May 2017 Corticosteroid Therapy Traumatically Intruded Teeth Antibiotic Resistance

JournaCALIFORNIA DENTAL ASSOCIATION

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DEPARTMENTS

217 The Associate Editor/Mentor Help

219 Letter

221 Impressions

255 RM Matters/Well-Stocked Emergency Medical Kits Can Help Mitigate Risk

261 Regulatory Compliance/Cal/OSHA Citations of Dental Practices

263 Ethics/Life Outside the Operatory and Dental Ethics 266 Tech Trends 221

FEATURES

227 The Oral Effects of Inhalation Corticosteroid Therapy: An Update This article reviews the literature on the complications of inhalation corticosteroid therapy with emphasis on its potential oral effects. Darren P. Cox, DDS, MBA, and Leticia Ferreira, DDS, MS

235 Traumatically Intruded : Three Case Reports and a Review of Current Recommendations This review evaluates the current information about management of traumatically intruded permanent teeth. Samah Omar, BDS, DDS, MSD; William F. Freccia, DDS, MS; Bonnie Retamozo, DDS, MSD; and Leif K. Bakland, DDS

244 Antibiotic Resistance and Good Stewardship This article examines ’s role in managing the antibiotic resistance problem through a more appropriate use of antibiotics. George Maranon, DDS

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Volume 45, Number 5 JournaCALIFORNIA DENTAL ASSOCIATION May 2017 CDA Classifieds.

Free postings. published by the Editorial Upcoming Topics Letters to the Editor California Kerry K. Carney, DDS, CDE June/Sports Dentistry www.editorialmanager. EDITOR-IN-CHIEF Priceless results. Dental Association July/General Topics com/jcaldentassoc 1201 K St., 14th Floor [email protected] August/The Dental Director Sacramento, CA 95814 Ruchi K. Sahota, DDS, CDE Subscriptions 800.232.7645 ASSOCIATE EDITOR Subscriptions are available cda.org Advertising only to active members of Brian K. Shue, DDS, CDE Doug Brown the Association. The ADVERTISING SALES CDA Offi cers ASSOCIATE EDITOR subscription rate is $18 and [email protected] is included in membership Clelan G. Ehrler, DDS 916.554.7312 PRESIDENT Andrea LaMattina, CDE dues. Nonmembers can PUBLICATIONS MANAGER [email protected] view the publication online Permission and at cda.org/journal. Natasha A. Lee, DDS Courtney Grant Reprints PRESIDENT-ELECT SENIOR COMMUNICATIONS Manage your subscription SPECIALIST Andrea LaMattina, CDE online: go to cda.org, log in [email protected] PUBLICATIONS MANAGER and update any changes to [email protected] Kristi Parker Johnson your mailing information. R. Del Brunner, DDS 916.554.5950 VICE PRESIDENT EDITORIAL ASSISTANT Email questions or other [email protected] changes to membership@ Blake Ellington Manuscript cda.org. TECH TRENDS EDITOR Richard J. Nagy, DDS Submissions SECRETARY www.editorialmanager. [email protected] Jack F. Conley, DDS EDITOR EMERITUS 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 Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the post that, too. And the best part— California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Jennifer George Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal it’s free to all CDA members. CHIEF MARKETING OFFICER of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. The California Dental Association holds the copyright for all articles and artwork published Carrie E. Gordon All of these features are designed to CHIEF STRATEGY OFFICER herein. The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for help you get the results you need, any expression of opinion or statement of fact, all of which are published solely on the authority Alicia Malaby of the author whose name is indicated. The association reserves the right to illustrate, reduce, faster than ever. Check it out for COMMUNICATIONS DIRECTOR revise or reject any manuscript submitted. Articles are considered for publication on condition yourself at cda.org/classifieds. that they are contributed solely to the Journal. Copyright 2017 by the California Dental Association. All rights reserved.

216 MAY 2017 Assoc. Editor CDA JOURNAL, VOL 45, Nº5

Mentor Health Brian K. Shue, DDS, CDE

ull of uncommon ambition, young Archie H. Hooker’s professional goals didn’t include joining Dentistry needs these young his father’s San Diego printing exceptional individuals to elevate business like his older brother. FArchie’s family recorded his occupation our profession in the future. as “apprentice-dentist” in the 1880 U.S. Census, when he was just 13 years old. Two years later, Hooker became the very fi rst librarian of the San Diego Public Just recently, I mentored a local younger, during my high school years. Library, which opened in a bank building high school student who balanced an I spent many hours job shadowing on the second fl oor right next to a dentist. excellent academic record with numerous William Quan, DDS, in my hometown This dentist was Daniel Cave, who had extracurricular activities. This well- of El Centro, Calif. I can still remember emigrated from France a decade earlier in rounded student began as a patient of the visits to his dental offi ce and all the search of a better climate for his health. mine, volunteered at my clinic and is now welcoming sights and interesting smells. With only $20 to his name, Dr. Cave a predental student in college. The student He talked to me about the many facets went on to establish a thriving dental recently came back for a checkup and is of dentistry, one time even chairside as practice and was elected to numerous still committed to becoming a dentist. If I he performed an anterior maxillary root civic leadership positions, including had played just a small part in encouraging canal on a patient. My experience at his Chamber of Commerce president. He this promising student to pursue a career offi ce created the foundation for me to also provided apprentice opportunities in dentistry, I would be satisfi ed. Dentistry build upon for my goals. Of course, the to young men who would eventually needs these young exceptional individuals fact that he’s my uncle helped, too. become registered California dental to elevate our profession in the future. Mentoring middle or high school practitioners — this in an era before Of course, the right kind of mentor at students can be a game-changer. Look dental school education and a board the undergraduate level can strengthen back on your formative years and you’ll examination were prerequisites in order the aspirations of any career-minded probably remember that one great to practice dentistry. Without a doubt, individual. I had two such advisors who mentor, the one who made a difference Dr. Cave would have been an infl uential made a signifi cant impact on my journey: in your career planning. Mentoring fi gure to any impressionable teen. Terry T. Tanaka, DDS, of Chula Vista, can be easy, too. In addition to just Hooker worked as San Diego’s Calif., whom I volunteered with for two simply talking about your profession librarian for two years, and he performed years at the University of California, when that “right” student crosses janitorial duties. Just imagine all the brief San Diego TMJ and Facial Pain clinic your path, resources are available to encounters and the casual conversations on Wednesday afternoons, and Lennon help you make a strong impression. that may have occurred on that second Goins, DDS, of La Jolla, Calif. Without Start with sharing the ADA webpage fl oor between him and the accomplished their help, encouragement and counsel, titled “Be a Dentist,” which is full of up- Dr. Cave. While no records have been I could have been sidetracked into to-date facts and the latest material about found to show that Hooker apprenticed taking the MCAT with my premed choosing dentistry as a career. It is designed with him (it’s possible, but I am still friends instead of the DAT and might for both high school and college students. researching this), it could be surmised that have ended up becoming a different Access the webpage at ada.org, go to the Dr. Cave’s success as a dentist may have kind of doctor. That wasn’t for me. “Education/Careers” tab, click on the had some infl uence on Hooker’s future. But looking back, my decision to selection “Careers in Dentistry,” then scroll You and I have an opportunity to become a dentist was most infl uenced down and click on “Be a Dentist.” A great provide this same kind of inspiration. by the mentor I had when I was much document to download is the ADA fact

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CDA JOURNAL, VOL 45, Nº5

sheet, “What can a career in dentistry offer Interested in Careers in Dentistry” found the San Diego County Dental Society, you?” which highlights service to others, at ada.org/mentoring. The ADA states, which he and six others founded in 1887. balanced lifestyle, self-employment, earning “Mentors can help you understand dentistry Their fi rst meeting was held on the second potential, status, prestige and a variety of from the other side of the chair and provide fl oor of that same San Diego dental offi ce career options. Those are similar to the guidance about pursuing dentistry as a across the hall from the library. By that reasons stated by the 2017 U.S. News and career.” Consider becoming a mentor. time, however, the offi ce was co-owned World Report when it chose “dentist” as Like Daniel Cave, you too can have by two other founding SDCDS members: the best profession in the United States. such a positive impact on a young mind. Dr. Edward S. Mathews and a young man The ADA offers other informative Dr. Cave moved on to Los Angeles and in named Dr. Archibald H. Hooker. ■ documents for the student, such as the 1911 became president of the Southern detailed “Dentistry Careers” and the California State Dental Association, Brian K. Shue, DDS, CDE, is the brochure that focuses on diversity, called which was an early form of the California dental director of a federally qualifi ed health “Something to Smile About: Careers in the Dental Association when it existed as two center. He is a certifi ed dental editor, the Dental Profession or the New Dentistry,” constituent entities. He was even one of San Diego County Dental Society editor to name a few. Another ADA webpage to CDA’s fi rst life members. Additionally, and is a fellow of the American College of recommend is “Mentoring Students (K–16) Dr. Cave served as the fi rst president of Dentists and the Pierre Fauchard Academy.

Free and early eDelivery.

Available for iPad, iPhone, Android or Kindle Fire. Check it out at cda.org/apps.

218 MAY 2017 Letter CDA JOURNAL, VOL 45, Nº5

Systemic Conditions and Oral Health

aving read the article clinical outcome, combined with an March 2017 Antibiotic Prophylaxis “Management of Infections agitated patient in pain, antibiotics Mandibular Fractures Photodynamic Therapy

and the Use of Antibiotic remain perfect fodder and a rapid JournaCALIFORNIA DENTAL ASSOCIATION Prophylaxis by Dentists: A short-term solution. The acute nature Review of the Evidence” in of dental pain often makes patients Hthe March Journal, we wish to point out mistakenly use any leftover antibiotics. the ambiguity on antibiotics that exists Patient demand and lack of prescribers’ in the literature, the most recent being updated knowledge have prejudiced the a campaign to sway patients away from decision to prescribe antibiotics at least as The Management 1 of Infections and thinking that antibiotics are a cure-all. much as the patients’ clinical diagnosis. the Use of Antibiotic Prophylaxis by Dentists: Third molars, for example, are at the A wide array of prescribing practices A Review of the Evidence confl uence of multiple facial spaces that with regard to clinical conditions, serve as a conduit for infection to spread. antibiotic of choice and duration of Extraction wounds inherently contain therapy do exist. This necessitates the bacterial inhabitants. However, antibiotic need for a more practical advice for prophylaxis seems to be unwarranted and dentists who can then value their clinical currently no clear-cut consensus on the judgment at the same time beholding use of antibiotics in soft tissue or bony their patients’ interest and safety.3,4 impactions. Depending on the nature of Studies have claimed there is no the surgical procedure, the degree of tissue difference in healing after routine The Journal welcomes letters trauma, clinical acumen of the surgeon and extractions in well-controlled and We reserve the right to edit all patient comorbidities, aseptic measures uncontrolled diabetics,5 but it would be communications. Letters should discuss have a defi nite role in the incidence of diffi cult to infer whether wound healing an item published in the Journal within surgical site infection, hence it is diffi cult would remain satisfactory in minor surgical the last two months or matters of general to conclusively cement the need for procedures in an uncontrolled diabetic. interest to our readership. Letters must be antibiotics for all third molar surgeries. Evidence-based decision-making no more than 500 words and cite no more Dentinal sensitivity and sharp- related to optimal antibiotic strategies than fi ve references. No illustrations will shooting pain often alarm patients to in surgical practice is the need of be accepted. Letters should be submitted the progression of caries from enamel to the hour. This will minimize rising at editorialmanager.com/jcaldentassoc. By to the and periapical tissues. antibiotic resistance and curb the idea sending the letter, the author certifi es that The virulence of the microbes and the that antibiotics are magic bullets for neither the letter nor one with substantially host reparative mechanism strike a treating life-threatening infection. similar content under the writer’s authorship balance to limit the spread of infection has been published or is being considered SAMEEP SHETTY, MDS, AND SAVIL UCHIL, BDS in an immunocompetent individual for publication elsewhere, and the author Manipal College of Dental Sciences by forming a / acknowledges and agrees that the letter and Mangalore, Karnataka, India . Cellulitis and abscess further limit all rights with regard to the letter become the infection before they progress to primary REFERENCES property of CDA. and secondary spaces of the head and 1. Hancocks S. Antibiotics don’t cure . Br Dent J neck. A timely intervention by dentists 2016 Nov 18;221(10):595. 2. Carrotte P. : Part 3. Treatment of endodontic and a preventive approach by patients emergencies. Br Dent J 2004 Sep 25;197(6):299–305. would be handy in curtailing the 3. Longman LP, Preston AJ, Martin MV, Wilson NH. progressive rise in antibiotic resistance. Endodontics in the adult patient: the role of antibiotics. 2000 Nov;28(8):539–48. Extirpation of the pulp tissue remains 4. Epstein JB, Chong S, Le ND. A survey of antibiotic use in a viable option, but is sometimes dentistry. J Am Dent Assoc 2000 Nov;131(11):1600–9. deferred for fear of local anesthesia 5. Huang S, Dang H, Huynh W, Sambrook PJ, Goss AN. The healing of dental extraction sockets in patients with Type 2 failure in an infl amed pulp and lack of diabetes on oral hypoglycaemics: A prospective cohort. Aust patient compliance.2 For a successful Dent J 2013;58:89–93.

