Medicine and Technology in Dentistry Dental Education Future of Organized Dentistry JournaCALIFORNIA DENTAL ASSOCIATION Dentistry in the 21st Century

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departments

105 The Editor/CDA’s Sesquicentennial

109 Letter/Stephen Shoong Hing Yuen, DDS (1931–2019)

111 Impressions

163 RM Matters/Wheelchair to Dental Chair: Safe and Smooth Patient Transfers 165 Regulatory Compliance/Know What Makes 111 an Electronic Signature Valid

170 Tech Trends

f e at u r e s 115 Professional Calling Originally printed in 1995, this article covers the first 125 years of the California Dental Association. Susan E. Lovelace

127 The Role of Medicine and Technology in Shaping the Future of Oral Health This commentary describes the changes taking place in dentistry and speculates on improvements that could happen soon. Namrata Nayyar, BDS, MS; David M. Ojcius, PhD; and Arthur A. Dugoni, DDS, MSD

133 Dental Education: But Not as We Know It This article discusses how dental education needs to move into a new direction that positions current and future dentists as integrated providers within the health team. Michael Reddy, DMD, DMSc, and Sara Hughes, MBE, EdD, MA, BSc

141 The Future of Organized Dentistry: Past Is Prologue Organized dentistry should embrace what the future brings and adapt in the most constructive ways possible. Peter A. DuBois

145 Societal Needs and the Role of Health Care in Shaping the Future of Dentistry in the 21st Century This commentary uses historic and demographic trends to describe national, California and Los Angeles County health needs in the 21st century. Harold C. Slavkin, DDS

157 Then and Now: Changing Influences on Dental Practice This article is a conversation between CDA Journal editorial staff, new dentists and a long-time veteran of the profession.

MARCH 2 0 2 0 103 CDA JOURNAL, VOL 48, Nº3

Volume 48 Number 3 March 2020 JournaCALIFORNIA DENTAL ASSOCIATION

published by the Management Blake Ellington Manuscript Journal of the California Dental Association California Peter A. DuBois Tech Trends Editor Submissions Editorial Board Dental Association Executive Director Jack F. Conley, DDS www.editorialmanager. Charles N. Bertolami, DDS, DMedSc, Herman Robert 1201 K St., 14th Floor com/jcaldentassoc Fox dean, NYU College of Dentistry, New York Carrie E. Gordon Editor Emeritus Sacramento, CA 95814 Chief Strategy Officer 800.232.7645 Robert E. Horseman, DDS Letters to the Editor Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental cda.org Kristine Allington Humorist Emeritus www.editorialmanager. Medicine, Pomona, Calif. Chief Marketing Officer com/jcaldentassoc Production CDA Officers Mina Habibian, DMD, MSc, PhD, associate professor Alicia Malaby Richard J. Nagy, DDS Randi Taylor Subscriptions of clinical dentistry, Herman Ostrow School of Dentistry Communications Director President Senior Visual Designer Annual subscriptions are of USC, Los Angeles [email protected] Editorial available to association Upcoming Topics members at a rate of $36. Robert Handysides, DDS, dean and associate professor, Judee Tippett-Whyte, DDS Kerry K. Carney, DDS, CDE April/Sleep-Disordered To manage your printed department of endodontics, Loma Linda University School President-Elect Editor-in-Chief Breathing Journal subscription of Dentistry, Loma Linda, Calif. [email protected] [email protected] May/TDSC online, log in to your cda. Bradley Henson, DDS, PhD, associate dean for research June/Health Literacy org account or email Ariane R. Terlet, DDS Ruchi K. Sahota, DDS, CDE and biomedical sciences and associate professor, Western [email protected] Vice President Associate Editor University of Health Sciences College of Dental Medicine, Advertising for assistance. View the [email protected] Pomona, Calif. Brian K. Shue, DDS, CDE Sue Gardner publication online at John L. Blake, DDS Associate Editor Advertising Sales cda.org/journal. Paul Krebsbach, DDS, PhD, dean and professor, section Secretary [email protected] of periodontics, University of California, Los Angeles, Gayle Mathe, RDH [email protected] 916.554.4952 School of Dentistry Senior Editor Steven J. Kend, DDS Jayanth Kumar, DDS, MPH, state dental director, Andrea LaMattina, CDE Permission and Treasurer Sacramento, Calif. Publications Manager Reprints [email protected] Andrea LaMattina, CDE Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral Kristi Parker Johnson Debra S. Finney, MS, DDS, publications manager health education, University of the Pacific, Arthur A. Dugoni Senior Communications Speaker of the House [email protected] School of Dentistry, San Francisco Specialist [email protected] 916.554.5950 Nader A. Nadershahi, DDS, MBA, EdD, dean, R. Del Brunner, DDS University of the Pacific, Arthur A. Dugoni School of Immediate Past President Dentistry, San Francisco [email protected] Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry The Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Periodicals postage paid at Sacramento, Calif. Postmaster: Michael Reddy, DMD, DMSc, dean, University of Send address changes to Journal of the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814. California, San Francisco, School of Dentistry The California Dental Association holds the copyright for all articles and artwork published herein. Avishai Sadan, DMD, dean, Herman Ostrow School of The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial Dentistry of USC, Los Angeles staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or Harold Slavkin, dean and professor emeritus, division of reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the biomedical sciences, Center for Craniofacial Molecular Biology, Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor Herman Ostrow School of Dentistry of USC, Los Angeles do advertisements constitute endorsement or approval of advertised products or services. Brian J. Swann, DDS, MPH, chief, oral health services, Copyright 2020 by the California Dental Association. All rights reserved. Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author Dental Medicine, Boston instructions and aims and scope statement. Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C. Connect to the CDA community by following and sharing on social channels

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104 MARCH 2 0 2 0 Editor CDA JOURNAL, VOL 48, Nº3

CDA’s Sesquicentennial

Kerry K. Carney, DDS, CDE

p on the 15th floor in the CDA building at 1201 K Street, Sacramento, In 1869, an informal meeting of 12 a hallway was once lined San Francisco dentists began the process of with images and documents Uof historical significance. The entire establishing the first dental society in California. floor is under reconstruction at the moment and all the artifacts have been removed for their preservation, but I have a sepia-toned memory of A motion was then adopted that Minutes of last meeting approved. that hall of history in my mind. the Secretary be instructed to notify all On motion a committee was appointed Along with portraits of men Dentists in San Francisco to meet at this consisting of Drs. Park, Ball, Birge, who played a role in the early history place on Saturday evening Sept. 11th at Dennis and Knowles to correspond with of organized dentistry in California, 8 o’clock for the above-named purpose, the dentists of the state in relation to there were three framed pages of and that a notice be published to that a state convention and take such steps minutes. These notes were hand- effect in the “Bulletin” and “Alta.” as may be necessary to that end. written in beautiful cursive script After some discussion, the motion Dr. Dennis then read an essay on on lined yellow notepaper. Though was reconsidered and a substitute the “Advantages of Dental Society.” the ink had faded, most of the accepted that the chair appoint a On motion, Dr. Dennis was information could be deciphered. committee of three to notify all Dentists requested to place his essay in the However, some of the 150-year-old in the city personally and explain to hands of the publishing committee. cursive conventions made some them the object of such meeting. On motion the members of the Society names and words difficult to recognize. Whereupon the chair appointed Drs. are requested to donate to the Society any What follows is my best rendering. Dennis, Deutch and Park as said committee. specimens they may have or can procure An informal Meeting of The meeting then adjourned until for the museum of the Society and the some twelve Dentists was held at Saturday evening Sept. 11th. Secretary shall take charge of the same. Mechanics Institute in San Francisco Secretary Dr. J.P. Crowell was appointed to on the 4th day of September The San Francisco Dental Society prepare an essay for next meeting. A.D. 1869 [emphasis added]. is the progenitor of the California On motion a committee of 3 consisting On motion Dr. Knowles was called State Dental Association. In 1869, of Drs. Ball, Pain and Burnett was to the chair. an informal meeting of 12 San appointed to take into consideration the And Dr. F. A. Park was chosen secretary. Francisco dentists began the process propriety of establishing a Dental School. The chairman then stated the of establishing the first dental society Society then adjourned. object of the meeting to be for in California. (It was originally called J. Ball the purpose of obtaining some the San Francisco Dental Association.) Secretary expression of the Dentists of San Almost immediately, these dentists saw By April 2,1870, the dentists had Francisco in reference to the the advantage of a statewide dental begun to pursue the establishment of formation of a Dental association. association. Only five months later on a dental school in California. They Whereupon it was found to be the March 5, 1870, they were establishing had secured a location as home for unanimous opinion of all present that no a committee to call a state convention their new society and approved an steps be taken or any business transacted to establish a state dental association. assessment on the members of $1 per in reference to such formation until March 5th, 1870 [emphasis added] month. At a conversion equivalent all persons practicing the profession The Society convened at the regular hour. of $19.23 in 2019, that would equal in this city be invited to be present. Quorum present. an annual fee of $230.76 in today’s

MARCH 2 0 2 0 105 MARCH 2020 EDITOR

CDA JOURNAL, VOL 48, Nº3

dollars. They also contacted 125 Report accepted and committee dischd. Dr. Cogswell was appointed to read dentists and proposed a statewide The executive committee report that they an essay on Volcanite at next meeting. convention to be held June 29, 1870. have made arrangements with the medical Adjourned April 2nd, 1870 [emphasis added] Societies to occupy jointly rooms no. 226 J. Ball Sec. Society met. Quorum present. Sutter St. This Society to pay 1/6 of the rent By the end of the two-day meeting, The minutes of last meeting and 1/6 of the expense of furnishing the rooms. convened on June 29, 1870, in St. were read and approved. The committee appointed to correspond Andrew’s Hall, YMCA Building in San Dr. Younger proposed the name with Dentists in reference to a state Francisco, 32 dentists had signed the of A.B. Wood for membership on convention. Report that they have issued a constitution for the California State a vote he was received as such. circular to 125 Dentists asking them to meet Dental Association. The two items at The committee appointed to report on on the 29th of June in this city and have the top of the list at that first meeting a school. Report. That the near approach received some answers all speaking favorable. were the establishment of a dental school of the time for the adjournment of the Dr. Cool moved that an assessment in California and the need for state legislature make it impossible to have the of one Dollar per Month be levied on regulation of the practice of dentistry in necessary law passed this session. each member payable monthly carried. order to weed out “charlatans and quacks.” We are celebrating the 150th anniversary of the establishment of the California Dental Association. In this issue, we take the opportunity to look back at our history and look forward to what lies ahead for CDA, organized dentistry and the possible future of our profession. In thinking about those artifacts, the fading minutes that document our history, one cannot help but wonder what dentists in 2070, on the 200th anniversary of CDA, may think when reviewing this sesquicentennial issue. Will they be surprised that our challenges are still similar and understandable? Will they be impressed with the prescience of some of our contributors? Or will those readers chuckle at our naivete and wonder at the tectonic social, economic, political and scientific changes that will have influenced the path of our profession? In Give health and hope. 2070, some of you will still be around to CDA Cares Long Beach Contribute your time and talents to relieve pain, weigh in and let your younger colleagues July 17–18, 2020 restore dignity and create smiles for others who know just how it was way back in 2020. n face barriers to accessing dental care. Long Beach Convention acknowledgment & Entertainment Center Volunteer to join us at CDA Cares. Special thanks to Deborah Elam and the San Francisco Dental Society for their help. Join us. cdafoundation.org/cdacares

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TOGETHER WE ARE LIMITLESS Letter CDA JOURNAL, VOL 48, Nº3

Stephen Shoong Hing Yuen, DDS (1931–2019)

“The greatest compliment you can give Steve groomed political relationships send a note about something you did a writer – is to tell him: ‘I read your stuff.’” to be at that table. Through the or something you wrote or something Rod Serling CDA Council on Legislation and worthy of a nudge or something when then through CalDPAC as chair, he he knew you were stuck. The note was He … was a writer. became positioned as a trusted resource brief, but he helped you to see what you His Chinese name would for legislators on dental matters. had not seen before. He was watching. foreshadow what he would become. He was appointed to a governor’s He was Teacher to those who The first Chinese character of his blue-ribbon committee to examine the need to tell their stories. name “Shoong” means “high respect.” workings of the dental board. Later, After retiring his dental pen The second Chinese character the governor would appointment (for Steve, his typewriter and later CDA is now 150 years strong and “Hing” means “celebration.” him to serve on the board of dental his keyboard) he taught residents more vibrant than ever. Be a part of Steve Yuen occupied some very lofty examiners. At the table he could at a senior center the skills to write the innovation, education, advocacy leadership seats in our profession. preside over regulations that govern their memoirs, their life stories. and camaraderie that unite our He was a CDA president. the practice of dentistry, preside over Steve was competitive. dynamic community of dentists. He was the chairman of the board examinations to earn a dental license He was a contender. Renew your membership today for Delta Dental. and preside over disciplinary actions for He held up his own scorecard at cda.org/renew. He was the president of the violations of the Dental Practice Act. against TV contestants on the California Board of Dental Examiners. Steve was an affirmation of game show “Jeopardy.” Steve was the editor of volume 1, No. the old apprenticeship system. He would spar and parry with 1 of the Journal of the California Dental When Odysseus was to embark on the best in commentary and critique Association. He was the very first CDA the Odyssey, he entrusted his Mentor on games between his alma mater editor when the Northern and Southern to advise his son Telemachus on the Cal against archrival Stanford. associations became one. His passion, politics and machinations of court. And what had a keener edge: his legacy to the profession, was his writing. Steve was Mentor. his razor-sharp editorial eye or his He continuously, meticulously As in olden times, an apprentice Chinese cleaver from his upscale perfected and shared his craft. studied the craft under a master craftsman. Chinese restaurant Kee Joon? Steve was a Craftsman. He was precise. He was the Craftsman moving Steve’s last chapter closed at age 88. As an editor, he elevated the art those entering our profession to an For the Chinese, double 8s are form for the Southern Alameda County awakening into the real world. actually very auspicious numbers. Dental Society Explorer, for the Journal As Telemachus would discover, They typically mean “bringing of the California Dental Association it was not only about learning the Prosperity or Good Fortune.” TODAY. and for the International College of technical craft. It was about learning the Yes, his life came full Dentists newsletters. As a former chair multitasking skills of running a practice, circle. What a metaphor! of the ADA Council on Journalism, skills not taught in classrooms. It was Steve, thank you for pointing the TOMORROW. he presided and taught the craft. about learning and grooming human skills. way for many of us in our journeys. On his mantle, he proudly displayed He was a Captain. He navigated You taught. You delighted. We learned. the International College of Dentists through controversial waters. He was Your occasional notes gave us Golden Pen Award for Journalism, the known for his fairness, his approachability, courage. You were watching. TOGETHER. Distinguished Service Award by the his clarity of direction and his clarity We read your stuff. American Association of Dental Editors and of speech. Those who followed Epilogue: When I got notes from the Meritorious Service Award by the Pierre learned the lessons of leadership by Steve, he often ended the note with ###. Fauchard Academy, a dental honor society. watching him. He celebrated their It’s a journalist’s notation that Steve understood the power of victories, their accomplishments and marks “the end of story.” the government over the profession. the ceilings they pushed forward. TOGETHER WE ARE There’s an old adage, “You have He was a storyteller, well, more s t e v e n d . c h a n , d d s LIMITLESS to be at the table to be heard.” like Yoda. From time to time, he’d Fremont, Calif.

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TOGETHER WE ARE LIMITLESS Impressions CDA JOURNAL, VOL 48, Nº3

Vaping Increases Risk of Lung Disease by 30%

Vaping is often promoted as a healthier alternative to smoking, but a new study by the University of California, San Francisco, found that vaping increases the chances of developing chronic pulmonary diseases like emphysema, asthma and bronchitis by 30%. And people who smoke both conventional and electronic cigarettes, which are the majority of vapers aged 18 and older, more than triple their risk of having respiratory illnesses. The study, published in the American Journal of Preventive Medicine in December, was the first to examine the long-term health impacts of vaping on a representative adult population. Researchers analyzed the adult Population Assessment of Tobacco and Health Waves 1, 2 and 3. The analysis, conducted in 2018–19, tracked 32,000 U.S. adults who had no previous signs of lung disease from 2013–16. Respondents who had ever used an e-cigarette, had ever used fairly regularly and currently used every day or some days were considered current users. Respondents who reported that they had ever used e-cigarettes but did not currently use e-cigarettes were considered former users, while those who reported that they had never used e-cigarettes, even once or twice, were considered never users. Those who currently smoked cigarettes, traditional cigars, filtered cigars, cigarillos, pipe tobacco or hookah every day or some days (regardless of whether “Dual users — the most common they had smoked 100 cigarettes in their lifetime) were considered current combustible tobacco smokers, while respondents who had use pattern among people ever smoked and currently did not smoke at all were classified who use e-cigarettes — get the as former smokers. Those who reported that they have never smoked, even one or two puffs, were classified as never smokers. combined risk of e-cigarettes Multivariable logistic regression was performed to determine and conventional cigarettes, the associations between e-cigarette use and respiratory disease, controlling for combustible tobacco smoking, demographic so they’re actually worse off and clinical variables. The research found the rate of chronic than tobacco smokers.” pulmonary illnesses among current vapers is 1.3 times higher than for nonusers compared to 2.6 times higher for smokers and more — STANTON A. GLANTZ, PHD than three times as high for those who do both. That would seem to validate the contention that e-cigarettes are safer. However, while in theory they are safer, in practice they are not because less than 1% of smokers switch completely to vaping, according to researchers. “Dual users — the most common use pattern among people who use e-cigarettes — get the combined risk of e-cigarettes and conventional cigarettes, so they’re actually worse off than tobacco smokers.” said lead author Stanton A. Glantz, PhD, a UCSF professor of medicine and director of the school’s Center for Tobacco Control Research and Education. “For most smokers, they simply add e-cigarettes and become dual users, significantly increasing their risk of developing lung disease above just smoking.” Learn more in the American Journal of Preventive Medicine (2019); doi.org/10.1016/j.amepre.2019.07.028. n

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CDA JOURNAL, VOL 48, Nº3

Single Dose of HPV Vaccine Could Avert Cancer A single dose of the HPV vaccine may be as effective at protecting Dentists May Underscreen against cervical cancer as the recommended two or three doses, according to for Oral Cancer a new study published online in the JAMA Network Open in December. The study findings support previous observational studies and post hoc A recent study published in the analyses of vaccine trials that demonstrated comparable effectiveness of one Journal of the American Dental Association dose to two or three doses, according to the authors, who were led by suggests that dentists underscreen Kalyani Sonawane, PhD, of the Center for Healthcare Data at the Department for oral cancer. Researchers from the of Management, Policy and Community Health at the University of Texas Harvard School of Dental Medicine Health Science Center at Houston School of Public Health. found that about 25% of U.S. adults The cross-sectional study analyzed National Health and Nutritional remember receiving a screening for Examination Survey (NHANES) 2009 to 2016 data. The study sample oral and oropharyngeal cancer at the included 1,620 women aged 18 to 26 of whom 1,004 were unvaccinated dental office, while current smokers and 616 received at least one dose of HPV vaccine: 106 received one dose, and other high-risk individuals were 126 received two doses and 384 received three doses. even less likely to be screened by Compared with unvaccinated women, infection with HPV was significantly a dentist or dental hygienist. less prevalent among women who received one dose, two doses or three doses The study used data from the 2015–2016 National Health and of HPV vaccine. There was no significant difference in prevalence for one dose Nutrition Examination Surveys, which versus two doses or one dose versus three doses, according to the study. are designed to provide nationally Despite the promising findings, the study had some limitations. The representative data about the health cross-sectional design precluded researchers from evaluating the timing of status of children and adults in the HPV vaccination compared with potential exposure. Also, immunization U.S. About 5,500 respondents who history was self-reported, making it prone to bias and preventing researchers had previously visited the dentist from concluding the effectiveness of individual doses. or another type of oral health care More than a decade after the introduction of the HPV vaccine in the U.S., it is professional were included in the study. reported only 51.1% of adolescents have About 1 in 4 U.S. adults aged 30 and completed the vaccine series, while a greater older said they were screened for oral percentage (68.1%) received at least one dose. cancer by a dentist or dental hygienist. Read more of this study in the JAMA However, the odds of receiving an oral Network Open (2019); doi:10.1001/ cancer screening varied by income, jamanetworkopen.2019.18571. race, age and smoking status. Despite being at an increased risk for oral cancer, adults who smoked cigarettes at the time were half as likely to have been screened for oral It is important to note that the screening and not advised the cancer at the dental office than those study was based on patient recall. patient of that fact. The study who had never smoked. Racial and Researchers did not have access to also did not include participants ethnic minorities and people with respondents’ dental records, which who used tobacco products other less than a high school education means the respondents may have than combustible cigarettes. were also less likely to be screened incorrectly remembered whether they Learn more about this study for oral cancer. However, current and received an oral cancer screening in the Journal of the American former smokers were more likely to be at the dental office. Hence, their Dental Association (2019); counseled about smoking cessation. dentist may have performed a cancer doi.org/10.1016/j.adaj.2019.07.017.

112 MARCH 2 0 2 0 CDA JOURNAL, VOL 48, Nº3

Dentists Can Improve Oral Health of Pregnant Women The National Maternal and Child “Oral Health Care During Pregnancy: National Oral Health Resource Center A National Consensus” stresses that (OHRC) released in January its seventh preventive, diagnostic and restorative in a series of updates highlighting how dental treatment is safe throughout dentists and other health professionals pregnancy and is effective in improving can improve the oral health of pregnant and maintaining oral health. It also affirms women and the children those women that oral health care is an important The report offers steps for oral will eventually bring to their practices. component of a healthy pregnancy. health professionals to take to assess pregnant women’s oral health status, advise pregnant women about oral health care, work in collaboration with prenatal care health professionals, provide support services to women and improve Dental Care Crucial for Dialysis Patients health services in the community. A study published in the journal PLOS One in December found that Pharmacological considerations for patients on hemodialysis had significantly worse oral health than their peers pregnant women are also listed in detail. and that these patients may also be at risk for arteriosclerosis. Additionally, the report includes The study compared the caries status and periodontal health of dozens of information for dentists to share patients with advanced kidney disease and healthy aged-match peers. with their pregnant patients on the Overall, patients on hemodialysis had higher rates of decayed, missing and importance of maintaining good oral filled teeth and teeth with entirely destroyed crowns. The researchers called health during pregnancy and after their for additional oral health support and care for these patients. baby is born. In addition to discussing “These results indicate that patients on [hemodialysis] are not receiving the information, dentists and other sufficient oral care and treatment,” wrote the authors, led by Taro Misaki, MD, from health professionals may photocopy the pages of the report or download and the division of nephrology at Seirei Hamamatsu General Hospital in Hamamatsu, print them to serve as a handout. Japan. “The main reason might be that patients must undergo [hemodialysis] three The purpose of the OHRC at times weekly at a hospital and might not have time to visit a dentist.” Georgetown University, McCourt School For the study, the researchers recruited 80 patients on hemodialysis from of Public Policy, is to respond to the needs Seirei Hamamatsu General Hospital and 76 age-matched control patients from of professionals working in states and a nearby dental clinic. Two dentists evaluated the caries and periodontal status of communities, with the goal of improving the patients with and without end-stage renal disease. Patients on hemodialysis oral health services for pregnant women, had significantly more teeth with entirely destroyed crowns, more missing teeth infants, children and adolescents, including and a higher prevalence of at least 24 decayed, missing and filled teeth than those with special health care needs, their peers. However, they were not more likely to have worse periodontal health. and their families (the maternal and Among patients on hemodialysis alone, those with at least 24 decayed, child health (MCH) population). The missing and filled teeth were also significantly more likely to have a pulse pressure OHRC serves the MCH population by of more than 80 mmHg. This finding suggests supporting health professionals, program patients on dialysis with more severe tooth decay administrators, educators and others may also be more at risk for hardening of the working in or with MCH programs. arteries, according to the study. Access “Oral Health Care During Read more in PLOS One (2019); Pregnancy: A National Consensus” doi.org/10.1371/journal.pone.0225038. at mchoralhealth.org/PDFs/ OralHealthPregnancyConsensus.pdf, and learn more about the OHRC at mchoralhealth.org.

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1870–1995 CDA JOURNAL, VOL 48, Nº3

Professional Calling On June 29, 1879, in San Francisco, 23 dentists gathered to found what is today the California Dental Association.

Susan E. Lovelace

AUTHOR

Susan E. Lovelace Editor’s Note: The following article was first published in the July 1995 issue of the was the managing editor and assistant director of Journal of the California Dental Association. Susan E. Lovelace did a beautiful job communications for characterizing the first 125 years of organized dentistry. For that reason, we decided to CDA from July 1993 reprint an updated and condensed version of her article for our 150th anniversary issue. to August 1995. ne hundred and twenty-five years ago, in 1870, California was a fledgling state, admitted to the union in 1850. The final stake of the transcontinental railroad had been driven (1869), easing access to the geographically isolated state. (Previous travelers were able to reach California only after a long, arduous voyage Oby ship, either around the Cape Horn or to Panama, followed by a three-hour train ride across the isthmus and another voyage or by traveling cross-country on horseback or in a wagon train or stagecoach.) Long-distance communication remained slow and difficult, despite the establishment of telegraph lines in 1853. The western U.S. was still regarded as a colony, a supplier of raw materials and a buyer of finished goods.1 Dentistry was struggling to enter the ranks of the professions. The first dental college had opened in Baltimore just 30 years prior in 1840. The American Dental Association (ADA) was only 11 years old, chartered in 1859. However, the practice of dentistry remained largely unregulated (the first law governing the practice was enacted in Alabama in 1841) and few practitioners had actually attended dental school. Anyone who wanted to could call themselves a dentist or a dental surgeon and many did. Early records note barbers, fish sellers and others who practiced dentistry part time. Into this scene the California State Dental Association (CSDA) was born, meeting for the first time on June 29, 1870, in St. Andrew’s Hall, YMCA Building in San Francisco. The dentists met “in accordance with a call issued by the order of the ‘San Francisco Dental Association’” formed the year before. Twenty-three dentists signed the constitution on the first day of the meeting, joined by another nine by the end of the meeting the next day. Now, in 2020, organized dentistry in California is celebrating the 150th anniversary of its birth. The California Dental Association (CDA) has more than 27,000 members and is the largest constituent of the ADA. Dentistry is an honored profession, with dentists consistently in the top ranks of trusted professionals, and the practice of dentistry is thoroughly regulated. (One of the first actions of the new CSDA was a call for state regulation of the profession, which was enacted in 1885.) California boasts six [soon to be seven] dental schools within its borders.

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It has been said that to understand the present and prepare for the future, one must have a firm grasp on the past. This Calvin Call Knowles, first and fourth president of CSDA. article examines the past as it relates to dentistry in California. It explores the world in which the dentist of 1870 operated. Some of the issues of the day are compared with those of dentistry today.

