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2005 Volunteer Heroes Dedicated to Organized winter journal 2006.qxp 1/9/2006 11:45 AM Page 4

Editorial

OPPORTUNITIES FOR ALL JOURNAL OF THE MASSACHUSETTS DENTAL

ACH BUDGET CYCLE, THE FEDERAL GOVERNMENT HAS ATTEMPTED TO CUT FUNDING FOR SOCIETY access to dental and medical care for the elderly, children, and the poor. Every year, EDITOR E additional programs are cut, and those programs that do survive have their funding Dr. David B. Becker reduced. Basic care, including training grants for general practice residencies (which pro- ASSISTANT EDITOR vide primary care access), has been targeted repeatedly. Dr. Arthur I. Schwartz The American Dental Association is constantly fighting these reductions in programs EDITOR EMERITUS while simultaneously searching for and designing new approaches and programs for access Dr. Norman Becker to care. Some of these programs are well publicized, while others are instituted without any MANAGING EDITOR OF fanfare. The National Foundation of Dentistry for the Handicapped, which provides dental PUBLICATIONS AND WEB SITE care for the elderly, the medically compromised, and the disabled, has a waiting list of more Melissa Carman than 12,000 patients. Care is provided on a volunteer basis in private dental offices, and the MANAGER, GRAPHIC DESIGN providers can choose to whom, when, and how treatment is given. The providers bear no Jeanne M. Burdette responsibility for administration or paperwork. The problem is that there are not nearly enough volunteers to provide needed care. GRAPHIC DESIGNER The Give Kids a Smile campaign is, frankly, largely successful as a public relations Katherine A.J. Kane project. It accomplishes the goals of publicizing the need for access to dental care for dis- advantaged children while providing diagnostic and some simple therapeutic services. It also EDITORIAL BOARD alerts elected officials and healthcare policymakers about the great difficulty that low-income Bruce Donoff, DMD, MD children have in accessing basic dental care. However, the provision of follow-up care is Russell Giordano, DMD difficult and encumbering. Children living below 125 percent of the federal poverty level Shepard Goldstein, DMD are half as likely to visit a dentist as children in families living at greater than 200 percent Stephen McKenna, DMD of the federal poverty level, according to the Agency for Healthcare Research and Quality. John McManama, DDS What is needed is accessible, ongoing, hands-on care for the underserved. We feel that Noshir Mehta, DMD the government is dropping the ball regarding the provision of care for those in need. Those Charles Millstein, DMD who are not able to afford care absolutely should receive it. It’s that simple. Philip Millstein, DMD The Massachusetts Dental Society is addressing these issues directly. Dentists are vol- Maria Papageorge, DMD unteering their time and money to make sure that those who need it have access to care. Michael Sheff, DMD The MassDentists CARE (Combining Access with Reduced Expense) program is designed Steven Tonelli, DMD to provide reduced-fee oral healthcare to children from income-eligible families who don’t have either dental insurance or MassHealth. The MDS staff screens the applicant families and, if found eligible, provides them with the names of volunteer dentists in their area. This is an easy way for dentists to improve access to dental care throughout Massachusetts. We Copyright © 2006 Massachusetts Dental Society ISSN: 0025-4800 urge all members to call the MDS and volunteer to provide this assistance. The JOURNAL OF THE MASSACHUSETTS Another new and exciting program is in its final planning stages. With support DENTAL SOCIETY [USPS 284-680] is from Procter & Gamble, the Society is planning to launch the Massachusetts Dental owned and published quarterly by the Massachusetts Dental Society, Two Willow Society Mobile Access to Care Project. The Society will own and manage a mobile den- Street, Suite 200, Southborough, MA tal van, which will travel to each of the 13 districts in the state for prearranged blocks 01745-1027. Subscription for nonmembers is $12 a year in the United States. of time. This will be another opportunity for individual members to voluntarily provide Periodicals postage paid at Southborough, care to those most in need in their communities. A formal announcement of this project MA, and additional mailing offices. is expected to be made at the upcoming Yankee Dental Congress 31. You will receive Postmaster: Send address changes to: JOURNAL OF THE MASSACHUSETTS DENTAL more details as the Society and local districts finalize plans for this exciting endeavor. SOCIETY, Two Willow Street, Suite 200, Keep this in mind as an opportunity for all Southborough, MA 01745. of us to provide services to those most Contributions: Please see page 60, contact the Communications Department, or visit in need. ■ www.massdental.org for author’s guidelines. Display ad closing dates: February 1, May 1, August 1, November 1. For more infor- mation, contact Lauren Marks, Exhibits Coordinator, at (508) 480-9797, extension 259, or email [email protected].

Member Publication American Association of Dental Editors

4 Journal of the Massachusetts Dental Society winter journal 2006.qxp 1/9/2006 11:45 AM Page 5

FINANCIAL SERVICES CORNER EDIA STAFF

Editor’s Note: The following is intended to be informational. You should consult with your financial advisor before investing.

GEARING UP FOR THE ROTH 401(K)

O YOU WANT TO PAY TAXES NOW OR PUT THEM OFF? an addition to your traditional 401(k) plan, providing a new Beginning on January 1, 2006, the Roth 401(k) will be opportunity to save for retirement. It allows you to make after-tax D permitted under the Internal Revenue Code. The idea contributions to a Roth 401(k) option under a traditional 401(k), behind this is to give Americans the ability to save more for and it permits participants to take qualified tax-free distributions retirement and to have more control over their savings. The versus taxable distributions provided by a traditional 401(k). Roth 401(k) option combines features of Roth IRAs with fea- Now the bigger question is, Which is better: a traditional tures of traditional 401(k) plans. 401(k) or a Roth 401(k)? That depends on your needs. Here is According to ING Investment Companies, a Roth 401(k) is a sample comparison:

Roth Traditional Scenario Tax Rate 401(k)Total 401(k) Total Advantage

Initial investment (pretax of $15,000) 25% $20,000 $15,000 Traditional Explanation: It takes a greater portion of your pretax income to equal the same investments as with a traditional 401(k), because you’re contributing to a Roth 401(k) after you pay income taxes.

Investment growth and the withdrawal* 25% $30,000 $22,500 Roth Explanation: Because you paid taxes when you made the contribution to the Roth 401(k), you’re not taxed when you withdraw. So, in effect, you can save more with the Roth 401(k).

What happens if tax rates increase? 35% $30,000 $19,500 Roth Explanation: Ending up at a higher tax bracket in retirement can affect your $30,000 savings in a traditional 401(k). In this situation, it resulted in a 30 percent net gain for the traditional 401(k) and 50 percent net gain for the Roth 401(k).

What happens if tax rates decrease? 10% $30,000 $27,000 Traditional Explanation: If you retire in a lower tax bracket, the traditional 401(k) may be better because you didn’t pay taxes on your contributions. Although you still receive more money with the Roth 401(k), the difference between it and a traditional 401(k) is less than the additional amount needed for an equal initial investment.

*If your investment of $15,000 doubles to $30,000

SOURCES: THE BOSTON GLOBE AND EDFS. (This material is not intended to replace the advice of a qualified tax professional. Before making any financial commitment, consult with your tax advisor.)

The financial professionals at Eastern Dental Financial on the Roth 401(k) or other EDFS services, please contact Services (EDFS) provide independent, objective financial advice. Maren Kenney at (800) 898-3342, extension 401, or email Utilizing advanced planning techniques, they can help you ana- [email protected]. Be sure to visit our new lyze and evaluate your current retirement investment plans to Web site at www.easterndentalfinancial.com. ■

determine which one is best for you, and either confirm or redefine Securities offered through NEXT Financial Group, Inc. Member NASD/SIPC. EDFS is your retirement time horizons. If you would like more information not an affiliate of NEXT Financial Group, Inc.

Vol. 54/No. 4 Winter 2006 5 winter journal 2006.qxp 1/9/2006 11:45 AM Page 6

Letters to the Editor

egarding the recent article by Bernard Recently, there was an article in the Boston Globe RFriedland, BCHD, MSC, JD, and Eric (September 5, 2005) that indicated that the Supreme Judicial Katzman, DMD (Vol. 54/No. 3 Fall 2005, Court would hear arguments regarding banning fingerprint evi- pages 22–25), I have met Dr. Friedland and am not surprised at dence. The reason being that the technique has never been sci- the quality and care that went into his study. Have you tested call- entifically validated. Fingerprints, in general, are made of an ing our three dental schools “after hours”? I have. No comment. individual by a police officer; Toothprints are made by an indi- I read along, enjoying the sleuthing telephone calls until I vidual. These are two different procedures. In the making of an came to the conclusion. There I hit a barrier with “This under- occlusal recording, there is great opportunity to take an improper mines the profession’s assertion that dentists are full-fledged impression. The reasons may extend from recording the bite of a health professionals and its rightful demand that dentists be three-year-old to placing a thermoplastic material intraorally and treated as such.” Based on this study, we don’t deserve to be having it harden prior to making a deep occlusal reproduction. treated as such? Dentists should emulate the “after hours”—or It’s not that the material doesn’t work, but in how many cases even within hours—of our medical colleagues: “Call 911 or go does a clinician make an ideal type of recording? to the closest emergency room.” What constitutes a dental A recent article by Samet et al. in the Journal of Prosthetic emergency? A loose ? A piece of tooth fractured on a Dentistry (Vol. 94, August 2005, pages 112–117)—“A Clinical spare rib? If, in fact, there were a true emergency, it would most Evaluation of Fixed Partial Denture Impressions”—showed that likely be a traumatic , which should go to the ER. the frequency of errors found in impressions sent to dental labo- I was one, in the past, who felt Dr. Friedland’s ethical ratories was an ongoing problem for the dental profession. responsibility. I listed my home phone, and made many trips Taking impressions for prosthetic replacements and taking from the suburbs to downtown to help a patient “after hours.” thermoplastic impressions for identification is not the same; That is, until one time, responding to a 12:30 a.m. call for help however, technique and timing are very important in both pro- from a regular patient, I went to the office and was held up at cedures. The question of whether this system has been tested and knifepoint, and never saw or heard from that patient again. evaluated in the scientific sense remains to be seen. I believe that We don’t ever demand respect; we earn it time and time is the reason there is such a telling difference in the article con- again, and deservedly so. cerning the ABFO. Until this system can be verified by whatever scientific means possible, it will remain a questionable method Justin Lee Altshuler, DMD, FICD for identification—even though well over 100,000 recordings Boston University School of Dental Medicine have been made. The use of computerized technology to digitally Boston map the impressions is really secondary to the impression-making technique. Using an accurate computer mapping system will not he articles concerning Toothprints® bite impressions that validate the procedure. The procedure must be tested clinically T were published in the Summer 2005 issue (Vol. 54/No. 2 and scientifically in order to determine its validity. Summer 2005, pages 13–22) are of great interest to the dental Again, thank you for presenting such an important subject. community. However, there appears to be a conflict between the American Board of Forensic Odontology (ABFO) and the inven- Philip Millstein, DMD tor and promoter of this technique. Cambridge

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6 Journal of the Massachusetts Dental Society massde winter journal 2006.qxp 1/9/2006 11:50 AM Page 15

HEALTH INSURANCE

GEORGE GONSER, MBA Mr. Gonser is managing director of MDSIS.

WHAT DO THE MEDICARE CHANGES MEAN TO YOU? The Medicare system is changing dramatically in 2006. The following is a brief outline of the program and what you need to know about some of the changes.

Eligibility make a selection by May 15 or you will have to pay a If you or your spouse is age 65 or older, you are eligible for higher premium each month after the deadline. To enroll Medicare. If you are approaching age 65, you have some work in the MDS PacifiCare Plan, contact us at (800) 821-6033. to do to prepare for selecting Medicare: 45–90 days prior to MDSIS will send you the materials to enroll in the plan of turning 65, you need to go to your local Social Security office your choice. and apply for Social Security along with Part A and/or Part B of the Medicare program. Comparison of PacifiCare Prescription Drug Plans (In-Network Preferred, 30-Day Supply) Medicare Program Components Overview Saver Select Comprehensive Monthly premium $22.04 $34.95 $39.11 • Part A: Medicare Part A is also known as Hospital Deductible None None None Insurance. This insurance covers 80 percent of inpatient When total costs Tier 1: $7.50 Tier 1: $7.50 Tier 1: $7.50 hospital care, skilled nursing facilities, and some hospice are $0–2,250 Tier 2: $22.00 Tier 2: $22.00 Tier 2: $22.00 and home healthcare expenses. For most people, who qual- Tier 3: $52.25 Tier 3: $64.50 Tier 3: 52.60 When total costs You pay 100% You pay 100% Tier 1: $7.50 ify based on hours worked in their lifetime and are residents are $2,250–3,600 Tier 2: You pay 100% of the United States, Part A is provided at no cost. Those Tier 3: $52.60–generic, who do not qualify due to lack of hours worked can opt or you pay 100%–brand into the program for a monthly fee. When total costs $2 for generic or $2 for generic or $2 for generic or are $3,600+, you preferred Rx and preferred Rx and preferred Rx and • Part B: Medicare Part B is also known as Medical pay the greater of: $5 for all other Rx $5 for all other Rx $5 for all other Rx Insurance, and it covers 80 percent of doctors’ services and or or or 5% coinsurance 5% coinsurance 5% coinsurance outpatient care. Medicare Part B has a $110 annual The information above is an outline only. Please contact PacifiCare Prescription Solutions for deductible before benefits are paid. The cost of Part B will specific benefit questions at (800) 797-9794. be $88.50 a month starting in 2006, and will be deducted If you are ready to enroll in a plan, please call MDS Insurance Services at (800) 821-6033. from the Social Security payment. One important note: If you do not sign up for Medicare Part B when you are first How MDS Insurance Services Can Help eligible, you will be subject to a 10 percent penalty for each These various Medicare plan selections are vital decisions for full 12-month period of the time you were eligible to do so. dentists and/or spouses ages 65 and over. Coverage, deadlines, Therefore, you must plan accordingly as you approach your 65th birthday. Prescription drug coverage is not included in and penalties have to be weighed and analyzed. MDS Insurance Part B. You must sign up for Part B at your local Social Services, Inc. (MDSIS) offers a supplement product to MDS Security office, online at www.socialsecurity.gov, or by dentists and spouses statewide. The costs are less than those of calling (800) MEDICARE. comparable plans, and the program allows complete freedom of choice of providers and hospitals without referrals or gatekeeping • Supplement Plans: Senior Supplement or Medicare requirements. Supplement plans basically fill the gaps by paying the 20 percent for services not covered by Parts A and B. These To find out more about the Medicare happenings and plans come in many shapes and sizes from HMO supple- options available to you and your spouse, contact MDSIS at ■ ment plans to indemnity plans, such as the MDS Senior (800) 821-6033. Supplement Plan, and vary in price. Supplement plans, which are not offered through the U.S. government, require The above information is a basic outline only. For all updated enrollment in Medicare Part A and B plans. information on Medicare, please visit www.medicare.gov or call • Medicare Part D: Starting January 1, 2006, new Medicare (800) MEDICARE. Prescription Drug coverage is available to everyone with Medicare. There are a variety of Part D plans to fit your needs. MDSIS is offering three products through PacifiCare. These plans are considered “credible” Part D programs. The signup period for Medicare Part D begins November 15, 2005, and ends May 15, 2006. Note: You will have to

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2005 Volunteer Heroes Together, We Can Make a Difference

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istory has taught us that change only happens when people get involved. HThe United States was founded in 1776 because common needs and goals brought the citizens of the original 13 colonies together to make a change, to better their lives and the lives of those around them. The Revolutionary War was won entirely through the efforts of volunteers, from the militia to Betsy Ross to the creators of the Declaration of Independence. They were people who wanted to work together to make a brighter future.

While not on as grand a scale as the founding of our great country, the concept of volunteerism as it e applies to organized dentistry shares the same basis: It is the coming together of a group of people with a common desire to make something better—in this case, the dental profession and, as a result, the oral health of the public.

As a nonprofit association, the Massachusetts Dental Society relies on its members to play an active role so that we can all achieve the goal of making the profession as strong as it can be. This is why, every year, the MDS honors those members who have given so tirelessly of themselves to better both organized dentistry and the Society. They are our “Volunteer Heroes,” and they are shining examples of why it is so important to be involved in the profession and the Society. Their boundless energy, selflessness, and gen- erosity of both time and expertise have made the Massachusetts Dental Society and all that it represents that much stronger. And for that, we thank them.

