September 2017 Cannabis and Periodontal Health Oral Lichen Planus and Dairy Allergy Pre-Eruptive Resorption and JournaCALIFORNIA DENTAL ASSOCIATION DiGeorge Syndrome

Consumption of Cannabis and Effects on Periodontal Oral Health Changing employment laws and a litigation-conscious public can intimidate the most confident dentists. Especially when practice employees are prepared to take legal action if they feel an employer breached their rights. With insights from Employment Practice Liability claims experience and calls to our Risk Management Advice Line, TDIC’s seminar shows how to best handle employment concerns. Gain the caution and control to navigate past potential violations such as pregnancy discrimination, termination and sexual harassment.* Get expert advice while earning C.E. credits and a 5% Professional Liability premium discount for two years. Even better, take the seminar online at your convenience.

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DEPARTMENTS

461 The Associate Editor/Baby Teeth Matter

463 Impressions

469 Winners of the 2017 Table Clinic Competition

495 RM Matters/Informed Consent: More Than Just a Form

499 Regulatory Compliance/What You Need To Know To Conduct a HIPAA Risk Analysis 506 Tech Trends 463

FEATURES 475 Consumption of Cannabis and Effects on Periodontal Oral Health Periodontal disease is only one health condition among many that can be affected by marijuana in terms of incidence, prevalence and manifestation. Further medical study will allow for better policy in regards to marijuana that may affect the population as a whole. Suellan Go Yao, DMD, and James Burke Fine, DMD

483 Oral Lichen Planus Flares Triggered by Cow’s Milk in a Patient With Elevated IgE Antibodies to Milk Because dairy elimination is feasible for most patients and the role of laboratory testing is unclear, at this time it is reasonable to try dairy elimination as an early step in management of patients with lichen planus. Nita Chainani-Wu, DMD, MS, PhD; Anuradha Nayudu, BDS; and Daniel Purnell, BA, MPH

489 Pre-Eruptive Resorption in a Patient With DiGeorge Syndrome This case report details a patient with concomitant DiGeorge syndrome and pre-eruptive resorption. Tory Silvestrin, DDS, MSD, MSHPE; Nasser Said Al Naief, DDS, MS; Dezhi Wang, MD, HTL, QIHC; and Leif K. Bakland, DDS

SEPTEMBER 2017 459 CDA JOURNAL, VOL 45, Nº9

Volume 45, Number 9 JournaCALIFORNIA DENTAL ASSOCIATION September 2017 CDA Classifieds.

Free postings. published by the Editorial Upcoming Topics Letters to the Editor California Kerry K. Carney, DDS, CDE October/Biofi lms www.editorialmanager. EDITOR-IN-CHIEF Priceless results. Dental Association November/Student Research com/jcaldentassoc 1201 K St., 14th Floor [email protected] December/Silver Diamine Sacramento, CA 95814 Ruchi K. Sahota, DDS, CDE Fluoride Subscriptions 800.232.7645 ASSOCIATE EDITOR Subscriptions are available cda.org Advertising only to active members of Brian K. Shue, DDS, CDE the Association. The CDA Offi cers ASSOCIATE EDITOR Sue Gardner subscription rate is $18 and ADVERTISING SALES is included in membership Clelan G. Ehrler, DDS [email protected] PRESIDENT Andrea LaMattina, CDE dues. Nonmembers can PUBLICATIONS MANAGER 916.554.4952 [email protected] view the publication online at cda.org/journal. Natasha A. Lee, DDS Courtney Grant Permission and SENIOR COMMUNICATIONS Manage your subscription PRESIDENT-ELECT Reprints [email protected] SPECIALIST online: go to cda.org, log in Andrea LaMattina, CDE and update any changes to PUBLICATIONS MANAGER Kristi Parker Johnson your mailing information. R. Del Brunner, DDS [email protected] VICE PRESIDENT EDITORIAL SPECIALIST Email questions or other 916.554.5950 [email protected] changes to membership@ Blake Ellington cda.org. TECH TRENDS EDITOR Richard J. Nagy, DDS Manuscript SECRETARY Submissions [email protected] Jack F. Conley, DDS EDITOR EMERITUS www.editorialmanager. com/jcaldentassoc Kevin M. Keating, DDS, MS TREASURER Robert E. Horseman, DDS HUMORIST EMERITUS [email protected] CDA classifiedsclassifieds wworkork harder to Stay Connected cda.org/journal bbringring you resuresults.lts. SeSellinglling a practice Craig S. Yarborough, DDS, Production MBA SPEAKER OF THE HOUSE Val B. Mina or a piece ooff equipment? Now you SENIOR GRAPHIC DESIGNER [email protected] can include photos to help buyers Go Digital cda.org/apps Kenneth G. Wallis, DDS Randi Taylor see the potential. IMMEDIATE PAST PRESIDENT SENIOR GRAPHIC DESIGNER Look for this symbol, noting additional video [email protected] content in the ePub version of the Journal. And if you’re hiring, candidates anywhere can apply right from Management Peter A. DuBois the site. Looking for a job? You can EXECUTIVE DIRECTOR post that, too. And the best part— Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the Jennifer George California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. it’s free to all CDA members. CHIEF MARKETING OFFICER Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. Carrie E. Gordon All of these features are designed to CHIEF STRATEGY OFFICER The California Dental Association holds the copyright for all articles and artwork published herein. The Journal of the California Dental Association is published under the supervision of help you get the results you need, CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for Alicia Malaby any expression of opinion or statement of fact, all of which are published solely on the authority faster than ever. Check it out for COMMUNICATIONS DIRECTOR of the author whose name is indicated. The association reserves the right to illustrate, reduce, yourself at cda.org/classifieds. revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal.

Copyright 2017 by the California Dental Association. All rights reserved.

460 SEPTEMBER 2017 Assoc. Editor CDA JOURNAL, VOL 45, Nº9

Baby Teeth Matter Ruchi K. Sahota, DDS, CDE

hat an amazing day! Everyone in the offi ce was smiling What was the most common reason? molar to molar as The answer from most of the parents was, our offi ce screened Wmore than 200 preschoolers. The children “Baby teeth will eventually fall out.” and their families lined our parking lot almost an hour before our offi ce opened. Teachers came and joined as well. Parents came and were a part of each patient’s awareness? Are parents aware that from mere cells. Yet, many of our appointment. And almost all of them had the single reason most children miss neighbors do not realize that baby smiles too! Of course, the preschoolers school in California is tooth pain? teeth are just as important to brush, mostly high-fi ved and grinned looking Could insurance coverage be another fl oss and save as adult teeth! I know. down at the goody bags they were awarded reason? How many of our children Let us all release another collective at the end of their appointments. have public or private dental benefi ts? sigh. I am preaching to the choir. We have been teaming up with the We checked off the urgent-care- But there may be hope on the local Fremont Unifi ed School District needed (pain, infection, swelling or soft horizon. It is an exciting time. There is for more than 25 years to, in many tissue lesions) box on the oral health a new sheriff in town. Jayanth Kumar, cases, introduce 3-year-olds and their assessment plan many times today. We DDS, MPH, is our state’s new dental parents to the idea of a dental home. asked the parents why these children director. It has been decades since Our offi ce has become a part of the had not been to the dentist. All of the California had a dentist as our state curriculum for these preschool classes. children knew where a dentist offi ce dental director, so in fact it is more For a few weeks before the visit to our was located near their home. Many of accurate to say that we fi nally have offi ce, the teachers review oral health the parents had taken their children a dentist-in-chief who can manage, education with the students. That way once or twice, just not recently. Most direct and oversee administration the concept of Dr. Nijjar and Dr. Ruchi of the children had at least one parent of our state’s dental health. He has “counting” their teeth is not foreign who was working and/or had been to committed to help promote healthy to the kids. But often the concept college. Most of the parents admitted habits, increase utilization of dental of the children visiting the dentist that their children had at one time services, support prevention and regularly is foreign to the parent/ complained about a tooth issue or early dental treatment, ensure better grandparent/guardian/caregiver who toothache. And fi nally,all of the education for the public, dentists and accompanies the children to our offi ce. children had public and private dental those who make decisions regarding Sure enough, the facts personify this benefi ts. Insurance was not the issue. dentistry in our state, and fi nally survey as well. Over a third of the children in Almost all of the parents of the and measure the progress of these our state are not going to the dentist. children who needed urgent care key indicators and the dental health We often estimate various reasons. had not taken their children to of our state. Dr. Kumar elaborated Could it be because of geographic the dentist recently. What was the on these goals at this year’s CDA location? Is the dentist offi ce too far most common reason? The answer Leadership Conference and noted the from the family’s house or the child’s from most of the parents was, “Baby initiatives that dentists are getting school? Could another reason be teeth will eventually fall out.” Let involved with throughout California. socioeconomic status? What role does us all release a collective … sigh. One such program is California’s income, education and occupation It is 2017. Our iPhones can talk Department of Health Care Services’ play in a parent’s decision to take or to us, listen to us and perform various Dental Transformation Initiative. not to take their child to the dentist? functions for us. There are self- The intent is to determine what will Could another reason be oral health driving cars. We are growing sheep help more children to be seen by the

SEPTEMBER 2017 461 SEPT. 2017 ASSOC. EDITOR

CDA JOURNAL, VOL 45, Nº9

dentist. To do this, the federal Center coordinate “tooth talks” in schools. The Journal welcomes letters for Medicare and Medicaid Services So many travel abroad to carry out We reserve the right to edit all (CMS) granted $740 million over dental missions. We CDA dentists communications. Letters should discuss an fi ve years to California to improve give back and do as much as we can item published in the Journal within the last its program. More caries assessments to help bring the importance of dental two months or matters of general interest are being completed and more data is education and care to our communities. to our readership. Letters must be no more being collected. Dentists who educate, In fact, screening 200 preschoolers than 500 words and cite no more than fi ve entice or convince parents to return was no easy task for the doctors in references. No illustrations will be accepted. for continuous recall visits to establish our offi ce or for our staff colleagues. Letters should be submitted at editorialmanager. a dental home will receive bonus But everyone agreed it was one of com/jcaldentassoc. By sending the letter, the reimbursements. And fi nally, local pilot the more fulfi lling days that week. author certifi es that neither the letter nor one projects (i.e., innovative ventures to Our team really enjoyed giving back. with substantially similar content under the prevent disease and increase needed Contributing to positive change writer’s authorship has been published or is being care) have been funded to help mend and development of the community considered for publication elsewhere, and the other impediments that could keep can improve staff morale and author acknowledges and agrees that the letter children at risk from needing the engagement. As a general note, we and all rights with regard to the letter become the “urgent care needed” box marked on know that millennials prefer working property of CDA. their oral health assessment form. In for an employer who prioritizes fact, my community’s own FQHC’s philanthropy — sometimes so much dental director is eager to start using so that they would be willing to earn the allotted funding to help alleviate less if they feel they are working for the barriers that keep patients from an offi ce that truly gives back. utilizing their dental services. But maybe some of us have been The intent is to drive families involved in some of these outreach efforts to the dental offi ce by focusing on at some time. With a dental director “high-value care, improved access and at the helm of our state’s dental plan, utilization of performance measures there will be many more opportunities to drive delivery system reform.” The to become involved. How will we program focuses on “caries assessment, know how to do so? The oral health prevention and enticing the critical departments will team up with the local factor of continuity of care.” dental societies. So reach out to your This is exactly what the doctor dental society. Be there. Be involved. ordered. Will there be a day when Stay involved. That way, we can raise all of our patients understand that our hand and do something to help. ■ going to the dentist is necessary and good for them? Will there be a day Ruchi K. Sahota, DDS, CDE, that dental health is top of mind practices family dentistry in Fremont, for most of the public in California? Calif., and serves as faculty at the Will there be a day when parents University of the Pacifi c, Arthur A. understand that baby teeth are Dugoni School of Dentistry. She is also a important and need to be protected? certifi ed dental editor, a consumer advisor As CDA dentists, we do our part. for the American Dental Association, Dental societies organize Give Kids past president of the Southern Alameda a Smile events. CDA Cares brings County Dental Society and a fellow hundreds of dentists together to help of the American College of Dentists, care for the thousands that stand in International College of Dentists and line for necessary dental care. We the Pierre Fauchard Academy.

462 SEPTEMBER 2017 Impressions CDA JOURNAL, VOL 45, Nº9

Do We Need a New Defi nition of Dentistry? David W. Chambers, EdM, MBA, PhD Every Saturday in America thousands of men buy three- eighth-inch drill bits. No one really wants a three-eighth- inch drill bit. Those who can help it avoid buying more than one. What we want is three-eighth-inch holes. The distinction is important. Customers want benefi ts, not features. Patients want oral health, not dentistry. The American Dental Association recently proposed a defi nition of oral health as “a functional, structural, aesthetic, physiologic and psychosocial state of well-being [which] is essential to an individual’s general health and quality of life.” The FDI World Dental Federation has just developed a defi nition as well: “Oral health is multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confi dence and without pain, discomfort and disease of the craniofacial complex.” The nub: There is much to like in these defi nitions. They focus on the patient; they speak to a richer life for everyone. 1. Dentistry and oral health are not The expanded ADA and FDI defi nitions represent both the same thing. an opportunity and a liability. CBCT images open the prospect for dentists to treat obstructive sleep apnea, but they 2. Opportunity without also place practitioners at legal risk for failing to diagnose responsibility is a dangerous oral cancers appearing in these images. Are dentists really responsible for patients’ “total well-being,” including “the position to defend. ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions?” This seems to suggest 3. Larger scope necessitates the need for more training and collaboration with other decreased independence. professions. Wider scope means more responsibility. But there is also danger in steering too close to the other side of the issue. Certainly dentists would not want David W. Chambers, EdM, MBA, PhD, is a professor to claim exclusivity for the new oral health outcomes of dental education at the University of the Pacifi c, Arthur being envisioned. Otolaryngologists, plastic surgeons, A. Dugoni School of Dentistry, San Francisco, and editor speech pathologists, psychologists, social workers and of the American College of Dentists. therapists of all types all have much to contribute to patients’ total well-being. At the least, involving dentists in “functional, structural, aesthetic, physiologic and psychosocial states” of patients will require collaborative working relationships with a very large number of sister professionals. At the worst, we can expect turf wars. Further, dentists may not want to assume complete responsibility even for traditional oral health care outcomes. Patients engage in inadequate home care, spotty follow up and damaging habits. Patients refuse optimal treatment plans and insurance companies may not pay for them. How can a dentist be held accountable for less than optimal oral health outcomes under such circumstances? There is a balance between opportunity and responsibility and between proper action and outcomes. ■

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CDA JOURNAL, VOL 45, Nº9

Prefabricated Blood Vessels May Revolutionize Root Canals While root canals are effective in saving a tooth that has become infected or decayed, this age-old procedure may cause teeth to become brittle and susceptible to fracture over time. Now researchers at Oregon Health and Science University in Research Leads to Treatment Portland, Oregon, have developed a process by which they can engineer new blood vessels in teeth, creating better long-term outcomes for patients and clinicians. for Rare Gum Disease Their findings were published online in June in Scientific Reports. A partnership between a University More than 15 million root canals are conducted annually in the United of Pennsylvania School of Dental States. The current procedure involves removing infected dental tissues and Medicine professor and a scientist at the replacing them with synthetic biomaterials covered by a protective crown. National Institutes of Health has led to Principal investigator Luiz Bertassoni, DDS, PhD, assistant professor of a successful new treatment for leukocyte restorative dentistry in the OHSU School of Dentistry and assistant professor of adhesion defi ciency (LAD), a rare genetic biomedical engineering in the OHSU School of Medicine, and colleagues used disorder that causes recurrent bacterial a 3-D printing-inspired process, based on their previous work fabricating infections and terrible gum disease. artificial capillaries, to create blood vessels in the lab. They placed a fiber mold “This is really exciting because we made of sugar molecules across the root canal of extracted human teeth and see that a treatment performed in mice injected a gel-like material, similar to proteins found in the body, filled with in our laboratory directly paved the dental pulp cells. The researchers removed the fiber to make a long way to a novel clinical treatment for a microchannel in the root canal and inserted endothelial cells isolated from the serious disease that was not responsive interior lining of blood vessels. After seven days, dentin-producing cells to any other treatments,” said George proliferated near the tooth walls and Hajishengallis, DDS, PhD, the Thomas artificial blood vessels formed inside the tooth. W. Evans Centennial Professor in Penn Read more of this study at Scientific Dental’s department of microbiology. Reports (2017); doi: 10.1038/ Dr. Hajishengallis has spent much of s41598-017-02532-3. his career studying periodontitis. In the course of his research, he came across Credit: OHSU/Kristyna Wentz-Graff a strain of mice that had striking bone loss at a very young age. Upon further investigation, he realized that these animals had the mouse form of LAD. Noting that the gum disease of LAD a researcher who had made similar The authors describe treating a 19-year- mice was likely attributable to very high observations in human LAD. The old patient with LAD who had severe levels of the signaling molecule IL-17, two decided to become partners in periodontitis and a chronic, nonhealing which leads to damaging infl ammation, research and published their fi rst joint wound. Using a drug that blocks the researchers used an antibody to block paper in 2014 in Science Translational activity of IL-23 and another signaling the activity of IL-17 or IL-23, a Medicine proposing that inhibition molecule, IL-12, the patient’s oral health molecule required for IL-17 production, of the IL-23/IL-17 pathway could dramatically improved along with his and inhibited the disease. During be an effective treatment of LAD. skin wound, which shared similar features a scientifi c conference in 2012, Dr. A recent report in The New England of immune malfunction as his gums. Hajishengallis met Niki Moutsopoulos, Journal of Medicine, authored by Drs. Learn more about this study at DDS, PhD, of the National Institute Moutsopoulos and Hajishengallis, The New England Journal of Medicine of Dental and Craniofacial Research, recounts the fruits of this partnership. (2017); doi:10.1056/NEJMoa1612197.