On the Brink: 1870 If you were thinking of setting up a dental practice in California in 1870, chances are you were planning on San Francisco, San Diego, Sacramento, Stockton or Los Angeles or within a few miles dental history timeline of any of those cities. These were the population centers of the = significant to CDA state, holding the best chance of supporting a dental practice. Not that dentists weren’t needed and appreciated in other parts of the state or that setting up a practice in the “big city” was 1830 Amalgam introduced in U.S. easy. Leland D. Jones described setting up a practice in San Diego not too many years later, in 1902.2 His three-room office cost 1835– Amalgam War 1850 $25 a month for rent, which he found hard to pay during the first couple of years. San Diego then had a population of about 17,000 1836 G.V. Black, founder of modern dentistry in U.S., and 15–20 established dentists. So, Dr. Jones started taking born in Illinois dentistry into the “back country.” There were no paved roads, so he would load his case of dental instruments and his foot engine 1838 Dental drill patented (John Lewis) onto the train for the ride inland to Lakeside 15 to 20 miles 1839 First dental magazine debuts away. Then he’d catch the stage to Julian, a 12-hour trip total. (American Journal of Dental Science) In Julian, Dr. Jones “got a little room off the hotel. I’d stay a week, then take the stage to Ramona.” Word of mouth would 1840 First dental society formed travel to let nearby residents know the dentist was in town. (American Society of Dental Surgeons) He did this for several weeks at a time for a number of years. First dental college opens A dental office could be set up almost anywhere. Neither (Baltimore, chartered in 1839) running water nor electricity, absolute necessities for modern 1841 First dental practice law enacted (Alabama) dentistry, were generally available, so specialized wiring and plumbing weren’t a problem. Chairs specifically for dentistry were few and 1842 Archwire for correcting irregularities introduced thus not expected. And the instruments necessary for rudimentary (J.M. Schange) practice of the trade were easily packed in a traveling case. But back to the city. What training might our imaginary 1844 First use of nitrous oxide in dentistry (Horace Wells) dentist have had to prepare him (there were very few female Vulcanization of rubber perfected dentists in those days) for this line of work? It is unlikely he 1846 Anesthetic properties of ether discovered attended a dental college: There existed fewer than 10 at the (William Morton) time, all in the U.S. Entrance requirements were minimal by our standards: high school graduation and a certificate from a 1848 First dental supply catalog on record high school principal. The course of study generally lasted three (Murphey’s Dental Catalogue) seven-month years. Graduating classes of 15 to 20 were common. California Gold Rush begins Of course, the aspiring dentist didn’t really require any 1850 California admitted to U.S. as 31st state training: There wouldn’t be a law in California regulating dental practice for another 15 years. You could simply set up shop, let 1853 Telegraph lines established cross-country people know you were available and convince them to patronize you. According to Baumann,3 “Itinerant barber/surgeons traveled 1854 All-porcelain dentures patented from town to town with hawkers and drummers to sell elixirs

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1856 First dental society in England organized (Odontological Society of London) California Medical Association founded

1859 American Dental Association founded

1860 Pony Express founded and entice people to go backstage to have extractions. The band would play loudly to drown out the screams of the patients.” 1861 First dental licensing law enacted (New York) A footnote under dentistry in the Encyclopedia Britannica of 18874 explained, “… for long (dentistry) was practised (sic) 1862 Rubber dam invented (Sanford Christie Barnum) to a large extent as a superadded means of livelihood by persons 1865 Civil War ends engaged in some other pursuit, and without any professional education whatever. The blacksmith, barber, watchmaker and 1867 First self-cleaning spittoons introduced others of the same class were the dentists of every village and (Whitcomb Fountain Spittoons) country town, and most were trained by preceptorship.” 1868 Electric dental engine invented (George F. Green) Once a person decided to practice dentistry, there began the acquisition of instruments and materials, and particularly 1869 San Francisco Dental Society formed for those outside the major Eastern U.S. cities, they made Transcontinental Railroad completed most of their own instruments using the materials at hand. Celluloid introduced to prosthetic dentistry As late as 1918, dental students were making their own Periodic law for classification of elements formulated instruments. Willard C. Fleming,5 who entered UCSF School (Dmitri Mendeleev) of Dentistry that year, recalled learning how to temper steel and cutting instruments out of chisels and hoes. 1870 California Dental Association organized A description of what the early dentist would require is found Ulysses S. Grant is president of U.S. in a 1945 issue of the CDA Journal:6 “In the early days of Dr. France declares war on Prussia Cave’s practice (Daniel Cave, a San Diego practitioner in the John D. Rockefeller founds Standard Oil Company 1870s and 1880s), as with nearly all dentists, a very important adjunct was a complete workshop or laboratory. In this there 1871 Dental foot engine introduced (James B. Morrison) had to be everything necessary to refine metals: furnace, casting 1873 Cements and other dental filling materials introduced boxes for making ingots to be rolled into plate form suitable for (George W. Beers) varied uses and so on. Foot-pedal lathes were then in use. Then there had to be dies for making wire and porcelain furnaces of 1877 First hydraulic chair invented different types. Platinum was extensively used in the making (Basil Manly Wilkerson) of ‘continuous gum’ work and the full denture cases.” 1880 Porcelain tooth soldered to gold backing patented Many dentists created their own denture bases by vulcanizing (O.M. Richmond) rubber, despite the Goodyear patents and enforcement activity. Daylight and gas or kerosene lamps provided illumination. 1881 University of California, San Francisco, Alcohol was still considered the best medication and School of Dentistry founded 3 anesthetic, although limited to extraction cases. 1882 National Association of Dental Examiners founded A dentist’s daily work consisted primarily of extractions, fillings and denture construction. Cleanings were offered, but not in great 1885 Southern California Odontological Society demand. Tooth transplantation and periodontal surgery and other formed (reorganized to become Southern California treatments were not unknown, but also not widely practiced. Dental Association in 1898) At the second annual session of the California State Geometric and mechanical laws of articulation Dental Association, Calvin Call Knowles, the first and fourth introduced (W.G.A. Bonwill) president of the CSDA, commented, “A first-class operator, by Legislation governing practice of dentistry enacted in California constant work at the chair, if he is rapid in his manipulations, may average not over five fillings per day or seven hours of 1887 San Diego Dental Society formed hard labor (more fall short than overrun this) — $25.”7 The decades just before 1870 were marked by many developments 1888 First motion pictures filmed (England) of importance to dentistry. Innovations included the first gold filling, Porcelain inlays patented (Charles Henry Land) nitrous oxide, ether, the rubber dam, Vulcanite-based dentures System for classifying malocclusions devised with premade teeth, gutta percha, zinc oxide and eugenol.”3 (Edward H. Angle)

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1889 Santa Clara Valley District Dental Society founded

1890 Microorganisms of the Human Mouth published (W.D. Miller) The bacterial origin of some diseases, including dental caries, 1891 Scientific cavity preparation advocated by was on the verge of recognition in Europe. The use of amalgam G.V. Black for fillings was being revived; the Amalgam Wars of earlier in 1893 First conviction in California for practicing dentistry the century had discredited use of the material. The size of the without a license dental arch and positioning of teeth were receiving attention. 8 Pacific Coast Dentist magazine debuts Dentists were interested in more than just teeth. McCluggage noted that, “Dental interests were not confined to medicobiological 1894 Sacramento District Dental Society formed subjects, nor were they restricted to a narrow concentration First commercial presentation of motion pictures on the individual patient. Dentists debated the value of environmentalist theories to explain what they seem to have 1895 Los Angeles Association of Dental Alumni formed regarded as the endemic character of caries in the United States.” (renamed Los Angeles Dental Society in 1908) A thorough knowledge of chemistry was also Roentgen rays discovered considered important. First automobiles regularly made for sale (Duryea Motor Wagon Co.) Why Organize? Despite the great strides being taken in the areas of 1896 College of Physicians and Surgeons Dental School the profession, news and techniques were slow to spread. founded (later to become University of the Pacific, Travel was limited and difficult. The 51 miles from San Arthur A. Dugoni School of Dentistry) Francisco to San Jose took nine hours by stage.9 Mail First X-rays of teeth taken (Friedrich Otto Walkhoff and Charles Edmund Kells) came to San Francisco from Salt Lake City just once a month, and the dental journals and books were few. 1897 American Dental Association (ADA) Dentists, long known as independent souls (in the early 1900s, and Southern Dental Association merge Dr. Fleming’s father, a great proponent of anatomy, encouraged to become National Dental Association him to study dentistry5 to maintain his independence), found (renamed ADA in 1922) themselves in need of a means of exchanging ideas. The profession University of Southern California School of had only recently emerged from an era of protecting innovations Dentistry founded (later to become Herman Ostrow School of Dentistry) and selling them to colleagues and apprentices as secrets. 10 Forensic dentistry makes its mark following Paris fire Commented Dr. Knowles, “I have bought and paid for, as ‘great secrets,’ various receipts of metal dies, solders, methods to 1898 Spanish-American War prevent warping of plates, receipts for the manufacture of teeth, Polonium and radium discovered tooth powders and washes, methods of preparing foil and methods (Marie and Pierre Curie) of using it; in fact, almost every item of practical knowledge, upon which I did not happen to blunder during the first decade of my 1899 Santa Barbara-Ventura County Dental practice, was bought, and eagerly bought and gladly paid for.” Society formed But, as the population and the profession grew, there was an 1900 Federation Dentaire International founded “increase of dentists of a type who were sincerely interested in 11 American Society of Orthodontists organized improving the position of dentists and dentistry in the area.” “We believe the time has come when associated 1901 Tri-County Dental Society formed effort may be of practical advantage to ourselves and to U.S. Steel Corporation organized the community in which we reside,” said Dr. Knowles.10 First airplane flight “The difference between now and then is solely due to (Gustave Whitehead at Bridgeport, Conn. — 1.5 miles) association. The profession on this coast, although ranking among its members many well-educated and most excellent operators, needs this friction of association to develop and make more effective its powers and usefulness. Sharing knowledge wasn’t the only reason for organizing. Dentists also wanted a means of regulating the profession.

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Drawing of the original dental foot engine.

According to McCluggage,8 “In the interest of dentist and layman alike, there arose a demand for the elimination of unqualified workers from the dental field.” In 1840, Solyman Brown12 argued, “Most other professions are protected either by statute or organized associations, from the encroachments of incompetence and imposture. Ours is guided by no civil enactment and in consequence, the members should supply the defect either by their individual or collective efforts.” The first constitution of the CSDA declared “among the objectives of this association, ‘To cultivate the science and art of dentistry and cognate sciences,’ ‘To elevate and sustain the character of the profession,’ ‘To promote mutual improvement, both professional and social.’”10 Three classes of membership were provided: acting, corresponding and honorary. Acting members were required to be graduates of a dental college or have been in practice for five years.10 The result of the move to create dental associations is summarized by Hopsmann:11 “Previously dentists of high ethics and progressive ideas had to go their way alone, or at best in the company of the few other of their kind with whom they happened to have contact. Now with an organization, with a definite place and time to meet, with common goals, ethical dentists might work together and benefit from one another’s knowledge and ideas. Professional problems could be dealt with on a large scale…”

First Actions Call for a School of Dentistry A dental school was the first item of business addressed in the opening remarks of the first state meeting in 1870: 1902 Earliest record of existence of Oakland Dental “Gentlemen, we need a college on this coast, and if we Club (later renamed Alameda County have not the necessary talent among ourselves, we can Dental Society) import it. We owe to those who are to take our places, Canadian Dental Association organized greater facilities for study and professional breadth than the Edgar Randolph Parker, later renamed times have afforded us. The future will demand education Dr. Painless Parker, arrives in San Francisco in all that constitutes the scholar and professional man, 10 1903 Aesthetic porcelain jacket crown introduced and refined in all that makes him a gentleman.” (Charles H. Land) Despite the early call from the profession, it was to Wright brothers fly at Kitty Hawk, N.C. take several years, and a great deal of discussion and negotiation, before the first University of California 1904 Carborundum introduced to dental profession dental school was founded in San Francisco in 1881. (S.S. White Co.) To be admitted to the school, a candidate had to be 18 years old 1905 Method of casting gold inlays using disappearing and to “present to the Faculty satisfactory evidence of a good moral wax pattern developed (W.H. Taggart) character.” No mention was made of prior education. However, students admitted for classes beginning in 1883 were required to 1906 San Francisco earthquake take an exam testing qualifications in orthography, grammar, physics A.L. Fones trains assistants to perform prophylactic and mathematics. Evidence of having graduated from a recognized procedures (beginning of dental hygienists) college or high school would exempt candidates from the exam.13

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1895 CSDA group photo on the steps of the U.S. Mint in San Francisco. Women were welcomed as members for the first time. At left is Carolyn M. McElroy, DDS (San Quentin), who became the first woman member in 1894. Marion Ward Craig, DDS (Oakland), (second from left) was the second woman to become a member. In the far upper right is Frances C. Treadwell, DDS (San Francisco), who declined membership.

Fees for the initial term were: matriculation, $5; tuition, $100; demonstrators’ fees, $30; and diploma, $30. Courses of study included Principles and Practice of Operative Dentistry and Dental Histology; Dental Pathology and Therapeutics; Mechanical Dentistry; Physiology; Chemistry; Anatomy; Surgery; Practical Anatomy; and Hospitals. Twenty-eight students attended the first session, including one woman; seven were graduated.

1908 San Gabriel Valley Dental Society formed Regulating the Practice of Dentistry 1911 Legislation passes leading to commissioned rank for Early state dental leaders recognized that establishing a dental dentists in the Army school wouldn’t be enough to stop the charlatans and quacks from discrediting the profession. Thus, in concluding his opening 1912 Fresno-Madera Dental Society formed remarks at the 1870 CSDA session, Dr. Knowles said, “Many other matters will probably come up during the sittings of this 1913 National Dental Association Scientific Foundation and Research Commission established Convention, and perhaps none more important than inquiry into Official Bulletin, predecessor to Journal of the the propriety of obtaining State legislation regulating the practice American Dental Association, debuts of dentistry. I am aware that great diversity of opinion exists on 10 Panel system dentistry introduced in England this subject, and it would be well to determine the matters.” National Dental Association reorganizes, adopting On the second day of that meeting, a resolution was adopted tripartite membership concept stating, “Resolved, That, to elevate the profession and to protect the community against charlatanism, State legislation is necessary.”10 1915 Harbor Dental Society formed The fourth meeting of CSDA saw the introduction of San Joaquin Dental Society formed proposed legislation to be presented to the state. A grandfather World Dental Congress, San Francisco clause excused all current dentists from complying with the Mount Lassen in Northern California erupts law, but required all new practitioners to have a diploma from a dental college or certificate of qualification issued by the “Board 1917 Earliest record of existence of Napa Solano of Examiners of the State Dental Association.” AB 67 was finally Dental Society enacted in 1885 and on March 12, 1885, California dental Connecticut enacts first law regarding licenses 1-561 were issued to dentists already practicing in the dental hygienists state.11 The dental board was appointed by the CSDA president. U.S. enters World War I

1918 Family of Czar Nicholas of Russia murdered Entering the Modern Era First dental hygiene curriculum in California (UCSF It’s hard to define just when the modern era of dentistry began. School of Dentistry) After all, the profession is continuously adapting to the growth in scientific knowledge as well as changing cultural values. However, 1919 Orange County Dental Society formed changes in the current generation of dental practice can be loosely Treaty of Versailles signed ending World War I grouped into three categories: the introduction of dental insurance, instruments and equipment and the advent of public relations. 1920 American College of Dentists founded

1921 Kern County Dental Society formed Dental Benefit Plan Emerge California law amended to permit licensing of Health insurance, which didn’t have its genesis in the dental hygienists U.S., was generally tied to attempts at socialization and wasn’t Carnegie Foundation survey of dental education very popular with typically conservative dentists. The post- conducted (William J. Gies) Depression era brought proposals of legislation at the federal and state levels and close scrutiny by health-related organizations. 1924 American Dental Assistants Association formed In 1943, Southern California Dental Association (SCDA)

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1925 Berkeley Dental Society formed Flexible materials for taking impressions begin to replace plaster

1926 Yosemite District Dental Society formed President Dr. Francis J. Conley commented, “It is not difficult (later split into Stanislaus Dental Society and to visualize a Utopian method of providing good, even better, Yosemite Dental Society) dentistry under a health insurance system with censorship, or 1927 First talking feature film (“The Jazz Singer”) supervision, but we should be wary of methods of control.”14 Charles Lindbergh flies from New York to Paris The first large-scale dental benefit plan in the U.S. was introduced in 1954: the International Longshoremen’s and 1928 Penicillin discovered (Alexander Fleming) Warehousemen’s Union-Pacific Maritime Association Welfare Fund Pilot Dental Program.15 Negotiations between labor and 1929 San Mateo Dental Society formed management resulted in an agreement to establish a one-year Stock market crash pilot dental care program for children under age 15, expending 1932 ADA first publishes Accepted Dental Remedies no more than $750,000 total. Care under the agreement, effective June 14, 1954, started Oct. 1, 1954, in San Francisco, 1934 Marin County Dental Society formed Los Angeles, Portland and Seattle. Two programs were set up: a closed panel, with a group of dentists working under a direct 1935 Earliest record of existence of Central Coast contract with trustees of the union’s Welfare Fund, and an Dental Society open-panel indemnification program. Parents were required Oregon dental law regarding advertising upheld to choose which type of care they wanted their children to by the Supreme Court receive, with no changes possible during the test period. Polymerized acrylic resin for denture bases introduced The plan required that treating dentists be members of the dental association or eligible for membership. It also required parents 1937 San Fernando Valley Dental Society formed of children aged 2 and older to make initial dental appointments Sulfanilamide for treating dry sockets introduced for the children as soon as possible after the plan took effect. Children were allowed a maximum of $75 for the 1938 Mail-order dentures declared fraudulent first year. For the closed panel plan, payment was on a 1939 capitated basis, implemented by a fee schedule. The fund Western Los Angeles Dental Society formed made monthly progress payments for each child seen as World War II begins well as paying for each item of service rendered.16 Effect of sodium fluoride on enamel demonstrated in vitro A slightly higher fee schedule was set up for the indemnity plan. However, dentists were permitted to charge more than the 1943 Earliest record of existence of Tulare-Kings and allowed fee and provide care above the allotted $75, as long as Contra Costa dental societies the parents agreed to pay the additional charges. Orthodontics, cosmetic dentistry and major surgery already covered under 1945 First water fluoridation (Grand Rapids, Mich.) the union’s medical plan were excluded from coverage. United Nations founded To meet requirements of California law, the indemnity World War II ends program had to be administered through a nonprofit corporation 1947 Oral and maxillofacial surgery recognized as a or an insurance company indemnity program. Coming into the dental specialty picture in June, the northern state association didn’t have time Prosthodontics recognized as a dental specialty to develop an agreement with the SCDA to establish a nonprofit Pedodontics (now pediatric dentistry) recognized as by October, although it immediately began negotiations. In a dental specialty the meantime, the union adopted a proposal from Continental Orthodontics recognized as a dental specialty Casualty Company to provide indemnification on a trial basis. Public health dentistry recognized as a dental Continental indicated that its sole reason for entering the specialty agreement was to gather data on the feasibility of such a program. Other groups quickly became interested in offering similar 1948 Periodontics recognized as a dental specialty plans. “Closed panels commenced to spring up,” reported CSDA’s dental care committee.16 “The fundamental ethical concepts of 1949 Oral pathology recognized as a dental specialty free choice of dentist and free choice of patient was threatened.”

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1951 Use of kinetic energy (air abrasion) for tooth preparation introduced

1953 Butte-Sierra Dental Society formed Loma Linda University School of Dentistry founded Korean War Armistice Agreement signed The committee studied the problem and determined that the best way for the profession to meet the demand 1954 First large-scale dental benefit plan, Washington was forming a nonprofit corporation.17 Dental Service, formed Meetings were held with SCDA to develop parameters for 1955 California Dental Association Service (CDS) such a corporation, which would serve as a legal vehicle to pay incorporated (later renamed Delta Dental) dentists for services rendered. It was to be “composed of licensed First belt-driven, high-speed angle handpiece dentists who would make all policy decisions, establish fees and introduced (Page-Chayes) carry on all other professional aspects of the corporation.”17 Numerous other companies had also begun negotiations 1956 Mid-Peninsula Dental Society formed for dental plans for their workers, including Pan American 1957 First clinically successful air-driven, high-speed World Airways, Stauffer Chemical Company, American handpiece introduced (S.S. White Co.) Smelting Company and several unions. “With this information,” reported the committee, “the Dental Care Committee doubts 1958 Southern Alameda County Dental Society that any member will question the need for immediate formed action if we are to prevent the growth of closed panel, clinic Faster-speed X-ray film introduced type operations throughout Northern California.”17 1959 Monterey Bay Dental Society formed With SCDA indicating it would be several months before it could make a decision, CSDA proceeded with drafting the necessary 1960 Redwood Empire Dental Society formed articles of incorporation. They were filed with the secretary of state Humboldt-Del Norte Dental Society formed in April. In May, the CSDA Board of Directors gave its blessing. Stannous fluoride added to toothpaste The House of Delegates provided final approval, and on May California law requiring registration of X-ray machines 31, 1955, the California Dental Association Services (CDAS, goes into effect also known as California Dental Services (CDS) and, after being Lasers first demonstrated renamed in 1986, Delta Dental Plan of California) was formed. Officers were elected and bylaws were adopted July 13, 1955. 1961 Northern California Dental Society formed To validate the corporation, it was necessary to sign up one- 1962 Sodium monofluorophosphate (MFP) added to fourth of the dental licentiates in the state. Without the support of toothpaste the south, this was a daunting task, particularly since it needed to be completed by October when the ILWU-PMA plan faced renewal.18 1963 Endodontics recognized as a dental specialty The ILWU-PMA plan was renewed with Continental providing the indemnity portion as CDS wasn’t yet operational. 1964 University of California, Los Angeles, School of The corporation did finally get off the ground despite misgivings Dentistry founded in both parts of the state. In December 1960, the Southern 1966 First dental sealant material, methyl cyanoacrylate, California State Dental Association voted to join the California created Dental Association Service corporation. That company, born in controversy, engendered even more when it parted company with 1967 Composite resins introduced (Michael Buonocore) the association some years later; for many, it remains controversial. 1969 First American astronauts land on the moon The Advent of Public Relations 1971 Soluble pyrophosphates (anti-tartar agents) If we think about it all, most of us would associate the developed for toothpaste term and concept of public relations with the 1960s. Actually, however, it began much earlier. Commented Dr. Conley in 1973 California Dental Association (northern) and 14 Southern California Dental Association merge 1943, “I should like to present to you dental education as First issue of Journal of the California Dental only one of a triad, with dental education as the foundation Association published or base; with the scientific accomplishments of dentistry U.S. pulls out of Vietnam as a second side; and running up the third side, ‘public relations’ as we are beginning to understand it today …

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1895–1896 CSDA President Irvin Hayes, Grass Valley, (center) and CSDA officers.

“‘Public relations’ suggests that from now on we, as a profession, must consult with and plan with agencies and authorities interested in the extension of dental service to those who need it. If we neglect this phase of public relations because of our lack of understanding or apathy, we shall be forced to accept whatever the future may bring. This, then, is the time for more aggressive action and the advantages of cooperation through our organization.” Aggressive public relations efforts were necessary to let the public know about the advances in dentistry. At that time, a visit to the dentist was viewed as necessary only in an emergency or because of pain. The idea of preventive dental care had not yet caught on with most people. Emergency dental visits also meant the association of dentistry with pain, a further deterrent. To meet its stated goal of the public good, dentistry had to convince the public that a dentition maintained with regular 1974 California’s Medicaid dental program, known as dental visits would be far less painful than one neglected. Denti-Cal, created Newspaper articles, health fairs, TV and radio spots, Glass ionomer cement fissure seals introduced brochures and public education pieces, dental health month activities and innumerable personal contacts with patients have 1975 California enacts the Medical Injury Compensation Reform Act (MICRA) all, over the years, contributed to the current recognition that regular visits to the dentist are a necessary part of optimizing 1977 First magnetic resonance imaging (MRI) body scan and maintaining overall good health. Then-president of CSDA of a human taken Dr. Lawrence Ludwigsen19 commented in 1958, “There appears to be a growing consciousness of the need for good dental 1980 Osseointegration concept introduced in U.S. (Per-Ingvar Brånemark) health which, too, adds to the demand for dental care.” CDA forms The Dentists Insurance Company Now all we have to do is convince people to act on what they know! 1983 CDA moves headquarters to Sacramento from Los Angeles Into the Future Scientists discover the virus that causes AIDS What will dentistry look like 150 years from now in 2170? On the occasion of CDA’s 125 anniversary in 1995, Jack D. 1984 Hydroxyapatite introduced to dental implantology Preston, DDS, the Don and Sybil Harrington Foundation Professor 1985 CAD/CAM introduced into dentistry of Esthetic Dentistry at the USC School of Dentistry, noted, “Over the past 125 years, dentistry has evolved from a trade to become 1989 CDA Update debuts a profession with a basis in science. It is increasingly oriented to biologic, diagnostic and therapeutic processes and less dependent 1990 CDA moves into newly built 1201 K Street offices upon mechanical approaches. In the next years, that evolution First dental laser approved by FDA for use on will continue. But it is difficult to prognosticate what social, intraoral soft tissue political and economic conditions will mediate the process.” Direct digital radiography introduced Other dental leaders agreed that 125 years ahead, at 1991 USSR disbanded least three generations from now, was a bit far in the future to expect rational predictions. So we asked for predictions 1995 CDA sponsors AB 733, mandating community encompassing the next 20 to 30 years instead. The answers water fluoridation for large California were interesting and, to say the least, thought-provoking. communities One idea espoused by several of our prognosticators is Triclosan (antimicrobial agent) under FDA that the lines between dentistry and medicine will fade. consideration as toothpaste additive

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1998 California passes Proposition 10, raising tobacco taxes by 50 cents/pack and creating First 5 California, an organization dedicated to improving lives of California children aged 0–5 and their families “I believe that dentists will become better managers of occlusal California authorizes registered dental hygienists in alternative practice (RDHAP) to expand disorders and of the oral manifestations of systemic disease,” said access to dental prevention and hygiene services Judson Klooster, DDS, dean emeritus and professor of restorative to underserved populations and communities dentistry at the Loma Linda University School of Dentistry. “Quite possibly, the wisdom that caused dentistry to become 2001 CDA establishes CDA Foundation a profession separate from its medical counterparts more than Cone beam technology introduced in U.S. a century ago will yield to a newer wisdom that returns dental (first introduced in Europe in 1996) expertise to the general umbrella of medicine and its specialties.” 2002 CDA Foundation creates annual student loan Other leaders also commented on the possibility of widely repayment grant program diverse levels of care. “There is likely to be a greater gulf between the haves and the have-nots. It could be a bizarre world, with walled 2003 Journal of the California Dental Association cities and limited resources,” suggested Harold Slavkin, DDS, newly publishes research on caries management by risk appointed director of the National Institute of Dental Research. assessment (CAMBRA®), detailing evidence for a paradigm shift in dental caries management Richard W. D’Eustachio, DDS, president of the ADA, had similar thoughts: “I’ve tried looking into my crystal ball 2004 CDA Foundation secures four-year, $7 million to see dentistry’s future and I get two different versions. One grant from First 5 California; in partnership with way, the crystal ball is perfectly clear. I see all sorts of scientific Center for Oral Health trains 16,000 dental and technological advances; and I see the oral health of professionals and 4,500 medical professionals in preventing early childhood caries (ECC) the American people being even better than it is today. “The other way, the crystal ball gets cloudy. Somehow 2006 California requires oral health assessments at the benefits of all the technological advances have not kindergarten entry (AB 1433) gotten through to the public. Changes in the marketplace and other outside forces have stood in the way.” 2008 California restructures dental assisting career ladder, creating orthodontic assistant and dental “The knowledge of genetics will be critical to dentists,” sedation assistant permits and adding training added Dr. Slavkin. “We will be able to design lives by and new duties at all levels of dental assisting genetic strengths, acknowledging genetic liabilities. If we have genetic insights early, we can suggest changes in 2009 Western University of Health Sciences College where someone lives, what they do and their diet.” of Dental Medicine founded Dental leaders also believed that nondental technology 2012 CDA and CDA Foundation launch CDA Cares, would affect the profession. an all-volunteer, free dental care event serving “The impact of computer technology on private practitioners California’s most vulnerable residents will continue to escalate rapidly, possibly leading to a chartless office with no radiographs, everything stored electronically,” 2013 CDA files lawsuit against Delta Dental of California said Charles J. Goodacre, DDS, MSD, dean of the Loma Linda 2014 California hires dentist as state dental director University School of Dentistry. “Practitioners also will have to develop California Oral Health Plan and ready access to distant video consultations where a patient’s implement dental public health programs condition would be transferred electronically to an educational California enacts legislation (AB 1174) institution or another practitioner for consultation.” authorizing use of electronic communication “Dental treatment at the sophisticated, diagnostic end will (teledentistry) for provision of dental care, become highly computer-mediated, which means that it can escape establishes virtual dental home model of care in the traditional dental office,” said David W. Chambers, EdM, MBA, California PhD, associate dean for academic affairs at UOP. “A team of super FDA approves silver diamine fluoride for use in U.S. as desensitizing agent dentists scattered throughout the world can constitute the brain power of a practice and direct and monitor the quality of care given 2016 California voters approve CDA-supported by many oral health care providers scattered in many locations.” Proposition 56, a $2 tobacco tax, to reduce Some leaders thought technology growth would lead to smoking and fund health programs other changes. “(It) will pose significant challenges with regard

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2017 CDA launches The Dentists Supply Company $30 million provided annually from Proposition 56 to State Office of Oral Health to implement California Oral Health Plan to dental education, licensure issues and continuing education 2018 CDA secures final court approval of $65 million programs,” posited John F. Zapp, ADA executive director. Delta Dental settlement for dentists “I would envision significant changes in the educational CDA publishes Update special edition — service,” commented Dr. Goodacre, “with students using “CDA and Dentistry Working to Reduce Opioid laptop computers during classes and having access to Misuse and Abuse” — describing current illustrations used by faculty as part of the course. There environment of opioid misuse and CDA’s would also be video imaging available of the ideal procedure leadership on the issue that the student could bring up on the computer screen and CalHealthCares program established by California Department of Health Care Services with $340 superimpose the image of his/her work to facilitate learning. million from Proposition 56, providing student loan “I also would expect a student to pick up a handpiece repayment awards and practice support grants to in a preclinical laboratory course and, on a monitor, prepare dentists and physicians for commitments to provide the tooth … These types of computer simulation will be much care to Medi-Cal patients more time efficient.” Organized dentistry was also predicted to change. 2019 TDSC.com expands to all 50 states “The debate will be over the pace of change, and the 2020 CDA’s Sesquicentennial leadership challenge will be to bring the whole organization along with environmental changes while avoiding schisms … The profession can and must make adjustments to forces as it recognizes and interprets them. In many ways, the reaction of dentistry to the trends that are emerging is more important than are the trends themselves,” said Dr. Chambers. n acknowledgments Special thanks to Dr. Cathy Sandeen and Flory Berger of the University of California, San Francisco, School of Dentistry for their invaluable research assistance and to Jack F. Conley, DDS, for his assistance in tracking down past presidents. Thanks, too, to Drs. Tom Jacobs and David Donnelly for sharing their photo and historical files. We also acknowledge the support of the UCSF and UOP Schools of Dentistry and MBNA America, Guggenheim Brothers Dental Supply Company and IDT for the dental history museum at the Anaheim Scientific Session. references 1. Lavender D. California, Land of New Beginnings. New York: Harper & Rowe; 1972. 2. Dr. Leland D. Jones, transcript of interview, UCSF School of Dentistry oral history project, 1967. 3. Baumann TH. San Diego County Dental Society 1887–1987. 1990. 4. Encyclopedia Britannica, 1887. 5. Dr. Willard C. Fleming, transcript of interview, UCSF School of Dentistry oral history project, 1967. 6. Committee on History, Dr. Daniel Cave, a Biography. J Cal State Dent Assoc Sep–Oct 1945. 7. Transactions of the California State Dental Association, second annual session, 1871. 8. McCluggage RW. A History of the American Dental Association. ADA, Chicago, 1959. 9. Rolle AF. California: A History. New York: Thomas Y. Crowell Co. Inc.; 1969. 10. Transactions of the California State Dental Association, first annual session, 1870. 11. Hopmans WF. A History of Dentistry in Southern California. 1948. 12. Brown S. Remarks on Professional Morality. Am JDSc Aug 1839. 13 Pamphlet introducing the first session of the University of California School of Dentistry. 1882. 14. Conley FJ. What can dentistry do for its own tomorrow? Cal State Dent Assoc J 19:4 1943. 15. CSDA Dental Care Committee memo. Sept. 27, 1954. 16. Dental Care Committee. Ethical dentistry and the Welfare Fund. Cal State Dent Assoc J 31:6 1955. John M. Riggs, DDS, an associate of Horace Wells, became the first 17. Dental Care Committee. Report to the House of Delegates. Cal State Dent Assoc J 31:3 1955. surgeon to operate with a patient under anesthesia when he extracted 18. Cuthbertson WL. Editorial: Robert O. Schraft to head nonprofit corporation. Cal State Dent Assoc J Wells’ tooth in 1844 while Wells was under the influence of nitrous 31:4 1955. oxide. Dr. Riggs was not a CSDA member but presented a paper at 19. Ludwigsen LR. President’s message. Cal State Dent Assoc J 34:2 1958. the 1895 meeting. Additional Bibliography Campbell JM. Dentistry: Then & Now. 3rd ed. Glasgow: Bell & Bain Ltd.; 1963. Prinz H. Dental Chronology. Philadelphia: Lea & Febiger; 1945. Ring M. Dentistry: An Illustrated History. New York: Mosby Yearbook Inc.; 1985.