Vol. 54/No. 4 Winter 2006 17 winter journal 2006.qxp 1/9/2006 11:53 AM Page 18

Sandra F. Cove, DMD

Why did you choose to join the MDS? What do you feel are the most In dentistry, our daily practice is con- important issues facing organized fined, and being a member of the dentistry today? Massachusetts Dental Society brings us, Insurance. It is troubling how medicine as dentists, together as a profession. It is has lost its luster as a profession; and I wonderful to collaborate with my peers would hate to see dentistry follow the at local events. I also use the MDS as a same pathway. Insurance has taken the resource for information in my daily autonomy out of medicine. For that rea- practice for my patients and myself. son, being a doctor is not as attractive as it once was. Today, insurance companies Why is involvement in organized dictate fees and push their influence on dentistry important to you? the patients, who as a result may make Giving back to dentistry as a profession poor decisions. Much of my daily work is very important to me personally. As is educating patients that they are dentists, we can only make an impact on responsible for their health, not their the direction of dentistry if we pull insurance companies. together as a profession, and that is done through our organization. How has the practice of dentistry changed since you began your career? Residence: Wellesley Please describe the extent of your Since hygiene school, I have seen the evo- volunteer experience in dentistry. lution of gloves, masks, and OSHA. The Office Location: Ashland Over the past six years, I have been helping largest change has been the world of with the Hands-On Committee for the esthetics and the public awareness for Specialty: General Dentistry Allied Scientific Program with the overall dental health, which has made Yankee Dental Congress. In the past, I dentistry more appealing to the general Education: Forsyth School for Dental Hygienists, was active in the Worcester District public. But the most fascinating change Tufts University School of Dental Medicine Dental Society, serving on both the to me has been the world of computerized Outreach Committee for the auxiliary dentistry and its rapid improvement. Number of Years in Practice: 13 schools and the Social Committee. Presently, with the Tufts University What would you say to a fellow dentist Number of Years of MDS Membership: 12 School of Dental Medicine, I am a co- to convince him/her to get more chair for the alumni association. At the involved in organized dentistry? school, I have also been a part-time Just do it! Volunteering will bring you instructor in the clinic, served on panels fulfillment that the daily practice of den- for graduating students, and also volun- tistry cannot. It is a wonderful profession teered in the oncology department where and the camaraderie that is felt both on I helped screen patients, made fluoride and off the playing field will bring you a trays, and helped patients through their surmounted feeling of honor. ■ treatment. In all my years in dentistry, I have always done some level of volunteer work; I find it extremely rewarding.

How has your volunteer experience impacted you professionally and personally? The teamwork displayed by the MDS staff has made me feel humbled and proud to be a part of the volunteer net- work within the Society. Even just being a small part of the larger picture of all of the volunteers in the MDS brings great honor to me. And it has a domino effect: My patients express that they feel the same about me when they see my involvement in organized dentistry.

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Timothy J. Hempton, DDS

Why did you choose to join the MDS? Yankee. On a number of occasions, I Most career paths include professional served as a room coordinator or as pre- organizations that provide information, siding chairperson for various courses. camaraderie, and guidance. After arriving Eventually, I was asked to serve on the in Massachusetts in July 1987, I learned Allied Program Committee and, subse- that the Massachusetts Dental Society is quently, the Scientific Committee. Over an outstanding example of an organiza- the years, I have also been fortunate to be tion that fulfills these goals. A professional included on the YDC program as a organization such as the MDS facilitates speaker, providing Minuteman sessions, communication with colleagues and pro- Lunch and Learn programs, lectures for vides opportunities to volunteer for various the RDH, and hands-on workshops. responsibilities in the cooperative man- In addition to my involvement with agement of the Society. YDC, I interacted on a more local level in When I was a kid, my mother always the Metropolitan District, serving as sec- told me that when you help others, you retary, treasurer, vice president, and pres- also help yourself. These words ring true ident for the Parkway Study Club, and I still. I joined the MDS to help, and as a subsequently held the same offices for the result of my membership, I have met Norfolk Study Club. During my tenure many members who have helped me. I am with these organizations, I met Dr. Mike Residence: Walpole convinced that involvement with the MDS Swartz, who played an important role in has had a very positive impact on my own mentoring me on the importance of Office Location: Dedham professional and personal growth. organized dentistry and encouraged my participation on the executive committee Specialty: Periodontology Why is involvement in organized of the Metropolitan District. dentistry important to you? Education: Dental school—SUNY at Stony Brook; When dentists join together in a profes- How has your volunteer experience Specialty training—Marquette University sional organization, they are able to impacted you professionally and amplify their efforts in advancing their personally? Number of Years in Practice: 21 own careers when they help others in I have found my experience of being their careers. Organized dentistry allows involved with the MDS professionally Number of Years of MDS Membership: 18 us to have a positive influence on our energizing and, on a personal level, a lot profession’s interactions with the public, of fun. It has been an uplifting experience our interactions with the government meeting and working with fellow dental and legislation, and the development of professionals, as well the hardworking useful continuing education programs. MDS staff. Over the years, I have had a great experience working with Michelle Please describe the extent of your Curtin, Marlene Petro, and Dorrey volunteer experience in dentistry. Prevost. They are all very patient and are My first experience with the MDS was in truly committed to our success. 1987. Dr. Nicholas Dello Russo contacted me, suggesting that I volunteer as a room What do you feel are the most coordinator for the Yankee Dental important issues facing organized Congress in January 1988. I went to dentistry today? preparation meetings before YDC and The greatest challenge organized dentistry had the opportunity to meet with other faces today is the same challenge it faced dental professionals who conveyed the from day one. That challenge is developing excitement associated with New England’s the next generation and future generations regional meeting. At that point, I was of ethical dentists who are committed to hooked on the concept of dentists volun- excellent patient care and who recognize teering their time to manage and develop the moral importance of concern for the not only continuing education programs welfare of their colleagues. It is critical but also a venue where professionals and that organized dentistry and the dental their guests could socialize in an engaging educational institutions interact very and comfortable atmosphere. closely in the process of developing Not long after my first YDC, I met responsible scholar-clinicians. Drs. June and Bill Lee, who also encour- aged me to continue as a volunteer with Continued on page 23

Vol. 54/No. 4 Winter 2006 19 winter journal 2006.qxp 1/9/2006 11:56 AM Page 20

Mary H. Kreitzer, DMD

Why did you choose to join the MDS? pated in decision making in the Valley When I first started practicing, right after District, which has been interesting and graduation, I felt a need to get involved mostly satisfying—although contentious and not be isolated. In particular, net- at times. And the networking aspect has working with colleagues at the local been a great experience for me in that I level was appealing to me, as well as the get to interact with different people and phenomenal access to resources that the personalities and have learned to be MDS provides, such as continuing edu- more diplomatic—especially when I cation and information regarding served as president of the VDDS—which OSHA, HIPAA, and much more. has been important, as I can sometimes be too direct and even abrasive. Why is involvement in organized dentistry important to you? What do you feel are the most There are many reasons why involvement important issues facing organized in organized dentistry is important to me. dentistry today? Among them: The need to get involved in Increased government control and access decision making at the local level, which to dental care for people who cannot might impact my practice. The ability to afford it. And as more companies decrease share ideas with colleagues. The aware- dental benefits, there will probably be a ness of what is going on politically with larger number of these families who won’t Residence: East Longmeadow regard to the practice of dentistry and be able to afford proper oral healthcare. how these political issues might impact Office Location: Longmeadow day-to-day practice. The support that How has the practice of dentistry organized dentistry has given to the fight changed since you began your career? Specialty: Oral and Maxillofacial Surgery for fluoridation, use of amalgam, access Certainly, there are more women in prac- to care, and other initiatives. tice. There is also more government Education: Harvard School of Dental Medicine; intrusion: some beneficial, most not so residency, Medical College of Virginia Please describe the extent of your beneficial, and some downright ludi- volunteer experience in dentistry. crous. The great strides in dental proce- Number of Years in Practice: 25 I have been on the Valley District Dental dures and materials in the past 25 years Society (VDDS) executive committee for has been fantastic—composites, implants, Number of Years of MDS Membership: 25 about 24 years, including serving as a bone grafting, cosmetic procedures, past president and present secretary for microscope use, invisible braces, just to the district group. I am a member of the name a few. How many of us remember local ethics committee, and I also sat on GV Black and line angles? ■ the local health council. I have been a volunteer at Yankee Dental Congress off and on for several years. I have served as social/entertainment co-chair, been a room coordinator several times, and taught CPR with members of my district society. I am also a CPR instructor for VDDS.

How has your volunteer experience impacted you professionally and personally? As a result of volunteering, I have gotten to know many of my colleagues and had the opportunity to work more closely with them. This interaction with col- leagues is in and of itself beneficial, as is the exchange of fresh ideas. Volunteering has afforded me the ability to meet and talk with colleagues from other towns, colleagues who I normally would have little or no contact with. I have partici-

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Joan Viantha Qureshi, DMD, Dip. Bact., MSc

Why did you choose to join the MDS? feel satisfied that we achieved a job well I think the Massachusetts Dental Society done for all concerned. After all, serving joined me while I was a senior at Tufts people is part of the reason we do our University School of Dental Medicine in work. 1984. Because of the tripartite structure of The successful growth of the MDS the American Dental Association, I bene- depends on its most valuable asset: its fited from the student membership. After varied membership. As MDS members, graduation, it was natural to remain a we must make every effort to improve member in the largest national professional the road for those who will come behind dental organization, and I chose to also us. As professionals, we have been given become involved at the state level. the chance; let’s ensure this for others in I had decided to be a solo practi- the future. We all need to become part of tioner in a small town close to home, so what happens in our profession. Only I sought guidance from the ADA. Since then will all members achieve equity. most of my professors were in academics and only part-time clinicians, the dental Please describe the extent of your school curriculum fell short on practice volunteer experience in dentistry. management issues. Within a few My first MDS volunteer experience was months, I was ready for business as a solo with the Young Dentist Committee, which practitioner. But there were still prob- is now known as the Standing Committee lems: how to build an efficient office and on the New Dentist. After serving for Residence: South Natick a clientele base, make appropriate refer- several years, I was promoted to the rals, obtain laboratory expertise, and Membership Committee. At both com- Office Location: Sherborn deliver optimal patient care. I knew that mittees’ meetings, I voiced my views that the growth of a practice starts slowly. if women, especially parents, were expected Specialty: General Dentistry As a result, I embraced the MDS and to fully participate as members in dental joined the Young Dentist Committee and society meetings and education programs, Education: Tufts University School of Dental the district study club. The close proximity then the MDS and the ADA needed to Medicine of MDS headquarters to my home and direct attention to the needs of women practice allowed me to volunteer when- dentists. By this time, I was already serving Number of Years in Practice: 20 ever called upon. Belonging to an orga- on the Scientific Committee for YDC, and nization to enhance my learning and to so I was asked to find speakers and subjects Number of Years of MDS Membership: 21 meet professional colleagues was not new appropriate to women dentists and their to me. As a researcher at Forsyth Dental specific needs. As a result of my strong Center, I belonged to the American and beliefs that women need to be better repre- International Associations for Dental sented and reach equality in professional Research and the American Society of dentistry, I have been involved with the Microbiology. And I continued to take Women’s Dental Society of Massachusetts, advantage of all the benefits that belonging having served as president and treasurer. to the MDS afforded me, such as contin- And of course, I have been involved uing education available through my dis- in the Yankee Dental Congress and proud trict and the Yankee Dental Congress. to serve on the YDC Planning Committee. One can’t volunteer for YDC without Why is involvement in organized being involved in all aspects, from pre- dentistry important to you? siding chair to general arrangements and The MDS has evolved into an organiza- even social activities. tion that embraces its members and non- In recent years, I have also been members, as well as societal issues. This involved in other MDS councils, serving can be attributed to the MDS encouraging as special consultant and now chair of its members to express their needs, but it the Abuse and Neglect Subcommittee can also be attributed to good leadership. and as the Metropolitan District repre- The MDS has quality members and is sentative for the Council on Access, diversified; it represents generalists, spe- Prevention, and Interprofessional Relations cialists, young professionals, seasoned (CAPIR). I have been an alternate and a practitioners, and retired and life mem- delegate for the MDS House of Delegates bers, and more importantly, it draws the students. I hope we can all look back and Continued on page 23

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Jeanne Velde, DMD

Why is involvement in organized excellent schools. Recently, funds were dentistry important to you? granted to Middlesex Community I love the camaraderie I receive from my College, in my home district, to increase fellow dentists. I enjoy being involved in its dental hygiene class. This is one clear our organization and working on com- example of how the work of the MDS mon issues. The MDS provides many councils directly improves our practices vital services and opportunities for on the local level. members that require the input and I am also involved as a volunteer involvement of its members in order to dentist at a local free clinic at Lazarus be effective, such as continuing educa- House in Lawrence, MA. Lawrence is tion, promotion of the profession, one of the poorest cities in New England, development and education of auxil- with a large percentage of families living iaries, insurance, and business affairs. It below the poverty level. Lazarus House is important to me to be involved in the is an organization that provides services process so that the ideas and programs such as emergency housing and clothing, developed by the MDS represent den- hot nutritious meals, and job training tists like me. and counseling to the homeless and nearly homeless in the greater Merrimack Please describe the extent of your Valley. It also opened a small dental clinic volunteer experience in dentistry. in order to provide very basic dental Residence: North Andover I have enjoyed being involved in the services to the homeless and working Merrimack Valley District Society by acting poor, with the mission being to alleviate Office Location: Haverhill as a liaison to the Middlesex Community pain and provide solutions to dental College dental hygiene and dental assis- problems that keep people from getting Specialty: General Dentistry tant programs and the Northern Essex back into the job market. Community College dental assisting pro- I have been involved with Lazarus Education: Fairleigh Dickinson University School gram. I also represent the MDS on the House for about seven years now, volun- of Dentistry advisory board for Middlesex Com- teering once a month in the clinic, helping munity College, Health Professions divi- to recruit other dentists, and finding Number of Years in Practice: 24 sion, as well as for Northern Essex. I try sources of donated equipment and sup- to make our local members aware of the plies. It is very rewarding work. Recently, Number of Years of MDS Membership: 22 particular needs of our local auxiliary for example, I treated a beautiful 4-year- education programs. I have also served old Kenyan boy who was in the United on our district executive committee. States for cardiac surgery, and a 15-year- In addition, I have held various posi- old boy who had been sent home from tions at Yankee Dental Congress, including school repeatedly because of toothaches. room coordinator, presiding chair, and It is a joy to be able to use my training to general arrangements. alleviate pain for people who truly have On the state level, I served for several no other options. years on the Council on Dental Education and continue to serve on the How has your volunteer experience Council on Dental Practice, which was impacted you professionally and given the task of finding ways to increase personally? the number of dental hygienists. This Being a volunteer provides a sense of work has been exciting because the connection with others in my profession results of our work directly affect work- on a local, state, and national level. ing dentists. We surveyed practicing den- tists and hygienists, contracted consult- What do you feel are the most ants, and worked with focus groups to important issues facing organized assess needs. dentistry today? We brought our compiled results to One of the most important issues is the MDS House of Delegates and were affordable healthcare insurance for our delighted by the response to our request employees. Both the MDS and the for a special dues assessment to use American Dental Association provide directly for this effort. We have been able critical services in regulatory compliance to grant funds, specifically earmarked for increasing class size, to a number of Continued on page 23