464 SEPTEMBER 2017 CDA JOURNAL, VOL 45, Nº9

Studies Reveal Secrets of Tooth Calcium Two studies on calcium isotopes in method for measuring proportions of teeth have provided new insights into stable calcium isotopes. This method both the extinction of marine reptiles and allows new scientifi c advances in all the weaning age in humans. The fi ndings kinds of domains, such as estimating of these studies, conducted by National weaning age in humans from milk Center for Scientifi c Research researchers teeth or fi nding a new explanation Human canine milk tooth from which the enamel was taken to measure the proportions at Lyon ENS and Université Claude for the extinction of marine reptiles. of calcium isotopes. The enamel is around Bernard Lyon and published in Current There are six stable isotopes of 500μm thick. Credit: Théo Tacail Biology and PNAS, open new avenues for calcium on Earth. These isotopes do not research in anthropology and paleontology. generate natural radioactivity but make A team of geochemists has it possible to identify chemical reactions are formed by the fractionation of developed a new high-precision through their specifi c signatures, which the different calcium isotopes during biological processes and are marked in bones and teeth. The method used by the researchers analyzes the degree of isotopic fractionation in these tissues. Breast milk is the substance in which Long-Term Breast-Feeding Can Lead to Cavities calcium isotopes are most fractionated. Children who are breast-fed for two years or longer are more likely to have Thus, by analyzing milk teeth, it is dental cavities, according to a study published in the July issue of Pediatrics. possible to trace someone’s diet in the Researchers analyzed breast-feeding behaviors and sugar consumption for early years of their life. The more milk 1,129 children in Pelotas, Brazil. At age 5, the children visited a dentist and in the diet, the more the dental calcium were examined for decayed, missing and filled primary tooth surfaces and contains light isotopes. By cutting into severe early childhood caries. Severe early childhood caries were defined as milk teeth and measuring isotopic six or more decayed, missing and filled primary tooth surfaces. ratios using a mass spectrometer, the Among the children in the study, 23.9 percent had severe cavities and 48 researchers observed that teeth begin percent had at least one tooth surface affected by a cavity. Kids who were mineralization with very considerable breast-fed for two years or longer had a 2.4 times higher risk of having severe isotopic differences and that these values maintain stable proportions until cavities, compared to kids who were breast-fed for less than a year. weaning. By knowing the speed at which “There are some reasons to explain such an association,” said Karen Peres, tooth enamel is formed, researchers MDS, PhD, lead author of the study and associate professor at the University have been able to develop a way to of Adelaide in Australia. “First, children who are exposed to breast-feeding estimate weaning age in our ancestors. beyond 24 months are usually those breast-fed on demand and at night. In another fi eld, isotopic analysis of Second, higher frequency of breast-feeding and nocturnal breast-feeding on dental calcium allowed researchers to demand makes it very difficult to clean teeth in this specific period.” show that on the eve of the extinction The study also found that breast-feeding of dinosaurs, large marine reptiles were between 12 and 23 months did not bring at the top of the marine food chain. The with it a higher risk of cavities. About study suggests that this competitive one-quarter of the kids were breast-fed for situation could be the reason for 24 months or longer. their disappearance as a result of the Learn more about this study at Pediatrics scarcity of their shared source of food. (2017); doi:10.1542/peds.2016-2943. Learn more about these studies at Current Biology (2017); doi: dx.doi. org/10.1016/j.cub.2017.04.043 and PNAS (2017); doi: 10.1073/pnas.1704412114.

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CDA JOURNAL, VOL 45, Nº9

Virtual Beach Improves Dental Patient Experience In a study published in the journal Environment & Behavior, a team of researchers at the Universities of Plymouth, Exeter and Birmingham in England worked with a dental practice to find out whether virtual reality encounters, such as walking on a beautiful beach, could improve patient experience during routine dental procedures such as fillings and tooth extractions. Patients who agreed to take part in the study were randomly allocated to one of Credit: Graham Colm three conditions: standard care (as in a normal practice); a virtual walk around a beach using a headset and handheld controller; or a walk around an anonymous Blocking Yeast-Bacteria virtual reality city. Results found that those who “walked” around the beach were Interaction May Prevent less anxious, experienced less pain and had more positive recollections of their treatment a week later than those in the standard-care condition. These benefits Biofi lms That Cause were not found for those who walked around the virtual city. Childhood Caries The authors of the research stress that the type of virtual reality environment the patient visits is important. The fact that only patients who visited the beach Though most tooth decay can be and not the virtual city had better experiences than standard care is consistent blamed on bacteria, such as Streptococcus with a growing body of work that shows that natural environments, and marine mutans, the fungus Candida albicans may environments in particular, can help reduce stress and anxiety. be a joint culprit in early childhood “Our research demonstrates that under the right conditions this technology can caries, according to research published be used to help both patients and practitioners,” said Karin Tanja-Dijkstra, PhD, the recently in the journal PLOS Pathogens. study’s lead author. Learn more In earlier research, a team from the about this research at Environment & University of Pennsylvania School Behavior (2017); doi.org/10.1177/ of Dental Medicine found that C. albicans, a type of yeast, took advantage 0013916517710077. of an enzyme produced by S. mutans to Virtual beach in England. form a particularly intractable biofi lm. Credit: University of Plymouth In a new study, the researchers have pinpointed the surface molecules on the fungus that interact with the bacterially derived protein. Blocking that interaction impaired the ability of yeast to form a biofi lm with S. antimicrobial and might be able to target and even more worldwide,” Dr. Koo mutans on the tooth surface, pointing the enzyme or cell wall of the fungi to said. “In addition to fl uoride, we to a novel therapeutic strategy. disrupt the plaque biofi lm formation.” desperately need an agent that can “Instead of just targeting bacteria The fi ndings point to a new direction target the disease-causing biofi lms to treat early childhood caries, we may for treatment of early childhood caries, and in this case not only the bacterial also want to target the fungi,” said according to the study. The current component but also the Candida.” Hyun (Michel) Koo, DDS, PhD, senior standard of care, beyond the use of fl uoride Koo and colleagues are now working author on the study and a professor as a preventive approach, is to target on novel therapeutic approaches for in the Penn Dental department of only the bacteria with antimicrobials targeted interventions, which can be orthodontics and divisions of pediatric or to use surgical interventions if the potentially developed for clinical use. dentistry and community oral health. tooth decay has become too severe. To learn more about this study, “Our data provide hints that you might “This disease affects 23 percent go to PLOS Pathogens (2017); doi. not need to use a broad-spectrum of children in the United States org/10.1371/journal.ppat.1006407

466 SEPTEMBER 2017 CDA JOURNAL, VOL 45, Nº9

Periodontal Pathogen May Interfere With Conception A common periodontal pathogen had discontinued contraception in may delay conception in young women, order to become pregnant. Clinical oral according to a study carried out at the and gynecological examinations were University of Helsinki and published in performed. Detection of major periodontal the Journal of Oral Microbiology. Previous pathogens in saliva and analysis of serum studies have shown that periodontal and saliva antibodies against major diseases may be a risk for general periodontal pathogens as well as a vaginal health, but no data on the infl uence of swab for the diagnosis of bacterial vaginosis periodontal bacteria on conception or at baseline were carried out. Subjects were becoming pregnant have been available. followed-up to establish whether they Porphyromonas gingivalis, a The study population comprised did or did not become pregnant during bacterium associated with periodontal 256 healthy nonpregnant women who the observation period of 12 months. diseases, was signifi cantly more frequently detected in the saliva among women who did not become pregnant during the one-year follow-up period than among those who did. The levels of Dental Workers Don’t Take All Steps To Control salivary and serum antibodies against this Nitrous Oxide Exposure pathogen were also signifi cantly higher in women who did not become pregnant. Although most dental professionals use a scavenging system to prevent Statistical analysis showed that the nitrous oxide gas from escaping during a procedure, adherence to other fi nding was independent of other risk recommended practices is lacking, according to a study of a survey conducted factors contributing to conception, such by the National Institute of Occupational Safety and Health (NIOSH). The study as age, current smoking, socioeconomic was published in the Journal of Occupational and Environmental Hygiene. status, bacterial vaginosis, previous NIOSH surveyed 284 dentists, dental hygienists and dental assistants in deliveries or clinical periodontal disease. private practice who had used nitrous oxide in the previous week. More than 93 Women who had P. gingivalis in the percent of respondents said they had employed a nasal scavenging mask or local saliva and higher saliva or serum antibody exhaust ventilation around a patient’s mouth when using nitrous oxide. However, concentrations against this bacterium 51 percent reported that they did not check for leaks when using the gas on adult had a threefold hazard for not becoming patients and 47 percent did not check before using it on pediatric patients. pregnant compared to their counterparts. The survey also found that the flow of nitrous oxide started before the mask was Increased hazard was nearly fourfold if applied to 16 percent of adult patients and 14 percent of pediatric ones, and the flow more than one of these qualities and of nitrous oxide was not halted before turning off the oxygen flow to 10 percent of clinical signs of periodontitis were present. adult patients and eight percent of pediatric ones. Additionally, 13 percent of dental “Our study does not answer the practices do not have standardized procedures for minimizing nitrous oxide exposure. question on possible reasons for infertility, Successful management of nitrous oxide should include nasal scavenging masks, but it shows that periodontal bacteria supplementary LEV if needed, adequate general ventilation, regular inspection of may have a systemic effect even in lower nitrous oxide delivery and availability of amounts and even before clear clinical standard procedures to minimize signs of gum disease can be seen,” said exposure, according to NIOSH. periodontist and researcher Susanna Paju, Learn more at the Journal of DDS, PhD, of the University of Helsinki. Occupational and Environmental “More studies are needed to explain the Hygiene 14 (6), 409-416 (2017). mechanisms behind this association.” Learn more about this study at the Journal of Oral Microbiology (2017); doi. org/10.1080/20002297.2017.1330644.

SEPTEMBER 2017 467 Practice Support

Dental Benefit Plans

“Why do I feel so uncoordinated about dental benefits?”

While many of your patients rely on dental benefits to fund their care, your focus should be on the best care possible. That’s why CDA Practice Support has experts and tools to help you navigate the dynamic world of benefit plans. Get guidance on the unique requirements of provider agreements, managing and filing dental claims efficiently and effectively, understanding your appeal rights and much more.

Call an analyst or explore our library of online resources, including legal reference guides and sample letters.

800.232.7645 cda.org/dentalbenefitplans Abstracts CDA JOURNAL, VOL 45, Nº9

Winners of the 2017 Table Clinic Competition

Dental, dental hygiene and dental assistant students and military/residents from across the state competed in the California Dental Association’s annual Table Clinic Competition at CDA Presents in Anaheim May 4-6. First-place winners from the contests were invited to submit abstracts of their work to appear in the Journal. CDA continues to collaborate with the California Dental Hygienists’ Association for the RDH portion of the competition.

SCIENTIFIC DENTAL STUDENT WINNER

Christina Chi and with grade 3 water; (2) brushing with Minna Chun accept activated charcoal (COAL); (3) agitating congratulations from in coconut oil (OIL); and (4) positive Drs. Clelan (Butch) control (HP) treated with 20% hydrogen Ehrler and Mark peroxide. Color change was monitored: Romanelli on behalf of (1) visually with VITA Bleachedguide their team for winning 3D-Master; (2) instrumentally with the clinical dental student category. Not VITA Easyshade Compact Advance pictured are Arfassa 4.0; and (3) imaging with ShadeWave Gullo, Darlene Teddy software. Baseline (T1), one day and Emily Hwang. post-whitening (T2) and one month Effi cacy of Do-It-Yourself Whitening: post-whitening (T3) measurements Color Monitoring with Diff erent Shade were taken. The Kruskal-Wallis test Assessment Tools indicates baseline measurements were Christina Chi, Minna Chun, Arfassa not signifi cantly different among the Gullo, Darlene Teddy and Emily Hwang, four groups (p > 0.05). At T2 and T3, Loma Linda University School of Dentistry there was signifi cant difference among Abstract: The objective of this study the four groups (p < 0.05) due to the HP was to evaluate the effi cacy of natural group. This study confi rms the whitening whitening products using three shade effi cacy of hydrogen peroxide and assessment tools. Extracted human provides valuable evidence supporting teeth were embedded in typodonts. a new shade assessment method.

Four experimental groups were studied: THE CORRESPONDING AUTHOR, Christina Chi, can be reached at (1) negative control (NC) treated [email protected].

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COMMUNITY/EDUCATION DENTAL STUDENT WINNER

Leveraging Informatics and Web- designed to facilitate meaningful Based Technologies To Relieve communication between patients Access to Oral Health Care Barriers and oral health providers. Employing in Disadvantaged Communities the application permits remote triage Corey D. Stein, MS, Western of patients’ dental conditions while University of Health Sciences, ascertaining chief complaints prior to College of Dental Medicine direct examination. By utilizing self- Abstract: Nationwide oral health reported, qualitative metrics exchanged disparities disproportionately hinder through a secure network of health care access to care for underserved professionals, this protocol is aimed to populations. As web-based applications expedite clinical processes, increase become ubiquitous across U.S. positive patient outcomes and enhance demographics, health policymakers and health care utility. We discussed the dental professionals need to explore proposed intervention and its potential Drs. Clelan (Butch) Ehrler and Mark Romanelli present Corey D. Stein with his award. He won the new technological interventions to relieve barriers that currently restrict community/education dental student category with to enhance health care availability a Southern California community his research on leveraging informatics and web- and support clinical practices. The from optimal oral health care. forthcoming manuscript detailed the based technologies to relieve access to oral health THE AUTHOR, Corey D. Stein, can be reached at care barriers in disadvantaged communities. implementation of a web-based protocol [email protected].

SCIENTIFIC DENTAL STUDENT WINNERS

Clinical and Radiographic Presentations in MRONJ After Bisphosphonates vs. Denosumab Edwin Eshaghzadeh and Chantal Hakim, University of California, Los Angeles, School of Dentistry Abstract: Not available.

THE CORRESPONDING AUTHOR, Edwin Eshaghzadeh, can be reached at [email protected].

Chantal Hakim and Edwin Eshaghzadeh accept their award from Drs. Clelan (Butch) Ehrler and Mark Romanelli for winning the scientific dental student category.

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RDA STUDENT WINNERS

Drs. Clelan (Butch) procedures. Unclean dental unit water Ehrler and Mark lines may potentially cause patients, Romanelli congratulate especially children, the elderly and those Pamela Cabello, with compromised immune systems, to Shawnee Lopez and acquire an infection they otherwise would Erlinda Benavidez, who have not had because of the biofi lm that won the RDA student collects inside the water lines. Our study category with their research on the safety involved running saliva/food particles of dental unit waterlines. through various dental hoses. Each hose was fl ushed using a different type of cleaning agent. We also had one hose that was not fl ushed at all. Based on our results, we decided whether fl ushing waterlines improves the cleanliness of Dental Unit Waterlines: Are Yours Safe? water and which cleaning agent works Pamela Cabello, Shawnee Lopez and best. We also tested the water from the Erlinda Benavidez, Citrus College air water syringe of two dental offi ces to In 2014, an elderly woman passed away see if there was any bacterial growth. We after contracting Legionnaires disease due predicted that fl ushing and disinfecting to unclean dental waterlines. Two years waterlines is crucial in keeping waterlines later, seven children were also hospitalized free of debris and as sterile as possible.

after contracting Mycobacterium from THE CORRESPONDING AUTHOR, Pamela Cabello, can be reached unclean waterlines during their pulpotomy at [email protected].

RDH INFORMATIONAL STUDENT WINNERS (CDA IN COLLABORATION WITH CDHA)

Tang Blanton and Jose Methods: Evaluation of literature Mendez receive their regarding benefi ts of early dysphagia award for winning the detection, existing standardized RDH informational screening tools and valid physiological student category. markers of dysphagia. Congratulating the Results: Standardized dysphagia students are Drs. Clelan (Butch) Ehrler and Mark screening improves patient outcomes as Romanelli and CDHA demonstrated by reduced hospital stay, representatives Brenda reduction of aspiration pneumonia and Kibbler, Lygia Jolle and lower mortality. Reduced tongue strength is Julie Coan. strongly correlated with dysphagia. Existing assessment tools and management materials can be adapted for use by dental professionals. Conclusion: Dental professionals can improve patient outcomes through Dysphagia: Under-Recognized and early dysphagia detection, referral to the Life-Threatening dysphagia team and treatment modifi cations Tang Blanton and Jose Mendez, West Los for dysphagia. Adoption of hospital Angeles College protocols may be appropriate for detecting Background: Dysphagia is a signifi cant dysphagic patients in dental practices. risk factor for aspiration pneumonia. This table clinic proposed a protocol for Elderly patients have an elevated risk dysphagia risk screening and management of dysphagia and aspiration pneumonia protocols based on risk categories.

due to aging changes in swallowing THE CORRESPONDING AUTHOR, Tang Blanton, can be reached at function and immune status. [email protected].

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RDH RESEARCH STUDENT WINNERS (CDA IN COLLABORATION WITH CDHA)

RDH research winners Methods: IRB exempt status; Victoria Santiago and 35-question survey distributed to students Melissa Cardenas in fi rst course session. Post survey accept their award distributed in last session. Data evaluation for winning the RDH of knowledge with Fisher’s exact test. research student category from Drs. Friedman’s test used to evaluate attitude, Clelan (Butch) access and confi dence, all at u = 0.05. Ehrler and Mark Results: Cohort one n = l 9 (100 Romanelli and CDHA percent); cohort two n = 79 (83 percent) representatives Brenda completed both surveys. Statistically Kibbler, Lygia Jolle signifi cant increase in knowledge in both and Julie Coan. cohorts. Cohort two showed signifi cant improvement in seven out of 10 knowledge questions (p < 0.001). Cohort one showed signifi cant improvement in three out Evidence-Based Practice of 10 knowledge questions (p = 0.002). Knowledge, Attitude, Access and Signifi cant difference in attitude, access Confidence of Students and confi dence in cohort one (p < 0.05). Victoria Santiago and Melissa Conclusions: Signifi cant Cardenas, Loma Linda University improvement in knowledge for both Background: Two cohorts’ cohorts; results suggest need to improve knowledge, attitudes access and knowledge in study design, level of confi dence of evidence-based evidence and analyzing results.

practice evaluated pre- and post- THE CORRESPONDING AUTHOR, Victoria Santiago, can be required research design course. reached at [email protected].

