RL, Miller RJ, Vlaskalic V, The Invisalign System in adult that it is advisable for the novice to begin orthodontics: mild crowding and space closure. J Clin Orthod with mild cases. 34:203-13, 2000. It is apparent that the combination of 9. Vlaskalic V, Boyd RL, Orthodontic treatment of a mildly crowded malocclusion using the Invisalign System. Case Report fixed appliance therapy and the Invisalign Aust Orthod J 17: March 2001. System is often a prudent treatment 10. Boyd et al, Periodontal implications of orthodontic alternative to offer patients. To date, three treatment in adults with reduced or normal periodontal tissues vs adolescents. Am J Orthod 96:191-8, 1989. of the 38 subjects in this study had some To request a printed copy of this article, please contact/Vicki degree of fixed appliance and Invisalign Vlaskalic, BDSc, MDSc, UOP School of Dentistry, 2155 Webster combination to complete orthodontic St., Room 130, San Francisco, Calif, 94115. treatment to an appropriate standard. The Invisalign System is an attractive alternative to traditional orthodontic appliances for the adult population due to its removable, esthetic nature, allowing high standards of oral hygiene during treatment. As such, it has attracted many patients who would not have otherwise sought treatment. However, it remains to be determined exactly how the dental profession will ultimately incorporate this system, with the introduction to the rest of the profession being a relatively recent occurrence. What is clear is that the role of the Invisalign System should be based on sound clinical results and not directed by consumer demand.
Conclusion The Invisalign System of orthodontic tooth movement is a feasible alternative to traditional fixed and removable appliance therapy in select cases. The system has experienced a rapid clinical evolution and will likely continue to do so. Clinical results from this study and other sources suggest that permanent dentition patients with mild to moderate malocclusions may benefit from carefully planned orthodontic treatment using this system. The ultimate clinical potential of this product remains unclear without further investigation. References 1. Kesling HD, The philosophy of the tooth positioning
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University of Southern California School of Dentistry: Dental Education for the 21st Century
Harold C. Slavkin, DDS
alifornia is the fifth-largest the oral health professions since 1897.2 authors economy in the world, In 1923, USC began its dental hygiene with 34 million people who program under the direction of Cora L. Harold C. Slavkin, DDS, is the dean and G. Donald speak 224 different dialects Ueland and has sustained a baccalaureate and Marian James and languages.1 By 2050, program. During the mid-20th century, Montgomery Professor of CCalifornia’s population will exceed 50 USC developed a number of superb dental Dentistry at the University million people.1 We have some of the specialty programs in oral-maxillofacial of Southern California finest universities in the world. We are surgery, orthodontics, pediatric School of Dentistry. innovators; and we thrive on discovery dentistry, periodontics, prosthodontics, in our laboratories, clinics, and hospitals. endodontics, and general practice When we think of California, many residency, which continue to contribute to of us think about adventure, higher dental education and science. In 1974, USC education and outstanding universities, began its graduate program in craniofacial information technology, biotechnology, biology administered by the Graduate the entertainment industries of motion School of the university, the first in the pictures and television, agriculture, nation; and it continues to educate and import/export shipping industries, train outstanding PhD graduates who cultural diversity, sunshine, physical serve on the faculty of many outstanding fitness, and fun. In great measure, the dental schools in America and abroad. universities and colleges of the Golden In 2002, USC began its first advanced State have and continue to provide education in general dentistry program. the talent, knowledge, and innovative As USC enters this current academic technology that continue to fuel the year (July 1, 2002, through June 30, 2003), success of California. we are proud of our history and tradition The School of Dentistry at the of clinical excellence and more than 13,000 University of Southern California alumni in the oral health professions. graduated its first class in 1900. USC has For more than a century, we have taken been contributing to what is thought, pride in the development of professional what is taught, and what is practiced in human beings through learning and
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teaching, research, professional practice, and various forms of service to the community and our profession. We are USC School of Dentistry extremely proud of our clinical-excellence students legacy in operative and restorative 553 dental students; 95 dental hygiene students; 60 advanced standing international dentistry as well as orthodontics, oral dentists; 97 postdoctoral students in advanced specialty programs (21 concurrently surgery, periodontics, endodontics, pursuing advanced degrees); and 62 MS and PhD candidates. pediatric dentistry, dental hygiene, Faculty craniofacial molecular biology, and 118 full-time faculty and more than 400 part-time faculty. community outreach programs. We have Programs evolved with California. We have grown through the remarkable advances made Doctor of dental surgery in the oral health professions, especially Doctoral dental program (four-year program) the profound changes and advances made Advanced standing program for international dentists (two-year program) in the dental sciences that affect what we teach, how we learn, and how we critically Bachelor of science in dental hygiene think in the 21st century. Dental hygiene program USC has a distinguished faculty Post-certificate hygiene program that have earned significant state, national, and international respect for Advanced specialty certificates their contributions to what is thought, Advanced education in endodontics taught, and practiced in the oral health Advanced education in general dentistry professions. For example, our faculty contribute to organized oral health Advanced education in oral and maxillofacial surgery** professions with individual members Advanced education in orthodontics* serving in the Institute of Medicine Advanced education in pediatric dentistry* (National Academy of Sciences), fellows in the American Association for the Advanced education in periodontics* Advancement of Science, fellows in the Advanced education in prosthodontics American College and International General practice residency College of Dentists, Pierre Fauchard Academy, and numerous roles in the *In conjunction with the USC Graduate School, offers combined programs