MARCH 2 0 2 0 125 “Adding oral sedation to my skill set transformed my practice. This course changed everything, I am now treating phobic patients who have neglected their teeth for years and the new patient referrals keep coming.” — John Magnis DDS, Oxnard, CA • Expand your practice/patient base by offering oral sedation for adults • Preserve fearful adult patients and related productivity WOrkShOp SCheDule: • Perform dental work in fewer appointments • Will teach you SAFE guidelines for oral sedation for adults April 3-5, 2020 • LIVE patient demonstration March 29, 2020 • California Dental Board approved course (Recertification) • Course meets ADA guidelines; qualifies for most States for Oral (minimal) sedation permit* *Check with your individual state for specific requirements for issuing an oral (minimal) sedation permit July 24-26, 2020 For a group of doctors (6-doctors minimum), course can be given anywhere in California at YOUR place November 20-22, 2020 Depending on location and number of participants, travel fees may apply periklis proussaefs DDS, MS 25 Ce hour is a prosthodontist and Associate Professor at Loma Credit Linda University. Dr. Proussaefs has received formal training in all forms of sedation since 1997. He has been providing dental care under I.V. (moderate) Course Fee: $1,965 or oral (minimal) sedation. His seminars focus on $575 per staff member patient safety, airway management, monitoring, (Staff member participation encouraged.) and handling emergencies. The course involves lecturing, hands-on training on a manikin, and real $765: Recertification oral sedation patient experience. dentistry doctor “Dear Dr. Periklis Proussaefs, Thank you for the wonderful course. I was doing conscious $875: Recertification conscious sedation for many years and took several renewal courses. Yours was indubitably the sedation doctor best. Very informative. Extremely to the point. Clear and very captivating. I learned a lot this Sunday and started work on Monday refreshed, energetic, and eager to use all my new knowledge. I strongly recommend this course to doctors who are willing to introduce sedation to their practice or the ones who need renewal. Thank you.” —Anna Durkin DDS, general dentist, San Marcos, CA “A definite must take class for any dentist to further your career. You will learn a lot.” —Kevin Chou DDS, general dentist, Bakersfield. C.I.D.E. www.DentalOralSedation.com California Institute of Dental Education Periklis Proussaefs DDS, MS Nationally Approved PACE Program (805) 676-1063 Provider for FAGD/MAGD credit Approval does not imply acceptance by any regulatory authority or AGD endorsement or (805) 676-1611 Approval from 09/01/2019 to 08/31/2021 Provider ID # 390855 innovation

CDA JOURNAL, VOL 48, Nº3

The Role of Medicine and Technology in Shaping the Future of Oral Health

Namrata Nayyar, BDS, MS; David M. Ojcius, PhD; and Arthur A. Dugoni, DDS, MSD

a b s t r ac t This commentary describes the changes taking place in dentistry and speculates on improvements that could happen soon. Advances in health care will have an impact on the integration and delivery of oral care; conversely, there is growing acceptance that oral health impacts systemic health. Technological innovations are changing the face of medical care and are quickly becoming integrated into dentistry. Advances in novel antimicrobials, genomics, robotics and artificial intelligence are transforming our ability to diagnose and manage disease.

AUTHORS

Namrata Nayyar, Arthur A. Dugoni, DDS, ore than 10,000 years The history of dentistry is as BDS, MS, is an assistant MSD, is dean emeritus, ago, a Sumerian found a ancient as the history of humanity professor of clinical oral professor of orthodontics better way. He invented and civilization.1 Dental treatment health at the University of and senior executive the Pacific, Arthur A. Dugoni for development at the the wheel, perhaps the has come a long way from the earliest School of Dentistry. University of the Pacific, world’s greatest single known evidence of dentistry in Conflict of Interest Arthur A. Dugoni School Mtechnological achievement. Since then, 7000 B.C. with the Indus Valley Disclosure: None reported. of Dentistry. In 2004, he millions of individuals — some celebrated civilization to current approaches became the first and only and some unknown, some by design and and diagnosis and treatment. Over David M. Ojcius, PhD, is person in the United States the chair of and a professor or Canada to have a dental some by accident — have found a better way. the past seven decades, we’ve gone of biomedical sciences at school named in his honor Thomas Edison found a better way – the from ignorance to understanding the University of the Pacific, while holding the position incandescent lamp; Henry Ford – the mass- because of the standards and quality Arthur A. Dugoni School of dean. produced automobile; Alexander Graham of education, our clinical efforts and of Dentistry. His research Conflict of Interest Bell – the telephone; Alan Turning – the scientific research. From a primitive is currently focused on Disclosure: None reported. the immune response to computer; Bill Gates – Microsoft Windows; form of medicine, the incorporation periodontal pathogens. Steve Jobs – the iPhone and iPad. The of modern-age technologies into Conflict of Interest desire and the motivation to find a better dentistry within the last 50 years has Disclosure: None reported. way are integral parts of human nature. accelerated this transformation. We Americans are known for our “Yankee Oral health in the 21st century is ingenuity.” We are a nation constantly not just a “drill-and-fill” routine. While striving to find, and sometimes obsessed with earlier efforts in dentistry conformed finding, a better way to do our jobs, teach our to removal of diseased tissue and children, refine our goods, sell our products, restoration of lost tooth structure, newer interact with people, maintain our health, advances are emphasizing prediction test our skills and stretch our endurance. and prevention of the disease process.

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Within our lifetimes, a sea of change tissue and organ transplants, use of novel not far when patients, alerted by the results in the knowledge and perception of dental antimicrobials or even application of from genetic tests for susceptibility genes, diseases has occurred. Historically, oral genomics to create personalized oral care, will bring the genetic analysis for counseling health has been separated, clinically and will have a lasting impact on patient or treatment by oral health professionals. administratively, from the overall health care. The integration of dental practices A promising development where care delivery system; in recent times, there with comprehensive medical teams — genomics overlaps with other areas of has been a major effort to incorporate oral embedding dentists within a team of dentistry is in the use of salivary imaging health in overall health care diagnosis.2 physicians, pharmaceutical providers and diagnostics employing novel salivary This is due to the realization that oral along with geneticists — would be a first proteins, nucleic acids, metabolites and care is the gateway to prevention and step toward providing comprehensive other markers for the early detection of early detection of many nonoral systemic diagnosis and treatment for all patients. both oral and nonoral disease.10–14 The ailments. In 2000, “A National Call To An obvious area where medicine potential for correlating the profile of the Action To Promote Oral Health,” published can influence delivery of oral care is in microbial community (the microbiota) by the surgeon general, called for “changing personalized dentistry. The increasing in our saliva with susceptibility to oral or the perception” of oral health as separate systemic disease is intriguing.15–17 Due to the from overall health and charged oral health ever-evolving nature of microbes and the and other health professionals to partner desire to avoid abuse of antibiotics, novel in research, treatment and policy efforts.3 The surgeon general’s antimicrobial therapies are being developed There is growing evidence that office will issue a 2020 that rely on the use of naturally occurring oral health plays a significant part in report on oral health to salivary antimicrobial proteins like development of systemic diseases like histatins, immunoglobulins and defensins.18 cardiovascular disease, diabetes mellitus, show us how we’re In addition, the targeted delivery of various cancers and dementia.4,5 The doing and challenge antimicrobial proteins using salivary gland surgeon general’s office will issue a 2020 us to new action. gene transfers is being considered.19 report on oral health to show us how we’re Advances in bioengineering to replace doing and challenge us to new action.6 lost tooth structure or entire teeth are being Although we live in one of the made at a rapid pace. In groundbreaking most technologically, medically and availability of genetic testing and genome studies, researchers created 3D printed scientifically advanced societies, we clearly sequencing data and their relative tooth buds that show many similarities to still have much work to do if we are to live affordability have opened many possibilities natural tooth structure.20 Other researchers up to our full potential. In this country, we for the identification of novel markers for developed a strategy that allows autologous still have more than 28 million citizens oral diseases through genetic sequencing. mesenchymal cells derived from bone without health care coverage,7 two out of The option exists for adapting preventive marrow to supply nerves to bioengineered three adults without dental insurance,8 oral care targeting individuals with higher teeth.21 These exciting developments point 37,000 new cases of oral cancer each year7 genetic susceptibility or predisposition toward a future where damaged teeth could and a continuing crisis in oral health. to certain oral diseases. Because most be restored completely and biologically As we move forward into an exciting oral conditions are a result of genetic without the use of crowns and fillings. decade of promise and change, we would like and environmental factors, a risk profile to encourage you — our best and brightest combined with other tools could be a useful Robots Are Coming for Our Jobs — to take on new challenges, to take some predictive tool, which could influence With artificial intelligence, we will risks and to challenge the status quo. treatment procedures and preventive have better personalized health care, more As a society, we are in a flux due to care. The American Dental Association efficient shopping, improved transportation, the sweeping changes occurring in all announced general guidelines for the use of enriched entertainment and, in general, aspects of life, including the health care genetic testing in dental practice.9 So far, 13 more creative jobs and less mundane work. industry, which will impact oral health as genes have been identified as involved in Workplace automation through well. The emergence of new technologies, the caries process, while 11 are implicated in robotics has significant advantages, be it robotics, artificial intelligence, the periodontal disease process. The day is but there is also skepticism in dentistry

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attached to their use to treat patients.22 Coming to Your Office: “Alexa, Potential uses of AI could be in smart While robotics is employed in many Show Me the Bitewings of No. 20” patient scheduling and communication medical and surgical procedures, dentistry While the use of digital radiographs through machine learning and booking is still in the early stages of robotics is a standard of care now, incorporation appointments with patients directly. for routine dental procedures. Thus, of artificial intelligence (AI) could be robotics is now used routinely in many the next milestone in better predicting Technology: A Game Changer dental clinics for digital impressions and patterns of caries and other diseases.26 in Orthodontics digital milling. Robots are also being With the ability to learn from past data, AI Recent innovations in orthodontics integrated in dental clinics for other has significant potential in detecting and include cone beam computed tomography procedures.23 A company announced last predicting caries in often-overlooked areas (CBCT) and 3D visualization, intraoral year that it obtained approval from the of radiographs or at least stages of caries. scanners, facial scanners, instant teeth Food and Drug Administration (FDA) For many dentists, routine eye fatigue modeling software capabilities and new to market a first-of-its-kind robotically sets in after observing 10 to 15 black- appliance developments using robotics assisted dental surgical system called and-white X-rays. This is where AI-based and 3D printing. Digital technology Yomi. A design for robot-assisted dental has dramatically changed and will surgery for 3D surgical planning and continue to change the nature of clinical guided placement of dental implants practice and orthodontic education. already exists. In China last year, a robot With the ability to learn 3D printing is one of the fastest dentist replaced a dental implant for from past data, AI has growing digital technologies and allows the first time. A human programmed significant potential in orthodontists to develop and produce the precise measurements in order to their own appliances (customized ensure the implants fit correctly, but detecting and predicting brackets, orthopedic appliances and the robot did the physical work.24 caries in often-overlooked clear aligners) with nearly limitless There is also potential for predictable areas of radiographs. potential applications. Sensor technology surgical and dental outcomes using can also be integrated in monitoring end-to-end digitization and reduction patients’ compliance and optimizing of postoperative symptoms as well as tooth movements and bone remolding. patient management by programming software can help the dentist, by training The sensor chips can be integrated machines to recognize signs of stress the software with stored images and in brackets in the fixed orthodontic like pupil dilation, elevated blood replicating predictions in a standardized appliances and clear aligners.29 pressure and tachycardia. Deep pattern for caries detection.27 There are learning systems have already shown the advantages of speed, availability What About Training of Future Dentists? clinically acceptable performance and elimination of bias using AI-based Advances in AI have the potential for detecting diabetic retinopathy technology for radiographic detection, not only to affect patient behavior in a population-based screening.25 eliminating the burden on radiologists and treatment, but also recruitment Advances in digital technology have to read and interpret simple images. and training of our future dentists. already introduced computer-assisted Among the most innovative predictive With the use of customer resource designing and milling in everyday use uses of AI are the integration of smart management (CRM) for student in dentistry. While a few years ago the toothbrushes, which could analyze success,30 there is already the possibility concept of same-day digital dentistry teeth as the patient brushes, check for developing a comprehensive was treated as a novel concept, this with cloud-based AI software against a recruitment and assessment tool improvement is now increasingly viewed database of images and alert the subject for prospective students in general as a standard inpatient convenience of of either present or emerging teeth higher-education institutions. CRM modern dental practice. Digitization of caries and cracks.28 Furthermore, the would enable educators to learn and health records is also having a major subject could schedule the next dentist predict what is working and what is impact on standardization of care in visit while brushing their teeth with not working for individual students both oral health and medical settings. a smartphone assisted by AI again. in dental schools. The education

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could be more personalized, tailored The power to shape the future Mar;87:115–124. doi: 10.1016/j.archoralbio.2017.12.022. around the students’ experiences and is earned through persistence. The Epub 2017 Dec 23. 14. Meagher RJ, Kousvelari E. Mobile oral heath technologies abilities. We could follow a student’s future for dentistry is not uncertain. based on saliva. Oral Dis 2018 Mar;24(1–2):194–197. doi: progress from the start, analyze and The future is what we choose to 10.1111/odi.12775. advise the growth, spot weaknesses make it. The decades ahead will be 15. Carpenter GH. The secretion, components and properties of saliva. Annu Rev Food Sci Technol 2013;4:267–76. doi: and help them achieve success. exciting, awesome, challenging and 10.1146/annurev-food-030212-182700. inspiring, and they are ours to shape. 16. Marsh PD, Do T, Beighton D, Devine DA. Influence of saliva on Are We Ready for the Future? The dreamers of a decade ago are the oral microbiota. Periodontol 2000 2016 Feb;70(1):80–92. doi: 10.1111/prd.12098. Amplification of the flood of new considered realists in the present, and the 17. Zhang CZ, Cheng XQ, Li JY, et al. Saliva in the diagnosis of discoveries in technology requires dreamers will now usher in the future. n diseases. Int J Oral Sci 2016 Sep 29;8(3):133–7. doi: 10.1038/ dynamic collaborations between basic and ijos.2016.38. 18. Van Nieuw Amerongen A, Bolscher JG, Veerman EC. Salivary clinical research that can lead to clinical references 1. Wikipedia. Dentistry. en.wikipedia.org/wiki/Dentistry. proteins: Protective and diagnostic value in cariology? Caries Res application. It is not hard to imagine 2. Maxey H. Integration of Oral Health with Primary Care in 2004 May–Jun;38(3):247–53. a future when the patient will walk Health Centers: Profiles of Five Innovative Models. National 19. Samuni Y, Baum BJ. Gene delivery in salivary glands: from the bench to the clinic. Biochim Biophys Acta 2011 into a clinic and be treated as a whole Association of Community Health Centers; 2017. www.nachc. org/wp-content/uploads/2015/06/Integration-of-Oral-Health- Nov;1812(11):1515–21. doi: 10.1016/j.bbadis.2011.06.014. being, starting with genetic testing and with-Primary-Care-in-Health-Centers.pdf. Epub 2011 Jul 6. consideration of environmental factors to 3. Office of the Surgeon General (U.S.). National call to action 20. Monteiro N, Smith EE, Angstadt S, Zhang W, Khademhosseini A, Yelick PC. Dental cell sheet biomimetic tooth bud model. identification of predisposing genetic risks to promote oral health. Rockville, Md.: National Institute of Dental and Craniofacial Research (U.S.); 2003. Report No.: Biomaterials 2016 Nov;106:167–79. doi: 10.1016/j. and nutritional counseling. The patient 03–5303. biomaterials.2016.08.024. Epub 2016 Aug 17. will be provided with a comprehensive 4. Bui FQ, Almeida-da-Silva CLC, Huynh B, Trinh A, Liu J, 21. Strub M, Keller L, Idoux-Gillet Y, et al. Bone Marrow Stromal Cells Promote Innervation of Bioengineered Teeth. J Dent Res 2018 oral and medical treatment plan, using AI Woodward J, et al. Association between periodontal pathogens and systemic disease. Biomed J 2019 Feb;42(1):27–35. doi: Sep;97(10):1152–1159. doi: 10.1177/0022034518779077. to learn from the patient’s past behavior 10.1016/j.bj.2018.12.001. Epub 2019 Mar 2. Epub 2018 Jun 7. and help to predict and refine future 5. MacKenzie D. Have we found the true case of diabetes, stroke 22. Wolf ZB. The robots are coming for your job, too. CNN Sept. 3, 2019. www.cnn.com/2019/08/24/politics/economy-us- behavior, interactions and treatment. and Alzheimer’s? New Scientist Aug 7, 2019. www.newscientist. com/article/mg24332420-900-have-we-found-the-true-cause- workforce-automation/index.html. One of the most serious challenges of-diabetes-stroke-and-alzheimers. 23. Holland K. Are you OK with having a robot dentist? Healthline for the leaders in our profession is the 6. National Institutes of Dental and Craniofacial Research. 2020 2018. www.healthline.com/health-news/are-you-ok-with-a-robot- dentist#1. imperative to motivate the unconcerned, Surgeon General’s Report on Oral Health. www.nidcr.nih.gov/ news-events/2020-surgeon-generals-report-oral-health. 24. Lui K. A Chinese Robot Has Performed the World’s the uninformed and the uncommitted 7. Berchick E. Most Uninsured Were Working-Age Adults. First Automated Dental Implant. Time Sept. 22, 2017. time. members among us. We, as a profession, Census. www.census.gov/library/stories/2018/09/who-are- com/4952886/china-world-first-dental-surgery-robot-implant. 25. Bellemo V, Lim G, Rim TH, Tan GSW, Cheung CY, Sadda S, must find a better way to reduce barriers to the-uninsured.html. 8. American Dental Association Health Policy Institute. Dental et al. Artificial Intelligence Screening for Diabetic Retinopathy: care; a better way to fund education and benefits coverage in the U.S. www.ada.org/~/media/ADA/ The Real-World Emerging Application. Curr Diab Rep 2019 Jul student aid; and a better way to increase Science%20and%20Research/HPI/Files/HPIgraphic_1117_3. 31;19(9):72. doi: 10.1007/s11892-019-1189-3. 26. Shuman L. How artificial intelligence is shaping dentistry. dental health care awareness and improve pdf?la=en. 9. American Dental Association. Oral Health Topics, Genetics Dental Economics Feb. 1, 2019. www.dentaleconomics.com/ the dental health of all our citizens. We and Oral Health. www.ada.org/en/member-center/oral-health- macro-op-ed/article/16386252/how-artificial-intelligence-is- need to enhance our technology; enrich topics/genetics-and-oral-health?source=VanityURL. shaping-dentistry. 27. Gupta S. The Future of Artificial Intelligence in Dentistry. our educational programs; elevate our 10. Chojnowska S, Baran T, Wilinska I, Sienicka P, Cabaj- Wiater I, Knas M. Human saliva as a diagnostic material. Healthcare in America Aug. 20, 2018. healthcareinamerica.us/ innovation and research, which has been Adv Med Sci 2018 Mar;63(1):185–191. doi: 10.1016/j. the-future-of-artificial-intelligence-in-dentistry-114e04fc4e8f. the source of our excellence; and heighten advms.2017.11.002. Epub 2017 Nov 14. 28. Philips A. AI-Powered Innovations That Are Transforming Dentistry. Becoming Human: Artificial Intelligence Magazine Aug. the standards and quality of care, which 11. Eftekhari A, Hasanzadeh M, Sharifi S, Dizaj SM, Khalilov R, Ahmadian E. Bioassay of saliva proteins: The best alternative 16, 2018. becominghuman.ai/ai-innovations-transforming-dentistry- have made our profession, because of its for conventional methods in noninvasive diagnosis of cancer. aef03479664d. value systems, the envy of the rest of the Int Int J Biol Macromol 2019 Mar 1;124:14246–1255. doi: 29. Stocker B, Willmann JH, Wilmes B, Vasudavan S, Drescher D. Wear-time recording during early Class III facemask treatment using world. Our profession must not restrict 10.1016/j.ijbiomac.2018.11.277. Epub 2018 Dec 1. 12. Farah R, Haraty H, Salame Z, Fares Y, Ojcius DM, Said TheraMon chip technology. Am J Orthod Dentofacial Orthop tomorrow’s range of choices, and we must Sadier N. Salivary biomarkers for the diagnosis and monitoring 2016 Sep;150(3):533–40. doi: 10.1016/j.ajodo.2016.04.016. not dilute our capacity to solve tomorrow’s of neurological diseases. Biomed J 2018 Apr;41(2):63–87. doi: 30. Salesforce. Student success. www.salesforce.org/highered/ student-success. problems. We have the talent, ability and 10.1016/j.bj.2018.03.004. Epub 2018 May 10. 13. Ghallab NA. Diagnostic potential and future directions of determination to pay the price in dollars, biomarkers in gingival crevicular fluid and saliva of periodontal the corresponding author, David M. Ojcius, PhD, can be time and leadership to find a better way. diseases: Review of the current evidence. Arch Oral Biol 2018 reached at [email protected].

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CDA JOURNAL, VOL 48, Nº3

Dental Education: But Not as We Know It

Michael Reddy, DMD, DMSc, and Sara Hughes, MBE, EdD, MA, BSc

a b s t r ac t Dental education has evolved, thanks to leaders who challenged the profession with insightful observations of the forces shaping the field of oral health. The fundamental design of the U.S. oral health education model is now nearly a century old and exists in a rapidly changing environment — an environment with a new set of forces that will reshape dental education as we know it. Changing health care challenges, health care economics and the exponential growth of science and technology are driving a major shift in oral health. These influences necessitate the need to move dental education into a new direction that positions our current and future dentists as integrated providers within the health team. The Advancing Dental Education in the 21st Century initiative is the current effort underway to move in that direction and meet health care needs of the year 2040.

AUTHORS

Michael Reddy, DMD, Sara Hughes, MBE, EdD, he fundamental design of the The Gies Report certainly continues DMSc, is dean and a MA, BSc, is associate U.S. oral health education to provide guiding principles after professor at the University dean (education) and a model is nearly a century old. nearly a century. However, the range of of California, San Francisco, professor at the University School of Dentistry. of California, San Francisco, Much of the current education knowledge and technology in the 21st Conflict of Interest School of Dentistry. can be traced directly to the century begs a broader approach to oral Disclosure: None reported. Conflict of Interest T1926 Gies Report,1 which called for the health professional education. Moreover, Disclosure: None reported. integration of schools of dentistry with the current curriculum standards do not universities and for oral health practice encompass needs that may be likely 20 based on scientific discovery. It indicated years hence. We foresee these needs that dental disorders are directly related to including the introduction of new the general health of a person and called technologies requiring development for action on health disparities. Many of adaptability skills, along with an of these calls to action are issues we still increased emphasis on communication struggle with at academic health centers. ability and empathy. We also believe The report has had a profound and lasting there will be even more collaborative effect on dental education, much like the health care, requiring teamwork strategies Flexner Report, which was part of the and time management competency same Carnegie Foundation Series, and for integration of oral health care it set the stage for medical education.2 into the overall health care system.

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Beyond Gies, major influences on adapt to new knowledge that was once set of recommendations and facilitated oral health education include the 1995 considered outside their respective discussions of those recommendations. Institute of Medicine Report, which made domains. Concurrently, there has been The project challenges the profession a series of recommendations focused increased understanding of the overall to look forward, not only to assess on interprofessional education, the wellness of the patient as well as the the current state of dental education, importance of dental schools at research- patient’s community. Health systems have but also to look at future trends that intensive universities, expanding the pool responded by increasing collaboration will impact the dental profession of oral health professionals, addressing between clinical practitioners, and we over the next 20 years. Some of the the financial model of education and foresee this trend continuing to grow. issues this initiative highlights for establishing a workforce that reflects The American Dental Education dental education include financing the nation’s diversity.3 The IOM Report Association Commission on Change education, population health and revealed that the fundamental sciences and Innovation in Dental Education5 areas of unmet need, evolution were commonly taught during the first highlighted the importance of critical of treatment technologies and a two years of dental school by basic thinking and advanced learning rapidly changing delivery system. science faculty and clinical relevance Together, these studies serve as was inconsistently integrated into the a guide to contemplate the future curriculum. Conversely, the clinical education of an oral health professional. sciences often were taught by faculty who Our character as a It is clear that our future dental were not actively involved in research- strongly proactive professionals must and will have different related activities. This resulted in a 2+2 health care profession training. Our character as a strongly model where clinical decision-making proactive health care profession with was not consistently based on solid with a historical emphasis a historical emphasis on preventive science. In turn, this led to renewed on preventive care care should not diminish. Rather, we evidence supporting the concept of should not diminish. should build upon that tradition with evidence-based dentistry. The report new skills for a changing health care concluded that dentistry should not landscape. Similarly, existing oral health be taught in isolation and that other professionals must be adaptive to change members of the health care team could methodologies for an innovative and may need continuing professional benefit from oral health knowledge curriculum. In order to integrate new development, with a broader scope, rather as much as oral health providers knowledge and assess the biomedical than the current model of continuing benefit from working with pharmacy, literature published throughout a dental education. Continuing professional nursing, medicine and social work. lifetime, graduates must be sophisticated development, as part of a process of Another landmark study on education consumers of science and technology. lifelong learning, would expand the is the Macy Study on New Models The goal of this initiative is not to scope of new knowledge acquisition of Dental Education,4 which again make every dentist a research scientist, beyond mere clinical updates to include emphasized the oral health-overall health but rather to give dentists the tools to more diverse education in areas critical connection, clinical practice challenges critically assess knowledge, be open to the profession’s future. Examples and research in dental education.4 to new ideas and incorporate new include social and personal skills The report forecast that scientific and evidence into practice after careful development to support new models of technological advances in molecular interpretation of the scientific results. team-based practice; informatics and biology, immunology and genetics, along The most recent project, known as approaches for integrating information with an aging population with more “Advancing Dental Education in the from multiple disciplines; and sources complex health needs, would increasingly 21st Century,” is a multiphase initiative to maximize quality of life for patients. link dentistry and medicine, leading to designed to take a comprehensive look While these are not traditionally thought the need for changes in dental education. at oral health practice. The first phase of as areas of continuing education, they This has led to increased demand for resulted in 38 manuscripts divided may be essential to keep dentists current dentists and physicians to acquire and into six sections (SIDEBAR)6–11 and a with the latest clinical dental research.

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Driving Forces for Future Knowledge Needs Advancing Dental Education in the 21st Century Changing Health Challenges U.S. health care systems will face The project challenges the profession to look forward, not only to significant challenges in meeting the needs assess the current state but to also look at future trends that will impact of an aging population. Seven chronic the dental profession over the next 20 years. diseases — heart disease, cancer, stroke, chronic obstructive pulmonary disease What is the current state of dental education? (COPD), pneumonia and influenza, The current dental curriculum, implications of student debt and dental school Alzheimer’s disease and chronic kidney finances, expansion of enrollment, student diversity, pre- and postdoctoral disease — account for the majority of deaths education, safety net status of dental school clinics and trends in faculty. and health care spending (84%) in the — Allan Formicola6 U.S.12,13 The impact of most of these diseases is cumulative, manifesting and exacting How many dentists are needed in 2040? greater tolls in older adults. Moreover, some The oral health of the population, changes in the utilization of dental services, predict that the next generation will have a new technologies, growth of dental group practices and the demand for care. decreased lifespan along with a compromised — Howard Bailit7 quality of life as a result of these ailments. To address these challenges, health What should oral health professionals know in 2040? care of the future must focus less on acute, Predoctoral education, advanced dental education, the provision of hospital-based interventions and more on medical services within dental practice, the incorporation of oral health compliance with medications, medical services into primary care and medical practice and interprofessional interventions and lifestyle changes. education and practice. Outpatient providers are the critical link — Jane Weintraub8 in bringing about this shift. By expanding their range of practice and becoming an How will the dental delivery system change in 2040? integrated part of primary care, dentists The decline in solo practice and increase in large group practice, limited can help support the country’s transition integration of medical and dental care, working with allied dental staff. to a prevention-focused approach to — Howard Bailit9 health. Our tradition of preventive care uniquely positions dentists to advance this What are the status and future of allied dental education? approach; this is something dentistry adds to Current and future educational systems for dental assisting, dental interprofessional education. Future dentists hygiene, dental therapy and dental laboratory technology. will need more training in psychosocial — Jacquelyn Fried10 and behavioral intervention to encourage desired patient behaviors. Along with What are the status and future of dental research and scholarship? this, the incidence of oral disease largely Dental schools face an uncertain future fueled by a volatile funding will continue to decline14 and utilization environment and inadequate mentoring/training of research faculty. They will of dental services will further shift toward be challenged to develop sustainable research and patient care collaborations underserved populations with an emphasis with other health professions. Dental practitioners in the future are likely to place on pediatrics, geriatrics and oncology greater emphasis on managing the overall health of their patients while patients. This emphasizes the need to promoting closer integration with other health professionals. educate oral health professionals with a — Peter Polverini11 continuous skills development mindset that will prepare dentists for an integrated team approach to health care (TABLE).

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TABLE Preparing Dentists for an Integrated, Team Approach to Health Care

Education Clinical Biomedical Sciences Behavioral Population Health Move educational experience to Better integrate these health care- Instruct oral health professionals Training must include large group practices, community focused disciplines into dental in behavioral and psychosocial multidisciplinary partnerships to clinics, virtual care, etc. curriculum. patient needs. improve health outcomes.

Skills Clinical Communication Analytical Teamwork Basic medical knowledge to Necessary to share ideas, foster Ability to question evidence, Interprofessional health teams analyze risk factors, screen for creative collaboration, serve analyze data across multiple will include social service, other medical conditions. multicultural patient base. health care disciplines. experts.

