3:45 – 4:45 PM - ET Tobacco, E-cigarettes, and Cannabis: What Oral Health Providers Should Know
Abrey Daniel, DDS Lin Chan, DDS • OPEN POLLING QUESTION 1
2 • OPEN POLLING QUESTION 2
3 Disclosure
We have no actual or potential conflict of interest in relation to this program/presentation.
4 Tobacco, E-Cigarettes, and Cannabis: What Oral Health Providers Need to Know
By: Abrey Daniel, DDS Lin Chan, DDS
Funded by the CDPH under Contract # 17-10698 Objectives:
• Learn about the evolution of tobacco and the new trends of e-cigarettes and cannabis products.
• Learn the negative effects including oral health risks of tobacco, e-cigarettes, and cannabis products.
• Acquire information on brief interventions and available resources for dental offices.
6 Tobacco
• A plant grown for it’s leaves that is smoked, chewed or sniffed • Contains an addictive chemical, Nicotine • Nicotine acts as a pesticide for the plant • Smoked tobacco: cigarettes, cigars, bidis, kreteks • Loose tobacco: in a pipe or hookah • Chewed tobacco: chewing tobacco, snuf, dip, snus,
7 Types of Tobacco Products
www.cdph.ca.gov
8 History of Tobacco
• 6000 BC – Native Americans first start cultivating the tobacco plant • Circa 1 BC – Indigenous American tribes start smoking tobacco in religious ceremonies and medicinal purposes • 1612 – First successful commercial crop was cultivated by John Rolfe; tobacco used as cash-crop
Source: Tobacco Free Life 9 History of Tobacco (Continued) • 1730 – First American tobacco companies in Virginia • 1847 - Philip Morris (UK) start selling hand-rolled Turkish cigarettes • 1880 – James Bonsack develops first cigarette- rolling machine • 1890 – American Tobacco Company opens its doors • 1902 – Philip Morris start selling cigarettes in the US - Marlboro 10 Glamorization of Smoking
• Tobacco industry had a lot of product placement deals from the 1920’s to the 1950’s • Movie stars were in cigarette advertisements • Stars were seen as “cool” when they would light their cigarettes
1.Resource: Tobacco settlement endowment trust and CDC 11 Lucille Ball in a Chesterfield cigarette ad. Ronald Reagan in a 1949 Chesterfield cigarette ad.
12 Smoking and Hollywood
• In the 1980s, 4 tobacco companies worked with Hollywood for product placement • Companies: Philip Morris, RJ Reynolds, American Tobacco Company, and Brown and Williamson • One company offered free monthly cigarettes to actors • 1998 Master Settlement Agreement Tobacco companies could not receive payment for advertising tobacco products on motion pictures, television, theatrical productions, or live performance
1.“How the tobacco industry built its relationship with Hollywood”
13 1964 Surgeon General’s Report
• First report of the Surgeon General’s Advisory Committee on Smoking and Health
• Addressed the health effects of smoking in 1964
• Based on over 7,000 articles relating to smoking and disease – Cause of lung cancer and laryngeal cancer in men – Cause of chronic bronchitis
Source: CDC “History of the Surgeon General’s Reports on Smoking and Health”
14 Bans and Policies Federal Cigarette Labeling and Advertising Act of 1965 • Require health warning on cigarette packages • Called for the Department of Health, Education, and Welfare to annually report the health consequences of smoking
Public Health Cigarette Smoking Act of 1969 • Banned cigarette advertising in the broadcasting media
Source: CDC
15 Bans and Policies
• In 1995, smoking was banned in all enclosed workplaces in California
• In 2000, inflight smoking was banned on all domestic and international flights in the United States
• 2004, CA banned smoking within 20 feet of the entrance of a public building
• As of 2016, 28 states have statewide bans on smoking in enclosed workplaces, bars, and restaurants
16 Local Southern California Smoking Bans
Calabasas • In March 2006, Calabasas, California passed the strictest smoking ban
Beverly Hills • On June 4, 2019, Beverly Hills outlawed the sale of tobacco products • Exemptions: Cigar lounges and hotels • In effect January 1, 2021
17 Proposition 56 • California Ballot passed November 8, 2016
• Increase cigarette tax by $2.00
• Prior to this, cigarette tax was $0.87
• Revenue going towards: 1. Enforcing tobacco laws 2. Physician training to increase the number of primary care and emergency physicians in the state 3. Tobacco-use prevention
18 Health Effects of Smoking
• Heart Disease • Stroke • Lung Cancer • Decreased Immune Function • Respiratory Disease – Asthma – Chronic Obstructive Pulmonary Disease
19 Smoking Tobacco and Oral Health
• Tooth Staining • Oral cancer • Impaired healing • Gingival recession • Oral leukoplakia • Nicotine stomatitis • Periodontal disease • Gingival keratosis • Tooth loss
• Dental Caries Photo: emedicine.medscape.com
20 E-Cigarettes History of E-Cigarettes
• 1963: Herbert Gilbert patented the first smokeless, non-tobacco cigarette device
• 2003: First commercially successful electronic cigarette is created in Beijing, China by Hon Lik, a pharmacist, inventor, and smoker.