with craniofacial biology American Dental Association, American leading to a specialty certificate and MS degree. Dental Education Association, American ** In conjunction with the Keck School of Medicine, offers a combined program leading to a specialty Association of Dental Research, various certificate and MD degree. dental specialties, the California Dental Master of science Association, and numerous local dental Craniofacial biology program societies. Our faculty contribute through scholarship to innovation and discovery, Doctor of philosophy and they are ranked No. 6 in federal Craniofacial biology program research support for biomedical research Combined degree programs: among the 55 dental schools in America. USC is ranked No. 2 in the citation index DDS-MBA program with the Marshall School of Business for our faculty contributions to the oral DDS-MS program with the Leonard Davis School of Gerontology health scientific literature (oral surgery, DDS-MS program with the Rossier School of Education dentistry, and oral medicine). USC faculty are internationally recognized for their significant contributions to continuing dental education in dental anesthesia, medical emergencies, esthetic dentistry and dental materials, implantology,
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imaging, and instrumentation in dental in our region. In Southern California, living in a remarkable time in oral health hygiene. Since 1900, when Dean Edgar 7 million people do not have dental history. We have the opportunity to Palmer presided over the first graduation insurance or access to oral health care; revisit previous assumptions, consider the of 12 USC dental students, faculty and this disturbing oral health disparity is emerging new biological and behavioral graduates have contributed to what is particularly pronounced in poor and sciences, consider the individual and thought, taught, and practiced in the oral working-poor people who live in our community quality of life issues, assess health professions.1 region. One major opportunity for USC the costs and management of health care, This paper will highlight strategies and the other four dental schools of and improve the cultural diversity of our and advances that will reacquaint the California is to collaborate to improve the profession while increasing access to oral reader with the University of Southern safety net for larger percentages of the health care for all people.3-6 The social, California. population with particular attention to economic, and political dimensions are infants and toddlers, their caregivers, and truly significant! The Present Opportunities the poor elderly of the Golden State. The USC School of Dentistry is a Of course, the recent explosion of Strategic Planning, Accreditation, and “learning organization,” dedicated to our informatics and biotechnology heralds University Reviews own ongoing learning, flexibility, comfort a true “biological revolution” within As you read this article, I have with change, and openness to new ideas. dentistry and medicine. The completion completed just more than two years as the We are committed to improving the of the human genome; the completion 11th dean of the USC School of Dentistry. health of all people through education of numerous microbial genomes; the Two years before I arrived, under the and training, innovation and discovery, advances in diagnostics, treatments, and direction of interim dean Jerry Vale and patient and community oral health, therapeutics; as well as novel biomaterials led by Roseanne Mulligan, USC organized and leadership. We seek to provide are affecting what we think, what we to engage in a comprehensive “self-study” outstanding undergraduate, graduate, teach, and how we practice clinical in preparation for the American Dental and postgraduate academic programs dentistry in California. The intellectual Association national accreditation. This of instruction for highly qualified boundaries of dentistry are expanding!3-7 process engaged hundreds of faculty students leading to academic degrees in At USC, we consider the full array (full-time and part-time), students the oral health professions; extend the of clinical competencies that we set (dental hygiene, predoctoral, residents, knowledge of oral health by encouraging in our research intensive university- graduate students), staff, and alumni. and assisting faculty in the pursuit of based schools of dentistry – health Their intensive work over two years innovations and discovery scholarship; promotion, risk assessment, disease resulted in the “self-study” documents improve the oral health of the people prevention, diagnostics, treatment that were submitted to the ADA. This body of Southern California; stimulate planning, treatments (numerous of information (descriptions, analyses, and encourage in our students those technique-sensitive procedures) and evaluations, and recommendations) was qualities of scholarship, leadership, and therapeutics, health services, health invaluable to me in my learning about the character that mark the true oral health outcomes, multicultural competencies, community culture, core values, priority professional; serve California and the patient management and human setting, and ambitions for the future. The nation in providing lifelong learning to behavior, business management practices, timing was excellent. The process coincided oral health professionals; and, provide informatics, conflict resolution, and with my return to USC from Washington, oral health leadership in the solution mediation.7-9 D.C., where I had worked and lived with my of community, regional, national, and The knowledge and technology wife from July 1995 through July 2000 as international complex problems. expansion is nothing short of remarkable. director of the National Institute of Dental Being located in Southern California There is more to know and more to teach and Craniofacial Research, one of the 20 (eight counties comprising 24 million than ever before within the same time institutes that make up the National people), our university is “an engaged frame of professional dental education.7-9 Institutes of Health in Bethesda, Md. As university” that forms collaborations and All of us in dental science, education, I began my USC tenure on Aug. 14, 2000, partnerships with our communities to and patient care have a significant the two-year “self-study” developed improve the quality of life. The School opportunity to rethink our admissions by my USC colleagues provided an of Dentistry is aligned with our parent policies, the four-year curriculum, how opportunity to gain an appreciation for university, and we have a long and we learn and how we teach, and the and understanding of their assessment distinguished history of community clinical competencies that we establish of strengths, weaknesses, opportunities, outreach programs that affect the people as our functional goals.7-9 Today, we are and threats.