MAY 2017 219 Practice Support New regs? We’ll keep you posted.

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Moral Decoys David W. Chambers, EdM, MBA, PhD

I have a killer business plan, and I am looking for a few special people with the talent and vision to seize the opportunity. There is a crying and growing need for images demonstrating the damage that can be done by greedy, bureaucratic and misguided liberals and pseudo-scientists. My company would rent out victims to inform the public and embarrass the meddlers. The fi rm would be called Moral Decoys. Of course, such fi rms already exist. They are a multibillion- dollar industry, mostly centered on public relations, lobbying and legal outfi ts. The correct technical name is a “front.” The strategy is straightforward: Scare the public to prevent rule-makers from imposing unfavorable restrictions. In the 1970s, proposed regulation of chlorofl uorocarbons used in refrigeration was delayed and weakened by the Alliance for Responsible CFC Policy. On the outside, this was small manufacturers of air conditioning units and a group of citizen scientists working for the public good. Actually, it was a coalition of a few large chemical companies and was managed by a public relations fi rm. Early recycling legislation was opposed because it would put mom-and-pop operations out of business and create toxic pest hazards. The nub: Fluoride causes cancer. The Affordable Care Act was supposed to increase unemployment and tip the balance 1. One’s own moral motives can away from full-time to part-time work. The opposite has be protected from scrutiny by in fact been the case. The grandest of the moral decoys has been “shareholder interests.” First noticed in the claiming to be protecting others’ 1980s, CEOs have made it an all-purpose justifi cation interests. for short-term profi t above all other considerations. My business of renting out moral decoys will be based on 2. The best dodge against two ethical pillars. First, actions are always undertaken for moral responsibility is to avoid the benefi t of others. One’s own advantage will be held in becoming a data point in strictest confi dence. Second, ethical focus will be on specifi c individual cases. Statistics and overall impact are out of bounds. general statistics. If I could remember the individual’s name, I would put 3. Moral decoys are available him on the board of Moral Decoys. He was pretty famous back in the day when full-mouth cosmic reconstructions for rent. were going to bring dentistry to the stature it deserved. He was invited to give a talk on professional ethics to students at our dental school. He mostly showed his work, and David W. Chambers, EdM, MBA, PhD, is professor there was no doubt that it was drop-dead gorgeous. He of dental education at the University of the Pacifi c, Arthur also made a point that insurance companies and uppity A. Dugoni School of Dentistry, San Francisco, and editor hygienists were literally bankrupting dentists, especially of the American College of Dentists. those losers who were trying to get by doing amalgams and prevention. A good 40 minutes into the presentation, he announced that he could summarize all of dental ethics on a single slide. It was a picture of two small children on wild animal skin rugs with large Harley-Davidsons in the background. He said, “I put my family fi rst.” ■

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Study Finds Mutations Responsible for Cleft Researchers at the University of Exeter, United Kingdom, located a novel gene mutation causing cleft and cleft palate defects (CLP), which slows the turnover of hyaluronan, an important component of the hard palate, according OSA Causes Complications to a study published recently in the journal PLOS Genetics. The genetics underlying cleft lip and cleft palate are poorly understood. By in Dental Implants studying individuals with syndromic CLP from Amish and Northern Saudi Arabian New data from research conducted by families, the researchers identified the responsible mutations. Syndromic CLP is OSI Araba University Hospital, Spain, accompanied by other congenital defects such as the heart anomaly cor demonstrate a strong correlation between triatriatum sinister, where the heart develops a third atrial chamber on the left side. obstructive sleep apnea (OSA) and The collaborative team mapped the condition to mutations in the HYAL2 complications with previously implanted gene, which encodes an enzyme that breaks down hyaluronan, a oral prosthetics, according to a study carbohydrate polymer found widely in connective tissue and in the hard published in the Journal of Oral Implantology. palate. Enzyme assays showed that the mutations reduced HYAL2 protein Obstructive sleep apnea (OSA), a levels in the tissues, which likely inhibited hyaluronan turnover ultimately disorder in which breathing repeatedly impacting development of the palate and other body parts. Further starts and stops during sleep, has frequently experiments using mice that lack HYAL2 showed that the mice develop been linked to sleep , a condition defects similar to human syndromic CLP, including cor triatriatum sinister. in which the jaw is clenched and tightened The findings also illustrate the fundamental importance of HYAL2 and hyaluronan during sleep creating excessive teeth turnover for normal human and mouse development. A grinding. Both conditions are linked to better understanding of the factors contributing to these health issues; however, no previous studies anomalies may contribute to the development of new linked OSA to prosthetic complications. treatments for these common birth defects, such as Researchers from OSI Araba hymecromone, a drug that blocks hyaluronan synthesis. investigated how OSA affects implant- For more on this study, see the journal PLOS Genetics borne prostheses. The frequency with at dx.doi.org/10.1371/journal.pgen.1006470. which a complication occurred and the type of complication were studied in 67 patients. Of those 67 patients, the researchers found that 16 experienced complications, 13 of whom had OSA. Among these 16 patients with than those without bruxism. This their prostheses. The success rate of complications were 22 prostheses with a shows that people suffering from implants, which is reported to be between total of 30 issues. The researchers found OSA or bruxism have a more diffi cult 92 and 97 percent, shows a strong these complications consisted of porcelain time with successful prosthetic correlation between OSA and prosthetic fracture, fracture of the screw/implant, implantation, according to the study. complications. The researchers believe loosening of the screw and decementation. The study noted that as awareness that additional exploration is necessary During the study, researchers of the reciprocal relationship between to further understand the risk factors also noted a strong relation between OSA and dental diseases increases, and frequencies of these occurrences. individuals who suffer from OSA and one new aspect of interest could be the For the full text of the study, those who suffer from bruxism. Past occurrence of technical complication “Frequency of Prosthetic Complications studies revealed that those affl icted in fi xed prosthodontics. This study Related to Implant-Borne Prosthesis in a with bruxism had a higher instance of shows that 81 percent of patients with Sleep Disorder Unit,” see the Journal of complications with implant prostheses OSA experienced complications with Oral Implantology 43 (1), 19-23 (2017).

222 MAY 2017 CDA JOURNAL, VOL 45, Nº5

Friends, Family Play Crucial Roles in Oral Health Care Social networks — not Facebook health services research at Boston and Twitter, but the “in real life” University’s Henry M. Goldman networks of friends, family and School of Dental Medicine, specializes acquaintances — may play an in social epidemiology with a focus overlooked role in oral health care, on oral health. In 2008, she and according to research presented other members of BU’s Center for in February at the American Research to Evaluate and Eliminate and the infl uence of “motivational Association for the Advancement Dental Disparities began a new line interviewing” on how women care for of Science conference in Boston. of research focused on understanding their children’s diet and oral health. Brenda Heaton, an assistant oral health and disease among Some women Heaton interviewed professor of health policy and Boston public housing residents had been born and raised in the unit that they were living in and were now raising their own child in that unit. “So we had grandmother, mother and child in one unit,” she New Prospect for More Eff ective Treatment of said. Those close connections infl uenced how people behaved. To Nerve Pain make signifi cant progress against Thanks to a newly tested substance, the pain of trigeminal neuralgia can be diseases like , Heaton had reduced to a tolerable level without troublesome side effects, according to a to tap into those networks herself. study involving the Center of Dental Medicine at the University of Zurich and To understand the connections that published in The Lancet. Trigeminal neuralgia is characterized by sharp, already existed within the community, lancinating pain in the teeth or facial area usually caused by an irritation of the Heaton needed to draw a social map. trigeminal nerve, the cranial nerve responsible for the sensory innervation of the Since 2008, her team has interviewed facial area, parts of the scalp and the oral cavity. close to 200 women living in Boston Pain signals reach the brain via the activation of sodium channels located in the public housing and identifi ed nearly membranes of nerve cells. The sodium channel 1.7 is frequently expressed on 1,000 individuals who were infl uential. pain-conducting nerves, and higher pain intensity is linked to higher channel Heaton is using those network maps activity. Blocking this sodium channel, usually by a local anesthetic, inhibits the pain. to fi nd similarities in how information In trigeminal neuralgia, the nerve damage is presumed to be at the base of fl ows through these communities. The the skull. However, this region is hard to reach by local injections and therefore ultimate goal, she says, is to use the requires drug treatment. The novel substance BIIB074 tested in this study maps to introduce health information inhibits the sodium channel 1.7 state-dependent, which means the more active and resources into a community in ways that change long-term behaviors. this sodium channel gets, the stronger it is blocked by BIIB074. By contrast, “You can’t design those currently available medications block the sodium channel 1.7 irrespective of interventions until you actually have the nerve activity and commonly result in burdening a really strong grasp of the network side effects. “Unlike conventional drugs, which often structure,” said Heaton. “The power cause tiredness and concentration problems, BIIB074 of this approach is that it focuses on was not only effective, but also very well tolerated,” prevention rather than cures. It might explained Dominik Ettlin, a UZH dental specialist. take a village, but tooth decay is an Read more about this study in The Lancet 16 (4), entirely preventable health outcome.” 291-300 (2017). Image: Center of Dental Medicine; UZH For more information about the Boston public housing research project, go to bu.edu/creedd/projects/project2.

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Dentist Designs Waterless Toothbrush A Park City, Utah, dentist in collaboration with local high school students has designed a toothbrush and flossing tool that doesn’t require water or spitting. An electron microscope image of the The brush is designed for children but can be used by anyone, according to a enamel of a Tyrannosaurus rex tooth. Image: Kotov Lab, University of Michigan recent article in the Park Record newspaper. Marielle Pariseau, DMD, was inspired to develop the toothbrush after a supervised toothbrushing and flossing program she started in Canada several years Synthetic earlier was short lived. The program was modeled after Scotland’s Childsmile Core, May Lead to More Resilient a nationwide initiative to help improve the health of children’s teeth through the distribution of dental packs and supervised toothbrushing programs. Dr. Pariseau Structures quickly discovered that putting dozens of children together and giving them Unavoidable vibrations, such as toothbrushes and water was just asking for trouble, so the program didn’t last long. those on airplanes, cause rigid structures Now a Utah resident, Dr. Pariseau began working with students in the Park to age and crack, but researchers at the City Center for Advanced Professional Studies program at Park City High School University of Michigan may have an to design the waterless toothbrush. The bristles of the brush are prepasted with answer for that — design them more like xylitol, an FDA-approved compound that is safe to swallow and proven to tooth enamel, which could lead to more reduce bacteria that cause cavities. resilient fl ight computers, for instance. The Pariseau intends to sell the toothbrushes through her company, TeethFirst, but results of their research were published in she also started a Kickstarter campaign to raise funds to help establish supervised the March issue of the journal Nature. toothbrushing programs in local kindergarten classes. Most materials that effectively “If we start putting a system like this in the schools, then absorb vibration are soft, so they don’t all the kids get to brush at least once a day for the correct make good structural components. amount of time, under supervision, and they also floss,” she For inspiration on how to make hard said. “And they learn to do that as a routine. That is what is materials that survive repeated shocks, going to change the dynamics of oral health.” the researchers looked to nature. “Artifi cial enamel is better than Marielle Pariseau, DDM. Image: Bubba Brown/Park Record solid commercial and experimental materials that are aimed at the same vibration damping,” said Nicholas Kotov, the Joseph B. and Florence V. Cejka professor of chemical engineering. Evolution had hit on a design that baking it to cure the plastic between He and his team examined many worked for pretty much everyone coats. It took 40 layers to build up structures in animals that had to with teeth. And unlike bone, a single micrometer of enamel-like withstand shocks and vibrations: bones, which can be repaired, enamel had structure. Then, they laid down another shells, carapaces and teeth. These to last the lifetime of the tooth, layer of zinc oxide nanowires and fi lled living structures changed from species withstanding repeated stresses and it in with 40 layers of polymer, repeating to species and over the eons. Tooth general vibrations without cracking. the whole process up to 20 times. enamel told a different story. Under Bongjun Yeom, a postdoctoral The group demonstrated that their an electron microscope, it shared a researcher in Kotov’s lab, recreated synthetic tooth enamel approached the similar structure whether it came from the enamel structure by growing zinc ability of real tooth enamel to defend a Tyrannosaurus, a walrus, a sea urchin oxide nanowires on a chip, layering two itself from damage due to vibrations. or Kotov himself (he contributed his polymers over the nanowires, spinning Read more of the study in Nature, own wisdom tooth to the effort). the chip to spread out the liquid and 543, 95–98 (2017).