• 2006-2007: Electronic cigarettes introduced to the U.S.
22 Common Nicknames
• E-cigs • E-hookahs • Hookah pens • Vapes • Vape pens • Mods • JUUL • ENDS (electronic nicotine delivery systems)
23 E-CIGARETTES COME IN MANY DIFFERENT SHAPES
E-cigarettes are devices that heat a liquid into an aerosol that the user inhales.
Source: CDC’s Office on Smoking and Health Design and Appearance
• Traditional tobacco cigarettes • Cigars • Pipes • Everyday items like pens USB memory sticks
25 Components
• Mouthpiece - to inhale
• Cartridge or reservoir – holds liquid solution
• Heating element (atomizer)
• Power source (battery)
26 E-Liquids
SOLVENT FLAVORING WATER NICOTINE (PROPYLENE GLYCOL AND/OR GLYCERIN)
27 USE OF FLAVORS IS PROMINENT AMONG YOUTH
Source: U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General—Executive Summary.
Source: CDC’s Office on Smoking and Health E-Cig Flavors
• 15,500 e-cigarette flavors
• Most are fruit
• Presence of diacetyl, a flavoring chemical in flavored e-cigarettes.
• Diacetyl was found to be associated with bronchiolitis obliterans or “popcorn lung”
1.Allen JG, Flanigan SS, LeBlanc M, Vallarino J, MacNaughton P, Stewart JH, Christani D. 2016. Flavoring Chemicals in E-Cigarettes: Diacetyl, 2,3-Pentanedione, and Acetoin in a Sample of 51 Products, Including Fruit-, Candy-, and Cocktail-Flavored E-Cigarettes. Environmental Health Perspectives.
29 Effects of Sweet Flavors in E-Cig
• E-Cig sweet flavored aerosols have similar physio-chemical properties as high- sucrose, gelatinous candies and acidic drinks
• May increase cariogenic potential – Promote S. mutans attachment on tooth enamel – Increase demineralization of enamel surface
1.Kim SA, Smith S, Beauchamp C, Song Y, Chiang M, Giuseppetti A, et al. (2018) Cariogenic potential of sweet flavors in electronic-cigarette liquids. Plos ONE 13 (9): e0203717 2.US Food and Drug Administration
30 E-cigarettes Make Aerosol, Not Vapor
Source: CDC’s Office on Smoking and Health Same Players, New Products
Source: CDC’s Office on Smoking and Health E-cigarette Poisonings 2011-2014
Source: American Association of Poison Control Centers
Source: CDC’s Office on Smoking and Health Food and Drug Administration Rulings
• Nicotine warning labels must be on vaping products and they must list all ingredients (in 2018)
• Federal minimum age to purchase tobacco products increased from 18 to 21 years of age (Dec 2019)
• FDA finalizes enforcement policy to cease manufacture, distribution and sale of flavored e-cigs (other than menthol and tobacco) (Jan 2020)
34 Nicotine
• According to the CDC, 99% of e-cigarettes contain nicotine
• Nicotine in e-liquids absorbed from the lungs into the bloodstream
• Nicotine stimulates the adrenal glands to release hormone epinephrine (adrenaline) → stimulates CNS (increase BP, breathing and heart rate)
• Nicotine activates the brain’s reward circuits and increases levels of chemical messenger in the brain (dopamine), which reinforces rewarding behaviors
35 HOW DOES NICOTINE IN E-CIGARETTES IMPACT THE BRAIN?
Youth who use nicotine can harm the parts of the brain that control attention, learning, mood, and impulse control.