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Independently – under the leadership these initiatives and proposed four critical emphasizes student-centered, patient- of Provost Lloyd Armstrong, Jr. – our pathways: focused, small group-oriented, inquiry- parent university administration and all nnCommunications – Understanding based strategies of learning, with of the colleges had completed a rigorous and helping to solve technical, social, learners addressing developmentally “self-study” that produced the university- cultural, legal, and political issues of appropriate patient-based problems.9 wide Strategic Plan (1994 and revisions in communications in its many forms. nnInnovation and discovery – The 1998). This plan serves as the blueprint for nnLife sciences – Coordinating and School of Dentistry plans to expand developing the entire university including building on considerable expertise in scientific research in oral infection and the School of Dentistry. The plan sets the life sciences ranging from basic immunity, innovations in antimicrobial forth four strategic initiatives to leverage biological sciences to clinical and therapeutics, molecular epidemiology USC’s distinctive characteristics. The four engineering applications. of complex human diseases, oral strategic initiatives are: nnThe arts – Coalescing our considerable health disparities, health services nnInitiative 1: Undergraduate education strengths in the arts to move USC to and outcomes research, chronic facial – Provide a distinctive undergraduate the center of the cultural stage in Los pain, oral-dental-facial rehabilitation experience built on excellent liberal Angeles. and esthetics, bioengineering, arts and professional programs, nnThe urban initiative – Exploring how tissue engineering and biomaterials, incorporating unique opportunities for complex urban environments function implantology, and “virtual craniofacial- career preparation through innovative and how to improve them. oral-dental patient reality.” collaborations between the liberal arts Importantly, the university-wide nnPatient care and community oral and our diverse array of professional strategic plan and the work of the USC health – Oral diseases and disorders schools. dental community meshed and indicated represent the most common chronic nnInitiative 2: Interdisciplinary a clear alignment including many positive diseases of children. In Southern research and education – Create the opportunities for collaborations and California, infants, preschool, and organizational flexibility, and capacity leveraging of resources. Five months after K-12 children constitute a “silent for teamwork, to become a world I began my tenure as dean, we completed and neglected epidemic” of tooth center for innovative interdisciplinary and published a strategic plan for the USC decay, tooth pain, oral infections, research and education in selected School of Dentistry “Shaping the Future” and related poor school attendance. areas. (2001-2006). The plan contains our vision; The problems are very significant nnInitiative 3: Building on the resources mission; our “SWOT” analysis (strengths, in that many of these infants and of Southern California and Los Angeles weaknesses, opportunities, and threats); children reside in close proximity to – Create programs of research and four strategic directions or initiatives; both University Park and the Health education that utilize and contribute to and four critical operational factors with Science campuses of USC. In addition, the special characteristics of Southern goals and objectives. “Shaping the Future” oral health addresses pregnancy, California and Los Angeles as a center serves as a blueprint for the future of the premature babies, craniofacial birth of urban issues, multiculturalism, arts, School of Dentistry. defects, craniofacial-oral-dental entertainment, communications, and trauma, severe malocclusion, head business. USC School of Dentistry Strategic Plan and neck cancers (e.g. oral and nnInitiative 4: Internationalization – The strategic plan is organized into pharyngeal cancers), a variety of oral Build upon USC’s strong international four strategic directions. Each strategic and periodontal infections, chronic base of alumni, students, established direction is described briefly in the body facial pain, osteoporosis, osteoarthritis relationships, and Southern California’s of the strategic plan followed by goals and as related to temporomandibular joint position as an international center to objectives. Each of these four strategic diseases and disorders, xerostomia or enhance future global opportunities directions detail actions to be completed “dry mouth.” and a number of related for education, research, and career within the next three to five years. The oral health diseases and disorders. development. Because of the four strategic directions are: The challenges represent the entire characteristics of Southern California nnEducation and learning – Based life span, from conception through and of our students and alumni, focus on critical analyses of a five-year senescence, and include individual efforts on the countries of the Pacific educational demonstration project, patients, families, communities and Rim and of Central and South America. problem-based learning, we proposed populations. Improving the oral health In addition, the university-wide plan to utilize PBL to achieve our of all people of all ages and all cultures outlines strategies and actions to realize educational goals. The PBL pedagogy is fundamental to the mission of USC.
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nnLeadership for the oral health distinguished academicians drawn from to provide students, faculty, and staff professions – Our goal is to educate throughout the university; and with opportunities to address the oral and foster leadership through critical nnAn external review and site visit health care needs of all people over the thinking, problem-solving, cultural by a panel of distinguished dental entire lifespan – ranging from prenatal competencies, and a shared desire academicians drawn from around the care through hospice care.3 And USC to improve the health of all people. country (Drs. Bruce Baume, laboratory continues to be dedicated to nurturing At USC, we are dedicated to nurture chief, gene therapy/therapeutics, the future leadership for the oral health learners to consider multiple career NIH; Bruce Donoff, dean, Harvard professions. pathways including careers in science, School of Dental Medicine; and technology, education, and organized Charles Bertolami, dean, UCSF School References 1. Baldassare M, California in the New Millennium: The dentistry and beyond. We recognize of Dentistry. Under the leadership Changing Social and Political Landscape. University of the importance of equipping faculty of Chuck Shuler, associate dean for California Press, Berkeley, 2000. and students with leadership skills and Academic Affairs, the combined final 2. Done HN, Gardner J, eds, 100th Year Centennial of the University of Southern California School of Dentistry. USC incentives so they may effectively stand report was submitted to the provost Dental Alumni Association, Redondo Beach, Calif, 1997. for, and communicate, the USC model. who in turn will soon engage the 3. Slavkin HC, Expanding the boundaries: Enhancing dentistry’s faculty and administration of the contribution to overall health and well-being of children. J Dent Ed 65:1323-34, 2001. University Academic Performance School of Dentistry. Our shared goal 4. Slavkin HC, The human genome, implications for oral health Review is to define measurable goals and and diseases, and dental education. J Dent Ed 65: 463-79, 2001. The University of Southern California objectives for the School of Dentistry 5. Tabak LA, A Revolution in biomedical assessment: The development of salivary diagnostics. J Dent Ed 65:1335-9, was founded in 1880. At that time, the to attain and/or sustain pre-eminence 2001. founders anticipated that USC would grow in the oral health professions. 