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Study Links Changes in Oral Microbiome with Dental Disease A team of scientists from The found in the mouth and increased risk Forsyth Institute and the Dasman of cavities and gum disease, reinforcing Diabetes Institute in Kuwait have the need for preventive dental care and found that metabolic diseases, which greater integration between medical and are characterized by high blood dental care. The study was published pressure, high blood sugar and obesity, in the journal PLOS ONE in March. lead to changes in oral bacteria and While scientists know a great put people with metabolic diseases deal about which bacteria live in our “The mouth represents a rich at greater risk for poor oral health. mouth and throughout the body, it is microbiome that is easily accessible,” said A study of more than 8,000 10-year- still unclear whether differences in the Dr. Max Goodson, the study’s lead author. olds in Kuwait showed that metabolic human microbiome that are seen in Researchers measured the glucose diseases led to increases in salivary many disease states are a symptom of the concentration, bacterial counts and glucose, alterations of the bacteria disease or part of the underlying cause. relative frequencies of 42 bacterial species in whole saliva samples from 8,173 Kuwaiti adolescents using DNA probe analysis. In addition, clinical data related to obesity, dental caries Intervention Improves Dental Health of Elderly and were collected. Data A tailored preventive oral health intervention significantly improved the were compared between adolescents cleanliness of teeth and dentures among elderly home care clients, and with high salivary glucose (HSG) functional ability and cognitive function were found to be strongly associated and glucose concentration and with better oral hygiene, according to a University of Eastern Finland study those with low salivary glucose. published in the journal Age and Ageing. Investigators found that HSG The study is part of a larger intervention study, NutOrMed (optimizing nutrition, was associated with dental caries and oral health and medication for older home care clients), comprising a six-month oral gingivitis in the study population. health and nutrition intervention among home care clients aged 75 years or older. The overall salivary bacterial load An interview and an oral clinical examination were carried out in the in saliva decreased with increasing intervention group of 151 participants and in the control group of 118 salivary glucose concentration. Under participants. The mean age of the intervention group was 84 years and 85 years HSG conditions, the bacterial count in the control group. The intervention group received a tailored intervention of oral for 35 of 42 species was signifi cantly and denture hygiene. They were advised to brush at least twice daily with fluoride reduced and relative bacterial toothpaste and to clean interdental spaces, dentures and daily. Both frequencies in 27 species were altered, groups were reinterviewed and re-examined after six months. The intervention as compared with LSG conditions. significantly reduced the number of plaque-covered teeth and improved denture These alterations were stronger hygiene, while the reduction in the number of plaque- predictors of high salivary glucose covered teeth was associated with functional ability than measures of oral disease, and cognitive function, according to the study. obesity, sleep or fitness. These However, nearly half of the teeth in the intervention observations clearly indicate that group had plaque even after the intervention. In the metabolic diseases, such as diabetes, control group, oral health habits deteriorated during that produce elevated glucose in the six-month follow-up. Read more of this study at Age blood and saliva can significantly alter the oral microflora. Ageing (2017); 1–6. doi: 10.1093/ageing/afx020. To learn more about this study, see PLOS ONE (2017);12(3): e0170437. doi:10.1371/journal.pone.0170437.

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corticosteroids

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The Oral Eff ects of Inhalation Corticosteroid Therapy: An Update

Darren P. Cox, DDS, MBA, and Leticia Ferreira, DDS, MS

ABSTRACT Inhaled corticosteroids (IC) are commonly used for the treatment of respiratory diseases. Although these medications are generally considered safer when compared to oral systemic corticosteroids, there is evidence for potential systemic and local adverse effects with their use. Therefore, dentists should be aware of these adverse effects, especially the commonest local effects that can involve the oral mucosa. This article reviews the literature on the complications of IC therapy with emphasis on its potential oral effects.

AUTHORS

Darren P. Cox, DDS, Leticia Ferreira, DDS, lucocorticosteroids are fetal tissues.1,2 Nevertheless, the main MBA, is an associate MS, is an assistant a class of corticosteroids reason these substances are widely used professor of and professor of pathology and produced by the adrenal in medicine is due to their potent anti- medicine at the University medicine at the University of cortex and regulated infl ammatory and immunosuppressant of the Pacifi c, Arthur A. the Pacifi c, Arthur A. Dugoni Dugoni School of Dentistry. School of Dentistry. She by the hypothalamic- activities. Glucocorticosteroids inhibit the He is a 1990 graduate obtained her dental degree Gpituitary-adrenal (HPA) axis. The main migration and accumulation of neutrophils of the LSU School of from the Universidade human endogenous glucocorticoid is and at sites of infl ammation Dentistry and completed his Federal da Bahia in Bahia, cortisol; however, numerous synthetic and suppress the phagocytic, bactericidal residency in oral, head and Brazil, in 2006 and analogues of this hormone are available. and antigen-processing activity of neck pathology at Emory completed a residency 1,3 University Hospital, Atlanta, in oral and maxillofacial Glucocorticosteroids have several these cells. Glucocorticosteroids in 2000. pathology and a master’s important metabolic functions in the also appear to suppress T-cell helper Confl ict of Interest in biomedical sciences at body. They are important mediators of the function and inhibit the synthesis Disclosure: None reported. Texas A&M Health Science stress response and, as the name indicates, of pro-infl ammatory mediators Center, Baylor College of have important effects on the metabolism (i.e., , other , Dentistry in Dallas in 2011. Confl ict of Interest of glucose increasing glycogenolysis and leukotrienes and prostaglandins). These Disclosure: None reported. gluconeogenesis, inhibiting peripheral hormones can also induce utilization of glucose and increasing of infl ammatory cells, predominantly glucose release from the liver, overall of eosinophils and lymphocytes of the leading to hyperglycemia. These T-cell lineage.3,4 Hence, these effects are components also affect the metabolism highly desirable in the treatment of a of fat, protein and bone and regulate variety of acute and chronic infl ammatory growth and development, especially in conditions and autoimmune diseases.

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TABLE Orally Inhaled Corticosteroid Medications

Corticosteroid Dose form Strength Brand names Adult dosing Fluticasone furoate Dry powder inhaler 100 or 200 mcg Arnuity Ellipta 1 puff inhaled qd Breo Ellipta* 1 puff inhaled qd Mometasone furoate Dry powder inhaler 220 mcg Asmanex Twisthaler 1–2 puff s/day inhaled divided qd-bid Metered dose inhaler 100 or 200 mcg Asmanex HFA 2 puff s inhaled q12h Fluticasone propionate Dry powder inhaler 50, 100 or 250 mcg Flovent Diskus 1–2 puff s inhaled bid Metered dose inhaler 44, 110 or 220 mcg Flovent HFA 2 puff s inhaled bid Beclomethasone dipropionate Metered dose inhaler 40 or 80 mcg Qvar 1–4 puff s inhaled bid Ciclesonide Metered dose inhaler 80 or 160 mcg Alvesco 1–2 puff s inhaled bid Budesonide Dry powder inhaler 90 or 180 mcg Pulmicort Flexhaler 2 puff s inhaled bid Nebulized 0.25 mg/2ml, 0.5 mg/2 ml, Pulmicort Respules 0.25–1 mg/day NEB divided qd-bid ** 1 mg/2 ml Metered dose inhaler 80 or 160 mcg Symbicort*** 2 puff s inhaled bid Triamcinolone acetonide Metered dose inhaler Azmacort**** Flunisolide Metered dose inhaler 80 mcg Aerospan 2–4 puff s inhaled bid Aerobid**** Aerobid-M**** *Combination of fl uticasone furoate and vilanterol, which is a long-acting beta2-adrenergic agonist (LABA). **Pediatric dosing, 1 to 8 years of age. ***Combination of budesonide and formoterol fumarate dehydrate, which is a long-acting beta2-adrenergic agonist (LABA). ****Discontinued in the U.S. due to the FDA’s mandated phaseout of inhalers that contain chlorofl uorocarbons (CFCs).

All in all, exogenous glucocortico- immune system and predispose the patient These substances are especially effective in steroids are therapeutically used for a to several common and rare infections and asthmatic patients because they regulate variety of conditions such as replace- even saprophytic sepsis.1 Long-term use of gene expression of infl ammatory mediators, ment therapy in adrenal insuffi ciencies, oral glucocorticosteroids is also associated help control edema, production of mucus for the control of acute and chronic with other serious side effects, including and the eosinophil infi ltration typically infl ammation, allergic reactions, autoim- osteoporosis, metabolic disease and seen in asthma.1 Indeed, several studies mune diseases, the prevention of graft increased risk of cardiovascular disease.8–11 have confi rmed that corticosteroids are rejection after organ transplantation effective in diminishing asthma symptoms, and the treatment of myeloproliferative Inhalation Corticosteroid Therapy improving airway hyperesponsiveness,13 diseases such as certain leukemias.1,5,6 Glucocorticosteroids is commonly controlling airway infl ammation,14 Unfortunately, the long-term use of referred to in the medical and reducing frequency of exacerbations13 and glucocorticosteroids is associated with pharmaceutical literatures as just decreasing the number of hospitalizations several potentially serious side effects. The corticosteroids. One of the most common and fatalities due to the disease.15,16 most common side effect of prolonged use of uses of corticosteroids today is in the ICs are not only important in the these medications is suppression of the HPA treatment of asthma, where inhaled maintenance treatment of asthma, but axis, resulting in a reduction in endogenous corticosteroids (ICs) are considered the they can also be used in the management cortisol production from the adrenal cortex most potent anti-infl ammatory medication of patients with chronic obstructive and eventually causing adrenal cortical available and the most consistently effective pulmonary disease (COPD). COPD is atrophy. This suppression might cause long-term control medication for mild, a general term for pulmonary diseases serious complications if the exogenous moderate or severe persistent asthma.12 characterized by persistent airfl ow glucocorticosteroid therapy is suddenly How precisely corticosteroids affect the limitation from the lungs that is not stopped or if the patient’s demand of pathogenesis of asthma is not entirely fully reversible. COPD encompasses two cortisol increases, such as during a stressful understood. However, infl ammation is an main diseases: chronic bronchitis and event.7 Moreover, due to their potent important component of this disease and, emphysema. COPD affects more than immunosuppressant effects, the chronic use as stated previously, corticosteroids have 10 percent of the U.S. population and is of glucocorticosteroids may compromise the potent effects on the immune system. the fourth leading cause of death in this