MILITARY/RESIDENT WINNER

Drs. Clelan (Butch) obstructive sleep apnea (OSA), results Ehrler and Mark from a closed or restricted upper airway. Romanelli present Lt. For OSA to result, an airway closure Jabrenta Hubbard, must exist, breathing cessation must DMD, with her award occur during sleep and an anatomical for winning the military/ anomaly in the oral pharyngeal region resident category. Her research focused on the that hinders neurochemical and treatment of obstructive neuromuscular control of breathing sleep apnea. must also be present. Depending on the severity of the sleep apnea, OSA can be treated medically, surgically or with nonsurgical appliances. One particular nonsurgical appliance includes the Can’t Breathe When Sleeping mandibular advancement device. These Lt. Jabrenta Hubbard, DMD devices may be as effective as surgical Naval Hospital Camp Pendleton treatment. Varying fabrications exist for Abstract: Imagine a deep sleep when the mandibular advancement devices. all of a sudden you stop breathing. The The method demonstrated is the oral involuntary cessation of breathing is sleep apnea appliance (OSAP).

what occurs with sleep apnea. The THE AUTHOR, Lt. Jabrenta Hubbard, can be reached at most common form of sleep apnea, [email protected].

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Thank you to the following judges for the annual Table Clinic Competition held at CDA Presents in Anaheim May 4–6.

RDA Competition Patricia Alvarez, RDA Izabella Ambartsumyan, RDA Shari Becker, RDA Lisa Bocanegra, RDA Maleah Brooks, RDA Melrose Nabua, RDA Maria Christina Ochoa, RDA Karen Schroeder, RDA Manolita Teh, RDA Tobi Trotta, RDA Georgina Vargas-Burket, RDA

RDH Competition Alan Budenz, DDS Howard Richmond, DDS Judith Strutz, DDS

Dental Student Competitions Kai Chiao Chang, DDS Jaymie Coria, DDS Marileth Coria, DDS Samuel Demirdji, DDS Ramesh Gowda, DDS James Lau, DDS to practicing Mei Lu, DDS Pradip Patel, DDS on your terms. Leonard Raimondo, DDS

Claudia Ritholz, RDA Every practice is unique. That’s why CDA created R. Jerry Smith, DDS The Dentists Service Company as a new subsidiary Ann Steiner, DDS focused on helping you achieve your vision Zaw Thu, DDS of success. Grow your patient base, streamline

operations and boost productivity with TDSC’s Military/Resident Competition practice management advising services. Monica Bruce, DDS Kai Chiao Chang, DDS Ready to see results? Let’s go. Wyeth Hoopes, DDS Hemant Joshi, DDS Madhavi Joshi, DDS Ann Steiner, DDS 888.253.1223 tdsc.com James Strother, DDS Ken Yaros, DDS

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Consumption of Cannabis and Eff ects on Periodontal Oral Health

Suellan Go Yao, DMD, and James Burke Fine, DMD

ABSTRACT Cannabis plays a role in the legal, medical and dental fi elds. With more states passing medical marijuana laws, policymakers are concerned about possible cannabis use among nonpatients. Oral health effects include periodontitis, bone loss and gingival enlargement. Its Schedule I classifi cation makes it diffi cult to run randomized controlled studies on its effects. However, further medical study will allow for better policy concerning marijuana that may affect the population as a whole.

AUTHORS

Suellan Go Yao, DMD, is a James Burke Fine, DMD, annabis, which is more Administration and Function clinical instructor at Columbia is senior associate dean commonly known as There are three main routes of University College of Dental for academic aff airs and marijuana, is derived administration: inhalation to the lungs Medicine, Department of professor of clinical dentistry Periodontics in New York. at Columbia University from the plant Cannabis by smoking the vaporized plant, ingestion She also maintains a private College of Dental Medicine sativa. “Cannabinoids” to the gut of lipophilic, alcoholic or practice in New York. in New York. He is an Care a group of molecules that act on supercritical fl uidic extracts of the plant Confl ict of Interest Disclosure: attending dental surgeon at the cellular cannabinoid receptors. and topical application to the skin of the None reported. Presbyterian Hospital Dental They are divided into three groups: plant extract.3 Smoking marijuana is the Service in New York. Dr. Fine has a private practice limited endogenous (endocannabinoids), most common route because of its ease to periodontics in Hoboken, synthetic and phytocannabinoids of use and rapid effects. Hashish can be New Jersey, and is in the (plant derived). Delta-9- baked and eaten in foods or mixed with faculty practice at Columbia tetrahydrocannabinol (THC) and tobacco. Hash oil is commonly spread University. cannabidiol (CBD) are in the third on the tip of a cigarette and smoked.2 Confl ict of Interest 1 Disclosure: None reported. group. THC is considered the plant’s Other routes are oromuscosal, rectal, main constituent and is the most intravenous and cannabidiol adsorption.4 psychoactive component, while CBD The endocannabinoid system consists is nonpsychoactive. There are three of receptors, their ligands and ancillary forms of cannabis: marijuana, which proteins. The endogenous receptors are consists of dried leaves and flowers, CB1 and CB2. The CB1 receptors are hashish, which is resin from the flower found in the cerebral cortex, limbic areas, heads compressed to small blocks, basal ganglia, cerebellum and thalamic and hash oil, which is a thick liquid areas, whereas the CB2 receptors are found extracted from hashish. Marijuana has in the cells in the immune system, mostly the least concentrated form of THC.2 the macrophages.2 These areas in the brain

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TABLE 1 Summary of Adverse Effects

Study Summary Wang et al., 20088 The most common nonserious adverse eff ects were dizziness, somnolence events, muscle spasm events, other gastrointestinal tract disorder, pain events, dry mouth events and bladder disorder. The rate of these nonserious events was almost two times higher in the cannabinoids group than the control. Lynch and Campbell, 20119 No serious adverse events were found, but the most frequent nonserious adverse events reported were sedation, dizziness, Aggarwal, 20133 dry mouth, nausea and disturbance in concentration. Tan et al., 200910 Smoking both tobacco and cannabis synergistically increase the risk of respiratory symptoms and chronic obstructive Aggarwal, 20133 pulmonary disease, but smoking only cannabis was not associated with this increased risk.

where the CB1 receptors are found are duration, cumulative consumption or age Legal Status involved in cognition, memory, reward, of start of cannabis smoke and the risk of Cannabis is classifi ed as a Schedule pain perception and motor coordination.5 lung cancer in never smokers. However, I substance by the U.S. Food and Drug The CB1 receptor is 10 times more there was a suggestive association between Administration (FDA). Schedule I drugs, prevalent in the central nervous system high intensity and cumulative cannabis substances or chemicals are defi ned as drugs than the other studied receptor involved smoking on adenocarcinoma lung cancer. with no currently accepted medical use in pain, the μ-opioid receptor.3 and a high potential for abuse. Schedule I Medical Use Origin drugs are the most dangerous drugs of all Adverse Eff ects The use of cannabis as a medicine the drug schedules with potentially severe Acute adverse effects can include dates back to approximately 2737 BC in psychological or physical dependence.14 anxiety, panic reactions and psychotic China, where it was used for rheumatic Two categories of cannabinoid medicines symptoms, which are most commonly pain, intestinal constipation, disorders are currently used in North America. The reported by beginner users.5 However, of the female reproductive system and fi rst is cannabis-derived pharmaceuticals, because there is a low expression of the malaria.11,12,13 In the 20th century, the which include dronabinol, nabilone and receptor in the brainstem, cannabinoids medical indications of cannabis were nabiximols. Dronabinol is a schedule have minimal toxicity and have an summarized in Sajou’s Analytic Cyclopedia II drug and nabilone is a schedule III absence of fatal overdose or respiratory of Practical Medicine (1924) in three areas: drug. Both were approved in 1985 for depression. Withdrawal symptoms can sedative or hypnotic, analgesic and other the treatment of nausea and vomiting include restlessness, irritability, mild uses. But in the early 1900s, the medical associated with cancer chemotherapy agitation, insomnia, nausea and cramping. use of cannabis started to decline because in patients who have not responded to There have been reviews and studies of increasing availability of synthetic other conventional antiemetic therapy. of the adverse effects3,8,9,10 (TABLE 1). pharmaceuticals, potency variability and Dronabinol was also approved for the Tobacco smoking has been considered unreliable supply sources that made it treatment of anorexia-associated weight a cause of lung cancer. Cannabis smoke diffi cult to get replicable effects. And loss in AIDS patients in 1992.15 The contains many of the same carcinogens as lastly, also because of legal restrictions. second category is phytocannabinoid-dense tobacco smoke.6 The International Lung In 1937, the Marijuana Tax Act imposed botanicals or medical cannabis. On Nov. Cancer Consortium (ILCCO) is a group a tax on use of the plant. Then in 1941, 5, 1996, California became the fi rst state of lung cancer researchers established cannabis was removed from the U.S. to legalize medical cannabis.16 Twenty- in 2004 who share compatible data of pharmacopeia. The 1960s saw a boom in fi ve states and the District of Columbia ongoing and completed lung cancer case the recreational use of cannabis in the have legalized medical use of cannabis control and cohort studies from different younger population in the Western world, (TABLE 2). In November 2012, Colorado geographical areas and ethnicities. One and this boost of consumption along with and Washington also passed legislation of its key goals is to evaluate potential better scientifi c knowledge about the for the legal production, sale and use of lung cancer risk factors that are diffi cult plant contributed to an increased scientifi c recreational cannabis. In Alaska, Oregon to evaluate in individual studies. Zhang interest in cannabis. This interest was and the District of Columbia, marijuana et al.7 did a pooled analysis based on the renewed in the 1990s when the receptors is legalized also for recreational use. After individual level data from the participating and the endogenous cannabinoid system the November 2016 election, medical ILCCO studies. They found little or in the brains were described. This marijuana laws recently passed in Arkansas, no association between the intensity, interest has been increasing since.11 Florida and North Dakota but still have yet

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TABLE 2 States With Legalized Medical Use of Cannabis

Alaska Minnesota Arizona Montana California Nevada cannabis. These include the evaluation votes supported medical marijuana. It is Colorado New Hampshire of the physiologic and psychological often debated whether the answer of the effects, individual health risks, various question belongs to the physician or to the Connecticut New Jersey delivery systems and short-term clinical patient (if legalized). While a majority of District of Columbia New Mexico trials to determine effectiveness for clinicians recommend the use of medical Delaware New York targeted medical conditions.15 marijuana in certain situations, many from Hawaii Ohio Pain is the No. 1 reason that both sides believe in the need for more 21 Illinois Oregon cannabis is prescribed to patients. In research for a stronger basis of evidence. Maine Pennsylvania reference to pain, cannabis has been best researched clinically for its role in Nonlegal, Nonmedical Use Maryland Rhode Island the management of neuropathic pain As more states pass medical marijuana Massachusetts Vermont and malignant pain. Other chronic laws, policymakers are concerned with Michigan Washington pain syndromes, especially those that the possible increase of cannabis use

Source: medicalmarijuana.procon.org involve hyperalgesia and allodynia and among nonpatients. Looking at marijuana acute pain, have also been described. A possession arrests in cities from 1988 2011 systematic review of cannabinoids to 2008, Chu16 found that these laws to be effective. California, Massachusetts for treatment of chronic noncancer increase marijuana arrests among adult and Nevada all passed measures for pain looked at studies of neuropathic males by approximately 15–20 percent. legalizing recreational use of marijuana. pain, fi bromyalgia, rheumatoid arthritis Based on data on treatment admissions Laws for recreational use in Massachusetts and mixed chronic pain syndromes. to rehabilitation facilities, he found and Nevada have not yet been It concluded that “overall there is that marijuana treatments among adult implemented.17 Louisiana has changed evidence that cannabinoids are safe and males increased by 10–20 percent after its law concerning medical marijuana modestly effective in neuropathic pain the passage of these laws. This suggests from “prescribed to recommended.”18 In with preliminary evidence of effi cacy in a positive legalization effect on illegal January 2014 in New York, the governor fi bromyalgia and rheumatoid arthritis.” It marijuana use. Limitations of the study issued a directive that allowed 20 hospitals also mentioned that smoked cannabinoid are that bias may be introduced by the to dispense medical cannabis to patients botanicals demonstrated a signifi cant potential endogenous responses of police, who have been certifi ed by a doctor to analgesic effect in HIV neuropathy.3,9 rehabilitation facilities and treatment have certain conditions, such as cancer. In February 2013, the clinical decisions patients; the arrest and treatment data It also created a limited research program interactive at nejm.org presented a case do not answer whether these medical for New York’s health department to vignette concerning a cancer patient marijuana laws increase initiation establish guidelines and make decisions asking her doctor for the possibility rates among general populations and as to which hospitals can participate of using marijuana to alleviate the the study assumes homogeneity in in the program. These hospitals would pain, nausea and fatigue. It posed two medical marijuana laws across the states. decide which patients would qualify for recommendations: recommending or However, Chu concludes that the study the medical cannabis use and receive the not recommending medicinal use of presents evidence that some indicators cannabis from the federal government.19 marijuana with a defense for both options of heavy marijuana use do respond by experts (J. Michael Bostwick, MD, to these medical marijuana laws. Pain Management and Prescribing Gary M. Reisfi eld, MD and Robert Pacula et al.22 also examined the In 1999, the Institute of Medicine L. DuPont, MD) in the fi eld.20 The impact of medical marijuana laws on released its fi rst report indicating that polling results showed 76 percent of all marijuana use in the general population cannabinoids may have a role in the votes in favor of the use of marijuana and among youth. They found that treatment of pain, movement and memory, for medicinal purposes. Most of the while simple dichotomous indicators of but that there are risks associated with the votes came from the U.S., Canada and medical marijuana laws are not positively use. It made six major recommendations Mexico. In North America, 76 percent associated with marijuana use or abuse, to the medical community to better of votes supported medical marijuana; such measures hide the positive infl uence establish the safety and effi cacy of outside North America, 78 percent of legal dispensaries have on adult and youth

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TABLE 3 Summary of Oral Health References

Study Summary Thomson et al., 200824 Cannabis smoking may be a risk factor for periodontal disease independent of tobacco use. Balayssac and Zangarelli, 200828 Thomson et al. study should have included other drugs such as methylenedioxymethamphetamine (MDMA, ecstasy), cocaine and alcohol. Hujoel, 200829 Thomson et al. study contributed to other evidence that destructive periodontal disease occurs at a younger age that previously believed and it gives the dental professional the ability to detect possible unhealthy lifestyles. Lopez and Baelum, 200930 No evidence to suggest use of cannabis is positively associated with periodontal disease in population of Chilean high school students. Nogueira- Filho et al., 20111 Cannabis smoke may impact alveolar bone by increasing bone loss resulting from ligature-induced periodontitis. Rawal et al., 201232 Chronic marijuana use may result in gingival enlargement similar to phenytoin-induced enlargement. Baddour HM, 198434 Layman FD, 197833 Thomson et al., 201325 Periodontitis commences relatively early in adulthood and its progression accelerates with age, particularly among smokers (tobacco or cannabis). Kayal et al., 201435 Illicit drug use is associated with more severe forms of periodontitis. Zeng et al., 201426 The study fi ndings confi rm the importance of chronic smoking (tobacco or cannabis) as a risk factor for periodontal attachment loss. Meier et al., 201627 Cannabis use for up to 20 years is associated with periodontal disease, but unrelated to health problems in early midlife. Periodontal health showed a robust adverse association in analyses of persistent dependence and joint-years.

use, particularly heavy use. It is clear that potential, downplay the adverse health within a month of their third birthdays not all the laws are equal. They found that effects, create a large market as quickly and then every two years starting at ages 5 in general medical marijuana law polices as possible and protect this market via to 15 and then at ages 18, 21, 26, 32 and have no impact on recreational marijuana lobbying, campaign contributions and 38. More than 90 percent of the cohort use or are associated with reduced advocacy efforts. As seen with tobacco, self-identify as European24,25,26,27 (TABLE 3). marijuana consumption depending on this private industry of marijuana may Thomson et al.24 looked at the the population and behavior assessed. not safeguard the public health.23 independent contributions of cannabis However, because of the heterogeneous and tobacco smoking to periodontal effects of specifi c underlying policy Oral Health Eff ects disease using the DMHDS. They found dimensions, they infl uence users Smoking tobacco is a recognized that regular exposure to cannabis differently based on the user’s age and behavioral risk factor for periodontal smoke was strongly associated with the use. They found that states that allow disease. However, smoking cannabis prevalence and incidence of periodontal dispensaries face a greater risk of increased may also contribute to the etiology attachment loss by age 32. Limitations of recreational use and related negative of periodontal disease. Studies have the study were the self-reported smoking consequences relative to other medical found that some oral effects can include exposure data and that periodontal marijuana law policy frameworks. With periodontitis at an earlier age, gingival attachment loss was measured at three the changing of medical marijuana laws, enlargement similar to Dilantin-induced sites as opposed to six sites. However, it is important to understand the possible enlargement in long-term chronic cases strengths included the high follow-up heterogeneous effects of these policies. and bone loss. Several studies used the rates, prospective determination of There is also fear that marijuana Dunedin Multidisciplinary Health and smoking exposure and use of data on will follow the path of tobacco, in terms Development study (DMHDS). It is a periodontal incidence and prevalence. of advertising, addictiveness and use. longitudinal study of a complete birth Cannabis use in New Zealand does not The tobacco industry increased due to cohort at the Queen Mary Hospital in typically involve mixing with tobacco. product development, marketing and Dunedin, New Zealand, from April 1, Periodontal epidemiological research lobbying. The marijuana industry can 1972 to March 31, 1973. Perinatal data should determine if the association exists become similar and deny addiction was obtained and the cohort was assessed in other populations. David Balayssac,