Source: CDC’s Office on Smoking and Health Nicotine and Brain Development
• Teen years are critical for brain development, which continues into young adulthood about 25 years old
• Nicotine changes the way brain cell connections or synapses are formed, which can harm the parts of the brain that control attention and learning
• Affects development of brain’s reward system, continued e-cigarette can lead to nicotine addiction and other drug (i.e. cocaine and methamphetamine) addiction
37 JUUL (“JUULing”)
• Introduced in 2015
• E-cigarette that resembles a flash drive
• Youth-friendly flavors i.e. mango, mint, and fruit-medley
• Double the concentration of nicotine found in other e-cig
• 1 JUUL pod = 59 mg/ml nicotine = 1 pack of 20 cigarettes = 200 puffs
38 JUUL Contains a High Amount of Nicotine
Source: CDC’s Office on Smoking and Health JUUL- Resembles a Flash Drive
40 E-Cigarettes and Teens
• E-cigarettes are the most commonly used tobacco product among youth
• E-cigarettes may serve as introductory product for preteens and teens who tend to go on to use other tobacco products
• Teens who used e-cigarettes are at greater risk for smoking cigarettes in the future
Source: CDC
41 1.www.drugabuse.gov/related-topics/trends-statistics/infographics/monitoring-future-2019-survey-results-overall-findings 42 E-cigarettes and Oral Health
• Nicotine stomatitis attributed to exposure to high-temperature smoke
• Nicotine associated with periodontal disease
• Oral and facial trauma caused by explosions and fires from e-cigarette device malfunctions
• Xerostomia (Dry Mouth)
• Flavorings can cause caries
1.Malhotra R, Kapoor A, Grover V, Kaushal S. Journal of Indian Society of Periodontology. 2010 Jan-Mar; 12 (1): 72-79.
43 FDA Approved Smoking Cessation Products
Nicotine Replacement Access Usage Therapy Types Patch Over the Counter Place on the skin Gives a small and steady amount of nicotine Gum Over the Counter Chew to release nicotine
Lozenge Over the Counter Place in mouth like hard candy Releases nicotine as it dissolves in the mouth Inhaler Prescription Inhaling through mouthpiece gives a specific amount of nicotine Nasal Spray Prescription Pump bottle containing nicotine Put into nose and spray
44 Quit Smoking Resources
1-800-QUIT-NOW
1-855-DEJELO-YA (Spanish)
Smokefree.gov
SmokefreeTXT
45 Conclusive Evidence
• Most e-cigarette products contain and emit numerous potentially toxic substances. • E-cigarette devices can explode and cause burns and projectile injuries. • Intentional or accidental exposure to e-liquids (from drinking, eye contact, or dermal contact) can result in adverse health effects including but not limited to seizures, brain injury, and vomiting. • Intentionally or unintentionally drinking or injecting e-liquids can be fatal.
Surgeon General Report: E-cigarette Use Among Youth and Young Adults, 2016.
46 CDC Report: EVALI Outbreak
• As of February 18, 2020, 2807 cases of E-cigarette, or Vaping, product use Associated Lung Injury (EVALI) • 68 deaths • Vitamin E acetate – chemical of concern • THC present in most of the vaping product samples
Source: CDC 47 Vitamin E Acetate
• Used as an additive, thickening agent in THC-containing e-cigarette, or vaping products
• Vitamin found in many foods (vegetable oils, cereal, meat, fruits, and vegetables, dietary supplement and cosmetic products (skin creams) – Does not cause harm when ingested or applied
• Interfere with normal lung function when inhaled
• Evidence is not sufficient to rule out contribution of other chemicals of concern
Source: Lauren Bishop/CDC 48 Cannabis
49 50 http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx 51 Legalization in California
• Compassionate Use Act of 1996 (Prop 215) – 1st state to legalize medical cannabis
• Adult Use of Marijuana Act (Prop 64) – November 2016 – Legalize recreational use of cannabis
52 Controlled Substance Act (1970) Schedule I
• No accepted medical use
• High potential risk for abuse
• Ex: Heroin, LSD, Ecstasy
Photo Credit: ThinkStock
53 Research Challenges For clinical research, the clinician needs: • Department of Health and Human Services (HHS) approval • Food and Drug Administration (FDA) approval • National Institute Drug Abuse (NIDA) supplies marijuana grown at University of Mississippi
• August 2016, DEA allowed additional places to grow marijuana for FDA-approved research. DEA will oversee the new growers.