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country. The 2014 update of the Global children who have mild or moderate morbidity to the patients, they might Initiative for Obstructive Lung Disease persistent asthma, low- to medium-dose hinder compliance with treatment.31 (GOLD) strategy document recommends IC therapy may have the potential of is one of the most combined IC/long-acting B2-agonist (ICS/ reducing growth velocity, although these common of these effects and will be LABA) as possible maintenance therapy effects appear to be small, transient and discussed in more detail later in this for COPD patients with severe and very noncumulative.25,26 Moreover, currently review. Dysphonia is also one of the severe airfl ow limitation and for those there is not suffi cient evidence to determine most common side effects and has with ≥ 2 exacerbations in the prior year.17 whether continuous IC administration been reported in 5 to 50 percent of Inhalation is an established and during childhood affects fi nal adult patients using ICS.32 Asthmatic patients important route of drug administration height.22 An increase in risk for dermal presenting with dysphonia while using that has been used therapeutically for thinning,27 cataracts28 and glaucoma29 ICs showed a bilateral adductor vocal thousands of years, with its fi rst documented have also been reported with IC use. cord deformity with bowing of the cords use dating all the way back to ancient These potential systemic side effects of on phonation. This side effect appears Egyptian times.18 The purpose of inhaled IC therapy are less signifi cant than with a to be related to the dose and potency of corticosteroid therapy is for the drug to the IC and may represent a reversible be deposited directly at the site of airway local steroid myopathy affecting the infl ammation, thus reducing the risk of vocal cord muscles. In some patients, the systemic corticosteroid exposure while The purpose of inhaled dysphonia is not associated with vocal potentiating the anti-infl ammatory effect cord deformity and has been attributed at the precise site of the disease. Currently, corticosteroid therapy is to laryngeal candidiasis.33 Dubus et al. there are several inhaled corticosteroids for the drug to be found in asthmatic approved for clinical use (TABLE). These deposited directly at the children using IC. This fi nding depended medications exhibit a wide range of potency on whether the children used a spacer and inhaler/formulation options.19 The site of airway infl ammation. device equipped with a face mask (5.2 medications are either solutions, suspensions percent), a nebulizer with a face mask or of solid drug particles in a gas or dry powder a nebulizer without a mouthpiece (14.3 solid particles, which can be generated percent).34 This side effect is believed from different devices such as pressurized comparable dose of oral cortiscoteroids,7 to be due to a direct local action of the metered-dose inhalers, dry powder inhalers and the National Asthma Education and IC on the facial skin, and treatment and nebulizers.20 Most of the clinical benefi t Prevention Program Expert Panel Report with oral erythromycin or topical from ICs in adolescents and adults with 312 states that the effi cacy of low- to metronidazole has been recommended asthma is achieved at relatively low doses medium-dose IC therapy outweighs any for severe cases.34,35 Cough during equivalent to 250μg of fl uticasone per day.21 small risks of adverse effects and that these inhalation,34,36,37 dry throat,36 sensation Although considered safer than long- medications are well tolerated and safe if of thirst34,36 and throat clearing36 have term oral corticosteroids, studies have used at the recommended dosages. The also been reported in patients using ICs. shown that ICs can cause systemic and expert panel recommends that in order The frequency of all these adverse effects local adverse effects. Potential systemic to reduce the potential for adverse effects varies widely, depending on study design complications of long-term IC therapy with IC therapy, only the lowest dose of and length of the observation period.31 include suppression of the HPA axis, IC that maintains asthma control should In an attempt to reduce the potential although clinically signifi cant suppression be used, and clinicians should consider for local adverse effects with the use of is unlikely to occur except at high doses.22 adding a long-acting beta2-adrenergic ICS, the National Asthma Education and Studies have also shown dose- or duration- agonist (LABA) to a low or medium dose Prevention Program Expert Panel Report dependent decreases in bone mineral of IC rather than using a higher-dose IC. 312 recommends the use of spacers or density in adult patients using ICs,23,24 Local adverse effects are the valved holding chambers (VHCs) with a however this increased risk appears small commonest side effects encountered nonbreath-activated, metered-dose inhaler and only clinically signifi cant when high with the long-term use of IC.30 Although and for patients to be advised to rinse their doses of ICs are used.22 In treatment of these effects do not cause signifi cant mouths (rinse and spit) after inhalation.

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FIGURE 1A. Erythematous candidiasis seen FIGURE 1B. Candidal hyphae were readily FIGURE 1C. Pseudomembranous of the soft palate on palatal mucosa in a patient on chronic steroid identifi able on periodic acid-Schiff stained sections (thrush) seen in a patient on chronic inhalation steroid inhalation therapy (yellow arrow). (yellow arrow) (100x). therapy.

Oral Eff ects of Inhalation for more than six months found a 6 to 14 treated. In most cases, preventive measures Corticosteroid Therapy percent prevalence of oral candidiasis.43 should be recommended to minimize The consensus of the studies reviewed infections. Adequate oral hygiene and Oral Candidiasis was that ICs promote clinical infection mouth rinsing following each use of ICs Oral candidiasis is the most common by Candida and typically presented as are simple ways of reducing local effects.48 human fungal infection38 with symptom- the erythematous or pseudomembranous Mouth rinsing with water (rinse and spit) free carriage rates in the general variants (FIGURES 1A–1C). Lesions were after inhalation may reduce the risk of population ranging from 20 to 75 percent. generally localized to areas where the spray oropharyngeal candidiasis. Moreover, Candida albicans is considered a normal was deposited and varied according to the the use of prodrugs (e.g., ciclesonide) commensal resident of the oral fl ora that dosage and frequency of use. Lesions were that are activated in the lungs but not in causes no problems in healthy populations. typically amenable to topical antifungal the oropharynx49 and new formulations While overgrowth is well-known in therapy such as nystatin oral rinses. and devices that reduce oropharyngeal the chronically immunosuppressed, as Purported mechanisms of deposition may minimize such side effects. seen in advanced HIV or in patients pathogenicity involved with ICs as Current evidence suggests that in adults, immunosuppressed to prevent transplant related to oral candidiasis are varied. systemic effects of ICs are not a problem rejection, local factors such as denture Generalized immunosuppression and at doses of 400 μg or less of budesonide wearing and impaired salivary function anti-infl ammatory effects of corticosteroids or equivalent a day.50 Spacer devices and systemic factors such as extremes of are well-known to play a major role attached to inhalers could reduce the age, smoking, diabetes mellitus, nutritional in the development of candidiasis.44 local effects of the steroids.51 However, defi ciencies and antibiotics are also known Localized corticosteroid-induced topical or systemic antifungal therapy, risk factors for the development of oral immunosuppression is a feature of IC use, such as with nystatin or fl uconazole, may and oropharyngeal candidiasis.38 With so it is logical that this would lead to oral be necessary during the entire treatment.52 denture wearers, it has been demonstrated candidiasis by providing selective growth that residual IC was signifi cantly higher advantages for Candida. In addition, Oral Hairy in full denture wearers than in partial prolonged IC therapies could damage Oral (OHL) was denture wearers, as well as the occurrence mucosal barriers predisposing to oral fi rst described as a new oral lesion in of candidiasis,39 which can compound candidiasis.45 Furthermore, ICs are known association with AIDS in 1985.53 At the effects of the altered conducive to reduce salivary total immunoglobulin that time, it was thought to be an AIDS- microenvironment produced by dentures.38 A (IgA), possibly predisposing to defi ning condition and seen exclusively First reported in 1964, 20 percent development of oral candidiasis when in male homosexuals. However, soon of asthmatic patients treated with combined with additional host factors.46 after it was demonstrated in an HIV- dexamethasone inhalers developed oral It is known that the local mucosal seronegative, heterosexual man suffering candidiasis40 and subsequently in 198641 immunosuppressive effects of ICs revert from an acute myeloblastic leukemia who and 198842 as a consequence of other oral to normal on discontinuation of the IC,47 developed clinically and histologically ICs. A literature review of trials done in but this therapy often must be continued typical hairy leukoplakia.54 Subsequently, 2001 of more than 100 patients using ICs indefi nitely because of the condition being other reports in the literature appeared

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FIGURE 2A. This 65-year-old HIV-negative male FIGURE 2B. Hematoxylin and eosin stained section FIGURE 2C. Epstein–Barr virus-encoded presented with these somewhat linear white plaques on shows nuclei in mid spinous layer of the epithelium small RNAs (EBERs) detected by positive in-situ his lateral tongue (yellow arrows). His only risk factor exhibiting prominent peripheral margination of chromatin hybridization (yellow arrow) (400x). (Image was oral inhalation steroid therapy for emphysema. or “nuclear beading” (yellow arrows), an indication of courtesy of Drs. William Binnie and John Wright.) Epstein-Barr virus-induced cytopathic eff ect (400x). documenting cases of hairy leukoplakia OHL classically presents on the in patients with leukemia.55,56 In 1992, lateral border of the tongue as unilateral two cases of hairy leukoplakia were or bilateral, nonwipeable, white patches reported in patients with no known risk with a corrugated surface (FIGURES factors for HIV infection or any evidence 2A–2C).61,63,64 More uncommonly, of other forms of immunosuppression,57 OHL can involve the ventral and suggesting that some instances of hairy dorsal surfaces of the tongue, fl oor of leukoplakia can represent isolated and the mouth, buccal mucosa, soft palate innocuous Epstein-Barr virus (EBV) and oropharyngeal mucosa.61,63,65 infection. In 1994, hairy leukoplakia was The pathogenesis of OHL is complex. reported for the fi rst time in a patient After primary infection, those infected FIGURE 3. Lesions of angina bullosa on systemic steroids for the treatment of carry the virus throughout their lives and hemorrhagica on the lateral tongue (yellow arrow). ulcerative colitis and in 1995 in a patient shed low levels of infectious particles (Image courtesy of Dr. Lynn Solomon). with asthma.58,59 Since then, cases have in the saliva even in a state of health.66 been reported in patients on long-term In the immunocompetent, the virus is anticonvulsant treatment with the unable to replicate in the lingual epithelial shed virus.62 The authors caution that the antiepileptic lamotrigine due to acquired cells, therefore it is likely that systemic reported incidence of OHL in patients on immunodefi ciency.60 The fi rst large series conditions and local factors converge inhaled steroids is quite low, although this of oral hairy leukoplakia in HIV-negative leading to suppressed immune function. could be a function of the lack of symptoms patients was reported in 2010, where These factors allow for abundant viral and awareness of this condition or that the eight of 10 patients were on steroid replication and activation of signaling clinical lesions of non-HIV OHL are more treatment for COPD, one patient was on pathways with upregulation of proliferative subtle than the HIV-related lesions.63 prednisone therapy for a gastrointestinal and anti-apoptotic genes that induce A diagnosis of OHL in patients not stromal tumor and one patient had acanthosis and hyperproliferation of the known to have HIV should trigger a no history of immunosuppression.61 epithelium. Due to widespread use of complete review of the medical history, A review of the literature found 67 of systemic, topical and inhaled corticosteroids with particular attention to medications 76 patients with OHL without HIV in immunocompetent individuals, a rise used, specifi cally, ICs. Once identifi ed, associated with immunosuppressant drug in the incidence of reported cases of OHL further treatment is unnecessary. regimens, 32 of whom were on systemic in non-HIV infected individuals has immunosuppressant therapy for renal occurred. The mechanism by which these Angina Bullosa Hemorrhagica or bone marrow transplantation and 10 medications lead to OHL is not completely Angina bullosa hemorrhagica is a patients were being treated for COPD understood, but they are thought to rare and benign disorder characterized by and asthma using ICs.62 Chambers predispose users to opportunistic infections painless and sturdy blood-fi lled blisters et al. described 35 cases of non-HIV and to increased oropharyngeal excretion of the mouth that appear suddenly and related OHL, 28 (80 percent) of whom and rate of reactivation of EBV leading to rupture within 24 to 48 hours (FIGURE 3). were on chronic IC medication.63 re-infection of lingual epithelial cells by The cause is somewhat ill-defi ned but is

