Dental Implants Prepless Veneers Peg Laterals JournaCALIFORNIA DENTAL ASSOCIATION Injection Molded Composites

Cosmetic : Conservative Approaches, Confident Smiles Nicholas C. Marongiu, DDS NEED SUPPLIES TO COMPLY? PROTECT YOUR TEAM AND SAVE

Through The Dentists Supply Company, it’s easy and affordable to save big on the dental supplies that help you meet Cal/OSHA standards.

• Up to 40% off personal protective equipment* • Up to 23% off Cal/OSHA compliant labels* • Up to 29% off sharps containers* • Up to 21% off safety glasses and goggles*

Shop TDSC.com for negotiated savings and free shipping on the supplies you love from over 350 trusted manufacturers.

SHOP ONLINE AND START SAVING TODAY

* Savings compared to the manufacturer’s list price. Actual savings on TDSC.com may vary. Feb. 2020 CDA JOURNAL, VOL 48, Nº2

departments 53 The Associate Editor/Finding a Way

57 Letters to the Editor

59 Impressions

89 RM Matters/Keeping Office Payments Safe and Secure

91 Regulatory Compliance/Role of the Infection Control Coordinator

95 Ethics/Refer or Not: That’s the Question 98 Tech Trends 59

f e at u r e s 63 : Conservative Approaches, Confident Smiles An introduction to the issue. Nicholas C. Marongiu, DDS

65 Compromised Anterior Single Implant Restoration Using Pink Ceramic This article discusses how using pink ceramic can be a viable option in cases where soft tissue is deficient. John F. Weston, DDS

73 Minimize Preparations for Maximum Results This article focuses on prepless veneers as an excellent, yet conservative aesthetic option that can yield outstanding results. Adamo E. Notarantonio, DDS

77 Treatment Planning and Managing the Peg Lateral Incisor Different options and treatment considerations while managing peg laterals are discussed in this article as well as highlights from one case that was managed based upon limitations of the patient’s desires. Jeffrey W. Lineberry, DDS

81 Treatment of the Dreaded Black Triangle: A Case Report and an Introduction to Injection Molded Composite Dentistry This article describes an injection overmold technique with heated multiviscosity resins in precise matrices with a perfect gingival seal and without cutting the tooth to accommodate indirect ceramics. David J. Clark, DDS

FEBRUARY 2 0 2 0 51 CDA JOURNAL, VOL 48, Nº2

Volume 48 Number 2 February 2020 JournaCALIFORNIA DENTAL ASSOCIATION

published by the Management Kristi Parker Johnson Permission and Journal of the California Dental Association California Peter A. DuBois Senior Communications Reprints Editorial Board Specialist Dental Association Executive Director Andrea LaMattina, CDE Charles N. Bertolami, DDS, DMedSc, Herman Robert 1201 K St., 14th Floor publications manager Fox dean, NYU College of Dentistry, New York Carrie E. Gordon Joie R. Harrison Sacramento, CA 95814 Communications and [email protected] Chief Strategy Officer Steven W. Friedrichsen, DDS, professor and dean, 800.232.7645 Media Relations Specialist 916.554.5950 Western University of Health Sciences College of Dental cda.org Kristine Allington Medicine, Pomona, Calif. Chief Marketing Officer Blake Ellington Manuscript Tech Trends Editor CDA Officers Submissions Mina Habibian, DMD, MSc, PhD, associate professor Alicia Malaby Richard J. Nagy, DDS of clinical dentistry, Herman Ostrow School of Dentistry Communications Director Jack F. Conley, DDS www.editorialmanager. President Editor Emeritus com/jcaldentassoc of USC, Los Angeles [email protected] Cris Weber Robert Handysides, DDS, dean and associate professor, Creative and UX Director Robert E. Horseman, DDS Letters to the Editor Judee Tippett-Whyte, DDS department of , Loma Linda University School Humorist Emeritus www.editorialmanager. President-Elect of Dentistry, Loma Linda, Calif. Editorial com/jcaldentassoc [email protected] Production Kerry K. Carney, DDS, CDE Bradley Henson, DDS, PhD, associate dean for research Ariane R. Terlet, DDS Editor-in-Chief Randi Taylor Subscriptions and biomedical sciences and associate professor, Western Vice President [email protected] Senior Visual Designer Annual subscriptions are University of Health Sciences College of Dental Medicine, [email protected] available to association Pomona, Calif. Ruchi K. Sahota, DDS, CDE Upcoming Topics members at a rate of $36. Associate Editor John L. Blake, DDS March/CDA’s 150th To manage your printed Paul Krebsbach, DDS, PhD, dean and professor, section Secretary Anniversary of periodontics, University of California, Los Angeles, Brian K. Shue, DDS, CDE Journal subscription [email protected] April/Health Literacy School of Dentistry Associate Editor online, log in to your cda. May/History of TDSC Steven J. Kend, DDS org account or email Jayanth Kumar, DDS, MPH, state dental director, Gayle Mathe, RDH Treasurer [email protected] Sacramento, Calif. Senior Editor Advertising [email protected] for assistance. View the Sue Gardner publication online at Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral Nicholas C. Marongiu, DDS Debra S. Finney, MS, DDS, Advertising Sales cda.org/journal. health education, University of the Pacific, Arthur A. Dugoni Guest Editor Speaker of the House [email protected] School of Dentistry, San Francisco [email protected] Andrea LaMattina, CDE 916.554.4952 Nader A. Nadershahi, DDS, MBA, EdD, dean, Publications Manager 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 and director, UCLA Center The Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, for Children’s Oral Health, University of California, Los 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Periodicals postage paid at Sacramento, Calif. Postmaster: Angeles, School of Dentistry Send address changes to Journal of the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814. Michael Reddy, DMD, DMSc, dean, University of The California Dental Association holds the copyright for all articles and artwork published herein. California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial Avishai Sadan, DMD, dean, Herman Ostrow School of staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published Dentistry of USC, Los Angeles solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Harold Slavkin, dean and professor emeritus, division of Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor biomedical sciences, Center for Craniofacial Molecular Biology, do advertisements constitute endorsement or approval of advertised products or services. Herman Ostrow School of Dentistry of USC, Los Angeles

Copyright 2020 by the California Dental Association. All rights reserved. Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author health policy and epidemiology, Harvard School of instructions and aims and scope statement. Dental Medicine, Boston

Richard W. Valachovic, DMD, MPH, president emeritus, Connect to the CDA community by American Dental Education Association, Washington D.C. following and sharing on social channels

@cdadentists

52 FEBRUARY 2 0 2 0 Assoc. Editor CDA JOURNAL, VOL 48, Nº2

Finding a Way

Ruchi K. Sahota, DDS, CDE

here is always a way. The fable of the crow and the pitcher rings true in everyday life. On As CDA members, we have help. We have the his daily walk, a thirsty crow opportunity for CDA staff to look into why these stumbled upon a pitcher. It challenges are occurring and provide us a solution. Tlooked to be full of water. But when the crow went to drink out of the pitcher, his beak could not reach the water. He kept trying and trying and trying. He finally gave up. The water looked so What is the first challenge that comes against members, including but not good, so fulfilling. So, obviously, the to mind? Is it benefit plans? Is it retrieving limited to inappropriate claim delays crow did not want to give up. He had the payment from dental benefit plans and denials” and asked for this data to an idea. He started to drop pebbles into for the treatment we have provided? Is be used to address benefits-related issues the pitcher, so the water would rise it retrieving the payment from dental and opportunities for CDA advocacy. to the top. His beak then eventually benefit plans that they have promised The task force’s mission and its key reached the desired water. His thirst their insured patients? Is it retrieving findings led the members to create the was quenched. Success was achieved. payment from the dental benefit plans for Dental Benefit Issues Submission form, It could be a lightbulb moment, benefits the employers have negotiated which allows members to communicate where a sudden, creative idea that for their employees? Is it trying to their challenges with claim delays, can help us achieve our goals enters advocate on behalf of our patients for denials and other relations with insurance our minds. It could be a useful but the payments they deserve because the companies. As CDA members, we coincidental circumstance that provides patients are doing their part in paying the have help. We have the opportunity an alternative way of doing things premiums? These challenges are often for CDA staff to look into why these that helps solve a problem. Or it the most frustrating parts of my day. challenges are occurring and provide us could be a helpful person who has the Our CDA Dental Benefits and a solution. We have this opportunity experience to show us another way. Economics Task Force was charged by 24 hours a day, seven days a week. The daily grind of our routines in the House of Delegates (HOD) a few CDA staff reports that though it the four walls of our offices offers many years ago to address dental benefit plans varies based on each situation, the challenges. Some solutions are easy to and economic issues of practices and average time to close a case in the last grasp, and others seem like the water in offer recommendations on how CDA six months is three days. Extended the crow’s pitcher. Inevitably, we need could assist members dealing with these turnaround times may result when staff to find these solutions. We need to find challenges, prioritize researching dental has to reach out to the insurance company a way. Time is money, is it not? What payment denials and delays and urge and wait for its response, of course. does this sentiment mean to you? Is it the board of trustees to intervene and Most members who have submitted that we have a limited reserve of time take appropriate action if necessary. the form have been most satisfied at every day, so doing everything as quickly The task force found that “benefits and its accessibility. The form is online as possible is important to capitalize on reimbursement models have not kept up and accessible 24 hours a day, seven its value? Or is that we should spend our with changes in health care environment; days a week. Members have also noted time and exertion on things that will systemic and bureaucratic challenges with the quick follow-up and resolution of result in the successes we are looking for? plans continue; and [noted that there issues. But most of all, we can appreciate How much time are we wasting when is a] challenge for dental offices to keep the opportunity for education — the we keep trying to get the water out of up.” The HOD resolution also called opportunity for the lightbulb moment the pitcher? How much money are we for obtaining data regarding “members’ that helps us realize how to get the wasting on our repeated attempts? concerns about dental carriers’ actions water into the crow’s beak. This is not

FEBRUARY 2 0 2 0 53 FEB. 2020 ASSOC. EDITOR

CDA JOURNAL, VOL 48, Nº2

a novel initiative for CDA. Years ago, opportunities for training our staff. catch the rope.’ Then I knew that my CDA created the Practice Support It helps us identify unfair practices troubles had come to an end. And I climbed Center – a library of resources, guides and issues where dental benefit plans up the rope calling ‘Thank you my friend.’” and templates. CDA has continued are breaking the law or contracts so We should not hesitate to accept to honor its mission statement over that CDA advocacy staff and its legal help. But even though this resource the years: It “is committed to the team can pursue these incidents. has been available since April 2019, success of our members in service Within six months, CDA staff many members do not know about it. to their patients and the public.” helped 774 members. So there is Not knowing where the rope is when The HIPAA-protected Dental help out there. Because we are CDA we are stuck is a rampant problem. Benefits Issues Submission form on members, we do not have to be crows For example, many of my local dental cda.org does more than just help us trying to decipher how to get water out society’s members did not know they help our patients with reimbursements. of a pitcher. Dr. Suess said, “I floated had the opportunity to get free online It also helps to identify emerging 12 days without toothpaste or soup. I C.E. through the dental society, trends. It helps to identify common practically almost had given up hope. although it had been announced at plan errors. It helps to identify When someone high shouted, ‘Here, meetings and in newsletters and emails. Many of my neighbors did not know our local library gives us free museum passes, free online magazine access and free notary services — although it has been publicized for years and years. There is always a way. It takes members less than two minutes to fill out the Dental Benefits Issues Submission form online. CDA staff will take it from there. They will hold members’ hands, work with them through the process and coach them to avoid the frustrating back and forth with insurance companies. We are lucky; help is a click away. Visit cda.org and reach for that rope you need to climb out, my friend. n

Ruchi K. Sahota, DDS, CDE, practices family dentistry in Fremont, Give health and hope. Calif., and serves on the CDA Board of Trustees. She is also a certified dental CDA Cares Long Beach Contribute your time and talents to relieve pain, editor, a consumer advisor for the American July 17–18, 2020 restore dignity and create smiles for others who face barriers to accessing dental care. Dental Association, past president of the Long Beach Convention Southern Alameda County Dental Society & Entertainment Center Volunteer to join us at CDA Cares. and a fellow of the American College of Dentists, International College of Dentists Join us. cdafoundation.org/cdacares and the Pierre Fauchard Academy.

54 FEBRUARY 2 0 2 0

From dentist-centric insurance to savings on dental supplies to support on the business side, CDA has innovated and grown to serve members for 150 years. Explore your benefits and renew today at cda.org/renew.

READY? LET’S GROW.

TOGETHER WE ARE LIMITLESS Letters CDA JOURNAL, VOL 48, Nº2

November 2019 Fluoride Varnish Pediatric Pain Assessment Denture Fracture Strength

JournaCALIFORNIA DENTAL ASSOCIATION No Comparison A History of Water Fluoridation in California: Lessons Learned As a dentist editor who is You Lost Me at Toothbrushes interested in history, I read with I was left scratching my head after interest Dr. Brian Shue’s November reading Dr Shue’s November 2019 2019 editorial on comparisons of editorial about toothbrushes and World War II German and American concentration camps and wondered “concentration” camps and the what the heck it was doing in CDA’s facilities now used to house migrant Journal. It had nothing to do with Vol 47 N

aliens along the U.S.-Mexico border. dentistry. As I attend the CDA House o 9 While the conditions in any facility of Delegates, I marvel about what a used to house a lot of people are not diverse crowd we are. Different ethnic desirable, it would indeed be preferred backgrounds, different religious beliefs, From dentist-centric insurance for those housed to have personal different alma maters — and yet we are the Auschwitz Death Camp because to savings on dental supplies care items like simple toothbrushes, friends and colleagues with a common he was a dental student was fascinating to support on the business side, toothpaste and other toiletries. It code of ethics and dedication to our to me. Jacobs even provided dental CDA has innovated and grown indicates a lack of knowledge to state profession. In today’s hyperpolarized treatment to his Nazi captors. These to serve members for 150 years. that these conditions are similar to the political climate, there are many skills no doubt kept him alive as Explore your benefits and renew concentration camps in Germany, such who would read Dr Shue’s article an asset to this death camp. today at cda.org/renew. as Auschwitz, or even like the ones and get “triggered” by one extreme As a forensic dentist, I am in the U.S. at the same time period. view or the opposite. Are detainees intrigued by stories of our dental I’d suggest should anyone doubt Dr. getting adequate treatment or maybe colleagues who did extraordinary Shue’s comparisons to search Google even better than they deserve? Is the things during their time in history. pictures of the wartime German separation of families and the use of Whether it was Paul Revere concentration camps at the time of icebox rooms a form of torture? Who is identifying the remains of a fallen their rescue. I have seen pictures Alexandria Ocasio Cortez? She isn’t a American patriot weeks after a from the current detention centers at CDA trustee. She represents a district Revolutionary War battle by recognizing our southern border and I do not see in New York City. Please! Leave politics a partial denture he had fabricated any comparison. As Army General out of CDA. Dentistry is my safe place. or George Washington’s many sets of Sherman said during the Civil War, j oa n d e n d i n g e r , d d s ill-fitting dentures or the use of dental “War is hell.” Certainly any detention Yucaipa, Calif. records to confirm the identities of is hell — just at different levels. presidential assassins John Wilkes I would like to see the conditions Compelling Accounts of Our Past Booth and Lee Harvey Oswald or the READY? improve for these detainees, As a longtime (and lifetime) establishing of positive postmortem and I’m sure Dr. Shue would as member of CDA, I have very identifications of World War II Nazi well. However, that is not what much come to appreciate and look hierarchy or the retelling of Dr. Ben he is trying to point out. forward to reading the editorial in Salomon’s heroics during the World LET’S As a fellow member and former each issue of our CDA Journal. War II Battle of Saipan, I have loved president and a former editor-in- Our editorial staff has received these compelling accounts of our past. chief of the American Association many well-deserved awards in past Once again, I wish to commend of Dental Editors and Journalists, years and has been an excellent source, Dr. Brian Shue and all the editorial GROW. I proudly congratulate Dr. Shue bringing interesting topics forward. contributors who produce an on his editorial and will not be The November 2019 issue featured excellent Journal of the California surprised at all if it garners another Dr. Brian Shue. His story entitled Dental Association. journalistic award for the Journal of “Toothbrushes and Concentration s t e p h e n m . loj e s k i , d d s the California Dental Association. Camps” once again hit it out of the c da t r u s t e e Arcadia, Calif. da n i e l j e n k i n s , d d s , c d e park. The story of a Jewish first-year TOGETHER Editor, Tri-County Dental Society dental student, Benjamin Jacobs WE ARE LIMITLESS (Bronek Jakubowicz), who survived

FEBRUARY 2 0 2 0 57 STRENGTH. SAVINGS. CONFIDENCE. CDA has leveraged the strength of our large membership to deliver even more value, including resources to support you in the business side of practice. Endorsed Programs provide money-saving solutions from vendors that have been vetted by CDA. cda.org/endorsedprograms

Feel like it’s going to take forever to pay off your dental school loans? As a CDA member, you’ve now got access to a student FEATURED ENDORSED PROGRAM loan refinancing program that helps you better navigate debt. Save significantly over time by trading in existing high-interest loans for a single new loan at a lower interest rate.

CommonBond offers members loan refinancing that’s designed for dentists at a 0.25% rate discount*, plus a $500 cash bonus.** Lower monthly payments to improve cash flow or pay off student debt faster.

* 0.25% discount will be reflected on the final truth-in-lending disclosure. ** $500 credited to your PayPal within 6 weeks of funding. Lending decisions are not impacted in any way by participation in this offer. Offer is non-transferable. No substitutions. Limit one offer per loan.

TOGETHER WE ARE LIMITLESS Impressions CDA JOURNAL, VOL 48, Nº2

Conventional Fillings? Not Always Best

The FiCTION trial, a three-year study comparing three different treatment options for tooth decay in children’s teeth, found no evidence to suggest that conventional fillings are more effective than sealing decay into teeth or using prevention techniques alone in stopping pain and infection caused by tooth decay in primary teeth. The study, led by dentists from the Universities of Dundee, Newcastle, Sheffield, Cardiff, Queen Mary University of London and Leeds, was published in the Journal of Dental Research in November 2019. The trial also found that 450 children who took part in the study experienced tooth decay and pain regardless of which kind of dental treatment they received. During the study, more than 1,140 children between the ages of 3 and 7 with visible tooth decay were recruited by dentists working in one of 72 dental clinics throughout the country. One of three treatment approaches was then chosen randomly for each child’s dental care for the duration of the trial, which was up to three years. “What is absolutely clear The first approach avoided placing any fillings from our trial is that the best and aimed to prevent new decay by reducing sugar intake, ensuring twice-daily brushing with fluoridated way to manage tooth decay toothpaste, application of fluoride varnish and placing is not by drilling it out or of fissure sealants on the first permanent molar teeth. The second option involved drilling out tooth decay, sealing it in — it’s by which was based upon what has been considered the preventing it in the first place.” standard “drill-and-fill” practice for more than 50 years together with preventive treatments. The third treatment — NICOLA INNES, PHD strategy was a minimally invasive approach where tooth decay was sealed in under a metal or a filling to stop it progressing, together with preventive treatments. The main trial findings found no evidence to suggest that any of the treatment strategies were better than the other in terms of making a difference in the children’s experience of pain or infection, quality of life or dental anxiety between groups. All three ways of treating decay were acceptable to children, parents and dental professionals. “Our study shows that each way of treating decay worked to a similar level but that children who get tooth decay at a young age have a high chance of experiencing toothache and abscesses regardless of the way the dentist manages the decay,” said lead author Nicola Innes, PhD, chair of pediatric dentistry at the University of Dundee. “What is absolutely clear from our trial is that the best way to manage tooth decay is not by drilling it out or sealing it in — it’s by preventing it in the first place.” Learn more about this study in the Journal of Dental Research (2019); doi.org/10.1177/0022034519888882. n

FEBRUARY 2 0 2 0 59 FEB. 2020 IMPRESSIONS

CDA JOURNAL, VOL 48, Nº2

E-scooters Result in More Craniofacial Trauma Researchers from the Texas A&M College of Dentistry found that 60% of patients who visited the emergency department in Dallas from July 2018, Chewing Sugar-Free Gum when e-scooters became available in the area, to February 2019 had head and face injuries. The study was published in November 2019 in the Journal Slows Caries Progression of Oral and Maxillofacial Surgery and featured in a DrBicuspid.com article. Chewing sugar-free gum may The research team calculated results for all variables, including incident be a supplement to preventive oral notes, patient interviews, diagnostic tests, treatment and contributing factors health routines in children, according such as the use of alcohol and protective equipment. Results showed that 52 to a systematic review conducted of the 90 patients who went to emergency departments with e-scooter-related by researchers from King’s College injuries experienced injuries to their head and face. They experienced many London, Guy’s Dental Hospital and types of craniofacial trauma, including cuts, bruises, concussions, intracranial published in the Journal of Dental hemorrhage and Le Fort II and III fractures. Of the craniofacial injuries, 58% Research Clinical & Translational were considered severe. Research in November 2019. Approximately 20% of all scooter-related trauma admissions involved The review found that chewing alcohol use and no riders reported wearing helmets, although e-scooter rental sugar-free gum produces effects companies make users sign disclosures requiring them to wear protective gear in reducing the advancement of dental caries comparable to other and refrain from drinking alcohol, according to the study authors. interventions, such as supervised Though the results were telling, the study had some limitations. The researchers toothbrushing programs and oral health only studied emergency visits associated with e-scooter use at a single trauma education, according to the authors. center in a metropolitan area with four Level I trauma centers. Also, the trauma In recent years, chewing sugar- reported likely was an underrepresentation of all free gum has emerged as a possible injuries related to e-scooters because the results were adjunct to existing caries prevention limited to those riders who sought medical attention, strategies. Scientists have found that according to the authors. chewing gum that doesn’t contain Read more about this study in the Journal sugar increases saliva flow, which of Oral and Maxillofacial Surgery (2019); can act as a natural barrier to protect doi.org/10.1016/j.joms.2019.12.004. teeth. Also, sugar-free gum can act as a carrier for antibacterial ingredients, including xylitol and sorbitol. King’s College London researchers analyzed studies published between Sugar-free gum was found to reduce and feasibility of using this 1946 and 2018, identifying a dozen caries advancement, with a preventive method in public health. “With that explored the effects of chewing fraction of 28%, according to the consideration of cost and patient sugar-free gum and the intervention authors. There were no reports of adverse preference, this information could outcomes on oral health conditions events in any of the studies analyzed. help to develop national policy — specifically, dental caries in However, clinicians should exercise care directives on caries prevention adults and children. Most of the when generalizing the results for patients and dictate the direction of future subjects in the studies analyzed other than children and young people, clinical research,” the authors wrote. were children ranging in age from because only one of the 12 studies Learn more about this study in 4 to 14. A grant from Mars Wrigley analyzed included adult participants. Journal of Dental Research Clinical and the Wrigley Oral Healthcare The authors plan to do further & Translational Research (2019); program funded the research. research to determine the acceptability doi.org/10.1177/2380084419887178.