Photo Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. 54 Cannabinoids: CBD and THC
55 Cannabis (Marijuana)
60+ Cannabinoids – chemical compounds that interact with cannabinoid receptors in the brain
• Cannabidiol (CBD) – usually used in medical Marijuana
• Delta- 9-Tetrahydrocannabinol (THC) – psychoactive effects, “high”
Concentration of THC depends on source and preparation
Atakan, Therapeutic Adv Psychopharm, 2012, 2(6), 241-254.
56 Percentage of THC in Marijuana Increases
1.ElSohly MA. Potency Monitoring Program quarterly report no 123 — reporting period: 09/16/2013-12/15/2013. Oxford: University of Mississippi, National Center for Natural Products Research; 2014.
57 Forms and Usage
58 Cannabis (Marijuana)
3 Subspecies of genus Cannabis
• Cannabis sativa • Cannabis indica • Cannabis ruderalis
Cross-breeding results in hybrids with high levels of THC and CBD depending on the species and strains
Atakan, Therapeutic Adv Psychopharm, 2012, 2(6), 241-254. Photo by NIDA 59 Forms of Cannabis
1. Marijuana - Dry leaves and flowers - Most common, least THC concentration 2. Hashish (Arabic for “dry herb”) - Resin from flower heads compressed ThinkStock
3. Hash Oil Credit: Photo - Oil extracted from hashish - Most potent, highest THC concentration
1.Cho CM, Hirsch R, Johnstone S. General and oral health implications of cannabis use. Australian Dental Journal 2005;50(2):70-74
60 Methods of Use
• Combustible (smoking)
• Edible
• Vaporized
• Topical (lotion, chap stick)
• Spray
• Drink
Photo Credit: ThinkStock 61 Marijuana and Its Usage
• Pot, weed, hash, reefer, bud, kush
• Smoked
• Rolled into cigarette and smoked (joint, blunt)
• Pipe, water pipe (bong)
• Can be mixed with tobacco
(spliff)
Photo Credit: ThinkStock
Photo Credit: ThinkStock
62 Hashish and Its Usage
• Baked and eaten in foods (pot brownies, butter, oil) • Cannabinoid-infused edibles (gummy bears treated with cannabinoid extracts) • Energy drinks with THC • Smoked with tobacco • Vaporizing – electronic device to vape liquid THC or hash oil (liquid pot, dabbing,
weed pen)
ThinkStock Photo Credit: Credit: Photo
63 Inhalation vs Consuming
Onset: Fast Inhalation: Duration: Short
Onset: Slow Consuming: Duration: Longer
64 Dual-Use of Cannabis with Tobacco
• Dual-use of tobacco and marijuana increases the dependence of both nicotine and cannabis
• Health effects are compounded – Elevated respiratory distress and reduced lung function compared with cannabis use or tobacco use alone
1. Agrawal A, Budney A, Lynskey M. The Co-occurring Use and Misuse of Cannabis and Tobacco: A Review. Addiction. 2012 Jul; 107(7): 1221-1233. 2.Moore BA, Augustson EM, Moser RP, Budney AJ. Respiratory effects of marijuana and tobacco use in a U.S. sample. J Gen Intern Med. 2005 Jan;20(1):33–7. 3.Taylor DR, Fergusson DM, Milne BJ, Horwood LJ, Moffitt TE, Sears MR, et al. A longitudinal study of the effects of tobacco and cannabis exposure on lung function in young adults. Addiction. 2002 Aug;97(8):1055–61. 65 Synthetic Cannabinoids
66 Synthetic Cannabinoids – “Spice” or “K2”
Source: DEA (United States Drug Enforcement Administration) 67 Synthetic Cannabinoids - “Spice” or “K2”
• Synthetic cannabinoids sprayed on dried, shredded plant material or vaporized to produce a high.