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thought to be associated with various Rare cases of reversible tongue lymphoblastic leukemia. J Endocrinol 2003;178(1):19–27. factors including diabetes and use of oral hypertrophy have been reported in 7. Lipworth BJ. Systemic adverse eff ects of inhaled 67–69 corticosteroid therapy: A systematic review and meta- ICs, but has also been described as premature infants treated with inhaled analysis. Arch Intern Med 1999;159(9):941–55. a result of trauma from mastication as beclomethasone for bronchopulmonary 8. de Vries F, Pouwels S, Lammers JW, et al. Use of inhaled well as dental or anesthetic procedures.67 dysplasia and in a 4-month-old asthmatic and oral glucocorticoids, severity of infl ammatory disease 34,74 and risk of hip/femur fracture: A population-based, case- These lesions tend to occur on the child using inhaled budesonide. control study. J Intern Med 2007;261(2):170–7. soft palate, but have been reported on This side effect was theorized to 9. Souverein PC, Berard A, Van Staa TP, et al. Use of other mucosal surfaces and are not be due to a direct effect of the IC oral glucocorticoids and risk of cardiovascular and cerebrovascular disease in a population-based, case-control associated with blood dyscrasias, bleeding causing either hypertrophy of tongue study. Heart 2004;90(8):859–65. disorders or autoimmune diseases.70 musculature or local fat accumulation. 10. Vegiopoulos A, Herzig S. Glucocorticoids, metabolism Lesions burst spontaneously and heal Hypothyroidism was ruled out as a and metabolic diseases. Mol Cell Endocrinol 2007;275(1– 2):43–61. without scarring within one week. A possible cause of the tongue enlargement 11. Wei L, MacDonald TM, Walker BR. Taking recurrence rate of up to 30 percent in the affected premature infants glucocorticoids by prescription is associated with has been reported.67 When assessing a through T4 laboratory values.74 subsequent cardiovascular disease. Ann Intern Med 2004;141(10):764–70. blood-fi lled blister in the oral cavity, 12. National Institutes of Health, National Heart, Lung and blisters associated with autoimmune Conclusion Blood Institute. National Asthma Education and Prevention diseases such as , mucous IC formulations have reduced the Program. Full report of the Expert Panel: Guidelines for the diagnosis and management of asthma 2007. www.nhlbi.nih. membrane , epidermolysis need for systemic corticosteroids for gov/fi les/docs/guidelines/asthgdln.pdf. bullosa acquisita and linear IgA disease chronic respiratory diseases such as 13. Juniper EF, Kline PA, Vanzieleghem MA, et al. Eff ect should be considered as well as erythema asthma and COPD thus reducing the of long-term treatment with an inhaled corticosteroid (budesonide) on airway hyperresponsiveness and clinical multiforme and fi xed drug eruptions. risk for potential serious complications. asthma in nonsteroid-dependent asthmatics. Am Rev Respir Blood-fi lled oral blisters may also be However, as demonstrated in this review, Dis 1990;142(4):832–6. seen in patients with bleeding disorders, localized effects on the oropharynx 14. Jeff ery PK, Godfrey RW, Adelroth E, et al. Eff ects 71 of treatment on airway infl ammation and thickening of leukemia or vasculitic disease. Features and oral cavity mucosa have become basement membrane reticular collagen in asthma. A that could distinguish angina bullosa increasingly prevalent with the increase quantitative light and electron microscopic study. Am Rev hemorrhagica from these prior entities in diagnosis of these respiratory diseases Respir Dis 1992;145(4 Pt 1):890–9. 15. Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low- would include its isolated and infrequent and consequent treatment by IC therapy. dose inhaled corticosteroids and the prevention of death appearance and lack of concomitant Therefore, it is important for all dentists from asthma. 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Hanania NA, Chapman KR, Kesten S. Adverse eff ects of 51. Toogood JH, White FA, Baskerville JC, Fraher LJ, 69. Horie N, Kawano R, Inaba J, et al. Angina bullosa inhaled corticosteroids. Am J Med 1995;98(2):196–208. Jennings B. Comparison of the antiasthmatic, oropharyngeal hemorrhagica of the soft palate: A clinical study of 16 31. Roland NJ, Bhalla RK, Earis J. The local side eff ects of and systemic glucocorticoid eff ects of budesonide cases. J Oral Sci 2008;50(1):33–6. inhaled corticosteroids: Current understanding and review of administered through a pressurized aerosol plus spacer or 70. Beguerie JR, Gonzalez S. Angina bullosa hemorrhagica: the literature. Chest 2004;126(1):213–9. the Turbuhaler dry powder inhaler. J Allergy Clin Immunol Report of 11 cases. Dermatol Reports 2014;6(1):5282. 32. Toogood JH, Jennings B, Greenway RW, Chuang L. 1997;99(2):186–93. 71. Vaillant L, Fontes V. [Bullous diseases of the oral Candidiasis and dysphonia complicating beclomethasone 52. Epstein JB, Polsky B. Oropharyngeal candidiasis: A mucosa]. Rev Prat 2002;52(4):385–8. treatment of asthma. J Allergy Clin Immunol review of its clinical spectrum and current therapies. Clin 72. Fallah-Tafti S, Mansouri D, Masjedi MR, Marashian M, 1980;65(2):145–53. Ther 1998;20(1):40–57. Faridian D. Churg Strauss syndrome after introducing oral 33. Williams AJ, Baghat MS, Stableforth DE, et al. 53. Greenspan D. Oral viral leukoplakia (“hairy” steroid to inhaler: A report of three cases. Iran J Allergy Dysphonia caused by inhaled steroids: Recognition leukoplakia): A new oral lesion in association with AIDS. Asthma Immunol 2006;5(2):89–94. of a characteristic laryngeal abnormality. Thorax Compend Contin Educ Dent 1985;6(3):204–6, 08. 73. Holt DJ, Varga E, Field EA. Lingual ulceration related 1983;38(11):813–21. 54. Syrjanen S, Laine P, Niemela M, Happonen RP. Oral to inhalers used for respiratory disease. Br Dent J 34. Dubus JC, Marguet C, Deschildre A, et al. Local hairy leukoplakia is not a specifi c sign of HIV-infection but 1997;182(9):350–2. side-eff ects of inhaled corticosteroids in asthmatic related to immunosuppression in general. J Oral Pathol Med 74. Linder N, Kuint J, German B, Lubin D, Loewenthal children: Infl uence of drug, dose, age and device. Allergy 1989;18(1):28–31. R. Hypertrophy of the tongue associated with inhaled 2001;56(10):944–8. 55. Nicolatou O, Nikolatos G, Fisfi s M, et al. Oral hairy corticosteroid therapy in premature infants. J Pediatr 35. Held E, Ottevanger V, Petersen CS, Weismann K. leukoplakia in a patient with acute lymphocytic leukemia. 1995;127(4):651–3. [Perioral dermatitis in children under steroid inhalation Oral Dis 1999;5(1):76–9. therapy]. Ugeskr Laeger 1997;159(47):7002–3. 56. Cho HH, Kim SH, Seo SH, et al. Oral hairy leukoplakia THE CORRESPONDING AUTHOR, Darren P. Cox, DDS, MBA, can 36. Pinto CR, Almeida NR, Marques TS, et al. Local adverse which occurred as a presenting sign of acute myeloid be reached at dcox@pacifi c.edu. eff ects associated with the use of inhaled corticosteroids in leukemia in a child. Ann Dermatol 2010;22(1):73–6. patients with moderate or severe asthma. J Bras Pneumol 57. Eisenberg E, Krutchkoff D, Yamase H. Incidental 2013;39(4):409–17. oral hairy leukoplakia in immunocompetent persons. A 37. Shim C, Williams MH Jr. Cough and wheezing from report of two cases. Oral Surg Oral Med Oral Pathol beclomethasone aerosol. Chest 1987;91(2):207–9. 1992;74(3):332–3. 38. Akpan A, Morgan R. Oral candidiasis. Postgrad Med J 58. Zakrzewska JM, Aly Z, Speight PM. Oral hairy 2002;78(922):455–9. leukoplakia in a HIV-negative asthmatic patient on systemic 39. Ohbayashi H, Adachi M. Infl uence of dentures on steroids. J Oral Pathol Med 1995;24(6):282–4. residual inhaled corticosteroids in the mouths of elderly 59. Fluckiger R, Laifer G, Itin P, Meyer B, Lang C. Oral asthma patients. Respir Investig 2012;50(2):54–61. hairy leukoplakia in a patient with ulcerative colitis. 40. Dennis M, Itkin IH. Eff ectiveness and Complications of Gastroenterology 1994;106(2):506–8. Aerosol Dexamethasone Phosphate in Severe Asthma. J 60. Gordins P, Sloan P, Spickett GP, Staines KS. Oral Allergy 1964;35:70–6. hairy leukoplakia in a patient on long-term anticonvulsant 41. Schechtman RL, Archard HO, Cox D. Oropharyngeal treatment with lamotrigine. Oral Surg Oral Med Oral Pathol candidiasis associated with steroid-containing inhalers. N Y Oral Radiol Endod 2011;111(5):e17–23. State Dent J 1986;52(1):24–6. 61. Piperi E, Omlie J, Koutlas IG, Pambuccian S. Oral hairy 42. Ciancio SG. Drugs in dentistry. Oral candidiasis and leukoplakia in HIV-negative patients: Report of 10 cases. Int steroid inhalers. Dent Manage 1988;28(1):63–4. J Surg Pathol 2010;18(3):177–83. 43. Ellepola AN, Samaranayake LP. Inhalational and 62. Prasad JL, Bilodeau EA. Oral hairy leukoplakia topical steroids and oral candidosis: A mini review. Oral Dis in patients without HIV: Presentation of two new 2001;7(4):211–6. cases. Oral Surg Oral Med Oral Pathol Oral Radiol

MAY 2017 233 You are the champion of the smile. You are the reason people grin for the camera and stand tall in front of the class. This confidence you give to your patients is just one reason why CDA is passionate about your profession. From legislative advocacy to exceptional insurance to innovative education, we’re here to support and protect you.

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cda.org/member ® intruded teeth

CDA JOURNAL, VOL 45, Nº5

Traumatically Intruded Permanent Teeth: Three Case Reports and a Review of Current Recommendations

Samah Omar, BDS, DDS, MSD; William F. Freccia, DDS, MS; Bonnie Retamozo, DDS, MSD; and Leif K. Bakland, DDS

ABSTRACT Intrusion of permanent teeth is not extensively covered in the literature compared to other . Treatment guidelines have been published and clinical data is accumulating to support the current recommendations, which are illustrated in the three cases here. This review evaluates the current information about management of traumatically intruded permanent teeth. As more data accumulates, uncertainties with respect to both treatment recommendations and long-term outcomes can be expected to be elucidated.

AUTHORS

Samah Omar, BDS, Bonnie Retamozo, ntrusion is a traumatic dental various developmental disturbances, DDS, MSD, is an associate DDS, MSD, is an assistant (TDI) that affects primary and including mild , professor of pediatric professor of endodontics at permanent dentition. The most or root dilacerations, partial or total arrest dentistry at the Loma the Loma Linda University Linda University School of School of Dentistry. frequently involved permanent teeth of root development and/or eruption 6 Dentistry. Confl ict of Interest are maxillary ; 68.5 percent of disturbances. Therapeutic orthodontic Confl ict of Interest Disclosure: None reported. Iintrusion injuries affect central incisors intrusions are sometimes performed Disclosure: None reported. compared to 22.2 percent affecting following some TDIs such as extrusive Leif K. Bakland, DDS, lateral incisors.1,2 Other permanent and lateral luxations.7,8 Primary tooth William F. Freccia, DDS, is emeritus professor of MS, is s diplomate of endodontics at the Loma teeth, however, may also be forcibly intrusions and orthodontic intrusions 3 the American Board of Linda University School of intruded. Because the consequences are not covered further in this review. Endodontics and a fellow Dentistry. of traumatic intrusion are often quite Forty-nine percent of intrusion of the American and the Confl ict of Interest severe, it is fortunate that the incidence injuries occur from falling and hitting the International Colleges of Disclosure: None reported. is not high; various studies indicate maxillary incisors against a hard object. Dentists. Confl ict of Interest that intrusion of permanent teeth The remaining injuries occur from bicycle 1,4 Disclosure: None reported. constitute less than 2 percent of TDIs. accidents (29 percent), motor vehicle In contrast, intrusion of primary teeth is accidents (12 percent) and sports and quite common, comprising 50 percent fi ghts (10 percent).1 Usually only a single of primary teeth luxation injuries and is involved although several teeth 29 percent of all primary teeth TDIs.5 can also be intruded at the same time.1,2,9 Such injuries can lead to damage of Concomitant injuries such as crown succedaneous tooth buds leading to fractures may also occur, complicating

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both the treatment and the prognosis.1,2,10 The 6- to 15-year-old age group is most often involved.1,2,9,11,12 Wigen et al.12 found that 45 out of 51 (88.2 percent) intrusion cases affected 6- to 12-year-old children, FIGURE 1B. and this carries with it special problems. The damage that occurs to an FIGURES 1. Ankylosis-related resorption of an intruded intruded tooth can be extensive, immature left maxillary right central incisor, which had including disruption of the blood fl ow been traumatically intruded four years earlier (1A). The patient was 8 years old at the time of the accident. The to the pulp, crushing of the periodontal FIGURE 1A. tooth had not re-erupted spontaneously. Photograph was ligament (PDL) and stripping away taken at the same time as the radiograph showing the of pieces of and PDL, in esthetic problem of an ankylosed tooth (1B). (Courtesy of addition to trauma to the surrounding Loma Linda University School of Dentistry Clinic) alveolar bone and root.4,13 These TABLE injuries often lead to pulp , root resorption and marginal bone loss, in Intrusive Luxation Guidelines22 addition to disruption of normal tooth Apex Intrusion Spontaneous Orthodontic Surgical development and eruption.4,12,14–16 Open <7mm ■ Traumatic disruption of blood ■■ fl ow to the pulp has signifi cant Open >7mm consequences.4,17,18 The pulp can recover Closed <3mm ■ from minor disruptions by increased Closed 3–7mm ■■ reparative dentin deposition leading to Closed >7mm ■ a rapidly diminishing pulp space and extensive mineralization of the pulp. Source: 2012 IADT Guidelines for Traumatic Dental Injuries.22 The recommendations are based on current best evidence. Insults that are more serious usually lead to , which will arrest root development. This can be a serious bacterial infection and monitoring the complications associated with intrusions, sequel in children and adolescents vitality status of the pulp are important there is also the problem of marginal resulting in thin walls and short, steps to be taken as part of the initial bone loss and alveolar fractures, often compromised roots. On the other hand, management of intruded teeth.20 noted when several teeth are intruded.10 incomplete root development may permit The PDL is often severely damaged Diagnosis of trauma-related intrusion revascularization of the pulp because during the axial intrusion of a tooth. The is based on history and clinical and of the wide apical opening of the root trauma causes a crushing and tearing radiographic observations.1,22,23 The canal and increased blood fl ow. In cases of the PDL and cementum covering clinical evaluation usually reveals of successful revascularization, normal the roots. Haas et al.13 showed that in the presence of one of infraocclusion root development will continue and new severely intruded teeth about 50 percent in relation to adjacent teeth, lack of hard tissue can be deposited against the of the root surfaces were denuded of PDL. physiologic mobility and little or no root canal wall leading to a thickening Denuded root surface areas are targets for pain to percussion, which often has of the root. Occasionally during osteoclastic activity resulting in ankylosis- a metallic sound.1,22,23 The severity of revascularization, ingrowth of bone related resorption (FIGURE 1A), which intrusive injuries can vary from relatively can also take place.19 The presence of can prevent an intruded tooth from re- minor intrusions to severely or totally concomitant crown fracture contributes erupting (FIGURE 1B).16,21 If bacteria gain displaced teeth into the alveolar bone to the risk of pulp necrosis, which can access to the pulp before it revascularizes, or even the nose. The reported range of facilitate bacterial invasion of a pulp that they can stimulate infection-related intrusion is 2–8 mm.1,22 Radiographic is defenseless due to loss of or diminished external resorption of the root. Along observation usually shows a reduction blood supply. Protecting the pulp from with the pulpal and periodontal or absence of normal PDL space and

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FIGURE 2A. FIGURE 2B. FIGURE 2C.