60 FEBRUARY 2 0 2 0 CDA JOURNAL, VOL 48, Nº2

Toothbrushing Associated With Reduced Heart Failure Risk A recent study found that frequent risk of heart failure and a 10% lower toothbrushing was associated with lower risks risk of developing atrial fibrillation, of atrial fibrillation and heart failure. The according to researchers from the Ewha study was published in the European Journal Womans University College of Medicine of Preventive Cardiology in December 2019. in South Korea. These study results were Brushing teeth at least three times per independent of several variables, including day was associated with a 12% reduced age, gender, socioeconomic status, exercise frequency, alcohol consumption and other behaviors that can damage the heart. The study included about 161,000 people between the ages of 40 and 79 who Cellphone Use Leads to Head, Neck Injuries had no histories of atrial fibrillation or heart The number of head and neck injuries related to cellphone use has failure and had participated in the Korean increased steadily over a recent 20-year period, according to a study National Health Insurance System. They published in the JAMA Otolaryngology — Head & Neck Surgery in underwent medical examinations and December 2019 and reported in an article on DrBicuspid.com. dental checkups between 2002 and 2003, Distractions, such as texting while walking, led to most of the injuries, and the researchers collected and analyzed many of which were not serious. However, some injuries showed potential for information about the participants’ height, long-term complications. weight, lab test results, medical conditions, With the regular daily use of phones and the number of head and neck lifestyle choices and habits. injuries, researchers from the Rutgers New Jersey Medical School in Newark When checkups were completed about 10 years later, the researchers found set out to discover whether a link existed between the two. They conducted a that 4,911 of the participants developed cross-sectional study of cellphone-related head and neck injury cases reported atrial fibrillation and 7,971 developed to the National Electronic Injury Surveillance System database, which is heart failure. Frequent toothbrushing, operated by the U.S. Consumer Product Safety Commission and collects data defined as at least three times per day, was about emergency department visits from approximately 100 U.S. hospitals. significantly associated with attenuated Between January 1998 and December 2017, approximately 2,500 risks of atrial fibrillation and heart failure. patients went to emergency room departments with head and neck injuries Though the mechanisms behind the related to cellphone use. The estimated weighted U.S. total was about relationship between toothbrushing and 76,000 patients, according to the study. In 2007, a sharp increase occurred the reduced risks of these heart conditions at about nine new cases per 1 million people. By 2016, the numbers peaked were not investigated, the authors noted to about 29 new cases per 1 million people. one potential reason for the connection: About 33% of patients with cellphone-related injuries experienced head injuries, Frequent toothbrushing decreases bacteria and another approximately 33% had injuries to their faces, including the eye and in the subgingival biofilm, which prevents nose areas. About half of the injury diagnoses were cuts and bruises, but about 18% it from relocating to the bloodstream. experienced internal organ injuries, according to the study. The authors pointed out that the “Growing dependence on cellphones in modern life large group of participants and the long may require that steps be taken to educate and promote period in which they were examined safe practices for using these devices,” the authors wrote. strengthened the findings. However, Read more of this study in the JAMA researchers looked at only one country Otolaryngology — Head & Neck Surgery (2019); with an Asian population, so the study doi.org/10.1001/jamaoto.2019.3678. could not be generalized to all ethnicities. Learn more about this study in the European Journal of Preventive Cardiology (2019); doi.org/10.1177/2047487319886413.

FEBRUARY 2 0 2 0 61 introduction

CDA JOURNAL, VOL 48, Nº2

Cosmetic Dentistry: Conservative Approaches, Confident Smiles

Nicholas C. Marongiu, DDS

GUEST EDITOR

Nicholas C. Marongiu, Let us always meet each other with a smile, John F. Weston, DDS, demonstrates DDS, earned his doctorate for the smile is the beginning of love. the management of compromised single of degree — Mother Teresa anterior implant cosmetics through from the Loma Linda University School of application of white and pink ceramics. Dentistry where he served osmetic dentistry, the art and The following two articles exemplify as president of the Dental science of dentistry, dates to conservative cosmetic dentistry and the Student Association and the 1920s when a California importance of communication between the chair of the California dentist, Dr. Charles Pincus, clinician, ceramic technician and patient. Dental Association Student Delegation. He maintains used temporary acrylic veneers No-prep veneers, as presented in the 1 hospital privileges at Scripps Con actors’ teeth for movie shoots. The article by Adamo E. Notarantonio, DDS, Memorial Hospital and proceeding three decades of dental research in treating deficient laterals demonstrates is adjunct faculty at the produced the benefit of acid etching teeth the ability to restore confidence in the University of California by Dr. Michael Buonocore, which became smile without any sacrifice of healthy San Diego School of 2 Medicine. Dr. Marongiu is the foundation of systems. tooth structure. The article by Jeffrey W. a member of the American This foundation led to the development of Lineberry, DDS, discusses the treatment Academy of Cosmetic predictable porcelain bonding techniques modalities and considerations when Dentistry, Orange County in the 1980s by Dr. John Calamia, igniting treating peg laterals and demonstrates the Academy of Cosmetic the practice of cosmetic dentistry.3 conservative additive treatment approach Dentistry, Los Angeles Academy of Cosmetic As material science and techniques of a single tooth to enhance the smile. Dentistry, American Dental evolve, the practice of cosmetic dentistry The last article, by David J. Clark, Association, California continues to evolve. What was once DDS, introduces injection molding in Dental Association, San considered elective, unnecessary or direct dentistry as a means to manage Diego County Dental aggressive dental treatment has shifted focus black triangles in the smile line. This Society and the Academy of General Dentistry. to preserving healthy tooth structure and direct technique is extremely conservative, Conflict of Interest minimal intervention to create conservative providing an excellent solution for patients Disclosure: None reported. cosmetic restorative outcomes to restore the desiring minimally invasive treatment smiles and self-confidence of our patients. options to address spaces at the gumline. The advances in ceramic systems allow the Together, these articles represent creation of natural, beautiful smiles while the conservative focus in cosmetic the advances in etching/bonding allow the dentistry to restore the beauty and conservation of natural tooth structure and confidence in our patients’ smiles.n the conservative goal of cosmetic dentistry. In everyday dentistry, we seldom treat references ideal cases. Patients are in our chairs 1. Pincus CL. Building mouth personality. A paper presented at the California State Dental Association; 1937: San Jose, Calif. because there is a problem and they J Cal Dent Assoc 1938 Jul–Aug 14:125–129. are looking to us to fix it. Learning to 2. Simonsen RJ, Calamia JR. Tensile Bond Strengths of Etched identify, predict and manage less than Porcelain. J Dent Res vol. 62, abst no. 1099, 1083. 3. Calamia JR. Etched Porcelain Facial Veneers: A New ideal cases produces predictable outcomes Treatment Modality Based on Scientific and Clinical Evidence. with happy patients. The first article by N Y J Dent 1983 Sep–Oct;53(6):255–9.

FEBRUARY 2 0 2 0 63 All-on-4®All-on-4® DentalDental All-on-4®All-on-4® DentalDental ImplantAll-on-4®ImplantAll-on-4® SolutionSolution DentalDental ImplantImplant SolutionSolution CourseImplantCourseImplant TRANSFORMTRANSFORMSolutionSolution YOURYOUR PRACTICEPRACTICE CourseCourse TRANSFORMTRANSFORM YOURYOUR PRACTICEPRACTICE CourseCourse TRANSFORMTRANSFORM YOURYOUR PRACTICEPRACTICE

InquireInquire aboutabout SCHOLARSHIPSSCHOLARSHIPS upup toto $5,000$5,000 atat [email protected]@4Minstitute.com Inquire about SCHOLARSHIPS up to $5,000 at [email protected] SAVE $1,000InquireInquireInquireInquire on All-on-4® aboutaboutaboutabout SCHOLARSHIPSSCHOLARSHIPS Course with CODE upupupup CDA1K totototo $5,000$5,000 OR SAVEatatatat [email protected]@[email protected]@4Minstitute.com 20% OFF with CODE 204MI SAVE $1,000Inquire on All-on-4® about SCHOLARSHIPSSCHOLARSHIPS Course with CODE up CDA1K to $5,000$5,000 OR atSAVE [email protected] 20% OFF with CODE 204MI SAVE $1,000Inquire on All-on-4® aboutDiscountDiscount SCHOLARSHIPS Course codescodes with validvalid CODE whenwhen enrolledupenrolled CDA1K to $5,000 3030 daysORdays SAVEprioratprior [email protected] toto 20% course.course. OFF with CODE 204MI SAVESAVE $1,000$1,000 onon All-on-4®All-on-4® CourseCourseSAVE withwith 20% CODECODE OFF CDA1KCDA1Kwith CODE OROR 204MI SAVESAVE 20%20% OFFOFF withwith CODECODE 204MI204MI SAVE $1,000$1,000 on All-on-4®Discount Course codes with valid CODE when enrolled CDA1KCDA1K 30 daysOROR SAVEprior to 20% 20%course. OFFOFF with CODE 204MI204MI SAVE $1,000 on All-on-4®DiscountDiscountDiscount Course codes codescode with validvalid CODE whenwhen enrolledenrolled CDA1K 3030 daysdaysOR priorSAVEprior toto 20% course.course. OFF with CODE 204MI ACQUIREACQUIRE THETHE NECESSARYNECESSARYDiscountDiscount codescodes SKILLS SKILLSvalidvalid whenwhen TOTO enrolledenrolled ATTRACTATTRACT 3030 daysdays AND ANDpriorprior toto COMPLETE COMPLETE course.course. FULL-ARCHFULL-ARCH ACQUIREDENTAL THE NECESSARYIMPLANT CASES SKILLS RANGING TO ATTRACT FROM AND $20,000 COMPLETE - $50,000. FULL-ARCH ACQUIREACQUIREDENTAL THETHE NECESSARYNECESSARYIMPLANT CASES SKILLSSKILLS RANGING TOTO ATTRACTATTRACT FROM ANDAND $20,000 COMPLETECOMPLETE - $50,000. FULL-ARCHFULL-ARCH ACQUIREACQUIREDENTAL THETHE NECESSARYIMPLANTNECESSARY CASES SKILLSSKILLS RANGING TOTO ATTRACTATTRACT FROM ANDAND $20,000 COMPLETECOMPLETE - $50,000. FULL-ARCHFULL-ARCH ThereThere areare overoverDENTALDENTAL 6060 millionmillion IMPLANTIMPLANT peoplepeople CASES CASESwhowho needneed RANGINGRANGING thisthis procedureprocedure FROMFROM andand NOT NOT$20,000$20,000 enoughenough -- $50,000. doctors$50,000.doctors toto performperform it!it! There are overDENTALDENTAL 60 million IMPLANTIMPLANT people CASESCASESwho need RANGINGRANGING this procedure FROMFROM and NOT $20,000$20,000 enough -- $50,000.doctors$50,000. to perform it! ThereThere areare overover 6060 millionmillion peoplepeople whowhoUpcoming Upcoming needneed thisthis CourseprocedureCourseprocedure Dates:Dates: andand NOTNOTAdditional enoughenough Courses:doctorsdoctors toto performperform it!it! ThereUpcoming are over All-on-4®60 million peopleCourse Dates:who need this procedure and NOT enough doctors to perform it! There are overJanuary 60 million 24-26, people 2020 who ...... Upcoming need thisLive Courseprocedure Surgery Dates: + and Hands-on SalesNOTAdditional Processenough & Courses:doctors Marketing to perform it! Upcoming JanuaryAll-on-4® 24-26, Course 2020 Dates: ...... UpcomingUpcomingLive CourseCourse Surgery Dates:Dates: + Hands-onAdditional Courses: UpcomingLive FebruaryJanuary SurgeryAll-on-4® +24-26, 8, Hands-on Course2020 2020 ...... Dates: ...... UpcomingUpcomingSalesLive CourseCourse Surgery Process Dates:Dates: + & Hands-on MarketingSalesAdditionalFebruary Process 8, &Courses: Marketing2020 UpcomingJanuary JanuaryFebruaryJanuaryAll-on-4® 24-26,24-26,24-26, 8, Course 2020 202020202020 ...... Dates: ...... LiveLiveSales SurgerySurgery Process ++ & Hands-onHands-on MarketingSales Process & Marketing LiveJanuary FebruaryJanuarySurgery 24 -+24-26, 26,29,8, Hands-on 2020 20202020 2020 ...... SalesLivePRF/Phlebotomy Surgery Process + & Hands-on MarketingSalesFebruaryPRF/Phlebotomy Process 8,& Marketing2020 LiveLive FebruarySurgeryFebruaryJanuarySurgery ++ 24-26, 8, 8,29,Hands-onHands-on 20202020 2020 2020 ...... SalesSalesLivePRF/Phlebotomy Surgery ProcessProcess + && Hands-on MarketingMarketingFebruary 8, 2020 February 8, 2020 ...... Sales Process & MarketingFebruary 8, 2020 Live SurgeryLiveJanuaryJanuary MarchFebruarySurgeryFebruary + Cadaver 2424 7, --+ 26, 26,202029,8, 8,Hands-on 2020Lab, 2020 20202020...... Hands-on ...... SalesPRF/PhlebotomyAll-on-4®Sales ProcessProcess Dental && Marketing MarketingAssistants’FebruaryPRF/Phlebotomy Course 29, 2020 FebruaryFebruaryMarch 7, 29,202029, 20202020...... PRF/PhlebotomyPRF/PhlebotomyAll-on-4® Dental Assistants’PRF/Phlebotomy Course Live SurgeryJanuaryAprilFebruary + 24Cadaver 24 - 26,- 26,29, 2020Lab, 20202020 Hands-on ...... PRF/PhlebotomyAll-on-4®February PRF/PhlebotomyDental Assistants’29, 2020 Course LiveLive SurgerySurgeryMarchMarchFebruary ++ CadaverCadaver 7,21,21,7, 2020202029, 20202020 Lab,Lab, 2020...... Hands-onHands-on ...... All-on-4®DominatePRF/PhlebotomyAll-on-4®Dominate DentalwithDentalwith DigitalDigital Assistants’Assistants’ February AdvertisingAdvertising CourseCourse 29, 2020 AprilMarch 24 - 7,26, 2020 2020...... All-on-4® Dental Assistants’FebruaryMarch Course 7,29, 2020 2020 Live SurgeryLiveApril MarchSurgery + 24Cadaver -27,21,7, 26,+ 2020 Hands-on2020 2020Lab,...... Hands-on CaseAll-on-4®Dominate Acceptance Dentalwith All-on-4®Digital Assistants’ for Complete Advertising Dental Course Assistants’ Dentistry Course MarchMarch 21,21,27,7, 2020 20202020...... DominateDominateCaseAll-on-4® Acceptance withDentalwith All-on-4® DigitalDigital Assistants’ for CompleteAdvertisingAdvertising Dental Course Assistants’ Dentistry Course JulyApril 31March -24 August - 21,26, 2020 2,2020 2020 ...... Dominate withAll-on-4® Digital Advertising MarchDental 7,Assistants’ 2020 Course LiveLive AprilMarchSurgeryMarchSurgery 24-26, 27,21,21, ++ Hands-onHands-on 20202020 2020 ...... LiveCaseDominateDominate Surgery Acceptance withwith + DigitalCadaverDominateDigital for Complete AdvertisingAdvertisingMarch Lab,with Hands-onDigital 7, Dentistry 2020 Advertising MarchMarchApril 24-26, 27,27, 20202020 2020 ...... CaseCaseLive Surgery AcceptanceAcceptance + Cadaver forfor CompleteComplete Lab, Hands-on DentistryDentistry Live SurgeryJulyJulyLive 3131Surgery + --Cadaver AugustAugust + Hands-on 2,2, Lab, 20202020 Hands-on DominateMarchMarch with Digital21, 7, 2020 2020 Advertising JulyAprilMarchJulyAprilMarch 31-August 31-August 24-26,24-26, 27,27, 20202020 20202020 2,2, ...... 2020 2020...... LiveCaseLiveCase SurgerySurgery AcceptanceAcceptance ++ Hands-onCadaverDominateHands-onCadaver forfor CompleteComplete Lab,Lab,with Hands-onDigitalHands-on DentistryDentistry Advertising JulyOctober 31AprilApril - August 24-26,924-26, - 11, 2, 20202020 2020 ...... LiveLive SurgerySurgery ++ CadaverCadaverMarch Lab,Lab, Hands-onHands-on21, 2020 LiveLive SurgerySurgeryApril ++ CadaverCadaver 24-26, Lab,Lab,2020 Hands-onHands-on ...... Live SurgeryCase + CadaverDominate AcceptanceMarch Lab,with forHands-onDigital21, Complete 2020 Advertising Dentistry JulyOctoberOctoberJulyApril 31-August31-August 24-26, 9-11,9-11, 2020 2020 2020 2,2, 20202020 ...... LiveLive SurgerySurgery ++ Hands-onCadaverCadaverHands-on Lab,Lab, Hands-onHands-on Live SurgeryOctoberJulyJuly + Cadaver 31-August 31-August9 - 11, Lab,2020 2,2, Hands-on 20202020 ...... Live SurgeryCase + Hands-on AcceptanceMarch for27,21, Complete 2020 Dentistry OctoberOctoberJulyJuly 31-August31-August 9 - 11,9-11, 2020 2020 2,2, 20202020 ...... LiveLive SurgerySurgeryCase ++ CadaverHands-onHands-on Acceptance Lab, forHands-on Complete Dentistry OctoberOctoberOctober 9 - 11,9-11,9-11, 2020 20202020 ...... IncludedLive Livein this SurgerySurgery course…Case ++ CadaverCadaver AcceptanceMarch Lab,Lab, forHands-onHands-on27, Complete 2020 Dentistry October 9-11, 2020Included ...... Included in theLive in All-on-4® thisSurgery course… +Course: CadaverMarch Lab, Hands-on27, 2020 October 9-11, 2020 ...... Live Surgery + CadaverMarch Lab, Hands-on27, 2020 CLINICAL:CLINICAL: TheThe fundamentalsfundamentals ofof thethe All-on-4®All-on-4®IncludedIncludedIncludedIncluded treatmenttreatment in the concept, concept,ininin All-on-4® thisthisthis the thecourse…course…course… step-by-stepstep-by-step Course: All-on-4®All-on-4® didactic,didactic, treatmenttreatment planningplanning and care, live surgery, how the lab convertsIncludedIncluded the IncludedIncludedhybrid, inin the thethe hybrid inin All-on-4®All-on-4® thisthis delivery, course…course… how Course:Course: to manage complications, hands-on typodont, CLINICAL:CLINICAL:and care, live TheThe surgery, fundamentalsfundamentals how the oflabof thethe converts All-on-4®All-on-4®Included theIncludedIncluded hybrid, treatmenttreatment in the the concept, concept,hybridinin All-on-4® thisthis delivery, the thecourse…course… step-by-stepstep-by-step how Course: to manage All-on-4®All-on-4® complications, didactic,didactic, treatmenttreatment hands-on planningplanning typodont, surgery,CLINICAL:CLINICAL: lab station The TheTheThe fundamentals fundamentalsfundamentalsfundamentals AND restorative. of ofofof the thethethe Please All-on-4® All-on-4®All-on-4®All-on-4® note selecttreatment treatmenttreatmenttreatment courses concept, concept,concept,concept, include the thethethe Cadaver step-by-step step-by-stepstep-by-stepstep-by-step Lab All-on-4® hands-onAll-on-4®All-on-4®All-on-4® in didactic, didactic,didactic,didactic, addition treatment treatmenttreatmenttreatment to Live Surgery. planning planningplanningplanning CLINICAL:andandsurgery, care,care, lab livelive stationThe surgery,surgery, fundamentals AND howhow restorative. thethe laboflab the convertsconverts Please All-on-4® thenotethe hybrid, hybrid, treatmentselect thecoursesthe concept,hybridhybrid include delivery,delivery, the Cadaverstep-by-step howhow toto Lab managemanage All-on-4®hands-on complications,complications, indidactic, addition treatment hands-on hands-onto Live Surgery. planning typodont,typodont, andandCLINICAL: care,care, livelive The surgery,surgery, fundamentals howhow thethe lab labof the convertsconverts All-on-4® thethe hybrid,hybrid, treatment thethe hybridhybridconcept, delivery,delivery, the step-by-step howhow toto managemanage All-on-4® complications,complications, didactic, treatment hands-onhands-on planning typodont,typodont, and+surgery,surgery, PLUS care, labMARKETING:lab live stationstation surgery, ANDAND how restorative.Learnrestorative. the labhow converts to PleasePlease transform notethenote hybrid, selectyourselect marketing coursesthecourses hybrid includeinclude to delivery, make CadaverCadaver the how phones to LabLab manage hands-onhands-onring. Wecomplications, will inin addition additionteach you hands-on toto the LiveLive best Surgery.Surgery. typodont, advertising surgery,surgery,surgery,and+surgery, PLUS care, lab lablabMARKETING:lab live station stationstationstation surgery, AND ANDANDAND how restorative.restorative.restorative.Learnrestorative. the labhow converts Please toPleasePleasePlease transform note notenotenotethe hybrid, select selectselectyourselect marketing courses coursescoursesthecourses hybrid include includeincludeinclude to delivery, make Cadaver CadaverCadaverCadaver the how phones to Lab LabLabLab manage hands-on hands-on hands-onhands-onring. Wecomplications, willin ininin addition additionaddition additionteach you to tohands-ontoto Live theLiveLiveLive best Surgery. Surgery.Surgery.Surgery. typodont, advertising surgery,channels lab and station how toAND speak restorative. to your potential Please note patients select through courses your include ads, Cadaver landing pages,Lab hands-on and social in addition media. We’llto Live teach Surgery. your ++surgery,channels PLUSPLUS MARKETING:labMARKETING: and station how toAND speak Learnrestorative.Learn to yourhowhow topotential toPlease transformtransform note patients yourselectyour marketingthroughmarketing courses your include toto makeads,make Cadaver landing thethe phonesphones pages,Lab hands-onring.ring. and WeWe social will willin addition teach teachmedia. youyou We’llto the theLive bestteachbest Surgery. advertisingadvertising your team++ PLUSPLUS how MARKETING:MARKETING: to answer these Learn LearnLearnLearn calls, how howhow howhow to toto toto transform transformtransform transformconvert calls your youryouryour into marketing marketingmarketingmarketing patient to toexams,toto make makemakemake and the thethethe finallyphones phonesphonesphones how ring. ring.ring.ring. to We WeWeWesell will willwillthesewill teach teachteachteach cases you youyouyou and the thethethe change best bestbestbest advertising advertisingadvertisingadvertising lives. +channelschannelsteam PLUS how MARKETING: andand to answer howhow toto these speakspeak Learn calls, toto youryourhow how potentialtopotential to transform convert patientspatients callsyour throughintomarketingthrough patient youryour to exams, ads,makeads, landinglanding andthe phonesfinally pages,pages, how ring. andand to We sell socialsocial will these teach media.media. cases you We’llWe’ll and the teachchangebestteach advertising youryour lives. channelschannels+channels PLUS MARKETING: and andand how howhow to toto speak speakspeak Learn to toto your youryourhow potential potentialpotentialto transform patients patientspatients your through throughthroughmarketing your youryour to ads, ads,ads,make landing landinglanding the phones pages, pages,pages, ring. and andand We social socialsocial will media. teachmedia.media. you We’ll We’llWe’ll the teach teachteachbest advertising your youryour channelsteamteam howhow and toto answer answerhow to thesethesespeak calls,calls, to your howhow potential toto convertconvert patients callscalls intothroughinto patientpatient your exams,exams, ads, landing andand finallyfinally pages, howhow and toto sell sellsocial thesethese media. casescases We’ll andand changeteachchange your lives.lives. teamteamteamchannelsteam how howhowhow and to tototo answer answeransweranswer how to these thesethese thesespeak calls, calls,calls,calls, to your how howhowhow potential to tototo convert convertconvertconvert patients calls callscallscalls into into intointothrough patient patientpatientpatient your exams, exams,exams,exams, ads, landingand andandand finally finallyfinallyfinally pages, how howhowhow and to tototo sell sellsellsell social these thesethesethese media. cases casescasescases We’ll and andandand change changechangechangeteach your lives. lives.lives.lives. teamteam howhow toto answeranswer thesethese calls,calls, howhow toto convertconvert callscalls intointo patientpatient exams,exams, andand finallyfinally howhow toto sellsell thesethese casescases andand changechange lives.lives.