6. Ratner BD Replacing and renewing: Synthetic materials, and evolve with the Southern California biomimetics, and tissue engineering in implant dentistry. J Dent Ed 65:1340-7, 2001. region and that USC would serve as “an Prospectus 7. Cohen MM, Major long-term factors influencing dental engaged university” to collaborate with USC will complete our transition to education in the twenty-first century. J Dent Ed 66:360-73, public and private sectors to improve or school-wide PBL in two years. Our faculty 2002. 8. Hendricson WD, Cohen PA, Oral health care in the 21st enhance the intellectual, technological, will continue to contribute to what is century: Implications for dental and medical education. Acad financial, and “quality of life” for the thought, taught, and practiced in the Med 76:1181-206, 2001. people of California and beyond. For oral health professions. For example, 9. Shuler CF, Application of Problem-Based Learning to Clinical Dental Education. J Cal Dent Assoc 30:435-43, 2002. the first 50 years, USC was Southern the article in this issue contributed by California’s only major university. For Drs. Paul Denny and Mahvash Navazesh more than a century, USC has contributed indicates the numerous opportunities to what is thought, taught, and practiced to improve clinical diagnosis using in the numerous disciplines that make up saliva fluid as an informative solution the university. that reflects health and/or disease. Inherent in success is the zeal for USC faculty are significant contributors self-improvement. In this context, to craniofacial molecular biology, USC embraces not only the formal biomimetics and tissue engineering, accreditation processes of each of its oral cancer, biomineralization with colleges, but also seeks to define each emphasis upon enamel bioceramics, oral of its colleges’ academic performance infection and mucosal immunity, oral by national and international objective microbiological diagnostics, antimicrobial criteria. In the late 1990s, the provost therapeutics, “virtual head and neck of USC initiated a series of “self-study” patient” research and applications, and assessments of the academic performance educational research. USC is also a major of each of its colleges. The USC School contributor to esthetic dentistry as well of Dentistry was selected to be reviewed as implantology, and we remain dedicated beginning October 2001. The yearlong to reducing oral health disparities from process included: Bakersfield to the Mexican border using nnSelf-assessment; numerous venues such as community- nnA projected five-year written plan; based clinics, school sites, hospitals, nnInternal reviews by a panel of and mobile units. Our new emphasis is
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Saliva: A Fountain of Opportunity
Mahvash Navazesh, DMD; Paul Denny, PhD; and Stephen Sobel, DDS
abstract Saliva continues to demonstrate that it is more complex than generally perceived and has more diagnostic value than is generally appreciated. This article will review some of the components and functions of saliva; discuss its promise as a diagnostic aid; review some of the problems associated with inadequate salivary function; and, it is hoped, enhance oral health care providers’ appreciation of the importance of saliva in everyday clinical practice.
aliva, often described as being provides the fluid current that moves food authors “99 percent water,” mirrors and microbes out of the oral cavity. The an individual’s health; and coating property of saliva is complex and Mahvash Navazesh, DMD, the complexity of saliva can alternatively lubricate tooth surfaces is an associate professor offers multiple windows of as well as contribute a protective layer and chair in the Division opportunity for monitoring general to oral soft tissues that protects against of Diagnostic Sciences at S the University of Southern wellness, assessing oral health and desiccation and microbial colonization.2-5 California School of disease, tracking the progression and The remineralization capability of Dentistry. treatments of systemic disease, assessing saliva depends upon the combination of risk, and detecting substance abuse.1 its uncompromised buffer systems and the Paul Denny, PhD, is a professor of biochemistry Many and various attributes of saliva systems it employs to maintain calcium in the Division of are routinely referenced in forensic and phosphate ions in a supersaturated Diagnostic Sciences at dentistry; but the challenge for exploiting state relative to the hydroxyapatite of USC School of Dentistry. the full potential of saliva for diagnosis, enamel. When the pH of saliva drops to pharmacological monitoring, and risk near 5.5 or lower, the equilibrium between Stephen Sobel, DDS, is an associate professor assessment remains.2 the free ions and the mineral shifts to of clinical dentistry in the The oral cavity is one of the most favor demineralization. The antimicrobial Division of Diagnostic important portals into the body. Saliva properties of saliva depend upon a variety Sciences at USC School of represents the first line of defense against of enzymes and proteins that individually Dentistry. foreign pathogens as well as commensial have demonstrated antibacterial, residents when high population densities antifungal, and/or antiviral activities. Saliva can also be pathogenic. The flow of saliva initiates the general digestive process by the allows for the constant cleansing of oral secretion of a variety of digestive enzymes tissues with its beneficial properties and whose role is to degrade food and bacterial