FIGURE 2D. FIGURE 2E. FIGURE 2F.

FIGURE 2H.

FIGURE 2G. FIGURE 2I.

FIGURES 2. Delayed spontaneous re-eruption of an intruded maxillary central incisor. Photograph was taken immediately after the accident (2A). Radiograph taken one day after the accident shows extent of intrusion (2B). Three weeks later, and with no sign of spontaneous re-eruption, minor tissue surgery was completed to allow attachment of an orthodontic bracket (2C). Ten weeks after the injury only minor re-eruption had taken place. Because the space for the incisor was not adequate, further orthodontic expansion of the space was necessary. Surgical repositioning was now considered (2D–E). On the day of the scheduled surgery six months posttrauma, the arch space had been increased additionally by orthodontic means and as a result the tooth had re-erupted noticeably (2F–G). The case management was changed to continue monitoring rather surgery. Eighteen months after the injury the incisor had re-erupted completely and with minor orthodontic rotation axially was now in a satisfactory position (2H). Radiograph taken four years after the traumatic injury shows the tooth with typical pulpal response following trauma (2I): extensive deposition of hard tissue in the pulp space and some blunting of the root apex. The tooth responded to pulp testing. (Courtesy of Loma Linda University School of Dentistry Pediatric Dentistry Graduate Clinic) a more apical location of the root and outcome among all TDIs. Long-term the severity of the injury infl uence cementoenamel junction compared to prognosis depends on several factors: the healing process and the long- adjacent teeth.1,22,23 Pulp vitality testing extent and severity of the injury, stage term outcome the most.15,17,25,26,28 using cold stimulus or electric pulp tester of root development, patient’s age, There are three recommended usually will give no response initially.1,22 tooth position and concomitant injuries options to manage traumatic intrusions Managing intrusive injuries can be to the crown and soft tissues.10,16,22,24–27 besides the choice of extraction diffi cult and has the least predictable The stage of root development and (TABLE). The fi rst option is to monitor

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the tooth for re-eruption.14,22 This Case One Percussion sounds also returned to should not be confused with “doing A healthy 7-year-old male fell and normal. Five months after the accident, nothing.” Monitoring is an active severely intruded his maxillary left central the tooth had re-erupted less than 2 mm process, in which the patient is on a incisor so that only the incisal edge was toward its normal position in the arch. scheduled, periodic program to record visible (FIGURE 2A). The tooth was tender After evaluating the options, the child’s evidence of re-eruption, test for pulpal to percussion and radiographs confi rmed parent agreed to proceed with surgical response and evaluate radiographs the diagnosis of intrusion and absence of repositioning. An appointment for the for possible pathological changes. A root fracture (FIGURE 2B). The treatment surgery was arranged for three weeks later. major unsolved problem is that the recommended to and accepted by his On the day of the surgical length of time to wait for re-eruption parent was to actively monitor the tooth appointment, six months posttrauma, is not predictable. As more data is for spontaneous re-eruption. Three weeks the re-examination revealed a surprising collected from clinical cases and later, there were no signs of re-eruption. fi nding — the tooth had re-erupted research, a better understanding of this To allow for orthodontic extrusion, laser signifi cantly (FIGURE 2F). It was concept may emerge. It appears that gingivectomy was performed to facilitate asymptomatic; it responded normally to immature teeth have better odds for bracket attachment (FIGURE 2C). pulp vitality testing and the percussion re-eruption than more developed teeth. sounds were normal. Radiographically, The other two treatment options are the PDL space appeared normal and surgical repositioning and orthodontic the pulp space showed calcifi c change extrusion. The literature supports both Five months after the indicating continued root development options25,28 as well as suggestions for a (FIGURE 2G). The tooth continued to combination of the two.14 Available accident, the tooth had re-erupt, but because the axial position data seem to indicate that either re-erupted less than of the tooth was slightly rotated, it was procedure has about the same expected 2 mm toward its normal orthodontically realigned about one 9,14 outcome. If the teeth are fully formed position in the arch. year following the traumatic injury and or nearly so, needs completed in four months (FIGURE 2H). to be part of the management.10,11,29 A fi nal radiograph was taken four years Finally, surgical removal of an after the traumatic intrusion (FIGURE intruded tooth may be necessary either 2I) and showed some blunting of the because of extensive complications Ten weeks after the injury, no progress root apex and extensive calcifi cation of associated with the injury or was noted. The adjacent teeth had tipped the pulp. The tooth was asymptomatic, because of patient preference.16 toward the intruded tooth, reducing responded normally to pulp testing Intrusion of teeth has earned a the space available for it (FIGURE 2D), and had a normal percussion sound. reputation for being one of the most necessitating orthodontic expansion of severe TDIs because of the fact that the interdental space and repositioning Case Two pulp necrosis, root resorption and of the tipped teeth. A slight dull metallic An 11-year-old boy had a swimming ankylosis occur perhaps more often sound was heard when percussing the pool accident in which he fractured the than with other TDIs.4,16 But using the tooth, but no defi nitive radiographic incisal edges of the maxillary central incisors knowledge that has been gained in change indicative of ankylosis was seen and also intruded them about 5 mm into recent years, active management and (FIGURE 2E). Even though ankylosis was the alveolus. At the time, he was in active selecting the best treatment option not confi rmed, because of the lack of any orthodontic treatment, which probably for the specifi c case of intrusion may eruption of the intruded tooth, surgical prevented the teeth from being intruded lead to more satisfactory outcomes. repositioning was now considered. further. Two weeks after the accident the The three case reports presented During the following two months, boy was examined by an endodontist. here describe the treatment and the increasing space between the Radiographically, the roots were at a stage of outcomes of intruded teeth managed adjacent teeth was measured and found development consistent with the boy’s age with monitored re-eruption, orthodontic to gradually become adequate for surgical and with closed apices (FIGURE 3A). A few extrusion or surgical repositioning. repositioning of the intruded incisor. days later, the endodontist accessed the pulp

238 MAY 2017 CDA JOURNAL, VOL 45, Nº5

FIGURE 3A. FIGURE 3B. FIGURE 3C.

FIGURE 3D. FIGURE 3E. FIGURE 3F.

FIGURES 3. Orthodontic extrusion of traumatically intruded teeth. This radiograph is of the right and left central incisors following traumatic intrusion in an 11-year-old boy who was in active orthodontic treatment at the time (3A). This radiograph was taken after pulp extirpation and placement of calcium hydroxide in the root canals (3B). Root canal treatment was completed three months after the injury (3C). Six-month control shows bony healing but suggestion of root resorption on the distal root surface of the left incisor (arrows) (3D). Radiographic evaluation 12 months posttrauma indicates possible root surface remodeling (arrows), but clinical testing confi rmed absence of ankylosis (3E). Ten-year control radiograph confi rms that the patient has healed satisfactorily from the injury to his central incisor teeth (3F). (Courtesy of Dr. Arthur LeClaire, Sunnyvale, Calif.) of both teeth, extirpated the pulps, placed ankylosis-related resorption, but the Case Three calcium hydroxide in the canals and sealed clinical tests did not support that (FIGURE An 8-year-old boy fell and hit a the coronal openings (FIGURE 3B). The boy 3D). At the 12-month follow-up visit, countertop, intruding his right lateral was then referred back to his orthodontist the teeth continued to be asymptomatic. and central incisors. He was examined who initiated orthodontic extrusion. No indications of ankylosis-related the next day and both teeth were Three months later, the root canal resorption were noticed clinically or completely intruded and not visible treatment was completed; the canals were radiographically, despite the appearance clinically. He did not complain of fi lled with gutta-percha and sealer and of slight irregularity on the distal aspects any pain. Because the radiographic the coronal access openings were fi lled of the right incisor root (FIGURE 3E). examination showed that both teeth with zinc oxide-eugenol (FIGURE 3C). The teeth were evaluated about had wide-open apical foramina The six-month follow-up radiograph 10 years after the accident, and they (FIGURE 4A), the management of the showed bony healing. A slight irregularity responded normally to percussion and injury would be active monitoring. on the distal aspect of the root of the mobility testing and showed no signs of The adjacent and opposing teeth left central incisor suggested a possible ankylosis-related resorption (FIGURE 3F). were all unaffected by the trauma.

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FIGURE 4A. FIGURE 4B. FIGURE 4C.

FIGURE 4D. FIGURE 4E. FIGURE 4F.

FIGURE 4I. FIGURE 4G. FIGURE 4H.

FIGURES 4. Surgical repositioning of severely intruded maxillary right central incisor. This radiograph of intruded right lateral and central incisors was taken the day after the accident (4A). The wide apical openings are consistent with their stage of development. Radiograph taken four weeks posttrauma shows minimal re-eruption of the intruded teeth (4B). Radiograph three months posttrauma (4C). The lateral incisor had partially re-erupted while the central incisor showed no change. Note continued apical root development in both incisors. Six-month radiographic control shows no change in position of the central incisor while the lateral incisor had re-erupted completely (4D). Radiograph one year posttrauma shows continued root development and minor external apical surface irregularity (arrow) (4E). This radiograph was taken immediately after surgical repositioning and splinting of the central incisor (4F). Two weeks after surgically repositioning the tooth, root canal treatment was completed (4G). Three years posttrauma, the patient was referred to an orthodontist for an eruption problem associated with the right maxillary cuspid (4H). Eight years after the root canal treatment was done, the patient requested bleaching of the central incisor that had discolored (4I). Radiograph shows cervical invasive root resorption (arrows) (4J). This radiograph was taken 12 years after the traumatic intrusion of the central incisor; it had broken in the cervical area from a minor traumatic impact to the tooth (4K). (Courtesy of Dr. William F. Freccia, Fayetteville, N.C.)