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HEMPTON continued from page 19 How has your volunteer experience What would you say to a fellow dentist impacted you professionally and to convince him/her to get more How has the practice of personally? involved in organized dentistry? dentistry changed since I believe my involvement in the MDS has No one can afford not to get involved you began your career? created situations that help to define me. with his or her profession. I would sug- When I started my career Participation allows me to share a com- gest you get involved at whatever level as a dentist in 1984, mon bond with my peers because we can you are able. Remember, there are few implant therapy was just all share our experiences. When we who can or choose to be leaders; most beginning to enter into share problems, we can come up with of us are happy being followers. Also, the mainstream of dental practice. Today, solutions together. The MDS did this get all the education your time allows: it is very much a part of conventional when malpractice insurance first hit our practice, practice, and practice some dental therapy. In addition, regeneration profession and has continued to do so more. But never forget the well-being of hard and soft tissues around the denti- with subsequent issues relating to fluo- of yourself, your family, and your tion, as well as site preparation for dental ride, amalgam, and infection control, patients, who easily become your implants, has dramatically improved. among many others. extended family. During my 21 years as a dentist, I On a personal level, few lives There is a saying that if you can’t have also been involved in academics, remain untouched by tragedy, and the find it in yourself, where will you go serving as an instructor for three years at biggest tragedy I have faced was the sud- for it? Life is a matter of choices. Be the Harvard School of Dental Medicine and den deaths of my husband and 4-year- best you can for as long as you can. As I on the faculty at Tufts University School old daughter, Sarah, in the fall of 1994 once wrote in the Yankee Dentist: of Dental Medicine for the last 15 years. while I was in Vancouver, BC, attending “Sometimes words can speak louder Through these experiences, I have been the Federation Dentaire Internationale. I than actions. Dentists are diverse but introduced to many members of the den- can’t fully describe the feeling at the united by an intense commitment to tal profession who are committed to fur- time, except to say that I felt quite alone quality education and patient care. thering our abilities to provide improved with my grief. I returned to work imme- Transferring information . . . increases dental health for the public. Having met diately only because of the support from awareness and understanding from one these people, I am convinced that, for my patients. Whatever satisfaction I had person’s expertise to the next, allowing our profession, the future is bright. received from my practice and profes- every dentist to be involved in organized sional associations helped pull me dentistry.” That’s how I see my involve- What would you say to a fellow dentist through those dark hours. ment in the Massachusetts Dental to convince him/her to get more Society. ■ involved in organized dentistry? What do you feel are the most There are dentists who will tell you that important issues facing organized the cost of an implant workshop is dentistry today? VELDE continued from page 22 $1,500, the fee for a course on occlusion I think the biggest issue is the role of is $800, and viewing a live Webcam technology in our organizations, in our and represent our inter- esthetics presentation is $300. But the practices, and in education. I am very ests with grassroots wonderful experience of working with concerned that dental schools and our efforts at state and your colleagues, sharing ideas, and mak- own practices will not be able to keep up national levels that we ing friends who share the same problems with the scope of technical achieve- could never do as indi- and concerns you do is truly priceless. ■ ments. We have gone from a tactile soci- viduals. ety to a digital society. This has affected learning and even delivery of dental care How has the practice of dentistry QURESHI continued from page 21 to our patients. Technology will impact changed since you began your career? everyone, whether setting up a new The practice of dentistry has become far as well as the Academy office, modifying an existing practice, or more technical. Esthetic dentistry, micro- of General Dentistry improving for efficiency in production. dentistry, and implant dentistry have really (AGD) House of I am also concerned about the falling come of age since I graduated in 1981. It Delegates. I also cur- volunteerism in our profession. It can be is a wonderful time to be a dentist. rently serve as editor of reasoned that the higher costs of a dental the Massachusetts AGD education and practices for recent gradu- What would you say to a fellow dentist publication Yankee ates are largely responsible. I would to convince him/her to get more Dentist. argue that similar economic stressors and involved in organized dentistry? At the district level, I am currently time constraints affect all generations of Being involved in our organization serving a second three-year term as trea- dentists. Volunteerism comes from within gives you a chance to make a difference surer and a second term as chair of the a person; it can’t be created or bought. It in the direction our organization grows. Community Health Committee. In the is also a part of the need to belong and It is a great opportunity to develop a past, I also served on the ADA Special the need to be charitable. If you don’t network of wonderful friends in den- Task Force on Membership at the district need these two things, then maybe volun- tistry who are working to make our level. teerism is not important to you. practices better. ■

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Screening for —A Matter of Life or Death MICHAEL A. KAHN, DDS Dr. Kahn is professor in the department of oral and maxillofacial pathology and director of the ITS division of Professional Services at Tufts University School of Dental Medicine.

uring dental school admis- Therefore, it is imperative that each sion interviews, applicants licensed dentist and the remainder of the dental healthcare delivery team be D often mention that one of regularly reminded about the impor- the appeals of choosing dentistry tance of oral cancer screening as well as refreshed in the proper head and neck over medicine is the avoidance of soft-tissue examination technique. The life-or-death situations. Paradoxically, purpose of this article is to update the if a dentist is a vigilant clinician, and dental clinician regarding the impor- tance and proper technique of oral can- an astute and knowledgeable diag- cer screening, as well as to review some nostician, he or she may be involved important information about premalig- nant oral lesions. in the early detection of one of the Overwhelmingly, the most frequent approximately 29,370 new cases of type of oral cancer reported in the United oral cavity/oropharyngeal cancer States is squamous cell carcinoma, aris- ing from the stratified squamous epithe- estimated by the American Cancer lial mucosal lining of the oral cavity.2-5 Society to have occurred in the Epidemiologic studies have shown that

1 approximately 95 percent of oral cancer United States last year. This inci- is of this type, with the remaining 5 per- dence is nearly three times the cent distributed among soft- and hard- amount of estimated cervical carci- tissue sarcomas, primary or metastatic melanoma, and salivary gland tumors.2,4-6 cases during the same time For this reason, unless specifically noted, period and nearly 5,000 more than the remainder of this article will deal with squamous cell carcinoma of the oral the estimated new cases of thyroid cavity proper and the adjacent skin and cancer. Although the American vermilion border of the . Cancer Society estimates that both Every hour, another three oral can- cer cases are diagnosed, and during that this past year’s cases of leukemia same hour, another American dies of and cutaneous melanoma occurred oral cancer. Both of these sobering facts have held constant for nearly the past more often—34,810 and 59,580, 30 years. The male-female incidence respectively—oral cancer continues ratio of oral cancer in the United States to represent a significant unknown, is currently 2:1, an increase from the 3:1 ratio of a generation ago, primarily due initially silent, and subsequently to the increase of tobacco use by painful morbid disease and often women.4,5,7-9 Despite these disturbing statistics, there has been one glimmer relentless killer of the American of hope during the past year—the public.1 American Cancer Society and the

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American Dental Association have ruption of the normal maturation pat- reported that for the first time in nearly tern of the ’s epithelium. 30 years, the relative five-year overall Subjective amounts of dysplasia are cate- (i.e., all races combined) survival rate gorized as mild, moderate, severe, or in improved to 59 percent, a small but sig- situ carcinoma, depending on the amount nificant positive change from the 50 to of epithelial thickness that exhibits dys- 55 percent cited for the past 20 years.1 plasia. Mild dysplasia is generally This encouraging trend may be due to described as involving only the lower earlier detection of lesions by the dental one-fourth of the epithelium’s thickness, healthcare delivery team with subse- moderate dysplasia involves one-half, quent, timely surgical biopsies. However, severe dysplasia involves three-fourths, despite this promising news, there and in situ carcinoma has top-to-bottom

remains a glaring disparity of five-year Figure 1. Sun-damaged left lower vermil- involvement but without invasion of the survival rates when they are stratified ion with subsequent biopsy demonstrating underlying lamina propria (i.e., connec- by race (e.g., Caucasians vs. African actinic keratosis with severe dysplasia. tive tissue) via violation of the basement Americans). Caucasians have a 61 per- membrane zone. cent five-year survival rate whereas for It is well known that a woman’s cer- African Americans the five-year survival vical epithelium may have similar degrees rate is only 39 percent.1 of dysplasia; however, the process of pro- Tobacco, whether of the smoke gression is slower and consistently sequen- (e.g., cigarettes, cigars, pipe) or smoke- tial. Unfortunately, many dentists do not less (e.g., chewing tobacco, snuff) vari- realize that early, mild dysplasia of the ety, continues to be the number-one eti- oral epithelium does not necessarily ologic factor of oral cancer, while alco- progress through the more involved hol is considered an important and sig- stages of dysplasia but may invade at any nificant synergistic cofactor (alcohol’s time. Therefore, it is essential that den- aldehyde component is thought to be tists continue to screen their patients for the primary culprit).2,5,7-9 If a person con- early premalignant lesions and have them tinues to smoke cigarettes, estimates thoroughly removed, even if only mild Figure 2. Biopsy-confirmed squamous cell car- range that he or she is from eight to cinoma of the lower lip and actinic keratosis dysplasia is present. more than 20 times more likely to develop with in situ carcinoma. squamous cell carcinoma. If that same Classic Warning Signs person also overindulges in the use of The dental team should always be cog- ethanol (alcohol beverage), then the nizant of the classic clinical warning likelihood of oral cancer can rise to signs of oral cancer: difficulty in chewing more than 80-fold.7 or speaking; a lump or thickening in the Other known etiologic or influencing mucosa, glands, or lymph node area; an factors of oral cancer include therapeutic ulceration that does not heal; abnormal radiation or, in the case of lip cancer, bleeding; and unexplained pain or pares- ultraviolet radiation. Certain viruses, thesia.13 Although this article, as previ- such as type VIII, ously stated, does not discuss intrabony Epstein-Barr virus, and particularly (i.e., jaw) cancer, the clinician should human papillomavirus, are thought to remember the classic radiographic inter- be, at times, oncogenic.10,11 The immune pretation signs of suspicious malignancy: status of the individual is also important asymmetry; irregular borders; focal and because when the immune system is com- symmetrical widening of the periodontal promised, oral cancer is much more likely.4 ligament; apical root resorption with a Diet and nutrition remain significant fac- “spike or nail” appearance; and, in tors, and recent molecular biological young people, superior displacement of studies show that sensitivity to mutagens, erupting teeth.5 metabolic enzymes, polymorphisms, It is vitally important that the den- DNA errors or lack of their repair, and tal provider be familiar with the nature certain cancer proto-oncogenes and and appearance of surface changes that tumor suppressor genes may play a sig- indicate possible premalignant or malig- nificant role.12 nant change. Head and neck cutaneous All dentists should refresh their surface changes in color, texture, and Figures 3A and 3B. An asymptomatic leuko- knowledge about the concept and degree plakia of right lateral tongue (A) and left morphology should always be investi- of premalignant oral lesions exhibiting anterior floor of mouth (B) discovered during gated and the patient informed. Lip can- routine oral screening. various amounts of dysplasia—the inter- cer of the skin and vermilion border due

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to chronic ultraviolet exposure may and malignant oral cancer.7,14,15 The most occur in any geographical area of the common extraoral site is the skin and United States. The classic visual warn- vermilion of the lower lip. Within the ing signs are an uneven coloration, oral cavity proper, the lateral and ventral splotchiness, development of a scale or surfaces of the tongue are the most com- crust, or blurring of the usual distinct mon, with the floor of the mouth proving border between the vermilion and skin to be the second most common. The soft or labial mucosa.4 complex is also a common site of Within the oral cavity proper, the involvement, specifically the uvula, soft most common premalignant clinical palate proper, anterior tonsillar pillar, changes are or erythro- and lingual retromolar trigone. plakia. These terms are solely clinical Figure 4. Asymptomatic speckled erythro- During the past few years, numerous plakia of the left soft palate complex. descriptions of a white or red plaque dental journals and publications have (slightly elevated above the plane of the emphasized to all dentists the importance mucosa) or patch that does not wipe off of performing a standard, reproducible, and cannot receive an alternative specific and frequent soft-tissue head and neck diagnosis. It is imperative to remember examination that can be competently that there is no correlation between the performed in 1½ to 3 minutes, once a size, color, or texture of a leukoplakia or thorough and complete review of the lesion and its final histo- patient’s medical, dental, and social his- logical diagnosis. It is rare, but a combi- tory is accomplished.3,13,18-22 nation of the two, erythroleukoplakia The two basic components of the (speckled leukoplakia), is also seen. head and neck examination, visualization Ideally, these clinical lesions must be and palpation, are performed adhering to biopsied as soon as possible unless a spe- a few basic principles. Namely, a properly cific etiology (e.g., defective restoration, focused and dispersed incandescent oper- denture clasp) is suspected, eliminated, Figure 5. Squamous cell carcinoma of the right atory light should be available, and with and the lesion resolved within two posterior lateral tongue. The lesion was ini- the patient properly positioned, the nor- tially thought to be a traumatic ulceration due weeks. to the adjacent tooth’s fractured crown. mally wet mucosal surfaces of the oral Eighty-five percent of oral prema- cavity proper should be dried, particularly lignancies or malignancies are leuko- the floor of the mouth and buccal plakias.4,6,13,14 They typically occur in a mucosa. Palpation is particularly impor- male with an average age of 60. Eighty tant to detect oral cancer that is not orig- percent of patients with leukoplakias inating from the surface epithelium and are cigarette smokers, and those who to help the clinician assess the amount of smoke frequently have more and larger possible induration present in more lesions. Waldron and Shafer reported advanced squamous cell carcinomas. that when leukoplakias are surgically biopsied and subsequently examined Suggested Screening Method microscopically, only 20 percent have There is no specific screening sequence hyperkeratosis with some degree of dys- that must be followed as long as the clini- plasia.14 Interestingly, the least common cian can systematically repeat it in each sites for leukoplakia—the tongue and patient. The following is a suggested floor of the mouth—are the most likely Figure 6. Papillary, exophytic, and ulcerative screening order of the extraoral and intra- squamous cell carcinoma of the anterior max- to be dysplastic, at 25 percent and 50 illary gingiva. oral head and neck soft tissues, with percent, respectively.14 emphasis on detection of lack of symme- Although more rare, erythroplakias increasing numbers of patients in the age try or changes in texture, color, function, are clinically even more significant, as range of 20 to 40 with no contributory and morphology. Bilateral visual and pal- Shafer and Waldron found that 91 per- social history (e.g., tobacco use, ethanol pation inspection should be applied to the: cent prove to have severe dysplasia or abuse, etc.).16,17 Equally disturbing is that 1. Pre- and postauricular facial region worse.15 They, too, are seen most often in these young adult patients seem to have a (lymph node and parotid gland) elderly males with an average age of 70. very biologically active, aggressive type 2. Anterior and posterior cervical chain The most common intraoral sites for ery- of squamous cell carcinoma for which of lymph nodes, thyroid gland, and throplakia are the lateral tongue, floor of the average age of survival once diag- remaining major salivary glands the mouth, soft palate, and alveolar ridge. nosed is often less than one year. (i.e., submandibular and sublingual) Recently, a very disturbing trend has Classic oral pathology studies of the 3. Three anatomical regions of the been reported in the dental literature— 1970s and 1980s found and validated upper and lower lip (i.e., skin of the tongue cancer incidence has doubled in certain oral and paraoral areas as being lip, vermilion border, and labial the past 50 years, most notably in the highest-risk sites for premalignant mucosa) and their commissures

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Whether the patient is young or old, there is no doubt that early detection of oral cancer is the key to reduction of morbidity and a longer span of survival.