Health Care Economics pressure from the Medicare-eligible stage classifications to one that uses As the percentage of the population population to push for dental benefits. knowledge of personal characteristics to with one or more chronic diseases The average out-of-pocket spending create a knowledge network (FIGURE 3, and annual health care costs both on dental care (2013–2016) was $922 view in detail at cda.org/Reddy3) and continue to rise (FIGURES 1 and 2),15,16 among those on Medicare benefits predict the future course of disease economic pressures on the health care who used any dental service.17 While — precision medicine and dentistry. system dictate that value be a central political discussion has been focused Today, this is limited to genomics but component in the delivery of care. on the specialty tier prescription drug has the potential to become the reality With continued pressure to deliver costs for certain chronic conditions, for all of health care in a decade. consistently higher value, emphasis on the average out-of-pocket spending for This approach raises the issue eliminating unnecessary procedures will prescriptions is highest with Medicare of how to effectively gather, store become the norm. Again, dentistry is beneficiaries at $1,487.17 As the public and interpret the massive amount of uniquely positioned to deliver this sort becomes more knowledgeable about how individual, population, institutional of value. Our “ounce of prevention” oral health impacts their bank accounts and environmental data required tradition, applied to overall health, and overall health, there will be an while promoting interoperability can be worth far more than the usual increased demand for covered services. and ensuring privacy and security. “pound of cure.” Furthermore, dentistry These economic factors will require Blockchain technology may be the should expand the scope of education education of health care professionals, solution to health care providers and and be prepared to manage diseases dentists included, who can deliver high- organizations by creating a decentralized and conditions that were considered quality, personalized care while being record system that can be shared aspects of other areas of primary care. evaluated by a value-to-cost ratio. with all stakeholders in the health At the same time, disruptive system.19 This likely will be combined innovation is further shaping health Science, Data and Technology with machine learning to process the care delivery. The oral health self- The practicing landscape will move multimillion data points available at care market is a prime example of from delivering oral health care to individual and population levels to such disruption. Direct-to-consumer delivering oral health. The emphasis identify the best course of treatment. models for delivering services such will be on prevention and wellness With data being used to drive the as home teeth whitening and mail- rather than diagnosis and treatment. future of health, so too will it be a order orthodontics are becoming more While we may not eliminate disease, major driver for health care provider prevalent as consumers demonstrate their data and technology will assist us in education. Schools of dentistry, along willingness/pressure to alter traditional understanding progression, providing with other arms within academic health care pathways for decreased cost. proactive intervention and actively centers, will be required to adapt by Health care consumerism will sustaining well-being. Key to this providing a structure that supports continue to be a major force shaping will be the development of systems virtual knowledge communities. the delivery of dentistry, with patients biology and multi-omics science.18 While some dental specialty care will electing to self-pay for procedures Understanding what is happening at continue to be delivered in individual that gain them improved health or a cellular level and translating that practices, care in the future will be aesthetics. Over the next few decades, knowledge into personalized health has increasingly interconnected, with most concierge dentistry likely will gain in the potential to change our approach oral health care being delivered in popularity. On the other end of the from one characterized by diagnosing group practices and localized health spectrum, there also will be increasing diseases and treating them based on hubs as part of an associated team.

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80% $12,000 $12,699 70%

60% $9,000 50% $8,518

40% $6,000 $6,178 30% $4,256 20% $3,000 10% $2,241 $850 0 0 1 2+ 4+ 0 1 2 3 4 5+ Number of chronic diseases Number of chronic diseases

FIGURE 1. Percentage of the 65+ population with FIGURE 2. Annual health care costs per person, by number of chronic diseases.15,16 one or more chronic diseases.15,16

Implications for Education In a world where health records are For example, increasing the didactic interoperable between health providers, knowledge of oral health for medical Knowledge-Based Education patients and their personal health care students is potentially beneficial; however, To educate the dentist practicing devices, it will be necessary for more of the its application in pediatrics is vastly in the future health care ecosystem, oral health professional’s education to be different than in palliative care. For oral clinical, biomedical, population delivered as part of a diverse, team-based, health knowledge to be understood, health and behavioral sciences must integrated health network. This will require applied and acted upon effectively, it be strengthened and integrated in our dental schools to move away from being must be customized for each surgical and curricula.8 The system should focus in a stand-alone building and become medicine specialty. This may require on the simultaneous application of physically or virtually embedded in the coordinating oral health education these four scientific areas rather than academic health system. To be successful programs for 30 or more residency and the demonstration of knowledge in this environment, the dentist’s scope of fellowship programs for medicine alone. at point-in-time examinations. practice will need to expand so that part The future dentist will need of their time is spent serving as a primary Clinical-Based Education in-depth analytical skills to ask care provider for the system.21 In addition For clinical education to be thoughtful questions, interpret to contemporary oral heath knowledge effective in a team-based model, most information, question evidence and clinical skills, the dentist will need educational experiences will need to and analyze data. They will need to acquire the basic medical knowledge be moved to patient-centered delivery communication skills to share ideas required to analyze risk factors and screen settings. This will include large and collaborate creatively with an for medical conditions. Logistically, the dental group practices, health care open mind that embraces different dentist will need to know how and when organizations, hospitals and community cultural perspectives. Greater depth to refer in the system and develop strong clinics. It also will include having of knowledge in other health care relationships with health navigators. nontraditional clinical experiences, disciplines and the utilization of Conversely, it is incumbent upon such as those in community settings, problem-solving skills to identify dental school faculty to integrate more telehealth and virtual care. The dentist patterns and implement health care oral health in the curricula of medicine, will require training in how to work solutions also will be required.20 The nursing, pharmacy, social work and with other health care professionals development of this new skill set will other health disciplines. This represents and social service experts to deliver require that we condense time spent a daunting task because oral health interprofessional health care through teaching the basic principles of science education must be tailored to the specific shared learning and experience.22 and preclinical skills and increase learning needs and areas of expertise As oral health care is delivered in more focus on biomedical science, critical for these professions, all of which are diverse settings, oral health professionals thinking and soft skills (f i g u r e 1 ). becoming increasingly specialized. will encounter more complex patients,

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not just in terms of their dental needs but references 2017 Jan;21(1):1–16. doi.org/10.1089/omi.2016.0144. 1. Gies WJ. Dental education in the United States and 19. Mertz L. (Block) chain reaction: A blockchain revolution also psychosocial, behavioral and medical Canada: A report to the Carnegie Foundation for the sweeps into health care, offering the possibility for a much- advancement of teaching. New York: Carnegie Foundation; health care needs. This will challenge the needed data solution. IEEE Pulse 2018 May–Jun;9(3): 1926. entry-level dentists treating these patients 4–7. doi: 10.1109/MPUL.2018.2814879. 2. Flexner A. Report on medical education in the United 20. Formicola AJ, Bailit HL, Weintraub JA, Fried JL, Polverini and will require that the range of oral States and Canada: A report to the Carnegie Foundation PJ. Advancing dental education in the 21st century: Phase for the Advancement of Teaching. New York: Carnegie health professionals expand. Everyone 2 report on strategic analysis and recommendations. J Foundation; 1910. on the oral health team, including Dent Educ 2018 Oct;82(10):eS1–eS32. doi: 10.21815/ 3. Field MJ, ed. Dental education at the crossroads: JDE.018.109. therapists, hygienists and assistants, will Challenges and change. Washington, D.C.: National 21. Prasad M, Manjunath C, Murthy AK, Sampath A, Academies Press; 1995. need more advanced skills, especially Jaiswal S, Mohapatra A. Integration of oral health into 4. Formicola AJ, Howard L, Bailit T, Beazoglou TJ, Tedesco in managing young children, older primary health care: A systematic review. J Family Med LA. Introduction to the Macy study report. J Dent Educ 10 Prim Care 2019 Jun;8(6):1838–1845. doi: 10.4103/ adults and people with special needs. 2008 Feb;72(2 suppl):5–9. jfmpc.jfmpc_286_19. 5. American Dental Education Association. Beyond the The dentist’s residency education 22. Smith PD, Mays KA. Dental students’ non-clinical crossroads: Change and innovation in dental education. will need to integrate with medical learning during community-based experiences: A survey of Washington, D.C.: ADEA, 2010. U.S. dental schools. J Dent Educ 2019 Nov;83(11):1289– residency education, advancing the 6. Formicola AJ. Current state of dental education: 1295. Jul 8. doi: 10.21815/JDE.019.130. Epub 2019 Jul Executive summary. J Dent Educ 2017 Aug;81(8):1008– model of collaborative team-based care. 8. PMID:31285366. As medical care continues to move 1014. doi: 10.21815/JDE.017.053. 7. Bailit HL. How many dentists are needed in 2040: the corresponding author, Michael Reddy, DMD, DMSc, outside of hospital settings, ambulatory Executive summary. J Dent Educ 2017 Aug;81(8):1015– can be reached at [email protected]. services in the community will expand, 1023. doi: 10.21815/JDE.017.054. giving dental residents the opportunity 8. Weintraub JA. What should oral health professionals know in 2040: Executive summary. J Dent Educ 2017 to deliver basic medical services and Aug;81(8):1024–1032. doi:10.21815/JDE.017.055. medical residents to explore dentistry. 9. Bailit HL. The dental delivery system in 2040: Executive The education system for clinical summary. J Dent Educ 2017 Sep;81(9):1124–1129. doi: 10.21815/JDE.017.068. experience must move from random 10. Fried JL. The allied dental professions in 2040: exposure in outpatient facilities to Executive summary. J Dent Educ 2017 Sep;81(9):1130– a more immersive experience that 1136. doi: 10.21815/JDE.017.069. 11. Polverini PJ. Dental research and scholarship in 2040: provides a clear learning pathway that Executive summary. J Dent Educ 2017;81(9):1137–1143. promotes acquisition of increasingly doi.org/10.21815/JDE.017.070. complex clinical skills and knowledge. 12. National Center for Health Statistics. Health, United States, 2015. Hyattsville, Md.: National Center for Health Statistics; 2016. www.cdc.gov/nchs/data/hus/hus15.pdf. Conclusion Accessed Aug. 26, 2019. Dental education is being shaped 13. Moses H, Matheson D, Dorsey ER, et al. The anatomy of health care in the United States. JAMA by a number of forces that require it to 2013;310(18):1947–1963. doi: 10.1001/ be fundamentally reimagined if we are jama.2013.281425. to meet oral health needs in the year 14. Eklund SA. The impact of improved oral health on the utilization of dental services. J Dent Educ 2017 2040. Many challenges, such as financing Aug;81(8):eS110–eS119. doi: 10.21815/JDE.017.017. education, eliminating persistent health 15. National Council on Aging. Healthy Aging Facts 2018. disparities and addressing unmet oral Arlington, Va. www.ncoa.org/news/resources-for-reporters/ get-the-facts/healthy-aging-facts. Accessed Aug. 29, 2019. health needs, exist against a backdrop of 16. The Robert Wood Johnson Foundation and Johns rapidly evolving science and technology, Hopkins University, Partnership for Solutions. Chronic shifting health challenges and a changing Conditions: Making the Case for Ongoing Care September 2004. www.partnershipforsolutions.org/DMS/files/ delivery system. These issues need to be chronicbook2004.pdf. Accessed Aug. 29, 2019. addressed simultaneously and will require 17. Freed M, Neuman T, Jacobson G. Drilling Down on our dental schools and academic health Dental Coverage and Costs for Medicare Beneficiaries. Kaiser Family Foundation March 13, 2019. www.kff.org/ centers to unify into a comprehensive medicare/issue-brief/drilling-down-on-dental-coverage-and- health system committed to providing costs-for-medicare-beneficiaries. Accessed Aug. 30, 2019. exceptional care focused on patients’ 18. Pirih N, Kunej T. Toward a taxonomy for multi-omics science? Terminology development for whole genome study n overall health and well-being. approaches by omics technology and hierarchy. OMICS

138 MARCH 2 0 2 0 Specializing in selling and appraising dental practices for over 45 years!

LOS ANGELES & VENTURA COUNTY ORANGE COUNTY LEMON GROVE— Fee for service general practice with over 48 years of goodwill CANOGA PARK— 25+ years of goodwill GP ANAHEIM— GP located in a small shopping located in 2 story corner building. Has 4 eq w/ 4 eq ops and 1 plmbd not eq op. Located center. Has 4 eq ops w/ digital x-ray. Ap- prox. 40-45 new patients/mo. ops. Grossed approx. $398K for 2019. Prop- in a single story bldg. Proj. approx. $359K Grossed approx. $1.35M in 2019. Net $876K. Prop- erty ID #5308. for 2019. Property ID #5241. erty ID #5296. SAN DIEGO & ESCONDIDO —(GP/Implant CERRITOS— GP with 40 yrs of goodwill in CORONA DEL MAR—Well established GP Selling as One) – Grossed $914K in 2018 shopping plaza. Grossed approx. $1.4M in with walking distance to the ocean. Consists of and Projecting approx. $951K for 2019. 2019. NET $261K. Property ID #5295. 3 eq ops. Grossed approx. $788K in 2019. Property ID #5285. Buyer’s net of $322K. Selling the property CENTURY CITY—GP in 11 story prof med in Escondido as well. Property ID #5275. FOUNTAIN VALLEY— GP in strip shopping bldg. Has 5 eq in a 1,955 sq ft. Grossed center w/ great street visibility. Grossed approx. $464K in 2019. Property ID 4509. RIVERSIDE COUNTY $238K in 2018. Has 4 eq ops and 1 plmbd DUARTE— GP established in1964 located in not eq. Great staff. Property ID #5293 RANCHO MIRAGE— Beautiful Fee for ser- a 2 story mixed bldg. Grossed approx. WESTMINSTER/FOUNTAIN VALLEY— Es- vice General / Implant practice located in $350K in 2019. Property ID #5183. tablished in 1978 GP in 2 story free stand- free standing bldg. Has 4 eq ops. . Grossed GRANDA HILLS— With 50 yrs of goodwill ing bldg. Grossed approx. $763K in 2019. $1M in 2018. NET $333K. Property ID this general practice grossed approx. $392K Has reasonable rent. Property ID #5291. #5284. in 2019. NET $149K. Property #5276. YORBA LINDA—GP in strip shopping center TEMECULA - Pedo and Ortho Practice! It’s with 33 years of goodwill. Has 3 eq operato- LONG BEACH—GP with approx. 60 yrs of located in a duplex single story building. ries. Grossed approx. $300K in 2019. Buy- goodwill. Projecting approx. $373K in 2019. Grossed approx. $1.3M in 2019 with a er’s net $113K. Property ID #5299. Property #5303. Buyer’ net of $557K. PPO/Cash/Denti-cal. Has 8 eq ops in a 3,500 sq ft office. Property ROWLAND HEIGHTS— Estab. in 2009, this ID # 5243. GP is located in a 1 story free standing bldg.

Grossed approx. $806K in 2019. NET LA QUINTA— Price Reduced! Well estab- $314K. Property ID 5278. SAN DIEGO COUNTY lished GP with over 8 years of goodwill. This modern designed practice has 8 eq ops. SAN GABRIEL— GP located n a 2 story CARLSBAD— This beautiful practice has over On a the busiest major intersection. building with 42 yrs of goodwill. Has 11 eq 22 yrs of goodwill. Has 4 eq ops in a 1,800 sq Grossed approx. $1.5M for 2019. NET ops. Grossed approx. $1.2M in 2019. NET ft suite. Fee for serviceSOLD office. Grossed ap- $344K. Property ID #5130. $243K. Property ID#5309. prox. $440K for 2018. Property ID # 5256. CARMEL VALLEY — Price Reduced! Turn key UPLAND—Beautiful general practice locat- SIMI VALLEY— GP w/ 54 years of goodwill practice with 3 eq ops and 1 plumbed not eq ed in 2 story building with 4 equipped oper- in free standing building. Grossed approx. on an approx. 1,815 sq ft suite. PPO and Cash atories. Grossed approx. $920K in 2019. $575K for 2019. NET $185K. ID #5294 only. Grossed approx. $325K in 2018. ID # Property ID #5237. 5274. VENTURA - GP w/ 4 eq ops . PPO & Cash UPCOMING PRATICES only. 40 years goodwill. Projection approx. EL CAJON (GP) - Price Reduced! Consists of 5 eq ops and equipped with 3D Sirona CBCT $470K in 2019. Property ID #5288. Digital X-ray. Grossed over $1M in the past Beverly Hills, Encino, Glendale, Laguna VENTURA (LH) - GP located in a 2 story med 10 years. Property ID # 5265. Niguel, Long Beach, Newport Beach and prof. bldg with 2 eq ops. Prop. #5304. San Bernardino

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CDA JOURNAL, VOL 48, Nº3

The Future of Organized Dentistry: Past Is Prologue

Peter A. DuBois

AUTHOR

Peter A. DuBois joined DA is celebrating its 150th market issues that were and are impacting the California Dental anniversary, giving us the dentistry. Because of these value offerings, Association as executive opportunity to look ahead our members are better able to compete director in March 2003. based on the lessons of in the ever-changing world of dentistry. In addition to serving as CDA’s executive director, the past. Through the In the late 1970s, professional liability he also serves as CEO of Cvisionary leadership of our volunteers, insurance rates were skyrocketing and its holding company and this association has driven, reacted to and dentists were being priced out of the vice chair of the boards experienced dramatic changes in many ability to provide patient care. CDA of CDA’s subsidiaries and aspects of dentistry over the past decades. member dentists took the bold step charitable foundation. Conflict of Interest Leadership in an ever-evolving of creating an insurer that is dentist- Disclosure: None reported. environment is at the core of what drives centric. TDIC was created in 1980 as a CDA and allows us to continue to create company governed by dentists to ensure and deliver tremendous member value. And their colleagues receive exceptional research is a primary driver of our ability service and unparalleled coverage. to lead through an evolving landscape. At that time, many in the industry Staying up to date on trends is a crucial part deeply questioned this venture. of our mission because, ultimately, we know Today, TDIC offers a complete change is coming. The more information we portfolio of professional insurance products, have, the more chance we have to succeed. including Professional and Business Constant evolution and improvement Liability, Commercial Property, Workers’ are ingrained in the culture at CDA. Compensation, Employment Practices This is ever-present in our continuing Liability and Cyber Suite Liability coverage. education course offerings at CDA TDIC covers more than 24,500 dentists Presents, the creation of volunteer in 15 states and continues to grow. task forces to analyze complex issues TDSC is a more recent venture that and new-member value propositions evolved through a member-led task that keep dentists competitive. force that studied emerging economic The Dentists Insurance Company trends in dentistry. What became clear (TDIC) and The Dentists Supply was that the vast majority of practicing Company (TDSC) are additional dentists were paying much higher rates examples of how consistently gathering for their dental supplies than large information and listening intently to our groups and dental service organizations members have led to exceptional value (DSOs). It was determined that by offerings from CDA. Both were started creating a group purchasing platform specifically in response to larger, changing through CDA, we could leverage the

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buying power of our 27,000 members This team approach to dentistry differs of the future. This is a potentially exciting to realize tremendous savings for solo from other traditional modes of solo or development where organized dentistry and small-group-practice members. small group practice. As we will see, this will have to adapt its membership models Operating since 2017, TDSC now team approach will well-position dentistry to meet the needs of those practices. serves all 50 states, where every tripartite to be a significant contributor to our member dentist in the country is able to changing health care delivery system. Communities and Communication enjoy savings of 20% or more on thousands The team practice model provides Organized dentistry has to be present of different types of dental supplies. A a stimulating practice environment for for our members and meet them wherever venture into online business-to-business dentists and other team members and they are. This comes through continuous supply sales of this scale by a professional creates a sense of community within a care innovation in our communication association is without precedent. The vision delivery setting. We see those dynamics first channels with the overarching goal and capacity for managed, thoughtful risk cultivated in smaller dental school cohorts, of staying connected to members. by our volunteer leadership is once again in practicing dental teams and in leadership Engagement is one of the key indicators of helping dentists chart a productive course within CDA and local dental societies. staying connected, and CDA, like other through turbulent economic times. organizations, continues to work to find Both of these member offerings exposed mediums that encourage this connection. the organization to tremendous risk; With the advent of social media, newer however, that risk was calculated and well- It is through this same commitment dentists are growing comfortable with known prior to entering into these ventures. to analytical, action-based communicating and socializing through Through meticulous research — of markets, research that CDA, through the their smartphones irrespective of platform. member needs and association capacity — So, we in organized dentistry must adapt TDIC and TDSC came to be. It is through vision and leadership of our to that. This is both a challenge and an this same commitment to analytical, action- volunteers, will shape and opportunity. As the reader sits with this based research that CDA, through the prepare for the future of dentistry. printed issue, there is likely an awareness vision and leadership of our volunteers, will that a digital evolution will occur for shape and prepare for the future of dentistry. publications such as this. The primary In considering the future of dentistry, challenge for scientific journals such as we can look to the seismic changes that By harnessing the power of online ours will be to retain the depth, breadth have occurred with our colleagues in the communities — we dare not prognosticate and quality of research and writing even medical profession over the course of the about what the world might look like in as the publication platform evolves. last 30 years. With those changes, we have 20 years — we will be able to build and Along with traditional publications the benefit of 20/20 hindsight, which will maintain larger communities of dentists like the Journal of the California Dental be an advantage as we determine strategies to serve patients. Social media can Association, the many different gatherings and tactics to shape and influence potential serve as a starting point to drive those of dentists will likely evolve over time. structural changes to the field of dentistry. in underserved areas to teledentistry Currently, components host events like options that are led and maintained by a continuing education seminars, mixers, How Dentists Practice dentist and include a well-trained dental monthly meetings and board meetings. At The majority of dentists today still team. This provides the potential for an a state level, dentists gather for our yearly practice in solo or small group practices enormous new patient base for dentists CDA Presents conventions in San Francisco and are integral and recognizable parts of willing to embrace this mode of technology. and Anaheim, along with many other their communities. The change I think An organization like CDA could, in opportunities — CDA Cares free clinics we can expect to see in practice, though, the future, potentially provide greater and activities necessary for governance and is starting in dental school, where newly support to technological efforts like this. leadership development. The same goes trained dentists are learning to work in Based on trends of where newer for our national representation. This begs teams and are becoming acculturated dentists are going to work and the the question: Over time, with dentists’ to practice with a team of clinical evolving economics of health care, large comfort in communicating through different professionals from other disciplines. group practices will be a significant part mediums evolving, will these models change?

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CDA recognizes the importance of diabetes, a heart condition, certain types disrupt the pipeline of care, increased asking these types of questions, even of cancer or other illnesses dentists are interprofessional practice and so forth. if the answer in the near term is “no,” trained to identify. Catching these chronic For a dentist just graduating from dental because continued evolution requires and, in some cases, deadly illnesses school in the future, by mid-career diligently looking within. In the near before they really begin to take hold is their realities will likely be decidedly term, it is possible, given overall shifts proven to improve health outcomes, different than those of graduates today. in regional perspectives and dynamics, save lives and reduce health care costs. We must embrace a markedly that CDA may work to organize regional As with communication among different reality to influence it in the sharing opportunities for states and larger dentists and between CDA and dentists, most productive way possible. Providing components to share best practices, both on in the future we will likely continue to deep, data-driven research and sound a member and volunteer leadership level. see changes in how dentists communicate policy guidance is a craft that CDA has At the core of this idea is the with patients. Again, it would be honed over several decades thriving importance of maintaining an overall foolhardy to suggest we could tell you in the largest state in the union. sense of community within dentistry what tools will be available to us in 20 California is a policy bellwether — among dentists, dentists and their of the nation. Public policy advocacy teams and dentists and their patients. is a core member benefit that touches Through these strong bonds, organized every single member of the dental dentistry has flourished over time and Regardless of what team. With this honed skill, we will will continue to grow in the future. technological changes may be well-positioned to represent and Regardless of what technological come, if we stay faithful to advocate for our members’ views and changes may come, if we stay faithful to positions on the evolution of the health growing and strengthening our community, growing and strengthening our care delivery model in California and dentistry as a whole will continue to prosper. community, dentistry as a whole nationally. In the future, we will likely will continue to prosper. see the growth of regional coalitions Patients lending voices on issues of concern, For many, the relationship between such as expanded access to care for dentist and patient is an enduring one. all populations and integration into Dentists become integral parts of their or 30 years, but what we do know is a larger health care ecosystem. communities, with entire families getting that CDA will continue to learn from routine care from one provider for and adapt to these changes to best Conclusion decades. Not only does this bolster our position dentists to succeed and provide Giving a “conclusion” for an sense of community, but a dentist is able quality health outcomes for patients. article on the future is difficult, as it to build long-term trust with a patient to is not possible to truly know what the better address oral health care needs. The Future of the Health Care World future holds. What we do know is that In these routine visits, patients We have witnessed an extraordinary organized dentistry should embrace and dentists have the most to gain. As shift in the health care world with our what the future brings and adapt in discussed in this article, the long-term colleagues in medicine. That which the most constructive ways possible. arch of the evolution of the health care used to be very similar to the practice of CDA can and will assist our ecosystem suggests the integration of dentistry today is now barely recognizable. members to adapt and embrace the dentistry into larger health networks, Within this shift are tremendous lessons possibilities of the future just as we building on the opportunities that can for dentists and organized dentistry. have done for the last 150 years. n be created when dentists are the health For a dentist in an established the author, Peter A. DuBois, can be reached at care provider patients see the most. practice, we may see some shifts in [email protected]. Integrating basic health screenings the near term — adaptations of dental into those visits has the potential to benefits, the possibility of a dental catch other potential chronic illnesses benefit in Medicare, greater consumer early, whether it is high blood pressure, awareness of choices, efforts to

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Societal Needs and the Role of Health Care in Shaping the Future of Dentistry in the 21st Century

Harold C. Slavkin, DDS

AUTHOR

Harold C. Slavkin, DDS, his commentary uses historic and beginning to revolutionize patient and is dean and professor demographic trends to describe population health care. Public-private emeritus, division of national, California and Los partnerships are spearheading the next biomedical sciences and the Center for Craniofacial Angeles County health needs in generation of genomics, epigenomics and Molecular Biology at the the 21st century. The assessment mobile phone platforms with thousands Herman Ostrow School Tencompasses current and projected health of health apps designed to monitor and of Dentistry of USC. From care delivery capacity and emphasizes curate individual variations that support 1995–2000, he served that “demography is destiny,” which individualized precision health care. as the director of the National Institute of Dental informs the future of health care and the The millennial and Generation Z and Craniofacial Research role of dentistry. For too long, the health cohorts, who represent the largest within the National Institutes care system has not met the full range of proportion of the adult population, are of Health in Bethesda, Md. needs for delivering quality, integrated well-educated, analytical and tech savvy Conflict of Interest and comprehensive care to all Americans and consist of more racial and ethnic Disclosure: None reported. throughout the life span or in managing minorities than in any past generation. health care spending. Costs are increasing; These generations are significant our system is the most expensive in the stakeholders in the U.S. and California. world, yet we rank 37th among the world’s By examining the many “moving parts” health care systems. Health care costs of U.S health care, demographic trends will continue to grow at 5.5% per year, inform the impact of multiple and opposed reaching $6 trillion by 2027. One-third forces that challenge enlightened self- of the population are not living longer, interests and the future of dentistry. are not healthier and are not receiving the best care for the dollars spent. Introduction Adverse issues persist for Medi-Cal, I very much appreciate the invitation Denti-Cal, the Children’s Health Insurance to contribute a commentary on what is Program (CHIP) and Medicare-eligible and what could be the future of dentistry cohorts of all ages regarding access, cost in the U.S. and California. At the and health outcomes. This commentary beginning of my tenure at the National also offers guarded enthusiasm regarding Institutes of Health (NIH) in Bethesda, this pivotal moment in American Md., I was invited by Secretary Donna health care history. An unprecedented Shalala, U.S. Department of Health and convergence of biomedical and behavioral Human Services, to provide leadership scientific knowledge, digital and biological for the first surgeon general report, “Oral technology and bioinformatics are Health in America,” released by David

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Satcher, MD, PhD, in May 2000.1 This inform how to approach the future of Many advances in dentistry related to commentary is drawn from factoids, dentistry, as historical and demographic oral and general health were highlighted concepts and insights gained in part from trends present lessons to be learned from in “Oral Health in America: A Report my membership in the National Academy our past mistakes (and triumphs) as a of the Surgeon General.”1 These studies of Medicine, the American Association health profession and as citizens within a demonstrated that craniofacial-oral- for the Advancement of Science, the complex global community.5,6,9,12–15 History dental diseases and disorders are among Santa Fe Group, organized dentistry and may even help us understand ourselves. the most prevalent human diseases, the University of Southern California over Demography examines and offers with significant health and economic the last half-century. These collaborative curated data sets reflecting the entire consequences that greatly reduce quality experiences shaped and informed my spectrum of society as well as details of of life for those affected. Many of these perspectives, coupled with ever-changing the human condition in terms of birth, diseases are largely preventable, yet they historic and demographic trends that race and ethnicity, education, marriage, persist and illustrate growing social and are used to inform health care policy. families, communities, health status and economic inequalities and inadequate Why history and demography? The employment and retirement.16–23 The support for prevention.1,10,13–15,23 This is study of history provides a detailed particularly evident for people living in picture of how and when our society poverty; poverty is the most significant was influenced by international and socioeconomic determinant of diseases domestic external forces, including the From history we learn in a society that rations health care environment, population numbers and according to income.1,7–10,13–15,19,23 composition, patterns of diseases and and better understand how This report did not address the 2020 disorders, education attainment, health these forces function today issues that impact the dental professional care, innovations and technologies, health and how they influence and workforce versus societal needs: parity care professional organizations, macro- between male and female applicants for and microeconomics and federal, state possibly define the future. dental education; tuition costs that are and county government performances.1–10 the most costly in public and private From history we learn and better universities; student debt upon graduation understand how these forces function of $200,000 to $300,000; postgraduate today and how they influence and possibly digital revolution has enabled exploration choices being guided by student debt define the future. A comparison of Social of curated data to be “mined” and provides repayment; significant trends showing Security legislation (1935), Medicare incredible opportunities for learning and increases in graduates pursuing corporate/ and Medicaid legislation (1964), CHIP, a teaching. For example, the U.S. is the group practices such as the 1,000 dental state-federal partnership providing health third-largest country in the world with service organizations (DSOs) that range in insurance including dental benefits to an estimated population of 330,149,796 size from five to more than 900 locations low-income children (1997), and the as of Dec. 19, 2019, behind China (1.39 and account for 20% of all dental more recent Affordable Health Care billion) and India (1.31 billion).16 The practices — projected to become 35% Act (2010) is valuable in anticipating most populated states are California with to 40% of dentists by 2030; the shortage and possibly informing our futures.11,12 a population of 39.5 million and Texas of dentists providing care to underserved “Demography is destiny” is an with a population of 28.7 million.17–23 The populations (e.g., Denti-Cal, Medi-Cal, aphorism that’s repeated in political U.S.’s most populated city is New York Medicare, public health, Indian Health and financial analyses with significant City with a population of 8.4 million. Los Service, etc.); the emergence of dental value applied to national, state and Angeles County is the most populated therapists in many states; expansion of county economic growth or decline, county in the nation with 11.6 million with scope of practice for dental hygienists; and the gross domestic product (GDP), ironically the most millionaires, the highest demand for services growing > 1% often Social Security, health care (access, life expectancy at 82.1 years of age, the supported by affluent older adults.19,23–28 cost and health outcomes) and the largest number of square miles, the largest Another confounding issue within public’s health, education, welfare and and most diverse economy and the greatest the U.S. health care system is that access, well-being. These ways of knowing can population of homeless in the nation.22 cost and dental treatment outcomes vary