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remains lingering in the oral cavity. Saliva malabsorption of gluten. Salivary IgA- is also a source of hormones and growth AGA measurement has been reported Table 1. Common Conditions factors.2,6-9 to be a sensitive and specific test for the Associated with Salivary Gland screening of this disease and monitoring Hypofunction. Saliva as a Diagnostic Aid the patient’s adherence to the required Saliva is a mixture of ions, small gluten-free diet.12,13 Sjögren’s syndrome Systemic Disorders organic molecules, enzymes, and proteins, is a chronic autoimmune disorder that Autoimmune some in multiprotein complexes and others affects many systems, including the complexed with other biochemicals.10 salivary and lacrimal glands. Attempts Cardiovascular Add to this the oral microorganisms and have been made to use xerostomia (dry Connective tissue their byproducts, and an ecological system mouth) and salivary gland hypofunction Endocrine is created that either maintains good oral (reduced saliva flow rate and/or altered health or, conversely, contributes to its sialochemistry) for the clinical diagnosis Neurologic decline.11 of this medical condition.14-16 A “yes” Psychiatric Science is only beginning to recognize response to any of these questions: “Have Metabolic the complexity of the ecology and you had a daily feeling of dry mouth for knows even less about how alteration of more than three months?” “Have you had Neoplastic individual components of the system can recurrent swollen salivary glands as an Infectious affect the whole. The understanding of adult?” “ Do you frequently drink liquid Pharmacotherapeutics these interactions may make it possible to aid in swallowing dry food?” along with Radiotherapy to manipulate the system in favor of an unstimulated whole saliva flow rate promotion and maintenance of oral health. of 0.1 ml/min have been included in the Chemotherapy The type and quantity of oral microbes revised European classification criteria Medications/Polypharmacy harbored in the oral cavity may contribute for the diagnosis of Sjögren’s syndrome.17 Analgesics to elevated risk levels for a number of Salivary steroid hormones have been systemic diseases. used to assess ovarian function18 and the Antihistamines Within the past 20 years, more than risk for preterm labor,19,20 to evaluate Antihypertensives 2,500 citations have focused on the child health and development,21 and Antidepressants diagnostic value of oral fluids. Saliva is a to study mood and cognitive emotional fountain of opportunities for innovation behavior.22 Cytotoxics and discovery, risk assessment and disease Human immunodeficiency virus Sedatives prevention, and pharmacotherapeutic infection is one of the best examples Anticonvulsives monitoring. The potential is great. for utilizing saliva as a diagnostic aid.23 Multiple uses for detection of drug A saliva test in a self-contained kit is Antiretroviral therapy abuse and treatment monitoring have available for HIV screening.24 Saliva is been developed. However, exploitation also used for the measurement of other of the full richness of the medium has viral pathogens such as hepatitis C, a Oral Conditions only begun. Below are some examples leading cause of liver cirrhosis;25 hepatitis Saliva can be used to detect oral fungal of systemic and oral conditions, along B surface antigen;26 cytomegalovirus; and periodontal infections, to assess with chemotherapeutics, where salivary herpes simplex viruses 6, 7, and 8;27 and susceptibility to dental caries, and to screen qualitative and/or quantitative changes epidemiological studies of Epstein Barr for oral neoplasms. Salivary fungal colony have been investigated as potential virus in schoolchildren.28 Saliva has also forming units can be used for detection diagnostic aids. received much attention in recent years of oral candidiasis.34 The salivary levels for its potential role in the diagnosis of pathogens such as Porphyromonas Systemic Conditions of Helicobacter pylori, the pathogen gingivalis, Streptococcus mutans, and Saliva has been studied in relation associated with peptic ulcer.29 Elevated Lactobacillus acidophilus can be utilized to sundry medical conditions including levels of some salivary markers have in risk assessments for periodontal congenital, autoimmune, endocrine, been associated with ovarian and breast diseases10 and dental caries.35,36. Elevated infectious, and neoplastic disorders. cancer.30-32 The potential value of saliva levels of some salivary proteins have also Celiac disease is a congenital disorder as a diagnostic aid for breast cancer been associated with oral squamous cell of the small intestine that involves detection is under evaluation by FDA.33 carcinoma.37 The possibility of oral cancer
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Figure 1. Fissured and lobulated tongue secondary to Figure 2. Atrophic and erythematous tongue in a patient Figure 3. Pseudomembranous candidiasis involving salivary gland hypofunction. with dry mouth complaint. tongue mucosa in a patient with salivary gland hypofunction and uncontrolled diabetes.
Figure 4. Erythematous candidiasis in a patient with Figure 5. Desiccated mucosa, absence of salivary pool, Figure 6. Cervical caries involving multiple maxillary salivary gland hypofunction who was on multiple xerogenic extensive restorative experience, and recurrent caries in a anterior teeth in the patient seen in Figure 5. medications. patient with Sjögren’s syndrome and severe salivary gland hypofunction.
is also reported to be higher in individuals and anticancer medications.43 It can also families of pharmacological agents48- who have high salivary levels of nitrate be used for evaluation of illicit drug use, 51(Table 1). Bacterial infections, viral and nitrite. Salivary levels of these two ethanol consumption, recreational drug infections, sialoliths, and medications factors are significantly associated with use, and tobacco consumption.44-47 A may act as local factors in reducing saliva the levels of dietary intake.38 The type and comprehensive list of medications easily secretion. On the other hand, Sjögren’s quantity of oral microbes harbored in the monitored in saliva is available elsewhere syndrome, rheumatoid arthritis, lupus oral cavity may contribute to elevated risk and is not discussed here.2,33 erythematosis, sarcoidosis, cystic fibrosis, levels for a number of systemic diseases. Alzheimer’s disease, uncontrolled Though the evidence rarely extends beyond When Production of Saliva Fails diabetes, hypertension, strokes, AIDS epidemiological correlation, there is reason The absence or loss of function of and HIV infection, and depression to anticipate that there are direct links any of the beneficial actions of saliva are systemic causes for salivary gland between uncontrolled oral disease and mentioned above can predispose an hyposecretion.52,53 Some consequences systemic conditions such as cardiovascular individual to oral disease and the systemic of persistent and severe salivary gland disease, and delivery of low birth weight, cascade that may follow. The importance hyposecretion are the onset and rapid premature babies.39-41 of saliva is never more clear as when there progression of dental caries, fungal is too little or none. There is a dramatic infection, and intraoral soft tissue Pharmacotherapeutics impact on oral health as well as a level changes54,55(Figures 1 through 6). Chronic Saliva can be used for monitoring the of discomfort and inconvenience that reduced saliva secretion may lead to systemic (plasma) levels of medications adversely affects personal freedom and the depression56 and tooth loss57 and affect as well as therapeutic responses to feeling of well-being. an individual’s quality of life.52 Salivary medications. For example, saliva can be The quality and quantity of saliva gland hypofunction may go unnoticed by used to monitor a patient’s compliance are affected by a broad array of local and patients and practitioners, because the with insulin therapy, psychotherapy,42 systemic conditions as well as by large subjective perception of dry mouth is not