4. Buccal mucosa References papillomavirus (HPV) in squamous cell 1. Cancer statistics, 2005. CA: Cancer J Clin carcinoma of the oral cavity and oropharynx. 5. Maxillary and mandibular attached 2005:55(1);10-14. J Laryngol Otol 2000;114:41-6. gingiva, corresponding alveolar 2. Bouquot JE. Epidemiology. In: Gnepp DR. 12. Notani PN, Jayant K. Role of diet in upper mucosa, and vestibules (i.e., Pathology of the head and neck. New York: aerodigestive tract cancers. Nutr Cancer mucobuccal fold) Churchill Livingstone; 1988. p 263-314. 1987;10:103-13. 3. National Institutes of Health. Detecting oral 13. Mashberg A, Samit AM. Early diagnosis of 6. Hard palate and soft palate com- cancer: a guide for health professionals. asymptomatic oral and oropharyngeal cancer. plex (pharyngeal tonsils, anterior Bethesda (MD): National Institute of Dental CA: Cancer J Clin 1995;45:328-51. and posterior tonsillar pillars, uvula and Craniofacial Research; 1995. 14. Waldron CW, Shafer WF. Leukoplakia revisited: and retromolar pads) 4. Neville BW, Damm, DD, Allen CM, Bouquot a clinicopathologic study of 3256 oral JE. Oral and maxillofacial pathology. 2nd ed. leukoplakias. Cancer 1975:36;1386-92. 7. Oropharynx, particularly the poste- Philadelphia: WB Saunders; 2002. 15. Shafer WF, Waldron CW. Erythroplakia of the rior pharyngeal wall (to accomplish 5. Silverman S. Oral cancer. 5th ed. American oral cavity. Cancer 1975:36;1021-28. this most proficiently, a tongue Cancer Society atlas of clinical oncology. 16. Corcoran TP, Whiston DA. Oral cancer in depressor blade should be available) Hamilton, Ontario, Canada: BC Decker; 2003. young adults. JADA 2000;131:726. 6. Kleinman DV, Crossett LS, Gloeckler Ries LA, 17. Gorsky M, Epstein JB, Oakley C, et al. 8. Dorsum, lateral border, ventral et al. Cancer of the oral cavity and pharynx: a Carcinoma of the tongue: a case series surface, and base of the tongue (to statistics review monograph, 1973-1987. analysis of clinical presentation, risk factors, accomplish this most proficiently, the NIH Monograph. Bethesda (MD): National staging and outcome. Oral Surg Oral Med Institute of Dental Research; 1992. tongue should be gently grasped Oral Pathol Radiol Endod 2004;98;546-52. 7. Blot WJ, McLaughlin JK, Winn DM, et al. with gauze wrapped around the 18. Glazer HS. Spotting trouble. AGD Impact Smoking and drinking in relation to oral and pha- 2003;18-19. anterior tip and moved toward each ryngeal cancer. Cancer Res 1988;48:3282-7. 19. Horowitz AM, Alfano MC. Perform a death- commissure, with particular atten- 8. Choi SY, Kahyo H. Effect of cigarette smoking defying act: the 90-second oral cancer tion directed toward the mid- and and alcohol consumption in the aetiology of examination. JADA 2001;132(Suppl):5S-6S, posterior lateral borders) cancer of the oral cavity, pharynx, and larynx. 36S-40S. Int J Epidemiol 1991;20:878-85. 20. Mages M. Missing pieces: why aren’t more 9. Floor of the mouth following 9. Schmidt BL, Dierks EJ, Homer L, et al. dentists performing oral cancer exams? thorough drying (palpation should Tobacco smoking history and presentation AGC Impact 2002;16-18. of oral squamous cell carcinoma. J Oral be two-handed: extended finger of 21. Opportunistic oral cancer screening: a Maxillofac Surg 2004;62:1055-8. one hand with support of the chin management strategy for dental practice. 10. Cox MF, Scully C, Maitland N. Viruses in the Br Dent Assoc 2000;6:1-36. and submandibular region with the aetiology of oral carcinoma? Examination of 22. Sciubba JJ. Oral cancer and its detection: the evidence. Br J Oral Maxillofac Surg other hand) history-taking and the diagnostic phase 1991;29:381-7. of management. JADA 2001;132(Suppl): Conclusion 11. Niv A, Slon-Vardi N, Gatot A, et al. 12S-15S. Whether the patient is young or old, Identification and typing of human there is no doubt that early detection of oral cancer is the key to reduction of morbidity and a longer span of survival. It is absolutely imperative that each den- tist develop his or her own standard soft- HYPNOSIS IN DENTISTRY tissue head and neck examination, and The New England Society of Clinical Hypnosis will offer a make it a frequent, repeatable part of the comprehensive course in Hypnosis in Clinical Practice in March 2006. dental appointment routine. Obviously, patients with any of the The 51st Annual Workshop trains dentists to use hypnosis to clinical and/or social factors mentioned above should undergo particular scrutiny. manage pain, anxiety and dental phobia. This is an intensive For too long the survivability statistics of workshop which is designed to equip dentists with the skills to oral cancer have languished in the realm of immediately begin using hypnosis. mediocrity. Licensed dentists should accept the responsibility to ensure that patients The Basic Workshop will be held March 4–5 and March 18–19, not only receive the best esthetic and func- tional restorative procedures and palliative 2006 at the Newton-Wellesley Hospital, Newton, MA. Tuition is care but also screening and treatment, if $495. Registration materials are available at www.nesch.org. necessary, of carcinomatous transforma- For further information, email [email protected]. tion at its earliest stages. You can make a difference; you must make a difference. ■

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Migraine with Aura and Dental Occlusion: A Case Report

Introduction The international classification of headache disorders defines migraine as “a common disabling primary headache disorder.”1 The term primary refers to a pathology that is not a symptom produced by another disorder, but is a dis- order itself. In fact, secondary migraine must be diagnosed and coded according to the causative disorder.1 MARCELLO MELIS, DMD, RPHARM Migraine is characterized by headache lasting 4-72 hours, with at least SIMONA SECCI, MD two of the following characteristics: unilateral location, pulsating quality, Dr. Melis is adjunct clinical instructor in the moderate or severe pain intensity, and aggravation by or causing avoidance Craniofacial Pain Center at Tufts University of routine physical activity. During headache, at least one of the following School of Dental Medicine. He maintains a must be present: nausea and/or vomiting, photophobia, and phonophobia.1 private practice in Cagliari, Italy. Dr. Secci is Migraine headache can be preceded by the appearance of visual and/or a doctor of radiology with a private practice in sensory and/or speech symptoms that develop gradually over more than Cagliari, Italy. 5 minutes and that last for less than 1 hour. In this case, it is diagnosed as migraine with aura.1 However, some reports have been found in the literature where patients Abstract diagnosed with migraine were successfully treated by correcting dental occlu- sion and reducing dental parafunctions.2-6 Such results may suggest that in igraine is defined as a pri- some cases, headache related to dental occlusion and dental parafunctions is mary headache; however, able to mimic a primary migraine headache, and therefore treatment of the causative disorder will resolve the headache. some reports may suggest M In this case study, we will try to understand if there is a relationship a relationship with dental occlusion between migraine headache, dental occlusion, and dental parafunctions. We and dental parafunction (clenching or will analyze the reports that have been published in the literature, and describe a clinical case of a patient affected by migraine with aura with concomitant grinding of the teeth). (TMJ) and masseter muscle pain, and successfully A patient diagnosed with treated by the use of a dental occlusal appliance (DOA). migraine with aura, with concomitant Case Report temporomandibular joint and masseter A 59-year-old Caucasian female patient came to our dental office for evalu- ation. Her chief complaint was a severe headache that had been diagnosed muscle pain, was treated by the use of as migraine with aura by different neurologists after assessment by two a dental appliance. The treatment suc- headache clinics in Pisa and Cagliari, Italy. The headache was described as an intense throbbing pain located in the ceeded in eliminating headache and forehead and temples, bilaterally, associated with photophobia and phono- visual aura, and significantly reducing phobia, nausea, and occasional vomiting. The headache usually lasted for the other symptoms. days if untreated and tended to start in the morning upon waking. Initially, the migraine was not preceded by aura, but then attacks started A headache related to dental alternating with episodes of migraine preceded by a visual aura that was occlusion and dental parafunctions described as the appearance of small pulsating scintillating flashes starting a few minutes before onset of the headache and persisting during the headache. seems to be able to mimic a primary Further investigations, including neurological and ophthalmic evalua- migraine headache. Therefore, dental tions, magnetic resonance imaging of the head, and echo-color Doppler of the carotid arteries, revealed the presence of an arachnoid located in the left evaluation is always advised for cerebral hemisphere that was considered unrelated to the symptomatology of headache diagnosis. the patient.

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Several medications were tried for During the following month, the masseter muscle fatigue and soreness, the treatment of headache, including patient was free from headache and the together with the report of nighttime nimesulide, ibuprofen, and indomethacin. visual aura started improving. In fact, the tooth-clenching activity by the patient. The only drug that was found effective duration and frequency of aura symp- We changed the thickness of the device was sumatriptan, which succeeded in toms began to decrease, and the small because, to our judgment, the previous aborting migraine attacks; however, an scotomas failed to enlarge to the point of one excessively increased the patient’s almost daily dose of the medicine was covering the entire visual field. TMJ and VDO, and we eliminated all tooth con- needed to control headache. masticatory muscle pain also subsided. tact other than the ones between the The presence of dental malocclu- During the second month, no more upper and lower , to maximally sion—more precisely, a reduction of the headache and aura symptoms occurred; reduce clenching activity.6 vertical dimension of occlusion (VDO) however, mild masseter muscle fatigue The results obtained were very posi- with evidence of a deep —made was occasionally present. At three- and tive. Both headache and aura symptoms a dentist provide the patient with a DOA six-month follow-ups, no recurrence of resolved, TMJ pain subsided completely, to use at night during sleep. The device headache and aura symptoms was reported and masseter muscle fatigue decreased had to be worn on the upper teeth, and it and TMJ pain was resolved, but there and became episodic with no further had even contact with all of the lower was still some masseter muscle fatigue need of treatment. teeth. The use of this appliance gradually present sporadically. No further treat- In light of the results of this single reduced the intensity and frequency of ment was proposed other than continuing case, correction of dental occlusion and migraine headaches, which ceased in a the use of the DOA at night during sleep. protection of the structures of the few weeks; nonetheless, aura attacks stomatognatic system from the stress of continued but were not followed by Discussion tooth clenching seems to be useful to headaches. The aura episodes started as The case showed how the use of a DOA eliminate migraine headache. previously described with the appearance at night during sleep was effective in Of course, no conclusions can be of small pulsating scintillating flashes, relieving both headache and aura symp- drawn from a single case; however, in the but then developed with the progressive toms in a period of two months. literature, similar cases have been reported. expansion of the flashes that proceeded The diagnosis of migraine with aura In the two studies of Lamey et al., with zigzag movements in a circle, de- had been made by several neurologists in migraine patients were treated by the limiting areas of black spots (scotomas) two different headache clinics in Italy, means of acrylic DOAs.3,5 In the first gradually enlarging, sometimes comprising and the clinical appearance seemed to study, 19 patients with migraine with the entire visual field, producing transient confirm that diagnosis. In fact, the criteria aura (classical migraine) with headache complete blindness of duration up to 40 of the International Headache Society1 attacks occurring more frequently on minutes. were fulfilled: The headache lasted for waking were selected.3 Therapy consisted At the time we first saw the patient, days if untreated; it was pulsating, of the use of a DOA to wear during sleep she also reported some masseter muscle severe, and caused avoidance of routine that produced a good clinical response fatigue and soreness on the right side, physical activity; it was associated with with considerable reduction of the inten- especially during mastication, and tem- nausea and, occasionally, vomiting, pho- sity and the frequency of the headaches. poromandibular joint dysfunction pain tophobia, and phonophobia. A visual The second study was carried out with a on the right side, exacerbated by aura was also present. To rule out the placebo-controlled design.5 Two different mandibular movements. She also reported presence of other disorders that might be appliances were made: an effective DOA nighttime tooth clenching. A reciprocal responsible for the headache and the with tooth coverage, and a placebo DOA click was palpated on the right TMJ dur- aura symptoms, investigations were per- without tooth coverage that only contacted ing opening and closing of the mouth, formed, including neurological and oph- the palatal mucosa. The placebo DOA suggesting anterior displacement of the thalmic evaluations, magnetic resonance did not produce any change in the sub- articular disc.7 Panoramic X-ray showed imaging of the head, and echo-color jects’ dental occlusion. Only migraine osteoarthrosis of both TMJs. Doppler of the carotid arteries, and the patients who used the DOA with tooth The old DOA that the patient was results were negative. Nonetheless, a coverage reported significant reduction of wearing at night increased the VDO by dental evaluation was not proposed in the number of headache attacks to about an amount that was considered exces- either of the headache clinics. 40 percent of that previously experienced. sive. Therefore, a new appliance was pre- The presence of made Intensity of headache was not evaluated. pared that moderately increased the a dentist decide to try a DOA to restore In a study by Quayle et al., 57 patient’s VDO, and the subject was the patient’s proper VDO, and nighttime patients suffering from different types of instructed to wear it every night during wearing of the device resolved her headaches were selected and treated with sleep; the new appliance also eliminated headache. We had the fortune to evaluate a soft DOA to wear at night during sleep.4 all tooth contacts other than the ones the patient after the headache was Among them, the subjects diagnosed with between the upper and lower incisors, to resolved, which is why although the migraine reported marked improvement maximally reduce clenching activity.6 diagnosis of migraine might have seemed or complete relief of headache symptoms; Additionally, serrapeptase, an antiede- correct, we decided to make a new DOA. on the other hand, subjects diagnosed mogenic medication, was prescribed to Another reason for the new device was with tension-type headache did not bene- reduce TMJ pain. the concomitant presence of TMJ pain, fit from the therapy. Unexpectedly,

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Forssell et al. describe the opposite out- the masticatory muscles in migraine Wastell D. Soft occlusal splint therapy in the come.2 They treated 35 patients with patients, which might be parafunctional treatment of migraine and other headaches. J Dentistry 1990;18:123-9. migraine, 36 patients with tension-type (tooth clenching) rather than functional. 5. Lamey PJ, Steele JG, Aitchinson T. Migraine: headache associated with pericranial ten- The mechanism through which the effect of acrylic appliance design on clinical derness (muscle contraction headache), tooth clenching could precipitate mi- response. British Dent J 1996;180:137-40. and 20 patients with both migraine and graine headache has not been demon- 6. Shankland WE. Migraine and tension-type tension-type headache (combination strated, but two hypotheses can be made: headache reduction through pericranial muscular suppression: a preliminary report. headache), performing occlusal adjust- Tooth clenching might be a trigger for J Craniomandib Pract 2001;19:269-78. ments to surfaces of the teeth. The exper- migraine attacks, increasing norepineph- 7. Okeson JP. Differential diagnosis and manage- iment consisted of a placebo-controlled rine release into muscle spindles and ment considerations of temporomandibular 6 disorders. In: Okeson JP, editor. Orofacial double-blind trial, where effective oc- vasoconstriction. If we accept the associ- pain: guidelines for assessment, diagnosis, clusal adjustment was carried out by ation between tooth clenching and and management. Chicago: Quintessence; adjusting the occlusal surfaces of the teeth stress,12-14 norepinephrine is also released 1996. p 113-84. to give bilateral simultaneous contacts by the adrenal cortex. These changes 8. Steele JG, Lamey PJ, Sharkey SW, Smith GM. Occlusal abnormalities, pericranial between the upper and lower teeth; con- stimulate the cervical sympathetic gan- muscle and joint tenderness and versely, placebo occlusal adjustment was glia to further produce norepinephrine, in a group of migraine patients. J Oral Rehab performed by adjusting the surface of the as supported by some animal studies.15-17 1991;18:453-8. teeth that do not come in contact with the Circulating and localized norepinephrine 9. Shankland WE. Nociceptive trigeminal inhibition-tension suppression system: a antagonist teeth, and therefore without would then generate headache, according method of preventing migraine and tension changing dental occlusion. Differently to Shankland6 and Anthony.18 headaches. Compend Contin Educ Dent from the Quayle study, Forssell et al. A second hypothesis is suggested 2002;23:105-8, 110, 112-13. found the frequency and intensity of by the fact that muscle soreness and 10. Lamey PJ, Burnett CA, Fartash L, Clifford TJ, McGovern JM. Migraine and masticatory headache was reduced in 79 percent and fatigue can produce not only localized muscle volume, bite force, and craniofacial 53 percent, respectively, of the patients but also referred pain.19,20 As thoroughly morphology. Headache 2001;41:49-56. affected by tension-type headache and described by Travell and Simons, such 11. Burnett CA, Fartash L, Murray B, Lamey PJ. Masseter and temporalis muscle EMG levels both migraine and tension-type head- pain can be frequently referred to the and bite force in migraineurs. Headache ache.4 No difference was detected head, giving headache, and the clinical 2000;40:813-7. between placebo and effective occlusal picture can mimic migraine headache.19 If 12. Okeson JP. Etiology of functional disturbances adjustment for migraine patients. this is true, the hypothesis is that muscle in the masticatory system. In: Okeson JP, editor. Management of temporomandibular Interestingly, abnormalities of dental fatigue caused by malocclusion and den- disorders and occlusion. 4th ed. St. Louis: occlusion were not more prevalent in mi- tal parafunction produced the secondary Mosby Year Book; 1998. p 149-79. graine patients, according to Steele et al., migraine. 13. Rugh JD, Solberg WK. Psychological implications but TMJ and masticatory muscle tender- In both cases, use of the DOA cor- in temporomandibular pain and dysfunction. In: Zarb GA, Carlsson GE, editors. Temporo- ness—together with tooth-clenching and rected the patient’s malocclusion, re- mandibular joint function and dysfunction. grinding habits—were found more fre- stored the correct VDO, and reduced Copenhagen: Munksgaard; 1979. p 255. quently in migraine patients, with two- tooth clenching, with the result of 14. Pingitore G, Chrobak V, Petrie J. The social 8 and psychologic factors of . thirds reporting dental parafunctions. decreasing masseter muscle fatigue and, J Prosthet Dent 1991;65:443-6. The hypothesis that dental parafunc- consequently, headache. 15. Modin MU, Pernow JAU, Lundberg JM. tion, especially tooth clenching, can be a Sympathetic regulation of skeletal muscle precipitating factor for migraine was Conclusion blood flow in the pig: a non-adrenergic 6,9 component likely to be mediated by neuro- proposed by Shankland, who reported The results reported in the literature and peptide Y. Acta Physiol Scand 1993;148:1-11. 62 percent reduction of migraine the outcome of the case described show 16. Dornyei G, Monos E, Kaley G, Koller A. episodes using a device fitting in the how primary migraine can be confused Myogenic responses of isolated rat skeletal upper incisors and contacting only the with migraine secondary to dental mal- muscle venule: modulation by norepinephrine and endothelium. Am J Physiol 1996;271 lower incisors, keeping the remaining occlusion and parafunction. For this rea- (1 Pt 2):H267-H272. teeth apart. Such a device had to be worn son, dental evaluation is always advised 17. Grassi C, Filippi GM, Passatore M. during sleep and had the intent of reduc- for headache diagnosis. ■ Postsynaptic alpha 1 and alpha 2 adrenoceptors ing muscular activity.6 Shankland’s mediating the action of the sympathetic system on muscle spindles in the rabbit. hypothesis seems to be confirmed by References Pharmacol Res Commun 1986;18:161-70. Lamey et al.’s findings that display how 1. Oleson J. The international classification of 18. Anthony M. Biochemical indices of sympa- headache disorders. 2nd ed. Cephalalgia thetic activity in migraine. Cephalalgia masseter and lateral pterygoid muscles 2004;24(Suppl 1):1-152. were 70 percent larger in migraine 1981;1:83-9. 2. Forssell H, Kirveskari P, Kangasniemi P. 19. Travell JG, Simons DG. Apropos of all patients compared with a control Changes in headache after treatment of muscles. In: Travell JG, Simons DG, editors. group.10 Also, maximal bite force and mandibular dysfunction. Cephalalgia Myofacial pain and dysfunction—the trigger 1985;5:229-36. EMG activity of the masseter and tempo- point manual. The upper extremities. 3. Lamey PJ, Barclay SC. Clinical effectiveness Baltimore: Williams & Wilkins; 1983. ralis muscles during maximum voluntary of occlusal splint therapy in patients with p 45-102. contractions were found to be signifi- classical migraine. Scottish Med J 1987; 20. Okeson JP. Pains of muscular origin. In: cantly higher in migraine patients.10,11 32:11-12. Okeson JP, editor. Bell’s orofacial pains. 4. Quayle AA, Gray RJ, Metcalfe RJ, Guthrie E, These findings suggest higher activity of Carol Stream: Quintessence;1995. p 259-94.