• Sold in form of dried, shredded plant material that looks like potpourri and is sometimes sold as “incense”
• “Synthetic marijuana" (or "fake weed") are often marketed as safe, legal alternatives to that drug.
National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services 68 Use of Synthetic Cannabinoids
• Smoke the dried plant material
• Brew as tea
• Buy synthetic cannabinoid products as liquids to vaporize in e-cigarettes
National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.
69 Synthetic Cannabinoids – Unpredictable Danger
• 177 different synthetic cannabinoids were reported in 2014.
• The amount and type of chemicals in each batch varies.
• Manufacturers are constantly changing chemicals to dodge laws.
National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.
70 Poison Control
• In 2016, there were 2,695 calls to poison control centers for
harmful exposure from these drugs.
• 28,531 ER visits were linked to synthetic cannabinoids in 2011.
• 78 percent of these ER visits were among adolescents and
young adults ages 12-29.
1.Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. 71 Marijuana and Teens
72 Marijuana Industry Target Youth
• Emerging marijuana industry target same youth populations that are targeted by tobacco.
• Marijuana industry follow similar strategy from tobacco industry to entice youth so they might become regular users in the future.
• Cannabis food, drinks, and candy are marketed to children inspired by youth-friendly products such as “Ring Pots” and “Pot Tarts”.
• Emergence of e-cigarettes – allows youth to vape cannabis products
73 Brain Development
• Brain continues to develop into the mid to late 20’s. – Brain growth occurs primarily in the white matter (connectivity and communication among neurons). • Exposure to neurotoxins during the brain’s developmental period can permanently alter the brain’s structure and function.
Meier, M. H., Caspi, A., Ambler, A., Harrington, H., …Moffitt, T.E. (2012). Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings from the National Academy of Sciences, USA, 109, E2657-E2664 74 Photo Credit: pixabay Adolescent Cannabis Use
• Increased risk for chronic cannabis use throughout adulthood • Impairment of cognitive development • Lower educational attainment • Associated with serious mental health disorders later in life: addiction, depression, anxiety, psychotic disorders • Lead to amotivational syndrome which impedes learning and schoolwork • Impairment was still evident after cessation of use for 1 y or more
1.Meier, M. H., Caspi, A., Ambler, A., Harrington, H., …Moffitt, T.E. (2012). Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings from the National Academy of Sciences, USA, 109, E2657-E2664
75 Medicinal Cannabis
76 Medicinal Use • Nausea and vomiting
• Chronic pain
• Inflammation ThinkStock
• Reduce spasticity in multiple sclerosis Photo Credit: Credit: Photo • Muscle spasm
• Appetite stimulant
– (cancer and HIV/AIDs patients)
• Helps reduce frequency of seizures
77 FDA-Approved Cannabinoids
Generic (Brand) Formulation Use
Dronabinol (Marinol®5mg) Oral capsule synthetic THC Treatment of nausea and vomiting associated with chemotherapy Dronabinol Liquid synthetic THC Treatment of nausea and (Syndros®5mg/mL) vomiting associated with chemotherapy Nabilone (Cesamet®1mg) Oral capsule synthetic THC Treatment of nausea and analogue vomiting associated with chemotherapy Cannabidiol Liquid purified CBD Childhood epilepsy (Epidiolex®100mg/mL) Approved in June 2018
78 Effects of Cannabis on Overall Health
79 Cardiovascular
• Tachycardia
• The risk of heart attack is several times higher in the hour
after smoking marijuana than it would be normally
1.Franz CA, Frishman WH. Marijuana Use and Cardiovascular Disease. Cardiol Rev. 2016(4):158-162
80 Respiratory (Long-term Smoking of Marijuana)
• Same contents as tobacco smoke (carbon monoxide, toxins, irritants, tar, carcinogens), except for nicotine
• Increased symptoms of bronchitis, coughing, wheezing, phlegm production and emphysema
1.Wu T-C, Tashkin DP, Djahed B, Rose JE. Pulmonary hazards of smoking marijuana as compared with tobacco. N Engl J Med. 1988;318(6):347-51. 2.Tashkin DP. Effects of marijuana smoking on the lung. Ann Am Thorac Soc. 2013;10(3):239-47. 3.Howden ML, Naughton MT. Pulmonary effects of marijuana inhalation. Expert Rev Respir Med. 2011;5(1):87-92.