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3. Zelles T, Purushotham KR, et al, Saliva and growth factors: always correlated with objective evidence hypofunction and its sequelae has been the fountain of youth resides in us all. J Dent Res 74:1826-32, of salivary hypofunction and vice versa. well-documented52,53,59,60 and will not 1995. Therefore, it is imperative to include be covered in detail here. The management 4. Shugars DC, Wahl SM, The role of the oral environment in HIV-1 transmission. J Am Dent Assoc 129:851-8, 1998. salivary gland assessment as part of may include hydration, regular at-home 5. Mandel ID, The functions of saliva. J Dent Res 66:623-7, 1987. everyday practice. Otherwise, practitioners and professional oral prophylaxis and 6. Baum BJ, Principles of saliva secretion. Ann NY Acad Sci may be faced with the consequences of dry fluoride therapy; medical, nutritional, 694:17-23, 1993. 7. Quissell DO, Steroid hormone analysis in human saliva. Ann mouth that lead to therapeutic rather than pharmacotherapeutic, and emotional NY Acad Sci 694:143-5, 1993. preventive approaches. counseling; and salivary stimulation and 8. Ambudkar IS, Regulation of calcium in salivary gland The importance of including an oral substitution as indicated.61-63 secretion. Crit Rev Oral Biol Med 11:4-25, 2000. 9. Dumbrigue HB, Sandow PL, et al, Salivary epidermal growth soft-tissue evaluation and cancer screening factor levels decrease in patients receiving radiation therapy when doing a dental examination has long Conclusion to the head and neck. Oral Surg Oral Med Oral Pathol 89:710-6, been established and is not questioned The wonders of saliva have recently 2000. 10. Kaufman K, Lamster IB, Analysis of saliva for periodontal by the profession. In view of the effects been appreciated by the media and diagnosis. A review. J Clin Periodontol 2000 27:453-65, 2000. on one’s quality of life in general, and the health professions.64 Dentistry 11. Lenander-Lumikari M, Loimaranta V, Saliva and dental the potentially disastrous effects on should support the development and caries. Adv Dent Res 14:40-7, 2000. 12. al-Bayaty HF, Aldred MJ, et al, Salivary and serum restorative treatment plans in particular, promotion of saliva as a window into antibodies to gliadin in the diagnosis of celiac disease. J Oral the dental profession must recognize wellness and a means for early disease Pathol Med 18:578-81, 1989. the need and the value of including an detection that leads to more-effective 13. Hakeem V, Fifield R, et al., Salivary IgA antigliadin antibody as a marker for coeliac disease. Arch Dis Child 67:724-7, 1992. evaluation of salivary function with every treatments, risk assessment for future 14. Sreebny LM, Zhu WX, The use of whole saliva in the new dental examination as well as ongoing oral and systemic diseases, and a simple, differential diagnosis of Sjogren’s syndrome. Adv Dent Res observations during treatment and recall. non-invasive alternative to blood and 10:17-24, 1996. 15. Fox PC, Spreight PM, Current concepts of autoimmune Consider as one example the patient urine tests. The authors envision that a exocrinopathy: Immunologic mechanisms in the salivary with salivary hypofunction who has had greater understanding of the dynamics pathology of Sjögren’s syndrome. Crit Rev Oral Biol Medical extensive full-coverage restorations and is of the oral environment mediated by 7:144-158, 1996. 16. Streckfus CF, Bigler L, et al, Cytokine concentrations soon found to have severe cervical caries saliva will provide opportunities for in stimulated whole saliva among patients with primary around the restorations. The implications developing batteries of multiple analyte Sjögren’s, secondary Sjögren’s syndrome, and primary for retreatment, chair time, cost, and tests dedicated to different aspects Sjögren’s syndrome receiving varying doses of interferon for symptomatic treatment of the condition: a preliminary study. J possible loss of patient rapport are of oral health, such as an individual’s Clin Oral Invest 5:133-5, 2001. significant.T able 2 is a flow chart to help remineralization potential, caries and 17. Vitali C, Bombardieri S, et al, Assessment of the European practitioners through the logical steps of periodontal disease risk, and even the classification criteria for Sjögren’s syndrome in a series of clinically defined cases: results of a prospective multicentre screening patients for possible salivary types and titers of oral microbes that study. The European Study Group on diagnostic criteria for gland hypofunction, and the time required contribute risk to other diseases or medical Sjögren’s syndrome. Ann Rheum Dis 55:116-21, 1996. is minimal. procedures. 18. Lu Y, Bentley GR, et al, Salivary estradiol and progesterone levels in conception and nonconception cycles in women: This flow chart contains four The value of saliva to humankind will evaluation of a new assay for salivary estradiol. Fertil Steril questions relative to saliva secretion. expand during the coming years as more 71:863-8, 1999. These questions have been significantly scholars, educators, health care providers, 19. Voss HF, Saliva as a fluid for measurement of estrodiol levels. Am J Obstet Gynecol 180:S226-31, 1999. associated with objective evidence of and policy makers come to appreciate its 20. Heine RP, McGregor JA, Dullien VK, Accuracy of salivary salivary gland hypofunction.58 These fascinating world. estriol testing compared to traditional risk factor assessment questions should be routinely asked of For more information about saliva, in predicting preterm birth. Am J Obstet Gynecol 180:S214-8, 1999. new and recall patients at the time of readers are encouraged to visit the 21. Granger DA, Schwartz EB, et al, Salivary testosterone examination, even if there is no complaint following sites: determination in studies of child health and development. of dry mouth. The clinical changes nn* www.sjogrens.org Horm Behav 35:18-27, 1999. 22. Van Honk J, Tuiten A, et al, Correlations among salivary involving the intraoral and extraoral hard nn* www.oralcancer.org testosterone, mood, and selective attention to threat in and soft tissues listed in the flow chart nn* www.nidcr.nih.gov humans. Horm Behav 36:17-24, 1999. have also been successfully utilized for nn* www.salivatest.com 23. Malamud D, Oral diagnostic testing for detecting human immunodeficiency virus-1 antibodies: a technology whose time identification of patients with salivary nn* www.nlm.nih.gov/medlineplus/ has come. Am J Med 102:9-14, 1997. gland hypofunction.55 Practitioners, when 24. Schramm W, Angulo GB, et al, A simple saliva-based test References performing clinical evaluations, should also for detecting antibodies in human immunodeficiency virus. 1. Tabak LA, A revolution in biomedical assessment: The Clin Diagn Laboratory Immunol 6:577-80, 1999. observe for objective evidence of salivary development of salivary diagnostics. J Dent Educ 65(12):1335- 25. Bello PY, Pasquier C, et al, Assessment of a hepatitis C hypofunction. 9, 2001. virus antibody assay in saliva for epidemiological studies. Eur J 2. Kaufman K, Lamster IB, The diagnostic applications of saliva The management of salivary gland Clin Microbiol Infect Dis 17:570-2, 1998. -- a review. Crit Rev Oral Biol Med 13(2):197-212, 2002. 26. Chaita TM, Graham SM, et al, Salivary sampling for