30 Journal of the Massachusetts Dental Society winter journal 2006.qxp 1/9/2006 12:27 PM Page 32 2005 Year In Another year has come and gone, and the Journal would Regional leadership like to take this opportunity to highlight some of the key forums held events of the past year for both the Massachusetts throughout Dental Society and the dental profession. state.

Voluntary amalgam separator program YDC 30 breaks CAPIR sponsors exceeds expectations records for statewide poster with more than 75 attendance. contest. percent of eligible dentists participating.

Give Dentistry a Try MDS hosts (dental auxiliary NEDLC in recruitment program) Boston. launches television campaign on Channel 5 in Boston.

Dr. Robert Faiella Dr. Andrea House of (left) becomes Richman elected Delegates MDS president, the MDS’s first approves 10 succeeding Dr. female vice resolutions. Alan DerKazarian. president.

MassDentists CARE children’s dental access program Journal of the Massachusetts launched. Dental Society is redesigned. MDS members respond to Hurricane Katrina.

Dr. Robert Faiella chairs Five MDS ADA reference committee members on Dental Access: The honored Dental Workforce and as 2005 makes presentation at the Volunteer ADA House of Delegates. MDS develops new Heroes. Yankee Dental Congress logo. winter journal 2006.qxp 1/9/2006 12:28 PM Page 33 In Review Winter 2005 Women’s leadership television public and networking awareness panel held. campaign begins on 12 TV stations statewide.

MDS nsors Dental FLOSSophy participates poster program launched on in Give Kids MDS Web site and in a Smile. Grants awarded for MDS programs a brochure. Mouths in All Tongues and Tips on Spit.

Third annual Fourth annual MDS Beacon Hill Foundation Golf Day held. Tournament is a success.

MDS creates of Dr. David Samuels new position MDS participates tes named General Chair of district in news conference es 10 of YDC 33, the first liaison with on Small Group ons. Yankee to be held at the hiring of Insurance bill. the new BCEC. Ellen Factor.

MDS Foundation announces more grants to dental Fall 2005 public awareness radio cam- hygiene schools. Delta Task Force continues its work. paign is broadcast on WEEI in Boston highlighting men’s dental health.

MDS announces MDS Foundation partnership with Procter holds its second & Gamble for the purchase annual Wine and of a mobile dental van as Chef event. part of the MassDentists CARE program. winter journal 2006.qxp 1/9/2006 12:28 PM Page 34

Predictors of Dental Implant Survival

THOMAS B. DODSON, DMD, MPH Dr. Dodson is an associate professor in the oral and maxillofacial surgery department at Harvard University School of Dental Medicine. He is also visiting oral and maxillofacial surgeon and director of the Fellowship in Clinical Investigation program in the department of oral and maxillofacial surgery at Massachusetts General Hospital in Boston.

Abstract Introduction PURPOSE—To summarize dental implant survival rates Since 2000, the author and his colleagues have had the privilege under a variety of clinical conditions and identify prog- and opportunity to review the clinical records of implant patients treated at the Implant Dentistry Centre in Boston. The nostic variables associated with implant survival. clinicians and staff provided free and unfettered access to these MATERIALS/METHODS—The articles reviewed in this records providing the data necessary to perform numerous out- paper were designed as retrospective cohort studies and come studies designed to estimate implant survival or complica- tion rates and identify prognostic factors associated with these composed of three subject cohorts having implants outcomes. These studies have been published as manuscripts1-7 placed between 1992 and 2003. The prognostic vari- or abstracts with the associated manuscripts currently under ables were categorized as demographic/health status, publication review8-11 or in progress.12 The specific aim of this anatomic, implant-specific, prosthetic, and perioperative/ paper was to review and summarize the key findings from the operative. The primary outcome variable was duration of above-referenced publications as they relate to prognostic fac- implant survival. Kaplan-Meier methods were used to tors associated with implant survival. estimate implant survival rates. Multivariate Cox propor- Materials/Methods tional hazards models were used to identify prognostic Study Design/Samples. All of the studies referenced in this article variables. were designed as retrospective cohort studies. The investigators enrolled and analyzed three different study cohorts derived RESULTS—During the study interval, 921 subjects had from the population of patients presenting to the Implant 2,996 implants placed. Implant survival rates at one year Dentistry Centre for the placement of one or more dental ranged from 90.3 percent for immediate-load implants implants between 1992 and 2003. to 96.2 percent for implants inserted into grafted sinuses. The largest cohort was composed of subjects who presented The five-year survivals ranged from 87.9 percent (sinus for implant placement between May 1992 and July 2000. This sample was used to estimate one- and five-year implant survival graft cases) to 91.2 percent (all implants). Frequently rates in subjects receiving dental implants, and to identify prog- cited prognostic variables included tobacco use and nostic factors associated with implant survival.7 A subsample of implant staging. Other prognostic variables identified this cohort was also used to ascertain the role of dentoalveolar included implant length, well size, implant coating, and reconstruction procedures (DRPs) and their relationship to timing of implant placement relative to tooth extraction. implant survival.6 Additionally, this cohort was used to under- stand better the role of maxillary sinus augmentation (MSA) CONCLUSION—Using implants to replace missing teeth procedures—i.e., external and internal sinus grafts with autoge- is a predictable procedure with five-year survival rates nous and allogeneic grafts—and their association with implant 8 approximating 90 percent. Some of the prognostic vari- survival. ables identified in these studies are under the control, at The second cohort was composed of subjects having ultra- short (6 x 5.7 mm) implants between January 1997 and June least to some degree, of the clinician and may be manip- 2002.9 This cohort was used to compare the one-year survival ulated to enhance implant survival. rates between ultrashort and standard-dimension implants. Prognostic factors, other than implant dimension, associated with survival were identified.

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The third cohort was composed of • Prosthetic variables: The main pros- Survival Analysis subjects having implants inserted and thetic variable for all of the cohorts The investigators recorded the following immediately loaded between July 2001 was type of prosthesis (fixed or information from each chart: date of and July 2003.10-12 This sample was used removable). For cohort of implants implant placement, dates of follow-up to estimate the one-year survival rates of immediately loaded, the investigators visits, and date of implant removal, if immediately loaded implants and to recorded the total number of units applicable. identify prognostic factors associated defined as the sum of implants, nat- Outcome variables. The primary with survival. ural teeth, and pontics making up outcome variable was implant survival. the temporary prosthesis. This vari- The time between implant placement and able was subdivided into three cate- Study Variables the date of the last follow-up or implant gories: the total number of natural Prognostic variables were grouped into failure, defined as implant removal, was teeth, the total number of pontic the following categories: units, and the total number of used to calculate the duration of implant • Demographic variables: These vari- implants. survival. ables included the patient’s age in Analyses. Descriptive statistics were • Perioperative or operative variables: years at the time of implant place- computed for all study variables. Non- These variables included antibiotic ment and the patient’s sex. parametric Kaplan-Meier survival analyses use, methods used to reconstruct the were used to compute the overall one- • Health-status variables: The investi- implant recipient site (DRPs—e.g., gators recorded current tobacco use internal or lateral sinus lifts, barrier year and five-year (if data were available) status and whether the subject had a membranes, autologous or allogenic survival rates with associated 95 percent medical condition affecting wound bone grafts), timing of implant confidence intervals. Covariates associated healing—e.g., diabetes, chronic placement relative to DRP (at the with survival were identified using inno- steroid use, or radiation therapy to time of or after the DRP), timing of vative Cox proportional hazards methods the head and neck. implant placement relative to the adjusted for clustered, correlated obser- • Anatomic variables: The anatomic tooth extraction (i.e., immediate or vations. Covariates with p-values <0.15 variables included implant location delayed), and timing of loading of and biologically important variables— (, , anterior, poste- the implants (i.e., immediate or i.e., age and sex—were considered candi- rior), dentition status (partially delayed). Implant staging was recorded date variables for inclusion in the multi- edentulous or edentulous), bone as two-stage, a delay between inser- variate Cox. quality (types 1 to 4), and implant tion and uncovering and placement relationship to other teeth or of the abutment, or one-stage, simul- Results implants. Bone quality was deter- taneous placement of the implant The studies cited in this paper include mined at the time of implant place- and abutment. subjects having implants inserted be- ment. The amount and appearance tween 1992 and 2003 using a variety of of bone in the flutes of the 3.5 mm ® Figure 1. Components of the Bicon techniques. In the study authored by reamer were evaluated following (Bicon, Inc., Boston, MA) implant Chuang et al., the sample was composed withdrawal of the reamer from the osteotomy. Type 1 classification was Implant well of 677 subjects having 2,349 implants used for cortical bone that was com- 2 or 3 mm in diameter between 1992 and 2000 under a variety pact and nearly bloodless; type 2 of clinical parameters, including grafted classification was used if the flutes and ungrafted sites, maxilla and were filled with red bone; type 3 mandible, and immediate insertion after classification was used for interme- extraction.7 Overall, the implant survival diate findings; and type 4 was used if rates, adjusted for clustered, correlated there was no bone in the flutes. observations, at one and five years were Implant relationship to other den- 95.4 percent and 91.2 percent, respec- toalveolar structures was grouped tively (see Table 1). into the following categories: num- In this cohort, four variables were ber of implants, number of root associated with implant survival: tobacco canal–treated teeth, number of teeth use, implant length, implant well size, and with periapical radiolucencies adja- staging of implant and abutment place- cent to the implant, and status of the ment (see Table 2). Nonsmokers had a implant site that was previously root 3.4-fold improvement in implant survival canal treated. when compared to tobacco users. Longer Implant • Implant fixture-specific variables: implants were associated with improved These variables included implant size survival, as were implants with larger (width 3.5–6 mm, length 5.7–11 mm), Restorative abutment (3 mm vs. 2 mm) well sizes. Implants that implant coating (uncoated, titanium were inserted, allowed to integrate, and plasma sprayed [TPS], and hydroxya- Diagram courtesy of Bicon, Inc., Boston, MA, then uncovered for abutment placement patite [HA]), and size of the implant amended by the author with permission. at a second operation (two-stage) had a well (2–3 mm). (See Figure 1.) fivefold increased chance of survival com-

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Table 1. Implant survival rates at 1 and 5 years after implant insertion. pared to implants in which the implants were inserted and abutments placed at Implant Sample Size 1-Year Survival p-Value 5-Year Survival p-Value one operation (one-stage). Finally, im- Reference Cohort (implants) Estimate1 (if indicated) Estimate1 (if indicated) plants inserted at some point after tooth extraction (delayed implants) were two Chuang et al.7 All implants 2,349 95.4 (94.2–96.6) N/A 91.2 (88.8–93.6) N/A times more likely to survive than implants placed at the time of tooth extraction Woo et al.6 DRP (yes)2 242 95.4 (92.6–98.2) 87.5 (76.5–98.5) (immediate implants). DRP (no) 435 95.1 (92.9–97.4) 0.9 91.1 (86.5–95.5) 0.9 In the second study, the investigators McDermott et al.8 MSA+ (yes) 473 96.2 (94.2–98.1) 87.9 (81.3–94.5) used the same study cohort described MSA- (no) 289 92.6 (89.3–95.2) 0.04 88.0 (82.8–93.1) 0.08 above to evaluate the effect of DRPs on 6 Gentile et al.9 6 x 5.7 mm4 45 92.2 (83.6–100.0) Not reported implant survival. To simplify statistical Non-6 x 5.7 mm 127 95.2 (91.1–99.3) 0.78 Not reported N/A analyses, without violating the assump- tion of independent observations, one 12 Chuang et al. Immediately 477 90.3 (86.9–93.7) 0.002 Not reported N/A implant was chosen randomly from each loaded implants5 Conventional implants 2,349 95.5 (94.6–96.2) Not reported subject for analysis. The subject and implant sample sizes were equal—i.e., 677. There were no statistically significant dif- ferences in the one- or five-year survival Table 2. Summary of the prognostic variables associated with implant survival adjusted rates between implants placed in recon- for confounders, biologically relevant variables, and clustered, correlated observations. structed sites when compared to unre- Reference Variable Statistics constructed sites (see Table 1). At one Hazard 95 Percent Category Specific Ratio Confidence Interval p-Value Table 1 and Table 2 Notes 1 Chuang et al. 7 Demographic Tobacco use (none) 3.4 2.0–5.9 <0.01 Point estimate of one- or five-year implant or health survival (95 percent confidence interval) adjusted for clustered, correlated observa- Implant-specific Implant length (mm) 1.4 1.3–1.7 <0.01 tions. Well size (3 mm vs. 2 mm) 2.5 1.3–5.0 <0.01 2DRP stands for dentoalveolar reconstruction procedures used to rehabilitate the implant Operative Staging (2- vs. 1-stage) 5.0 2.5–10 <0.01 recipient site—e.g., sinus grafting, barrier Immediate 2.0 1.2–3.5 0.01 membranes. DRP (yes) means that DRP (delayed implant insertion vs. insertion immediately following extraction) procedures were used. 3MSA stands for maxillary sinus augmentation 6 Woo et al. Demographic Tobacco use (none) 4.4 2.0–9.8 <0.001 (external or internal lift). MSA+ (yes) means or health that MSA was used to rehabilitate the implant Operative Dentoalveolar 1.4 0.7–2.9 0.32 recipient site. reconstructive procedure (no) 4Ultrashort implants. Staging 3.3 1.3–10.0 0.009 5Implants were inserted, restored, and an (2- vs. 1-stage) occlusal load placed on the restoration all on the same day. McDermott et al.8 Demographic Tobacco use (none) 3.5 1.7–7.2 <0.001 or health Note: One-year survivals ranged from 90.3 percent (immediately loaded implants) to 96.2 Anatomic Implant location 2.5 1.7–5.0 <0.001 percent for implants inserted into grafted (premolar vs. molar) sinuses. The five-year survivals ranged from 87.9 percent (MSA+) to 91.2 percent (all Operative Maxillary sinus 1.1 0.6–1.9 0.9 implants). augmentation (no graft vs. graft) 6 The model was adjusted for age, sex, Staging (2- vs. 1-stage) 10 3.3–14.3 <0.001 implant length, and prosthesis (fixed vs. removable). Gentile et al.9 Implant-specific Implant size 1.0 0.2–3.3 0.9 (non-6 x 5.7 mm vs. 6 x 5.7 mm) 7 The model to identify prognostic variables associated with implant survival were adjusted Operative Staging (2- vs. 1-stage) 5.0 See notes 0.049 for age, sex, position of implant in relation to Erakat et al.10 Implant-specific Coating 22.1 6.6–74.6 <0.001 other teeth or implants, and subject-specific (coated vs. uncoated) heterogeneous risk for implant failure. 8 The model was adjusted for age and sex. Operative Immediate 3.7 1.6–8.3 0.002 9 (immediate implant insertion after tooth extraction vs. delayed implant placement) The model was adjusted for age, sex, health status, and use of dentoalveolar reconstruc- Prosthetic Number of 1.8 1.3–2.5 <0.001 tive procedures. A confidence interval was restorative units not reported for implant staging because it was too unstable. Chuang et al.12 Implant-specific Implant length (mm) 1.3 Not reported in abstract <0.001 10 The model predicted implant survival for Anatomic Implant location 1.9 Not reported in abstract <0.001 immediately loaded implants and was ad- (mandible vs. maxilla) justed for age and sex. Operative Loading 2.9 Not reported in abstract 0.004 12 The model was adjusted for age, sex, well (delayed vs. immediate) size, and immediate implant placement.