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PhD, PharmD, and Aude Zangarelli, in the Thomson et al.24 study were older compound of marijuana smoke, which PhD, PharmD,28 commented to this study, and so their duration of exposure was most was administered via intraperitoneal stating that it did not provide data on the likely longer. Also, in this study, there may injections, while this study evaluated use of other illicit drugs in this population have been some residual effect of tobacco the marijuana smoke as a whole, which and that the association should take into smoke, because they think that cannabis is was inhaled. The current study results account potential confounding by other usually mixed with tobacco in hand-rolled demonstrate that cannabis smoke might substances that can affect oral health. As cigarettes. Even though this study did not alter bone pathophysiologic patterns a reply back to this comment, the authors confi rm a positive association between and might be related to impaired stated that they demonstrated that the cannabis use and signs of periodontitis, its immune function during the process effects of cannabis were independent of results may suggest that the periodontal of bone loss or activation of specifi c tobacco use and that the role of other effects may differ between a short-term receptors that might increase bone loss drugs in the etiology of periodontal disease and long-term exposure to cannabis that because the results were found in the should be studied. Hujoel29 thinks that it is also diffi cult to control confounding ligated sites. However, more studies this study contributes to the evidence that and that further studies are still needed. are needed to determine if marijuana destructive periodontal disease occurs at smoke is a threat to periodontal a younger age than previously believed. outcome for periodontal treatment. He thinks that primary prevention of Rawal et al.32 presented two cases destructive periodontal disease should Those who were longer-term of marijuana-associated gingival include smoking prevention and that the smokers and those of low enlargement. The association between dental profession has this opportunity to socioeconomic status (SES) were chronic cannabis use and gingival detect early signs of unhealthy lifestyles enlargement was reported by Layman33 with the high prevalence of dental care more likely to be in the groups and then Baddour et al.34 The cases in the young population in the U.S. with the least favorable trajectory presented in this paper showed In support of periodontal disease at of periodontitis experience. gingival enlargement that can be an earlier age, Lopez and Baelum30 did compared to gingival enlargement a study to investigate the association occurring with phenytoin use. Due between cannabis use and destructive to the similarities, there may be periodontal disease among adolescents. Nogueira-Filho et al.1 conducted common pathogenic mechanisms They used clinical attachment loss and a study that evaluated the possible that need to be further explored. necrotizing ulcerative gingival lesions effect of marijuana smoke inhalation Thomson et al.25 conducted (NUG) as outcomes for destructive on bone loss during the induction of another study using the DMHDS to periodontal disease and used data from a periodontitis in rats. They found that describe changes in the occurrence screening study for signs of periodontitis marijuana smoke inhalation increased of periodontal attachment loss and among high school students from Santiago, bone loss in the furcation area with evaluate risk factors for unfavorable Chile. The cannabis exposure groups were induced periodontitis rats but there was attachment loss progression through either “ever use of cannabis” or “regular no effect in periodontally healthy sites. ages 26, 32 and 38. They found that the use of cannabis.” Their fi ndings did not A limitation of the study was that some prevalence and extent of attachment corroborate with Thomson et al.24 Only animals may have died from respiratory loss increased with age with greater one statistically signifi cant association diffi culties and may not be comparable changes between the ages of 32 and was observed between the use of cannabis to doses inhaled by human marijuana 38 as compared to the ages 26 and 32 and the periodontal outcomes (“ever use users. The results of this study may and more new attachment loss than of cannabis” and presence of NUG) and differ from another study by Napimoga progression. There was a doubling of this association was not consistent with a et al.31 who demonstrated that the proportion of sites showing attachment deleterious effect of cannabis use. However, administration of cannabidiol from loss, especially among the anterior there was a temporal difference between marijuana signifi cantly inhibited bone teeth in the mid to late 30s. Those who how the two studies were conducted and the loss in experimental periodontitis in were longer-term smokers and those age groups studied were different. The group rats. However, that study looked at one of low socioeconomic status (SES)

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were more likely to be in the groups the importance of chronic smoking set of health problems assessed in early with the least favorable trajectory of (tobacco or cannabis) as a risk factor for midlife, fi ndings for cannabis were periodontitis experience. Limitations periodontal attachment loss. At age 32, compared against fi ndings for tobacco, of the study were that there were smoking cannabis weekly or daily was and the study could not comment on the some SES differences in those who associated with higher attachment loss. health effects of cannabis use in older were periodontally examined, the use The impacts of all covariates continued to adults or the safety of medical marijuana of partial recording protocols for the increase with age. A commentary by Brett use in patients who were already unwell. periodontal exams and the inability Duane, BDS, MPH, PHD, in Evidence- A recent study by Shariff et al.37 to determine whether any participant Based Dentistry36 reviewed the study. examined the relationship between had periodontal surgery by age 38. Another study using DMHDS was by frequent recreational cannabis use and This study implies that the eradication Meier et al.27 to test whether cannabis periodontitis prevalence in the U.S. of smoking can result in the greatest use from ages 18 to 38 was associated They analyzed data from the National population gains in periodontal health. with health at age 38 and whether Health and Nutrition Examination Survey With the use of illicit drugs as a cannabis use at those ages was associated (NHANES 2011–12) and found that problem worldwide and the lack of frequent recreational cannabis use was epidemiological research regarding associated with deeper probing depths, periodontal health of people addicted more clinical attachment loss and higher 35 to drugs, Kayal et al. conducted a This study confi rmed the odds of having severe periodontitis. study to determine the periodontal Their data are in agreement with other health status and oral hygiene in people importance of chronic existing studies. Limitations of the study addicted to drugs in Jeddah, Kingdom smoking (tobacco or are a possible selection bias due to the of Saudi Arabia. It was a cross-sectional cannabis) as a risk factor for exclusions of individuals with incomplete study conducted at Al-Amal Hospital, cannabis use or other covariates and a drug rehabilitation center, from periodontal attachment loss. because the cross-sectional nature of October to December 2012 with 57 male the study precludes any inferences on a inpatients who were recovering from causal relationship between cannabis use drug addiction. Cannabis was the drug of and periodontitis. This study supports choice of most participants. This study with individual health decline using the the idea that dental professionals population was of low education level same measure of health at both ages. As should be aware of cannabis use as a and socioeconomic status. They found comparison, they also tested associations possible risk factor for periodontitis. that illicit drug use, especially heroin between tobacco use and physical health. and cocaine, was associated with more Their fi ndings showed that cannabis use Conclusion severe forms of periodontal disease. over 20 years was unrelated to health Marijuana has a long history in Zeng et al.26 also used the DMHDS problems in early midlife. However, the medicine. Its Schedule I classifi cation to reexamine the periodontal effects of sole exception was that cannabis use makes it diffi cult to run randomized smoking and the impact of other putative was associated with periodontal disease. controlled studies on its effects. The risk factors through early to middle Cannabis use for up to 20 years was not need for more study of its effect as a adulthood cross-sectionally using a more associated with net metabolic benefi ts. medicine is clearly recognized as well informative approach. A generalized Their results should be interpreted in as the need for the evolving policies linear mixed model with a quasi-binomial the context of prior research showing concerning marijuana use. Periodontal approached was used as an extension that cannabis use is associated with other disease is only one health condition of the traditional multilevel modeling health problems. Limitations of this study among many that can be affected method for data analysis. Cannabis were that cannabis joint years were based by marijuana in terms of incidence, smoking was determined at ages 18, 21, on self-reports, it was diffi cult to separate prevalence and manifestation. Further 26, 32 and 38 by asking the participants cannabis and tobacco use, fi ndings were medical study will allow for better how many times they had used cannabis based on a single New Zealand cohort, policy in regards to marijuana that may in the previous year. This study confi rmed the conclusions were limited to a specifi c affect the population as a whole. ■

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REFERENCES 19. Milhofer J. Medical marijuana — Coming soon 35. Kayal RA, Elias WY, Albarthi KJ, Demyati AK, 1. Nogueira-Filho GR, Todescan S, Shah A, Rosa BT, to a medicine cabinet near you? Minn Med 2014; Mandurah JM. Illicit drug abuse affects periodontal health Tunes Uda R, Cesar Neto JB. Impact of Cannabis sativa Apr;97(4):44–46. status. Saudi Med J 2014;35(7):724–8. (marijuana) smoke on alveolar bone loss: A histometric 20. Adler JN, Colbert JA. Medicinal use of marijuana. N 36. Duane B. Further evidence that periodontal bone loss study in rats. J Periodontol 2011 Nov;82(11)1602–7. doi: Engl J Med 2013;368:866–8. increases with smoking and age. Evid Based Dent 2014 10.1902/jop.2011.100362. Epub 2011 Mar 29. 21. Adler JN, Colbert JA. Medicinal use of marijuana — Sep;15(3):72–3. doi: 10.1038/sj.ebd.6401038. 2. Cho CM, Hirsch R, Johnstone S. General and oral Polling results. N Engl J Med 2013;368(22):e20(1). 37. Shariff JA, Ahluwalia KP, Papapanou PN. Relationship health implications of cannabis use. Aust Dent J 2005 22. Pascula RL, Powell D, Heaton P and Sevigny EL. between frequent recreational cannabis (marijuana and Jun;50(2):70–4. Assessing the effects of medical marijuana laws on hashish) use and periodontitis in adults in the United States: 3. Aggarwal SK. Cannabinergic pain medicine. A concise marijuana use: The devil is in the details. J Policy Anal NHANES 2011–12. J Periodontol 2017 Mar;88(3):273– clinical primer and survey of randomized-controlled Manag 2015 Winter;34(1):7–31. 80. doi: 10.1902/jop.2016.160370. Epub 2016 Oct 8. trial results. Clin J Pain 2013 Feb;29(2):162–71. doi: 23. Richter KP, Levy S. Big marijuana — Lessons from big 10.1097/AJP.0b013e31824c5e4c. tobacco. N Engl J Med 2014 Jul;371(5):399–401. doi: THE CORRESPONDING AUTHOR, James Burke Fine, DMD, can be 4. Huestis MA. Human Cannabinoid Pharmacokinetics. 10.1056/NEJMp1406074. Epub 2014 Jun 11. reached at [email protected]. Chem Biodivers 2007 Aug;4(8):1770–1804. 24. Thomson WM, Poulton R, Broadbent JM, Moffitt TE, 5. Hall W, Degenhardt L. Adverse health effects Caspi A, Beck JD, Welch D, Hancox RJ. Cannabis smoking of non-medical cannabis use. Lancet 2009 Oct and periodontal disease among young. JAMA 2008 Feb 17;374(9698):1383–91. doi: 10.1016/S0140- 6;299(5):525–31. 6736(09)61037-0. 25. Thomson WM, Shearer DM, Broadbent JM, Foster 6. Moir, D, Rickert WS, Levasseur G, Larouse Y, Maertens Page LA, Poulton R. The natural history of periodontal R, White P, Desjardins S. A comparison of mainstream attachment loss during the third and fourth decades of life. and sidestream marijuana and tobacco cigarette smoke J Clin Periodontol 2013 Jul;40(7):672–80. doi: 10.1111/ produced under two machine smoking conditions. Chem jcpe.12108. Epub 2013 May 9. Res Toxicol 2008 Feb;21(2):494–502. Epub 2007 Dec 7 26. Zeng J, Williams SM, Fletcher DJ, Cameron CM, 7. Zhang LR, Morgenstern H, Greenland S, Chang SC, Broadbent JM, Shearer DM, Thomson WM. Reexamining Lazarus P, Dawn Teare M, Woll PJ, Orlow I, Cox B on the association between smoking and periodontitis in the behalf of the Cannabis and Respiratory Disease Research Dunedin study with an enhanced analytical approach. J Group of New Zealand, Brhane Y, Liu G, Hung RJ. Periodontol 2014 Oct;85(10):1390–7. doi: 10.1902/ Cannabis smoking and lung cancer risk: Pooled analysis jop.2014.130577. Epub 2014 Feb 20. in the International Lung Cancer Consortium. Int J Cancer 27. Meier MH, Caspi A, Cerda M, Hancox RJ, Harrington 2015 Feb;136(4):894–903. doi: 10.1002/ijc.29036. HL, Houts R, Poulton R, Ramrakha S, Thomson WM, Epub 2014 Jun 30. Moffitt TE. Associations between cannabis use and 8. Wang T, Collet J, Shapiro S, Ware MA. Adverse effects physical health problems in early midlife: A longitudinal of medical cannabinoids: A systematic review. Can Med comparison of persistent cannabis vs. tobacco users. JAMA Assoc J 2008 Jun;178(13):1669–78. Psychiatry 2016 Jul 1;73(7):731–40. doi: 10.1001/ 9. Lynch ME, Campbell F. Cannabinoids for treatment of jamapsychiatry.2016.0637. chronic noncancer pain; a systematic review of randomized 28. Balayssac D, Zangarelli A. Association of cannabis trials. Br J Clin Pharmacol 2011 Nov;72(5):735–44. doi: smoking and periodontal disease. JAMA 2008 May 10.1111/j.1365-2125.2011.03970.x. 21;299(19):2273; author reply 2273-4. doi: 10.1001/ 10. Tan WC, Lo C, Jong A, Xing L, Fitzgerald MJ, Vollmer jama.299.19.2273-a. WM, Buist SA, Sin DD. Marijuana and chronic obstructive 29. Hujoel PP. Destructive periodontal disease and tobacco lung disease: A population-based study. CMAJ 2009 and cannabis smoking. JAMA 2008 Feb 6;299(5):574–5. Apr;180(8):814–20. doi: 10.1001/jama.299.5.574. 11. Zuardi AW. History of cannabis as a medicine: A 30. Lopez R, Baelum V. Cannabis use and destructive review. 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Rawal SY, Tatakis DN, Tipton DA. Periodontal and oral doi:10.1002/phar.1187. manifestations of marijuana use. J Tenn Dent Assoc 2012 16. Chu YWL. The effects of medical marijuana laws on Fall–Winter;92(2):26–31. illegal marijuana use. J Health Econ 2014 Dec;38:43–61. 33. Layman FD. Marijuana: Harmful or not? Tex Dent J 17. State Marijuana Laws in 2017 Map. www.governing. 1978 Jun;96(6):6–8. com. Accessed Nov. 9, 2016. 34. Baddour HM, Audemorte TB, Layman FD. The 18. Louisiana SB 217. medicalmarijuana.procon.org/ occurrence of diffuse gingival hyperplasia in a patient using sourcefiles/louisiana-sb271-enacted.pdf. marijuana. J Tenn Dent Assoc 1984 Apr;64(2):39–43.

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CDA JOURNAL, VOL 45, Nº9

Oral Lichen Planus Flares Triggered by Cow’s Milk in a Patient With Elevated IgE Antibodies to Milk

Nita Chainani-Wu, DMD, MS, PhD; Anuradha Nayudu, BDS; and Daniel Purnell, BA, MPH

ABSTRACT A female patient with painful oral lichen planus that required daily topical corticosteroids completely eliminated cow’s milk/milk products (CMP) from her diet. Her oral discomfort improved about two months later and had mostly resolved by eight months. Blood tests showed an elevation of total immunoglobulin E (IgE) and CMP-specifi c IgE antibody titers. Over the next seven years, she was largely asymptomatic when continuing to avoid CMP, with the occasional inadvertent ingestion that resulted in fl ares.

AUTHORS

Nita Chainani-Wu, DMD, year master of public health ral lichen planus Hepatitis C virus has been associated MS, PhD, completed student with an emphasis (OLP) is a chronic, with oral lichen planus in some studies, her doctor of medicine in in epidemiology at the immunologically although the causal relationship of dentistry at the University University of California, 6 of Pennsylvania, her oral Irvine. She is a graduate mediated, mucocutaneous HCV with OLP is uncertain. 1 medicine clinical training research assistant at the disease. The clinical Symptoms of lichen planus can and master’s degree at the Beckman Laser Institute in Opresentation includes white reticular range from none in the milder cases University of California, San Irvine. striations on the oral mucosa that may be to severe discomfort particularly in Francisco, and a master of Confl ict of Interest Disclosure: accompanied by erythema and erosions.2,3 patients with erosive changes.2,7,8 public health and doctorate None reported. of epidemiology at the In most patients with lichen planus, These symptoms can have significant 1 University of California, Daniel Prunell, BA, MPH, a cause is never identifi ed. Some effects on oral and general health Berkeley. Her clinical has a bachelor’s degree medications such as ACE-inhibitors as they may interfere with oral expertise includes lesions in psychology from the or NSAIDS can trigger lichenoid drug hygiene9 as well as with chewing and aff ecting the soft tissues of University of California, reactions, which may have similar clinical therefore prevent intake of a healthy the mouth, including oral Berkeley, and a master of 10 premalignant conditions, public health law in bioethics features as lichen planus. These reactions diet in patients with severe OLP. and she has a private clinical and human rights from usually occur soon after these medications Sensitivity to acidic and spicy foods practice in oral medicine. Boston University. He is a are started, although in some cases they is often a complaint, and sometimes Confl ict of Interest Disclosure: consultant and technical can occur after the patient has been these foods are erroneously identified None reported. writer at Coherent Logix Inc. on the medication for months or years. by the patient as the cause of their in San Jose, Calif. Anuradha Nayudu, BDS, Confl ict of Interest Disclosure: Confi rmation of a lichenoid reaction OLP or the cause of flare-ups of the completed her bachelor None reported. to a given medication is done clinically OLP. However, it is likely by the of dental surgery at the and in retrospect, if discontinuation nature of these foods that they may University of Nasik, India, of the medication results in resolution simply induce irritation of preexisting and is currently a second- of clinical signs and symptoms.4,5 lesions rather than be a true causative