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hepatitis B surface antigen carriage: a sensitive technique 48. Navazesh M, Brightman VJ, et al, Relationship of medical suitable for epidemiological studies. Ann Trop Paediatr status, medications, and salivary flow rates in adults of 15:135-9, 1995. different ages. Oral Surg Oral Med Oral Pathol Oral Radiol 27. Lucht E, Brytting M, et al, Shedding of cytomegalovirus and Endod 81:172-6, 1996. herpes viruses 6, 7, and 8 in saliva of human immunodeficiency 49. Navazesh M, Mulligan R, et al, The prevalence of virus type 1-infected patients and healthy controls. Clin Infect xerostomia and salivary gland hypofunction in a cohort of HIV- Dis 27:137-41, 1998. positive and at-risk women. J Dent Res 79:1502-7, 2000. 28. Crowcroft NS, Vyse A, et al, Epidemiology of Epstein-Barr 50. Mulligan R, Navazesh M, et al, Salivary gland disease in virus infection in pre-adolescent children: application of a human immunodeficiency virus-positive women from the new salivary method in Edinburgh, Scotland. J Epidemiol WIHS study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Community Health 52:101-4, 1998. 89:702-9, 2000. 29. Reilly TG, Poxon V, et al, Comparison of serum, salivary, and 51. Navazesh M, Barron Y, et al, The relationship among HAART, rapid whole blood diagnostic tests for Helicobacter pylori and HIV disease markers, and salivary gland hypofunction. J Dent their validation against endoscopy based tests. Gut 40:454-8, Res 81, Abstract #1076 pg. A-153, 2002. 1997. 52. Ship JA, Pillemer SR, et al, Xerostomia and the geriatric 30. Di-Xia C, Schwartz P, Fan-Qin L, Salivary and serum CA patient. J Am Geriatr Soc 50:535-43, 2002. 125 assays for detecting malignant ovarian tumors. Obstet 53. Ship JA, Diagnosing, managing, and preventing salivary Gynecol 75:701-4, 1990. gland disorders. Oral Diseases 8:77-89, 2002. 31. Streckfus C, Bigler L, et al, A preliminary study of CA15-3 54. Epstein JB, vander Meij EH, et al, Effects of compliance and c-erbB-2, epidermal growth factor receptor, cathepsin-D, with fluoride gel application on caries and caries risk in and p53 in saliva among women with breast carcinoma. Cancer patients after radiation therapy for head and neck cancer. Oral Invest 18:103-11, 2000. Surg Oral Med Orla Pathol Oral Radiol Endod 82:268-75, 1996. 32. Streckfus CF, Bigler L, et al, The presence of c-erbB-2, 55. Navazesh M, Christensen CM, Brightman VJ, Clinical and CA 15-3 in saliva and serum among women with breast criteria for the diagnosis of salivary gland hypofunction. J Dent carcinoma: a preliminary study. Clin Cancer Res 6:2363-70, Res 71:1363-9 1992. 2000. 56. Reisine S, Parke A, Xerostomia and depressive symptoms 33. Streckfus CF, Bigler LR, Saliva as a diagnostic fluid. Oral among females with primary Sjogren’s syndrome (PSS), early Diseases 8:69-76, 2002. onset rheumatoid arthritis (RA) and healthy female controls 34. Hicks MJ, Carter AB, et al, Detection of fungal organisms (HC). J Dent Res 81 Abstract #2412 pg. A-305, 2002. in saliva from HIV-infected children: a preliminary cytologic 57. Thompson SD, Watkins, CA, et al, Dry mouth and oral analysis. Pediatr Dent 20:162-8, 1998. disease in 79+ elders. J Dent Res 81 Abstract #0986 pg. A-143, 35. Klock B, Svanberg M, Petersson LG, Dental caries, mutans 2002. streptococci, lactobacilli, and saliva secretion rate in adults. 58. Fox PC, Busch KA, Baum J, Subjective reports on Community Dent Oral Epidemiol 18:249-52, 1990. xerostomia and objective measurements of salivary gland 36. Kohler B, Bjarnason S, Mutans streptococci, lactobacilli performance. J Am Dent Assoc 115:581-4, 1987. and caries prevalence in 15 to 16-year olds in Goteborg. Part II. 59. Daniels TE, Wu AJ, Xerostomia – clinical evaluation and Swed Dent J 16:253-9, 1992. treatment in general practice. J Cal Dent Assoc 28:933-41, 37. Tavassoli M, Brunel N, et al, P53 antibodies in the saliva of 2000. patients with squamous cell carcinoma of the oral cavity. Int J 60. Navazesh M, Salivary gland hypofunction in elderly Cancer 78:390-1, 1998. patients. J Cal Dent Assoc 22:62-8, 1994. 38. Badawi AF, Hosny, et al, Salivary nitrate, nitrite and nitrate 61. Heifetz S, Fluorides for the elderly. J Cal Dent Assoc 22:49- reductase activity in relation to risk of oral cancer in Egypt. Dis 54, 1994. Markers 14:91-7, 1998. 62. White S, MacEntee M, Cho G, Restorative treatment for 39. Joshipura KJ, Douglass CW, Willett WC, Possible geriatric root caries. J Cal Dent Assoc 22:55-60, 1994. explanations for the tooth loss and cardiovascular disease 63. Navazesh M, Dry mouth: aging and oral health. relationship. Ann Periodontol 3:175-83, 1998. Compendium of Dental Education 2002 (accepted for 40. Morrison HI, Ellison LF, Taylor GW, Periodontal disease and publication) risk of fatal coronary heart and cerebrovascular diseases. J 64. Mestel R, The wonders of saliva. Los Angeles Times, Jan Cardiovasc Risk 6:7-11, 1999. 21, 2002, p S1. 41. Offenbacher S, Jared HL, et al., Potential pathogenic To request a printed copy of this article, please contact/ mechanisms of periodontitis associated pregnancy Mahvash Navazesh, DMD, USC School of Dentistry, 925 complications. Ann Periodontol 3:233-250, 1998. W. 34th St., Room 4320, Los Angeles, CA 90089-0641, or 42. El-Guebaly N, Davidson WJ, et al, The monitoring of saliva [email protected]. drug levels: psychiatric applications. Can J Psychiatry 26:43-8, 1981. 43. Takahashi T, Fujiwara Y, et al, Salivary drug monitoring of irinotecan and its active metabolite in cancer patients. Cancer Chemother Pharmacol 40:449-52, 1997. 44. Slavkin HC, Toward molecularly based diagnostics for the oral cavity. J Am Dent Assoc 129:1138-43, 1998. 45. Penttila A, Karhunen PJ, Pikkarainen J, Alcohol screening with the alcoscan test strip in forensic praxis. Forensic Sci Int 44:43-8, 1990. 46. Kidwell DA, Holland JC, Athanaselis S, Testing for drugs of abuse in saliva and sweat. J Chromatogr B Biomed Sci Appl 713:111-35, 1998. 47. Di Giusto E, Eckhard I, Some properties of saliva cotinine measurements in indicating exposure to tobacco smoking. Am J Public Health 76:1245-6, 1986.