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Using implants to replace missing teeth is a predictable procedure with success rates ranging from 85 percent to 96 percent implant survival with the highest, long-term success rates associated with implants managed using staged management protocols

year, the survival rates of the two groups smokers (p<0.001). Implants placed in the Erakat et al. estimated the one-year were nearly equal, 95 percent, and at five premolar region were 2.5 times more survival rate in a sample composed of years, the survival rate was 87.5 percent likely to survive than implants placed in subjects receiving immediately loaded in the DRP group and 91.1 percent the molar region (p<0.001). Finally, implants.10 The study was a retrospective (p=0.9) in the non-DRP group. implants placed in two stages were 10 cohort study composed of 209 subjects In this sample, two variables were times more likely to survive than implants having 477 implants inserted and loaded associated with implant survival: tobacco placed in the maxilla using a one-stage immediately with a functional, temporary use and implant staging (see Table 2). technique (p<0.001). prosthesis. The one-year survival rate, Nonsmokers had a 4.4-fold increased In the setting of atrophic alveolar adjusted for clustered observations, was likelihood for implant survival when bone, inserting ultrashort implants (<7 90.3 percent. The investigators identified compared to smokers. Subjects having mm in length) may be an alternative to three variables associated with implant sur- implants and abutments placed in a two- using DRPs. Gentile et al. compared the vival: implant coating, timing of implant stage manner were two times more likely survival rates of ultrashort implants (6 x insertion relative to tooth extraction, and to have their implants survive when com- 5.7 mm) to the survival rates of standard the number of restorative units. Coated pared to implants and abutments placed implants.9 The study was a retrospective implants had a 22.1-fold increased likeli- simultaneously (one-stage.) cohort study composed of 35 subjects hood for survival compared to uncoated The management of the atrophic having one or more ultrashort implants. implants (p<0.001). Implants placed imme- maxilla is particularly challenging. In the There were a total of 172 implants diately after tooth extraction were 3.7 study by McDermott et al., using the placed: 45 (26 percent) were ultrashort times more likely to survive than implants cohort described above, the investigators and the remaining 127 (74 percent) were placed at some time after tooth extraction wanted to assess the effect of grafting of standard implants. The one-year survival (p=0.002). The number of restored the maxillary sinus on implant survival.8 rates for the ultrashort and standard implants, relative to pontics, in the tem- The sample consisted of 318 subjects implants, adjusted for clustered observa- porary prosthesis was associated with having a total of 762 implants placed into tions, were 92.2 percent and 95.2 per- implant survival at one year (p<0.001). the posterior maxilla replacing either pre- cent, respectively (p=0.8). In the multi- Chuang et al. compared the one-year molar or molar teeth. The cohort was variate model, staging was associated survival rates between subjects with imme- divided into two groups, subjects with with implant survival. Consistent with diate-loaded implants and those with and without maxillary sinus augmen- the other studies, implants placed using implants loaded in a delayed manner.12 Im- tation (MSA), MSA-positive or MSA- two stages were five times more likely to plants loaded in a delayed manner had a negative, respectively. MSA consisted of survive than implants inserted using a statistically significant better one-year sur- external (lateral maxillary sinus augmen- one-stage technique. vival rate (95.5 percent) when compared tation with graft, either autogenous, allo- Traditionally, implants are not to immediate-load implants (90.3 per- genic, or both) or internal sinus lifts. The loaded during the osseointegration cent). In the multivariate model, implants one-year survival rates, adjusted for clus- phase of healing, necessarily delaying loaded in a delayed manner were 2.9 times tered observations, for MSA-positive and prosthetic restoration of the implant. more likely to survive than implants MSA-negative implants were 96.2 per- Needless to say, some patients may loaded immediately (p=0.004). The other cent and 92.6 percent, respectively. The object to this prolonged treatment variables associated with implant survival five-year survival rates, also adjusted for course. To address this patient-initiated were implant length and location. Longer clustered observations, were 87.9 percent demand for shorter treatment, clinicians implants were associated with improved and 88.0 percent for MSA-positive and have initiated innovative treatment pro- survival (p<0.001). Mandibular implants MSA-negative implants, respectively. tocols, including loading implants zero were 30 percent more likely to survive In the adjusted multivariate model, to three days after placement—i.e., than maxillary implants (p<0.001). there were no statistically significant dif- immediate load. Immediate loading of ferences (p=0.32) in implant survival implants not only shortens the treat- Discussion between implants placed into grafted and ment time, but also provides patients Two significant findings resulted from ungrafted sinuses. Three variables—to- with an acceptable esthetic appearance this set of studies. First, using implants to bacco use, implant location, and staging— during the treatment period. There is replace missing teeth is a predictable pro- were associated with implant survival. concern, however, that loading implants cedure with success rates ranging from Nonsmokers had a 3.5-fold improved immediately after insertion may de- 85 percent to 96 percent implant sur- implant survival rate when compared to crease implant survival rates. vival, with the highest, long-term success

Vol. 54/No. 4 Winter 2006 37 winter journal 2006.qxp 1/9/2006 12:28 PM Page 38

rates associated with implants managed one year. This finding suggests that the 6. Woo VV, Chuang SK, Daher S, Muftu A, using staged management protocols— best outcome may be associated with a Dodson TB. Dentoalveolar reconstructive procedures as a risk factor for implant failure. i.e., a delay between extraction and 1:1 ratio of restored implants to missing J Oral Maxillofac Surg 2004;62:773-80. implant insertion, between DRP and teeth and one should avoid using pontics 7. Chuang SK, Cai T, Douglass CW, Wei LJ, implant placement, between implant to replace teeth whenever possible. Dodson TB. Frailty approach for the analysis placement and uncovering, and between Contrary to the other studies, in the set- of clustered failure time observations in dental research. J Dent Res 2005;84:54-8. implant placement and loading. ting of immediate-load implants, imme- 8. McDermott NE, Chuang SK, Woo VV, Dodson Staged treatment protocols are asso- diate implant placement following tooth TB. Maxillary sinus augmentation as a risk ciated with the longest treatment time extraction was associated with an in- factor for implant failure. Abstract presented between extraction and restoration. In creased success rate. This unexpected at the 2003 Academy of Osseointegration, Boston, MA, February 2003. Manuscript an attempt to meet patient demand for finding merits further investigation. submitted for publication is under review. shorter treatment times, several alterna- The results from these studies should 9. Gentile MA, Chuang SK, Dodson TB. 6x6 mm tive protocols were developed—i.e., im- be generalized cautiously. As all of the implants: survival estimates and risk factors for failure. J Dent Res 2003; 82(Spec Iss A: mediate implant placement after tooth implants evaluated in this study were Abstr No 0873). Manuscript accepted for extraction or grafting, implant place- from one manufacturer, it is unclear publication by the Int J Oral Maxillofac ment and abutment insertion completed whether the results of these studies are Implant. simultaneously (one-stage), and immedi- applicable to other implant systems. 10. Erakat MS, Chuang SK, Yoo R., Weed M, Dodson TB. Immediate-load implants: survival ate loading of implants after placement. Demographic variables, such as tobacco estimates and risk factors for failure. J Oral While still quite successful in terms of use, may be generalized across implant Maxillofac Surg 2004;62(Suppl 1):38-9. survival, each of these alternative proto- systems. Implant-specific variables, such Manuscript submitted for publication is under review. cols was associated with an increased as coating, length, or well size, may not 11. Yoo RH, Chuang SK, Erakat MS, Weed M, risk for implant failure compared to con- be generalized to other systems. In addi- Dodson TB. Changes in crestal bone ventional treatment. When choosing tion, the clinicians involved with implant levels for immediately loaded implants. methods associated with shorter treat- placement and restoration are very expe- IADR/AADR/CADR 83rd General Session in Baltimore, MD. J Dent Res 2005;84(Spec Iss ment times, the clinician should discuss rienced, and clinical experience is associ- A: Abstract No 1494). Manuscript submitted for frankly with the patient the increased ated with implant success. ■ publication is under review. risk for failure, albeit small. 12. Chuang SK, Dodson, TB. Conventional versus immediate loading implants: survival analysis The second important finding from Acknowledgments and risk factors for dental implant failure. these studies is that there are a number The preparation of this manuscript was J Oral Maxillofac Surg 2005; 63(Suppl 1):35-6. of variables associated with prognosis supported by the Department of Oral Abstract accepted for presentation, manu- that are under the control, at least to and Maxillofacial Surgery Research script in progress. some degree, of the clinician. Tobacco Fund, Massachusetts General Hospital. use in three studies6-8 and implant staging The author thanks the other research in four studies6-9 were associated with collaborators in preparation of manu- survival rate. The clinician can encour- scripts and abstracts cited in this paper. age smokers to stop smoking before He would like to recognize the clinicians Focused on You. implant placement or defer placing and staff of the Implant Dentistry implants at all in tobacco users. Six other Centre, Boston, MA, for their coopera- Are you HIPAA compliant? variables (implant length, well size, coat- tion and the free and unfettered access to ing, timing of implant insertion relative their patient records. The April 2005 Security deadline has to tooth extraction, implant location, passed, but are you still struggling and number of restorative abutments) References with HIPAA compliance issues? Help were variably associated with implant 1. Chuang SK, Tian L, Wei LJ, Dodson TB. is on the way…the best-selling HIPAA Kaplan-Meier analysis of dental implant survival.6-10,12 Privacy and Security kits give you the survival: a strategy for estimating survival information you need to get the results As another example, the clinician with clustered observations. J Dent Res you want at a member rate. may elect to use DRP to increase the 2001;80:2,016-20. amount of available bone permitting 2. Chuang SK, Wei LJ, Douglass CW, Dodson Contact the ADA Catalog at TB. Risk factors for dental implant failure: a www.adacatalog.org or 800.947.4746 insertion of longer or wider implants. strategy for the analysis of clustered failure- The clinician can choose to use coated or time observations. J Dent Res 2002;81:572-7. to order yours today! uncoated implants. In the setting of 3. Chuang SK, Tian L, Wei LJ, Dodson TB. immediate-load implants, for example, Predicting dental implant survival by use of the marginal approach of the semi-parametric coating was an important predictor of survival methods for clustered observations. implant survival. Also, in the setting of J Dent Res 2002;81:851-5. immediate-load implants, the number of 4. Vehemente VA, Chuang SK, Dhaer S, Muftu A, Dodson TB. Risk factors affecting dental pontics in the temporary prosthesis was implant survival. J Oral Implantol 2002;28:74-81. associated with survival. Specifically, the 5. McDermott NE, Chuang SK, Woo VV, Dodson more restored implants—when com- TB. Complications of dental implants: identifi- pared to the number of pontics—the cation, frequency, and associated risk factors. Int J Oral Maxillofac Implant 2003;18:848-55. © 2005 American Dental Association. All rights reserved. more likely the implants will survive at

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40 Journal of the Massachusetts Dental Society winter journal 2006.qxp 1/9/2006 12:42 PM Page 41

n November 4, 2005, the State Room in Boston was the setting for a night of glamour, fun, and goodwill. The MDS Foundation Ohosted a Wine Tasting and Celebrity Chef Event with more than 160 attendees. This affair provided an elegant atmosphere for dentists, corporate executives from dental product and insurance companies, and their spouses to enjoy wines from different regions of Europe and the United States while overlooking the city lights of Boston. David Brown, meteorologist from WCVB-TV Channel 5, was also present to kick-off the Foundation’s 2nd Annual Giving Campaign. Dr. Alan K. DerKazarian was honored as being the first major donor in the amount of $10,000 to the Annual Giving Campaign. In addition to the wine tasting, guests were able to mingle through the candlelit room to taste food creations from six of Boston’s finest restaurants. Celebrity chefs from Aujourd’hui, JER-NE, Turner Fisheries, 29 Newbury, Aura, and Pepper’s were available to present some of their favorite recipes. A special thank you goes out to these fine chefs for donating their time and food to make this event possi- ble. A Hilton Head golf getaway, tour and tasting for 10 at Westport Rivers Winery, tickets to Wicked, Sullivan-Schein gift certificates, and a Four Seasons Hotel stay were just some of the prizes offered in the silent auction that evening. All proceeds benefited the MDS Foundation, which is dedicated to improving the oral healthcare of Massachusetts residents. This is just one of many fabulous events that the MDS Foundation will be hosting this year. Look for the MDS Foundation’s Casino Night on the Thursday night of YDC 31, immediately following the Opening Ceremony in the Sheraton Hotel. The following companies showed tremendous support of this event: Gentle Dental Associates, LLC; MDS Insurance Services, Inc.; Blue Cross Blue Shield of MA; LaVigne; EDIC; Dental Career Network; and UBS.

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Endoscopic Holography: A Minimally Invasive Oral Biopsy Technique

E. J. NEIBURGER, DDS Dr. Neiburger is a general practitioner in Waukegan, IL. He is vice president of the American Association of Forensic Dentists and past curator of anthropology at the Lake County Museum.

t is important to see the nature of the cells when diag- Endoscopic holography (endoholographic biopsy) is a new nosing oral lesions. This is often done microscopically technique that can overcome many disadvantages of traditional oral biopsy techniques.4,5 It utilizes laser holography, a photo- Iby removing lesions, either scraping individual cells graphic technique that will produce film images of in vivo lesions (cytology) or cutting out blocks of tissue (biopsy). The in any part of the mouth. No tissue is removed or damaged. This holographic image appears in 3D and, because of the monochro- problems encountered with these techniques involve the matic laser light and ultrahigh resolution film used, will possess patient’s discomfort, possibility of spreading a tumor sufficient resolution (3 microns) to be viewed microscopically.5 This will allow the dentist to examine real-life holographic (e.g., an incisional biopsy of malignant melanoma), images under the microscope and see the detail of actual cells delayed healing, and time required for the lab work photographed. (See Figures 1–3.) It is impossible to do this using (shipping of specimen, sectioning, staining, path review, standard white-light photography because of the inherent lack of adequate resolution, which is overcome by the laser hologram. etc.). Many dentists are hesitant to suggest biopsies of minor lesions because of the trauma, pain, and cost Equipment and Technique The holoendoscopic camera and film cassette is a small stainless incurred by the patient. steel tube, which is attached to a laser by an optical fiber and is The use of direct tissue examination using light pressed against the suspect lesion for an exposure, or photo (see Figures 1 and 2). The camera will produce a reflection hologram endoscopes, intraoral video, or macrophotography is of of the tissue in the single-beam Denisyuk configuration1,4,5 (see limited value because the poor resolution of the images Figure 3). The camera is withdrawn and the exposed film disk is removed, chemically developed, and examined under a stan- will not identify pathology on a cellular level.1-3 dard white-light microscope. The holoendoscope tube is 86 mm long and 10 mm in diameter. It has four parts (see Figure 2): 1. Film cartridge. The film used is standard sheet, holographic film (Agfa Holotest 8E75HD T3 or Geola PFG-03M), which is punched into 8 mm disks. This film has a high res- olution of 5,000 lines per millimeter. The disk is inserted into the cassette cartridge with the emulsion side facing away from the tissue. The film disk is the surface that touches the lesion upon laser exposure.1-3 After exposure, the film is removed, developed, washed, fixed, and bleached in a 5-minute developing process, and is then dried and examined.

42 Journal of the Massachusetts Dental Society winter journal 2006.qxp 1/9/2006 12:43 PM Page 43

Figure 1. Endoscopic holographic technique: four steps.

Figure 2. Schematic of a holographic endoscope.