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and are not equivalent from state to state. they are sick rather than maintaining Permanente, Geisinger, the Mayo In many states, a significant number health and a sense of well-being.7–10 This Clinic, the Cleveland Clinic, of children and adults are not insured commentary offers evidence that suggests Providence St. Joseph Health, CVS and this results in limited or no access it is time for a different approach to Health, Aetna, UnitedHealth Group, to care.9–15 Currently, analyses of the U.S. health care, one that aligns more Amazon, Ascension, Intermountain composition and needs of our society in with the other industrial nations that Healthcare, NorthShore University the 21st century (as a nation and within emphasize health maintenance rather HealthSystem and numerous academic California) illuminate enormous changes than treatment of disease.33–38 Presently, health science centers around the in socioeconomics, education attainment a number of studies have recommended a nation, demonstrate that integration and the distribution of craniofacial-oral- national single-payer health care system of oral health with individualized dental diseases and disorders.19,21,23–28 for all Americans with elimination precision health care significantly Ironically, poor children and older people, of waste as well as implementation of contributes to, and benefits from, especially from historically underserved innovations that reduce costs, increase integration into primary care.23,52–58 The communities, present the largest disease access and produce greater value. various success outcomes at reduced burden cohorts.1,7–15,23–28 Americans of all costs are based in part on core principles ages living in poverty are increasing, with from interprofessional education and dependency on federal- and state-supported clinical practice competencies.23,52–58 9–15,19,21,23–28 programs also increasing. The Historically, U.S. health current rate of growth for U.S. health Transformative Medical, Dental and care is approaching 20% GDP, becoming care treats patients when Public Health Reforms unsustainable unless major public and they are sick rather than “As we begin the 21st century, we private changes are made.9–12 Older people maintaining health and a can be proud of the strides we have present a large number of chronic diseases made in improving the oral health of associated with xerostomia, untreated sense of well-being. the American people. … Yet as we tooth decay, periodontal disease and take stock of how far we have come edentulism.1,9–15,19,23–28 Medicare currently in enhancing oral health, this report does not include dental benefits, yet the makes it abundantly clear that there are management of oral chronic infection is Another recommendation is to profound and consequential disparities associated with significant cost savings engage individualized precision health in the oral health of our citizens.” for patients with Type 2 diabetes.31–33 care, often utilizing mobile platforms David Satcher MD, PhD, “Oral Providing a periodontal disease treatment and thousands of health apps with Health in America: A Report for patients with Type 2 diabetes will a focus on maintaining health and of the Surgeon General”1 produce a savings of more than $63.5 well-being as well as providing risk billion over the period 2016–2025.31–33 assessment, diagnostics, treatments Three Reports Catalyzed Chronic degenerative diseases, such as and predictable health outcomes Transformation of Health Care in the periodontal diseases, often cause tooth data.39–51 These “disruptive” changes Early 20th Century mobility and tooth loss and serve as a portal embrace personalized health care The Carnegie Foundation invited for microorganisms and their products that already is impacting cancer Abraham Flexner, an accomplished to enter the bloodstream and become diagnostics, therapeutics and predicted educator, to survey the quality of medical associated with diabetes and pulmonary outcomes, employing individual schools throughout North America and and cardiovascular diseases.1,13–15,23,27,29-33 diet and exercise selections, lifestyle provide suggestions for improvement. The rate of growth for health care choices, environment, genomics The Flexner Report transformed health spending from the U.S. economy increased and pharmacogenomics, resulting professional education by establishing from 13% GDP in 2000 to > 18% GDP in in outstanding health outcomes for the biomedical model as the gold 2019 without improving patient treatment millions of people.39–51 A number of standard for university-based medical outcomes.10–15,17–28,34–37 Historically, comprehensive profit and nonprofit education, biomedical and behavioral U.S. health care treats patients when health care systems, such as Kaiser research and clinical training.2,3

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William Henry Welch and Wickliffe medical students.5,6,15,22,32,42–47 Dr. Gies’ Actions for the New Century Rose submitted a report to the Rockefeller recommendations continue to inspire “Oral Health in America: A Report Foundation that became the template for major improvements in our nation’s of the Surgeon General” analyzed oral public health professional education.4 This oral health, resulting in dentistry being health over the life span, the prevalence report established a new model of scientific a learned profession within North of oral health disparities, research education and training that integrated American universities and beyond. opportunities and recommendations for the laboratory mindset within the These three reports reflect the time improving health outcomes and called methods of public health administration and conditions of their era, focusing on for actions to improve the craniofacial- and epidemiologic fieldwork.4 The new identification of pathogens and control of oral-dental health of all Americans.1 model addressed issues of significance as acute infectious diseases in the emerging Dr. Satcher noted in his preface that it questioned the distinction between young American population. These “the mouth reflects general health and “maintenance of health” and “cure of reports were translated into action. well-being.”1 With that in mind, he disease.” It catalyzed the emergence of Each report asserted that societal health requested our nation’s health professions the U.S. Public Health Service, including needs must drive science, which informs to work together to decrease health the dental research section headed by disparities while improving health and H. Trendley Dean, DDS, the first director well-being. Private and public delivery of the National Institute for Dental systems were asked to develop strategies 5 Research in 1948 at the NIH. Dr. Dean’s The new model addressed to reduce oral health inequity. unit demonstrated from clinical trials Twenty years later, oral health in that fluoridation of public drinking water issues of significance as it America has continued to improve reduced tooth decay in schoolchildren questioned the distinction for the majority of the population, who had consumed fluoridated water between “maintenance of yet has not improved for almost one- since birth.5 This remains highly relevant third of the population due to ever- today as it instructs that the future must health” and “cure of disease.” increasing socioeconomic and health emphasize scientific evidence that impacts disparities between the privileged and the prevention of diseases and disorders, less privileged.1,9,10,13–15,23 Efforts by health maintenance and well-being. public-private coalitions, including Today and in the future, this education, research, patient care and CDA, HRSA, California HealthCare approach is significant to the prevention strategies. These reports Foundation, California Endowment, public’s health and well-being. significantly informed improving oral National Research Council and National In 1926, William Gies, PhD, a health around the world.1,5,6,13–15,23,33-35,43-49 Academy of Medicine, continue to professor of biochemistry and founder Key events followed including the Great address health literacy, risk assessment of the Columbia University College of Depression, World War II, the Marshall and health promotion within vulnerable Dental Medicine, published a report, Plan, the GI Bill and the creation of and underserved populations. Their efforts “Dental Education in the United the NIH including three institutes highlighted the major issues and produced States and Canada,” that “disrupted” (heart, cancer and dental) in 1948.1,5,23,48 many significant recommendations, dental education, research and clinical The second half of the 20th century including “Improving Access to Oral care.5,6 Dr. Gies argued that to serve heralded innovations in economics, Health Care for Vulnerable and the oral health needs, dentistry should science, technology, dentistry and oral Underserved Populations,”13 “Advancing be considered a specialty of medicine health care, university-level education, Oral Health in America,”14 “Oral Health and that dental schools should be increased life expectancy, progress in in America – Advances and Challenges,”23 based in research-intensive universities national and state infrastructure as “Phased Strategies for Reducing Barriers with full-time faculties dedicated to demonstrated within California and to Dental Care in California”57 developed teaching and research. His report rapid urbanization. However, inequities by CDA and the California State Oral recommended that dental students remained intact and intractable for many Health Plan by State Dental Director should gain the same foundation in the millions of Americans living at or below Jay Kumar, the Los Angeles County study of basic and clinical sciences as do twice the poverty line.1,7–10,13–15,18,23 Community Oral Health Improvement

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Plan (2019–2023)58 and the “Healthy improving health, well-being and equity oral-dental diseases and disorders (e.g., People 2030 Framework.”59 Additional across sectors need to be determined health outcomes for infant morbidity approaches to improve management of based on historic and demographic and mortality, tooth decay, gingivitis and chronic oral infection are drawn from trends that can lead to solutions for our periodontitis, oral cancers, head and neck the continued efforts to integrate oral nation’s and California’s health policies. trauma, tooth loss and edentulism, chronic health into primary health care within California’s socioeconomic health myofascial pain and life expectancy). HRSA’s federally qualified community needs indicate that demographic changes Tooth loss results from dental health centers and to advance health in our national, state and county caries and periodontal diseases, patient literacy programs.13–15,21,23,29–32,36–39,60,61 workforce, contributions to Social and dentist attitudes and behaviors, Security, Medi-Cal (Medicaid), CHIP and availability, accessibility of dental care, A Focus on the ‘Silver Tsunami’ Medicare benefits are in jeopardy.17–22,28,57,58 cost of care, prevailing standard of care, Is Urgently Needed California workers rank 45th out of 50 the oral microbial environment, diet Despite advances in health care states in the share of workers with access and genetics.1,7–15,23,28–33,49 Dental caries for the vast majority of the national to a retirement plan.17–22 The average and periodontal diseases are the primary and California population, all is not reasons for tooth extraction for people well.7–15,23–38 Glaring inequities in health of all ages. These conditions are largely and well-being persist both within and preventable through health promotion, between states and in other industrial Oral health status is often literacy, nutrition/diet choices, beverage countries, underscoring a collective failure choices, personal and professional to equitably share significant scientific considered the canary in the oral hygiene, community water discoveries and to implement health care coal mine, as a surrogate for fluoridation and dental sealants.1,23,56–61 advances for all citizens. At the same time, socioeconomic and In California, 1 in 2 adults present with challenges including new and emerging periodontal diseases. Further, 1 in 5 bacterial and viral diseases, antimicrobial sociobehavioral status. people are edentulous, which is more resistance and environmental and common among people aged 75 or older behavioral risks, often resulting from (26.7%).1,23–32,44–49,56–61 Edentulism is government deregulations, are becoming more prevalent among people with less increasingly apparent at a time of rapid California worker who turns 65 will have than a high school education (42.1%), change, threatening overall health and total assets of approximately $50,000 and those without dental insurance (27.0%), food security. Federal, state and county receive an average Social Security benefit non-Hispanic blacks (31.9%), Hispanics health systems, struggling to keep up with of $1,461 per month. This will not meet (18.2%) and among current everyday an aging and socioeconomically diverse basic mental, vision, hearing, dental and cigarette smokers (41.3%).24–28 society, are becoming more complex and medical needs. Today, 7.5 million Golden Looking to a future that reduces costly, placing additional demands on State workers, or 61% of the private the burden of disease will require a the capacity of health care workers and sector workers aged 25 to 64, have no transformation of efforts that emphasizes funding required for health care.9–15,23,27–38 access to a pension or 401(k) retirement risk assessment, prevention and wellness The aphorism “demography is plan that deducts savings in reserve from strategies rather than procedure-based, destiny” holds that population statistics their paychecks to enable postretirement volume-based, fee-for-service surgical and trends can predict and anticipate health needs to be addressed.17–22 treatment interventions. In many other a changing future — that of a nation, Oral health status is often considered industrial nations, single-payer health state or region or world. Demographic the canary in the coal mine, as a surrogate care funding (i.e., public or private) trends drawn from health care outcomes for socioeconomic and sociobehavioral emphasizes prevention (90%) more than are continuing to reflect changes that status.71,5–10,13–15,22,23,28,52–61 The most treatment expenses (10%) and produce pit need against resources and values significant determinant for relative much better health outcomes at a much and thus remain at the forefront of well-being is poverty.7–12 Currently, lower cost.30–38,59–61 Oral health promotion, the political landscape.7–15,17–23,34–37,57–61 30% of Californians live in or near risk assessment and prevention strategies Anticipating the future, measures for poverty, presenting 80% of craniofacial- also impact general health, well-being

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and many other inflammatory diseases health care. It also focuses on the whole Today, health advocates focus on across the life span.30–33,59–61 In 2019, individual and family rather than on the a systems-based strategy to improve there were 47 million people over the age illness of a specific organ, system or disease. population and individual health of 65 in the U.S., and this will double According to HRSA, there are outcomes and transition from fee for by 2050 according to demographers. several key roles that primary health care service to health outcomes to better Using an economic health cost savings practitioners fulfill in their pursuit of this control of health spending.9,52–55 Scientific, argument illustrated that by providing goal.15 These include providing a wider educational, technological and behavioral oral health preventions in the Medicare coverage of health care; preventing social innovations provide evidence that support population, periodontal disease treatment disparities in health care; organizing the benefits from personalized oral risk for diabetic patients will save $63.5 health services to meet health needs; assessment, diagnostics using genomics, billion over the period 2016–2025.31 advancing the concept that health and treatments and therapeutics, predictable health care are part of public policy in health outcomes and prevention.50,51 Why Integration of Oral Health Within every sphere; training leaders in effective Presently, a number of descriptions Primary Health Care? health care; and increasing the level for primary health care include scope of The Gies Report emphasized that care, access and integration of health care science informs clinical health care professions (dentists, physicians, nurses, and well-being for individuals and pharmacists, social services and allied populations across the life span.5,6 The Gies Report health professionals), continuous and Integrating mental, vision, hearing emphasized that science interprofessional teamwork that addresses and oral health care into primary informs clinical health needs of patients and their families and care, as suggested and now being community.15,52–56 To date, there is no U.S. implemented in a few settings, provides care and well-being for universal system of health care and no a “personalized” and “bundled” approach individuals and populations guaranteed access to basic services, and to individualized and comprehensive across the life span. yet, 47 million of the total population patient and population primary health are without health insurance.9 In 2019, care.43–49 Examples of integration are now 1 in 12 people gained health care from established within government, nonprofit federally qualified health centers and were organizations and private industry.15,52–56 of participation by all stakeholders supported by Medicaid or CHIP programs. Primary health care is the initial point in health, whether patients, dentists, This federal and state partnership provides of contact between a patient and the health nurses, pharmacists, physicians, public health care for 20% of the U.S. population care system that provides individuals with health workers, social services and or 72.4 million Americans. In 2019, 37.2 access to the information and resources those in the allied health services. million Californians (approximately they need for optimal health outcomes.15 These professionals and their staffs are one-third of the entire population) were Primary health care professionals typically responsible for the ongoing health of their enrolled in Medi-Cal or CHIP programs work with many different patients and patients by evaluating risk, introducing including 40% of all children, 50% of have broad knowledge about various the concepts of prevention and wellness, people with disabilities, 1 million seniors, physical, psychological and social ailments early diagnosis and managing and 4 million adults, 50% of all births and that may affect their patient and the treating common health conditions. 58% of long-term care. The cost was patients’ families. The recent advent of Important aspects are providing lifestyle $82 billion for that year.9–12,19,21,26,28,38 interprofessional health education and coaching emphasizing diet and exercise clinical practice provides significant and making referrals to specialists as Prospects for Digitized and Precision benefits for primary care including the needed. Comprehensive primary health Health Care integration of oral health with primary care increases access, reduces cost and In the mid-20th century, Joseph care practice.15,21,23,53–56 The main purpose improves health outcomes of patients, Schumpeter, a noted Austrian economist, is to improve the health of the public allowing them to be more productive popularized the term “creative by providing easy access to affordable, and efficient while reducing the financial destruction” to denote transformation comprehensive, quality and personalized burden on the health care system.11–12,15,52–56 that accomplished radical innovation

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vis-à-vis the digital revolution. Essentially, national income and output for a given Considerations for the Future (Looking the major economic forces have been country’s economy. Income inequality Toward 2050) radically transformed by digital technology is the most significant socioeconomic The challenge with health care regarding how we navigate our lives: determinant for health including oral reform has always been that incentives communicate, navigate, educate, curate health. The GDP was $19,485.39 are misaligned: Policymakers, providers, information and images, music, books, trillion in 2017 and represented 31.43% payers and patients all want different things. dictionaries, translation, video/films, of the world’s economy. Projections The task is to define goals, pathways to TV and how we purchase automobiles, suggest that U.S. budget debt will pursue and benchmarks to measure and maintain electronic health records and become 144% of the GDP by 2049.9,11 evaluate progress toward the goal. This create health applications for mobile Health care spending is the highest requires systems for sharing data, essential platforms that align with the practice of per capita for people aged 65 and to improved health and well-being. With dentistry and medicine (e.g., imaging, older for musculoskeletal diseases and bioinformatics and health care big data, it impressions, dental orthopedics and disorders, neurodegenerative diseases and becomes easier to move into a system of CAD-CAM). Digital innovations have cardiovascular diseases.9,28,29,34 It also is the “bundled” payments for health outcomes also resulted in the creative destruction or — that is in contrast to traditional ways disruption of many industries and services. of organizing health care, whereby payers But for the most part, health and health reimburse providers either per service or care to date have been largely unaffected, The near future is already per patient. Proof of principle is found insulated and almost compartmentalized impacted by digitized health in Kaiser Permanente, Geisinger, the from the digital revolution. Or has it? care, curated online content, Mayo Clinic and the Cleveland Clinic. Artificial intelligence and machine One common feature among these learning have already impacted precision e-patients, tech-savvy dentists institutions is that health professionals are health care, demonstrated in radiology and physicians and almost no compensated based on health outcomes, and imaging, pathology and dermatology, barriers to collaboration. not on numbers of procedures performed brain and radiology, orthopedic diseases, and fee-for-service compensation models. orthodontics and 3D printing of organs An implementation strategy is needed for biomedical applications.50 This to provide the content and impetus for unprecedented super-convergence of No. 1 cause for bankruptcy in America. national and state thought leaders and societal needs or desires, in the form of For example, as the population ages, more stakeholders, including patient and family smartphones, bandwidth, connectivity, people will be diagnosed with multiple health advocates, to utilize the demographic unlimited computing power via cloud chronic diseases including dementia. and sociobehavioral evidence, thereby server farms, genomics, biosensors and Trends predict that 1 in 6 women and 1 addressing societal needs that consider social networking, has rapidly entered in 11 men over age 65 will likely become the future as an essential component health care.40,50 The near future is already people with Alzheimer’s disease. In of population health and well-being. impacted by digitized health care, curated the general population, cardiovascular, Analysis of craniofacial-oral-dental online content, e-patients, tech-savvy cerebrovascular, metabolism, cancer, diseases and disorders has demonstrated dentists and physicians and almost musculoskeletal, neurodegenerative that cognitive functions coupled with no barriers to collaboration.40–51,60 and mental health comprise 60% the sensory input of vision, hearing, of current health spending.9,11,12,34–38 smell, taste and touch are profoundly Federal Spending: Looking to the Future It is anticipated that the future will important and underscore the truism that The federal budget for 2019 present increasing numbers of often “the mouth is connected to the rest of contained an appropriation for health unexpected medical emergencies, the body” as highlighted in a number of care spending of $3.38 trillion, yet antibiotic resistance, substance abuse studies beyond the Gies Report.1,23,34–39,57–61 end-of-year accounting now indicates and pain management challenges that The demographic factors presented actual health spending is $4.2 trillion could be addressed by interprofessional require action plans to achieve full access with oral/dental spending being health teams with potentially to affordable, quality health care across 5%.9,11,12,17–23,28,34,35 The GDP measures the better outcomes at lower costs. the life span. What transformations

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are necessary in education and clinical integration among dentistry and other the problems of the current U.S. health practice to fulfill these plans in theory and health professions may accelerate the care system. Politically, over the next practice, providing access to all people, eradication of tooth decay in children as well few decades, they will undoubtedly be reducing costs and increasing quality health as other craniofacial-oral-dental diseases. distributed throughout the American outcomes? Will the integration of dentistry, economy and become public policy medicine and nursing, with increased Integration of Oral Health Into Primary experts, leaders in the various health utilization of culturally appropriate Care by 2050? professions and associated universities behavioral and social services, dental Comparison of the U.S. health and industries. Based on numbers, hygienists and community-based health care system with nine other industrial talents and diversity, these generations administrators, be achieved by 2050? nations in 2019 indicated that the may truly shape the future of dentistry Of all of the extraordinary clinical average health spending of those nine and health care by 2050. They may achievements of the past century, nations is 9% GDP compared to 18.5% support public and private investments perhaps none can match prevention GDP for the U.S.9,33,34 Further analyses in health professional education (reduce from fluoridated drinking water, dental showed that health spending in the nine or eliminate health professions’ student sealants and oral hygiene, the prosthetic debt), biomedical and behavioral research, achievements of dental implants and digital platforms and health apps for the biomimetic achievements from glass eHealth, innovations in therapeutics to ionomers and porcelain. The confluence The single-payer model in address inflammatory diseases such as of the digital and biological revolutions other industrial nations has periodontitis and management of chronic produced digital imaging, CAD-CAM, 100% access, much lower pain and foster and sustain optimal electronic patient records, deciphering of trust, communication, cooperation and the human genome, the now-affordable costs (e.g., reduce drug collaborations among all stakeholders methodology for utilizing individual costs) and significantly associated with health and well-being and human and microbial genomics (and better health outcomes. professional health care organizations. epigenomics) for clinical applications, When reviewed in 2050, results advances in regenerative dentistry and from many pilot studies in California medicine, gene editing to cure diseases and and other states will use the criteria of utilization of saliva as a diagnostic fluid. nations was significantly different than access, cost and health outcomes. Based Genomics and epigenomics also inform U.S. spending — U.S. health spending on current comparisons, the U.S. GDP drug therapies (pharmacogenomics) so illustrated 90% for treatment whereas should decrease from 18.3% GDP to 10% that the precise therapy addresses the the other nine nations spent 90% on GDP as learned by comparison with other precise diagnosis, with a predictable prevention, health and well-being. industrial nations.33,34 U.S. access to health desired health outcome.40–51 We are One scenario that could be achieved care must increase from 70% to 100% to now on the verge of assessing our own is overall health care cost containment become equivalent with the other major genetic makeup and the promise of novel (e.g., reduce waste and bureaucracy) industrial nations. An integrated health approaches to health that will undoubtedly by using a single-payer model. Those care delivery system that increases access, herald a new stage in personalized health nine other nations use a single-payer reduces costs, significantly increases health care.40–51 Implementation of genomics and model and provide 100% access to outcomes and emphasizes health and well- pharmacogenomics into interprofessional all of their citizens, while the U.S. being can be realized by 2050. The various health professional education and covers 70% of its population.9,33,34 The published studies with recommendations clinical practices is imperative. single-payer model in other industrial now serve as blueprints for collaborative Meanwhile, to reduce or eradicate nations has 100% access, much lower efforts toward integration of oral health a disease or disorder, what metrics for costs (e.g., reduce drug costs) and into primary care, pediatrics and family craniofacial-oral-dental health outcomes significantly better health outcomes. medicine health care, including social should be established? Previously, polio, Another promising factor could services, nursing, dental hygiene and smallpox and diphtheria eradication reflect the millennial and Generation X pharmacy. Trust, collaboration and meant 100% eradication. The thoughtful cohort entering and engaging with solving cooperation among dentistry, medicine,

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nursing (e.g., nurse practitioner-dentist stakeholders will continue to address ■ Effects of addiction and mental model for primary care), public health, health care, especially upstream services health disorders on oral health. pharmacy and social services must that produce improved housing, clean ■ Oral health integration, become optimal and sustainable. water and air, transportation, prenatal workforce and practice. Investments for innovations care, preschool programs, K–12 education, ■ Emerging technologies in health professional education affordable postsecondary education (e.g., and promising science to and scope of practice need to be trade schools and colleges) and economic, transform oral health. initiated, analyzed and used to enable social and wellness opportunities.11–12 In addition, the “Healthy People transformations that increase access, Projected innovations offer opportunities 2030 Framework” is being released reduce costs and increase quality health to improve access, reduce costs and in 2020.59 outcomes, especially for federal- and advance risk assessment and diagnostics These contributions and the state-supported health care for eligible currently being pursued by Google, Los Angeles County Department of populations of California. The shortages Apple and a coalition of J.P. Morgan, Public Health Oral Health Program of dentists and physicians to provide Amazon and Berkshire Hathaway. Community Oral Health Improvement primary health care must be eliminated Plan (2019–2023)58 support the by removing obstacles associated with goals of staying healthy as well as student debt upon graduation. The interprofessional education and clinic current California state student loan When reviewed in 2050, health care with risk assessment and forgiveness program for dentists and results from many pilot diagnostic tools to enable dentists, physicians, started in 2019, must be studies in California and nurses and physicians to stratify applauded. In this example, funding patients and provide personalized and loan forgiveness is based on dentist other states will use the precision health care. The anticipated and physician commitment to provide criteria of access, cost success from these blueprints requires prevention, risk assessment and and health outcomes. a stable and robust democracy. precision health care for the historically History and demography indicate underserved and vulnerable populations. that building and sustaining a My experiences suggest that health democracy was, remains and will be care professionals will increasingly History, Demography and a Nation no easy task. The last half of the 20th continue interprofessional education of Health and Wellness century illustrates that stabilizing a and clinical practice and include social The Gies Report emphasized that robust democracy requires health, services and health navigators on the mouth is connected to the rest of education, cultural, social and economic their teams, especially without being the body and recommended that the benefits that enable all or most people burdened by student loan debt. From future embrace health literacy and health to dream and hope for a better tomorrow another perspective, prenatal, early promotion, risk assessment, diagnostics, for themselves, their children and child education and K–12 education treatments and therapeutics.1,5,6 One grandchildren. Tolerance, empathy, must provide world-class primary and hundred years later, a second surgeon health, education and prosperity were secondary education that fosters critical general’s report, “Oral Health in the “secret sauce” that nourished thinking, math and science, humanities, America — Advances and Challenges,” democracy in the U.S., especially the arts, health literacy and dedication will be released in 2020.23 This report in California, following World War to lifelong learning core competencies. will emphasize six major topics: II. Democracy reigned triumphant The transformations within health ■ Oral health across the life span for most, but not everyone enjoyed care during the previous 150 years have — children and adolescents. the benefits. Futurists assumed that produced remarkable improvements ■ Oral health across the life span democratic nations were immutable. in health and well-being for the vast — adults and older adults. Politically, many assumed that the majority of Americans and will continue ■ Effects of oral health on the future would not be different from well into the 21st century. Federal, state, community, overall well- the past. However, we realize that CDA leadership and members and other being and economy. freedoms and democracy are now in

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danger in the U.S. and Western Europe. and underserved populations. This worldpopulationreview.com/countries. Assessed Jan. 8, Health, education and economic continues today. Looking to the future, 2020. 17. Lewis K, Burd-Sharps S. The Measure of America inequality have become profound how can each of us better understand 2010–2011. New York: New York University Press; 2012. insults to the human condition. and articulate our enlightened self- 18. Lewis K, Burd-Sharps S. A Portrait of California The future is up to us, our personal interest and those we serve while 2014–2015. New York: Social Science Research; 2015. 19. California Heath Care Foundation. Medi-Cal facts humanism, activism and education. confronting the challenges and and figures: Crucial coverage for low-income Californians. Who will be the dominant opportunities of health care that will www.chcf.org/publication/2019-medi-cal-facts-figures- generations that become the future shape dentistry in the 21st century? crucial-coverage. 20. World Population Review. California population 2019 citizens and participants of our country? Demography is our destiny. We (demographics, maps, graphs). worldpopulationreview. Presently, millennials (i.e., 73 million ignore it at our own peril. n com/states/california-population. aged 23 to 38) are now the largest 21. Institute for Healthcare Improvements. 100 Million Healthier Lives, being used in California to living adult generation and outnumber references evaluate population health. www.100mlives.org and baby boomers aged 55 to 73. Following 1. U.S. Department of Health and Human Services. Oral www.100mlives.org/wp-content/uploads/2019/06/Full- millennials are Generation Z members Health in America: A Report of the Surgeon General. Report-053019.pdf. Accessed July 2019. Rockville, Md.: USDHHS, NIDCR, NIH; 2000. 22. Lewis K, Burd-Sharps S. A Portrait of Los Angeles now entering adulthood (aged 7 to 2. Flexner A. Medical Education in the United States County 2017–2018. New York: Measure of America 22). Both of these groups are on track and Canada: A Report to the Carnegie Foundation for Series; Nov. 29, 2017. to become the best educated and the Advancement of Teaching. New York: The Carnegie 23. U.S. Department of Health and Human Services. Oral Foundation for the Advancement of Teaching; 1910. Health in America — Advances and Challenges: A Report most diverse generations in American 3. Duffy TP. The Flexner Report — 100 years later. Yale J of the Surgeon General Oral Health in America: Rockville, history. Their education provides Biol Med 2011, 84(3):269–276. Md.: USDHHS, NIDCR, NIH; 2020. strategies to gain knowledge, skills and 4. Thomas KK. Cultivating hygiene as a science: The Welch- 24. CDC. QuickStats: Prevalence of edentulism in adults Rose Report’s influence at Johns Hopkins and beyond. Am aged > 65 years, by age group and race/Hispanic origin influence behavior. Success means a J Epidemiol 2016 Mar 1;183(5):345–54. doi: 10.1093/ — National Health and Nutrition Examination Survey, well-educated, healthy and motivated aje/kwv331. Epub 2016 Feb 17. 2011–2014. www.cdc.gov/mmwr/volumes/66/wr/ society that is sensitive to rapid and 5. Harris RR. Dental science in a new age: A history of mm6603a12.htm. Accessed May 2019. the National Institute of Dental Research. Rockville, Md.: 25. CDC. Total tooth loss among persons aged greater punctuated change, lifelong learning Montrose Press; 1989. than or equal to 65 years — selected states. www.cdc.gov/ and concerns for one another that 6. Gies WJ. Dental education in the United States mmwr/preview/mmwrhtml/00056723.htm. Accessed June translate into equity in education, and Canada: A report to the Carnegie Foundation for 2019. the Advancement of Teaching. New York: Carnegie 26. CMS. CMS Office of the Actuary releases 2017–2026 health care, justice and social services. Foundation; 1926. projections of national health expenditures. www.cms.gov/ In his book “The People vs. 7. Edelman P. So Rich, So Poor: Why It’s So Hard to End newsroom/press-releases/cms-office-actuary-releases- Democracy: Why Our Freedom Is Poverty in America. New York: The New Press; 2013. 2017-2026-projections-national-health-expenditures. 8. Sacks JD. The End of Poverty. New York: Penguin Group; Accessed July 12, 2019. in Danger and How To Save It,” 2005. 27. Centers for Disease Control and Prevention. National Yascha Mounk demonstrates that 9. Reinhardt UE. Priced out: The economic and ethical Center for Health Statistics, oral and dental health. www. two core components of democracy costs of American health care. Princeton N.J.: Princeton cdc.gov/nchs/fastats/dental.htm. Accessed July 2019. University Press; 2019. 28. Dentagraphics. California dental demographics. — individual rights and the popular 10. Moeller J, Starkel R, Quinonez C, Vujicic M. Income dentagraphics.com/california-infographic. Accessed May will — are increasingly at war with inequality in the United States and its potential effect on 2019. each other.62 We learn from the oral health. J Am Dent Assoc 2017 Jun;148(6):361–368. 29. Kramarow EA. Dental care among adults aged 65 doi: 10.1016/j.adaj.2017.02.052. Epub 2017 Apr 18. and over, 2017. www.cdc.gov/nchs/products/databriefs/ humanities that enlightened self- 11. Kronenfeld JJ, Kronenfeld M. Healthcare Reform in db337.htm. interest is a philosophy in ethics, America. 2nd ed. Santa Barbara, Calif: ABC-CLIO; 2015. 30. Coll PP, Lindsay A, Meng J, Gopalakrishna A, which states that people who act to 12. Obama B. United States health care reform: Progress to Raghavendra S, Bysani P, O’Brien D. The prevention of data and next steps. JAMA 2016 Aug 2;316(5):525-32. infections in older adults: Oral health. J Am Geriatr Soc further the interests of others (or the doi: 10.1001/jama.2016.9797. 2019 Sep 3. doi: 10.1111/jgs.16154. [Epub ahead of interests of the group or groups to 13. Institute of Medicine, National Research Council. print]. which they belong) ultimately serve Improving Access to Oral Health Care for Vulnerable and 31. Slavkin HC. A national imperative: Oral health services Underserved Populations. Washington, D.C.: The National in Medicare. J Am Dent Assoc 2017 May;148(5):281– their own self-interest. Celebration Academies Press; 2011. 283. doi: 10.1016/j.adaj.2017.03.004. of the 150-year anniversary of 14. Institute of Medicine. Advancing Oral Health in America. 32. Diaz PI, Valm AM. Microbial interactions CDA illustrates many examples of Washington, D.C.: The National Academies Press; 2011. in oral communities mediate emergent biofilm 15. Health Resources and Services. Integration of Oral properties. J Dent Res 2020 99(1):18–25. doi: doi. members meeting the health needs Health and Primary Care Practice. Rockville, Md.: U.S. org/10.1177/0022034519880157. of society, especially prevention and Department of Health and Human Services; February 2014. 33. Schwendicke F, Giannobile WV. Research treatment services for vulnerable 16. Top Population by Country 2020. for prevention of oral/dental diseases: How far