39183918 LongLong BeachBeach BlvdBlvd •• SuiteSuite 200200 •• LongLong BeachBeach •• CACA •• 9080790807 EnrollEnroll atat 4MInstitute.com4MInstitute.com3918 OROR Long contactcontact Beach usus atatBlvd 562-294-5200562-294-5200 • Suite 200 • or orLong [email protected]@4Minstitute.com Beach • CA • 90807 toto requestrequest toto bebe enrolled.enrolled. 39183918 LongLong BeachBeach BlvdBlvd •• SuiteSuite 200200 •• LongLong BeachBeach •• CACA •• 9080790807 EnrollEnroll atat 4MInstitute.com39183918 OROR Long Long contactcontact BeachBeach usus at atBlvdBlvd 562-294-5200 •• SuiteSuite 200200 •• or or LongLong [email protected] BeachBeach •• CACA •• 9080790807 toto requestrequest toto bebe enrolled.enrolled. EnrollEnroll atat 4MInstitute.com4MInstitute.com OROROROR contactcontactcontactcontact usususus atatatat 562-294-5200562-294-5200 orororor [email protected]@[email protected]@4Minstitute.com totototo requestrequestrequestrequest totototo bebebebe enrolled.enrolled.enrolled.enrolled. EnrollEnroll atat 4MInstitute.com4MInstitute.com OROR contactcontact usus atat 562-294-5200562-294-5200 oror [email protected]@4Minstitute.com toto requestrequest toto bebe enrolled.enrolled. dental implants

CDA JOURNAL, VOL 48, Nº2

Compromised Anterior Single Implant Restoration Using Pink Ceramic

John F. Weston, DDS

a bstr ac t As surgical procedures have become streamlined to a single procedure in many cases and 3D radiology has improved the ideal position of fixtures in the bone, implants are the best option in most cases. We can now predictably offer success rates of nearly 99% over 10 years1 and 96% over 15 to 20 years.2

AUTHOR

John F. Weston, DDS, ental implants have become the profiles can make the difference between is owner and director of standard of care for functional an unacceptable aesthetic result and Scripps Center for Dental and aesthetic replacement of totally seamless integration of implant Care, a multispecialty private practice limited to missing teeth. From single- restoration to the surrounding natural cosmetic and reconstructive tooth to multi-tooth and teeth and gums. There are multiple dentistry in La Jolla, Calif. Deven full-arch replacement, implants reasons that boney deficiencies may be Conflict of Interest can be an ideal choice and considered a present around implant sites, ranging Disclosure: None reported. predictable treatment plan for most of from previous localized infection around our patients’ edentulous areas. It was not a failing tooth, traumatic dental alveolar that many years ago most dentists offered events and postsurgical bone loss around implants as a “second” choice over fixed existing implants. Because we know or removable work. As dental that soft tissue contours follow bone implant surgical procedures have become contour, soft tissue grafting alone may not more streamlined to a single procedure always be successful long term.3 There and 3D radiology has proven to offer are cases where a perfectly integrated predictable guidance for the ideal position implant is located in a spot where the of fixtures in the bone, implants are now ideal soft tissue is not present, and the best recommendation in most cases. even with modern grafting procedures, We can predictably offer survival rates surgical correction to generate ideal of nearly 99% over 10 years1 and success “pink” contours may not be possible. It’s rates of up to 96% over 15 to 20 years.2 always amazing to see how one small However, any clinician who has missing or asymmetrical papillae can restored anterior implants has come make or break an anterior implant case. across cases where sufficient bone is not Maintaining or creating the ideal “pink available at the site, therefore they are and white balance” with an implant faced with the associated lack of proper case is often the most critical factor soft tissue contours. Having enough bone to aesthetic success with restorations is important but having ideal soft tissue in the “aesthetic smile zone.”4

FEBRUARY 2 0 2 0 65 dental implants

CDA JOURNAL, VOL 48, Nº2

FIGURE 2. FIGURE 3. Preoperative PAX Preoperative CBCT initial condition. initial condition.

FIGURE 1. Preoperative intraoral initial condition.

Thankfully, there are alternative FIGURE 4. options using artificial “pink” as a Dislodged implant replacement when soft tissue grafting from initial impression. is not successful or results are less than expected. These techniques do not rely on biology but rely on proper treatment planning, excellent lab communication and artistry. When soft tissue is deficient, using pink ceramic can be a viable option and can literally save a case and change it from being a complete FIGURE 5. BMP and CT grafting two weeks failure aesthetically to a successful and postoperative. potentially life-changing result.5,6 It is often difficult to establish ideal bone routine dental treatment or implant The patient in this case had a contours when there is significant infection placement. The patient had an implant provisional crown on the implant and around a failing implant site. Often the soft placed in No. 8 position secondary to a said the temporary was attached the tissue defects associated with infection and traumatic event as a child. The patient same day the implant was placed. We bone loss around failing implants can be reported that the tooth previously elected to make a preliminary impression extremely difficult to repair and “chasing” received unsuccessful root canal therapy, to fabricate some kind of a provisional, the defects surgically to build bone can developed an infection then received but upon retrieval of the impression, the sometimes result in larger defects. This apical surgery with subsequent extraction implant and provisional came out with case presentation is an example of how and loss of the central incisor tooth. the impression. The patient was informed using pink porcelain around an ideally Initial examination revealed a direct that stability of anterior implants can integrated replacement implant created provisional on the No. 8 endosseus sometimes become compromised for a successful aesthetic outcome when a implant. The tissue was red and inflamed a number of reasons. While not a rare significant unplanned loss of hard and soft around the implant soft tissue interface, phenomenon, anterior implant failure tissue occurred. Using an aesthetic risk and there was class 2 to 3 mobility and can occur due to the loss of buccal assessment and understanding how and yellow exudate on palpation of buccal bone after surgical placement. This can when to use pink porcelain can help when tissue. The 2D periapical radiograph happen if the implant is placed too close planning for a successful outcome when showed the implant placement was to the buccal plate or placed without surgical procedures have run their course.7 spaced well in proximity to the adjacent proper grafting of new buccal bone in The patient is a male college student teeth but lateral bone loss was present in the buccal implant space at the time who moved to California from the East the incisal and middle one-third. A 3D of surgery. Immediate loading either Coast and presented for evaluation of radiographic exam was completed mainly with a provisional or permanent crown one anterior implant in position No. 8. for documentation reasons and revealed can also have an effect on the stability He said, “My doctor told me I’m ready for a total lack of supporting buccal plate of the buccal plate8,9 (FIGURE 4). the permanent crown on my implant.” bone. It was obvious that restoring the After careful evaluation by our The patient is a healthy 30-year-old current implant was not a viable option as oral surgeon, the resulting defect was with no medical contraindications to requested by the patient (FIGURES 1–3). determined to be too large to predictably

66 FEBRUARY 2 0 2 0 CDA JOURNAL, VOL 48, Nº2

FIGURE 6. Bonded provisional. FIGURE 7. Defect after implant placement healing.

FIGURE 8. FIGURE 9. 3D implant Final implant planning. PAX healing complete.

FIGURE 10. DSD planning image. Veneers on Nos. 8 and 10 will extend to the current tissue line covering the tooth structure.

restore with traditional calcified use of a tissue-supported provisional, Seven soft tissue variables were graded particulate graft material, so a treatment such as a resin-based removable partial using a 0–1–2 score with 2 being the plan was formulated that included bone denture or flipper10,11 (FIGURE 5). best and 0 being the worst.13 Additional morphogenetic proteins (BMP) grafting, Approximately four weeks later, hard and soft tissue grafting procedures stainless mesh and connective soft a bonded provisional was placed for were presented, however, discussion with tissue grafting with six to nine months’ the remainder of healing. After nine the patient revealed a concern to limit minimum healing. The initial existing months, 3D radiography evaluation the number of surgeries and the patient condition was deceiving, and surgical determined that sufficient bone was unwilling to try another grafting excavation of the site revealed a very replacement had taken place to allow event. An initial plan to consider using large exudate-filled, active three-wall for a new implant to be placed. 3D pink ceramic to make up for the missing defect that included severe bone loss virtual implant planning commenced tissue volume was offered as a possible on the lateral sides as well as buccal with plans for placement of a new alternative to end the long surgical process surfaces. The palatal lingual bone was Straumann 4 mm by 12 mm tapered already undertaken (FIGURES 6–9). fully intact. The surgical treatment plan bone-level endosseus implant in the No. The first step after implant healing was completed without incident by 8 tooth site. If at all possible, CBCT progressed successfully was to complete our team’s oral surgeon and a vacuum- scans should be used to facilitate ideal 2D digital smile design planning on formed clear Essix tray was fabricated to placement of implants in the anterior facially oriented smile and lip retracted hold a composite tooth in the missing region.12 As healing progressed, it images. This allowed for initial planning tooth area. This style of tooth-supported became obvious that even with an ideal of tooth proportions for the veneers on single-tooth provisional was initially abutment choice and placement, the teeth Nos. 7, 9 and 10 as well as the delivered immediately after surgery, pink aesthetic score (PES) would end implant crown on No. 8 including initial which allowed for minimum-required up being very low due to significant design outline of pink substructure.14,15 aesthetics without adding pressure to vertical bone loss and associated papillae To create a natural appearance in this the graft site. One of the side effects of soft tissue loss. PES is a system used to case, papilla extensions would extend using BMP grafting is postoperative soft reproducibly evaluate peri-implant soft partially onto the adjacent tooth/root tissue swelling that can prohibit the tissue around single-tooth implants. surface areas. One of the concerns when

FEBRUARY 2 0 2 0 67 dental implants

CDA JOURNAL, VOL 48, Nº2

FIGURE 12. Opposing arch digital impression. FIGURE 11. digital impression. FIGURE 13. CO record digital impression. using a pink substructure is making sure the underlying tissue areas are smooth, allowing for proper hygiene and adaption of the pink substructure to the surface. It was decided to veneer the adjacent teeth, covering the tissue-recessed root areas with ceramic to protect all exposed tooth surface areas. This design would eliminate the chance for plaque to be in contact with root areas as any potential buildup of bacterial plaque under the pink FIGURE 14. Dentin shade image veneer preps. FIGURE 15. Tooth shade image. ceramic extensions would be contained between ceramic layers (FIGURE 10). An intraoral “test drive” was Shade reference images were made on low speed. The surrounding tissues completed and approved by the patient. showing dentin shades and comparison were cleaned and disinfected with This is a procedure that allows the to adjacent teeth along with gingival peridex. Using a latex-free lip retractor planned smile to be placed over the shades to natural surrounding tissue.6 (OptraGate, Ivoclar Vivadent AG), a patient’s existing teeth using silicon It was obviously very helpful in this dry try-in was completed to verify the templates of the 3D design and printed case to restore adjacent teeth next to restorations’ seat passively when viewed models. This allows the clinician and the implant with conservative veneers. under magnification. A total etch, patient to view the planned changes This allowed for better shade matching fourth-generation bonding resin (Scotch prior to any permanent tooth reduction and idealization of soft and hard tissue Bond Multi-Purpose) was chosen for or alterations. Preparation guides contours. The patient was instructed its established high bond values and were then used to complete minimal to “bristle floss” the provisional with reliable long-term success.17,18 A wetting reduction veneer preps on teeth Nos. chlorhexidine while waiting for lab agent of glutaraldehyde (Gluma, Kulzer 7, 9 and 10 adjacent to the implant. fabrication of the ceramic veneers. GmbH, Hanau, Germany) was used A digital impression was completed It was decided that lithium disilicate after total etch to reduce sensitivity for fabrication of the veneers that was the best choice for restorative and improve bond strengths. A “rapid- included an opposing arch scan material for the veneers with all seating” technique was applied where and bite scan.16 A custom shrink- functional surfaces (IPS e.max, Ivoclar all restorations were bonded at once to-fit, spot-bonded provisional was Vivadent AG, Schaan, Lichtenstein) to support each other and save time.19 fabricated on teeth Nos. 7, 9 and 10. and a cut-back layered design on the After initial resin clean-up and margin This type of provisional is fabricated facial surfaces (FIGURES 14 and 15). curing, an air barrier of water-based, using a silicone template of the final Once lab work was completed, the water-soluble lubricant was placed to seal design that is filled with provisional patient returned for insertion of the margins followed by 40 seconds of dual material and seated over the preps final veneers on teeth Nos. 7, 9 and 10. buccal and lingual light curing. Final and allowed to cure completely. Local anesthesia was placed; using a clean-up of the margins was completed The provisional is then carefully high-speed electric handpiece, sagittal with a No. 12 blade, and the lingual trimmed at the margins, polished cuts were made in the facial surface of margins were blended, finished and and occlusion verified. The implant the provisional veneers. The BisGMA polished using a red-stripe diamond on tooth No. 8 was provisionalized prototypes were then split and removed. football-shaped bur and rubber-tipped separately using a screw-retained The small areas of etched “spot bond” high-speed polishers (Shofu Dental temporary abutment (FIGURES 11–13). were removed using a dry diamond bur Corp., San Marcos, Calif.). Separation

68 FEBRUARY 2 0 2 0 CDA JOURNAL, VOL 48, Nº2

FIGURE 18. Pink shade tabs image.

FIGURE 16. Seated veneers and zirconia abutment. FIGURE 17. Final veneer and implant temp.