2. Diaphragm. The holoendoscope fiber.1,5 This fiber-containing cable 1/1000 second is needed, yielding a tube has a diaphragm allowing for a can be of any reasonable length and fluence of 6 microjoules per square wide holoscopic aperture. This allows easy movement and place- centimeter.1,2 allows the formation of an image ment of the holoendoscope. with low speckle noises (marks) and 4. Laser. An Argon or Krypton CW Once exposed and developed, the 1,4,5 a high lateral resolution. laser with 30 mW of power holographic film can be viewed in white 3. Optical fiber. The laser energy that (Spectra Physics #164, 165) can be polarized light using a standard com- creates the hologram is transmitted used to supply the laser energy pound microscope with a 10X eyepiece to the holoendoscope through an (e.g., 514 nm) needed for exposure. and a 40X objective lens. This 400-power insulated 4 micron Corning optical An exposure time of 1/400 to magnification will allow the dentist to see

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The microscopic images are sufficiently detailed so that the clinician can clearly see the lesion’s cells and determine if pathology is present.

cells imprinted on the hologram at a sure) and easily loaded and developed. know of no commercial company that 3.36-micron resolution1,3 (see Figures 1 The exposure process is fast (a fraction supplies manufactured holoendoscopes and 3). of a second), so the patient is not incon- or precut disk film. These items, while Though not entirely necessary, venienced. It is easy to take multisite easy enough to make, must be created by superior holographic images can be holograms compared to the natural the practitioner. made on tissue that has been stained reluctance clinicians face in doing multi- prior to exposure. Good results have incisional biopsies on questionable Conclusion been achieved with a 30-second stain lesions. A new technique of intraoral biopsy is application using 0.2% aqueous Trypan As with anything, there are some described in which a small, tubular endo- Blue, Methylene Blue, Toluidine Blue, disadvantages. Though the holograms scope holding holographic film and con- Phloxine B, Rose Bengal, or Neutral have a large focal depth, this technique nected to a laser by an optical fiber cable Red stain.1,3,5 cannot see deep into the tissues. can create holograms of tissue/lesions Holograms of a few cells’ thickness are which possess such high resolution (3 Advantages/Disadvantages all that can be seen. Thus, as with cytol- microns) that they can be examined The holographic biopsy technique has ogy, deeper-lying tumors cannot be under a microscope. The microscopic many advantages over standard cytol- detected. The holographic equipment is images are sufficiently detailed so that ogy/biopsy practices. The holoendoscope initially expensive, especially for the the clinician can clearly see the lesion’s (camera) can be placed anywhere in the lasers, which may cost around $1,000, cells and determine if pathology is pres- oral cavity, especially in the pharynx and and the microscope, which may cost ent. This is done inexpensively, within the back of the tongue. It can provide a $500. Also, it is advised that you stain minutes, on-site, and without any sur- good image of the lesion’s cell structure the tissue for 30 seconds before taking gery or discomfort to the patient. In spite yet requires no anesthesia, painful cut- the hologram; this is a separate, though of the disadvantages, this technique ting, or pathology lab operations. It can quick, process. appears to present a useful alternative to be done on-site, immediately producing Additional disadvantages involve the biopsy. ■ good, permanent holograms of high res- need for a developing process (e.g., chem- olution and in three dimensions. The film icals, tank, dark room), safety glasses, and Acknowledgments process is inexpensive (pennies per expo- laser warning systems. At this time, I Special thanks to Andent Inc. and Dr. Hans Bjelkhagen for their assistance and permission to publish the accompanying illustrations.

References 1. Friedman M, Bjelkhagen H, Epstein M. Endoholography in medicine. J Laser Appl 1988 Fall:40-4. 2. Friedman M, Bjelkhagen H, Epstein M. A dye- scattering method for holoscopic endoscopy through optical fibers. 1988 Engineering in Medicine and Biology Society; 198. Proceedings of the Annual International Conference of the IEEE; November:120-30. 3. Bjelkhagen H. What is possible with holo- graphic endoscopy? Proc SPIE 1992;1647: 66-74. 4. Bains S. CCD captures holograms to image through tissue. Laser Focus World 1993;9:20-2. 5. Mehta P. Holographic techniques. 2004 Hololight Consultancy;11:1-12.

Figure 3. Photomicrograph of cells on a hologram as seen through a microscope (400X).

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Clinician’s Corner

A Clinico-Pathologic Correlation: Fibrous Dysplasia

MICHAEL A. KAHN, DDS MARIO LUCCA, DMD MARIA B. PAPAGEORGE, DMD, MS Dr. Kahn is associate professor of oral and maxillofacial pathology, Dr. Lucca is clinical instructor of oral and maxillofacial surgery, and Dr. Papageorge is professor and chair of oral and maxillofacial surgery at Tufts University School of Dental Medicine.

History

35-year-old white male presented to Tufts

University School of Dental Medicine after A evaluation at the New England Medical Center Emergency Department. The patient presented

with a chief complaint of jaw pain and left-sided facial

swelling. He reported the onset of his swelling nine days

before his presentation, with symptoms worsening in

the 24 hours prior to our examination. The patient’s his- Figure 1. Photograph of intraoral clinical presentation illustrating mass in left posterior-lateral vestibule. tory of present illness included a biopsy positive for a

fibro-osseous lesion to the left mandible in 1998. Our

patient had been noncompliant with follow-up related Clinical examination revealed our patient’s condition to be to these findings, and had not received treatment other generally stable and he was afebrile. Extraoral findings included swelling of the left mandible, paresthesia of the left inferior than a biopsy since that time. The patient’s past medical alveolar nerve distribution, and lymphadenopathy of the left submandibular. His intraoral examination revealed vestibular swelling adjacent to teeth numbers 18 and 19, and a significant history was otherwise nonsignificant. He reported taking buccal-to-lingual expansion was appreciated in this area (Figure 1). There were no significant changes in his mucosa. no medications; however, his social history was positive The teeth on the left side were slightly mobile and his occlusion was stable. for smoking tobacco (one pack per day for 21 years) but A panoramic radiograph revealed a mixed radiopaque and radiolucent lesion apical to the left first and second included no alcohol or recreational drug use. molars, extending posteriorly to the left ramus and anteriorly 48 Journal of the Massachusetts Dental Society winter journal 2006.qxp 1/9/2006 12:59 PM Page 49

to the left mental region. A large, well- by fibrous tissue and nonfunctional circumscribed radiolucency was also osseous structures.1 Fibrous dysplasia is appreciated apical to teeth numbers 18 a benign entity of unknown etiology. and 19 (Figure 2). An axial computed The alteration of bone involves a tomography view (bony window setting) fibrous transformation of medullary revealed a significantly expanded left bone, which undergoes a maturation mandible with a central radiolucency process into dense lamellar bone.1 This (Figure 3). process creates a bony expansion that is Biopsy of the left mandible and ex- responsible for the findings appreciated traction of teeth numbers 18 and 19 clinically. were performed under ambulatory gen- Fibrous dysplasia can affect one or Figure 2. Panoramic image of left mandible eral anesthesia. Purulent material was with well-circumscribed radiolucency apical many bones (monostotic or polystotic). expressed from this site with apical to teeth numbers 18 and 19. The mixed radio- The monostotic variant includes juvenile lucent and radiopaque area extends from the curettage. Apical tissue from teeth num- left ramus posteriorly to teeth numbers 27 and adult onsets, and the polystotic vari- bers 18 and 19, bone distal to number and 28 anteriorly. The condyle can not be ant may or may not be associated with appreciated in this view but is not infiltrated 18, and periosteum buccal to number 18 by the lesion. endocrine abnormalities and disorders were collected and submitted for histo- that present syndromically.1 Hyper- logical evaluation. parathyroidism and McCune-Albright syndrome are a few systemic examples; Differential Diagnosis however, they did not manifest in our Fibrous dysplasia patient. Central ossifying The monostotic variant of fibrous Odontogenic infection dysplasia most commonly involves the Diffuse sclerosing osteomyelitis jaws and accounts for 70 percent of all Cemento-osseous dysplasia cases.2 Fibrous dysplasia’s incidence is Paget’s disease twice as common in the maxilla than Malignant bone tumor the mandible, but is traditionally unilat- 2 Figure 3. Axial computed tomography (bony eral. This unilateral localization of the Histological Findings window setting) illustrating expansion of the lesion in the patient helps to eliminate Histological examination of the apical left mandible. cemento-osseous dysplasias such as tissue collected from teeth numbers 18 periapical cemento-osseous dysplasia and 19 revealed findings typical of a (PCD) and florrid cemento-osseous dys- and fibrocellular stroma plasia (FCD) from our differential. The consistent with a benign fibro-osseous radiographic manifestation of PCD is lesion. Periosteum collected from the primarily in the anterior mandible, and buccal area of number 18 was nonspecific FCD is most commonly a bilateral with chronic soft-tissue . process. Paget’s disease also presents Sections from bone distal to number 18 with a more comprehensive radiographic revealed vital bone with mature lamina- distribution and is not considered in tions and prominent osteoblastic rimming. this case. The accompanying stroma surrounding The radiographic features of the spicules of vital bone was highly cel- Figure 4. Low-magnification H&E-stained slide fibrous dysplasia are pronounced. The lular and fibro-osseous in character showing numerous spicules of bone and lesions present with an ill-defined osteoblastic rimming. The stroma is cellular (Figures 4 and 5). The specific shape of and fibro-osseous in character. periphery and irregular trabecular pat- the mature lamellar bone, with accompa- terns. The deposition of abnormal tra- nying fibrocellular stroma, strongly sug- beculae is consistent with the mixed gests a benign fibro-osseous process such radiopaque and radiolucent picture of as fibrous dysplasia. fibrous dysplasia. Early radiolucent lesions are gradually replaced by later Diagnosis radiopaque lesions as abnormal bone Fibrous dysplasia with a coincident peri- is proliferated.1 Traditionally, this radicular infection of teeth numbers 18 “abnormal” bone is described radi- and 19. ographically to have a “ground glass” appearance. Discussion With emphasis on the radiographic Fibrous dysplasia is a localized alter- manifestation, diffuse sclerosing osteo- ation of normal bone metabolism Figure 5. High-magnification H&E-stained myelitis, malignant bone tumor, and cen- slide showing osteoblastic activity and acute whereby bony architecture is replaced and chronic inflammation. tral ossifiying fibroma are considered in

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the differential diagnosis. But clinically, diffuse sclerosing diagnosis and early detection are important in all cases because osteomyelitis rarely exhibits expansion of bone other than that differing disease processes often present with similar radio- involving the periosteum, and late-stage osteomyelitis often graphic patterns but very often are treated by critically differ- exhibits histological sequestra.3 Although our patient did suffer ent methods.3 from an overlying periradicular infection of teeth 18 and 19, Lesions of fibrous dysplasia are self-limiting and growth his infection did not advance to the level of osteomyelitis. is limited primarily by pubertal and hormonal changes.2 Malignant bone tumor and other bone malignancies can also be Treatment is often provided to address cosmetic concerns and suspected radiographically but, again, are distinguished histo- functional disturbances. Surgery can involve continued conser- logically. No malignancy exists in our specimens. vative reduction or complete excision depending on the size of Central ossifying fibroma is radiographically and histolog- the lesion.1 ically similar to fibrous dysplasia, but differs in its detailed In our patient’s case, the lesion was locally aggressive, character. Both are benign with particular radio- affecting the left inferior alveolar nerve distribution, and the site lucent features. However, radiographically, central ossifying was secondarily infected. At the time of our patient’s presenta- fibroma does not present with ill-defined borders. The lesion is tion, his left condyle was not yet included in the lesion and typically encapsulated with a well-defined border.3 could be salvaged. Left mandible resection with immediate Clinically, fibrous dysplasia presents in the second reconstruction using bone harvested from the posterior iliac decade of life, while central ossifying fibroma is more com- crest was the recommended treatment for this patient. His post- mon in the third and fourth decades.3 Distinguishing operative course has been uneventful, and continued follow-up between these two lesions is important because treatment of and evaluation is ongoing. ■ central ossifying fibroma requires complete enucleation, while the treatment for fibrous dysplasia may be more con- servative.3 References 1. Sapp J, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial Conclusion pathology. Philadelphia: Mosby; 1997. 2. White S, Pharoah M. Oral radiology, principles, and interpretation. 4th ed. It is when all the histological and radiographic data are St. Louis: Mosby; 2000. observed collectively with the history that the findings in our 3. Singer S, Mupparapu M. Clinical and radiographic features of chronic monostotic case corroborate and suggest fibrous dysplasia. But careful fibrous dysplasia of the mandible. J Can Dent Assoc 2004 Sep;70(8):548-52.

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PATHOLOGY SNAPSHOT

GEORGE GALLAGHER, DMD, DMSC SADRU KABANI, DMD, MS VIKKI NOONAN, DMD, DMSC Dr. Gallagher is professor, Dr. Kabani is professor and director, and Dr. Noonan is assistant professor of oral and maxillofacial pathology at Boston University School of Dental Medicine.

ORAL LYMPHOEPITHELIAL CYST

Oral lymphoepithelial cyst: small, yellow-white nodule shown at the tonsillar fossa (left), the posterior lateral tongue border (center), and the floor of the mouth (right), respectively.

RISING IN LYMPHOID TISSUE OF THE ORAL AND PHARYNGEAL ful in the diagnosis of these cystic lesions. In most cases, oral lympho- Amucosa, the oral lymphoepithelial cyst typically presents as an epithelial tend to rupture spontaneously; however, for those asymptomatic yellow-white circumscribed nodular submucosal patients complaining of discomfort associated with the lesion or irri- mass rarely measuring greater than 5 mm in diameter. The oral tation likened to a “tickle in the throat,” excisional biopsy may be lymphoepithelial cyst commonly presents in the region of distri- indicated. bution of accessory lymphoid tissue (Waldeyer’s ring): the posterior Histologic examination reveals a cystic cavity lined by unre- lateral tongue border in the region of the foliate papilla, the markable stratified squamous epithelium surrounding a lumen that u. palatine tonsil, the anterior floor of the mouth, and occasionally may contain keratinous debris from desquamating lining epithelial on the soft palate. cells. A variable amount of lymphoid tissue is found within the The presence of characteristic delicate surface vascularity is help- cyst wall. ■

bers ts ing ific al CCDDAADD he to Dentist Well-Being Committee p l Dentists in recovery helping dentists with chemical dependency • Confidential support group meetings each month throughout the state • Private consultations available upon request • Confidentiality and anonymity guaranteed

Contact: PO Box 716, Andover, MA 01810 24-hour Hotline: (800) 468-2004 Visit: www.cdad.org d.

52 Journal of the Massachusetts Dental Society winter journal 2006.qxp 1/9/2006 1:05 PM Page 54

DENTAL EDUCATION

MELISSA CARMAN, MANAGING EDITOR Highlighting key events taking place in dental education in Massachusetts.