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FIGURE 1A. FIGURE 1B. FIGURE 1C. FIGURES 1. Images from November 2006. Presence of white reticular lesions on buccal mucosa and gingiva. Erythema is seen on facial gingiva. Histopathology was “consistent with lichen planus.” factor. Conversely, foods that are and stopped using mouth rinse when with increased erythema of the oral soft and bland such as dairy products the symptoms started. She did not eat mucosa occurred. Soft acrylic trays may be identified by patients as hard candy or chew gum. She did not were fabricated in June 2007 for use noncontributory to the disease flares have any skin or vaginal symptoms. with the previously prescribed topical and even soothing and helpful.10 She reported a history of asthma and 0.025% fl uocinonide paste in order to In a literature search, we were hypothyroidism. Her only medications increase contact time of the topical unable to identify any published were daily Levoxyl and albuterol inhaler medication with the oral mucosa reports of a given food as a potential as needed. She was also on calcium while decreasing the amount ingested. causative factor in a case of oral supplements and a multivitamin. She Periodic worsening of symptoms, or lichen planus. This is the first report reported no known drug allergies. She fl are-ups, were well controlled using to our knowledge of a patient with reported no history of tobacco use the topical corticosteroids in the soft oral lichen planus, where ingestion and alcohol consumption consisted of acrylic trays over the next several of cow’s milk was identified as one to two glasses of wine per week. months of follow-up, however she a trigger for her oral flares and On examination, white reticular continued to have a chronically elimination of cow’s milk intake and lesions on the right and left buccal present low level of oral discomfort. any foods containing cow’s milk/ mucosa as well as white reticular In November 2007 in an attempt milk products (CMP) was followed by lesions and associated erythema on to identify a food-based trigger for significant and sustained resolution the upper and lower facial gingiva the flares, a dairy elimination diet of the clinical signs and symptoms were seen (FIGURES 1A–1C). The was discussed with the patient. She of lichen planus. Furthermore, IgE clinical impression was oral lichen was advised to refrain from cow’s testing showed an elevation in total planus. A biopsy of the right buccal milk and all milk products and foods IgE antibody levels and cow’s milk mucosa confi rmed the clinical containing milk. After two months of specific IgE antibody levels, and diagnosis of OLP. A board-certifi ed avoiding cow’s milk and milk products, occasional ingestion of cow’s milk oral pathologist read the biopsy she reported only slight improvement containing products (oral challenges) and it was consistent with OLP. in oral symptoms. However, at her resulted in recurrence of symptoms. Initial management included a six-month follow-up she reported swish-and-spit mouth rinse of an significant symptom improvement Case Report elixir of dexamethasone (twice per after continued avoidance of foods A 49-year-old female with a chief day) and application of a topical and beverages containing cow’s milk. complaint of “sensitivity in the mouth” 0.025% fl uocinonide paste (0.05% Notably, this improvement occurred was initially seen in November 2006. fl uocinonide ointment mixed with in spite of the patient being under She reported oral sensitivity of three equal parts Orabase-B) three times significant life stress, a factor that weeks’ duration. At onset, this was per day. At the one-month follow- she had previously identified as a only when brushing; however, the up, she reported some improvement trigger for her lichen planus flares. sensitivity had worsened over the past in symptoms and no adverse effects In October 2008, a blood test to week, especially when eating spicy or from the medication. She was measure total immunoglobulin E high-temperature foods. She reported continuing to refrain from spicy food. (IgE) levels as well as IgE levels to that she had not started any new However, over the next few months foods included in a standard food medications or toothpaste recently worsening of oral discomfort along panel was obtained. Two weeks

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FIGURE 2A. FIGURE 2B. FIGURE 2C. FIGURES 2. Images from August 2012. Signifi cant and sustained regression of clinical signs and symptoms of oral lichen planus. prior to the test, she was advised to containing cow’s milk. Overall, her along with antifungals such as nystatin consume milk and milk products. symptoms were reduced to the point can be used in patients with this However, she reported that she was where she could eat spicy foods with- complication who need continued unable to ingest much milk or milk out pain or discomfort. Oral mucosal use of topical corticosteroids. Other products during this time, as her OLP examination revealed signifi cant medication options include topical fl ared when she started to do so. reduction of gingival erythema and formulations of immunosuppressants The blood draw and testing was a regression of the white reticular like cyclosporine12 and tacrolimus.13 done at Quest Diagnostics laboratory lesions on her buccal mucosa High-dose oral curcuminoids extracted in Northern California. The total (FIGURES 2A–2C). She was advised to from turmeric (Curcuma longa) have immunoglobulin E level was elevated continue using topical fl uocinonide demonstrated effi cacy in control of at 795 kU/L, (normal range: < 114 paste on an as-needed basis for fl ares. OLP and have a good safety profi le.14 kU/L). Food-specifi c IgE antibodies to As of her follow-up in October In some instances where symptoms are the following common food allergens 2015, the patient’s symptoms remain severe and chronic, adjunctive steroid- were included in the standard food under good control. She continues to sparing agents such as mycophenolate panel: clams, egg whites, codfi sh, refrain from consuming cow’s milk or Mofetil or azathioprine are used in corn, milk, peanuts, scallops, shrimp, milk products. She uses fl uocinonide combination with corticosteroids15 soybeans, walnuts, wheat and sesame in case of fl ares. Her lichen planus And more recently biologics such seeds. The levels for all but milk lesions remain limited and stable as etanercept have been used.16 and egg whites were within normal and are confi ned to the gingiva with Some of these medications can have limits. Specifi c IgE levels to milk were the presence of minimal erythema. signifi cant toxicity and side effects elevated at 1.4 kUA/L. This is in the especially when used long term.17 Class 2 range (0.7 to 3.49, moderately Discussion If an environmental trigger for elevated level indicating that this food Management of symptomatic OLP was identifi ed for a given patient, is a probable contributing factor to oral lichen planus involves the use such that avoidance of the trigger total allergic load-per ImmunoCAP of anti-infl ammatory medications could result in control of symptoms, interpretive guidelines). Specifi c IgE to reduce discomfort and accelerate this would positively affect the levels to egg whites were also elevated healing of ulcerations. These health of the patient by alleviation at 0.9 kUA/L, within Class 2 range. medications may include topical of oral discomfort, the resultant At her follow-up examinations and systemic corticosteroids2,11 that improvement of oral hygiene and in 2009, she reported that she had are commonly used to control OLP nutrition and by eliminating the need been avoiding cow’s milk and milk symptoms. Systemic corticosteroids for potentially toxic medications. products completely but had continued have signifi cant side effects when Identifi cation of food triggers in eating eggs. She reported signifi cant used long term, therefore their use is oral lichen planus can be challenging, improvement in OLP symptoms, which limited to control of severe disease as it is an immunologically mediated she attributed to this dietary change. or for short-term use for control of condition likely involving cell She had also noted that on several acute fl ares. A common side effect of mediated delayed hypersensitivity occasions she experienced fl are-ups topical steroid use is oral candidiasis; mechanisms2 and there may be a time with worsening oral symptoms when therefore, compounded oral pastes lag between ingestion of the food and she had inadvertently consumed food containing topical corticosteroids exacerbation of symptoms and signs.

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Cow’s milk is a common food years have consistently resulted in REFERENCES allergen18 and has been identified exacerbations of symptoms of oral 1. Sugerman PB, Savage NW. Oral lichen planus: Causes, diagnosis and management. Aust Dent J 2002 as a possible trigger for autoimmune lichen planus. Therefore, there was Dec;47(4):290–7. PMID: 12587763. or immunologically mediated clinical evidence for the role of dairy 2. Chainani-Wu N, Silverman S Jr., Lozada-Nur F, Mayer conditions such as rheumatoid prior to blood testing for total and P, Watson JJ. Oral lichen planus: Patient profile, disease 19,20 21 progression and treatment responses. J Am Dent Assoc arthritis, atopic dermatitis, food-specific IgE levels, and the history 2001 Jul;132(7):901–9. PMID: 11480643. recurrent aphthous stomatitis,22 continues to indicate an ongoing 3. Canto AM, Müller H, Freitas RR, Santos PS. 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PMID: 22632394. weeks delay after dairy elimination both in adding to our understanding 13. Hodgson TA, Sahni N, Kaliakatsou F, Buchanan before noticeable improvement was of the pathogenesis of OLP and in JA, Porter SR. Long-term efficacy and safety of topical evident. However, within six to management of patients with OLP. tacrolimus in the management of ulcerative/erosive oral lichen planus. Eur J Dermatol 2003 Sep–Oct;13(5):466– eight months of dairy elimination Because dairy elimination is feasible 70. PMID: 14693491. the patient’s symptoms had almost for most patients and the role of 14. Chainani-Wu N, Collins K, Silverman S Jr. Use of resolved and she had significantly laboratory testing is unclear, at this time curcuminoids in a cohort of patients with oral lichen planus, an autoimmune disease. Phytomedicine 2012 Mar decreased topical steroid use. In it is reasonable to try dairy elimination 15;19(5):418–23. PMID: 22305276. addition, occasional oral challenges as an early step in management of 15. Verma KK, Mittal R, Manchanda Y. Azathioprine for with dairy that occurred when the patients with lichen planus, particularly the treatment of severe erosive oral and generalized lichen planus. Acta Derm Venereol 2001 Oct–Nov;81(5):378–9. patient ingested foods containing those with symptoms severe enough PMID: 11800155. dairy products over the last seven to require medications. ■ 16. Yarom N. Etanercept for the management of oral

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lichen planus. Am J Clin Dermatol 2007;8(2):121. PMID: 17428119. 17. Chainani-Wu N,Wu TC. Immunosuppressants. J Calif Dent Assoc 2008 Oct;36(10):775–9. PMID: 19044098. 18. Sackesen C, Assa’ad A, Baena-Cagnani C, Ebisawa M, Fiocchi A, Heine RG, VonBerg A, Kalayci O. Cow’s milk allergy as a global challenge. Curr Opin Allergy Clin Immunol 2011 Jun;11(3):243–8. PMID: 21522064. 19. Parke AL, Hughes GR. Rheumatoid arthritis and food: A case study. Br Med J (Clin Res Ed) 1981 Jun 20;282(6281):2027–9. PMID: 6788180. 20. Panush RS, Stroud RM, Webster EM. Food-induced (allergic) arthritis. Inflammatory arthritis exacerbated by milk. Arthritis Rheum 1986 Feb;29(2):220–6. PMID: 3513771. Free eDelivery. 21. Pourpak Z, Farhoudi A, Mahmoudi M, Movahedi M, Ghargozlou M, Kazemnejad A, Eslamnoor B. The role of cow milk allergy in increasing the severity of atopic dermatitis. Immunol Invest 2004 Feb;33(1):69–79. PMID: 15015834. 22. Besu I, Jankovic L, Konic-Ristic A, Raskovic S, Besu V, Djuric M, Cakic S,Magdu IU, Juranic Z. The role of specific cow’s milk proteins in the etiology of recurrent aphthous ulcers. J Oral Pathol Med 2013 Jan;42(1):82–8 PMID: 22924810. 23. Cavallo MG, Fava D, Monetini L, Barone F, Pozzilli P. Cell-mediated immune response to beta casein in recent- onset insulin-dependent diabetes: Implications for disease pathogenesis. Lancet 1996 Oct 5;348(9032):926–8. PMID: 8843812. 24. Carr R, Forsyth S, Sadi D. Abnormal responses to ingested substances in murine systemic lupus erythematosus: Apparent effect of a casein-free diet on the development of systemic lupus erythematosus in NZB/W mice. J Rheumatol Suppl 1987 Jun;14 Suppl 13:158–65. PMID: 3497268. 25. Yusoff NA, Hampton SM, Dickerson JW, Morgan JB. The effects of exclusion of dietary egg and milk in the management of asthmatic children: A pilot study. J R Soc Promot Health 2004 Mar;124(2):74–80. PMID: 15067979. 26. du Toit G, Meyer R, Shah N, Heine RG, Thomson MA, Lack G, Fox AT. Identifying and managing cow’s milk protein allergy. Arch Dis Child Educ Pract Ed 2010 Oct;95(5):134–44. PMID: 20688848. 27. David TJ, Waddington E, Stanton RH. Nutritional hazards of elimination diets in children with atopic eczema. Arch Dis Child 1984 Apr;59(4):323-5. PMID: 6721557. 28. O‘Loughlin S, Diaz-Perez JL, Gleich GJ, Winkelmann RK. Serum IgE in dermatitis and dermatosis: An analysis of 497 cases. Arch Dermatol 1977 Mar;113(3):309-15. PMID: 139128.

THE CORRESPONDING AUTHOR, Nita Chainani-Wu, DMD, MS, PhD, can be reached at [email protected]. Available for iPad, iPhone, Android or Kindle Fire. Check it out at cda.org/apps.

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CDA JOURNAL, VOL 45, Nº9

Pre-Eruptive Resorption in a Patient With DiGeorge Syndrome

Tory Silvestrin, DDS, MSD, MSHPE; Nasser Said Al Naief, DDS, MS; Dezhi Wang, MD, HTL, QIHC; and Leif K. Bakland, DDS

ABSTRACT DiGeorge syndrome (DGS) is associated with defects of the palate, truncus arteriosus and tetralogy of Fallot, as well as cognitive defects and neuromuscular problems. Pre-eruptive resorption (PER) is a rare resorptive entity found within the dentin in the occlusal aspect of an unerupted tooth. A literature search could not identify any previous report on a patient diagnosed with both DGS and PER. This case report details a patient with concomitant DGS and PER.

AUTHORS

Tory Silvestrin, DDS, Dezhi Wang, MD, HTL, arly diagnosis and treatment of The patient in this report had the MSD, MSHPE, is an QIHC, graduated medical pre-eruptive resorption (PER) is notable dental fi nding of PER along assistant professor of school at Shanghai Jiao important for dentists in order with a systemic disorder of DGS. An endodontics at the Loma Tong University and is a Linda University School laboratory manager in the to prevent progression of this extensive review of the literature did not of Dentistry. He holds a department of pathology at entity to a degree that could yield any reports of a similar combination dental degree, endodontic the University of Alabama Erender a tooth unrestorable. Many of conditions. While a connection certifi cate, a master of at Birmingham. general dentists acquire panoramic between the two conditions appears to science in dentistry and a Confl ict of Interest radiographs on growing patients, and be unlikely, the combination is unique master’s degree in health Disclosure: None reported. professions education. this is the ideal medium for initial and apparently not previously reported. Confl ict of Interest Leif K. Bakland, DDS, recognition of PER. This case report Disclosure: None reported. is a professor emeritus of discusses the occurrence of PER in Case Report endodontics at the Loma a patient with concurrent DiGeorge A 12-year-old girl in mixed Nasser Said Al Naief, Linda University School of syndrome (DGS). To our knowledge, dentition stage was found during routine DDS, MS, is chair of the Dentistry. He is a former department of pathology dean and department chair. this is the fi rst report of a patient with radiographic examination to have a and radiology at the He has also authored many concomitant DGS and PER. The pre-eruptive occlusal radiolucency in the Oregon Health Sciences texts and articles. importance of this study is to provide a mandibular left second molar (tooth No. School of Dentistry and Confl ict of Interest case report showing a possible association 18). She was in orthodontic treatment to the director of the oral and Disclosure: None reported. with DGS and dental anomalies correct a bilateral mandibular crossbite maxillofacial pathology laboratory. — specifi cally PER. Additionally, and her complaint was of intermittent, Confl ict of Interest this manuscript provides a literature spontaneous, dull throbbing pain in Disclosure: None reported. review of the prevalence, management her teeth after sugary drinks. Her and proposed etiologies of PER. dentist restored several teeth with

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CDA JOURNAL, VOL 45, Nº9

FIGURE 2. Radiographic image of extracted tooth No. 18 prior to decalcifi cation. The extent of tooth resorption can be seen as well as the presence of osteodentin within the resorptive area (arrow). Undiff erentiated pulp mesenchymal cells within the cell-rich zone terminally diff erentiate into FIGURE 1. Panoramic radiograph showing an intracoronal radiolucent lesion in the unerupted mandibular left odontoblast-like cells to deposit this osteodentin, second molar (tooth No. 18). which is composed of odontoblasts becoming trapped in a newly formed matrix and the tubular pattern becoming obscured and distorted causing the abnormal radiolucent appearance of this entity. carious lesions and her pain subsided. Six months after the surgical A subsequent panoramic radiograph exposure of the tooth, the patient showed the presence of a pre-eruptive returned and was referred for endodontic coronal radiolucency in tooth No. consultation. An extensive medical One hour prior to the dental 18 (FIGURE 1). A layer of bone was history was obtained that included a procedure, the patient took 2 g observed above the unerupted tooth. diagnosis of DGS, which was made amoxicillin as prescribed. Under nitrous The quality, coloration and hardness when she was 5 years old. DGS is an oxide sedation, she received local of the enamel on the affected tooth was autosomal dominant syndrome and is anesthesia of 3.4 mL, 2% lidocaine with clinically indistinguishable from the associated with the deletion of part of 1:100,000 epinephrine by left inferior other teeth in the patient’s dentition. chromosome 22.1 A feature of DGS alveolar nerve block and lingual and This was a contributing factor for the is tetralogy of Fallot, a condition buccal infi ltration. Tooth No. 18 was referral for evaluation of the patient, characterized by congenital cyanotic isolated with a dental dam and the as no one tooth in particular clinically cardiovascular malformations,1 for overlying enamel was removed with a appeared different than any other which her physician had recommended diamond bur under copious water spray, (i.e., no pathosis or developmental premedication with amoxicillin (2 g) exposing reddish, granular resorptive disturbance was noted). The deciduous one hour before any dental procedure. tissue underneath. After unroofi ng teeth presented no caries and the enamel She had also been diagnosed with the entire lesion, it was removed quality was indistinguishable from a asthma and had H1N1 fl u three years using spoon excavators. Along with patient with otherwise intact dentition earlier. Two years earlier, she had cardiac the lesion, some of the underlying and within normal limits on all teeth. surgery to manage her tetralogy of demineralized dentin was also removed Two options for managing the Fallot. Her list of medications included resulting in exposure of the dental pulp condition were presented to the patient furosemide (Lasix), an antihistamine in the mesiolingual area of the pulp and her guardian. One would be to (loratadine), spironolactone chamber. The extensive resorptive surgically expose the unerupted tooth (Aldactone), montelukast (Singulair) defect left insuffi cient tooth structure and remove the resorptive lesion. The and fl uticasone propionate (Advair for restoration, and the tooth was second option would be to wait for the Diskus). Based on the clinical and extracted using a Molt No. 9 periosteal tooth to erupt before removing the radiographic evaluations, a treatment elevator and a No. 151 extraction lesion. They chose the latter option plan was presented and accepted for forceps. The socket was irrigated with and returned one year later when the the management of the PER: Removal saline and covered with sterile gauze. tooth had partially erupted. The crown of the resorptive lesion to evaluate Hemostasis was confi rmed before the was then further exposed surgically, but the possibility for restoring the tooth. patient was dismissed and postoperative the patient delayed the return visit to Absent suffi cient coronal tooth instructions were provided to the have the resorptive lesion removed. structure, the tooth would be extracted. patient and her guardian. Postoperative