FIGURE 19. Pink ceramic wings. FIGURE 20. Final smile image. The crown and pink ceramic wings were fabricated using an e.max framework and layered with creation porcelain to mimic the natural shades of the adjacent veneers and surrounding gingival tissue. The pink ceramic “wings” were designed to slide over the top of the adjacent veneered tooth structure and rest on top of ceramic veneered areas only. Note, none of the pink areas rest on or over soft FIGURE 21. Floss access to underside of pink abutment. FIGURE 22. Floss access to implant fixture. tissue. The design allows floss to safely pass in between the ceramic layers for easy cleansing. This required a strong and cleaning of the interproximal areas to match the veneers. The pink ceramic framework (lithium disilicate) to support was accomplished using a hand-held was attached to the crown to fill in the the delicate aesthetic layering porcelain interproximal saw (Ceri-Saw strips, areas of missing tissue. The ceramist that was used externally to match the DentMat, Lompoc, Calif.) and yellow utilized the stereolithography (STL) gingival shade of the surrounding tissues. perforated diamond strips until flossing files for accurate and predictable digital The abutment was seated and screw was smooth on all proximal surfaces. planning, design and fabrication of a tightened by hand and the crown was After the veneers were delivered, a custom zirconia abutment and e.max dry seated to confirm a passive path of scanbody (Straumann Scanbody, Institut crown.20–22 Shade reference images insertion of crown and wings over the Straumann AG, Basel, Switzerland) that included tooth shade tabs (Vita top of the adjacent teeth. The abutment was placed on the tooth No. 8 implant classical, Vita North America, Yorba was then torqued to 35nC with a fresh and a digital scan was made that Linda, Calif.) and pink shade tabs were screw and Teflon tape packed into the recorded the implant position, depth recorded for the ceramist to use for access. The crown was then cemented and rotation as well as its orientation final layering of the lithium disilicate with a very light coat of resin cement to the adjacent veneer surfaces. These frameworks. A custom, screw-retained self-etching adhesive (RelyX Unicem2, digital files were sent to the lab with provisional was fabricated and attached 3M ESPE, St. Paul, Minn.) to eliminate a prescription for a custom zirconia to the implant for final evaluation of the chance of any excess cement at the abutment and cementable e.max crown the aesthetic area (FIGURES 16–18). crown/implant margin23 (FIGURES 19–22).

FEBRUARY 2 0 2 0 69 dental implants

CDA JOURNAL, VOL 48, Nº2

FIGURE 24. Final PAX of implant abutment and crown.

GM, da Cunha LF, Gonzaga CC. Digital smile design and mock-up technique for esthetic treatment planning with porcelain laminate veneers. J Conserv Dent 2018 Jul– Aug;21(4):455–458. doi: 10.4103/JCD.JCD_172_18. 16. Zandinejad A, Lin WS, Atarodi M, Abdel-Azim T, Metz MJ, Morton D. Digital workflow for virtually designing and milling ceramic lithium disilicate veneers: A clinical report. Oper Dent 2015 May–Jun;40(3):241–6. doi: FIGURE 23. Final profile. 10.2341/13–291-S. Epub 2015 Feb 23. 17. Barkmeier WW, Erickson RL. Shear bond strength of composite to enamel and dentin using Scotchbond Multi- Any time you have a site where white esthetic scores. Clin Implant Dent Relat Res 2018 Purpose. Am J Dent 1994 Jun;7(3):175–9. 18. Erickson RL, Barkmeier WW, Latta MA. The role an implant failure has occurred and a Oct;20(5):770–777. doi: 10.1111/cid.12631. Epub 2018 Jul 26. of etching in bonding to enamel: A comparison of new implant is being placed, there is 5. Kim TH, Cascione D, Knezevic A, Nowzari H. Restoration self-etching and etch-and-rinse adhesive systems. Dent some reservation as to the long-term using gingiva-colored ceramic and a ridge lap pontic Mater 2009 Nov;25(11):1459–67. doi: 10.1016/j. dental.2009.07.002. Epub 2009 Aug 7. success of the second implant. When with circumferential pressure: A clinical report. J Prosthet Dent 2010 Aug;104(2):71–6. doi: 10.1016/S0022- 19. Dondi dall’Orologio G, Lorenzi R, Anselmi M, Opisso pink ceramic is utilized, there is an 3913(10)00107-1. V. Dentin desensitizing effects of Gluma Alternate, Health- added layer of potential complication 6. Papaspyridakos P, Amin S, El-Rafie K, Weber HP. Dent Desensitizer and Scotchbond Multi-Purpose. Am J Dent 1999 Jun;12(3):103–6. for the clinician, ceramist and patient. Technique to Match Gingival Shade When Using Pink Ceramics for Anterior Fixed Implant Prostheses. J 20. Abduo J, Elseyoufi M. Accuracy of intraoral All factors must be addressed, such Prosthodont 2018 Mar;27(3):311–313. doi: 10.1111/ scanners: A systematic review of influencing factors. Eur J as patient biology and health as jopr.12483. Epub 2016 Apr 1. Prosthodont Restor Dent 2018 Aug 30;26(3):101–121. doi: 10.1922/EJPRD_01752Abduo21. well as local factors like occlusion 7. Viana PC, Kovacs Z, Correia A. Purpose of esthetic risk assessment in prosthetic rehabilitations with gingiva-shade 21. Aragón ML, Pontes LF, Bichara LM, Flores-Mir C, and framework design as it relates ceramics. Int J Esthet Dent 2014 Winter;9(4):480–9. Normando D. Validity and reliability of intraoral scanners to soft tissue periodontal health. 8. Sarnachiaro GO, Chu SJ, Sarnachiaro E, Gotta SL, compared to conventional gypsum models measurements: A systematic review. Eur J Orthod 2016 Aug;38(4):429–34. Addressing all factors and having good Tarnow DP. Immediate implant placement into extraction sockets with labial plate dehiscence defects: A clinical case doi: 10.1093/ejo/cjw033. Epub 2016 Jun 7. lab communication will provide the series. Clin Implant Dent Relat Res 2016 Aug;18(4):821– 22. Marghalani A, Weber HP, Finkelman M, best success in these compromised 9. doi: 10.1111/cid.12347. Epub 2015 Apr 27. Kudara Y, El Rafie K, Papaspyridakos P. Digital versus conventional implant impressions for partially cases. The final images of this case 9. Degidi M, Nardi D, Daprile G, Piattelli A. Buccal bone plate in the immediately placed and restored maxillary edentulous arches: An evaluation of accuracy. J Prosthet reveal beautiful anatomical contours single implant: A seven-year retrospective study using Dent 2018 Apr;119(4):574-579. doi: 10.1016/j. and shade matching of tooth and computed tomography. Implant Dent 2012 Feb;21(1):62– prosdent.2017.07.002. Epub 2017 Sep 18. 23. Lopes ACO, Machado CM, Bonjardim LR, Bergamo tissue revealing an ideal example of 6. doi: 10.1097/ID.0b013e31823fce9f. 10. Herford AS, Lowe I, Jung P. Titanium mesh grafting ETP, Ramalho IS, Witek L, Coelho PG, Bonfante EA. The how using artificial pink can be an combined with recombinant human bone morphogenetic Effect of CAD/CAM crown material and cement type attractive and predictable replacement protein 2 for alveolar reconstruction. Oral Maxillofac on retention to implant abutments. J Prosthodont 2019 Feb;28(2):e552–e556. doi: 10.1111/jopr.12927. Epub for missing natural gingiva when Surg Clin North Am 2019 May;31(2):309–315. doi: 10.1016/j.coms.2018.12.007. Epub 2019 Mar 7. 2018 Jul 2. additional surgery is no longer an 11. Scarano A, Assenza B, DI Cerbo A, Candotto V, Santos the author, John F. Weston, DDS, can be reached at option (FIGURES 23 and 24). n DE, Oliveira P, Lorusso F. Bone regeneration in aesthetic areas using titanium micromesh. Three case reports. Oral [email protected]. references Implantol (Rome) 2017 Jan 21;10(4):488–494. doi: 1. Lambrecht JT, Filippi A, Künzel AR, Schiel HJ. Long-term 10.11138/orl/2017.10.4.488. eCollection 2017 Oct– evaluation of submerged and nonsubmerged ITI solid-screw Dec. titanium implants: A 10-year life table analysis of 468 12. Orentlicher G, Horowitz A, Goldsmith D, Delgado-Ruiz implants. Int J Oral Maxillofac Implants 2003 Nov– R, Abboud M. Cumulative survival rate of implants placed Dec;18(6):826–34. “fully guided” using CT-guided surgery: A seven-year 2. Winitsky N, Olgart K, Jemt T, Smedberg JI. A retro- retrospective study. Compend Contin Educ Dent 2014 prospective long-term follow-up of Brånemark single Sep;35(8):590–98, 600. implants in the anterior maxilla in young adults. Part 1: 13. Fürhauser R, Florescu D, Benesch T, Haas R, Mailath Clinical and radiographic parameters. Clin Implant Dent G, Watzek G. Evaluation of soft tissue around single-tooth Relat Res 2018 Dec;20(6):937–944. doi: 10.1111/ implant crowns: The pink esthetic score. Clin Oral Implants cid.12673. Epub 2018 Oct 15. Res 2005 Dec;16(6):639–44. 3. Levine RA, Huynh-Ba G, Cochran DL. Soft tissue 14. Omar D, Duarte C. The application of parameters augmentation procedures for mucogingival defects in for comprehensive smile esthetics by digital smile design esthetic sites. Int J Oral Maxillofac Implants 2014;29 programs: A review of literature. Saudi Dent J 2018 Suppl:155–85. doi: 10.11607/jomi.2014suppl.g3.2. Jan;30(1):7–12. doi: 10.1016/j.sdentj.2017.09.001. 4. Chen J, Chiang C, Zhang Y. Esthetic evaluation of Epub 2017 Sep 23. natural teeth in anterior maxilla using the pink and 15. Garcia PP, da Costa RG, Calgaro M, Ritter AV, Correr

70 FEBRUARY 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 Projecting approx. $1.3M for 2019. Net $840K. 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 FOUNTAIN VALLEY— GP in strip shopping Selling as One) – Grossed $914K in 2018 shopping plaza. Grossed approx. $1.4M in center w/ great street visibility. Grossed and Projecting $951K for 2019. Buyer’s net 2019. NET $324K. Property ID #5295. $287K in 2018. Has 4 eq ops and 1 plmbd not eq. Great staff. Property ID #5293 of $322K. Selling the property in Escondido CENTURY CITY—GP in 11 story prof med as well. Property ID #5275. bldg. Has 5 eq in a 1,955 sq ft. Grossed LAGUNA HILLS — With 16 yrs of gdwll this approx. $464K in 2019. Property ID 4509. GP is in a single story shopping center. Has RIVERSIDE COUNTY 4 eq ops in a 1,200 sq ft suite. Property ID DUARTE— GP established in1964 located in #5290. RANCHO MIRAGE— Beautiful Fee for ser- a 2 story mixed bldg. Grossed approx. vice General / Implant practice located in WESTMINSTER/FOUNTAIN VALLEY— Es- $350K in 2019. Property ID #5183. free standing bldg. Has 4 eq ops. . Grossed tablished in 1978 GP in 2 story free stand- GRANDA HILLS— With 50 yrs of goodwill ing bldg. Grossed $737K in 2018. Has rea- $1M in 2018. NET $333K. Property ID this general practice grossed approx. $380K sonable 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 LONG BEACH—GP with approx. 60 yrs of with 33 years of goodwill. Has 3 eq operato- located in a duplex single story building. goodwill. Projecting approx. $373K in 2019. ries. Grossed approx. $323K in 2019. Buy- Grossed approx. $1.4M in 2019 with a Property #5303. er’s net $113K. Property ID #5299. Buyer’ net of $647K. 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. $817K in 2019. NET LA QUINTA— Price Reduced! Well estab- $237K. 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. 22 yrs of goodwill. Has 4 eq ops in a 1,800 sq building with 42 yrs of goodwill. Has 11 eq Grossed approx. $1.5M for 2019. NET ops. Grossed approx. $1.2M in 2019. NET ft suite. Fee for serviceSOLD office. Grossed ap- prox. $440K for 2018. Property ID # 5256. $344K. Property ID #5130. $243K. Property ID#5309. CARMEL VALLEY — Price Reduced! Turn key SAN BERNARDINO — General practice SIMI VALLEY— GP w/ 54 years of goodwill practice with 3 eq ops and 1 plumbed not eq located in single story free standing bldg w/ in free standing building. Projecting approx. on an approx. 1,815 sq ft suite. PPO and Cash 4 eq ops. Seller owns building. Grossed only. Grossed approx. $325K in 2018. ID # $621K for 2019. NET $200K. ID #5294 $500K in 2019. Property ID #5289. 5274. VENTURA - GP w/ 4 eq ops . PPO & Cash EL CAJON (GP) - Price Reduced! Consists of 5 UPLAND—Beautiful general practice locat- only. 40 years goodwill. Projection approx. eq ops and equipped with 3D Sirona CBCT ed in 2 story building with 4 equipped oper- $470K in 2019. Property ID #5288. Digital X-ray. Grossed over $1M in the past atories. Grossed approx. $920K in 2019. 10 years. Property ID # 5265. Property ID #5237.

Happy New Year! youtube.com/mycpsteam faceboook.com/mycpsteam

FREE CONSULTATION WWW.CALPRACTICESALES.COM Phone: (800) 697-5656 CA BRE #00283209 CONTACT US FOR A CHALLENGES WORKING WITH BENEFIT PLANS?

WE’RE HERE TO HELP. Our smart analysts and sharp tools can help you navigate working with dental benefit plans. And, a streamlined process makes it more convenient to share your challenges with claim denials, delays and miscommunications. Once your online form is submitted, you’ll get expert guidance on your next steps.

TOGETHER WE ARE LIMITLESS Learn more at cda.org/practicesupport. prepless veneers

CDA JOURNAL, VOL 48, Nº2

Minimize Preparations for Maximum Results

Adamo E. Notarantonio, DDS

a b s t r ac t Public awareness has resulted in patients requesting more minimally invasive cosmetic options. The old adage of extension for prevention has been replaced with minimal to no-prep dentistry, risk assessment and conservative treatment. This article focuses on prepless veneers as an excellent, yet conservative aesthetic option that can yield outstanding results.

AUTHOR

Adamo E. Notarantonio, ith more access to Dentistry has built its educational pillar DDS, is a graduate of the information online and accreditation process on the concept State University of New and increased public of “responsible aesthetics.” That being York at Stony Brook School of Dental Medicine. He is awareness, our said, high-level aesthetics can be achieved a member of the American patients are more with minimal amounts of dentistry. Dental Association, the Winclined to do less than more. With readily Whereas porcelain veneers used to be Academy of General available images of overly prepped teeth, the gold standard for cosmetic dentistry, Dentistry, the American patients have been more inclined to say, “I more conservative approaches, such as Equilibration Society, the American Academy of do not want my teeth shaved for veneers” composite resin and prepless veneers, are Cosmetic Dentistry and the or other cosmetic procedures. With the becoming more appealing to both the International Congress of movements of biomimetic dentistry and patients and the dental practitioner. Oral Implantologists. responsible aesthetics, high-end aesthetic Conflict of Interest options have arrived that are minimally to Case Study Disclosure: None reported. noninvasive. The old model of drill and A 29-year-old female presented to the fill, mechanical retention and extractions office following three years of Invisalign. has been replaced with risk assessment, Her chief complaint was simple. She preventive care and adhesive dentistry. was unhappy with her “small outer two An article by Ericson defines minimally front teeth.” An intraoral exam revealed invasive dentistry as “a systematic tooth size discrepancies of teeth Nos. 7 respect for the original tissue.1 This and 10 as compared to the rest of the implies that the dental profession realizes anteriors (FIGURES 1–3). Although the that an artifact is of less biologic value gingival heights of the lateral incisors than the original tissue.” Furthermore, were more apical than desired, the the American Academy of Cosmetic patient’s low lip line and her affirmative

FEBRUARY 2 0 2 0 73 prepless veneers

CDA JOURNAL, VOL 48, Nº2

FIGURE 1. Preoperative smile 1:3 view. FIGURE 2. Preoperative retracted 1:3 view. FIGURE 3. Close-up 1:1 of the upper anteriors.

FIGURE 6. Final restorations.

for the final restorations to be 100% in enamel. An article published by Galip Gürel, DDS, stated that veneers bonded to dentin were 10 times more likely FIGURE 4. Provisionals shown over existing teeth FIGURE 5. Photoshop virtual mock-up of before to fail than those bonded to enamel.4 with blue pencil marking depth cuts. and after. Following approval from the patient, the treatment of the case began. “no” answer when I mentioned returning provisionals overlying the teeth with Digital impressions were taken to to extrude them, the depth cuts marked in pencil to help with an iTero scanner (San Jose, decision was made to leave the teeth visualize removal. Because the decision Calif.) and sent to the laboratory along where they were as the gingival zeniths was made, in conjunction with my with all initial photos, photos with were only visible in a retracted view. ceramist, to go completely prepless, a corresponding shade tabs in color and For many cosmetic cases, a diagnostic different mock-up was performed. The black and white as well as a polarized wax-up would be performed, and initial 1:1 photo was imported into photo to aid in characterization. utilizing a matrix fabricated from this Photoshop and by utilizing the Liquify The patient presented a few weeks wax-up, the restorations would be tried filter, a virtual mock-up was completed later for insertion. The veneers were in with a bis-acrylic material, such as and presented to the patient. (FIGURE 5). razor thin in the area of the body, InstaTemp (Sterngold Dental LLC, From photo retouching to artistic effects, with a majority of the porcelain in Attleboro, Mass.) or Luxatemp (DMG the Liquify filter is a powerful tool for the areas to be added to (FIGURE 6). America, Englewood, N.J.). This is every Photoshop user. This filter allows The veneers were tried in with water helpful for two reasons. One, it gives us to push, pull, rotate, reflect, pucker and the decision was made to place a the patient a chance to see the desired and bloat the pixels of any image.3 From wedge on the mesial of tooth No. 7 to final outcome as well as experience a dental perspective, it allows us to alter ensure an easy and passive insertion. the new shape, size or position of the an image without excessive distortion, (FIGURE 7). The intaglio surface of teeth prior to final restorations, prior to creating an extremely natural look to the veneers (lithium disilicate) were beginning treatment. Secondly, it allows what sometime can be an unrealistic treated with 9% HF acid, rinsed, dried us to use the final outcome as a prep or artificial result in other programs. with air and silanated with two-part guide to ensure minimal preparation and As mentioned previously, the central silane. No anesthetic was administered, removal of tooth structure, if preparation dominance and slightly palatal position and careful placement of a rubber dam is indeed necessary.2 FIGURE 4 is an of the lateral incisors gave way to the with absolute isolation was completed.5 excellent example of this, showing the decision of prepless veneers. This allows (FIGURE 8). The surfaces to be bonded

74 FEBRUARY 2 0 2 0 CDA JOURNAL, VOL 48, Nº2

FIGURE 7. Isolation with placement of wedge. FIGURE 8. Complete rubber dam isolation. FIGURE 9. Etch application slightly past finish line of veneers.

FIGURE 10. Placement of Teflon tape to avoid FIGURE 11. Tack cure and removal of cement prior FIGURE 12. Close-up immediately postoperative. bonding to adjacent tooth. to final curing. to were air abraded with a prep start upon insertion. The veneers were utilizing 50-micron aluminum oxide. carefully placed, the cement tack This helps ensure the most ideal surface cured for three seconds and the excess to bond to.6 Following air abrasion, material removed with a rubber tip the enamel was etched with 35% stimulator and floss in the contact phosphoric acid with BAC (Bisco areas (FIGURE 11). The excess cement Dental Products, Schaumburg, Ill.) was cleaned and polished utilizing for 15 seconds. The etch was only porcelain polishing discs and points. placed half way up the facial surface FIGURE 12 shows the final restorations because the infinity margin on the immediately after insertion. The FIGURE 13. Immediate postoperative smile. veneer did not extend past this area. patient returned four weeks later for The etch was then rinsed and dried final photos and was ecstatic with the (FIGURE 9).Two coats of All-Bond outcome of her procedure (FIGURE 13). references Universal (Bisco Dental Products) The concept of less is more is used 1. Ericson D. What is minimally invasive dentistry? Oral Health were applied and dried with warm air to express the view that a minimalist Prev Dent 2004;2 Suppl 1:287–92. for 30 seconds. Prior to a 10-second approach to artistic or aesthetic 2. Kern M, Oliver Ahlers MO. Controlling the depth of ceramic veneer preparations by using a color marker in the depth light cure, a piece of Teflon tape was matters is more effective. In cosmetic grooves. J Prosthet Dent 2015 Dec;114(6):862–4. doi: placed on the distal of tooth No. 8 to dentistry, specifically in the longevity 10.1016/j.prosdent.2015.06.010. Epub 2015 Sep 12. avoid bonding the contact together of veneers, the less removal of tooth 3. Adobe Photoshop User Guide. Liquify filter overview. helpx. adobe.com/photoshop/using/liquify-filter.html. (FIGURE 10). The veneers were bonded structure and the more enamel to bond 4. Gurel G, et al. Influence of enamel preservation on with Choice 2 cement (Bisco Dental to, the increasingly greater chance of failure rates of porcelain laminate veneers. Int J Periodontics Products). This cement is a light-cure survival the practitioner has. With Restorative Dent 2013 Jan–Feb:33(1)31–19. 5. Browet S, Gerdolle D. Precision and security in restorative resin cement. Prior to placing the the improvement of materials in dentistry: The synergy of isolation and magnification. Int J cement in the veneers, the cement was conjunction with the artistic skill of Esthet Dent 2017;12(2):172–185. preheated in a composite warmer. The many laboratory technicians, not only 6. D’Arcangelo C, Vanini L. Effect of three surface treatments on the adhesive properties of indirect composite restorations. J reason behind this is that because the can we ensure longevity, we can also Adhes Dent 2007 Jun;9(3):319–26. veneers were so thin and the chosen deliver natural unrivaled beauty. n cement on the thicker side, heating the author, Adamo E. Notarantonio, DDS, can be reached at [email protected]. the cement will make the material acknowledgment The author thanks the outstanding skills of ceramist Julian less viscous and minimize the chance Cardona in Guayaquil, Ecuador. Without his expertise, this the thin porcelain shell fracturing case would not be possible.