154 MARCH 2 0 2 0 CDA JOURNAL, VOL 48, Nº3

have we come? J Dent Res 2020 99(1):5–7. doi: 48. Slavkin HC. The impact of research on the future of 10.1177/0022034519889054. dental education: How research and innovation shape 34. Kamal R, Cox C, McDermott D, Ramirez M, Sawyer dental education and the dental profession. J Dent B. U.S. health system is performing better, though still Educ 2017 Sep;81(9):eS108–eS127. doi: 10.21815/ lagging behind other countries. www.healthsystemtracker. JDE.017.041. org/brief/u-s-health-system-is-performing-better-though-still- 49. Divaris K. The era of the genome and dental lagging-behind-other-countries. Accessed May, June 2019. medicine. J Dent Res 2019 Aug;98(9):949–955. doi: 35. Key facts about spending by disease in OECD countries 10.1177/0022034519845674. (Australia, Canada, the Czech Republic, England, Finland, 50. Topol EJ. Deep Medicine: How Artificial Intelligence France, Germany, Hungary, Israel, Japan, Korea, the Can Make Healthcare Human Again. New York: Basic Netherlands, Slovenia, Sweden, Switzerland and the United Books; 2019. States). stats.oecd.org. Accessed June 2019. 51. Hunter DJ, Longo DL. The precision of evidence 36. Frakt AB. Making health care more productive. needed to practice “precision medicine.” N Engl J Med JAMA 2019;322(23):2274–2275. doi:10.1001/ 2019 Jun 20;380(25):2472–2474. doi: 10.1056/ jama.2019.19695. NEJMe1906088. Epub 2019 Jun 3. 37. Levine DM, Landon BE, Linder JA. Quality and 52. Donoff B, McDonough JE, Riedy CA. Integrating experience of outpatient care in the United States oral and general health care. N Engl J Med 2014 Dec for adults with or without primary care. JAMA Intern 11;371(24):2247–9. doi: 10.1056/NEJMp1410824. Med 2019 Mar 1;179(3):363–372. doi: 10.1001/ 53. Spielman AI, Fulmer T, Eisenberg ES, Alfano MC. jamainternmed.2018.6716. Dentistry, nursing and medicine: A comparison of core 38. Glickman A, DiMagno SSP, Emanuel EJ. Next competencies. J Dent Educ 2005 Nov;69(11)1257–1271. phase in effective cost control in health care. JAMA 54. Silk H, King R, Bennett IM, Chessman AW, Savageau 2019 Mar 26;321(12):1151–1152. doi: 10.1001/ JA. Assessing oral health curriculum in U.S. family medicine jama.2019.1608. residency programs: A CERA study. Fam Med 2012 Nov– 39. National Research Council. Toward precision medicine: Dec;44(10):719–722. Building a knowledge network for biomedical research and 55. Dwiel K, Hesketh MA, Alpert JL, Cellini J, Goodell a new taxonomy of disease. Washington, D.C.: National K, Phillips RS, Sullivan EE. The impact of oral health Academies Press; 2011. www.nap.edu/catalog/13284/ training for primary care physicians: A systematic review. toward-precision-medicine-building-a-knowledge-network- Fam Med 2019 Mar;51(3):251–261. doi: 10.22454/ for-biomedical-research.2011. FamMed.2019.232634. 40. Topol EJ. The creative destruction of medicine: How the 56. Nguyen, DH, Martin, JT. Common Dental Infections digital revolution will create better health care. New York: in the Primary Care Setting. Am Fam Physician 2008 Mar Basic Books; 2012. 15;77(6):797–802. 41. Slavkin HC. From phenotype to genotype: Enter 57. California Dental Association. Phased strategies genomics and transformation of primary health care around for reducing the barriers to dental care. www.cda.org/ the world. J Dent Res 2014 Jul;93(7 Suppl):3S–6S. doi: advocacy/access-to-care. Accessed May 2019. 10.1177/0022034514533569. Epub 2014 May 5. 58. County of Los Angeles Public Health. Community Oral 42. Collins FS, Varmus H. Perspective: A new initiative Health Improvement Plan (2019–2023). publichealth. on precision medicine. N Engl J Med 2015 Feb lacounty.gov/ohp. Accessed August 2019. 26;372(9):793–5. doi: 10.1056/NEJMp1500523. Epub 59. Office of Disease Prevention and Health Promotion. 2015 Jan 30. Healthy People 2030 framework. Dental health/Oral 43. Slavkin HC. Personalized oral medicine and the health objectives have been part of this initiative since contemporary health care environment. In: Polverini PJ, ed. 1979. www.healthypeople.gov/2020/About-Healthy- Personalized Oral Health Care: From Concept Design to People/Development-Healthy-People-2030/Framework. Clinical Practice. Zurich: Springer International Publishing; Accessed July 2019. 2015:1–18. 60. National Academies of Sciences, Engineering and 44. Wright JT. Genomics of dental caries and caries risk Medicine. Relevance of health literacy to precision assessment. In: Polverini PJ, ed. Personalized Oral Health medicine: Workshop in brief. Washington, D.C.: National Care: From Concept Design to Clinical Practice. Zurich: Academies Press; 2016. Springer International Publishing; 2015:87–98. 61. Office of Disease Prevention and Health Promotion. 45. Garaicoa-Pazmino C, Decker AM, Polverini PJ. National action plan to improve health literacy. health.gov/ Personalized medicine approaches to the prevention, communication/initiatives/health-literacy-action-plan.asp. diagnosis, and treatment of chronic periodontitis. In: Accessed June 2019. Polverini PJ, ed. Personalized Oral Health Care: From 62. Mounk Y. The People vs. Democracy. Boston: Harvard Concept Design to Clinical Practice. Zurich: Springer University Press; 2018. International Publishing; 2015:99–112. 46. Slavkin HC. Embracing Precision Dentistry and the author, Harold C. Slavkin, DDS, can be reached at Medicine. Decisions in Dentistry 2017 Mar;3(3):12–17. [email protected]. 47. Slavkin HC. From high definition precision healthcare to precision public oral health: Opportunities and challenges. J Public Health Dent 2018 Dec 5. doi: 10.1111/ jphd.12296. [Epub ahead of print].

MARCH 2 0 2 0 155 Specialists in the Sale and Appraisal of Dental Practices Practices Serving California Dentists since 1966 How much is your practice worth?? Wanted Let’s make 2020 Great!

NORTHERN CALIFORNIA SOUTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6174 HUMBOLDT COUNTY’S UNIVERSITY COMMUNITY – 4003 PEDO CHINESE / HISPANIC 3,000+ Charts. Move to your office. ARCATA Special opportunity in special area to raise one’s children and Full Price $150,000. enjoy quality of life benefits as they should be enjoyed. Best location, great 4006 ALTA LOMA High identity Center. Absentee. Grossing $700,000. foundation and dedicated Team. Seller chooses to work 3-day week. 2019 5-ops, 3 equipped. collected $350,000+. Beautiful Victorian building available as optional 4009 IRVINE Lady DDS Grossing $1 Million. 5-ops. Partnership. purchase. Practice screams to be full-time. 4011 DIAMOND BAR Dream Million Dollar location. 5-ops. Several 6173 SAN FRANCISCO – “OUT-OF-NETWORK 2019 collected restaurants bring in droves of customers on daily basis, FP $150,000. $1,315,000. 6-ops. 8-days of Hygiene. 1,500+ active patients. Contract 4013 ORANGE COUNTY BEACH CITY Grossed $70,000 last month. with specialists to perform referred work in-house and take to next level. 4-ops with room for more. Full Price $800,000. 6172 SAN FRANCISCO’S EAST BAY - “OUT-OF-NETWORK” 4015 HEMET Easy way to Gross $500,000. Grossing $240,000 on 1-day per Shall be available shortly. 2019 collected $850,000. 4-days of Hygiene. week. Full Price $110,000. Requires skilled, easy-temperament and great communicator as Successor. 4019 $1 MILLION NET PROFIT Opportunity of a lifetime. 6171 SANTA ROSA Great DNA here for this long-established practice. BAKERSFIELD AREA Grossing $40,000/month on 2 day week. Strong patient foundation per 6+ day Hygiene Schedule. Consistent $1+ BURBANK -NORTH HOLLYWOOD HMO Grossing $2.2 Million. High Tech. 5 ops. Million in Collections each of last 5-years. Great Team. 4-operatories. INGLEWOOD Established since 1970. Includes real estate. 6170 MANTECA / RIPON AREA Excellent platform for the ambitious. IRVINE Lady DDS grossing $1 Million. Will share office. 2019’s revenues totaled $850,000+. 5-days of Hygiene. Practice refers LA HABRA Huge Shopping Center. Well maintained. PT Seller will stay. endo, most OS and implant placements. Extensive patient base. Successor LADERA RANCH 4-ops. Grossing $500,000. High Growth area. should contract with specialists to perform work being referred. Office is LAGUNA WOODS Grossed $800,000 during Renovation. Renovation done. perfect for making this a full-service practice. Should gross $1 Million. 6169 VACAVILLE Long established Delta PPO practice. 5-days of MIRACLE MILE NEAR FAIRFAX Beautiful corner suite with Wilshire hygiene. 2019 trending $700,000+ with Available Profits of $285,000. view. 3-ops recently remodeled. Great north side location. Full Price $300,000. ORANGE Grossing $1.2 Million. State-of-art beautiful! 6168 SACRAMENTO’S CAMPUS COMMONS “Bread & butter” ORANGE COUNTY High profile shopping center. Grossing $1.5 Million. Delta PPO practice averages $480,000 in collections per year. Well liked ORANGE COUNTY Near Chapman / Tustin Streets. Gross $400,000. Merge or Dentist. 10+ weeks off a year. 4-days of Hygiene. 3-D Cone Beam. Great grow. implant upside as retirees in area require this service. Practice here and ORANGE COUNTY BEACH 5-ops. Gross $1.2 Million first year. Area growing. live in Folsom or El Dorado Hills. Full Price $200,000. ORANGE COUNTY BEACH CITY Absentee. Grossing $900,000+. 4-ops, room for 5th. Hands-on Owner will do $1 Million first year. 6167 NORTH SANTA CLARA COUNTY – “OUT-OF-NETWORK” Perfect for Skilled Dentist seeking strong patient relationships and wants ORANGE COUNTY BEACH CITY Grossing $800,000 part-time. Valuable Real Estate may be available. to be insurance independent! 2019 trending $850,000+ on Owner’s 3-day PALM SPRINGS AREA Grossing $1.5 Million. 8-ops. week. Office has been upgraded and charting is paperless. REDLANDS 5-ops. Grossing $500,000. Low overhead. Part Time Seller. Full 6166 TRI-VALLEY’S PLEASANTON 2019 trending $850,000+ in Price $450,000. collections. Averages 20 new patients per month. Attractive 4-op office, RIVERSIDE Lady DDS Grossing $300,000. 3-ops. Full Price $250,000. Digital Pan and Fabrication Center. Available Profits of $465,000. SAN DIEGO GROUP 4 offices Grossing $3.7 Million. 6165 ROSEVILLE ORTHO – “OUT-OF-NETWORK” Stanford SAN JUAN CAPISTRANO BEACH Grossing $200,000 on 16 hour week. Ranch. Great satellite office. $455,000 invested in build-out, furnishings, SANTA CLARITA 70,000 Autos pass daily. Tremendous upside. Full Price $250,000. computers and equipment. 3-chair Bay. Digital Pan with Ceph. Averages 3 SOUTH BAY AREA Absentee owned Nets $750,000 on gross of $2.3 Million. New Patients per month. Full Price $125,000. Lots of options to grow to $3.5 million. 6164 SAN FRANCISCO BAY AREA - “OUT-OF-NETWORK” SOUTH ORANGE COUNTY Crown Valley Shopping Center. 4 ops. Highly regarded as evidenced by 25+ new patients per month. Collections Grossing near $800,000. Lots of new home development nearby. topped $2 Million each of last 3-years with Profits averaging $1 Million. SOUTH ORANGE COUNTY 2-offices, each doing near $800,000. Available Paperless. 3D Cone Beam. Seller shall work-back to affect orderly by one Seller transition. Rare opportunity for Dentist seeking Superior Platform to UNION PRACTICE - INLAND EMPIRE Grossing $650,000 on 2.5 day practice their craft at highest level. week. Nets close to $400,000. 6163 LAKEPORT Attractive option to practicing in ultra-competitive UPLAND 3-ops, low overhead. Seller will transition. Full Price $360,000. settings in expensive housing markets. Practice here, decompress and have WANTED: IRVINE - NEWPORT BEACH - COSTA MESA - TUSTIN more time for yourself. 6-op facility completely networked. 2018 “High Fee-for-Service” Dentist lost lease. Seller will merge his 40-year practice collected $956,000. 2019 trending $1+ Million. Full Price $240,000. doing $800,000 into yours. Perfect opportunity to brand his patients to your 6158 FORTUNA Relaxed lifestyle in Humboldt County’s Banana Belt. office and complete purchase later. Adjacent to Ferndale. Perfect for Dentist seeking small town living. 2018 WEST LOS ANGELES Prestigious Medical Building. Grossing $800,000. Collected $395,000 with $156,000 in Profits. 2019 trending $400,000+. 6- WESTMINISTER Starter in busy strip center. 50% Hispanic and 50% weeks off. Lots of work referred. Full Price $75,000. Vietnamese. Full Price $85,000. viewpoint

CDA JOURNAL, VOL 48, Nº3

Then and Now: Changing Influences on Dental Practice

s the Journal of the California about the possibilities of the profession, Dental Association undertook from delivering care from a more the opportunity to use this whole-body approach to volunteering landmark CDA anniversary in their communities and adopting new to explore the future of the techniques and technologies, and about Adental profession, we knew that investigation the opportunity that this profession would not be complete without including gives them to constantly learn. the viewpoint of dentists just beginning their James Han, DDS, graduated from careers and who will experience that future. the University of California, San What follows is a conversation between Francisco, School of Dentistry in CDA Journal editorial staff, new dentists 2011 and finished his pediatric dental and a longtime veteran of the profession. residency at the NYU College of Some may be able to close their eyes Dentistry in 2013. As he entered the and remember the days when no one had profession, he didn’t expect to be greeted dental coverage, technology was limited, with the tough challenge of finding there were restrictions on marketing and an associateship in a private practice. every dental student was set on opening Meanwhile, as Dr. Han searched for their own practice following graduation. one of these coveted positions in his Today’s new dentists face a very hometown of San Francisco, his student different reality trying to determine if debt was weighing on him. He then opening their own practice makes sense recalled the marketing and recruiting given today’s challenges and opportunities. of corporate dentistry while in school, If they open their own practice, they are whether at events or in publications, not only shouldering significant student and felt compelled to try it out. debt but trying to manage a qualified “The availability was immediate. The dental team, demands from insurance timing of it just fell into place. They had companies and government regulators everything set up where there was little and ever-advancing clinical practices. that you needed to negotiate, and I feel They do this while also navigating the like they have a very strategically crafted business/marketing side of the practice offer to get new grads,” said Dr. Han, to bring in new patients who are looking who would also go on to take a part-time more closely at the cost of care. Yet, job at an established pediatric dental as these obstacles provide challenges, private practice in San Francisco while many new dentists are still passionate splitting his time in corporate practice.

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Diana Heineken, DMD, graduated other options, such as a DSO, to help he was practicing, which came with from the dental school at the Western him get on his feet financially. its own unique set of challenges, but University College of Health Sciences Dr. Heineken spent six months student debt was not one of them. in Pomona, Calif., a few years ago and working at a DSO, which she said showed “I came out of school with no debt. entered a dental service organization her what she can do with a private I also came out of school when there (DSO) shortly after. As much as she practice. Likewise, the educational were very few group practices, so you wanted to open her own practice, component of working at a corporate went into solo practice for yourself,” she was facing $500,000 in debt and practice is something Dr. Han viewed as Dr. Brown said. That is what almost understood she had to be strategic a benefit. Working part time at two very everyone expected to do in those days. about her financial future. different models of practice at the same “I had to plan out my finances for the time (a corporate practice and private Dental Benefits next 20 to 25 years and how I am going practice) as a recent graduate allowed him Something else that wasn’t around to pay the large tax bill associated with to determine what worked best for him. when Dr. Brown began practicing was loan forgiveness. Most students are not As Dr. Han gained more experience, he dental coverage. Dr. Brown said he prepped with the knowledge on how to remembers when there were movements deal with this throughout the duration of within the dental community to the loan repayment,” Dr. Heineken said. encourage peers not to sign up with Student debt had Marc Bernardo, “I was fortunate with the benefit companies when they first arrived DMD, also a graduate of WesternU, timing and being rewarded on the scene. Slowly, dentists would wondering if a future even existed by that loan repayment decide to accept plans, and he noticed for him in California as a dentist. over time how benefits influenced “I was thinking to myself, ‘Should program, but even with that practice, with dentists feeling the I move out of the state where there $300,000, I am still left with pressure to align practice decisions with is an opportunity to buy a house and about $200,000-plus in debt.” covered services. Benefits also brought starting a family at an earlier time changes in patient behavior. Before is more reasonable?’” he said. dental coverage was available, dentists Luckily, Dr. Bernardo found some worked toward building a loyal patient debt relief in the form of Proposition formulated a vision for delivering care base that would remain with the practice 56, the 2016 tobacco tax initiative. and thought the best way to actualize it as long as patients were treated well. CDA-supported Proposition 56 has was to open his start-up practice in 2015. With the introduction of a benefit plan earmarked more than $30 million for loan “I can see from the majority of new to pay for care, however, patients began repayment and practice location grants grads’ perspective, they are looking to look more at costs and what was for dentists who will commit to making for personal cash flow, they want a going to be covered and what wasn’t. at least 30% of their annual patient base job, they want that ideal position that “If a patient had a benefit program active Medi-Cal dental patients. Dr. may provide the work balance they that paid a $5 higher reimbursement, they Bernardo is a 2019 recipient of this award, are looking for and for these reasons would easily switch dentists to reap that allowing him to do mobile dentistry for a DSO is attractive. However, I think benefit,” Dr. Brown said. “The loyalty we special needs or homebound patients working in a large corporate practice once felt from patients is something that two days a week and work as a partner can also be an educational opportunity has been influenced by outside payers and, at a family practice the remaining days. to study different practice models and frankly, I think was lost quite a while ago.” “I was fortunate with the timing and educate yourself,” Dr. Han said. Dr. Heineken says patients put a being rewarded by that loan repayment Past CDA President Eugene Brown, lot of weight on what their insurance program, but even with that $300,000, DDS, is a graduate of the USC School benefits cover and are convinced I am still left with about $200,000-plus of Dentistry (now the Herman Ostrow that these companies have their in debt,” he said. If it wasn’t for this School of Dentistry of USC) and best interests in mind. She sees this loan repayment program, Dr. Bernardo practiced for 50 years before retiring as a challenge for modern practice indicated he would have had to consider in 2008. It was a different time when owners to overcome and to effectively

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communicate benefits to patients’ oral new risk factors to oral disease. You’ve now focusing on preventive care is health beyond limited benefit coverage. got to be a proactive clinician and try to a growing opportunity for patients Dr. Han says patients should intercept the problems before they occur.” and dentists,” Dr. Heineken said. understand that they have autonomy over For Dr. Heineken, what excites her On the same note, one of Dr. their own health care options and that about dentistry is the ability to work as a Bernardo’s main goals is to prevent they shouldn’t have to base every decision health care professional and see immediate patients from having dental disease on their insurance company. On the results from the care she provides. present in their mouths. other side of the coin, he says insurance “We have instant and very tangible “I have seen an increase in geriatric companies should listen to providing results. It is nice to see yourself and pediatric patients within our clinicians as information about treatment helping patients get out of pain or private practice. So with these patients is disseminated so patients everywhere can seeing the cosmetic improvements in I always stress the preventive approach be served to the current standards of care. someone’s smile — it’s all very tangible to oral care so it doesn’t progress to “There is a huge disconnect between and within our reach,” she said. the point that dental visits can be clinicians’ training, the patient’s intimidating. My goal is to help them expectations of the standard of care and not reach that state, so education is current reimbursement processes,” Dr. Han key,” Dr. Bernardo said. “I spend a said. “If you had a Venn diagram of these lot of time educating them … I think things, none of them would overlap.” “There is a huge that is important just so I can build disconnect between clinicians’ rapport with the patient while helping The Excitement of Dentistry training, the patient’s them to avoid diseases where more With dentistry, these new treatment is going to be needed.” professionals are able to participate expectations of the standard in a balance of science, engineering, of care and current Opportunities in the Future technology, art and, of course, health, reimbursement processes.” In terms of the future, these new and this clearly excites them. They dentists saw two unique opportunities may have grown up wanting to help for the profession: merging dentistry and people or learned how dentistry can medicine and the rise of group practices. change lives and decided to pursue Preventive Care Approach When Dr. Bernardo was in dental it for a career. For Dr. Han, disease The changes these dentists are already school, he had the opportunity to work prevention challenges and learning seeing in the profession largely center with a Federally Qualified Health Center opportunities are a driving force. on a shift toward a more preventive where dentistry, medicine, optometry “I was drawn to pediatrics because I am care approach. Dr. Heineken says she is and a pharmacy were all under one roof. open to the challenge of truly preventing beginning to see more parents interested He found that setup to be convenient for dental disease. We learn in school all the in making sure their kids are getting patients and practitioner, who used the different techniques to treat the symptoms proper care and nutrition. Additionally, opportunity to collaborate on patient care. of dental disease, but I think the true for the geriatric population, she said just “It gave me a lot of peace of mind. challenge is connecting with patients a couple of generations ago periodontal I also think patients feel like they are and families to educate them enough so disease was not very well understood or getting higher-quality care when they the disease does not present itself,” he cared for, and now there is a big emphasis have a team working together to provide said. “That always motivates me because on how to keep teeth and restore them that service,” Dr. Bernardo said. you never know who is going to walk properly. And with that is an effort to keep Such partnerships can allow through your practice door. There’s always geriatric patients functional and healthy. dentistry to work hand-in-hand some challenge to delivering effective “With all the new research and with medicine to deliver whole- preventative care, whether it be cultural information about how diabetes is body health to patients through an differences or shifts in diet trends. It’s involved, stroke is involved, heart interprofessional health care strategy. neat to see what’s going on in these kids’ diseases, all these things that go So, how do you make this day-to-day routines, which may reveal back to dental care, I think right system more prevalent?

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Dr. Han says the artificial delineation more emphasis on diagnosis and the value it offers to them as professionals, between health care professionals should sending patients to the right places.” whether it is the insurance TDIC offers, be dissolved and everyone needs to From the business side of things, a group savings on supplies through TDSC, understand what can be accomplished practice may afford dentists more buying educational and networking opportunities through interprofessional collaboration. power and the ability to share liability and at CDA Presents The Art and Science of As more research becomes available deliver adequate coverage to patients. Dentistry, the community involvement about the oral-systemic connection, “Perhaps that may be a disrupting through the CDA Foundation and CDA then perhaps more effective care could competitor to the corporate practice model, Cares, practice support or the advocacy at be delivered by reshaping dental school but I think that is more location specific,” the state Capitol. Dr. Bernardo attributes curriculums and interprofessional Dr. Han said. “In places like San Francisco, CDA advocacy to the passage of the practice, he said. Revisions to dental it is kind of space-prohibitive and cost- Proposition 56 tobacco tax, which funded insurance also may play a part. prohibitive to perhaps do that initially, the student loan repayment grant that is “How we manage dental insurance but I definitely think that is more than a helping him erase $300,000 in loan debt. claims and coding is much different trend. I think that is happening now.” “CDA’s advocacy has really helped than managing medical insurance my family and me out financially because claims and coding,” Dr. Han said. of my student loans, and it protects the “There’s no reason why diseases of future of dentistry. I owe a lot to organized any kind need to be coded differently. “Seeing group practices dentistry, and throughout my career, I just There’s an artificial classification in hope I can help pay it back,” he said. how we process that information.” succeed and being able to Dr. Heineken said every part of Having every element of health provide patients with a lot of the journey as a dentist is a little bit care under one roof may seem like a specialists under one roof is different for everyone, and CDA is niche concept today, but the growing able to tackle those different parts popularity of group practices over true comprehensive care.” from a comprehensive perspective. the years is a good example of how “As you continue your career and change can occur in the profession. stay involved in your dental societies, For example, Dr. Brown recalls you are going to find that the networking that when he began his career, “group Organized Dentistry is more important than anything else practice” was almost a bad word. For all of the things that have you can pay money for,” she said. “If you look back, the things we did changed over the years, the one Dr. Han sees organized dentistry 50 years ago were short-sighted, like constant has been organized dentistry. as an educational resource that not valuing group practices,” he said. Dr. Brown was quick to note, “I helps him navigate everything “The philosophy then was open your watched [CDA] for many years as an happening in the profession. practice, be a good guy and wait for association, how proactive it is and “If not for all the newsletters and your patients to come. It didn’t work all these things we are talking about things I learn at the meetings, I think a lot great then, and it doesn’t work today.” came about because of activity within of new dentists would be in the dark. It’s When dentists join forces, they become the dental association — TDIC came been a huge resource for me,” he said. “I stronger as a practice, and Dr. Heineken about, we formed our own company and would hope the new grads recognize there says this competitive edge is valuable. solved a lot of problems. Today, with is so much to learn and it’s so important to “Seeing group practices succeed government regulation and insurance put faces to people’s names [at events] and and being able to provide patients and everything else, we have a voice there’s no reason to not to get involved.” n with a lot of specialists under one roof through CDA, which is a better collective is true comprehensive care. I think voice than you have as an individual.” competition is driving a part of our With the challenges new dentists industry in a great way,” she said. face and the opportunities that lie ahead, “We are putting a lot more emphasis organized dentistry is there to support on specialists. We are putting a lot them, and these new dentists recognize