490 SEPTEMBER 2017 CDA JOURNAL, VOL 45, Nº9

evaluation 14 days later showed good healing. Because of her young age, tooth No. 17 was expected to erupt into the vacated No. 18 position. The extracted tooth was preserved with the guardian’s permission to be FIGURE 4. Ground section stained with methylene processed for histological evaluation. blue basic fusion special demonstrates globular FIGURE 3. Sections of the tooth stained with A radiograph taken of the extracted dentin and osteodentin deposition (arrow) within the Giemsa stain (left) and hematoxylin and eosin (right). tooth shows the extensive resorption resorptive region. Osteodentin and abnormal dentin is indicated by the FIGURE 2 of the crown ( ). arrows. Osteodentin is formed after injury to the pulp or irregular displacement of odontoblasts and can be Histological Evaluation a response to disrupted growth/eruption of teeth with The tooth was placed in a 15 ml altered biomechanical and developmental stresses. Eppendorf tube with 70% ethanol This osteodentin has a sparse and irregular tubular and subsequently bisected using a pattern with some cellular inclusions. diamond coated blade. One of the halves was decalcifi ed using 4.3% ethylenediaminetetraacetic acid, of the parathyroid gland, respectively.1 the progression may slow down before as described by Cho et al.2 and Cardiovascular abnormalities are the tooth erupts.9 The unpredictable subsequently embedded in paraffi n, also characteristically present.1,6–7 nature of PER is illustrated in a and then two 4μm-thick sections were Aside from several systemic and report by Holan et al.11 who found obtained, one of which was stained with developmental abnormalities associated resorption involving the pulp before hematoxylin and eosin stain and the with this condition, patients also the tooth erupted, suggesting that other was stained with Giemsa stain.3 present with characteristic craniofacial the progression of the resorptive Both stains delineated the presence features, including hypertelorism, lower action may increase at the time of of a prominent resorptive area in the than usual ear lobes, downward eye eruption. In most cases, however, the tooth crown and also the deposition slanting, micrognathia, cleft palate and lesions extend no further than two- of abnormal dentin and osteodentin a broad nose.1 Additional craniofacial thirds of the dentin thickness.12 (FIGURE 3). The other specimen half conditions of DGS include delayed After teeth with PER are fully was sectioned and grinded into an tooth development and eruption of erupted, it is diffi cult to differentiate about 30μm-thick section by using permanent teeth as well as enamel PER from occlusal caries.13 In an EXAKT Cutting and Grinding hypoplasia. Further, histomorphological the absence of bacteria, however, system (EXAKT Technologies, examinations of patients’ dentitions occlusal carious does not occur prior Norderstedt, Germany) and stained often display increased calcifi cation to eruption.14 It can also be diffi cult with methylene blue and basic fusion of the dentin and deposition of to differentiate PER from external stain, demonstrating the deposition osteodentin within the pulp.8 resorption. McNamara15 reported of globular dentin/osteodentin within PER appears as a radiographic lesion on a case of a molar with apparent the resorptive area (FIGURE 4).4,5 adjacent to the dentinoenamel junction intracoronal resorption that upon in the occlusal aspects of the crown histological examination after Discussion and is often an incidental fi nding on extraction appeared to have an occlusal DGS is a very rare embryologic radiographs of unerupted teeth.9 The developmental pit communicating with disorder, characterized by defects in radiographic appearance usually shows the resorptive defect in the underlying tissues derived from the third and teeth with thin occlusal enamel and dentin. Another possible differential fourth branchial arches and pouches radiolucent areas toward the mesial diagnosis has been Turner’s hypoplasia, and accompanied by cellular immune aspects of the crowns,10 which was not but many of the patients diagnosed defi ciency, hypocalcemia as a result of the case in this report. The resorptive with PER lesions have no history of thymic aplasia (hypoplasia) and agenesis lesions appear to be progressive, but previous infection of primary molars.9

SEPTEMBER 2017 491 digeorge syndrome

CDA JOURNAL, VOL 45, Nº9

Clinically, the enamel in teeth with lacunae but with no evidence of caries suggestion has been that PER could PER appears thin, and radiographically or microbiota.14 Clinical symptoms be due to abnormal development of the undermined dentin and enamel are most often absent even if the pulp the crown follicle, though no data is have a shell-like appearance. Below has become involved.10 However, available to support that.18 It has also the occlusal enamel, the lesion Brunet-Llobet et al.16 presented a case been thought that the pathogenesis appears as soft red tissue with a of severe pain attributed to PER. of this lesion is due to local pressure different texture and appearance The etiology of PER has not been from eruption causing the resorptive than carious dentin. Histologically, fi rmly established. One suggestion entity,18 and possibly that invasion the resorptive lesion is composed of has been that damage to the reduced of resorptive cells through minor loose fi bromyxoid tissue containing enamel epithelium of the developing defects in enamel can lead to the islands and strands of odontogenic tooth may allow invasion of cells from pre-eruptive resorption.15,17,19–20 epithelium as well as infl ammatory the periodontium leading to PER.13 There have been many case reports cells (including multinucleated giant That possibility has been questioned on PER in permanent teeth.11,14,20,21–27 cells, osteoclasts and other chronic because of absence of observed The most frequently affected tooth infl ammatory cells) and resorption developmental defects.17 Another is the permanent mandibular second molar.24 A recent case series showed a 5:1 ratio of the mandible versus the maxilla.17 Permanent maxillary second premolars are the second most frequent Compounding Pharmacy for Dentists teeth and anterior teeth are the least frequent ones.10 PER predominantly involves single teeth,28,29 but a case Why choose a compounding pharmacy? of multiple involved teeth has been Through our pharmacy you can obtain: reported.30 The prevalence of PER has been reported to be 0.5–6 percent, 9 Powerful topical anesthetics with higher strengths but this percentage is greater when 9 Combinations of effective ingredients in customized formulations third molars are included.9,13,14 The 9 Dental products that are not commercially available presence of PER is not related to the sex or race of patients,13 nor to their Compound Topical Anesthetics medical status, but a recent case report of a patient with amelogenesis 9 Multiple flavors imperfecta and multiple PER lesions 9 Extra-thick gel or plasticized ointment base suggests that there may be a link Topical Anesthetic Formulations Include: between this systemic condition and t
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492 SEPTEMBER 2017 CDA JOURNAL, VOL 45, Nº9

pre-eruptive resorption treated with REFERENCES unerupted mandibular molar. Am J Orthod Dentofacial Orthop surgical exposure of the unerupted 1. Conley ME, Beckwith JB, Mancer JF, Tenckhoff L. The 2005;127:67–71. spectrum of the DiGeorge syndrome. J Pediatr 1979;94:883– 21. Yaqoob O, DiBiase AT, Kane R, Fleming PS. Pre-eruptive tooth, removal of the resorptive 90. coronal resorption of a maxillary canine: A case report. tissue, pulpotomy and restoration 2. Cho A, Suzuki S, Hatakeyama J, Haruyama N, Kulkarni AB. Orthodontics 2011;12:148–51. with glass ionomer and amalgam. A method for rapid demineralization of teeth and bones. Open 22. Manan NM, Mallineni SK, King NM. Case report: Dent J 2010;4:223–9. Idiopathic pre-eruptive coronal resorption of a maxillary Others have suggested simply placing 3. Molina DM, Oporto JA. Comparative study of dentine permanent canine. Eur Arch Paediatr Dent 2012;13:98–101. a sealant on the occlusal surface of staining techniques to estimate age in the Chilean dolphin, 23. Counihan KP, O’Connell AC. Case report: Pre-eruptive the affected tooth and monitoring Cephalorhynchus eutropia (Gray, 1846). Aquatic Mammals intracoronal radiolucencies revisited. Eur Arch Paediatr Dent 1993;19:45–8. 2012;13:221–6. the site for progression of the lesion 4. Luque PL, et al. Comparison of two histological techniques 24. Johnson M, Harkness M. Pre-eruptive coronal radiolucency and have reported success over a for age determination in small cetaceans. Mar Mammal Sci in a mandibular premolar: A case report and literature review. period of fi ve or more years.18,23,33 2009;25:902–19. N Z Dent J 1997;93:84–6. 5. Kvaal SI, Solheim T, Bjerketvedt D. Evaluation of preparation, 25. Dowling PA, Fleming P, Corcoran F. A case report of Extraction creates associated problems staining and microscopic techniques for counting incremental pre-eruptive coronal resorption in a mandibular canine. Dent in a growing child that need both lines in cementum of human teeth. Biotech Histochem Update 1999;26:444–5. short- and long-term attention. 1996;71:165–72. 26. Keetley DA. A case report of pre-eruptive coronal 6. Fukui N, Amano A, Akiyama S, Daikoku H, Wakisaka S, resorption in a mandibular canine. Dent Update 2000;27:100. Patients with DGS have early Morisaki I. Oral fi ndings in DiGeorge syndrome: Clinical 27. McEntire JF, Hermesch CB, Wall BS, Leonard DL. Case childhood hypocalcemia, which is features and histologic study of primary teeth. Oral Surg Oral report: Pre-eruptive intracoronal resorption. Oper Dent often associated with autism-related Med Oral Pathol Oral Radiol Endod 2000;89:208–15. 2005;30:553–6. 7. Bockman DE, Kirby ML. Dependence of thymus development 28. Nik NN, Abul Rahman R. Pre-eruptive intracoronal dentin behaviors and may contribute to on derivatives of the neural crest. Science 1984;223:498– defects of permanent teeth. J Clin Pediatr Dent 2003;27:371– hypocalcemia of developing teeth.34 500. 5. If developing teeth lack the requisite 8. Soejima Y IM, Shinji H, Tsukamoto S, Motokawa W. Dental 29. Seow WK, Wan A, McAllan LH. The prevalence of fi ndings of DiGeorge syndrome: Report of a case. Jpn J Pediatr pre-eruptive dentin radiolucencies in the permanent dentition. hard tissue to form correctly during Dent 1995;33:1109–16. Pediatr Dent 1999;21:26–33. odontogenesis, then potentially this 9. Ari T. Management of “hidden caries:” A case of severe 30. Seow WK. Multiple pre-eruptive intracoronal radiolucent could explain the concomitant fi nding pre-eruptive intracoronal resorption. J Can Dent Assoc lesions in the permanent dentition: Case report. Pediatr Dent 2014;80:e59. 1998;20:195–8. of DGS and PER in the patient. 10. Hata H, Abe M, Mayanagi H. Multiple lesions of 31. Miloglu O, Karaalioglu OF, Caglayan F, Yesil ZD. Pre- Dentin dysplasia is an unlikely intracoronal resorption of permanent teeth in the developing eruptive coronal resorption and congenitally missing teeth in a diagnosis given that the pathosis dentition: A case report. Pediatr Dent 2007;29:420–5. patient with amelogenesis imperfecta: A case report. Eur J Dent 11. Holan G, Eidelman E, Mass E. Pre-eruptive coronal 2009;3:140–4. appears to be isolated to a single resorption of permanent teeth: Report of three cases and their 32. Davidovich E, Kreiner B, Peretz B. Treatment of severe pre- tooth, rather than the most common treatments. Pediatr Dent 1994;16:373–7. eruptive intracoronal resorption of a permanent second molar. presentation of dentin dysplasia 12. Brooks JK. An unusual case of idiopathic internal root Pediatr Dent 2005;27:74–7. resorption beginning in an unerupted permanent tooth. J Endod 33. Czarnecki G, Morrow M, Peters M, Hu J. Pre-eruptive manifesting in all teeth due to its 1986;12:309–10. intracoronal resorption of a permanent fi rst molar. J Dent Child autosomal dominant inheritance 13. Seow WK. Pre-eruptive intracoronal resorption as an entity 2015;81:151–5. pattern.35 Given that this case of occult caries. Pediatr Dent 2000;22:370–6. 34. Muldoon M, Ousley OY, Kobrynski LJ, Patel S, Oster 14. Spierer WA, Fuks AB. Pre-eruptive intracoronal resorption: ME,Fernandez-Carriba, et al. The eff ect of hypocalcemia in presents an isolated tooth with Controversies and treatment options. J Clin Pediatr Dent early childhood on autism-related social and communication PER in a patient with DGS, it is 2014;38:326–8. skills in patients with 22q11 deletion syndrome. Eur Arch much more plausibly related to the 15. McNamara CM, Foley T, O’Sullivan VR, Crowley Psychiatry Clin Neurosci 2015;265(6):519–24. N, McConnell RJ. External resorption presenting as an 35. Li F, Liu Y, Liu H, Yang J, Zhang F, Feng H. Phenotype patient’s existing syndrome rather intracoronal radiolucent lesion in a pre-eruptive tooth. Oral Dis and genotype analyses in seven families with dentinogenesis than attributed to dentin dysplasia. 1997;3:199–201. imperfecta or dentin dysplasia. Oral Dis 2016;doi10.1111/ This report of a patient with PER 16. Brunet-Llobet L, Lahor-Soler E, Miranda-Rius J. Oral pain odi/12621 [Epub ahead of print]. due to severe pre-eruptive intracoronal resorption in permanent concomitant with a diagnosis of DGS tooth. Eur J Paediatr Dent 2014;15:332–4. THE CORRESPONDING AUTHOR, Tory Silvestrin, DDS, MSD, appears to be the fi rst such report in 17. Kjaer I, Steiniche K, Kortegaard U, Pallisgaard C, Bille MSHPE, can be reached at [email protected]. the literature. Abnormalities in the ML, Seirup T, et al. Pre-eruptive intracoronal resorption observed in 13 patients. Am J Orthod Dentofacial Orthop dentin that have been reported in 2012;142:129–32. patients with DGS previously were 18. Moskovitz M, Holan G. Pre-eruptive intracoronal also seen in this patient with PER. radiolucent defect: A case of a nonprogressive lesion. J Dent Child 2004;71:175–8. Thus, a possible link between the 19. Blackwood HJ. Resorption of enamel and dentine in systemic condition of DGS and PER the unerupted tooth. Oral Surg Oral Med Oral Pathol warrants further investigation.8 ■ 1958;11:79–85. 20. Klambani M, Lussi A, Ruf S. Radiolucent lesion of an

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 RM Matters CDA JOURNAL, VOL 45, Nº9

Informed Consent: More Than Just a Form TDIC Risk Management Staff

common allegation in many The Dentists Insurance Company Sillis recounts a case in which a professional liability claims is reminds dentists that while informed dentist was sued for causing injury the lack of informed consent. consent discussions vary from treatment to the inferior alveolar nerve from a Patients argue that had they to treatment, information should third molar extraction. The dentist known about the possibility always include the following: had used a standard informed consent Aof complications, they would have made ■ The nature of the form that included nerve damage as a different decision regarding their dental recommended treatment. a potential risk; however, the form treatment. One of the best ways dentists ■ The risks, complications and benefi ts did not include the potential for can protect themselves in these cases is of the recommended treatment, permanent injury to the nerve. by ensuring patients are armed with the including the likelihood of success. “Simply adding that term on the facts needed to make informed decisions. ■ The alternatives to that treatment, form would have successfully defended Informed consent requires a dentist including doing no treatment. against that claim,” Sillis said. to explain the likelihood of success of ■ An explanation of the treatment In another case, a patient claimed a given procedure and its risks, benefi ts plan’s expected sequence of events. the dentist performed root canal therapy and alternatives. A dentist, not a staff member, must lead this conversation. The amount of time spent discussing options and answering a patient’s questions depends on the level of risk. Higher risk levels and more invasive treatments are two indicators that more time and detail should be spent informing the patient about the risks, benefi ts and alternatives to You are not treatment, including no treatment at all. a sales goal. “Informed consent is not a form. It is a conversation,” said John Sillis, an attorney at Zaro & Sillis in Sacramento, Calif. “Whether you use consent forms for each procedure or write the information in the patient’s chart, you as the doctor must have some measure of a conversation with the patient about the risks, benefi ts and alternatives of the proposed treatment.” Sillis says the discussion of risks, You are a dentist deserving of an insurance company relentless benefi ts and alternatives, or RBA, should in its pursuit to keep you protected. At least that’s how we see be documented in the chart as “RBA it at The Dentists Insurance Company, TDIC. Take our Risk discussed and questions answered” or Management program. Be it seminars, online resources or our “RBAQA.” To prove the discussion Advice Line, we’re in your corner every day. With TDIC, occurred, dentists are advised to establish you are not a sales goal or a statistic. You are a dentist. a custom and a practice; that is, a habit in the way they practice. While a dentist may have trouble recalling ® the details of a specifi c case, they can Protecting dentists. It’s all we do. convey the typical protocol that they 800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783 would customarily employ for the procedure, even years later, Sillis added.

SEPTEMBER 2017 495 SEPT. 2017 RM MATTERS

CDA JOURNAL, VOL 45, Nº9

unnecessarily. The teeth in question additional treatment up to and including parents can be problematic so proceed had received several restorations for extraction or simply had the discussion with caution. It should also be noted recurrent caries. Though the risk of orally with the patient, including that that dentists cannot charge patients for pulpal involvement was possible due to information and then noted it in the a sign language interpreter and dentists the extent of the old restorations, the chart, ‘RBA discussed,’” Sillis said. who are subject to ACA 1557 must dentist did not use a consent form nor did According to TDIC, informed consent provide for language translation. he document that he had discussed this discussions are often complicated by TDIC also reminds dentists that only possibility with the patient. The teeth language barriers. If a patient is hearing a legal guardian can provide consent for remained symptomatic and required root impaired, the dentist is obligated to minor patients. For divorced parents, canal therapy and the patient fi led suit. provide a sign language interpreter. this means only the parent with legal “The dentist could have avoided If the patient speaks a language not custody. If in doubt, TDIC recommends the suit by either having used a spoken by the dentist, insurance requesting legal documentation of prepared consent form that included providers are required to provide a custody. Emancipated minors can language that the treatment may not translator. The practice of allowing provide their own informed consent. resolve the symptoms and may require minor children to translate for the Although patients ultimately decide which treatment avenues to take, their signed forms aren’t always enough to protect a dentist from liability. Patients cannot consent to substandard care, whether or not they sign forms, nor should a dentist practice below the standard of care at patients’ requests. Conversely, a dentist should not continue to treat patients who continue to refuse recommended treatment and should consider dismissing them from care following a formal dismissal protocol. Procedure-specifi c informed consent forms in multiple languages are available to TDIC policyholders. To download, visit tdicinsurance.com/ risk-management/informed-consent. Making an informed decision is the right of every patient, but it is the responsibility of dentists to ensure patients have the comprehensive information needed to exercise that right. Patients have numerous options when it comes to their oral health and only with thorough considerations of the risks, benefi ts and alternatives can they truly provide informed consent. ■

TDIC’s Risk Management Advice Line at 800.733.0633 is staffed with trained analysts who can answer informed consent and other questions related to a dental practice.