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As expected, the crown did fracture (FIGURE 4K) following a minor impact to the teeth 12 years after the traumatic intrusion. The cervical resorption no doubt weakened the tooth and made FIGURE 4J. FIGURE 4K. it susceptible to fracture with even minor impact injuries. On the other hand, the lateral incisor that re-erupted The patient was re-examined four hydrochloride (4.4 cc, 1:100,000 spontaneously is doing fi ne and has weeks later and the lateral incisor had epinephrine) was used for local anesthesia, showed no sign of resorption. The re-erupted slightly, but the central incisor and a mucogingival soft tissue fl ap trauma management of this patient had barely moved (FIGURE 4B). The was raised to provide access to the allowed him to retain the compromised incisal edges of both teeth were visible intruded tooth. The root was covered central incisor during the growth and the teeth responded normally to dry by bone, but the crown was visible. and development of the ice pulp testing; they were not painful to Forceps were used to extract the tooth until suitable prosthetic replacement percussion. Three months post-trauma from its intruded position and then was more feasible at a later age. the patient was examined again and the placed in a normal position. The soft lateral incisor had continued to re-erupt tissue fl ap was repositioned and sutured Discussion while the central incisor remained in its securely. The tooth was splinted to Developing recommendations for the intruded position with only the incisal the adjacent teeth using orthodontic management of traumatically intruded edge barely visible. Radiographically, both wire and composite (FIGURE 4F). Root permanent teeth is a work in progress. root apices appeared to be closing (FIGURE canal treatment was completed two An example of such an evolving change 4C). While neither tooth was painful to weeks later (FIGURE 4G) and the splint is evident with the modifi cations in the percussion, the percussion sound from was removed after another two weeks. International Association for Dental the central incisor was dull and suggested The patient tolerated the procedure Traumatology (IADT) Guidelines possible development of ankylosis. well and the healing was uneventful. between 200730 and 2012.22 Agreement Six months after his accident, the The patient was evaluated regularly; is emerging concerning the intruded patient showed continued re-eruption three years after the trauma, he was immature tooth. Allowing for spontaneous of the lateral incisor while the central referred for orthodontic treatment for a re-eruption appears to have general incisor showed no change in position problem with eruption of the maxillary support.4,9,11,12,14,16,29 More than 30 years (FIGURE 4D). Discussion about considering right cuspid (FIGURE 4H). Nine years ago, Jacobsen11 reported on the results a surgical or orthodontic approach began, after the traumatic intrusion and eight of 37 intruded immature teeth that but due to various circumstances, the years after repositioning and endodontic were allowed to re-erupt. The degree patient did not come for follow-up until treatment, the patient returned for of intrusion varied from complete to six months later, about one year after consultation regarding discoloration minimal intrusion and all re-erupted. the injury. The lateral incisor was in a of the central incisor (FIGURE 4I). In More recently, Wigen et al.12 reported normal position, but the central incisor preparation for bleaching, radiographic on a similar number of immature teeth had not moved. Radiographically, the examination showed evidence of and found that 35 of 37 incisors re- root of the central incisor had continued cervical root resorption (FIGURE 4J). erupted satisfactorily over a period of to develop with a suggestion of external Clinical observation after opening three to 12 months. In the study by surface irregularity apically (FIGURE the coronal access showed resorptive Andreasen et al.,14 there were less healing 4E). Percussion sound continued to perforation on the distal cervical aspects complications when immature teeth were be dull. Because of the possibility of of the tooth. The perforation was sealed allowed to re-erupt compared to active ankylosis, surgical repositioning was with zinc oxide-eugenol cement and (orthodontic or surgical) repositioning. favored over orthodontic extrusion. successful bleaching was completed, Identifying the degree of develop- The surgical repositioning was but the patient was informed about the mental maturity in an intruded tooth done 14 months posttrauma. Lidocaine possibility of future crown fracture. is frequently based on the description

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suggested by Moorrees et al.31 in which bone loss.14 The IADT Guidelines22 as other avenues available, such as cracks seven stages of root development attempt to specify when the choice and unprotected dentinal tubules. This will were described. For the purpose of of may be suitable, such lead to infected pulp necrosis and the teeth categorizing the maturity of intruded as when spontaneous eruption fails will require endodontic treatment.11,12 If teeth, while not usually mentioned and when a mature tooth has been root canal treatment becomes necessary in the case reports and other articles, intruded between 3–7 mm. Clinical in a very immature tooth, it will have the root apex is recognized as having data will need to be collected to test reduced resistance to fracture as can be a wide-open apical foramen (Moorrees such recommendations. The timing seen in case three. Revascularization occurs stage fi ve), a half-closed foramen of orthodontic extrusion seems to be more frequently in cases of spontaneous (stage six) or a narrow apical foramen quite fl exible in that immediate or re-eruption than in assisted repositioning.14 (stage seven). It is reasonable to expect delayed initiation of extrusion leads The most serious outcome complication intruded teeth with stage fi ve apical to similar outcomes.14 If choosing is root resorption,4,12 which is related to openings to re-erupt in most instances, orthodontic extrusion, probably the damage to the cementum covering of while those with stage seven openings most obvious disadvantages would be the external root surface.13 The exposed are less likely to do so, although some the treatment cost and time involved. dentin is subject to osteoclastic activity if may re-erupt.12 Those in stage six with the damaged area is not repaired with new half-closed foramina are less predictable, cementum after the injury. As in other but should be given an opportunity to traumatic dental injuries, there are two re-erupt. One possible explanation for When choosing re-eruption types of resorption: infection-related and the frequent re-eruption of the very ankylosis-related.35 Infection-related can immature intruded teeth is that less as the treatment choice, be prevented and arrested if already present damage may have occurred to the tooth determining how long to when the diagnosis is made with endodontic because of the softer bone surrounding wait for movement of the treatment. On the other hand, ankylosis- the teeth in young children.10 related resorption is progressive and cannot When choosing re-eruption as intruded tooth is challenging. be arrested. It has been pointed out that the treatment choice, determining antibiotics are of no value in preventing how long to wait for movement of the either pulp necrosis or root resorption.14 intruded tooth is challenging. The TDIs that result in intrusion of teeth IADT Guidelines22 recommend “a Surgical repositioning has been are sometimes so severe that the choice few weeks” while others suggest two described and has the advantage of less of extraction may be unavoidable.4,13 to three weeks.16 It is clear that data time involvement than orthodontic Retaining compromised teeth for as long is not available to base a more precise treatment.2,9,14,25,34 The IADT Guidelines as possible in children and adolescents recommendation. As illustrated in case indicates that surgery should be considered should be considered for supporting one reported here, more than fi ve months for all teeth with > 7 mm traumatic continued growth and development and after the intrusion the tooth began to intrusion.22 Stabilization of surgically allowing better options for replacement show signs of re-eruption, possibly as repositioned teeth is recommended for at a later time. It is diffi cult to know a result of adequate space generated four to eight weeks using a nonrigid if in some cases severely intruded by separating the adjacent teeth splint.22 While the IADT Guidelines teeth have been surgically removed orthodontically. Other unusual cases of are moving toward developing fairly simply because of expediency or lack late re-eruption have been reported.23,27 specifi c recommendations, clinical of updated information on dental Orthodontic repositioning of data must be collected over time traumatology. The availability of the intruded teeth is also supported in to test such recommendations. IADT Guidelines and the Andreasen the literature,4,9,14,22,28,32,33 however, Disruption of pulpal blood supply Trauma Guide on electronic media it does not appear to be superior to in intruded teeth is a major concern. If may help to change that situation if surgical repositioning.4,9,14 A possible revascularization does not take place, the it exists. The websites are available advantage to the orthodontic approach bloodless pulp tissue becomes a target for to all at iadt-dentaltrauma.org and is that it may result in less marginal bacterial invasion through the apex as well dentaltraumaguide.org.

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Conclusion of the effect of treatment variables such as treatment Welbury R. A study of the management of 55 traumatically delay, method of repositioning, type of splint, length of intruded permanent incisor teeth in children. Eur Arch Information is gradually accumulating splinting and antibiotics on 140 teeth. Dent Traumatol Paediatr Dent 2009;10:25–28. regarding all aspects of traumatic intrusive 2006;22:99–111. 30. Flores MT, Andersson L, Andreasen JO, Bakland LK, luxation of permanent teeth. The 15. Sonmez H, Sonmez IŞ, Tunç EŞ. Late-term complications Malmgren B, Barnett F, Bourguignon C, DiAngelis A, of intruded permanent incisors: Two case reports. Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, von Arx evolving knowledge base will provide a Oral Surg Oral Med Oral Pathol Oral Radiol Endod T. Guidelines for the management of traumatic dental continuing opportunity for advancement 2008;105:e80–4. injuries. I. Fractures and luxations of permanent teeth. Dent in treatment protocols for this very 16. Albadri S, Zaitoun H, Kinirons MJ. UK National Traumatol 2007;23:66–71. ■ Clinical Guidelines in Paediatric Dentistry: Treatment of 31. Moorrees CFA, Fanning EA, Hunt EE. Age variation serious type of traumatic dental injury. traumatically intruded permanent incisor teeth in children. of formation for 10 permanent teeth. J Dent Res Int J Paediatr Dent 2010;20(Suppl 1):1–7. 1963;42:1490–1502. 17. Andreasen FM, Pedersen BV. Prognosis of luxated 32. Medeiros RB, Mucha JN. Immediate versus late REFERENCES 1. Andreasen JO, Bakland LK, Matras RC, Andreasen permanent teeth — the development of pulp necrosis. Endod orthodontic extrusion of traumatically intruded teeth. Dent FM. Traumatic intrusion of permanent teeth. Part 1. An Dent Traumatol 1985;1:207–20. Traumatol 2009;25:380–385. epidemiological study of 216 intruded permanent teeth. 18. Andreasen FM, Yu Z, Thomsen BL, Anderson PK. 33.Umesan UK, Chua KL, Kok EC. Delayed orthodontic Dent Traumatol 2006;22:83–9. Occurrence of after luxation extrusion of a traumatically intruded immature upper 2. Neto JJ, Gondim JO, de Carvalho FM, Giro EM. injuries in the permanent dentition. Endod Dent Traumatol permanent incisor — a case report. Dent Traumatol Longitudinal clinical and radiographic evaluation of 1987;3:103–15. 2014;30:406–410. severely intruded permanent incisors in a pediatric 19. Roberts J, Olsen C, Messer H. Conservative 34. Erverdi N, Kargül B. Complete intrusion of maxillary population. Dent Traumatol 2009;25:510–14. management of an intruded immature maxillary permanent permanent central incisors. J Clin Pediatr Dent 2002;27:9– 3. Cai H-X, Long X, Cheng Y, Li X-D, Jin H-X. Dislocation of central incisor with healing complication of pulp bone. Aust 11. an upper third molar into the maxillary sinus after severe Endod J 2001;27:29–32. 35. Andreasen JO, Bakland LK. Pathologic . trauma: A case report. Dent Traumatol 2007;23:181–3. 20. Lauridsen E, Hermann NV, Gerds TA, Ahrenshurg In Ingle’s Endodontics, 6th ed., Ingle JI, Bakland LK, 4. Al Khalifa JD, Al Azemi AA. Intrusive luxation SS, Kreiborg S, Andreasen JO. Combination injuries Baumgartner JC eds. Chapter 37 Hamilton: BC Decker, of permanent teeth: A systematic review of factors 3. Extrusion or lateral luxation and concomitant crown 2008. pp. 1358–1382. important for treatment decision-making. Dent Traumatol fractures without pulp exposure. Dent Traumatol 2014;30:169–75. 2012;28:379–85. THE CORRESPONDING AUTHOR, Samah Omar, BDS, DDS, MSD, 5. Carvalho V, Jacomo DR, Compos V. Frequency of 21. Cunha RF, Pavarini A, Percinoto C, Lima JEO. Influence can be reached at [email protected]. intrusive luxation in and its effect. Dent of surgical repositioning of mature permanent dog teeth Traumatol 2010;26:304–7. following experimental intrusion: A histologic assessment. 6. Anthonappa RP, Ongtengco KL, King NM. A report of an Dent Traumatol 2002;18:304–8. impacted primary maxillary central incisor. Dent Traumatol 22. DiAngelis AJ, Andreasen JO, Ebeleseder KA, Kenny 2013;29:420–2. DJ, Trope M, Sigurdsson A, Andersson L, Bourguignon C, 7. Al-Zubir NM. Orthodontic intrusion: A contemporary Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, review. J Orthod Res 2014;2:118–24. Pohl Y, Tsukiboshi M. International Association of Dental 8. Caprioglio A, Caprioglio C, Mariani L, Caprioglio D. Traumatology guidelines for the management of traumatic Orthodontics and Traumatic Injuries to the Teeth. Edizioni dental injuries: 1. Fractures and luxations of permanent Martina, Via A.P. Orlandi, Bologna, Italy 2014. pp. 56–7. teeth. Dent Traumatol 2012;28:2–12. 9. Tsilingaridis G, Malmgren B, Andreasen JO, Malmgren 23. Schott TC, Engel E, Göz G. Spontaneous re-eruption O. Intrusive luxation of 60 permanent incisors: A of a permanent maxillary central incisor after 15 years of retrospective study of treatment and outcome. Dent ankylosis — a case report. Dent Traumatol 2012;28:243– Traumatol 2012;28:416–22. 6. 10. Andreasen JO, Bakland LK, Andreasen FM. Traumatic 24. Çalişkan MK, Gomel M, Türkün M. Surgical extrusion intrusion of permanent teeth. Part 2. A clinical study of the of intruded immature permanent incisors. Case report and effect of pre-injury and injury factors, such as sex, age, review of the literature. Oral Surg Oral Med Oral Pathol stage of root development, tooth location and extent of Oral Radiol Endod 1998;86:461–4. injury including number of intruded teeth on 140 intruded 25. Ebeleseder KA, Santler G, Glockner K, Hulla H, permanent teeth. Dent Traumatol 2006;22:90–8. Pertl C, Quehenberger F. An analysis of 58 traumatically 11. Jacobsen I. Clinical follow-up study of permanent intruded and surgically extruded permanent teeth. Endod incisors with intrusive luxation after acute trauma. J Dent Dent Traumatol 2000;16:34–9. Res 1983;62:486, abstract no. 37. 26. Humphrey JM, Kenny DJ, Barrett EJ. Clinical outcomes 12. Wigen TI, Agnalt R, Jacobsen I. Intrusive luxation of for permanent incisor luxations in a pediatric population. I. permanent incisors in Norwegians aged 6–17 years: Intrusions. Dent Traumatol 2003;19:226–73. A retrospective study of treatment and outcome. Dent 27. Gomes GB, de Costa CT, Bonow MLM. Traumatic Traumatol 2008;24:612–8. intrusion of permanent teeth; 10-year follow-up of two 13. Haas M, Kenny DJ, Casas MJ, Barrett EJ. cases. Dent Traumatol 2013;29:165–9. Characterization of root surface periodontal ligament 28. Chaushu S, Shapiro J, Heling J, Becker A. Emergency following avulsion, severe intrusion or extraction: orthodontic treatment after the traumatic intrusive luxation Preliminary observations. Dent Traumatol 2008;24:404–9. of maxillary incisors. Am J Orthod Dentofacial Orthop 14. Andreasen JO, Bakland LK, Andreasen FM. Traumatic 2004;126:162–72. intrusion of permanent teeth. Part 3. A clinical study 29. Stewart C, Dawson M, Phillips J, Shafi M, Kinirons M,

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Antibiotic Resistance and Good Stewardship

George Maranon, DDS

ABSTRACT This article examines dentistry’s role in managing the antibiotic resistance problem through a more appropriate use of antibiotics.