81 Marijuana Use and Pregnancy
• 1 in 25 women in U.S. report using marijuana while pregnant
• Using Marijuana during pregnancy increase baby’s risk of
developmental problems
• Breathing marijuana smoke may also increase the chances for
developmental problems in baby 1.CDC
82 Effects of Cannabis on Oral Health
83 Effects of Cannabis and Oral Health
• Higher DMF (Decayed, Missing, Filled) teeth scores
• Higher plaque scores
• Xerostomia → increase risk of caries
• Increased appetite in particular for
cariogenic foods
• Cannabis smoking → periodontal
attachment loss and periodontitis
1. Cho CM, Hirsch R, Johnstone S. General and oral health implications of cannabis use. Australian Dental Journal 2005;50(2):70-74 2. Thomson W, Poulton R. Broadbent JM, et al. Cannabis smoking and periodontal disease among young adults. JAMA 2008;299(5):525-531. 3.Shariff JA, Ahluwalia KP, Papapanou PN. J Periodontol. 2017 Mar;88(3):273-280 4.Ortiz AP, González D, Ramos J, Muñoz C, Reyes JC, Pérez CM. J Periodontol. 2018 May;89(5):540-548 84 Oral Implications of Cannabis Use
Oral Implications of Cannabis Use Associated Implications Dry mouth (Xerostomia) Increased risk of cares Increased risk of periodontal disease Halitosis
Thermal Injury Hyperkeratinisation due to higher combustion temperature of cannabis Leukoedema multifactorial reasons: genetics, alcohol, tobacco and cannabis use
Candidal Infection Increased risk of candida infection – poor oral hygiene/denture hygiene Oral Cancer Cannabis contains similar carcinogens to tobacco Possibility of a link with cannabis use However more evidence required
1.S. Joshi and M. Ashley. Cannabis: A joint problem for patients and the dental profession. British Dental Journal 2016;220(11):597-601 2.Marks, et al. Cancer Epidemiol Biomarkers Prev. 2014 Jan;23(1):160-71. 85 What Is Advised?
86 Cannabinoid Intoxication
• Ask recent history of cannabis use
• Assess behavioral or psychological changes (euphoria, impaired judgement, motor skills)
1.Grafton SE, Huang PN, Vieira AR. Dental treatment planning considerations for patients using cannabis: A case report. J AM Dent Assoc 2016;147(5):354-361 2.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013
87 Dental Considerations
• Cognition must be considered for informed consent for treatment
• Local anesthetic containing epinephrine may prolong tachycardia following an acute dose of cannabis
• Advise patients to avoid cannabis use during post-surgical care to avoid smoke after surgical procedures
88 Recommendations
Check medical history. Emphasize the importance Complete a comprehensive of regular dental visits and oral exam oral care
Encourage healthy, Employ preventive nutritious snacks, i.e. Xylitol measures, such as fluoride instead of sweet, cariogenic rinses and to avoid alcohol- snacks containing products
89 Five A’s Approach to Tobacco Cessation
• ASK: Ask about marijuana use
• ADVISE: Advise users to quit
• ASSESS: Assess their willingness to quit
• ASSIST: Assist with a quit plan
• ARRANGE: Arrange follow-up contact
Marijuana Anonymous • Use 12 Steps of Recovery founded by Alcoholics Anonymous
90 Thank you
91 • OPEN POLLING ANSWER 1
92 • OPEN POLLING ANSWER 2
93 3:45 – 4:45 PM - ET Tobacco, E-cigarettes, and Cannabis: What Oral Health Providers Should Know
Abrey Daniel, DDS Lin Chan, DDS THANK YOU!
Questions about CE? Email: [email protected]