FEBRUARY 2 0 2 0 75 Founded by dentists. Focused on you.

See what makes TDIC Professional Liability coverage different.

We’ve kept our promise to protect only dentists for 40 years and counting. Since 1980, TDIC has delivered uncompromising coverage to our professional liability policyholders: • Insurance designed for the unique needs of your profession • Expert in-house claims team and razor-sharp legal team • Risk Management Advice Line guidance at no cost • A (Excellent) rating from AM Best for 25 consecutive years*

Join our community of policyholders today. Visit tdicinsurance.com/PL or call 800.733.0633.

* AM Best company rating effective March 2019. For the latest rating, access ambest.com.

Coverage specifically underwritten by The Dentists Insurance Company includes Professional Liability, Commercial Property, Cyber Suite Liability and Employment Practices Liability. TDIC also underwrites Workers’ Compensation in California. TDIC Insurance Solutions offers other coverages as an agent or broker through other insurance carriers. Available coverage limits and discounts vary by carrier and are subject to carrier underwriting.

® Protecting dentists. It’s all we do. 800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783 @TDICinsurance peg laterals

CDA JOURNAL, VOL 48, Nº2

Treatment Planning and Managing the Peg Lateral Incisor

Jeffrey W. Lineberry, DDS

a b s t r ac t Spacing and gaps in the anterior segment create an aesthetic dilemma for many patients. It is not uncommon for the underlying cause of spacing to be secondary to microdontia or smaller than normal teeth. Peg laterals are a common issue when it comes to microdontia, and this can create spacing and gaps along with impacting other teeth position in the arch, leading to poor aesthetics. A case study is presented on the management and treatment of a peg lateral.

AUTHOR

4,5 Jeffrey W. Lineberry, ne of the most common linked to genetic phenotypes, however, DDS, has been a practicing aesthetic concerns that it can be prevalent (as high as 40%) in dentist since 2000 and patients see dental those families affected. Peg laterals are practices general dentistry professionals about is the more prominent in females (1.35 times focusing on complex 3 cosmetic dentistry, spacing between their front greater than males), found more often on 3 and Oteeth. Spacing between one or multiple the left side and with a higher occurrence TMJ/TMD care. He is an teeth can be a result of a multitude of rate in the Mongoloid population (3.1%) accredited fellow of the reasons, including smaller tooth size and versus black (1.5%) and white (1.3%).3 American Academy of proper proportions. Microdontia, a term Peg laterals are usually found unilaterally; General Dentistry. Conflict of Interest used to describe teeth that are smaller or bilateral presentation is extremely rare. Disclosure: None reported. undersized compared to normal-sized teeth, When it comes to the management can lead to a Bolton discrepancy, especially and long-term treatment success of peg when it is present in one arch. Bolton laterals, there are many aspects that discrepancy1 is an analysis developed to dental professionals must consider. In this determine ratios of mesiodistal widths of article, different options and treatment maxillary and mandibular teeth and helps considerations while managing peg laterals identify malocclusions. Microdontia can are discussed as well as highlights from be generalized but more often than not one case that was managed based upon is localized, involving only one or a few limitations of the patient’s desires. teeth. One of the most common situations In order to successfully manage and treat that we see in dentistry involving peg laterals, dental professionals need to microdontia and the anterior segment is first consider the patient’s final wishes and the lateral incisor, also known as the “peg” limitations for the outcome they desire. This lateral. Peg laterals2 or malformed laterals begins with the initial patient consultation are a subclass of a genetic mutation of and interview to find out and clarify the oligodontia and hypodontia. Fortunately, patient’s desired outcome. Once the patient this condition accounts for less than 2%3 has shared their desires, the dentist can of the general population and is often then proceed with the examination process,

FEBRUARY 2 0 2 0 77 peg laterals

CDA JOURNAL, VOL 48, Nº2

FIGURE 1. Preoperative smile. FIGURE 2. Preoperative smile, right lateral view. FIGURE 3. Preoperative retracted view.

FIGURE 4. Preoperative right lateral retracted view. FIGURE 5. Preoperative retracted 1:1 view. FIGURE 6. Preoperative right lateral 1:1 view.

which includes reviewing the patient’s ■■ When smiling, how much of the is compromised, it has been suggested that medical history and doing a thorough patient’s teeth show, including an interdisciplinary approach is key to review of the soft and hard tissue health gingival levels? Is the tooth optimum outcome.6,7 An interdisciplinary throughout the entire dentition, with that needs to be restored in the approach in case management will include focus upon the patient’s chief concern. For proper position or does it need working with an orthodontist to facilitate the very best possible outcome, a series to be moved or do the tissue proper 3D positioning — mesially distally, of photos that include a full-face smile, a levels need to be managed? buccally lingually and apically gingivally nonretracted smile from the frontal aspect ■■ Is it possible to provide an — in order to create ideal contours and as well as right and left lateral views, aesthetically pleasing restoration a periodontal surgeon to manage any retracted views showing frontal, right and based on the current position and gingival architecture discrepancies in the left views and occlusal views of the upper length-to-width ratio of the current smile zone to allow the restorative dentist and lower arches should be taken with tooth? How does it correlate to to create a restoration that is natural a high-quality digital SLR camera along adjacent teeth, how will it correlate in appearance and undetectable. If the with upper and lower models, a facebow to the contralateral tooth, and peg lateral is treated in a less than ideal and bite registration, allowing the treating can we achieve an ideal result? position, an acceptable outcome may be dentist and/or dental laboratory to be able ■■ Is the current tooth position possible and could be simply achieved to evaluate the patient’s situation properly. acceptable to the patient or with additive direct resin bonding, but it is this something that will is imperative for the restorative dentist Treatment Planning and Review need to be changed? to convey the possible less than ideal Once this information is gathered, the ■■ If chosen to treat the tooth in its outcome to the patient before treatment. process of treatment planning the peg lateral current position, can it be done in a The dental professional can then can begin. Evaluation of the photographs way to minimize tooth preparation? create a diagnostic wax-up that will to see how the peg lateral is impacting ■■ Is the patient happy with allow for visualization of the end result, the patient’s situation and correlating the their current shade or do which is an ideal way of finding out if photos to the models is paramount. Some they desire to change it? the patient’s current desires and goals critical points to consider when evaluating In the management of the peg lateral, align with the tooth position at hand. the photos and models to develop your and especially when the tooth is in a poor The wax-up allows both patient and final treatment plan for your patient are: position or the gingival or “pink aesthetics” dentist to determine if the final result

78 FEBRUARY 2 0 2 0 CDA JOURNAL, VOL 48, Nº2

FIGURE 7. Full smile, postoperative view. FIGURE 8. Postoperative right lateral view. FIGURE 9. Postoperative retracted 1:2 view.

FIGURE 10. Postoperative retracted right-lateral 1:2 view. FIGURE 11. Postoperative right lateral retracted 1:1. FIGURE 12. Postoperative 1:1 retracted view. will be aesthetically pleasing and can be and finished. Furthermore, repair of direct It is important to ensure that the peg used to either create a provisional for resin restorations over time is possible and lateral is in an ideal position to create an the final porcelain restoration or can be appears to be a viable treatment modality.13 emergence profile in the final restoration to used to create a putty stent that can be Composite resin material will continue support the surrounding papilla as well as be used for a direct bonded restoration. to evolve and may overcome many of the easy to maintain and clean by the patient. In selecting the final restoration, the current issues of chipping and discoloration Otherwise, poor initial positioning may clinician has choices in the future. Nevertheless, composite resin lead to overhangs on the final restoration to manage the peg lateral: direct resin can be contraindicated in patients who making tissue health and maintenance restoration and indirect porcelain have a sensitivity to resin-based products. difficult and ultimately leading to long- restoration. Each one has risks and benefits, Indirect restorations may require more term failure. Another vital portion of the and both can serve as excellent long-term tooth preparation in order to create a path final restoration when developing the restorations8–12 and should be adequately of insertion and adequate restorative room peg lateral into a normal-sized tooth is shared and described for the patient to be for the dental ceramist to achieve ideal that the clinician and/or lab needs to pay able to make an informed decision. Direct results. Indirect ceramic restorations tend particular attention to lateral and protrusive resin restorations can serve as excellent to maintain their overall surface texture movements. Interferences and restriction long-term restorations,8 but are more and polish over time and may stain less of the movement of the lower cuspid, clinically challenging for the restorative than direct resin restorations, but this which moves through these embrasure dentist because the final outcome is totally is a questionable benefit.14 Ultimately, spaces, can occur when changing the shape dependent on the individual clinician. An indirect restorations shift much of the and length of the peg lateral along with excellent outcome requires a high level of focus of the creativity and blending of the altering the overall incisal embrasures on skill and artistry in order to achieve ideal final restoration to the ceramist versus the mesial and distal incisal aspects. This form, function and aesthetics. Additionally, the restorative dentist. Another concern can lead to unforeseen forces and pressures resin restorations minimize preparation of with the selection of direct versus indirect on the restored peg lateral, especially in the peg lateral tooth because they do not restorations is the overall cost of the patients with parafunctional habits. require a path of insertion that may be final restoration for the patient, which Because the tooth is already undersized needed for an indirect restoration. Resin is typically less when a direct restoration and if it is in the proper position to be restorations can discolor over time versus a is placed because it does not require an restored, minimum preparation of the porcelain restoration but can be repolished additional lab cost for the restoration. peg lateral will be needed as the final

FEBRUARY 2 0 2 0 79 peg laterals

CDA JOURNAL, VOL 48, Nº2

restoration is additive in nature. Any The patient was anesthetized and tooth if the dental professional takes the removal of tooth structure other than to No. 7 was minimally prepared, keeping the time, information and proper records define preparation finish lines will weaken entire preparation in enamel to allow for and develops an appropriate treatment the tooth further. Keeping the preparation proper fabrication of the final restoration. plan prior to treating the patient. n in enamel maximizes the overall strength Enameloplasty was performed on tooth references of the tooth as well as the final bond of No. 27 to allow for proper clearance 1. Bolton W. Disharmony in Tooth Size and Its Relation to Treatment tooth to restoration, whether it be direct or and functional clearance in excursive of Malocclusion. Angle Orthod 1958 Jul;28(3):113–130. indirect in nature because enamel bonding movements. A final impression was taken 2. Grahnén H. Hypodontia in the permanent dentition a clinical and genetical investigation. Odont Rev 1956;7:1–100. is still the gold standard when it comes to with polyvinylsiloxane and a provisional 3. Hua F, He H, Ngan P, Bouzid W. Prevalence of peg-shaped predictability and long-term stability. was fabricated for the patient to wear to maxillary permanent lateral incisors: A meta-analysis. Am J Orthod evaluate overall aesthetics and function. Dentofacial Orthop 2013 Jul;144(1):97–109. doi: 10.1016/j. ajodo.2013.02.025. PMID: 23810051. Clinical Case Review The patient returned to the office three 4. Arte S, Nieminen P, Pirinen S, Thesleff I, Peltonen L. Gene In this clinical case, the patient weeks later. The provisional was removed defect in hypodontia: Exclusion of EGF, EGFR and FGF-3 as presented with a chief complaint of “I and the final restoration was tried in for candidate genes. J Dent Res 1996 Jun;75(6):1346–52. doi: 10.1177/00220345960750060401. PMID: 8831628. don’t like my small tooth. Can you fix it?” evaluation of the final shade, contour and 5. Arte S, Nieminen P, Apajalahti S, Haavikko K, Thesleff (FIGURES 1–6). Her medical history was contacts. After patient approval of the I, Pirinen S. Characteristics of incisor-premolar hypodontia noncontributory, and a comprehensive final restoration, the area was isolated. in families. J Dent Res 2001 May;80(5):1445–50. doi: 10.1177/00220345010800051201. PMID: 11437217. exam was completed and a series of A #00 cord was placed to help keep the 6. Ittipuriphat I, Leevailoj C. Anterior space management: photos and mounted models were taken. tissue displaced during placement. The Interdisciplinary concepts. J Esthet Restor Dent 2013 Feb;25(1):16– It was noted that the patient had existing tooth was cleaned thoroughly using a 30. doi: 10.1111/j.1708-8240.2012.00515.x. Epub 2012 May 29. PMID: 23374405. crowding and spacing and that functional microetcher (Microetcher IIA, Danville 7. Claman L, Alfaro MA, Mercado A. An interdisciplinary approach wear was present on the anterior segment Materials, Carlsbad, Calif.) to remove for improved esthetic results in the anterior maxilla. J Prosthet of teeth and existing decay in some of any residual cement and then thoroughly Dent 2003 Jan;89(1):1–5. doi: 10.1067/mpr.2003.5. PMID: 12589277. the posterior teeth. Multiple options rinsed. The tooth received an application 8. Zorba YO, Bayindir YZ, Barutcugil C. Direct laminate veneers were discussed with the patient including of 35% phosphoric acid for 20 seconds with resin composites: Two case reports with five-year follow- orthodontics to correct the crowding and to and was rinsed thoroughly and dried. ups. J Contemp Dent Pract 2010 Jul 1;11(4):E056–62. PMID: 20953565. redistribute the spacing, whitening to help A copious amount of a light-cured self- 9. Scarpelli AC, Reboucas AP, Compart T, Novaes-Júnior JB, Paiva enhance the color of the existing dentition, priming dental adhesive (Prime & Bond SM, Pordeus IA. Seven-year follow-up of esthetic alternative for the caries control and then restoration of the NT, Dentsply, Milford, Del.) was applied, restoration of peg-shaped incisors: A case study of identical twins. Gen Dent 2008 Jan–Feb;56(1):74–7. PMID: 18254565. peg lateral. Restorative options for the lightly air dried to remove the excess and 10. Izgi AD, Ayna E. Direct restorative treatment of peg-shaped peg lateral included a direct bonded and cured. The final restoration was seated maxillary lateral incisors with resin composite: A clinical report. an indirect porcelain bonded restoration. using Variolink resin cement base (Ivoclar J Prosthet Dent 2005 Jun;93(6):526–9. doi: 10.1016/j. prosdent.2005.03.016. PMID: 15942612. Risks, benefits and options were discussed Vivadent AG, Schaan, Liechtenstein) 11. Braun J. Treatment of the peg lateral incisor: A case study. J at length, and the patient decided that all only and the excess cement was removed. Indiana Dent Assoc 2001 Spring;80(1):16–7. PMID: 11444123. she desired was whitening of her existing The restoration was tacked in place 12. Alberton SB, Alberton V, de Carvalho RV. Providing a harmonious smile with laminate veneers for a patient with peg-shaped lateral dentition and restoration of the peg lateral using a curing light (Valo, Ultradent) incisors. J Conserv Dent 2017 May–Jun;20(3):210–213. doi: with an indirect porcelain restoration. for a few seconds. Any remaining excess 10.4103/0972-0707.218311. PMID: 29279628. PMCID: Upper and lower whitening trays were cement was removed and the tooth was PMC5706325. 13. van de Sande FH, Moraes RR, Elias RV, Montagner AF, Rodolpho fabricated and the patient was sent home cured on the facial and lingual aspect PA, Demarco FF, Cenci MS. Is composite repair suitable for anterior with 10% whitening gel (Opalescence, for 40 seconds. Occlusion was checked restorations? A long-term practice-based clinical study. Clin Oral Ultradent, South Jordan, Utah). While the and verified. The patient returned a few Investig 2019 Jun;23(6):2795–2803. doi: 10.1007/s00784-018- 2722-5. Epub 2018 Oct 27. PMID: 30368661. patient was wearing her trays, the models weeks later for final photos FIGURES( 7–12) 14. Wakiaga J, Brunton P, Silikas N, Glenny AM. Direct versus were sent to the dental laboratory for a final and was very happy with the end result, indirect veneer restorations for intrinsic dental stains. Cochrane diagnostic wax-up. The patient returned to as it exceeded her expectations. Database Syst Rev 2004;(1):CD004347. Review. Update in: Cochrane Database Syst Rev 2015;12:CD004347. PMID: the office approximately three weeks after Obtaining ideal results in the 14974066. whitening. She was happy with her whiter treatment of the peg lateral can be the author, Jeffrey W. Lineberry, DDS, can be reached at smile, and her overall shade had stabilized. very predictable and straightforward [email protected].

80 FEBRUARY 2 0 2 0 gingival embrasures

CDA JOURNAL, VOL 48, Nº2

Treatment of the Dreaded Black Triangle: A Case Report and an Introduction to Injection Molded Composite Dentistry

David J. Clark, DDS

AUTHOR

David J. Clark, DDS, raditional composite placement interface (TRI) allows for graceful color founded the Academy of for aesthetic rehabilitation of blending of the composite to tooth and Microscope Enhanced open gingival embrasures, or has also retained its shine and resisted Dentistry. He lectures worldwide and maintains a black triangles, has historically stain. Traditional hand-manipulated private practice in Tacoma, been viewed with skepticism by composite bonding is typically limited Wash. Tmany restorative dentists, orthodontists to certain regions of the tooth and then Conflict of Interest and periodontists. Many patients are told marginated. With this technique, the Disclosure: Dr. Clark there is no healthy option. Patients are entire tooth is covered in composite has financial interest in Bioclear Matrix Systems often told that either nothing should then quickly sculpted and finished with and receives honoraria be done or are offered aggressive and a specific polishing technique. This from 3M. physiologically costly procedures such marginless approach yields stubborn as crowns, veneers or physiologically resistance to stain accumulation. inappropriate interproximal reduction (IPR) in conjunction with orthodontic Case Presentation treatment (TABLE 1).1,2 The problem The patient presented with a desire should not be underestimated, to treat the black triangle between as one-third of adults suffer the teeth Nos. 8 and 9 (FIGURE 3A). After aesthetic and functional dilemmas a comprehensive evaluation and associated with black triangles.3 photographs (FIGURE 3B), the patient The etiologies of black triangles are agreed to a more comprehensive approach decreased interproximal bone height involving injection overmolding involving from periodontal disease, attachment the four maxillary incisors and elimination loss, periodontal surgery or trauma; of three black triangles. The patient also excessive embrasure space and deficient wanted to brighten his teeth by using papilla form affected by root angulation, shade B-1. He did not want removal of interradicular distance, crown form and any healthy tooth structure and accepted distance between alveolar bone and the treatment plan to add fullness to interproximal contact; a patient’s biologic the teeth, approximately 1 mm, to mask width and inherent or thinning gingival the dark bands on the central incisors. biotype; and age including patient habits, The Bioclear Smile Design gauge iatrogenic issues and adult orthodontics. (Bioclear, Tacoma, Wash.) helped to A full-mouth black triangles case show the tooth size discrepancy between originally treated in 2012 (FIGURES 1) is his central incisors (FIGURES 4). The shown at six-year follow-up in FIGURES 2. patient opted to forgo restorative Note the infinity-edge tooth-restoration orthodontics to move the midline.

FEBRUARY 2 0 2 0 81 gingival embrasures

CDA JOURNAL, VOL 48, Nº2

TABLE 1 Conventional Solutions for Open Gingival Embrasures • Orthodontic extrusion to coronally reposition interproximal bone and subsequent enameloplasty or restoration. • Orthodontic repositioning of divergent roots or widely spaced roots along with enameloplasty to narrow the embrasure space and encourage gingival adaptation. • Interproximal bone graft. • Soft tissue graft or papilla reconstruction. • Subtractive porcelain restorations or composite bonding (white and/or pink). • Removable prosthesis in severely compromised cases.