160 MARCH 2 0 2 0 Making your transition a reality.

Dr. Thomas Dr. Russell Dr. Rishi Jim Jay Kerri Gina Steve Jaci Kim Thinh Wagner Okihara Salwan Engel Harter McCullough Miller Caudill Hardison Ta Tran LIC #01418359 LIC #01886221 LIC #02085289 LIC #01898522 LIC #01008086 LIC #01382259 LIC #02015193 LIC #00411157 LIC #01927713 LIC #02085576 LIC #01863784 (916) 812-3255 (619) 694-7077 (909) 239-2800 (925) 330-2207 (916) 812-0500 (949) 300-0312 (707) 391-7048 (951) 314-5542 (949) 675-5578 (408) 687-5001 (949) 675-5578 45 Years in Business 38 Years in Business 10 Years in Business 46 Years in Business 36 Years in Business 35 Years in Business 30 Years in Business 30 Years in Business 26 Years in Business 16 Years in Business 11 Years in Business PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS NORTHERN CALIFORNIA SACRAMENTO: Downtown/Midtown: Hi- GREATER MODESTO AREA PEDO POMONA: Great potential! Low rent. 4 Op traffic, 4 Ops, under 5% Delta Premier patients. PRACTICE: New Listing! Digital, 7 Op practice practice. Only open 2 days/wk. Seller is retiring. AUBURN & FOOTHILLS AREA: New 2018 GR $607K on 30 Dr. hrs/wk. #CA590 in 2,812 sf. Practice has small growing patient 2018 GR $279K. Priced to sell. #CA610 Listing! Fast growing practice in 2,500 sf w/ 6 SACRAMENTO AREA: Price reduced by base, priced as start-up/acquisition opp. #CA646 SAN FERNANDO VALLEY: New Listing! 10 equip Ops, 1 add’l plumbed. 2019 GR on track to $100K! GP & Specialty HMO/some PPO Practice. exceed $1.2M on 3 avg Dr. days/wk. #CA632 MERCED AREA: New Listing! 30+ yrs Ops, 8 Equip, hi-tech, fantastic location. Digital, 9 Ops, I/O Cam, Digital Pano. 2017 GR $1.1M+, Goodwill in great location. 4 Ops, Dentrix, Digital, Pano, CT Scan. GR $1.1M+. #CA664 CONCORD: East Bay, Contra Costa 2018 Quickbooks (to be verified) GR $680K. 5,000 I/O Cam, Laser, Pan/Ceph. 2018 GR $691K. SAN GABRIEL VALLEY: 4 Ops, Digital Community: Digital Practice with 3 Ops, sf bldg. avail. #CA567 #CA642 modern/attractive bldg., PPO, 1,200 sf, and X-rays, 65 yrs Goodwill. Most specialty work SACRAMENTO AREA: ASKING PRICE MODESTO AREA PERIO PRACTICE: 4 Ops, referred out, most PPO plans are accepted. Busy Dentrix. 2018 GR $1M+ on 34 avg. Dr. hrs/wk. SIGNIFICANTLY REDUCED! Seller considering #CA595 5th available. 1,600 sf. LANAP Laser and Digital road with great visibility, open 4 days/wk. Nicely all offers. 4 Equip Ops w/1 additional available, 45 Sensor. 2019 GR $455K on 4 day/wk. Bldg. also appointed; excellent opportunity. #CA596 CONTRA COSTA COUNTY: Records for only + yrs Goodwill in well-established location. 1,403 available. #CA598 the Pedo and/or Ortho portion of Practice. 11+ sf office condo available for purchase. 2018 GR SIMI VALLEY: 3 Ops, 30 yrs Goodwill. 2018 yrs Goodwill. Buyer must be within 15 miles of $574K. #CA603 MODESTO AREA: Established neighborhood GR $263K w/ $77K Adj. Net. #CA626 with 60+ yrs Goodwill. 5 Ops, 1,450 sf. 2018 GR Contra Costa County. Asking Price is below SAN FRANCISCO: New Listing! LOW RENT! SIMI VALLEY: 6 Ops, 5 Equip. Great location, appraised value. #CA576 $1.1M+ on 3 day/wk. Dental Condo also available low rent, 45 yrs Goodwill. 2018 GR $297K w/ 30+ yrs Goodwill. Beautiful 4 Op office w/ strong for purchase or lease. #CA635 FAIRFIELD AREA: New Listing! 4 Ops in hyg program. 2018 GR $700K+. #CA657 $89K Adj. Net. #CA637 1,500 sf, 30+ yrs Goodwill. Dentrix PMS, I/O STOCKTON AREA: New Listing! Great opp to SIMI VALLEY: 6 Ops, 39 yrs Goodwill. Strong SAN JOSE: Great cash flow in beautiful retail purchase practice and bldg, 3,000+ sf with 6 Ops, Cam, Digital X-ray, paperless practice. 2018 GR space with hi-traffic and visibility. Spacious 3,150 hyg. program. Prof. bldg. EagleSoft, Digital, Pano. $840K on 4 day/wk. #CA655 good hyg recall. 2018 GR $1M+ on avg 37 hrs/ 2018 GR $783K. #CA617 sf w/ 10 Ops, 6 Equip. 2018 GR $998K. #CA600 wk. #CA616 FOLSOM/RESCUE/EDH AREA: New Listing! SOUTH ORANGE COUNTY PERIO: 4 Ops, SONOMA COUNTY: 2018 GR $906K. 1,000 sf, VISALIA: Practice+Bldg, 5 Ops, 2,000 sf, street 5 Ops, Digital, Modern space w/ low OH. 2018 3 Ops w/ opportunity to expand. Paperless, 3 Equip, Coastal Community, Modern, Busy strip GR $773K. Office condo also for sale. #CA581 frontage, 2019 GR of $353K. Great deal for quick center location near hi-end residential. 2018 GR Dentrix, Digital, I/O Cam. Selling both Practice sale, Most Specialty referred out. #CA628 FREMONT: 4 Equip Ops in 1,800 sf. Dentrix and portion of dental building ownership. #CA594 $900K+. #CA643 PMS, Digital X-ray, Diode Laser, I/O Cam. SONOMA COUNTY: Price Reduced! Modern SOUTHERN CALIFORNIA SOUTH BAY/TORRANCE AREA: 6 Ops in #CA547 GP offering a broad range of service. 6 Ops in prof. bldg. 44 yrs. Goodwill. SoftDent, Digital X- BAKERSFIELD AREA: 6 Ops, 39 yrs Goodwill, rays, I/O Cam, and Laser.Visiting Specialists keeps FREMONT: Priced to sell! 40+ yrs Goodwill. 2,200 sf, seller-owned facility. 2018 GR $802K w/ Dentrix, and I/O Cam. 2018 GR $475K w/ $165K Spacious 2,900 sf suite with 9 Equip Ops in 4 hyg days. Digital, Dentrix, I/O Cam, Laser. procedures in-house. Strong hyg. prog. 2018 GR Net Income. Unique opportunity to merge two $1M+. #CA624 stand-alone bldg. 2018 GR $631K. #CA607 MOVE-IN READY, this will not last! #CA564 practices to one large one. #CA622 WEST COVINA: New Listing! State-of-the-art GREATER EL DORADO HILLS: Multi- SONOMA COUNTY: GP in 1,890 sf w/ 4 Ops. BAKERSFIELD AREA: Practice +RE (Merger doctor practice, 3,000 sf office, 8 Ops, 7 Equip, 2017 GR $529K on 3 Dr. days/wk. and 3½ hyg practice with 3 Ops and is all digital and modern w/ #CA622) 5 Ops, 4 hyg days. Most specialty with 1 day of Hygiene/wk. 2019 GR $1.2M+ with I/O Cam, Digital X-rays, and Digital Pan. Sellers days. Dexis, Dentrix, I/O Cam, laser. Real Estate referred, room to grow! 2018 GR $375K #CA623 will consider working back part-time. #CA578 available for purchase. Doctor retiring. #CA563 Adj. Net of $420K in a great location with low BAKERSFIELD PEDO: Rare opportunity to rent. #CA661 GREATER SACRAMENTO: Price Reduced SONOMA COUNTY: Large GP, 2018 GR above purchase a successful 30+ yr old Pedo practice w/ WESTERN SAN FERNANDO VALLEY: by $50K! PPO Practice with 4 Ops, digital $2.8M. Stand-alone 3,000 sf prime Real Estate, 72 Ortho/Oral Surgery services. Over 4k active sensors, imaging system, I/O Cam. Practice open NP/mo.10 hyg days. 6 Ops, Pano X-ray, Dexis, 5 Ops, 4 Equip, EagleSoft, Digital, Laser, I/O Cam. patients, avg. 40 NP/mo. $2.5M+ GR for past 3 12+ yrs Goodwill, Prof. bldg. near hospital. 33 yrs. 2017 GR $652K; Office Condo available Cameras, Laser, Dentrix. Both Business & Real yrs. #CA599 for purchase. #CA561 Estate for sale or Lease. Doctor Retiring. #CA544 Accepts PPO and 3 HMO plans. 2018 GR $484K COVINA: Well-established, great visibility, 4 w/ $218K Adj. Net. #CA614 GREATER SACRAMENTO: New Listing! SONOMA COUNTY: 2018 GR $2M+. 8 Ops in Ops, Digital X-rays. Seller refers out most difficult Great area w/ 38 yrs Goodwill. 4 Ops in 1,100 sf. 4,600 sf, 13 hyg days on 4½ day/wk. 42 yrs specialty work so there is room to grow. Bright, SAN DIEGO 2018 GR of $1M+ on 32 hrs/wk. #CA656 Goodwill. Doctor retiring and will work back. cheery space, word-of-mouth referrals. #CA634 EAST COUNTY, EL CAJON: New Listing! GP Paperless, Digital, hi-tech, modern. #CA601 HAYWARD: New Listing! Dr. retiring from LOS ALAMITOS: New Listing! Beautiful state- & Multi-Specialty, Great strip mall location. 14 cozy, 900 sf, 3 Op practice with opportunity to VACAVILLE AREA: New Listing! Centrally- of-the-art practice with 4 Ops, and mostly Ops, 10 Equip, PPO/HMO/Denti-Cal. #CA647 purchase part of the bldg. Desirable area. #CA649 located & hi-traffic location with 25+ yrs associate-run. Digital, cash and PPO in a great ENCINITAS: 4 Ops. Busy retail center. LAKE TAHOE AREA ENDO PRACTICE: Goodwill. 5 Ops in 1,700 sf. 2018 GR $567K on location. GR $900K w/ $390K Adj. Net. #CA662 Remodeled 5 yrs. ago with new equipment. 32 hrs/wk. #CA645 3 Ops, 3 digital sensors, Cone Beam in 1,100 sf. LOS ANGELES: 5 Ops + 3 chair Ortho bay. Dentrix, Digital, Pano, and Laser. 4 hyg. days/wk. Consistent GR $525K for the last three years on VALLEJO: New Listing! 4 Ops, 1,650 sf w/ Visiting Perio, 2 hyg days. EZ Dental, Digital, 3D 2018 GR $813K. #CA574 32 avg. Dr. hrs/wk. #CA602 below-market rent. 2019 GR $791K, 4 hyg days/ CBCT, Digital Ceph. 2018 GR $1.7M+. #CA619 LA JOLLA: New Listing! UTC Area, Leasehold wk, low OH. #CA469 LAKE TAHOE AREA: GP practice with 5 Ops LOS ANGELES: West Side, 5 Ops, 4 Equip, with patients. 7 Ops Digital in retail center with w/ 6th Open, Operatory views of Lake Tahoe, WOODLAND/DAVIS AREA: 6 Ops, 40+ yrs EagleSoft, Digital, 40 yrs Goodwill, Up-and- strong anchors. Priced to sell! #CA663 only 34 Delta Premier patients, 2,100 sf. 2019 Goodwill. Real Estate available. 2018 GR $1.1M+ coming area. 2018 GR $523K. #CA640 MISSION VALLEY: GP/Multi-Specialty, 24 GR $579K on 22 avg. Dr. hrs/wk. #CA608 on 32 Dr. hrs/wk. #CA629 LOS ANGELES: New Listing! Near Glendale, 4 Ops, 18 equip, Digital, Seller motivated for quick MONTEREY: New Listing! 4 Op, 1,600 sf in YUBA CITY AREA: 46 yrs Goodwill, GP Ops in stand-alone bldg w/ great visibility. Low sale. #CA638 highly desirable area with plenty of free parking. Practice with 3 Ops w/ 4th Open in 1,400 sf. Priced rent and $6K/mo. CAP check. Room to grow! GR NORTH COUNTY COASTAL ORTHO: New 2018 GR $1M+ on 32 hrs/wk. #CA650 below professional Valuation. 2018 GR $271K. $200K+ with low OH. #CA665 Listing! 4 Chairs + Consult Room, Desirable area, #CA580 MONTEREY PENINSULA: Practice LOS ANGELES: 7 Ops. Prof. bldg. in great Digital Pano/Ceph, Excellent location. 2018 GR established for 70+ years, 32 w/ present owner. CENTRAL CALIFORNIA location of LA. Strong hyg. program w/ 5+ hyg. $273K. #CA653 Beautiful 1,130 sf office w/ 3 Ops. Dentrix PMS, days/wk and 37 yrs. Goodwill. 2018 GR $983K w/ NORTH COUNTY PERIO: 4 Ops, 3 Equip. Dexis Digital X-ray, I/O Cam, Diode Laser. 2019 CENTRAL COAST ENDO PRACTICE: 3 Ops, $277K Adj. Net. #CA606 Newer equip. including CT Scanner, Digital, GR $520Kon 4 day/wk. #CA625 Digital X-rays, Paperless, Cone Beam CT, and PBS NORTH ORANGE COUNTY: 5 Ops, has been Dentrix. Well-maintained complex. Priced to sell NORTHERN CALIFORNIA PEDO Endo Software. 2018 GR $1.1M+ w/ $635K Adj. open since 1965. Dentrix, digital Pano. Retiring quickly. 2018 GR $269K. #CA605 Net. #CA489 PRACTICE: New Listing! Large practice in seller will assist w/ smooth transition. One-story POWAY: New Listing! 3 Ops, located in a busy downtown location, 5,000 sf. 7 equipped Ops, 2 CENTRAL VALLEY PEDO PRACTICE: New prof. bldg. 2018 GR $231K. Room to grow. Most strip center w/ room to grow! Digital X-rays, I/O additional plumbed. 2018 GR $3M+. #CA658 Listing! Shared space w/Ortho, 7 Op, 3,800 sf. specialty procedures are referred out. #CA558 Cam, Pano, and Laser. 2018 GR $226K. #CA659 PLEASANT HILL: 23+ yrs Goodwill. 1,438 sf 2019 GR of $610K as part-time practice. Great ORANGE COUNTY ENDO PRACTICE: Built starter practice or satellite office. #CA660 SAN DIEGO COUNTY ORTHO: Rare modern office on busy roadway. 4 Ops, Dentrix in 2018, 6 Ops, 5 Equip, 3 Scopes, Cone Beam Opportunity in the San Diego County area, PMS, Paperless, Digital Pan, I/O Cam, Diode FRESNO AREA: GP and Prosthodontic Practice CT, fully digitized and paperless. 19 yrs Goodwill. Established office with updated computer Laser. 2018 GR $762K on 4 day/wk. #CA654 prime for a GP to purchase. 4 Ops, 1,500 sf, Digital GR for the past 3 yrs at $1.3M+. Very low OH. hardware. Paperless with many years of goodwill. REDDING AREA: New Listing! Modern Sensors, film Pano, DentalMate Software, Seller retiring. #CA593 Excellent location. This will sell quickly. #CA615 practice in 1,600 sf with 4 equipped Ops, 1 attractive office bldg. 2018 GR $386K. #CA588 PALM SPRINGS AREA MULTI- additional plumbed. 2018 GR $558K on 32 hrs/ GREATER FRESNO AREA: Great location for SPECIALTY: 5 Ops + 1 add’l plumbed in 2,500 OUT OF CALIFORNIA wk. #CA648 well-established practice with 40+ yrs Goodwill. 6 sf. 27 yrs Goodwill. Hi-end patient base. Rent is NORTH COAST, OREGON: Minutes to the ROCKLIN/LINCOLN AREA: New Listing! 10 Ops, Digital X-ray, Diamond Dental PMS. 2018 only $3,600/mo! Dentrix, Digital, CT Scan and ocean. Dr works 3 days per week, 2 days of Ops, 6 equip, 4 plumbed,. 2,619 sf. Growth GR $638K. #CA621 Gemini Dual Wave Laser. History of $1.2M+/yr. hygiene. 2019 GR $404K, practice positioned for potential in all Specialties, 2018 GR $747K on 4 GREATER MODESTO AREA PEDO #CA604 growth, Dr. is retiring. #OR112 days/wk. #CA641 PRACTICE: New Listing! Digital, 7 Op practice in PASADENA: 4 Ops, 3 Equip, Dentrix, Digital, SOUTHWEST PORTLAND: 7 Ops, 6 Equip, 2,812 sf. Practice has small growing patient base, CBCT. Great location! This won’t last! #CA651 Dentrix, Digital, Pano. Well-maintained leased priced as start-up/acquisition opp. #CA646 space. 2019 GR $605K. #OR115 Northern California Office www.henryscheinppt.com Southern California Office 1.800.519.3458 1.888.685.8100 Henry Schein Corporate Broker #01230466 Call us today at (855) 337-4337 or visit www.integritypracticesales.com

A Professional Team Dedicated to Your Success

Bill Kimball, DDS Darren Hulstine Trevor Kimball, PhD Brian Flanagan Ken Skeate Tim Miller Broker / Partner Broker / Partner President Northern California Southern California Southern California (619) 933-6225 (805) 878-0633 (805) 748-7439 (707) 898-0842 (805) 338-5850 (714) 272-8408 DRE# 01921421 DRE# 01899816 DRE# 02078646 DRE# 01947466 DRE# 00885612 DRE# 02107070

“Selling a practice can be an emotional experience and we were guided through the process with care and responsiveness. I honestly can’t imagine any aspect of the sale that could have been handled any better.” - R. Bishop, DDS

Call us today at (855) 337-4337 and approach your sale with confidence. Visit www.integritypracticesales.com to see all our dental practices for sale.

Vista + RE: $450,000 | 4 ops Ventura: $375,000 | 6 ops San Francisco: $1,057,000 | 4 ops SOLD! Escondido: $180,000 | 2 ops Ventura Turnkey: $110,000 | 3 ops San Jose: $200,000 | 4 ops Chula Vista: $430,000 | 5 ops Santa Barbara County: $270,000 | 3 ops Watsonville + RE: $491,000 | 5 ops Palm Desert Area: $199,000 | 5 ops Santa Barbara + RE: $1,200,000 | 4 ops San Anselmo: $230,000 | 2 ops South Bay + RE: $649,000 | 6 ops N. Santa Barbara County: $1,437,000 | 9 ops NEW! Carmel: $495,000 | 4 ops Irvine: $1,100,000 | 4 ops Santa Barbara County: $179,000 | 4 ops Bakersfield: $185,000 | 4 ops West Covina: $160,000 | charts Santa Barbara: $122,000 | 4 ops NEW! Porterville: $1,140,000 | 12 ops Glendale: $550,000 | 4 ops Santa Maria + RE: $360,000 | 4 ops Bakersfield: $275,000 | 3 ops SOLD! Santa Monica: $510,000 | 5 ops N. San Luis Obispo County: $1,500,000 | 6 ops Folsom: $330,000 | 6 ops Agoura Hills: $225,000 | 3 ops San Luis Obispo: $861,000 | 3 ops NEW! Sacramento: $420,000 | 4 ops Newhall: $250,000 | 5 ops Central Coast: $485,000 | 4 ops Rancho Cordova: $225,000 | 4 ops Valencia: $600,000 | 5 ops Central Coast: $548,000 | 5 ops Sacramento Area: $315,000 | 5 ops Thousand Oaks: $85,000 | 3 ops Central Coast: $390,000 | 3 ops Roseville: $315,000 | 5 ops Westchester: $550,000 | 4 ops Central Coast Endo: $750,000 | 5 ops Shasta County: $135,000 | 5 ops Camarillo: $275,000 | 5 ops San Luis Obispo County: $650,000 | 4 ops S. Lake Tahoe: $225,000 | 3 ops Ojai: $350,000 | 4 ops NEW! Fairfield: $55,000 | 3 ops California City: $350,000 | 6 ops

DRE #01911548 Broker-Partners: Darren Hulstine and Bill Kimball, DDS RM Matters CDA JOURNAL, VOL 48, Nº3

Wheelchair to Dental Chair: Safe and Smooth Patient Transfers

TDIC Risk Management Staff

ental practices welcome TDIC’s Risk Management analyst patients of all ages and abilities. advised the dentist that waiting for While most patients come If moving a patient causes the caregiver to return was the best and go without incident, physical injury to the patient decision in this case. Safety is of the those with limited mobility or the staff member, it can utmost importance in the dental office. Dmay need help transferring to and from It is not worth risking an injury, either the dental chair. In an ideal scenario, put the practice at risk for to the patient or staff members. these patients will bring along a a liability claim. If practice In another case reported to the Advice caregiver or family member to help with owners refuse to move a Line, a male staff member had assisted a transfers. In other cases, it is up to the patient in a wheelchair. In doing so, the dental practice to provide solutions. patient for fear of injury, it employee sustained a shoulder injury that Not only are practice owners required can lead to unhappy patients. required surgery. The incident resulted in to make their office spaces wheelchair a workers’ compensation claim. In a Risk accessible, they are also obligated to Management analyst’s discussion with ensure all patients have equal access to dental care. For those patients who have a long-term disability as defined by the Americans with Disabilities Act, they must make a reasonable effort to move the patient. But this type of physical assistance is not without risk. If moving a patient causes physical injury to the patient or the staff member, it can put the practice at risk for a liability claim. If practice owners refuse to move a patient for fear of injury, it can lead to unhappy patients. In one case, a dentist contacted The answers Dentists Insurance Company’s Risk Management Advice Line to ask if he was responsible for moving a patient from his wheelchair to the operatory chair. The patient in question was a long-term patient who usually came to his appointments with his son or a caregiver. In this instance, the caregiver From one-on-one risk management advice by phone had left the office to run an errand, so the to informed consent forms to expert-led seminars, patient asked the dental assistant if the office staff could help him transition to we’re here to help you practice with confidence. the dental chair. The dentist felt that his We are The Dentists Insurance Company. team could not safely move the patient. He explained to the patient that he Learn more at tdicinsurance.com/rm had a bad back and did not want to risk

further injuring himself. Staff waited for ® the caregiver to return, but the patient Protecting dentists. It’s all we do. became upset and believed the office 800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783 should provide this kind of assistance.

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CDA JOURNAL, VOL 48, Nº3

the dentist, it was determined that the to do so, are not at risk for exacerbating 4. Perform the two-person transfer. employee had no training in providing a previous injury and are trained on the 5. Position the patient after this type of assistance to patients. The proper method of transferring patients. the transfer. office relied on the employee because he The National Institute of Dental and 6. Transfer the patient from the was the only male in the office and the Craniofacial Research has developed dental chair to the wheelchair. dentist perceived him to be the strongest. a downloadable guide on safe patient Practice owners are encouraged to The analyst advised the caller that transfers using the two-person method provide training to staff members on depending on staff for patient transfers (nidcr.nih.gov/sites/default/files/2017-09/ these methods. The training should should only be considered as a last resort. wheelchair-transfer-provider-guide.pdf). include a “practice run” or role- If a patient with limited mobility presents In this method, one clinician stands playing exercise where employees are without a caregiver or family member to behind the patient while another able to become comfortable with the assist, the first step is to ask whether the initiates the lift from the patient’s legs. method prior to using it on patients. patient has the upper-body strength to The method consists of six steps: There may be patients who are too transition themselves to the chair. If not, 1. Determine the patient’s needs. heavy or too fragile to lift using this two- practices should ensure employees tasked 2. Prepare the dental operatory. person method. In these cases, the practice with this responsibility are willing and able 3. Prepare the patient’s wheelchair. can also rent a hydraulic or manual patient lift. These lifts ease patient transfers through the use of a sling. Offices with a high number of patients with limited mobility may consider purchasing a lift. While practice owners should be proactive in meeting the needs of all their patients, those patients with limited mobility often require additional assistance. Developing strategies for transferring these patients to and from the dental chair ahead of time can avoid uncomfortable or risky situations. No matter the method or mode a practice decides to implement, patients and staff will appreciate that you have formulated a plan with their comfort and safety in mind. n

TDIC’s Risk Management Advice Line is a benefit of CDA membership. If you need to schedule a no-cost consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 800.733.0633.

164 MARCH 2 0 2 0

LDM_CDA_Journal_1.3_Square_LindaBrown_05_23_17.indd 1 5/24/2017 9:21:40 PM Regulatory Compliance CDA JOURNAL, VOL 48, Nº3

Know What Makes an Electronic Signature Valid

CDA Practice Support

ental practices moving a. Receives a UETA/ESIGN the image cannot be authenticated. to paperless systems must Act-compliant consumer California law defines a digital signature consider implementation consent disclosure that as “an electronic identifier, created by of technology that captures reasonably demonstrates computer, intended by the party using legally valid electronic the consumer’s ability to it to have the same force and effect Dsignatures. Valid signatures are receive electronic records as the use of a manual signature.”1 essential to several patient transactions in the formats that will Software that generates a digital such as health history completion be used for delivering the signature can add a level of security and review, informed consent and required information. and authentication through use of financial agreements. Risk increases b. Affirmatively agrees to PINs, passwords or digital certificates. for a practice if a patient signature use electronic records cannot be authenticated. It is critical for the transaction. E-Signature Use in Patient Records a dental practice owner understand c. Has not withdrawn consent and E-Prescribing what makes an e-signature valid in to use electronic records. The California Dental Practice order to select the most appropriate 4. The electronic signature must Act requires every licensed health technology for the practice. This article be associated with the process by professional who performs a service on discusses what makes an e-signature which the signature was generated. a patient in a dental office to identify valid and types of e-signatures. One example of this is a signature themselves in the patient record by The U.S. Electronic Signatures generated after clicking through signing their name or an identification in Global and National Commerce a software program’s dialog box number and initials next to the service Act (ESIGN Act) and the Uniform combined with some other performed and to date the entries in Electronic Transactions Act (UETA) identification process. Other the record.2 In order to comply with together establish the requirements examples include a digitized picture this legal requirement when using for e-signature to be recognized as of a handwritten signature or a an electronic health record software valid under U.S. law: complex encrypted authentication and to ensure the record’s validity, 1. Authority to sign. Each signer system. The signature should be a dental practice owner should: must have authority to sign. The logically associated with the record ■ Ensure each individual authorized electronic signature process should being signed. Signature should be to perform a service on a patient has create and preserve evidence of verifiable (verification through an their own unique access credentials the identity of each signer. audit trail is one way of doing it). to the electronic health record 2. Intention to sign. An example 5. Electronic signature records are (EHR) and instruct them not to of demonstrating this intention retained and are reproducible for share the credentials with others. is to offer opt-in/opt-out reference by all parties or the person ■ Have policies and procedures boxes during the process. entitled to retain the record. for accessing and signing 3. Consent to do business Individual states and certain industries the patient record. electronically. Each party must may set requirements over and above the ■ Regularly review the EHR audit consent. Consent does not ESIGN Act and UETA. UETA is codified trail to ensure compliance. An have to be all or nothing. A in California Civil Code sections 1633.1- electronic signature can be consumer can choose to conduct 1633.17. Dentists contracted with one or validated by an audit trail that business electronically for one more dental plans should verify respective shows the date and time each transaction but not for another. plan requirements for e-signature, if any. electronic record is signed, the The circumstances in which a system identifier for the electronic dental practice needs a patient Digital Signature record being signed and the signature are considered “consumer A digital signature is one type of identity of the person signing transactions” and, as such, the e-signature. It should not be confused the electronic record. Regular practice must ensure the patient with a “digitized signature,” which is review of the EHR audit trail is a or patient’s legal representative: just an image of a signature on paper; HIPAA Security Rule safeguard.

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Mandatory use of e-prescribing in California will start in 2022. E-prescribing software is widely available, but dentists who need to prescribe controlled substances should be aware that e-prescribing for controlled substances requires additional security mandated by U.S. Drug Enforcement Agency regulations. In addition to going through a third-party identity- proofing process, prescribers are required to use a two-factor authentication process to “sign” an e-prescription for controlled substances. The factors Share your must be two of the following: ■ Something known (a password, for example). CDA story. ■ Something possessed (a hard token, such as a fob or cellphone, to receive a short-term code). ■ A biometric, such as a fingerprint. For 150 years, the California Dental Association Only a prescriber is allowed to sign a prescription so prescribers may not give has supported a brilliant community of dentists. any of the factors to another individual. n Be a part of our anniversary celebration by references sharing why you joined CDA and your favorite 1. Government Code §16.5, leginfo.legislature.ca.gov/ faces/codes_displayText.xhtml?lawCode=GOV&heading membership moments, photos and videos. 2=GENERAL%20PROVISIONS; Civil Code §1633.2(h), leginfo.legislature.ca.gov/faces/codes_displayText.xhtml ?lawCode=CIV&division=3.&title=2.5.&part=2.&chapter =&article=. Join in at cda.org/150. 2. Business & Professions Code §1683, leginfo.legislature. ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC §ionNum=1683.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

166 MARCH 2 0 2 0 CARROLL “Matching the Right Dentist to the Right Practice” & C O M P A N Y

4389 SALINAS GP Large & stable patient base. Seasoned and 4390 MOUNTAIN VIEW GP Located near thriving downtown area with dedicated staff. Practice with an emphasis on Restorative treatment. 4 a large daytime business draw in modern 1,183 sq. ft. office. State-of- doctor days & 5 hygiene days per week. Average GR $910K. Retiring the-art equipment. Practice has been steadily growing. 2017 GR $750K, owner. 2018 GR $902K & 2019 on schedule for $962K. Seller willing to help for smooth transition. 4376 SANTA CRUZ COUNTY GP Incredible practice opportunity offering 31 yrs of goodwill. EZ freeway access and parking. Close to 4382 MONTEREY COUNTY GP Sophisticated practice in Monterey amenities and shopping. Nicely appointed 1,200 sq. ft office with 4 ops. Bay area. Highly desirable location and neighborhood, a spacious high Owner/Doctor works 4 days/week. Hygiene 6 days/week. 1,200+ active tech office with state of the art equipment. $900K+ average GR with 4 patients. Average GR $1.6M with average adj. net of $756,029.00. doctor days/week and 4 hygiene days/week. Well respected within the Owner/Doctor will help for smooth transition. Asking $1,206,000. local community. Loyal and stable patient base with 30+ yrs of goodwill. Asking $678K. 4381 SOUTH SAN FRANCISCO GP Retiring dentist offering 23 year practice close to Kaiser Hospital. 4 op facility with new & recently 4343 CAPITOLA GP Gorgeous, state-of-the-art practice offering 33+ upgraded equipment. Great location in desirable neighborhood. Owner years of goodwill. Beautifully appointed office environment and building, willing to help for smooth transition of the practice. Average gross located within minutes of charming downtown Capitola, known for its receipts approximately $250K with average 60% overhead. Asking colorful, seaside shSoOpsLaDnd restaurants tucked into a hillside along $170K. Soquel Creek. Must see this office to appreciate its splendor. Asking $643K for practice. Seller owns building, it is available for purchase, or 4359 SANTA CRUZ GP offering 30+ years of goodwill within walking to lease. distance to the beach! Located in a well-established, attractive, single story professional building complex w/ample parking, good visibility and 4366 SONOMA COUNTY GP Fabulous practice and location within easy access. 2 doctor days/week, 2 hygiene days/week, 380 active one of the North Bay’s gems of a town. Classically beautiful and well patients with approx. 10 new patients/mo. 3 fully equipped ops in 850 appointed office with 4 ops in 1,425 sq. ft. Fantastic storefront location sq. ft. Average GR $250K with Average adj net of $135K. Asking price on a well traveled road, walking distance to the pedestrian-friendly center $150K. of downtown. 900+ active patients, all fee-for-service. Not a Delta Dental Premier Provider. 4 doctor days/week and 4 hygiene days/week. Last 4387 SF GP 50 year Nob HIll neighborhood practice with approximately two years average GR $865K with average adj. net of $407K. Seller will 1,000 active patients. Almost no Delta Premier patients. Average GR help for smooth transition. Asking $650K. $600K. Seller transitioning into retirement. Asking $315K. 4375 LOS GATOS FACILITY Seller offering fully equipped, state-of- 4351 SEBASTOPOL AREA GP & BLDG. Charming practice situated the-art, modern, 2 operatory facility including furniture, fixtures and amidst rolling hills, soaring redwood trees and lush vineyards. Offering leasehold assets in medical office building adjacent to Los Gatos 70+ years of goodwill. Beautiful, modern facility with 3 fully-equipped Community Hospital. Asking $250K. ops (room for a 4th op) and digital x-ray. Equipment in pristine condition, most purchased 2016-2018. 2019 GR annualized at $679K+ with adj. 4362 MARIN COUNTY GP Seller owned 1,550 square foot facility with net of $210K. Average 3.5 doctor days/week and 4 hygiene days/ 5 fully-equipped ops. Owner/Doctor transitioning into retirement and week. 800 active patients, all fee-for-service. Seller owns the building, it offering 36 years of goodwill in desirable area. Located on a well traveled is available for purchase. Asking $305K for practice, $425K for building. road in a charming town with temperate weather, easy, outdoor living Owner/doctor willing to help for smooth transition. and natural beauty. Enjoy California living at its best. No Delta Premier patients. Excellent reputation and word-of-mouth referrals. Seller will 4370 SAN JOSE PROSTHODONTIC PRACTICE Cosmetic and help for smooth transition. Average Gross Receipts last 2 yrs is $450K. prosthodontic practice established 40+ years. Located in a busy Asking $248K for the practice. Bldg condo is available for purchase. commercial/residential area of San Jose, close to several amenities, referral sources. Approx 700SaOctLivDe patients, all completely fee-for- UPCOMING: service (Seller is not contracted with any insurance companies or Delta). San Francisco, Redwood Shores, Los Gatos & San Jose GPs Asking $299K.