Massachusetts College of Pharmacy and dental medicine teachers. In addition to maintaining his private Health Sciences practice, Dr. McManama still directs 17 percent of the predoc- N AUGUST 29, 2005, MASSACHUSETTS COLLEGE OF PHARMACY toral curriculum, teaches in the BUSDM clinic, mentors students O and Health Sciences formally dedicated the new Esther M. and junior faculty, and lectures to professional organizations Wilkins Forsyth Dental Clinic, a state-of-the-art facility that will around the world. provide both students and faculty with some of the most Dr. Judith Jones, chair of the Department of General advanced technology in the country. The new clinic is located at Dentistry, nominated Dr. McManama for the Metcalf Cup. In the Palace Road entrance of the school. her nomination letter, Dr. Jones noted that Dr. McManama The clinic was named taught 17 percent of the predoctoral curriculum when she through a leadership gift made arrived at the school in 2001, and that “even with the workload by Dr. Esther M. Wilkins, a he carried, the quality of his teaching was and continues to be Forsyth Dental Hygiene superlative.” Program alumna and author, “This is a wonderful honor for both Carl and the School of whose textbook Clinical Practice Dental Medicine,” says Dr. Spencer N. Frankl, dean of BUSDM. of the Dental Hygienist is now in “Carl is a perfect example of what a teacher should be: knowl- preparation for a 10th edition. edgeable, dedicated, engaging, and compassionate.” ■ Among those taking part in the rib- bon cutting of the Esther M. Wilkins “The faculty, staff, and I Forsyth Dental Hygiene Clinic are have worked tirelessly with Harvard School of Dental Medicine Boston Mayor Thomas M. Menino N UNE ARVARD and Dr. Esther M. Wilkins, center. numerous individuals to get to J 10, 2005, H this point,” says Dr. W. Gail O School of Dental Medi- Barnes, program director of the Forsyth Dental Hygiene cine officially dedicated its Program. “We are so appreciative of the MCPHS administra- newly constructed Research tion for seeing the vision, and of Dr. Wilkins for her generosity.” and Education Building, which The facility features an appointed reception area with a had been under construction multimedia display offering the latest guidelines on oral health for two years. The six-level,

and early detection of oral disease; a clinical treatment area fea- 60,000-square-foot facility, Photograph courtesy of Rothman Architects.Anton Photograph Grassl. by Partners The new Research and Education turing 28 operatories equipped with state-of-the-art dental located at 188 Longwood Building at Harvard School of chairs, as well as computers and highly specialized software that Avenue in Boston, houses Dental Medicine. facilitate chairside periodontal charting; a 12-station dental HSDM departments, state-of- materials lab, equipped with a computerized instructor’s station; the-art laboratories, class- digital radiologic imaging and private imaging rooms; and pri- rooms, an auditorium, and vate offices for Forsyth faculty and a shared office for clinical common areas. The entire first instructors and supervising dentists, which enhance opportuni- level, a majority of the second ties for collaboration among students and faculty. level, and portions of the “The new clinic gives students and faculty the opportunity remaining levels are devoted to to familiarize ourselves with the latest dental technology,” says education, technology, and fac- Photograph by Steve Gilbert HSDM Dean R. Bruce Donoff speaks Dr. Barnes. “Once they graduate, it may be years before they are ulty offices. Levels three at the dedication of the new able to work in this type of environment again.” ■ through five house the 60,000-square-foot facility. Laboratories for Molecular Boston University School of Dental Medicine Dental Medicine, comprised of the Center for Research in OHN MCMANAMA, DDS, A GENERAL PRACTITIONER IN Craniofacial Development and Behavior; the Bone and Joint J Cambridge and a professor of general dentistry at Boston Disease Center; the Center for Mucosal Biology; and the Center University School of Dental Medicine, is the recipient of the 2005 for Biomaterials Science. Metcalf Cup and Prize for A main impetus for the new building, in addition to the Excellence in Teaching. The school’s continued growth, was to unite departments, students, Metcalf Cup is BU’s highest and faculty in state-of-the-art classrooms and research facilities teaching award and is awarded capable of supporting the latest in specialized research equip- based on the recommendations ment and technology. of alumni, faculty, and students. By design, the HSDM Research and Education Building Since 1976, Dr. McManama “fosters interdisciplinary and multidisciplinary learning and dis- has taught 31 courses to more Photo credit: Michael Hamilton/ BU covery,” said HSDM Dean R. Bruce Donoff in a speech at the Dr. John McManama receiving the than 4,300 dental students and Metcalf Cup and Prize. building’s dedication, “and gets us ever closer to creating an aca-

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Making A Big What is MassDentists CARE? MassDentists CARE (Combining Access with Reduced Expense) is a program to help Difference By children from income-eligible families receive quality dental care through volunteers of the Massachusetts Dental Society who agree to provide selected services at a reduced fee. Starting Small Who is eligible to participate? Low-income children through the age of 18 who do not have either dental insurance or MassHealth Dental coverage are eligible to participate. Once approved by the MDS, children can participate in the program for two years. After that, their parents/guardians must reapply for the program.

How do I become a MassDentists CARE provider? Members of the Massachusetts Dental Society can become a provider simply by filling out an enrollment form. For more information on the program and to access the enrollment form, log on to www.massdental.org and click on the Members Section. Or call the Massachusetts Dental Society at (800) 342-8747, extension 271, or email Andrea DeFeo at [email protected].

Combining Access with Reduced Expense

demic dental center where education, research, and patient care occur simultaneously, and inform and improve one another.” Additionally, to further integrate research and clinical train- ing in dental medicine, HSDM recruited four top scientists and clinicians for the Department of Oral and Developmental Biology and the Department of Restorative Dentistry and Biomaterials Sciences. ■

Tufts School of Dental Medicine Great Expressions Dental Centers has exciting opportunities for General Dentists, Endodontists, R. AIDEE HERMAN, ASSOCIATE CLINI- Periodontists, Orthodontists and Oral Surgeons. We cal professor of periodontology at D are looking for highly motivated practitioners to join Tufts University School of Dental our team in Michigan, Ohio, Virginia, Georgia, Medicine, has been named an ambassador Florida, Massachusetts and Connecticut. GEDC for the National Health Service Corps provides our associates with an excellent practice (NHSC). The NHSC brings together cli- environment and rewards them with a comprehensive nicians to provide primary healthcare to compensation package along with medical insurance, life insurance, malpractice insurance, paid vacations, adults and children in the communities 401(k) and reimbursement for continuing education of greatest need across the United States. and membership dues; relocation assistance available. Dr. Herman was selected because, GEDC has grown into one of the largest private according to the NHSC, she is a “role providers of dental care in the United States and has Dr. Aidee Herman named model for students and a valuable been “Exceeding Patient Expectations” for over 20 NHSC ambassador. resource with knowledge of the commu- years. Contact Vicki Gorlitz @ (248) 203-1118, or nity, relationships with students and NHSC scholars, and the email [email protected]. Please visit our website at www.greatexpressions.com for reputation as a leader in primary care on campus.” additional information! Also, Fizza Jafry, a student at Tufts University School of Dental Medicine (Class of 2006), has been named a Boston Schweitzer Fellow for 2005–2006. Fellows commit to a year of service with a community agency, and design and implement health-related com- Take Advantage of the munity outreach projects. Jafry will expand Project CORRECT MDS Discount! (Child Oral Rehabilitation Residential Education Counseling and Based on the combined buying power of the membership, the Therapy) at the Franciscan Children’s Hospital to include the MDS has secured a variety of business discounts for you to take Kennedy Hope Academy, a unit for autistic and/or mentally advantage of. When contacting a vendor for a service, be sure to ask for your “MDS Discount.”A full list of MDS business services delayed residents. Currently, Project CORRECT serves one unit at is available at www.massdental.org. the hospital, the Residential Assessment Program. ■

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TECHNOLOGY TODAY

PAUL FEUERSTEIN, DMD Dr. Feuerstein is technology editor of Dental Economics and a general practitioner in North Billerica. He can be contacted by emailing [email protected] or by visiting www.computersindentistry.com. EXTREME OFFICE MAKEOVER

HE PROLIFERATION OF DENTAL TECHNOLOGY PRODUCTS HAS Offices have had to remove banks of drawers to get all of this introduced a new problem for most practitioners: equipment in comfortably and so that it’s easily accessible. T Where do you put all this stuff? The initial With the advent of new devices with USB con- thrust was to put it all at the front desk, but more nections, the seemingly simple setup can become a and more practitioners are placing an increasing nightmare if you are trying to plug into the back number of items right in the treatment rooms. of a computer that is tucked away. Luckily, The front desk areas have been retrofitted there are inexpensive USB hubs that can be to house computers and monitors. Typically, mounted in a more convenient location. there is some space under most front coun- They usually can accommodate four devices ters to fit a computer or two. A private office and have a long connection cord, which can or consult room appears to be the logical— wind its way to the remote computer. If the although not the best—place for the server computers are older, they may still have and hub. One novel place for these compo- USB1 inputs, which run the new equipment at nents is the old darkroom, if you have gone dig- a snail’s pace. For the frugal office that does not ital. The room usually has at least one fan and want to change computers, a USB2 card can be room for a person to move around. If it is used as purchased and installed for about $30. “computer central,” the fans and/or ventilation system Digital X-ray sensors pose a new problem. should be upgraded because computers give off a lot of heat They have long attached wires and are just begging for a and, with multiple fans, noise. Hubs, servers, central stereo, storage place other than a hook on the wall. Some of the newer phone system, DSL/cable modems, and more can all coexist nicely systems plug right into the X-ray head, which has been retrofit- in this little room. ted with cables. A nice solution is to put the sensors in a cabinet It is essential that there be at least one or two dedicated elec- drawer with a hole cut in the back panel, which allows the wires trical circuits in the room, along with a grouping of battery back- to feed out the back. The drawer can be pulled open, the sensor ups to keep things going in the event of the all-too-common New taken out (with an area in that same drawer for barriers) and England power failure. You can actually invest in a commercial shut back in after use, out of the way. uninterruptible power supply, as well as surge protection to the Monitors pose a more complex issue, especially if the office has whole room, set up at the service box. Backup disks, drives, and decided to run two monitors in the room—in front of and behind tapes can be used but not stored in this area. Many offices mis- the patient. A variety of mounts are available, allowing fixation to takenly set up shelves for the old backups right in this room for walls, ceilings, and existing light poles. Still, the connecting wires the convenience, but those backups should be kept off-site. The will have to be snaked around to accommodate this design. The exception is if there are “redundant” backups: a copy can stay in ultimate solution is to replace the old cabinets and, in some cases, the room in the event of a small disaster that just needs to go chairs with new models. Almost all new units have monitor wiring back to the previous set, just to get up and running. and mounts built in. There is a place for the CPU that is easy to With the cost of flat screens dropping, there is no reason to access, is well ventilated, and has conduits to run the cables as well take up valuable front desk real estate with an old CRT monitor. as extra electrical outlets. There are handpiece hangers that accom- High-quality screens are available in computer stores as well as modate intraoral cameras and will, in fact, activate the monitor and at retailers such as Wal-Mart and Target at prices sometimes viewing software when the camera is lifted from the unit. below $200. You do not need high-end graphics at the front It may be necessary to do a bit of remodeling in order to desk—only in the areas that will require diagnostic quality. And incorporate all of these technologies. The doctor and staff should the staff will love the extra room on the desktop. spend some time sitting in operator and patient positions, and The treatment rooms were originally configured to house walk through the workflow of the various pieces of equipment. tubs, trays, and assorted instruments. All of a sudden, you needed They can then figure out the best locations and determine if a a place for the curing light and light source for loupes. When retrofit is possible, or if it is time to look at the available cabi- intraoral cameras arrived, if you didn’t have a cart-based system, netry. We all tend to remodel our homes—repaint, repaper, and you had to find counter space for the box and, of course, the TV put in new cabinets—more often than the offices that we spend or computer monitor. Where can you put a computer in the treat- most of our waking hours in and that have far more traffic flow. ment room? Under a sink where it can get ruined with a leak? Sit back, take a look around, and enjoy the tax credits. ■

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BOOK REVIEWS NORMAN BECKER, DDS, EDITOR EMERITUS

Oral and Maxillofacial Trauma, Third Edition to treatment, as well as the new equipment and materials, have RAYMOND J. FONSECA, ROBERT V. WALKER, resulted in a need to rewrite and update this third edition of NORMAN J. BETTS, H. DEXTER BARBER, .” AND MICHAEL P. POWERS The opening chapters outline the biological basis of Elsevier Saunders Publishers endodontics as it is understood today, and the remaining chap- ters describe the techniques and materials currently used. Topics he editors, in order to update those covered in this valuable textbook include biological and clinical T areas where the body of knowledge rationale for therapy and treatment; patient assessment; has changed or where new areas have ; treatment options; pre-endodontic management; evolved, have utilized the expertise of root canal morphology; root canal system preparation; intra- chapter contributors to accomplish that canal medication and temporary seal; root canal system obtura- goal for this third-edition textbook. tion; endoperio interface; surgical endodontics; management The text maintains the basic format of acute problems; tooth resorption; root canal retreatment; of the first two editions, with four sec- restoration of the root-treated tooth; endodontic treatment of tions covering the various types of trauma. primary teeth; and ways to reduce the risk of legal action in Part One, “Basic Principles in the endodontics. Management of Trauma Injury,” covers Each of these topics is presented well, with clear photographs metabolic responses, surgical nutrition, and the healing of and updated information, as well as alternative approaches. An traumatic wounds. Part Two, “Systemic Evaluation of the added feature is the individual color-coding of each chapter, Traumatized Patient,” includes discussion of emergency and which adds to the ease of finding the various topics. intensive care, airway management, nonpenetrating chest trauma, All in all, the contributors have been very thorough in their and shock. Chapters on the evaluation and management of presentation of new medicaments of the future as well as the the major organ systems include neurological, abdominal, comparison of the mechanical approach. urologic, and orthopedic , which can be affected by the trauma. Part Three, “Management of Head and Neck Injuries,” fea- Clinical Success in Early tures a “state-of-the-art” chapter on applied surgical anatomy Orthodontic Treatment and includes essential reading devoted to clinical and radio- ANTONIO PATTI AND graphic evaluation of traumatic head and neck injuries. GUY PERRIER D’ARC Chapters on diagnosis and treatment of all kinds of fractures Quintessence Publishing and the comprehensive management of soft-tissue injuries are also included. s a general practitioner who is de- Finally, Part Four, “Special Consideration in the A pendent on referrals to properly Management of Traumatic Injuries,” covers such topics as guide my patients, I found this an inter- firearm and burn injuries, specific considerations for the geri- esting book to review. The fact that atric patient, as well as prosthetics, biomaterials, and recon- Dr. Robert M. Ricketts, the father of structive procedures needed to repair traumatic defects. “bioprogressive ,” was named as one of the people The editors present the materials in two volumes, each of to whom this book was dedicated alerted me to the fact that the which is well illustrated and expertly presented. Although the debate between the philosophies of early treatment and the ide- content is of primary value to maxillofacial surgeons, the mate- ology of those practitioners who wait until second molars and rial can be appreciated by all practitioners. all premolars are present was to be presented. Along with the photographs and drawings, the text was of great value in helping me understand the philosophy promoted by Endodontics, Third Edition the “early intervention” school. But of greater significance to CHRISTOPHER J. R. STOCK, KISHOR me, it helped me better understand the construction and funda- GULABIVALA, AND RICHARD T. mentals of the various appliances used in orthodontia. WALKER As a nonorthodontist, I couldn’t weigh in on the deci- Elsevier Mosby Publishers sion about when to start treatment since our referrals are sent to those practitioners who have previously treated our n the preface, the editors state, “The patients. However, the text did stimulate me to discuss the I principles of endodontic therapy have philosophy and rationale of care with the practitioners to not changed greatly. Modern approaches whom we refer. ■

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FINAL THOUGHTS

ROBERT A. FAIELLA, DMD, MMSC Dr. Faiella is president of the Massachusetts Dental Society. He maintains private periodontics practices in Osterville and Duxbury.

ACCESS TO ORAL HEALTHCARE AS A MORAL IMPERATIVE

HE ISSUE OF ACCESS TO HEALTH SERVICES, AND SPECIFICALLY Another barrier is the lack of oral health literacy regarding access to oral healthcare, has been a point of debate in the utilization of services. Underserved populations may suffer T recent years, primarily because of the complexity of de- further from the inability to interpret their need for care. fining the problem. The ideology of access would allow for the Awareness programs must be developed to increase the oral provision of care to all who need it by a workforce dedicated to health literacy of those in need and to determine the impact of the task without the constraints of a business model, and funded literacy on utilization of available services. by social programs that are fair to both the recipients and the Ultimately, however, the biggest barrier to the success of care providers. The solution to the access issue may lie not in any access program is its dependency on funding. Dr. James what we need to do—because we know what we need to do— Mongan, president and CEO of Partners HealthCare, has stated but rather in identifying the barriers that a frank discussion of funding for access must begin with that prevent us from doing it. a discussion about values. Whether in the form of taxes or One such barrier exists with- employer mandates (which are, in effect, another form of taxes), in the dental workforce itself. providing access to care costs money. And after 30 years in the Those parties interested in stak- battle for broader health insurance, Dr. Mongan is convinced ing a claim within the access that the debate over access is more about values than it is about issue tend to develop agendas specific plans. The theory, he explains, is that as we moved from outside traditional delivery the social improvements of the postwar era in the 1940s, we systems, to the exclusion evolved into a more affluent, consumer nation with more of a of others in the workforce. focus on individual needs. The need to cut taxes as political While it is understandable benefit became more important than supporting programs for that the entry point to the the greater good. Hence, social justice issues—and the values access system cannot be behind them—have been put aside. at the highest level of The Massachusetts Dental Society has developed access education by provider, models to articulate the moral imperative we have as a profes- the coordination of care sion to provide for the public health. Yet we all understand that and interaction within these charity programs can never substitute for a true solution the workforce must be to the access problem. They are, however, an expression of our transparent and inclu- values toward society. sive, in order to ensure In Massachusetts, the debate on healthcare access is about the best outcomes for the to take center stage on Beacon Hill, with at least three options patients. The educational to be presented to the legislature. Ultimately, the prevailing system and licensure communities would require not only a commitment to participation and must work to develop this funding, but also a commitment to social justice. The members coordination by allowing the of the legislature must keep their promise to those who elected expansion of the workforce them by funding programs that are fair to both the underserved within the context of delivery and the providers of care. In doing so, dental professionals in systems that protect patient Massachusetts will be in a better position to honor our commit- interests. ment to our values, and to society. ■

64 Journal of the Massachusetts Dental Society