FIGURE 1A. FIGURE 1B. FIGURE 1C. FIGURES 1. Preoperative (A), immediate postoperative (B) and six-year follow-up (C) photographs of a full-mouth black triangle case. The composites used were heated Filtek Supreme Ultra Body Shade (B-1) and a small amount of Filtek Supreme Flowable composite. This flowable comes in the same Body shade, which allows an ideal match between the different viscosity resins.

Injection molding requires attention FIGURES 2. to the four cornerstones of the method: Preoperative (A) and six-year radiographs (B) of the case ■■ A thorough preparation of the in Figure 1. After viewing the tooth surfaces before acid etching radiographic integrity and the is critical to avoid staining or long-term favorable soft tissue debonding. Nonsurgical tooth response, most periodontists preparation is achieved with an air/ and orthodontists feel water/abrasive slurry of aluminum comfortable with this method trihydroxide. This procedure as a conservative, permanent removes the biofilm. Inattention to and healthy option. biofilm removal is a leading cause of stain and debonding. Application of phosphoric acid alone does not properly address biofilm removal. Phosphoric acid selectively removes the mineral component of dentin FIGURE 2A. FIGURE 2B. and enamel. Biofilm is mostly organic and will therefore not be to the use of light-body impression ■■ The polish. The reader is encouraged removed with phosphoric acid. material followed by heavy- to learn the simplified two-step ■■ Matrix selection, contact body impression material. Some polishing process by watching management and proper seating. clinicians perform the technique online videos. A prerequisite ■■ Injection molding with uncured with flowable composite alone. for long-term polish retention is adhesive as a surfactant, heated However, most paste composites dependent on the elimination of flowable composite, followed have better shine retention than voids and bubbles often introduced immediately by heated paste their flowable counterparts. with hand manipulation of composite. The three resins are Therefore, the ideal restoration composites. Injection-molded then light cured together. The today should reach a 95% ratio composite has a high degree of combination of flowable and regular of paste to flowable composite in integrity without the bubble and paste composite can be compared aesthetic and load-bearing areas. voids of traditional bonding.

82 FEBRUARY 2 0 2 0 CDA JOURNAL, VOL 48, Nº2

green-colored matrices that have more curvature than the yellow-colored matrices were chosen. Next, a pair of size-appropriate correspondingly FIGURE 3A. FIGURE 3B. color-coded Bioclear black triangle FIGURES 3. Preoperative photographs of the case to be treated in this article. The midline black triangle was likely matrices are tried in for each caused by root position (A). The lateral incisor black triangle is resultant of concave tooth anatomy and a small root (B). embrasure. Although we measure and pair the matrices for each embrasure, the injection molding is performed one tooth at a time to allow for a monolithic, stain-resistant outcome. Tooth No. 8 is injection molded first. The green matrices are placed at the midline (FIGURES 7–10). The other embrasures have smaller black triangles. The pink-colored matrices, which are the least curvaceous of FIGURE 4A. FIGURE 4B. the four colors, are used in the other FIGURES 4. The Bioclear Smile design gauge is placed intraorally at a 45% angle and locked behind the embrasures. “Shield” matrices (inactive maxillary canines or maxillary first bicuspids. In this case, the left central incisor is significantly wider. matrices that shield the neighboring teeth) are placed on the neighboring Composite Heating Case Presentation and Technique teeth on either side of the tooth and Composite warming is not new. Summary will later be used as active matrices. However, it was rarely viewed as a Before the rubber dam is placed, These shield matrices help maintain necessary component of composite the TruContact sanders (Bioclear) the embrasure shape as the active dentistry before the advent of injection are used to smooth, remove calculus matrix system becomes pressurized molding and injection overmolding. The and lighten the tension of the contact during injection molding. The matrixed injection method utilizes Filtek Supreme areas and allow the matrices to seat tooth No. 8 is acid etched, rinsed and Ultra (3M ESPE, St. Paul, Minn.) in fully (FIGURE 5A). Once the rubber dried. Scotchbond Universal adhesive the Body shades, plus the color-matched dam is placed, disclosing solution is (3M ESPE, St. Paul, Minn.) is placed Filtek Supreme Ultra flowable composite. applied to highlight biofilm and then on enamel, massaged into dentin for 3M has recently completed an extensive blasted with an air/water/abrasive 20 seconds, air thinned but not light analysis of the safety of heating the above- slurry of aluminum trihydroxide cured. Then heated Filtek Supreme mentioned composite and 3M’s Filtek (FIGURE 5B). Nowhere is this more Ultra Flowable (3M ESPE) is injected One Bulk Fill and Bulk Fill Flowable for critical than the interproximal area into the active matrices followed posterior teeth. Their resins can safely where access to traditional scaler with heated Filtek Supreme paste. be heated for more than an hour in the and prophy cups is difficult. Injection molding using heated appropriate heater without degradation Next, the black triangle gauge is composite with the Bioclear method of the resins. Other studies showing the inserted buccal-lingually below the has similarities to industrial injection safety of heated composite are in TABLE 2. contact to assess the mesiodistal size molding. In dentistry, the sides (mesial of the black triangle (FIGURES 6). and distal) of the tooth are well- Can All Resins Be Heated? The gauge will bind at one of the contained all the way to the bottom of We have observed two resins that four colors. In this case, the gauge the sulcus. In the center of the tooth, should definitely not be heated and others was binding between the yellow and there is a gap that allows injection of that cannot be heated for very long. green areas of the gauge. The patient the composite. This distinct injection Clinicians can either use the 3M material or preferred a complete elimination of zone is often referred to as the umbilical check with the manufacturer of their resins. the black triangle. Therefore, the cord or umbilicus of the restoration.

FEBRUARY 2 0 2 0 83 gingival embrasures

CDA JOURNAL, VOL 48, Nº2

TABLE 2 Recent Research Validating Heating of Specific Composite Resins

Benefits of heating Citation Heating of the composite does not affect mechanical characteristics of Filtek Supreme Ultra composite Agre M, et al. Physical and Esthetic Properties including diametral tensile strength, flexural strength, depth of cure and compressive strength. of a Warmed . J Dent Res vol. 98A, abst no. 1670, 2019.4 This study concerns leaching of chemicals out of the composite. A comparison was performed to evaluate Dunbar T, et al. Gravimetric Extraction of the relative amount of material extracted from warmed or nonwarmed, light-cured, resin-based composite Warmed and Room Temperature Experimental material in three separate solvents to help determine the potential safety of warming techniques in composite Composite. J Dent Res vol. 98A, abst no. 1877, use. There was no statistical difference between the room temperature and warmed samples at most 2019.5 extraction times. Fracture toughness was increased for Filtek One Bulk Fill when specimens were preheated. Abdulmajeed A, et al. Fatiguing and Preheating Effect on Mechanical Properties of Composite Resins. J Dent Res vol. 98A, abst no. 1879, 2019.6 Heated composite is safe to the pulp. In the study, the extent of the increase in pulpal temperature with heated composite was only 0.8 C. In contrast, a 5 C intrapulpal temperature rise was seen for all groups Daronch M, Rueggeberg FA, Hall G, De Goes during photopolymerization. MF. Effect of composite temperature on in vitro intrapulpal temperature rise. Dental Mater 2007 Oct;23(10):1283–8. Epub 2007 Jan 2.7

With industrial injection molding, the remnant of the injection zone is referred to as a “vestige.” When casting dental gold restorations, there is a “sprue” that connects the casting to the melted gold mass. It is purposeful excess that sits above the controlled contour that is later cut back and blended to the restoration surface. With dental injection molding, the umbilicus can be prone to voids. Therefore, it should be maintained as 1 mm to 3 mm of excess, light cured and then FIGURE 5A. FIGURE 5B. cut back to the grade of the matrix FIGURES 5. The teeth are isolated with a heavy rubber dam (A), dried, then disclosed with the dual-color disclosing containment zone. The supragingival solution (B). The contacts are sanded in sequence to lighten the tension of the contacts. This will in turn allow full seating excess in the umbilicus is maintained of the matrices. A secondary benefit is to remove hard and soft biofilm, which are common to the peri-contact area. as to not disturb the composite. The matrices are massaged back to shape with the unique paddle instrument, and any flowable composite in the gingival area is blotted away with dry brushes. Little to no hand manipulation of the composite is the goal with injection molding. Once thoroughly light cured, the shield matrices and the active matrices are removed. The excess areas are quickly removed with a dry coarse FIGURE 6A. FIGURE 6B. flame bur (Komet, Lemgo, Germany). FIGURES 6. The Bioclear Black Triangle Gauge (patent pending) is shown in two of the three embrasures that Then the tooth is taken to 80% of the will subsequently be treated. Color-coded matrices will subsequently be utilized that match the colored area of the final shape with the 3M Sof-Lex coarse gauge where it binds when viewed from the incisal. disc (3M ESPE) (FIGURE 10). The process

84 FEBRUARY 2 0 2 0 CDA JOURNAL, VOL 48, Nº2

FIGURE 7. At the midline area, the gauge was FIGURE 8. A high-magnification view of the FIGURE 9. The first tooth has been overmolded and between yellow and green. The patient wanted aggressive curvature of the black triangle matrices matrices removed. Note the orange color along the absolute closure of the black triangle, so the green and tight gingival seal is demonstrated. If the contacts incisal edge where the adhesive was transported to. matrices were used. For a slightly open embrasure, are not appropriately lightened with the sander the yellow matrices would have been utilized. mentioned previously, the operator may see a gingival The other embrasures were restored with the pink gap. This indicates that the matrix is not fully seated, matrices. The “large” matrices from the “large” tub the matrices should be removed, the contact sanded were utilized for this case. The “small” matrices are more aggressively and then matrices reinserted. commonly used for lower incisors.

FIGURE 10. The excess or “umbilicus” has been quickly FIGURE 11. The left central incisor is overmolded. FIGURE 12. The mesial is treated with the pink amputated with a dry coarse diamond bur; the tooth is The “shepherd” matrix on the mesial of the lateral is matrix and the distal is treated with the Bioclear A-102 then taken to the 80% completion state with a SoFlex XT currently inactive but will later be used as an active or matrix from the original Bioclear System in the HD Coarse disk (3M) before moving on to the next tooth. “aquarium” matrix. thickness. Because the contacts were all naturally occurring in this case, the slightly thicker HD matrices can be used. The HD version of Bioclear Mylar at 75 microns is significantly stronger and stiffer than is repeated one tooth at a time (FIGURES is used in a disposable cup to create the 50-micron version. Each thickness version is used 11 and 12). The single porcelain veneer omnidirectional super-fine scratches. depending on the clinical situation. on tooth No. 7 was removed and replaced Next, the Magic Mix is completely with the same basic injection overmolding removed with air-water spray. Finally, process used on the other teeth. Because a diamond impregnated cup (RSP the original porcelain veneer was very Polisher, Bioclear) is used with light conservative, no dentin was exposed. pressure. Care should be taken with Another aid was the fact that the any polisher used without water spray contacts were still present in enamel, coolant, as it can create heat. Then which is very helpful to the clinician the same diamond impregnated cup is as the matrices are stabilized nicely. used with copious air-water spray and heavy pressure to achieve the ultra- FIGURE 13. Immediate postoperative view. Note the The Final Step: The Polish glossy appearance. This process sets the ultra-glossy finish imparted by the polish. Monolithic First, the pre-polish is completed injection molded restoration apart from injection molded composite holds real promise as the structural and optical integrity of the composite, Filtek with a worn SoFlex XT disc (3M the often-grainy finish of “bonding.” Supreme Ultra, is maximized. ESPE) to create a matte finish and to The immediate postoperative remove any deep scratches left by the photograph (FIGURE 13) demonstrates diamond bur. Next comes the two- immediate and complete black triangle step polish. Magic Mix (Bioclear) closures. The matrices are specifically

FEBRUARY 2 0 2 0 85 gingival embrasures

CDA JOURNAL, VOL 48, Nº2

designed to put the apical extent of the contact area within 5 mm of the bone level. This distance is the Tarnow guideline: The maximum distance from crestal bone to contact area to achieve a papilla in 100% of cases is 5 mm. Pre- and postoperative radiographs (FIGURES 14) demonstrate evidence of the smoothness and healthy contours FIGURE 14A. FIGURE 14B. of a large black triangle closure of the central incisor embrasure. FIGURES 14. Preoperative (A) and immediate postoperative (B) radiographs are shown. Note the smooth transition of the tooth-restoration interface (TRI) and the aggressive change in emergence profile. Aesthetic transformation is One of the key elements of the method is the change in emergence profile begins subgingivally. That not a new concept in restorative subgingival adaptation and aggressive emergence profile was difficult to achieve before the advent of a dentistry (FIGURES 15). However, dedicated black triangle matrix. injection overmold with heated multiviscosity resins in precise matrices with an exquisite gingival seal and without cutting the tooth to accommodate indirect ceramics is new. The reader can contact 3M Oral Care or Bioclearmatrix.com for more information. n

references 1. Kim J, Clark DJ. Full-mouth black triangle treatment protocol. Dent Today 2017 Aug;36:72–77. 2. Kim, J. Restorative orthodontics with injection molding: Intra-arch and inter-arch case solutions. Dent Today 2019 Jan;62–65. 3. Kurth J, Kokich V. Open gingival embrasures after orthodontic treatment in adults: Prevalence and etiology. Am J Orthod Dentofacial Orthop 2001 Aug;120(2):116–123. 4. Agre M, et al. Physical and Esthetic Properties of a Warmed Dental Composite. J Dent Res 2019 vol 98A, abstract 1670. 5. Dunbar T, et al. Gravimetric Extraction of Warmed and Room Temperature Experimental Composite. J Dent Res 2019 vol 98A, abstract 1877. 6. Abdulmajeed A, et al. Fatiguing and Preheating Effect on Mechanical Properties of Composite Resins. J Dent Res 2019 FIGURE 15A. FIGURE 15B. vol 98A, abstract 1879. 7. Daronch M, et al. Effect of composite temperature on FIGURES 15. Preoperative (A) and immediate postoperative full-face photographs (B). in vitro intrapulpal temperature rise. Dent Mater 2007 Oct;23(10):1283–8. Epub 2007 Jan 2. doi.org/10.1016/j. dental.2006.11.024.

the author, David J. Clark, DDS, can be reached at [email protected].

86 FEBRUARY 2 0 2 0 SELL YOUR PRACTICE ...... to the right buyer! Knowing how, means doing all of the following - with precision:

1. Valid practice appraisal.

2. Contract preparation and negotiations, including critical tax allocation consideration.

3. Bank financing or Seller financing, with proper agreements to adequately protect the Seller and make the deal close - realistically and expeditiously.

4. Performance of “due diligence” requirements, to prevent later problems.

5. Preparation of all documentation for stock sale, when applicable.

6. Lease negotiations.

All six of these services costs no more.

LEE SKARIN Maybe even less! INC. & ASSOCIATES Lee Skarin & Associates is Cali- fornia’s leading Dental Practice Broker. Their in-house attor- Lee Skarin & Associates ney, Kurt Skarin, PhD., J.D., has scores of Buyers in their specializes in these matters. He does all of the above, and more. database. The Buyers’ profiles He is the catalytic agent that personal desires and financial makes the sale happen - quick- ability have been categorized to ly and smoothly. expertly select the right Buyer for your practice. Expert Buyer selection solidifies a deal. Lee Skarin & Associates services Dental Practice Brokers Offices: all of Southern California. CA DRE #00863149 805.777.7707 818.991.6552 Your calls are invited. Put our thirty years of experience to work for you! Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461 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. RM Matters CDA JOURNAL, VOL 48, Nº2

Keeping Office Payments Safe and Secure

TDIC Risk Management Staff

rom facial recognition software to report the loss to the bank and police personal identification numbers, as soon as they are made aware of it. countless protections are in Basic security measures, such as place to safeguard our private Credit card processors will video cameras, motion sensors and financial data. In the dental office, typically refund fraudulent alarms, can thwart most criminals. Fdata encryption, anti-virus software charges to a victim’s account To keep your credit card terminals and firewalls are the go-to preventive safe, TDIC recommends taking the measures, not to mention the classic as long as the victim reports following additional precautions: lock-and-key methods for securing the crime immediately and ■■ Lock the terminal away in hardware and other items of value. follows the protocols laid out a locked cabinet or drawer Unfortunately, smart thieves can, in their contracts. at the end of each day. and have, found ways to outwit many ■■ Take the terminal home with of the most advanced security systems. you at the end of each day. In one case reported to The Dentists ■■ Password protect your terminal, Insurance Company’s Risk Management particularly for any refund functions. Advice Line, a thief broke into a dental office and made off with the credit card terminal, resulting in $11,000 in charges from the dentist’s account. The dentist became aware of the theft after finding his glass office door broken. Upon reviewing the video footage, he witnessed the suspect, who was wearing a bandana, enter the office and take the credit card terminal. The entire incident took less than 60 seconds. The dentist reported the incident to his bank. answers The bank initially refunded the money, but then the dentist received a letter from the bank stating that the bank wanted the money back. Apparently, the criminal used the terminal to post credits from the dentist’s merchant account to prepaid credit cards. The credits were small, ranging from $300 to $400 each, From one-on-one risk management advice by phone totaling $11,000. The prepaid credit card to informed consent forms to expert-led seminars, company also demanded repayment. Luckily, the dentist had reported the we’re here to help you practice with confidence. machine as stolen and the charges were We are The Dentists Insurance Company. made after it was taken from his office. Credit card processors will typically Learn more at tdicinsurance.com/rm refund fraudulent charges to a victim’s

account as long as the victim reports ® the crime immediately and follows the Protecting dentists. It’s all we do. protocols laid out in their contracts. 800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783 This usually requires the merchant to

FEBRUARY 2 0 2 0 89 FEB. 2020 RM MATTERS

CDA JOURNAL, VOL 48, Nº2

■■ Upgrade your terminal to a computer and processing transactions offices, including fees and processing self-disabling device, which through a web-based platform. times. In addition, not all of them requires the initial setup to be While credit cards remain the offer the same level of fraud protection conducted if the terminal loses gold standard in merchant payments, and conflict resolution services power. This also requires the peer-to-peer payments are grabbing offered by credit card companies. issuing bank to be contacted in a stronghold as well. These payment One of the biggest concerns for order to have your merchant methods, which include companies dental practices with regard to peer-to- number reassigned to the unit. such as Venmo, PayPal and Zelle, allow peer payments is privacy. Depending Dental practices may also want users to transfer funds directly from bank on the provider, transactions can be to consider alternative methods of accounts or credit cards to merchants. open to the public; in fact, some, accepting credit card payments. For On-demand payments are certainly including Venmo, allow users to example, mobile card readers, such becoming the norm, as transactions connect with “friends” and allow as Square, plug directly into your can be made within seconds from any transactions to be viewable to everyone smartphone or tablet and transfer smartphone. While accepting such in the network. Privacy settings can data via an app. Virtual card readers payments is convenient for patients, override this function, but it is up to operate similarly, connecting to a there are some considerations for dental the user to change their settings. And while financial data is encrypted on most peer-to-peer apps and servers, user identity isn’t, which can open the door to liability claims stemming from potential HIPAA violations. Every dental practice owner wants to make the payment process as fast and convenient as possible. But with convenience often comes risk. Taking a few steps to ensure the security of financial data can help mitigate those risks. Using security technology, following basic security best practices and offering alternative payment methods can protect your patients and your practice from fraud and theft. 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.