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Oral Gratification Out of Control
urrent studies, along with tently studying the percentage of calories a startling glimpse of Anna derived from the fat in the foods they are Nicole Smith, confirm our about to purchase. The wheels of ratio- observation that obesity is so nalization turn audibly in their heads. To rampant in this country that aid them and us in this determination, Cit can almost be considered the norm. the government has dictated that the Concurrent research is pointing toward nutritional value of the product be listed overmastication as the prime etiology of prominently on the package. This has the most TMJ problems and intractable love same effectiveness as cancer warnings handles. We are obsessed with food. It placed on cigarettes because the amount Robert E. functions nicely as nutritive Xanax and at is expressed in grams. In this country, Horseman, DDS the same time is the essential ingredient the metric system has met with the same in all social intercourse. popularity you would experience upon We don’t eat because we’re hungry, learning the Osbourne family has moved but because it’s time, or because food is in next door. constantly displayed on TV with only As a result, except for the scientific occasional interruptions for the program- community that can at least pretend to ming. Food can be clearly heard impor- grasp the concept, nobody has any idea of tuning from the fridge, “Turn on the light, how much or what a gram is. Telegrams let’s party down!” we know; cablegrams, sure, but the gram Actually, we rationalize, there is noth- without a prefix is an entity completely ing better to do and there is so much food, outside our frame of reference. Look it we owe it to the farmers to help reduce up and find out how many grams are in a the glut. All this in spite of the fitness pound if you feel guilty for not knowing, craze now in its third decade and the mil- but you’ll forget it moments later without lions of dollars spent on diet foods. The hesitation or regret. exhortations of Suzanne Somers flogging You might accept that a milligram is the Thigh Master and the chimera of the one-thousandth of a gram, but you can’t six-pack abs are apparently not enough. say that easily without lisping like Syl- The lip service given the fat-free diet also vester the puddy-tat. You could perhaps features lips wrapped around anything agree that a kilogram is a thousand grams, that tastes, smells, looks or feels good. but does that mean you could hold that All the gondolas in the supermarket much in your hand or would you need a are accompanied by frowny citizens in- forklift? See, you don’t know! If you could
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hold a thousand grams in your hands, We think the surgeon general, who should have been, “Don’t chew anything then a gram couldn’t amount to a hill of may be too busy advocating the use of for six months, or better yet, never.” beans, could it? That’s what we think, and birth control devices to pay enough atten- We concede that this may be an that’s what the mayonnaise and potato tion to more practical matters, should re- unworkable suggestion much like “be sure chip manufacturers, for example, are slyly quire warning labels to be placed on these to floss every day.” Even if implemented, encouraging us to believe. Mayonnaise products stating that the contents will go dedicated trenchermen would soon figure contains only 12 grams of fat, they assure directly to the hips, supersaturating those out how to get their mass quantities of us in the sincere manner of a used car areas and bypassing normal routes. food transdermally, by I.V., or incorporat- salesman sliding quickly over the fact that Laboratory tests with rats, while con- ed into suppositories. In the meanwhile, the car has 200,000 miles on it. They are ceding that these animals in their natural we see no harm in returning the word hoping you won’t notice the small print state seldom wear form-fitting outfits, “gram” back to its proper definition of the on the label casually mentioning that the indicate that continued use of the product female half of one’s grandparents. 12 grams of fat occurs in each and every by a human consumer will require her tablespoon of the dressing. Potato chips to shoehorn herself into Spandex pants have only 10 grams of fat per serving, at considerable risk to her self-esteem. they state in the same reassuring manner Then there is the additional possibility of you’d use with a patient about to get an laying out upwards of $4,000 for services injection. And how much is a serving? It’s rendered by professional fat removers one ounce. Six chips? Eight? Who would wielding large suction hoses. know? Nobody at our house, where a 12 We dentists have shamefully ne- ounce bag of chips in the presence of two glected our responsibility here. What’s adults lasts no longer than five minutes the question most often asked us? “How -- much less in the grimy paws of children soon can I eat on this, Doc?” Like they and adolescents. can’t wait, haven’t chewed anything for Further deliberate obfuscation of an an hour and loss of oral gratification is already murky subject occurs when the threatening to unhinge them. Regretfully, agency in charge of Consumer Obfusca- our traditional response has been, “Don’t tion decides to subdivide its fat report chew on that side for four to six hours.” into saturated, unsaturated and polyun- Or, “Don’t chew anything hard, fibrous, saturated categories. They know they are tough or sticky at lunch (or dinner) to- on pretty safe ground here, because the day.” As guardians of the oral orifice and same people who can’t get a fix on a gram professional people wearing serious white are going to come up equally clueless with coats upholding our pledge to care for all this saturation information. the health of our patients, our response
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