496 SEPTEMBER 2017 CARROLL “Matching the Right Dentist to the Right Practice” C &COMPANY 4150 SANTA CRUZ COUNTY GP 4185 SILCON VALLEY ORTHO Seller retiring from successful 33 year general practice. Fee- Compact, well-run practice available due to relocation. for-service only practice. Fully-equipped 4 op facility in Established 23 years in convenient, high traffic location near beautiful, remodeled Seller owned building. Buliding also for major routes. 1,100 sq. ft. leasehold with reception, waiting sale. room, 3 chairs, exam room, lab/sterilization area, storage area, private office + bathroom, patient bathroom. 2.5-day 4162 PETALUMA GP doctor week offers ample opportunity to expand. Asking Retiring Seller looking to transition a stable and loyal patient $186k. base. Averaging 10-15 new patients per month with 2 dedicated days of hygiene and approx. 3 doctor days per 4171 PLEASANTON GP week. 2016 Gross Receipts $304K+. Asking $150K for Put the "pleasant" in Pleasanton. Well-established, 25 year practice. 7 ops (5 fully equipped) in 2,400 sq. ft. Single family practice in a rapidly growing community with small story, stand alone dental building available to purchase, or town flavor. BeautifullyNG remodeled office with 5 ops., Seller will supply long-term lease with a Right of First receptionD area,I business office, private office, staff lounge Refusal to buy the building. andE dedicatedN parking. Seller transitioning to retirement, workingP 4 doctor days per week. 5 year average GR $509K 4145 ROSEVILLE GP +. Seller owned 1,700 square foot condominiumized suite Well-established GP offering 27+ years of goodwill. Owner for sale with practice. Asking price for practice $313K. relocating out of the area. General & Cosmetic Practice with 6 fully equipped ops. Lots of upgraded/newer 4127 MENLO PARK GP equipment. Opportunity to purchase single story 2,700 sq. GP offering 35+ yrs of goodwill, this gem on the Peninsula ft. stand-alone professional bldg. Asking price for the is truly a find.N 4G ops in 950 sq. ft. 2016-2014 average GR Practice $520K. $567K withDI average adj. net of $156K. 750+ active patients.EN 4 hygiene days a week generate 40-45% of the 4129 PETALUMA GP revenue.P Asking $417K. GP located in stunning 1,856 sq. ft. seller owned facility. State-of-the-art office includes 6 ops, staff lounge, 4108 HUMBOLDT COUNTY GP reception area, private office, business office, lab area, Well-established, high performing general practice boasts 6 sterilization area, consult room, separate storage area, fully equipped ops. in 2,900 sq. ft. free standing office w/ bathroom plus private bathroom. Asking $525K. Digital X-L ray,D 2 platinum Dexis sensors, & Cerec Omnicam & MCXLSO units. Perfect for a dentist who wants to escape 4169 NAPA GP the grind and live along the coastline. 2016 GR $1.5M+. General practice inN sellerG owned building in a prime location. Asking $995K. Remodeled, state-of-the-art,DI 2,000 square foot, beautiful office withE 7N ops. Over 2,000 loyal patients. Asking $817K. UPCOMING: P Mid-Peninsula Endo, San Mateo GP, Sonoma County 4177 SAN JOSE PROSTHO Perio & San Bruno GP Implant, cosmetic and prosthodontic practice, established 25+ yrs in desirable West San Jose area close to several amenities and referral sources. Ideal for the restorative general dentist inspired by cosmetic and implant dentistry, or a prosthodontist. 3 fully equipped ops in 1,600 square ft. Bright and modern treatment rooms in well established professional medical building. Lots of on-site parking, EZ freeway access. 3 yr. average GR $1.2M+ with adjusted average net of $500K+ Asking $813K.

4133 NAPA GP Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll Napa County GP in newly furnished, fully equipped 2 op facility with digital x-ray. 4 doctor day/week with 3 hygiene Carroll & Company days. Monthly average revenue of $36K. Seller willing to 2055 Woodside Road, Suite 160 help for a smooth transition. Asking $331K. Redwood City, CA 94061 BRE #00777682

carroll.company [email protected] (650) 362-7004 (650) 362-7007 DENTAL PRACTICE BROKERAGE Making your transition a reality.

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PRACTICE SALES • PARTNERSHIPS • MERGERS • VALUATIONS/APPRAISALS • ASSOCIATESHIPS • CONTINUING EDUCATION

NORTHERN CALIFORNIA SAN FRANCISCO: )LQDQFLDO'LVWULFWRI¿FH /26$1*(/(6: 3ULFH5HGXFHG! 3HULR 7(0(&8/$: New Listing! 2SV 3UDFWLFH2SV

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What You Need To Know To Conduct a HIPAA Risk Analysis CDA Practice Support Staff

risk analysis of a dental Inventory Information Assets practice’s electronic Begin the process by identifying information systems and listing where and who holds the combined with a risk The dental practice’s dental practice’s ePHI. Examples management plan are designated HIPAA security of where ePHI can be held include Asignifi cant and necessary elements server, workstations, off-site back-ups, for HIPAA compliance. What is a offi cer should complete portable drives, laptop computers, HIPAA risk analysis? It is a process both analysis and plan. smartphones, photocopiers, email with which a covered entity evaluates service provider, claims clearinghouse, risks to the confi dentiality, integrity appointment reminders service and availability of electronic patient providers and off-site bookkeepers. information (ePHI). Although it is required, a risk analysis is missing or incomplete from many covered entities’ compliance programs. A review of enforcement actions taken by the U.S. Department of Health and Human Services Offi ce of Civil Rights (OCR) indicates many covered entities fail “to conduct an accurate and thorough risk analysis to assess the potential risks and vulnerabilities to the confi dentiality, integrity and availability of ePHI and failed to plan for and implement You have goals. security measures suffi cient to reduce those risks and vulnerabilities.” PARAGON can help you reach them. This article describes the steps a dental practice should take to complete Are you thinking of buying a dental practice, merging, or selling the assessment. Next month, this column your practice? The future you want is closer than you think. will review what needs to be included Our guidance makes all the difference. in a security risk management plan. The dental practice’s designated HIPAA 7DNH\RXUQH[WVWHSZLWKFRQ´GHQFH security offi cer should complete both &DOO3$5$*21WRGD\ analysis and plan and may use the services of an external information technology Your local PARAGON (IT) advisor if needed. A thorough dental transition consultant Trish Farrell discussion of the risk analysis process can be found on the Security Rule Guidance

Material page of the hhs.gov website, Approved PACE Program Provider 866.898.1867 FAGD/MAGD Credit www.hhs.gov/hipaa/for-professionals/ Approval does not imply acceptance [email protected] by a state or provincial board of dentistry or AGD endorsement security/guidance/index.html. paragon.us.com 4/1/2016 to 3/31/2020 Provider ID# 302387.

SEPTEMBER 2017 499 SEPT. 2017 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 45, Nº9

TABLE 1 Items to Document/Assess

Information Assets Threats Vulnerabilities Server Theft/burglary Security patches not applied Desktop computers, on-site Loss of power or electrical issue Inadequate anti-malware protection Back-up, on-site Flooding Unsecure network confi guration Back-ups, off -site/cloud Water damage from pipe leak Unsecure wireless router Laptop computers Earthquake Lack of administrative policies, e.g.: ■ ePHI disposal Tablets Fire ■ Equipment repair Smartphones Computer virus, malware ■ Unique user ID Photocopier Ransomware ■ Device removal Third-party service providers Network connectivity issue ■ Software Employee, accidental or intentional acts ■ Appointment reminders ■ Patient portal Hacker ■ Billing ■ Collections ■ Claims clearinghouse

Identify and list by role (for TABLE 2 example, hygienist, bookkeeper, Threat Occurrence/Impact on Practice software tech) who has access to ePHI and the respective level of 1 Low impact 2 Medium impact 3 High impact access. Identify and list the entities 1 Low risk 2 3 4 with whom the practice needs to have a HIPAA business associate 2 Medium risk 3 4 5 agreement and whether one is in 3 High risk 4 5 6 place. It is a good idea to include on the list contact information and effective and termination and new vulnerabilities are discovered and the impact it would have on the dates or respective agreements. over time, so a covered entity is not practice. Is the threat occurrence risk List the hardware and software expected to fi x each and every one. A low because employees are trained that store or use ePHI. Make note covered entity is expected to do the best to beware of phishing emails or is it of the software version and the date it can with the resources at hand and a medium risk? If a practice is hit by when security patches were applied. is not required to take extraordinary ransomware, will the impact be low, measures to address a vulnerability. medium or high? A dental practice’s Identify and Assess Threats and Make a list of natural, human and ability to quickly restore its data Vulnerabilities environmental threats to information and remove the malware, as opposed A “threat” to an information systems under the control of the dental to stopping ransomware, makes system can be a person or thing that, practice. Examples are numerous the impact to the practice low. intentionally or not, uses a system and include fi re, earthquake, water This process forces the consideration vulnerability to compromise ePHI. damage, power outage, disgruntled of consequences and whether the A “vulnerability” is a weakness in employee, employee error, hacker and practice has appropriate safeguards in system security procedures, design, theft (TABLE 1). Assess each threat for place to mitigate impact. Safeguards implementation or internal controls, for the likelihood of occurrence and the include physical items (a lock or offi ce example, an unsecured wireless network impact on the practice. For example, wall, for example), technical solutions or unknown backdoor to the practice consider the likelihood of an employee (encryption) and administrative database. It is diffi cult to know every mistakenly clicking on a phishing policies and procedures (no sharing vulnerability in an information system email that downloads ransomware CONTINUES ON 502

500 SEPTEMBER 2017 Specialists in the Sale and Appraisal of Dental Practices Practices Serving California Dentists since 1966 How much is your practice worth?? Wanted Selling or Buying, Call PPS today!

NORTHERNNORT CALIFORNIA SOUTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6130 MARIPOSARIPOSA Relaxed lifestyle in Sierra Foothill cocommunity.mm ANAHEIM – NEAR DISNEYLAND 4-ops. Grosses $40,000+/mth. 2016 collected $1 Million. Extremely strong Hygiene Department. Includes building. Full Price $650,000. Seller can work-back if Buyer desires. ANTELOPE VALLEY Prior DDS grossed $1.8 Million. 60,000 6129 35267+2'217,& PRACTICE – SAN MATEO 2016 autos pass intersection daily. $80 Billion in government contracts will collected $775,000 on 3.5 day week. Beautiful 5-op office. make this highest growth area in SoCal next 10-years. New DDS  overwhelmed. Will work back for MSO or Specialist. Renovated 8 op Excellent candidate for acquisition by nearby practice. Seller shall office. Working Owner will net $500,000 at $1.5 Million, and work back to assist in orderly transition. Acquire here or move into $800,000 when grossing $2 Million. Full Price $250,000. nearby practice. Choice is yours. ANTELOPE VALLEY Established 50 years. Absentee Owner. 6128 LOS GATOS AREA Capitation & PPO. 3-Adec equipped Grossing $1 Million. 6 ops. Rent $2,000/month. Full Price $800,000. ops, Pano, Digital charting. Collects $420,000+ year. Available BAKERSFIELD 50 year old practice and renovated building. 10,000 Profits of $190,000 in 2016. sq.ft. lot. 5 ops. Grosses $400,000-to-$600,000. Seller will let you work 6127 SAN RAFAEL’S NORTHGATE Collected $210,000 in before buying. Practice and RE $685,000 includes AR. 2016 on part-time schedule. Available Profits of $106,000. BURBANK / GLENDALE Absentee Seller. Grosses $1-to-$1.2 6126 FRESNO Located at busy intersection. Collected $616,000 Million. 6 ops. Gorgeous high identity corner building. Refers Endo, with profits of $364,000. 4-Ops. OS, Implants. $300,000 in recent renovations. Full Price 85% of Gross. CERRITOS – EMERGENCY SALE Grossing $450,000. 3 Hygiene 6125 OAKLAND AREA Collections average $735,000 per year. days. Digital with Pano. Well equipped for Implants. Full Price High income zip code with well employed Millennials next door. 10 $350,000. + new patients per month. Digital and paperless. DIAMOND BAR 5-Ops. Grosses $500,000. 6124 SAN RAMON 100% Out-of-Network. 5-Ops. 6-days of INLAND EMPIRE - EMERGENCY SALE Shopping Center. Hygiene. $700,000 per yearSOLD performer. Operated by part-time Associate. Fantastic staff. Grossing $350,000. 6122 SANTA CLARA - STARBUCKS "LIKE" LOCATION! Owner-Operator will do $500,000+. 5-Ops plumbed, 3 equipped. Best exposure in beautiful strip center. Office just remodeled. 5- Gorgeous office. Full Price $350,000. Ops. 2017 trending $1 Million in Collections on 4-days. Perfect INLAND EMPIRE - EMERGENCY SALE High identity Target platform to operate 6-days a week. Wants to do $1.5-to-$2 Million. Center. Grosses $1 Million. No marketing. 5-days Hygiene. 200,000 6121 NAPA VALLEY FAMILY PRACTICE Highly respected autos pass daily. Recently renovated at cost of $300,000. Bargain. community asset. Collections last 5-years have averaged $1.28 IRVINE / SANTA ANA Vons Shopping Center. 10-years old. Grosses $50-to-$60,000/month. Seller will work back 2 days. Near Million per year. Beautiful facility. Condo optional purchase. South Coast Plaza. Lots of new patients. Success assured. 6120 OAKLAND’S PIEDMONT AREA Highly coveted area. LAKE ELSINORE - HMO Established 40 years. Popular Seller Right off Highway 13. 3-daysSOLD of Hygiene. 4-Ops with 5th available. wants to work back 2 days. Grossing $550,000. Lots of room to go to 2016 collected $650,000+. $800,000 first year. 6 Ops. Low rent. 6119 NORTH BAY ORTHO Desirable family community. Best LOS ANGELES BEACH CITY Grossing $2.4 Million. Private & technology, cone beam and paperless. Owner works part-time. PPO. Building available. Seller requires work back contract. Take Revenue streams averaged $775,000/yearSOLD in past. Strong profits. home Net of $1 million. Full Price $2.4 Million. Bank approved Does no marketing to local Dental Community. Financing. 6118 SAN FRANCISCO’S EAST BAY Forty percent partnership LOS ANGELES - HMO Grossing $1.5 Million. in well positioned and branded practice. 2016 collected $2.53 NEWPORT BEACH’S FASHION ISLAND - “Coming Up!” Contact Million. 2017 trending $3.2+ Million in collections. Full Tom Fitterer and register interest. ORANGE COUNTY BEACH CITY - HMO Grossing $1.5 Million. complement of specialties. 6-month Trial Association wherein Full Price $1.3 Million. Hands-on Owner will do $2 Million. interested Candidate shall see ability to make $350,000+ per year. PEDO - PASADENA AREA Refers 30-to-40 ortho patients per 6107 EUREKA 100% Out-of-Network with insurance industry. month. Grossing $450,000. Low overhead. Fantastic for GP Group. 2016 collected $930,000+ on Doctor’s 20-hour week. Doctor's Full Price $390,000. Building available. schedule booked 3-months out.SOLD 7+ days of Hygiene. Highly SAN FERNANDO VALLEY Established 40-years. Recently respected. Full Price $250,000. Condo is optional purchase. renovated with best. Absentee Owner. Previously did $1 Million. 6 ops. 6098 WEST PETALUMA The business center of the North Bay! Grossing $550,000. Business parks are growing and young families are drawn to this TORRANCE Strip center on Hawthorne. 3 ops. Grosses $300,000. great family community perSOLD unique amenities of this historic river Refers Endo, OS, Implants, Perio and Ortho. Close to Palos Verdes. city. Collected $468,000 with Profits of $212,500. 4-days of Full Price $295,000. Hygiene. 6089 MOUNT SHASTA Small town living renowned for outdoor MORE OPPORTUNITIES AVAILABLE Bellflower, Corona, Dana lifestyle. 3-day week collectedSOLD $950,000. Very strong bottom line. Point, East LA, Ladera Ranch, Norco. San Juan Capistrano established 40 Digital including Pano. years, Lawndale Galleria, Anaheim, Irvine, Orange/Tustin. SEPT. 2017 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 45, Nº9

CONTINUED FROM 500 passwords). As each threat situation is considered, identify and list the T20 - §164.312(a)(2)(iv) Addressable Does your practice have policies safeguards already in place. This and procedures for implementing mechanisms that can encrypt and process prioritizes the security issues decrypt ePHI? that should be addressed (TABLE 2). ❍ Yes Risk Assessment Tools ❍ No A dental practice may fi nd a risk If no, please select from the following: assessment tool useful for its initial risk ❍ Cost analysis. A free security risk assessment ❍ Practice Size tool is available from the government ❍ Complexity at HealthIT.gov. It was developed in ❍ Alternate Solution collaboration with OCR and includes Please detail your current activities: video tutorials. The FIGURE shows a sample question from the tool. The ADA Complete HIPAA Compliance Kit, sold by the American Dental Please include any additional notes: Association, also includes a tool similar to the one from HealthIT.gov. Vendors such as IT consultants may offer an assessment tool or may simply perform Please detail your remediation plan: the assessment for the practice.

Next Steps A risk management plan must be Please rate the likelihood of a threat/vulnerability aff ecting your ePHI: ❍ Low developed. Considerations for the ❍ Medium plan will be reviewed in next month’s ❍ High column. Keep in mind that the risk analysis and risk management plan are Please rate the impact of a threat/vulnerability aff ecting your ePHI: ongoing processes. Once a risk analysis ❍ Low is completed, a covered entity should ❍ Medium review it on a regular basis and update ❍ High its plan as needed. “Regular basis” is Overall Security Risk: not defi ned in the HIPAA regulations, ❍ Low but an annual review is typically ❍ Medium recommended by information security ❍ High consultants. More frequent reviews may be necessary if a covered entity Related Information: implements a series of new technology. ■

Regulatory Compliance appears FIGURE. Sample HealthIT.gov risk assessment question. monthly and features resources about laws that impact dental practices. Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefi ts plans and regulatory compliance.