4338 PENINSULA PROSTHODONTIC PRACTICE Preeminent 45 year Prosthodontic practice located in mid peninsula neighborhood. State- of-the-art 1,242 square foot facility with 5 operatories. Seller willing to help in the transition. Outstanding refSerOraLl sDources. Average Gross Receipts $1.3M with 4 doctor-days per week. Asking $884K.

Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll

carroll.company [email protected] (650) 362-7004 (650) 362-7007 Timothy Giroux, DDS John M. Cahill, MBA Edmond P. Cahill, JD Your Life’s Work Jon B. Noble, MBA Mona Chang, DDS Comes Down To BAY AREA BAY AREA CONTINUED BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED

This Decision AC-989 SAN FRANCISCO (Facility): Busy Retail Shop- CC-963 SANTA ROSA: Practice & Real Estate Avail- DN-1031 CUPERTINO: This remarkable practice awaits only your talent and HG-1068 LAKE TAHOE AREA: Imagine living and practicing in the majestic ping Plaza w/ major anchor tenants! 3 ops Price able! 1765 sf w/ 5 ops Practice $395k & Real Es- skill! 1500sf w 3 ops + 1 add’l. $1.25M Sierra Nevadas and lake community! ~2500 sf w/ 3 Ops. $315k/Real Estate What separates us from Reduced $99k tate $735k DN-1041 SAN JOSE: This stunning practice is an excellent opportunity for Available AC-1059 DALY CITY: Amazing practice w/ seasoned CC-979 NOVATO: Seller Retiring. 803 sf w/ 3 ops new grads! 1207sf w 2ops + 1 add’l. Reduced! $175k HG-1089 CALAVERAS COUNTY: Est. 25 yrs w/ Stellar Reputation! 3000+ sf w/ other brokerage firms? staff in highly desirable neighborhood. 1500 sf w/ 4 near downtown and Old Town Novato. $195K DN-1003 PLEASANTON Facility: An excellent opportunity for a graduate or a 6 ops $465k/Real Estate Also Available

ops $345k (Real Estate $215k) dentist seeking a Satellite location. 1000sf w/ 3ops.N ow Only $60k HG-815 TRUCKEE AREA: Amazingly priced at 50% of Collections! ~1000 sf Western Practice Sales is locally AC-1072 DALY CITY: Seller to work back until May CC-1030 SANTA ROSA: Condo office in modern DN-1046 SANTA CRUZ AREA: Opportunities like this does not come along, w/ 3 ops $165k/ Real Estate Available owned by dentists and has been 2022! 1045 sf w/ 3 ops. Plumbed for 1 add’l $450k bldg w/ ample parking & adjoining Ortho practice! except once in a lifetime! Office 2050 sf w/ 5 ops. Total sq ft3880. HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neigh- proudly serving dentists in AC-1075 DALY CITY: Rare 2 DR Practice in Daly City. 1683 sf w 5 ops $325k $595k /Real Estate: $1.1mil borhood! ~1250 sf w/ 3 ops. Reduced Price $185k/Real Estate Available California for over 45 years. Our One seller would like to work-back. $795k CC-1049 SANTA ROSA: Fully Remodeled, Amazing DN-1067 CASTRO VALLEY: Conservative treatment & compassionate philos- HG-987 LAKE TAHOE AREA: LIVE THE DREAM! The mountains are calling you personal attention to our sellers AG-944 SAN FRANCISCO: An opportunity like this Location. 2000 sf w/ 5 ops $685k Real Estate Also ophy delivered in a warm environment. 1498sf w/ 5ops. $650k/Real Estate: to this Alpine Paradise! ~ 3,400 sf w/ 6 Ops $785K/Real Estate Available does not come along very often! ~998 sf w/ 3 ops Available $675k HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 and reputation of integrity and Reduced $495k CC-1074 SANTA ROSA: PRACTICE & REAL ESTATE DN-1084 SAN JOSE: Newly built-out in 2015, this beautiful, spacious, mod- ops Reduced Price: $265k honesty has made us Northern AG-993 WEST PORTAL AREA: Desirable area w/ easy AT ONE AMAZING LOW PRICE! You will not find ern office is conveniently located! 2204sf w/ 4 ops + 2 add’l$ 560k HG-934 GRASS VALLEY: Underworked PT base should support larger pro- California’s Preferred Dental commute to downtown San Francisco. ~1000sf w/ these build outs in this area for this price! 1200 sf duction numbers! ~1200 sf w/ 3 Ops $168,750/Real Estate Available Practice Broker. 3 ops Reduced Price: $395k 3 ops ONLY $300k NORTHERN CALIFORNIA HN-991 PLACERVILLE: Quality, conservative and compassionate practice! AG-1079 SAN FRANCISCO: Quality Practice in CG-1048 SONOMA: This highly successful family- Will consider work back. 1,654 + 473 sf w 5 ops. $675k

Heart of City! 1800 sf w/ 5 ops offering in-house oriented practice has it ALL! ~1500 sf w/ 4 ops EC-1018 WEST SACRAMENTO: All new leaseholds & top of the line PC EQ Our extensive buyer specialists $685k $630k in 5 ops! 6 ops currently in use. 10 ops total available! $795k CENTRAL VALLEY & SOUTHERN CALIFORNIA database BC-949 ALBANY: Desirable commercial/residential CN-911 SANTA ROSA: This fabulous practice is the EG-968 SACRAMENTO: Desirable, mid-town neighborhood, w/ ample area. Medical Prof Bldg w/ good frontage. 3200sf heart of the Wine Country! 2250 sf w/4 ops + parking in garage! ~1527 sf w/ 5 Ops. Reduced $480k IC-975 MODESTO: Established 33 years. 1,100 sf w/ 3 ops $225k allows us to offer you… w/ 4 ops $695k Real Estate: $1.8 EG-1012 EAST SACRAMENTO: A practice like this one does not come 1add’l. Seller Motivated $465k IG-881 TURLOCK: Long established has unsurpassed quality care. ~3500 sf BC-1010 ANTIOCH: Amazing Opportunity in CN-1090 VACAVILLE: This amazing, state-of-the-art available very often! ~ 2900 sf w/ 8 ops. $2.5M w/ 10 Ops (shared). Reduced: $295k Better Exposure Health Prof. Complex 2118 sf w/ 2 equipped ops practice is an outstanding opportunity! 2400 sf w/ 7 EG-1016 LINCOLN: Look no further than this growing community to IG-1007 GREATER MODESTO AREA: Combines a quality learning environ- Better Fit + 3 add’l $225k ops + 1 add’l. $695k / Real Estate $780k springboard into your success! ~1800 sf w/ 4 Ops Reduced $560k ment with relaxed rural living. ~3000sf w/ 6 ops. $645k BC-1022 OAKLAND: “Pill Hill” Area adjacent to DC-1080 ALAMEDA: Established for 25 years. Seller EG-1039 SIERRA FOOTHILS: The ideal opportunity to practice in this com- IG-1019 TRACY: This opportunity is waiting for you to sink your roots down Better Price! hospital! 1064 sf & 2 ops. Plumbed for 1 add’l retiring from this amazing practice. 1200 sf w/ 3 ops munity! ~1100 sf w/ 4 Ops. $350k and invest your future here! ~1200sf w/ 4 ops. $745k $150k $575k EG-1061 SOUTH AUBURN VICINITY: Come live, play and practice in the IN-1069 STOCKTON: Well-established & fully equipped w/ modern equip- BC-1056 SAN RAMON (Facility): Move-in ready DC-1094 LOS GATOS Facility: Unbeatable location! 2 heart of this pristine town! ~1100 sf w/ 4 Ops. $350k ment, this is an excellent opportunity! 1450sf w/ 3ops +1 add’l. $260k facility in well maintained professional complex. story Med/Prof Bldg near Netflix Headquarters! EG-1092 GRASS VALLEY/AUBURN: If you’ve always wanted to live in Gold IN-1091 TRACY: Spacious, beautiful, modernly equipped, well-designed and 1698 sf w/ 4 ops $80k 1059 sf w/ 2 ops $200k Country, look no further! ~ 1500 sf w/ 4 Ops $295K is a fully digital office! 2,200sf w/ 6 ops.$ 490k BG-1025 WALNUT CREEK: You won’t find a more DG-862 MID-PENINSULA: Rare gem with up to 7 EG-1093 AUBURN: Enviable location, stable patient base and located in JC-811 FRESNO COUNTY: Seller willing to consider Associateship for qualified outstanding opportunity than this extraordinary operatories in the Bay Area! ~2274 sf w/ 6ops + 1 the heart of town! ~ 1000 sf w/ 3 Ops $120k DDS w. intention to Buy In! Considerable Goodwill in Community! 3,000 sf practice! ~2138 sf w/ 6 ops. $750k Real Estate: add’l. $475k EN-1055 ROCKLIN Facility: Build your own success here in this family- w/ 6 ops $350k $995k DG-986 CAMPBELL: The ideal opportunity to prac- oriented community! 1650 sf w/ 4 ops +1 add’l. $95k JC-823 LOS BANOS: Heavy emphasis on hygiene. 1000 sf w/ 3 ops $80k BG-1085 BERKELEY: Stay young and on the cutting tice in this community! ~988 sf w/ 3 ops Seller EN-1077 DAVIS: Imagine living and practicing here! Hesitate and you may JC-1054 VISALIA: Practice AND REAL ESTATE! Prof Bldg on major thorough- edge as you practice in this UC collegiate town! ~ Motivated $288k miss out on your dream! 1100sf. w/ 5 ops. $575k fare. 2,260 sf w/ 6 ops $275k/ Real Estate $517k 1,600 sf w/ 4 ops $975k DG-1006 MONTEREY AREA: This practice is one FC-650 FORT BRAGG: Family-oriented practice. 5 ops in 2000 sf $350k BN-1023 RICHMOND: This is a rich opportunity for which every dentist aspires to! ~3400 sf w/ 8 ops for the Practice & $400k for the Real Estate SPECIALTY PRACTICES the astute dentist! 1450sf w/2 ops + 2 add’l. $ 50k/ Reduced $1.2M FG-1086 UKIAH: This excellent opportunity awaits your talent and skill! Real Estate $750k DG-1009 CARMEL: Amazing fee-for-service practice ~1200sf w/ 4 ops $550k BG-843 WALNUT CREEK Perio: Priced at 50% of collections! ~1085 sf w/ 4 BN-1060 LAYAFETTE: Imagine living, practicing & w/ no contracts! ~1150 sf w/ 4 ops $575K FN-855 NO. HUMBOLDT: Seller relocating! Long-established, 100% FFS ops $390k raising your family here in this community! DG-1014 MONTEREY: Don’t miss your opportunity practice! 1600 sf w/ 3ops + 1 add’l. $190k/ Real Estate Available BG-1024 WALNUT CREEK Prosth: Stellar reputation for providing the highest 1400sf w/ 3op. Seller Motivated $225k to live and practice in beautiful Monterey! ~1125 GN-1071 REDDING: Streamlined policies & loyal patient base, this quality level of treatment! ~2138 sf w/ 6 ops. $750k Real Estate: $995k BN-1067 SAN LEANDRO: Imagine owning this sf w/ 4 Ops. $650k practice is your springboard to success! 2264sf w/ 4 ops. $525k DG-1078 SARATOGA Ortho: One-of-a-kind, modern, high-tech orthodon- Call or email today for a free family-oriented practice with a large patient base. DG-1081 SAN JOSE: Located in popular retail GN-1073 BUTTE CO: Quality, fee-for-service practice with a stellar repu- tic boutique practice! ~ 1400 sf w/ 5 Ops $980K copy of Dr Giroux’s book 1495sf w/ 3 ops 2 + 1 add’l. $325k shopping center. Spacious 2800 sf office w/ 8 fully tation! 1800sf w/ ops. $375k / Real Estate Available GG-940 NORTH OF SACRAMENTO Pedo: Practice is on track to collect more CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 equipped ops $395k HG-1053 GRASS VALLEY: Well-established practice of 40+ years, known for than $1,000,000 in revenues this year! ~4300 sf w/ 5 ops. $660k ops 640 sf Collections $433k in 2017 $275k its quality dentistry! ~1200 sf w/ 3 ops $420K Top Ten Issues for Dentists Contemplating Retirement in Ten Years or Less 800.641.4179 [email protected] “ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM Timothy Giroux, DDS John M. Cahill, MBA Edmond P. Cahill, JD Your Life’s Work Jon B. Noble, MBA Mona Chang, DDS Comes Down To BAY AREA BAY AREA CONTINUED BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED

This Decision AC-989 SAN FRANCISCO (Facility): Busy Retail Shop- CC-963 SANTA ROSA: Practice & Real Estate Avail- DN-1031 CUPERTINO: This remarkable practice awaits only your talent and HG-1068 LAKE TAHOE AREA: Imagine living and practicing in the majestic ping Plaza w/ major anchor tenants! 3 ops Price able! 1765 sf w/ 5 ops Practice $395k & Real Es- skill! 1500sf w 3 ops + 1 add’l. $1.25M Sierra Nevadas and lake community! ~2500 sf w/ 3 Ops. $315k/Real Estate What separates us from Reduced $99k tate $735k DN-1041 SAN JOSE: This stunning practice is an excellent opportunity for Available AC-1059 DALY CITY: Amazing practice w/ seasoned CC-979 NOVATO: Seller Retiring. 803 sf w/ 3 ops new grads! 1207sf w 2ops + 1 add’l. Reduced! $175k HG-1089 CALAVERAS COUNTY: Est. 25 yrs w/ Stellar Reputation! 3000+ sf w/ other brokerage firms? staff in highly desirable neighborhood. 1500 sf w/ 4 near downtown and Old Town Novato. $195K DN-1003 PLEASANTON Facility: An excellent opportunity for a graduate or a 6 ops $465k/Real Estate Also Available

ops $345k (Real Estate $215k) dentist seeking a Satellite location. 1000sf w/ 3ops.N ow Only $60k HG-815 TRUCKEE AREA: Amazingly priced at 50% of Collections! ~1000 sf Western Practice Sales is locally AC-1072 DALY CITY: Seller to work back until May CC-1030 SANTA ROSA: Condo office in modern DN-1046 SANTA CRUZ AREA: Opportunities like this does not come along, w/ 3 ops $165k/ Real Estate Available owned by dentists and has been 2022! 1045 sf w/ 3 ops. Plumbed for 1 add’l $450k bldg w/ ample parking & adjoining Ortho practice! except once in a lifetime! Office 2050 sf w/ 5 ops. Total sq ft3880. HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neigh- proudly serving dentists in AC-1075 DALY CITY: Rare 2 DR Practice in Daly City. 1683 sf w 5 ops $325k $595k /Real Estate: $1.1mil borhood! ~1250 sf w/ 3 ops. Reduced Price $185k/Real Estate Available California for over 45 years. Our One seller would like to work-back. $795k CC-1049 SANTA ROSA: Fully Remodeled, Amazing DN-1067 CASTRO VALLEY: Conservative treatment & compassionate philos- HG-987 LAKE TAHOE AREA: LIVE THE DREAM! The mountains are calling you personal attention to our sellers AG-944 SAN FRANCISCO: An opportunity like this Location. 2000 sf w/ 5 ops $685k Real Estate Also ophy delivered in a warm environment. 1498sf w/ 5ops. $650k/Real Estate: to this Alpine Paradise! ~ 3,400 sf w/ 6 Ops $785K/Real Estate Available does not come along very often! ~998 sf w/ 3 ops Available $675k HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 and reputation of integrity and Reduced $495k CC-1074 SANTA ROSA: PRACTICE & REAL ESTATE DN-1084 SAN JOSE: Newly built-out in 2015, this beautiful, spacious, mod- ops Reduced Price: $265k honesty has made us Northern AG-993 WEST PORTAL AREA: Desirable area w/ easy AT ONE AMAZING LOW PRICE! You will not find ern office is conveniently located! 2204sf w/ 4 ops + 2 add’l$ 560k HG-934 GRASS VALLEY: Underworked PT base should support larger pro- California’s Preferred Dental commute to downtown San Francisco. ~1000sf w/ these build outs in this area for this price! 1200 sf duction numbers! ~1200 sf w/ 3 Ops $168,750/Real Estate Available Practice Broker. 3 ops Reduced Price: $395k 3 ops ONLY $300k NORTHERN CALIFORNIA HN-991 PLACERVILLE: Quality, conservative and compassionate practice! AG-1079 SAN FRANCISCO: Quality Practice in CG-1048 SONOMA: This highly successful family- Will consider work back. 1,654 + 473 sf w 5 ops. $675k

Heart of City! 1800 sf w/ 5 ops offering in-house oriented practice has it ALL! ~1500 sf w/ 4 ops EC-1018 WEST SACRAMENTO: All new leaseholds & top of the line PC EQ Our extensive buyer specialists $685k $630k in 5 ops! 6 ops currently in use. 10 ops total available! $795k CENTRAL VALLEY & SOUTHERN CALIFORNIA database BC-949 ALBANY: Desirable commercial/residential CN-911 SANTA ROSA: This fabulous practice is the EG-968 SACRAMENTO: Desirable, mid-town neighborhood, w/ ample area. Medical Prof Bldg w/ good frontage. 3200sf heart of the Wine Country! 2250 sf w/4 ops + parking in garage! ~1527 sf w/ 5 Ops. Reduced $480k IC-975 MODESTO: Established 33 years. 1,100 sf w/ 3 ops $225k allows us to offer you… w/ 4 ops $695k Real Estate: $1.8 EG-1012 EAST SACRAMENTO: A practice like this one does not come 1add’l. Seller Motivated $465k IG-881 TURLOCK: Long established has unsurpassed quality care. ~3500 sf BC-1010 ANTIOCH: Amazing Opportunity in CN-1090 VACAVILLE: This amazing, state-of-the-art available very often! ~ 2900 sf w/ 8 ops. $2.5M w/ 10 Ops (shared). Reduced: $295k Better Exposure Health Prof. Complex 2118 sf w/ 2 equipped ops practice is an outstanding opportunity! 2400 sf w/ 7 EG-1016 LINCOLN: Look no further than this growing community to IG-1007 GREATER MODESTO AREA: Combines a quality learning environ- Better Fit + 3 add’l $225k ops + 1 add’l. $695k / Real Estate $780k springboard into your success! ~1800 sf w/ 4 Ops Reduced $560k ment with relaxed rural living. ~3000sf w/ 6 ops. $645k BC-1022 OAKLAND: “Pill Hill” Area adjacent to DC-1080 ALAMEDA: Established for 25 years. Seller EG-1039 SIERRA FOOTHILS: The ideal opportunity to practice in this com- IG-1019 TRACY: This opportunity is waiting for you to sink your roots down Better Price! hospital! 1064 sf & 2 ops. Plumbed for 1 add’l retiring from this amazing practice. 1200 sf w/ 3 ops munity! ~1100 sf w/ 4 Ops. $350k and invest your future here! ~1200sf w/ 4 ops. $745k $150k $575k EG-1061 SOUTH AUBURN VICINITY: Come live, play and practice in the IN-1069 STOCKTON: Well-established & fully equipped w/ modern equip- BC-1056 SAN RAMON (Facility): Move-in ready DC-1094 LOS GATOS Facility: Unbeatable location! 2 heart of this pristine town! ~1100 sf w/ 4 Ops. $350k ment, this is an excellent opportunity! 1450sf w/ 3ops +1 add’l. $260k facility in well maintained professional complex. story Med/Prof Bldg near Netflix Headquarters! EG-1092 GRASS VALLEY/AUBURN: If you’ve always wanted to live in Gold IN-1091 TRACY: Spacious, beautiful, modernly equipped, well-designed and 1698 sf w/ 4 ops $80k 1059 sf w/ 2 ops $200k Country, look no further! ~ 1500 sf w/ 4 Ops $295K is a fully digital office! 2,200sf w/ 6 ops.$ 490k BG-1025 WALNUT CREEK: You won’t find a more DG-862 MID-PENINSULA: Rare gem with up to 7 EG-1093 AUBURN: Enviable location, stable patient base and located in JC-811 FRESNO COUNTY: Seller willing to consider Associateship for qualified outstanding opportunity than this extraordinary operatories in the Bay Area! ~2274 sf w/ 6ops + 1 the heart of town! ~ 1000 sf w/ 3 Ops $120k DDS w. intention to Buy In! Considerable Goodwill in Community! 3,000 sf practice! ~2138 sf w/ 6 ops. $750k Real Estate: add’l. $475k EN-1055 ROCKLIN Facility: Build your own success here in this family- w/ 6 ops $350k $995k DG-986 CAMPBELL: The ideal opportunity to prac- oriented community! 1650 sf w/ 4 ops +1 add’l. $95k JC-823 LOS BANOS: Heavy emphasis on hygiene. 1000 sf w/ 3 ops $80k BG-1085 BERKELEY: Stay young and on the cutting tice in this community! ~988 sf w/ 3 ops Seller EN-1077 DAVIS: Imagine living and practicing here! Hesitate and you may JC-1054 VISALIA: Practice AND REAL ESTATE! Prof Bldg on major thorough- edge as you practice in this UC collegiate town! ~ Motivated $288k miss out on your dream! 1100sf. w/ 5 ops. $575k fare. 2,260 sf w/ 6 ops $275k/ Real Estate $517k 1,600 sf w/ 4 ops $975k DG-1006 MONTEREY AREA: This practice is one FC-650 FORT BRAGG: Family-oriented practice. 5 ops in 2000 sf $350k BN-1023 RICHMOND: This is a rich opportunity for which every dentist aspires to! ~3400 sf w/ 8 ops for the Practice & $400k for the Real Estate SPECIALTY PRACTICES the astute dentist! 1450sf w/2 ops + 2 add’l. $ 50k/ Reduced $1.2M FG-1086 UKIAH: This excellent opportunity awaits your talent and skill! Real Estate $750k DG-1009 CARMEL: Amazing fee-for-service practice ~1200sf w/ 4 ops $550k BG-843 WALNUT CREEK Perio: Priced at 50% of collections! ~1085 sf w/ 4 BN-1060 LAYAFETTE: Imagine living, practicing & w/ no contracts! ~1150 sf w/ 4 ops $575K FN-855 NO. HUMBOLDT: Seller relocating! Long-established, 100% FFS ops $390k raising your family here in this community! DG-1014 MONTEREY: Don’t miss your opportunity practice! 1600 sf w/ 3ops + 1 add’l. $190k/ Real Estate Available BG-1024 WALNUT CREEK Prosth: Stellar reputation for providing the highest 1400sf w/ 3op. Seller Motivated $225k to live and practice in beautiful Monterey! ~1125 GN-1071 REDDING: Streamlined policies & loyal patient base, this quality level of treatment! ~2138 sf w/ 6 ops. $750k Real Estate: $995k BN-1067 SAN LEANDRO: Imagine owning this sf w/ 4 Ops. $650k practice is your springboard to success! 2264sf w/ 4 ops. $525k DG-1078 SARATOGA Ortho: One-of-a-kind, modern, high-tech orthodon- Call or email today for a free family-oriented practice with a large patient base. DG-1081 SAN JOSE: Located in popular retail GN-1073 BUTTE CO: Quality, fee-for-service practice with a stellar repu- tic boutique practice! ~ 1400 sf w/ 5 Ops $980K copy of Dr Giroux’s book 1495sf w/ 3 ops 2 + 1 add’l. $325k shopping center. Spacious 2800 sf office w/ 8 fully tation! 1800sf w/ ops. $375k / Real Estate Available GG-940 NORTH OF SACRAMENTO Pedo: Practice is on track to collect more CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 equipped ops $395k HG-1053 GRASS VALLEY: Well-established practice of 40+ years, known for than $1,000,000 in revenues this year! ~4300 sf w/ 5 ops. $660k ops 640 sf Collections $433k in 2017 $275k its quality dentistry! ~1200 sf w/ 3 ops $420K Top Ten Issues for Dentists Contemplating Retirement in Ten Years or Less 800.641.4179 [email protected] “ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 48, Nº3

A look into the latest dental and general technology on the market

Silk’n ToothWave (€299, Silk’n) Burner (Starts at $1.99/two plan types, Ad Hoc Labs Inc.) The annual Consumer Electronics Show in Las Vegas is a massive With the reported recent data leaks and breaches of high-profile technological wonderland showcasing innovations from all fields. This companies, private information about the lives of individuals is year, one such innovation is from a European beauty company called increasingly being compromised. Credit card accounts, Social Silk’n, which introduced the ToothWave, the world’s first toothbrush Security numbers and birthdates have long been the information to utilize radiofrequency (RF) technology to remove extrinsic stains sought after by those committing fraud. Phone numbers, used in and calculus. This patent-pending product utilizes two RF electrodes almost every aspect of daily life ranging from retailer rewards to separated by a silicon barrier to generate a 3-watt current that account memberships, are critical identifiers of personal information oscillates at a frequency of 3 MHz to remove particulates adhering and should be kept private. Burner is an app that provides a second to the tooth surface. The vendor points to two clinical studies it phone number to make texts or calls for any situation and can be commissioned that showed four to six weeks’ use of the ToothWave disposed of at any time. resulted in lower gingival bleeding, lower gingival inflammation, Signing up for Burner is easy and requires the phone number of plaque reduction, reduced calculus, reduced staining and whiter teeth. the device that the app is installed on, which it uses to send a Of note is that in its FDA clinical trials documentation (clinicaltrials.gov/ verification code via text message. Once the sign-up process is ct2/show/study/NCT03885609), its only claim is that of an complete, users can then search by area code for available numbers “RF-utilizing powered toothbrush for teeth whitening” and makes no from which to choose a second phone number. The main screen mention of calculus removal or gingival health. has a simple design and includes a history of calls or texts that used The ToothWave looks and feels like most well-built electric the second phone number. Toward the bottom are buttons to make toothbrushes, minus the ergonomic handle. Brush heads are calls, send messages, change settings and burn, which effectively removable and each ToothWave comes with two (one large, one disposes the second phone number. All calls are routed through small), along with a USB charging cable and stand. It has a single Burner’s temporary second phone number so recipients cannot button, which turns the device on or off and adjusts the vibration trace the originating phone line. Texts and video/picture messaging intensity. The vendor emphasizes that vibrations are not necessary work normally on the second phone number through the app. The components of ToothWave’s function and were only put in after app provides a full complement of settings for the second phone user feedback. All that is required to reap the benefits of the device line, such as voicemail, call and text forwarding, in-app VoIP and is to wet the brush head, apply toothpaste, turn on the device and Wi-Fi calling and integrations with many popular services, such as hold it up to all the tooth surfaces. A 30-second timer beeps to let Dropbox, Evernote, Google, SoundCloud and Slack, to extend its users know to move to the next quadrant, and it has an auto shut-off functionality. Call quality may vary among different cellular or Wi-Fi at two minutes. Using the ToothWave does not feel different from data networks, but works as intended. any other toothbrush, and the immediate results do not appear to With the California Consumer Privacy Act taking effect July 1, 2020, be noticeable. At the minimum, there does not appear to be any protecting personal data and privacy has become a primary concern mechanical harm with no change in tooth sensitivity. Additional for everyone. Consumers must be aware and responsible for their testing is necessary to gauge the ToothWave’s claims and its own data as they navigate through this digital age. With Burner, ultimate worth, but the lack of premium features, like a travel case, users can take action to keep their personal phone numbers private. ergonomic handle and quadrant-tracking technology, make this premium toothbrush feel like a nonpremium product. — Hubert Chan, DDS For this review, the vendor provided the reviewer the ToothWave as part of its media kit. — Alexander Lee, DMD

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