90 FEBRUARY 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, Nº2

Role of the Infection Control Coordinator

CDA Practice Support

o dental practice wants to compliance with standard precautions and TABLE experience an infection to provide feedback. The checklist can Infection Control Breaches That Have control breach, especially help identify deficiencies and lapses, and Occurred3 one that necessitates patient the infection control coordinator should n Instruments not properly processed. notification or draws media attempt to determine why lapses occur n Single-dose vials used for more than one patient. Nattention. Despite annual mandated and to correct the lapses by, for example, n Spore tests not processed appropriately. Cal/OSHA bloodborne pathogens retraining staff. Both the checklist and n Reuse of single-use devices. training for staff and dental licensees’ app allow completed forms to be kept biennial obligation to complete a two- for tracking and review purposes. hour infection control course, infection Key to assuring compliance with control breaches continue to occur. infection control procedures is for the ■■ Safe injection practices4 — How can a dental practice do better? office to have written policies and disposable needles and syringes One way is to implement procedures required by the Dental Board and single-dose medicines. an administrative procedure of California and Cal/OSHA. The ■■ Sterile instruments and devices recommended by the Centers for infection control coordinator can be — instrument cassettes, cassette Disease Control (CDC)1 but not assigned to develop and to regularly review wraps, sterilization pouches, required by regulation — designate and update the Cal/OSHA-required ultrasonic cleaning solution, an “infection control coordinator.” exposure control plan and the dental spore test strips, for example. This individual, trained in infection board-required protocols for instrument ■■ Clean and disinfected control, could coordinate and monitor processing, operatory cleanliness and environmental surfaces — the dental practice’s implementation management of injuries. A dental benefit cleaner, disinfectant, towels of infection control procedures. This plan may have additional requirements, or cloths and utility gloves. individual should be well-versed in so the infection control coordinator Infection control coordinators the dental board’s infection control should check the provider handbook will need to familiarize themselves regulation, Cal/OSHA bloodborne of each of the dental plans with which with respective products’ instructions pathogens regulation, state medical the dental practice is contracted. for use and ensure staff follow them. waste management law and CDC The infection control coordinator Surface disinfection products take recommendations for infection should ensure necessary supplies are various forms — spray, wipes and control in dental settings. A printed adequate and available for staff to concentrate, for example — and not version of the board’s regulation comply with standard precautions. following manufacturer’s instructions and Cal/OSHA’s regulation must be Standard precautions and the may place employees and patients available to all staff in the dental necessary supplies include: at risk because products may not practice. California’s Medical Waste ■■ Hand hygiene — soap, work as expected. “Disinfectants are Management Act is easily found on antibacterial and hand lotion. not interchangeable, and incorrect the internet, and CDA summarizes its ■■ Use of personal protective concentrations and inappropriate requirements for dental practices in equipment — gloves (appropriate disinfectants can result in excessive a sample medical waste management sizes), masks, eyewear, gown/ costs,” according to the CDC.5 To plan found on cda.org/practicesupport. jacket appropriate for procedure. ensure products work as expected and The CDC has an infection control ■■ Respiratory hygiene/cough etiquette to protect employees and patients, an checklist available both in print — reminder sign, masks for patients. infection control coordinator should and as a mobile app.2 The checklist ■■ Sharps safety (engineering check a disinfectant’s expiration delineates the agency’s infection control and work practice controls) — date and that staff are applying recommendations for dental settings, sharps container, single-hand disinfectant to a surface for at least from administrative measures to dental needle recapping device, single- the minimum recommended contact unit water quality. The infection control hand needle removal device, time. Another example of the need coordinator can use the checklist sharps with engineered sharps to review equipment instructions is periodically to assess dentist and staff protection, for example. that certain sterilizers require that

FEBRUARY 2 0 2 0 91 FEB. 2020 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 48, Nº2

instruments and cassettes be dry prior references Regulatory Compliance appears monthly to sterilization because those sterilizers 1. Centers for Disease Control and Prevention, Summary of and features resources about laws that impact Infection Prevention Practices in Dental Settings. www.cdc.gov/ are not designed to remove excess oralhealth/infectioncontrol/pdf/safe-care2.pdf. dental practices. Visit cda.org/practicesupport moisture from packaged instruments. 2. Centers for Disease Control and Prevention, DentalCheck Mobile for more than 600 practice support resources, Wet, sterile instrument packages do App, www.cdc.gov/oralhealth/infectioncontrol/dentalcheck.html including practice management, employment and Summary of Infection Prevention Practices in Dental Settings, not remain sterile for very long. www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf. practices, dental benefits plans and It is a best practice to establish 3. Centers for Disease Control and Prevention, Outbreaks and regulatory compliance. regular evaluation of a dental practice’s Patient Notifications in Outpatient Settings, Selected Examples, 2010–2014. www.cdc.gov/hai/settings/outpatient/ infection prevention program and of outbreaks-patient-notifications.html. Accessed July 5, 2019. staff’s understanding and adherence to 4. Centers for Disease Control and Prevention, Safe Injection Practices in Dentistry, www.cdc.gov/OralHealth/ minimum standards of infection control. infectioncontrol/pdf/safe-injection-practices.pdf. Accessed Having an infection control coordinator October 28, 2019. in a dental practice can be key to 5. Centers for Disease Control and Prevention, Disinfection Methods, Disinfection & Sterilization Guidelines, 2008. www. ensuring compliance and to reducing cdc.gov/infectioncontrol/guidelines/disinfection/disinfection- risk of an infection control breach. n methods/index.html. Accessed October 25, 2019.

92 FEBRUARY 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 asking $583K. 2018 GR $902K & 2019 on schedule for $962K. Seller willing to help for smooth transition. Asking $746K. 4376 SANTA CRUZ COUNTY GP Incredible practice opportunity offering 31 yrs of goodwill. EZ freeway access and parking. Close to 4382 MONTEREY COUNTY GP Gorgeous practice in scenic amenities and shopping. Nicely appointed 1,200 sq. ft office with 4 ops. Monterey Bay peninsula in ample seller owned building with state-of-the- Owner/Doctor works 4 days/week. Hygiene 6 days/week. 1,200+ active art equipment. $900K+ average annual gross receipts with 4 doctor patients. Average GR $1.6PMEwNithDaIvNeGrage adj. net of $756,029.00. days. Asking $678K. Owner/Doctor will help for smooth transition. Asking $1,206,000. 4343 CAPITOLA GP Gorgeous, state-of-the-art practice offering 33+ 4381 SOUTH SAN FRANCISCO GP Retiring dentist offering 23 year years of goodwill. Beautifully appointed office environment and building, practice close to Kaiser Hospital. 4 op facility with new & recently located within minutes of charming downtown Capitola, known for its upgraded equipment. Asking price to be determined. colorful, seaside shops aSndOrLesDtaurants tucked into a hillside along Soquel Creek. Must see this office to appreciate its splendor. Asking 4359 SANTA CRUZ GP offering 30+ years of goodwill within walking $643K for practice. Seller owns building, it is available for purchase, or distance to the beach! Located in a well-established, attractive, single to lease. story professional building complex w/ample parking, good visibility and easy access. 2 doctor days/week, 2 hygiene days/week, 380 active 4366 SONOMA COUNTY GP Fabulous practice and location within patients with approx. 10 new patients/mo. 3 fully equipped ops in 850 one of the North Bay’s gems of a town. Classically beautiful and well sq. ft. Average GR $250K with Average adj net of $135K. Asking price appointed office with 4 ops in 1,425 sq. ft. Fantastic storefront location $150K. on a well traveled road, walking distance to the pedestrian-friendly center of downtown. 900+ active patients, all fee-for-service. Not a Delta Dental 4387 SF GP 50 year Nob HIll neighborhood practice with approximately Premier Provider. 4 doctor days/week and 4 hygiene days/week. Last 1,000 active patients. Almost no Delta Premier patients. Average GR two years average GR $865K with average adj. net of $407K. Seller will $600K. Seller transitioning into retirement. Asking $315K. help for smooth transition. Asking $650K.

4380 SAN MATEO GP Unique opportunity to own a San Mateo GP. 4375 LOS GATOS FACILITY Seller offering fully equipped, state-of- This location generates significant foot traffic. Current Gross Receipts the-art, modern, 2 operatory facility including furniture, fixtures and annualizing at $431K with anSadOjuLsDted net of $192K. Seller will help for leasehold assets in medical office building adjacent to Los Gatos smooth transition. Asking $292K. Community Hospital. Asking $250K.

4351 SEBASTOPOL AREA GP & BLDG. Charming practice situated 4362 MARIN COUNTY GP Seller owned 1,550 square foot facility with amidst rolling hills, soaring redwood trees and lush vineyards. Offering 5 fully-equipped ops. Owner/Doctor transitioning into retirement and 70+ years of goodwill. Beautiful, modern facility with 3 fully-equipped offering 36 years of goodwill in desirable area. Located on a well traveled ops (room for a 4th op) and digital x-ray. Equipment in pristine condition, road in a charming town with temperate weather, easy, outdoor living most purchased 2016-2018. 2019 GR annualized at $679K+ with adj. and natural beauty. Enjoy California living at its best. No Delta Premier net of $210K. Average 3.5 doctor days/week and 4 hygiene days/ patients. Excellent reputation and word-of-mouth referrals. Seller will week. 800 active patients, all fee-for-service. Seller owns the building, it help for smooth transition. Average Gross Receipts last 2 yrs is $450K. is available for purchase. Asking $305K for practice, $425K for building. Asking $248K for the practice. Bldg condo is available for purchase. Owner/doctor willing to help for smooth transition.

4370 SAN JOSE PROSTHODONTIC PRACTICE Cosmetic and UPCOMING: prosthodontic practice established 40+ years. Located in a busy Santa Cruz County GP, San Francisco GP, Redwood Shores commercial/residential area of San Jose, close to several amenities, GP, Oakland GP & North Bay Oral Surgery Practice referral sources. Approx 700 active patients, all completely fee-for- service (Seller is not contraPctEedNwDithINaGny insurance companies or Delta). Carroll & Company Asking $299K. 2055 Woodside Road, Suite 160 Redwood City, CA 94061 4338 PENINSULA PROSTHODONTIC PRACTICE Preeminent 45 DRE #00777682 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 referral sources. Average Gross Receipts Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll $1.3M with 4 doctor-days peSrOwLeeDk. Asking $884K.

carroll.company [email protected] (650) 362-7004 (650) 362-7007 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# 01911548

“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 NEW! Ojai: $350,000 | 4 ops San Francisco: $979,000 | 4 ops SOLD! Escondido: $180,000 | 2 ops Ventura: $375,000 | 6 ops San Jose: $200,000 | 4 ops Chula Vista: $430,000 | 5 ops Ventura Turnkey: $110,000 | 3 ops Watsonville + RE: $491,000 | 5 ops Palm Desert Area: $199,000 | 5 ops NEW! Santa Barbara County: $270,000 | 3 ops San Anselmo: $230,000 | 2 ops South Bay + RE: $649,000 | 6 ops Santa Barbara + RE: $1,050,000 | 4 ops Bakersfield: $200,000 | 4 ops NEW! Irvine: $1,100,000 | 4 ops N. Santa Barbara County: $1,437,000 | 9 ops Bakersfield: $275,000 | 3 ops NEW! West Covina: $160,000 | charts Santa Barbara County: $179,000 | 4 ops Fresno County: $343,000 | 4 ops Glendale: $550,000 | 4 ops Santa Barbara: $122,000 | 4 ops Davis: $1,700,000 | 6 ops SOLD! Santa Monica: $510,000 | 5 ops Santa Maria + RE: $360,000 | 4 ops Folsom: $330,000 | 6 ops Agoura Hills: $365,000 | 3 ops N. San Luis Obispo County: $1,475,000 | 6 ops Sacramento: $270,000 | 6 ops Newhall: $250,000 | 5 ops San Luis Obispo: $861,000 | 3 ops Rancho Cordova: $225,000 | 4 ops Valencia: $600,000 | 5 ops Central Coast: $485,000 | 4 ops Sacramento Area: $315,000 | 5 ops Thousand Oaks: $85,000 | 3 ops Central Coast: $548,000 | 5 ops Roseville: $315,000 | 5 ops Westchester: $550,000 | 4 ops Central Coast: $390,000 | 3 ops Shasta County: $135,000 | 5 ops Camarillo: $275,000 | 5 ops Central Coast Endo: $950,000 | 5 ops S. Lake Tahoe: $225,000 | 3 ops Camarillo: $360,000 | 4 ops San Luis Obispo County: $650,000 | 4 ops California City: $350,000 | 6 ops

DRE #01911548 Broker-Partners: Darren Hulstine and Bill Kimball, DDS Ethics CDA JOURNAL, VOL 48, Nº2

Refer or Not: That’s the Question Henrik Hansen, DDS

situation occurred recently success, chances are they will appreciate in practice, I have come to appreciate that is not unusual in the your honesty and concern for their welfare. the specialists I work with more and office. A patient had a There are other advantages to referral. If the more. I consider them an invaluable asset toothache in an upper first patient hears the same diagnosis from two to my practice who help to make my molar and wanted me to different dentists, that helps them to accept professional life much more pleasant. n Ado the endo. I carefully explained that it. In the case of periodontal treatment, some things are beyond my abilities and follow-up and behavior modification are Henrik Hansen, DDS, is a general dentist endodontic therapy on an upper first crucial to long-term success. My experience practicing in Fairfield, Calif. He currently molar is definitely one of them. I told has been that those specialists have very serves on the CDA Judicial Council and is him that he would get a more predictable solid programs in place to help with that. a past chair of the Council on Peer Review result much faster and with less stress if I have also found that building a solid as well as a past member of the ADA a specialist did the treatment. Tongue in relationship with the specialists I refer to Council on Dental Benefit Programs. cheek, I said that, after all, that’s why God gives me someone I can call when I need made specialists: to help out us poor GPs. advice or help with a difficult situation. Have an ethical question you’d like to When I was much younger, I did For me personally, it’s impossible to be have addressed by the Judicial Council? almost every endo that came my way. In everything for everybody. After 41 years Email [email protected]. fact, I toyed with the idea of going back to school to become an endodontist. After spending lots of time looking for the second mesiobuccal (MB2) canal, I learned my lesson and stuck with the stuff I’m good at. Although it’s good to learn new skills and keep improving, I’ve learned to trust my “gut.” When it’s telling me I’m reaching beyond my skill level, it’s time to step back and reconsider. From my many years with Peer Review, I’ve seen lots of GPs who do treatment that meets the standard we’re all held to, namely to perform to the same level as the specialist. To them I say, more power to you. Your patients certainly appreciate your skills and that they don’t have to leave your office to receive the care they need. However, I have also seen cases where the treatment clearly does not meet that standard, and there is the problem. We have an ethical duty to recommend to the patient that which in our judgment will offer them the best treatment or any reasonable alternatives. If that means referral, then so be it. (CDA Code of Ethics, Section 9, Consultation and Referral) This can also be a practice builder if it’s put correctly. If the patient is told that you are looking out for their best interest by recommending a course of treatment that has the greatest chance for

FEBRUARY 2 0 2 0 95 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- BN-1067 SAN LEANDRO: Imagine owning this DG-1078 SARATOGA Ortho: One-of-a-kind, modern, high-tech orthodon- HG-1068 LAKE TAHOE AREA: Imagine living and practicing in the majestic ping Plaza w/ major anchor tenants! 3 ops Price family-oriented practice with a large patient base. tic boutique practice! ~ 1400 sf w/ 5 Ops $980K Sierra Nevadas and lake community! ~2500 sf w/ 3 Ops. $315k/Real Estate What separates us from Reduced $125k 1495sf w/ 3 ops 2 + 1 add’l. $325k DG-1081 SAN JOSE: Located in popular retail shopping center. Spacious Available AC-1059 DALY CITY: Amazing practice w/ seasoned CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 2800 sf office w/ 8 fully equipped ops $395k HG-815 TRUCKEE AREA: Amazingly priced at 50% of Collections! ~1000 sf w/ other brokerage firms? staff in highly desirable neighborhood. 1500 sf w/ 4 ops 640 sf Collections $433k in 2017 $275k DN-1031 CUPERTINO: This remarkable practice awaits only your talent and 3 ops $165k/ Real Estate Available

ops $345k CC-927 SAN RAFAEL: Build the practice of your skill! 1500sf w 3 ops + 1 add’l. $1.25M HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neighbor- Western Practice Sales is locally AC-1072 DALY CITY: Seller to work back until May dreams by increasing this 2-day work week! 800 sf DN-1032 PLEASANTON Facility: The perfect place to live, practice & raise a hood! ~1250 sf w/ 3 ops. Reduced Price $185k/Real Estate Available owned by dentists and has been 2022! 1045 sf w/ 3 ops. Plumbed for 1 add’l $450k w/ 3 ops $175k family! 1400sf w/4ops. Includes CTScan! $185k HG-987 LAKE TAHOE AREA: LIVE THE DREAM! The mountains are calling you proudly serving dentists in AC-1075 DALY CITY: Rare 2 DR Practice in Daly City. CC-979 NOVATO: Seller Retiring. 803 sf w/ 3 ops DN-1041 SAN JOSE: This stunning practice is an excellent opportunity for to this Alpine Paradise! ~ 3,400 sf w/ 6 Ops $785K/Real Estate Available California for over 45 years. Our One seller would like to work-back. $795k near downtown and Old Town Novato. $195K new grads! 1207sf w 2ops + 1 add’l. Reduced! $175k HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 personal attention to our sellers AG-871 SAN FRANCISCO: Seller Motivated! ~600 sf (Real Estate $215k) DN-1003 PLEASANTON Facility: This is an excellent opportunity for a gradu- ops Reduced Price: $265k w/ 2 ops Price Reduced $65k CC-1020 SANTA ROSA: Cash Flow of over $270k. ate or a dentist seeking a Satellite location. 1000sf w/ 3ops. $68k HG-934 GRASS VALLEY: Underworked PT base should support larger pro- and reputation of integrity and AG-944 SAN FRANCISCO: An opportunity like this Unique FFS Practice. 1320 sf w/ 4 ops. $450k DN-1046 SANTA CRUZ AREA: Opportunities like this does not come along, duction numbers! ~1200 sf w/ 3 Ops Reduced $168,750/Real Estate Availa- honesty has made us Northern does not come along very often! ~998 sf w/ 3 ops CC-1030 SANTA ROSA: Condo office in modern except once in a lifetime! Office 2050 sf w/ 5 ops. Total sq ft3880. ble California’s Preferred Dental Reduced $540k bldg w/ ample parking & adjoining Ortho practice! $595k /Real Estate: $1.1mil HN-991 PLACERVILLE: Quality, conservative and compassionate practice! Will Practice Broker. AG-993 WEST PORTAL AREA: Desirable area w/ easy 1683 sf w 5 ops $325k DN-1067 CASTRO VALLEY: Conservative treatment & compassionate philos- consider work back. 1,654 + 473 sf w 5 ops. $675k commute to downtown San Francisco. ~1000sf w/ 3 CC-1049 SANTA ROSA: Fully Remodeled, Amazing ophy delivered in a warm environment. 1498sf w/ 5ops. $650k/Real Estate:

ops Reduced Price: $395k Location. 2000 sf w/ 5 ops $685k Real Estate Also $675k CENTRAL VALLEY & SOUTHERN CALIFORNIA Our extensive buyer AG-1079 SAN FRANCISCO: Quality Practice in Heart Available NORTHERN CALIFORNIA database of City! 1800 sf w/ 5 ops offering in-house special- CC-1074 SANTA ROSA: PRACTICE & REAL ESTATE IC-975 MODESTO: Established 33 years. 1,100 sf w/ 3 ops $225k ists $685k AT ONE AMAZING LOW PRICE! You will not find EC-1018 WEST SACRAMENTO: All new leaseholds & top of the line PC EQ IG-881 TURLOCK: Long established has unsurpassed quality care. ~3500 sf allows us to offer you… BC-949 ALBANY: Desirable commercial/residential in 5 ops! 6 ops currently in use. 10 ops total available! $795k these build outs in this area for this price! 1200 sf w/ 10 Ops (shared). Reduced: $295k area. Medical Prof Bldg w/ good frontage. 3200sf 3 ops ONLY $300k EG-910 MIDTOWN SACRAMENTO: A thriving practice does not come IG-1007 GREATER MODESTO AREA: Combines a quality learning environ- Better Exposure w/ 4 ops $695k Real Estate: $1.8 CG-995 VALLEJO: Live, play and practice here along very often! ~1107 sf w/ 2 + 1 add’l. Reduced $210k ment with relaxed rural living. ~3000sf w/ 6 ops. $645k Better Fit BC-1010 ANTIOCH: Amazing Opportunity in Health where your lifestyle can’t be beat! ~2035 sf w/ 7 EG-968 SACRAMENTO: Desirable, mid-town neighborhood, w/ ample IG-1019 TRACY: This opportunity is waiting for you to sink your roots down Prof. Complex 2118 sf w/ 2 equipped ops + 3 add’l ops $1.175M parking in garage! ~1527 sf w/ 5 Ops. Reduced $480k and invest your future here! ~1200sf w/ 4 ops. $745k Better Price! $225k CG-1048 SONOMA: This highly successful family- EG-1012 EAST SACRAMENTO: A practice like this one does not come IN-1069 STOCKTON: Well-established & fully equipped w/ modern equip- BC-1022 OAKLAND: “Pill Hill” Area adjacent to oriented practice has it ALL! ~1500 sf w/ 4 ops available very often! ~ 2900 sf w/ 8 ops. $2.5M ment, this is an excellent opportunity! 1450sf w/ 3ops +1 add’l. $260k hospital! 1064 sf & 2 ops. Plumbed for 1 add’l Reduced $630k EG-1016 LINCOLN: Look no further than this growing community to JC-811 FRESNO COUNTY: Seller willing to consider Associateship for qualified $150k CN-911 SANTA ROSA: This fabulous practice is the springboard into your success! ~1800 sf w/ 4 Ops Reduced $560k DDS w. intention to Buy In! Considerable Goodwill in Community! 3,000 sf BC-1056 SAN RAMON (Facility): Move-in ready heart of the Wine Country! 2250 sf w/4 ops + EG-1039 EL DORADO HILLS VICINITY: The ideal opportunity to practice in w/ 6 ops $350k facility in well maintained professional complex. 1add’l. Seller Ready to Retire $499k this community! ~1100 sf w/ 4 Ops. $350k JC-823 LOS BANOS: Heavy emphasis on hygiene. 1000 sf w/ 3 ops $80k 1698 sf w/ 4 ops $80k DG-862 MID-PENINSULA: Rare gem with up to 7 EG-1061 SOUTH AUBURN VICINITY: Come live, play and practice in the JC-1054 VISALIA: Practice AND REAL ESTATE! Prof Bldg on major thorough- BG-1025 WALNUT CREEK: You won’t find a more operatories in the Bay Area! ~2274 sf w/ 6ops + 1 heart of this pristine town! ~1100 sf w/ 4 Ops. $350k fare. 2,260 sf w/ 6 ops $275k/ Real Estate $517k outstanding opportunity than this extraordinary add’l. $475k EN-1055 ROCKLIN Facility: Build your own success here in this family- practice! ~2138 sf w/ 6 ops. $750k Real Estate: DG-986 CAMPBELL: The ideal opportunity to prac- oriented community! 1650 sf w/ 4 ops +1 add’l. $95k SPECIALTY PRACTICES $995k tice in this community! ~988 sf w/ 3 ops Seller EN-1077 DAVIS: Imagine living and practicing here! Hesitate and you may BG-1085 BERKELEY: Stay young and on the cutting Motivated $288k miss out on your dream! 1100sf. w/ 5 ops. $575k BG-843 WALNUT CREEK Perio: Priced at 50% of collections! ~1085 sf w/ 4 edge as you practice in this UC collegiate town! ~ DG-1006 MONTEREY AREA: This practice is one FC-650 FORT BRAGG: Family-oriented practice. 5 ops in 2000 sf $350k ops $390k 1,600 sf w/ 4 ops $975k which every dentist aspires to! ~3400 sf w/ 8 ops for the Practice & $400k for the Real Estate BG-1024 WALNUT CREEK Prosth: Stellar reputation for providing the highest BN-952 BERKELEY: Don’t hesitate on this incredible Reduced $1.325M FN-961 EUREKA: Where the quality of life can’t be beat! 1400sf w. 4 ops. level of treatment! ~2138 sf w/ 6 ops. $750k Real Estate: $995k opportunity! ~835 sf w/ 3 Ops. Seller Motivated DG-1009 CARMEL: Amazing fee-for-service practice Practice Reduced: $395k/ Real Estate Available $395k! DN-1044 FOSTER CITY Pedo: Shared Space Situation. Conveniently $200k w/ no contracts! ~1150 sf w/ 4 ops $575K FN-855 NO. HUMBOLDT: Seller relocating! Long-established, 100% FFS located within walking distance of major corporations. 830sf w/ 3 BN-1023 RICHMOND: This is a rich opportunity for DG-1014 MONTEREY: Don’t miss your opportunity practice! 1600 sf w/ 3ops + 1 add’l. $190k/ Real Estate Available ops. $195k the astute dentist! 1450sf w/2 ops + 2 add’l. $50k/ to live and practice in beautiful Monterey! ~1125 GN-1071 REDDING: Streamlined policies & loyal patient base, this quality GG-940 NORTH OF SACRAMENTO Pedo: Practice is on track to collect more Call or email today for a free Real Estate $750k sf w/ 4 Ops. CALL FOR DETAILS! practice is your springboard to success! 2264sf w/ 4 ops. $525k than $1,000,000 in revenues this year! ~4300 sf w/ 5 ops. $660k copy of Dr Giroux’s book BN-1060 LAYAFETTE: Imagine living, practicing & DG-1042 MOUNTAIN VIEW: Amazing opportunity GN-1073 BUTTE CO: Quality, fee-for-service practice with a stellar repu- JG-757 VISALIA Perio: Incredible Giveaway at this price! Collections over raising your family here in this community! 1400sf providing quality, high-end dentistry! ~ 890 sf w/ 3 tation! 1800sf w/ ops. $375k / Real Estate Available $800k! ~2000 sf w/ 5 ops Steal at $150k w/ 3op. Seller Motivated $225k Ops $895K HG-1053 GRASS VALLEY: Well-established practice of 40+ years, known for Top Ten Issues for its quality dentistry! ~1200 sf w/ 3 ops $420K 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- BN-1067 SAN LEANDRO: Imagine owning this DG-1078 SARATOGA Ortho: One-of-a-kind, modern, high-tech orthodon- HG-1068 LAKE TAHOE AREA: Imagine living and practicing in the majestic ping Plaza w/ major anchor tenants! 3 ops Price family-oriented practice with a large patient base. tic boutique practice! ~ 1400 sf w/ 5 Ops $980K Sierra Nevadas and lake community! ~2500 sf w/ 3 Ops. $315k/Real Estate What separates us from Reduced $125k 1495sf w/ 3 ops 2 + 1 add’l. $325k DG-1081 SAN JOSE: Located in popular retail shopping center. Spacious Available AC-1059 DALY CITY: Amazing practice w/ seasoned CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 2800 sf office w/ 8 fully equipped ops $395k HG-815 TRUCKEE AREA: Amazingly priced at 50% of Collections! ~1000 sf w/ other brokerage firms? staff in highly desirable neighborhood. 1500 sf w/ 4 ops 640 sf Collections $433k in 2017 $275k DN-1031 CUPERTINO: This remarkable practice awaits only your talent and 3 ops $165k/ Real Estate Available

ops $345k CC-927 SAN RAFAEL: Build the practice of your skill! 1500sf w 3 ops + 1 add’l. $1.25M HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neighbor- Western Practice Sales is locally AC-1072 DALY CITY: Seller to work back until May dreams by increasing this 2-day work week! 800 sf DN-1032 PLEASANTON Facility: The perfect place to live, practice & raise a hood! ~1250 sf w/ 3 ops. Reduced Price $185k/Real Estate Available owned by dentists and has been 2022! 1045 sf w/ 3 ops. Plumbed for 1 add’l $450k w/ 3 ops $175k family! 1400sf w/4ops. Includes CTScan! $185k HG-987 LAKE TAHOE AREA: LIVE THE DREAM! The mountains are calling you proudly serving dentists in AC-1075 DALY CITY: Rare 2 DR Practice in Daly City. CC-979 NOVATO: Seller Retiring. 803 sf w/ 3 ops DN-1041 SAN JOSE: This stunning practice is an excellent opportunity for to this Alpine Paradise! ~ 3,400 sf w/ 6 Ops $785K/Real Estate Available California for over 45 years. Our One seller would like to work-back. $795k near downtown and Old Town Novato. $195K new grads! 1207sf w 2ops + 1 add’l. Reduced! $175k HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 personal attention to our sellers AG-871 SAN FRANCISCO: Seller Motivated! ~600 sf (Real Estate $215k) DN-1003 PLEASANTON Facility: This is an excellent opportunity for a gradu- ops Reduced Price: $265k w/ 2 ops Price Reduced $65k CC-1020 SANTA ROSA: Cash Flow of over $270k. ate or a dentist seeking a Satellite location. 1000sf w/ 3ops. $68k HG-934 GRASS VALLEY: Underworked PT base should support larger pro- and reputation of integrity and AG-944 SAN FRANCISCO: An opportunity like this Unique FFS Practice. 1320 sf w/ 4 ops. $450k DN-1046 SANTA CRUZ AREA: Opportunities like this does not come along, duction numbers! ~1200 sf w/ 3 Ops Reduced $168,750/Real Estate Availa- honesty has made us Northern does not come along very often! ~998 sf w/ 3 ops CC-1030 SANTA ROSA: Condo office in modern except once in a lifetime! Office 2050 sf w/ 5 ops. Total sq ft3880. ble California’s Preferred Dental Reduced $540k bldg w/ ample parking & adjoining Ortho practice! $595k /Real Estate: $1.1mil HN-991 PLACERVILLE: Quality, conservative and compassionate practice! Will Practice Broker. AG-993 WEST PORTAL AREA: Desirable area w/ easy 1683 sf w 5 ops $325k DN-1067 CASTRO VALLEY: Conservative treatment & compassionate philos- consider work back. 1,654 + 473 sf w 5 ops. $675k commute to downtown San Francisco. ~1000sf w/ 3 CC-1049 SANTA ROSA: Fully Remodeled, Amazing ophy delivered in a warm environment. 1498sf w/ 5ops. $650k/Real Estate:

ops Reduced Price: $395k Location. 2000 sf w/ 5 ops $685k Real Estate Also $675k CENTRAL VALLEY & SOUTHERN CALIFORNIA Our extensive buyer AG-1079 SAN FRANCISCO: Quality Practice in Heart Available NORTHERN CALIFORNIA database of City! 1800 sf w/ 5 ops offering in-house special- CC-1074 SANTA ROSA: PRACTICE & REAL ESTATE IC-975 MODESTO: Established 33 years. 1,100 sf w/ 3 ops $225k ists $685k AT ONE AMAZING LOW PRICE! You will not find EC-1018 WEST SACRAMENTO: All new leaseholds & top of the line PC EQ IG-881 TURLOCK: Long established has unsurpassed quality care. ~3500 sf allows us to offer you… BC-949 ALBANY: Desirable commercial/residential in 5 ops! 6 ops currently in use. 10 ops total available! $795k these build outs in this area for this price! 1200 sf w/ 10 Ops (shared). Reduced: $295k area. Medical Prof Bldg w/ good frontage. 3200sf 3 ops ONLY $300k EG-910 MIDTOWN SACRAMENTO: A thriving practice does not come IG-1007 GREATER MODESTO AREA: Combines a quality learning environ- Better Exposure w/ 4 ops $695k Real Estate: $1.8 CG-995 VALLEJO: Live, play and practice here along very often! ~1107 sf w/ 2 + 1 add’l. Reduced $210k ment with relaxed rural living. ~3000sf w/ 6 ops. $645k Better Fit BC-1010 ANTIOCH: Amazing Opportunity in Health where your lifestyle can’t be beat! ~2035 sf w/ 7 EG-968 SACRAMENTO: Desirable, mid-town neighborhood, w/ ample IG-1019 TRACY: This opportunity is waiting for you to sink your roots down Prof. Complex 2118 sf w/ 2 equipped ops + 3 add’l ops $1.175M parking in garage! ~1527 sf w/ 5 Ops. Reduced $480k and invest your future here! ~1200sf w/ 4 ops. $745k Better Price! $225k CG-1048 SONOMA: This highly successful family- EG-1012 EAST SACRAMENTO: A practice like this one does not come IN-1069 STOCKTON: Well-established & fully equipped w/ modern equip- BC-1022 OAKLAND: “Pill Hill” Area adjacent to oriented practice has it ALL! ~1500 sf w/ 4 ops available very often! ~ 2900 sf w/ 8 ops. $2.5M ment, this is an excellent opportunity! 1450sf w/ 3ops +1 add’l. $260k hospital! 1064 sf & 2 ops. Plumbed for 1 add’l Reduced $630k EG-1016 LINCOLN: Look no further than this growing community to JC-811 FRESNO COUNTY: Seller willing to consider Associateship for qualified $150k CN-911 SANTA ROSA: This fabulous practice is the springboard into your success! ~1800 sf w/ 4 Ops Reduced $560k DDS w. intention to Buy In! Considerable Goodwill in Community! 3,000 sf BC-1056 SAN RAMON (Facility): Move-in ready heart of the Wine Country! 2250 sf w/4 ops + EG-1039 EL DORADO HILLS VICINITY: The ideal opportunity to practice in w/ 6 ops $350k facility in well maintained professional complex. 1add’l. Seller Ready to Retire $499k this community! ~1100 sf w/ 4 Ops. $350k JC-823 LOS BANOS: Heavy emphasis on hygiene. 1000 sf w/ 3 ops $80k 1698 sf w/ 4 ops $80k DG-862 MID-PENINSULA: Rare gem with up to 7 EG-1061 SOUTH AUBURN VICINITY: Come live, play and practice in the JC-1054 VISALIA: Practice AND REAL ESTATE! Prof Bldg on major thorough- BG-1025 WALNUT CREEK: You won’t find a more operatories in the Bay Area! ~2274 sf w/ 6ops + 1 heart of this pristine town! ~1100 sf w/ 4 Ops. $350k fare. 2,260 sf w/ 6 ops $275k/ Real Estate $517k outstanding opportunity than this extraordinary add’l. $475k EN-1055 ROCKLIN Facility: Build your own success here in this family- practice! ~2138 sf w/ 6 ops. $750k Real Estate: DG-986 CAMPBELL: The ideal opportunity to prac- oriented community! 1650 sf w/ 4 ops +1 add’l. $95k SPECIALTY PRACTICES $995k tice in this community! ~988 sf w/ 3 ops Seller EN-1077 DAVIS: Imagine living and practicing here! Hesitate and you may BG-1085 BERKELEY: Stay young and on the cutting Motivated $288k miss out on your dream! 1100sf. w/ 5 ops. $575k BG-843 WALNUT CREEK Perio: Priced at 50% of collections! ~1085 sf w/ 4 edge as you practice in this UC collegiate town! ~ DG-1006 MONTEREY AREA: This practice is one FC-650 FORT BRAGG: Family-oriented practice. 5 ops in 2000 sf $350k ops $390k 1,600 sf w/ 4 ops $975k which every dentist aspires to! ~3400 sf w/ 8 ops for the Practice & $400k for the Real Estate BG-1024 WALNUT CREEK Prosth: Stellar reputation for providing the highest BN-952 BERKELEY: Don’t hesitate on this incredible Reduced $1.325M FN-961 EUREKA: Where the quality of life can’t be beat! 1400sf w. 4 ops. level of treatment! ~2138 sf w/ 6 ops. $750k Real Estate: $995k opportunity! ~835 sf w/ 3 Ops. Seller Motivated DG-1009 CARMEL: Amazing fee-for-service practice Practice Reduced: $395k/ Real Estate Available $395k! DN-1044 FOSTER CITY Pedo: Shared Space Situation. Conveniently $200k w/ no contracts! ~1150 sf w/ 4 ops $575K FN-855 NO. HUMBOLDT: Seller relocating! Long-established, 100% FFS located within walking distance of major corporations. 830sf w/ 3 BN-1023 RICHMOND: This is a rich opportunity for DG-1014 MONTEREY: Don’t miss your opportunity practice! 1600 sf w/ 3ops + 1 add’l. $190k/ Real Estate Available ops. $195k the astute dentist! 1450sf w/2 ops + 2 add’l. $50k/ to live and practice in beautiful Monterey! ~1125 GN-1071 REDDING: Streamlined policies & loyal patient base, this quality GG-940 NORTH OF SACRAMENTO Pedo: Practice is on track to collect more Call or email today for a free Real Estate $750k sf w/ 4 Ops. CALL FOR DETAILS! practice is your springboard to success! 2264sf w/ 4 ops. $525k than $1,000,000 in revenues this year! ~4300 sf w/ 5 ops. $660k copy of Dr Giroux’s book BN-1060 LAYAFETTE: Imagine living, practicing & DG-1042 MOUNTAIN VIEW: Amazing opportunity GN-1073 BUTTE CO: Quality, fee-for-service practice with a stellar repu- JG-757 VISALIA Perio: Incredible Giveaway at this price! Collections over raising your family here in this community! 1400sf providing quality, high-end dentistry! ~ 890 sf w/ 3 tation! 1800sf w/ ops. $375k / Real Estate Available $800k! ~2000 sf w/ 5 ops Steal at $150k w/ 3op. Seller Motivated $225k Ops $895K HG-1053 GRASS VALLEY: Well-established practice of 40+ years, known for Top Ten Issues for its quality dentistry! ~1200 sf w/ 3 ops $420K 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, Nº2

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

Withings Thermo ($99.95, Thermo) Pixel 19-Inch Bi-Color Ring Light ($109, PIXEL) Withings Thermo measures body temperature by scanning the Professional photo lighting equipment can be important for taking temporal artery with its 16 infrared sensors, which take over 2,000 good clinical photographs; after all, improper lighting can skew measurements per second. Setting up the smart thermometer is done the appearance of case outcomes, especially when lighting is through either the Withings Thermo or Withings HealthMate mobile inconsistent from before-and-after photographs. Thankfully, as app for iOS or Android and requires a free Withings account. After LED technology improves, user-friendly, portable and affordable account sign-in, a short step-by-step walk-through guides the user alternatives are arriving in the consumer market. While they still fall to pair the device to their smartphone with Bluetooth and add it to short of professional fixed studio-lighting rigs in terms of durability, their account. Users can optionally configure the device directly to they mimic the capabilities of their premium brethren admirably. a home Wi-Fi network to upload their measurements to the cloud Could these technologies, like the Pixel 19-inch ring light, be without the need to sync with their smartphone. The thermometer potential lighting solutions for small private practices looking to supports up to eight different profiles with each Withings account. standardize their photography? This review utilized a Nikon D3200 with a Sigma macro lens to evaluate the Pixel’s effects on extraoral To measure temperature, users remove the protective cap, press and intraoral photographs. the single button on the thermometer and scan across the forehead with the device. The thermometer vibrates when the measurement is The Pixel 19-inch ring light package comes with the light itself, a complete and the result shows on the display. Sliding a finger up or carrying bag, a power supply, a stand, a cellphone holder and a down the touch area of the display cycles through the different users cold shoe adapter for larger cameras. The light is easy to assemble and a subsequent press of the button assigns the measurement to and operate, which is fortunate because the included instructions the corresponding profile. A color LED next to the display indicates are sparse. A host of tiny LED bulbs is at the heart of the device, whether the person has a fever based on the age of the user profile producing 55 watts of light that can have its color temperature and ranges from green to yellow to red to indicate severity. modified with a knob. Placed approximately 3 feet from the patient, the Pixel eliminates most shadows when photographing A timeline of body temperature measurements can be viewed in a darkened room. In a room full of ambient light, the results are through the mobile app, where users can add additional notes, consistently shadow-free. Settings can be saved so that operators medicines taken or symptoms under the specific measurement. can go back to their favorite presets, allowing them to recreate The mobile app also automatically provides valuable health previous lighting. Because of its affordability, ease of operation advice based on the data and can direct users to Thermia, a and good results, the Pixel 19-inch ring light appears to be a viable service offered by Boston Children’s Hospital, for more insights product for practitioners looking to improve and standardize their and recommendations. Users have the option of connecting their clinical photographs. profiles to Apple Health or Google Fit, which combines health data from various sources to provide an overall picture of their — Alexander Lee, DMD health. The thermometer utilizes two replaceable AAA batteries that last up to two years. Withings Thermo is remarkably easy to use with its single button operation and simple-to-assign Would you like to write about technology? measurements to profiles, making it a welcome addition to quickly Dentists interested in contributing to this section should contact and accurately measure body temperature in a household. Andrea LaMattina, CDE, at [email protected]. — Hubert Chan, DDS

98 FEBRUARY 2 0 2 0 It’s simply brilliant! Come sharpen your skills at CDA Presents The Art and Science of Dentistry. Earn innovative C.E. and ignite your professional path through 200+ courses by inspiring speakers at the nation’s most exciting dental convention.

Learn more at cda.org/cdapresents.

® BRIGHT FUTURE BOLD IDEAS BIG IMPACT MAY 14–16, 2020 ANAHEIM CONVENTION CENTER HappyMY SMILE IS

#MYSMILEISPOWERFUL

Nadie, from Uzbekistan—a painter, hiker, and production worker—smiles because she loves to brighten people’s day. Opalescence Go® prefilled whitening trays are a convenient way she can whiten on her own schedule. A whiter smile is sure to brighten your patient’s day. That’s the power of a smile. Find out more at ultradent.com/mysmileispowerful.

© 2020 Ultradent Products, Inc. All rights reserved.