502 SEPTEMBER 2017 (;3(5,(1&(7+(',))(5(1&( t Lee Skarin and Associates has been serving the dental profession since 1959.

,1& t Kurt Skarin has over 30 years experience in dental practice sales.  t We have sold more practices than any broker in the state within the last 12 months. t Our experienced practice appraisals are backed with credentials unequaled among dental practice brokers. t We provide in-house legal counsel to advise you in all aspects of the sale and purchase, including the tax consequences of the sale. t Excellent financing is available, in most cases for 100% of the purchase price. t With a reputation for experienced, concientious, and ethical performance, we give our clients personal attention in all aspects of the purchase.

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With scores of Buyers, profiles of their practice interests and financial ability, /HH6NDULQ $VVRFLDWHV is able to find the right buyer for your practice. 2IÀFHV

Experience the difference. Call Lee Skarin and Associates  for responses to all of your questions - No obligation!  Visit our website for current listings: www.LeeSkarinandAssociates.com Dental Practice Brokers CA DRE #00863149 800.752.7461

BAY AREA BAY AREA CONTINUED BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED

Largest AC-566 SAN FRANCISCO: Views of Washington BN-504 RICHMOND: Established Practice & DN-693 SAN JOSE Facility: GC-472 ORLAND: Square. 3 ops +2 add’l, 1400sf $200k Real Estate! 1450sf w/ 2 ops + 2 add’l $100k / $150k $160k AC-624 SAN FRANCISCO: Wonderful patients, RE $700k DN-713 CASTRO VALLEY Lease: GG-453 CHICO: $200k Broker in solid income in great stand-alone bldg $475k BN-736 BERKELEY: Step into this quality prac- Call for details! GG-454 PARADISE: AC-640 SAN FRANCISCO: On 23rd Floor of pres- ce and you’ll know you belong here! 906sf DG-723 SAN JOSE: $525k tigious bldg, 2 ops in 700sf. Seasoned Staff. w/3 ops. $495k $850k GN-606 BUTTE COUNTY: Northern Seller Retiring $175k BG-734 ANTIOCH: Chance to own your own $125k AC-649 SAN FRANCISCO Facility: Richmond condo unit with this one! 1,323 sf w/ 4 ops. NORTHERN CALIFORNIA GN-656 NO. TEHAMA CO: Great Locaon! District, 3 ops+1 add’l, Equipment less than $315 / RE: TBD $275k California 5yrs old $120k CC-632 SAN RAFAEL: Small town life in vibrant, EC-531 GREATER SACRAMENTO: GN-667 OROVILLE: Great place to work & play! AG-645 SAN FRANCISCO: Low Overhead, com- growing city. 3 ops in 800sf office. Beautiful bldg $800k for Pracce & Real Estate $295k pact practice ready for expansion or relocation. $145k EG-685 LINCOLN/ROCKLIN: GN-668 BUTTE COUNTY: Retail/Commercial area. 2nd Floor $99k CC-661 SAN RAFAEL: Starter practice in beautiful $570k $95k AG-669 SAN FRANCISCO: RARE opportunity in location w/ like-new equipment. 3 ops, 900sf EG-716 ELK GROVE: GN-717 YUBA CITY: Extensive Buyer the heart of the city! 2 ops LOW OVERHEAD! $190k $270k Building available for purchase! $475k $88k CC-719 SAN RAFAEL: Panoramic views of Mt. EG-722 ROSEVILLE: HN-213 ALTURAS: Collected Database & AN-513 REDWOOD CITY: Pracce of your Tamalpias from each operatory window, 4 ops, $1.15M ~$760 in 2016! $195k dreams! 900sf w/ 4 ops + 2 add’l $350k 1,550sf $260k EG-727 SACRAMENTO: HN-280 NORTHEAST CA: $60k Unsurpassed AN-686 SAN FRANCISCO: Office designed w/ CC-720 SONOMA COUNTY: Well-established HN-618 SIERRA FOOTHILLS: paent flow & maximum office efficiency. practice w/stable pts base. Excellent signage, 3 $275k $95k Exposure allows 1000sf w/ 4 ops $825k ops, 940sf w/ newer high-end Equip $375k EN-625 SACRAMENTO: AN-712 SAN FRANCISCO: Easy accessibility, ex- CG-616 NAPA: State-of-the-Art practice. Seller $450k CENTRAL VALLEY us to offer you ceponal visibility, free parking & extremely low moving out of state! $425k EN-626 CARMICHAEL: rent! 1000sf w/ 2 ops + 2 add’l $89.5k CG-735 ROHNERT PARK: Collections over $600k, $300k IC-468 SAN JOAQUIN VALLEY BC-662 HAYWARD: Starter practice in the Net Profit over $230k and expertly located near EN-627 CARMICHAEL: $425k “Heart of the Bay” near hospital, 3 ops in major anchor tenants! $370k $268k IC-715 TRACY

1056sf $75k DC-480 SILICON VALLEY: Multi-Specialty prac- EN-628 ORANGEVALE: $435k BC-663 DANVILLE: Seller retiring from this tice. 14+ ops in 7500sf. Owner financing availa- 375k IG-687 TURLOCK: family-oriented practice. 4 ops in 1262sf ble $1.075M EN-654 CITRUS HEIGHTS: $298k $240K DC-671 SAN JOSE: Starter pracce. Desirable $150k JN-690 LINDSAY BC-681 WALNUT CREEK: Remodeled office. area. 6 npts/mo, 3 ops in 900sf $150k EN-660 ROSEVILLE: Pracce $150k/ Real Estate $150k Semi-rural community, 1000sf w/ 4 ops $432k DC-692 DUBLIN Facility: Modern digital office. $995k BC-682 CONCORD: Located in desirable, bus- 5 ops 1800sf $210k w/ Cone Beam Unit or EN-664 SACRAMENTO Facility: SOUTHERN CALIFORNIA tling community w/ seasoned, caring staff. 836sf $165k without $55k w/ 3 ops $224k DG-635 CASTRO VALLEY: Excellent locaon & EN-689 MIDTOWN SACRAMENTO Facility: KC-678 LOMPOC & SANTA MARIA: BC-710 WALNUT CREEK: Desirable location in stellar reputaon! Solo Group Pracce $650k $99k $240k stand-alone, single-story bldg. 1313sf w/ 3 ops DG-726 SAN JOSE: Busy, Vibrant Pracce. Col- EN-702 SACRAMENTO: $150k / RE $850k lecons over $1.1M on a relaxed 4 day work $495k SPECIALTY PRACTICES BG-724 RICHMOND: Spacious office w/ enor- week. ~2850sf w/7 ops $885k EN-708 SACRAMENTO: mous growth potential! 2000sf w/ 4 ops Prac- DN-665 SANTA CRUZ AREA: Loyal, stable, mul- $150k BC-709 HAYWARD Ortho: tice $138k / Real Estate $700k generaonal paent base. FFS. 1460sf w/ 4 ops FC-650 FORT BRAGG: $215k BG-731 LAFAYETTE: Well-educated, health con- $540k $350k for the Pracce & $400k for the Real Estate IC-543 CENTRAL VALLEY Ortho: scious paent base. 1,000 sf w/ 3 ops 35+ years DN-688 MONTEREY: State-of-the-art equip- FC-677 FORT BRAGG: $125k goodwill $265k ment & latest technology! 1900 w/ 5 ops $500k $1.4mil/RE $795k

800.641.4179 [email protected] Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD

BAY AREA BAY AREA CONTINUED BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED

Largest AC-566 SAN FRANCISCO: BN-504 RICHMOND: DN-693 SAN JOSE Facility: Aracve & spacious! Faces one of the GC-472 ORLAND: Live & practice in charming small town community. $200k $100k / city’s major thoroughfares. 1080sf w/4 ops $150k 1000sf w/ 2 ops. Seller Retiring $160k AC-624 SAN FRANCISCO: RE $700k DN-713 CASTRO VALLEY Lease: Well maintained, attractive, “Move-In GG-453 CHICO: 5000sf w/ 7 ops. Perfect for 1 or more dentists! $200k Broker in $475k BN-736 BERKELEY: Ready” dental office. 1500sf w/ 5ops Call for details! GG-454 PARADISE: 2550sf w/ 9 ops. 40 yrs goodwill! Amazing Oppor- AC-640 SAN FRANCISCO: DG-723 SAN JOSE: The pracce exceeds $1.2mil in collecons annu- tunity! $525k $495k ally! 1,450 sf w/ 5ops. $850k GN-606 BUTTE COUNTY: Hesitate & you’ll miss out on this one-of-a- Northern $175k BG-734 ANTIOCH: kind opportunity! 1700sf w/ 4 ops $125k AC-649 SAN FRANCISCO Facility: NORTHERN CALIFORNIA GN-656 NO. TEHAMA CO: Great Locaon! Ideal place to work, live & $315 / RE: TBD raise a family! 2468sf w/ 5 ops $275k California $120k CC-632 SAN RAFAEL: EC-531 GREATER SACRAMENTO: Beauful! 1750sf w/ 4 ops + 1 add’l GN-667 OROVILLE: Great place to work & play! Constant growth AG-645 SAN FRANCISCO: office $800k for Pracce & Real Estate aracng an influx of residents! 1000sf w/ 3 ops $295k $145k EG-685 LINCOLN/ROCKLIN: Perfect locaon in amazing community! GN-668 BUTTE COUNTY: Remodeled in 2010! Well-maintained, long- $99k CC-661 SAN RAFAEL: Retail Shopping Center w/ 4 ops $570k established professional complex. 1200sf w/ 2 ops $95k AG-669 SAN FRANCISCO: EG-716 ELK GROVE: Remarkable potenal for growth w/ aenon to GN-717 YUBA CITY: Seller Rering. All reasonable offers considered. Extensive Buyer $190k markeng & increased office hours! 1200sf w/3 ops $270k Building available for purchase! 2400sf w/ 5 ops $475k $88k CC-719 SAN RAFAEL: EG-722 ROSEVILLE: This WILL sell quickly! PRIME LOCATION in most HN-213 ALTURAS: Well managed w/consistent revenues! Collected Database & AN-513 REDWOOD CITY: desirable retail center in town! 1919sf w/ 4 ops $1.15M ~$760 in 2016! 2200sf w/ 3 ops + 1 add’l. $195k $350k $260k EG-727 SACRAMENTO: Steady Income from HMO. Increase office HN-280 NORTHEAST CA: Only Practice in Town! 900sf w/ 2 ops $60k Unsurpassed AN-686 SAN FRANCISCO: CC-720 SONOMA COUNTY: hours & begin adversing to watch the collecons skyrocket! 1100sf HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for w/3 ops $275k growth by increasing office hours! 750sf w/ 2 ops $95k Exposure allows $825k $375k EN-625 SACRAMENTO: Looking for an HMO pracce in a great Loca- AN-712 SAN FRANCISCO: CG-616 NAPA: on? 2500sf w/5 ops $450k CENTRAL VALLEY us to offer you extremely low $425k EN-626 CARMICHAEL: Lifestyle you just can’t be beat! HMO 1250sf w/ rent $89.5k CG-735 ROHNERT PARK: 3 ops $300k IC-468 SAN JOAQUIN VALLEY: High-end restorave pracce! 6 ops in BC-662 HAYWARD: EN-627 CARMICHAEL: Remarkable HMO opp. awaits your talent & 2500+sf office. Call for Details! $425k $370k skill! 1200sf w/3 ops + 1 add’l $268k IC-715 TRACY: 30+npts/mo. 1600sf, 5 ops +1 add’l. Seller starng new

$75k DC-480 SILICON VALLEY: EN-628 ORANGEVALE: Great place to work, play & live. HMO 1310sf career $435k BC-663 DANVILLE: w/ 4 ops + 1 add’l $3375k IG-687 TURLOCK: Established quality pracce - remarkable opportuni- $1.075M EN-654 CITRUS HEIGHTS: Well established & loaded with 30+ years of ty! 2000sf w/ 5 ops $298k $240K DC-671 SAN JOSE: goodwill! 1300sf, 3 ops + 2 add’l. $150k JN-690 LINDSAY: Stable, mul-generaonal, loyal & appreciave pa- BC-681 WALNUT CREEK: $150k EN-660 ROSEVILLE: Highly-esteemed, well-respected, fee-for-service ent base. 1700sf w/ 3 ops Pracce $150k/ Real Estate $150k $432k DC-692 DUBLIN Facility: pracce w/ loyal paent base. 2950sf w/ 5 ops $995k BC-682 CONCORD: $210k w/ Cone Beam Unit or EN-664 SACRAMENTO Facility: Great corner locaon, excellent visibil- SOUTHERN CALIFORNIA $165k without ity & easy access! 2300sf w/ 4 ops $55k $224k DG-635 CASTRO VALLEY: EN-689 MIDTOWN SACRAMENTO Facility: Bring your talent, hang your KC-678 LOMPOC & SANTA MARIA: Live & practice along the central BC-710 WALNUT CREEK: $650k sign & make it your own! 2000sf w/ 4 ops $99k coast. Plenty of room for growth, Call for Details! $240k DG-726 SAN JOSE: EN-702 SACRAMENTO: Long-established pracce w/ emphasis on pre- $150k / RE $850k ventave vs reacve denstry! 1600sf w 4 ops + 1add’l. $495k SPECIALTY PRACTICES BG-724 RICHMOND: $885k EN-708 SACRAMENTO: Family-oriented pracce with appreciave & Prac- DN-665 SANTA CRUZ AREA: loyal paent base. 1600sf w 4 ops + 1add’l. $150k BC-709 HAYWARD Ortho: Provide personalized care to wonderful tice $138k / Real Estate $700k FC-650 FORT BRAGG: Family-oriented pracce. 5 ops in 2000sf, 6 patient base. 5-8 npt exams/mo, 4 chairs/bay, 1948sf $215k BG-731 LAFAYETTE: $540k npts/mo $350k for the Pracce & $400k for the Real Estate IC-543 CENTRAL VALLEY Ortho: 1650sf w/ 5 chairs in open bay & DN-688 MONTEREY: FC-677 FORT BRAGG: Beauful, FFS Pracce, 4 ops +1 add’l, in plumbed for 2 add’l. Strong referrals and PT base $125k $265k 2375sf, Gross $1M+/yr $500k $1.4mil/RE $795k

“ASK THE BROKER” CAN NOW BE FOUND AT WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 45, Nº9

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

Seeing AI: Talking Camera for the Blind Study Says Facebook Connects the (Free, Microsoft Corp.) World More Than Any Other Internet Technology continually evolves to enhance the lives of those with sensory impairment. Powerful mobile devices coupled with the vast Resource array of data from the internet has fueled this evolution to create When it comes to social media and the internet, many resources even more useful applications than ever before. Seeing AI for iOS are largely used to connect people around the world. A new is one of these applications that gives people with low vision an study by System1 Research has discovered that Facebook is ability to see things from another perspective. It combines the use the best at doing that. The consumers surveyed for the study of the camera and speakers on mobile devices to translate sight to mentioned Facebook two times more than they mentioned sound with immediate feedback. Google and 10 times more than Twitter. Internet usage is also ruled by Facebook, according to the study. Around 81 percent of Seeing AI has several modes specifi cally designed to assist the those surveyed said they used Facebook regularly, compared to visually impaired with common tasks while using the camera in 79 percent for Google. the background. In Short Text mode, the user simply points the mobile device camera to any text and the app will read aloud any — Blake Ellington, Tech Trends editor words or sentences that it can detect continuously. With Document mode, the app will search for the borders of a document, snap a picture automatically when it fi nds one and immediately process Generation Z Purchasing Habits Reveal the photo for words that the user can then subsequently use VoiceOver to read aloud. Product mode scans for barcodes and Diff erences From Millennials identifi es products for the user with audio feedback. Person mode Move over millennials, there is a new generation beginning to allows the user to snap a picture of a person and receive back an enter the marketplace. Generation Z is the generation born after audio description of that individual, which includes gender, age 1995, and a new study says social media is an even bigger and the type of emotion displayed. Users can train the app with infl uence on their purchasing habits. The study, conducted a few pictures to recognize specifi c people so that Person Mode by Kantar Millward Brown, found that Snapchat impacts the can report back actual names of individuals. In Scene mode, users purchase decisions of 21 percent of Generation Z, which is can snap a picture of what is around them and receive back an double the percentage of millennials. As a whole, social media audio description of their surroundings along with any objects sways 80 percent of Generation Z when it comes to purchases, that it recognizes. Audio feedback is built-in for every feature in compared to 74 percent of millennials. Instagram is also a big the app. In low-light conditions, the app automatically utilizes the infl uencer of Generation Z at 44 percent. camera fl ash to increase visibility. All modes are accessible with a — Blake Ellington, Tech Trends editor swipe and tap at the bottom of the screen. While the app does its best to be accurate, complex typography and nonstandard word alignment have diffi culty being recognized. Additional modes are Would you like to write about technology? under development and will be made available with app updates. Dentists interested in contributing to this section should contact Leveraging the power of mobile technologies and the internet, Andrea LaMattina, CDE, at [email protected]. Seeing AI is a welcome assistant to those with low vision. Although not entirely accurate, it off ers a wide array of amazing features that help augment the other dominant senses in a simple and consistent manner. Seeing from another perspective has now become clearer. — Hubert Chan, DDS

506 SEPTEMBER 2017 Keep the CDA Presents energy alive.

Discover ongoing opportunities to learn, connect and grow:

• See and share the best moments from the convention in our Social Hub • Catch up on classes you missed online through our on-demand library • Check with our exhibitors for continuing deals on dental innovations • Mark your team’s calendar for the convention dates next year

Experience the nation’s leading dental convention. See what’s next at cdapresents.com.

The Art Anaheim, CA San Francisco, CA and Science May 17–19, 2018 Sept. 6–8, 2018 of Dentistry SIMPLE AND VERSATILE

BEFORE AFTER

ImaImaagesg s ccourttesesy of Drr.B. Bobo Loowwe

BEFORE AFTER

Imamagesess coc urttesesy of Dr. Ian ShuShumamann

BEFORE AFTER

IImamagesess courttesy of DrD . Sigaiggaal Jaacocobsoon

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