AUTHOR

George Maranon, t seems counterintuitive, but the on the following criteria: effi cacy, ease DDS, is a diplomate of greatest cause of antibiotic resistance is of administration, toxicity, development the American Board of the use of antibiotics. The inappropriate of resistant strains, use of combinations Oral and Maxillofacial Surgery. He received his prescribing and overuse of antibiotics and cost. He recognized that antibiotic dental degree from the has, over time, led to an epidemic of resistant strains were more likely University of California, Los Ibacterial resistance. The CDC estimates to develop in chronic infections Angeles, and his medical that in the United States more than 2 requiring longer therapy. Glaser went degree from New York million people become ill every year on to state, “The widespread use of a Medical College and completed his residency with antibiotic-resistant infections, given agent in a given infection may in oral and maxillofacial with at least 23,000 dying as a result.1 ultimately result in the development surgery at the Westchester With respect to the use of antibiotics of resistance in all strains, with the County Medical Center. He in dentistry, Waldron reported on the result that a different drug must be used maintains a private practice successful treatment of odontogenic in the treatment of the infection.”8 in oral and maxillofacial surgery in Encino, Calif. infections using penicillin in 1943. Caldwell wrote that antibiotic drugs Confl ict of Interest In 1947, Glaser et al. reported on do not supersede sound surgical principles. Disclosure: None reported. the effect of penicillin on transient Caldwell said there were numerous bacteremias following dental extractions. reasons to discourage the indiscriminate Patterns of antibiotic resistance soon use of antibiotic drugs and warned that began to emerge.2 As early as 1945, resistance of bacteria to these drugs was Demerec published a series of papers an increasingly serious problem. In the describing patterns of antibiotic article, Caldwell put forward antibiotic resistance and advancing a theory that treatment algorithms for clinical situations mutations were responsible. These in oral surgery. He cautioned that an changes originated as mutations that accurate diagnosis and appropriate surgical resulted in a stepwise development treatment were of primary importance and to higher levels of resistance.3–7 that “indiscriminate antibiotic therapy is Glaser presented his general unwarranted and may even be hazardous, principles of antibiotic therapy at a especially if it delays a full and accurate 1953 session of the American Dental diagnosis of a pathologic condition.”9 Association. He stated that the choice Concerning the dental specialties of antimicrobial agent should be based of periodontics and endodontics,

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TABLE 1 Glossary of Terms

Term Meaning Plasmid Genetic element that is not part of a bacterial chromosome, which is not essential for growth and for which has no extracellular form. Generally circular, these elements can “jump” from one organism to another, even across species lines. These elements become “vectors” for transferring genes from one bacterium to another. Such genes include genes for antibiotics. Transposon A type of transposable genetic element, which in addition to consisting of genes that allow movement in the genome carries other genes with it. These other genes frequently provide properties such as antibiotic resistance. The availability of such resistance genes then selects in favor of bacterial strains carrying the resistance genes. Transposons carry genes (“jumping genes”) around the bacterial chromosome and also carry genes into and out of plasmids. Vector Vector is a term for a genetic vehicle such as a plasmid or phage that can carry genes from one bacterium to another. Such genes include genes for antibiotic resistance. Transformation The bacterial uptake and incorporation of exogenous DNA from its surroundings through the cell membranes. (Bacterio)phage Phages are viruses that infect bacterial cells. These phages are “vectors” that need to get their own genetic material inside bacteria to and transduction multiply. In accomplishing their own replication, phages frequently carry other genetic material (sometimes plasmids) from one bacterium to another in a process called transduction. Conjugation Bacteria engage in “sex” to exchange genetic material. This exchange can take place when bacteria are stressed as is the case when they are being aff ected by antibiotics. This exchange is not always restricted to members of the same species. Such exchange can include genes for antibiotic resistance. Antiporter or effl ux Selective carriers bring externally available metabolites into bacterial cells and export metabolic end products. Antiporters are part pump of the normal components of cell membranes that carry specifi c substances out of cell interiors. Selective and highly active antiporters act as effl ux pumps that can pump antibiotics out of bacterial cells as fast as they enter. Overexposure to an antibiotic provides an environmental pressure on bacteria that selects for bacterial strains with genes that encode highly active antiporters. Multiple resistance Sometimes plasmids have accumulated genes for resistance against more than one antibiotic. Some antibiotics, such as tetracycline, encourage the process of acquisition of antibiotic resistance. In some cases, organisms acquire resistance to more than one antibiotic because the plasmids they acquire carry several diff erent genes for diff erent types of antibiotic resistance.

Adapted from Dever LA, Dermody TS. Mechanisms of Bacterial Resistance to Antibiotics. Arch Intern Med 1991;151(5):886–895.

Ostrander published an article in the trend toward increased bacterial protein, penicillin-binding protein. 1953 that questioned the effi cacy antibiotic resistance was challenged Other antibiotics affected by this of topical antibiotics as a cure for by the development of penicillinase mechanism include the tetracyclines, the Vincent’s and other resistant penicillins, cephalosporins, macrolides, trimethoprim, sulfonamides, stomatitis. He warned of the risks of clindamycin and aminoglycosides. aminoglycosides, chloramphenicol and development of resistant strains of the quinolones. A third mechanism bacteria and advocated for “the usual Mechanisms of Bacterial Antibiotic involves alteration of the bacterial procedures for restoring good mouth Resistance cell membrane permeability to hygiene.” Ostrander recognized the In the Archives of Internal Medicine, the antibiotics. This mechanism is importance of systemic antibiotics in Dever et al. described some of the responsible for resistance to several managing severe periapical infections antibiotic resistance. The fi rst is the antibiotics including the β-lactams, associated with swelling, fever and deactivation of the antibiotics by aminoglycosides and the quinolones. In malaise, but emphasized that the bacterial enzymes. An example of this is addition, there are mechanisms where use of these drugs should not be β-lactamase hydrolysis of the penicillins antibiotics may be actively removed used to overlook the importance of and cephalosporins. The second involves from the bacteria through effl ux pumps. “adequate root canal fi lling.”10 the alteration of bacterial proteins that This is a major source of resistance The words of the warning concerning are the targets of antibiotics. Methicillin against the tetracyclines. Bacteria may antibiotic resistance started to be resistance occurs by this mechanism also develop the ability to prevent the forgotten. For the next two decades, by alteration of the antibiotic target activation of the antibiotic within the

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TABLE 2 Mechanisms of Resistance for Antibiotics Used in Dentistry

Antibiotic Target for antibiotic activity Microbial response

Penicillin and cephalosporins Cell wall synthesis ■ Beta-lactamase destroys penicillin lactam ring ■ Enzymes making cell wall become resistant to penicillin eff ect ■ Proteins that bind penicillin change shape ■ Reduced autolysis

Erythromycin Ribosome protein synthesis ■ Antiporter effl ux pump pumps molecule out as fast as it gets in ■ Alter the shape of microbial molecules that would otherwise bind the antibiotic

Tetracycline and related Ribosome protein synthesis ■ Antiporter effl ux pump pumps molecule out as fast as it gets in antibiotics ■ Alter the shape of microbial molecules that would otherwise bind the antibiotic

Sulfa drugs, trimethoprim Interferes with normal bacterial metabolism ■ Microbial metabolic processes are changed and enzyme systems change (e.g., sulfa drugs and trimethroprim interfere their characteristics with folate metabolism)

Metronidazole DNA is damaged when the drug is activated ■ Microbial nitro-reductase is changed and no longer activates by bacterial nitro-reductase enzymes metronidazole into damaging form ■ Reduce uptake

Vancomycin Peptide antibiotic interferes with manufacture ■ Microbial enzyme systems change to make a slightly diff erent cell wall of cell wall that is not aff ected by this peptide antibiotic

Adapted from Dever LA, Dermody TS. Mechanisms of Bacterial Resistance to Antibiotics. Arch Intern Med 1991;151(5):886–895. cell, alter their growth requirements the same or different species (TABLE 1). But is there justifi cation for the use of and dilute the antibiotic effect by Bacterial resistance develops quickly prophylactic antibiotics prior to dental overproduction of antibiotic target sites. because of rapid bacterial cell division procedures to reduce the risk of IE? The Bacteria can have innate or natural rates, the large number of bacterial cells United Kingdom’s National Institute for immunity or they can acquire resistance by and the combination of horizontal and Health and Clinical Excellence (NICE) mutation. With mutation, a single point vertical gene transfer11 (TABLE 2). went beyond the AHA guidelines in March mutation conferring antibiotic resistance 2008 and recommended complete cessation allows strains with this mutation to Risks of Bacteremia From Dental of antibiotic prophylaxis for prevention proliferate while susceptible strains are Procedures of infective endocarditis. In a 2014 report inhibited or killed. The progeny of these in The Lancet, Dayer et al. report on the resistant bacteria will develop resistance Infective Endocarditis incidence of infective endocarditis in through replication. This is referred The risk of endocarditis from England from 2000–2013. In their study, to as vertical gene transfer. Antibiotic bacteremia secondary to dental they noted that the number of antibiotic resistance can also occur by horizontal procedures was recognized in 1923. prescriptions written for the prevention gene transfer through the processes In 1955, the American Heart Asso- of endocarditis decreased substantially. of transformation, transduction and ciation (AHA) fi rst developed guidelines During that same period, they reported an conjugation. Transformation, however, concerning the use of prophylactic antibiot- increased number of cases of IE in both is an uncommon process where DNA ics prior to dental procedures to prevent high-risk and low-risk individuals.14 conferring antibiotic resistance from lysed infective endocarditis (IE). The guidelines In 2007, the AHA in collaboration bacteria in the surrounding environment is have been modifi ed and their indications with the ADA published the most recent acquired by the bacteria and incorporated pared signifi cantly in recent years (TABLE 3). prophylaxis guidelines for prevention of into the bacteria’s genome. Transduction The revisions had been based primarily on bacterial endocarditis. The guidelines occurs when DNA is acquired from consensus opinions of risks and benefi ts state, “Only an extremely small number other bacteria via bacteriophages and not evidence based. Concerns remain of cases of infective endocarditis might be (bacterial viruses). Conjugation is the surrounding the fact that the guidelines prevented by antibiotic prophylaxis for direct cell-to-cell transfer of DNA via were based primarily on consensus opin- dental procedures even if such prophylactic plasmids or transposons to other bacteria. ions and that there is no evidence that therapy were 100 percent effective.” The This can occur between bacteria of antibiotic prophylaxis prevents IE.12,13 AHA states that antibiotic prophylaxis

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TABLE 3 Summary of Nine Iterations of AHA-Recommended Antibiotic Regimens From 1955 to 1997 for Dental/Respiratory Tract Procedures*

Year Primary regimens for dental procedures 1955 Aqueous penicillin 600 000 U and procaine penicillin 600 000 U in oil containing 2% aluminum monostearate administered IM 30 minutes before the operative procedure. 1957 For two days before surgery, penicillin 200 000 to 250 000 U by mouth four times per day. On day of surgery, penicillin 200 000 to 250 000 U by mouth four times per day and aqueous penicillin 600 000 U with procaine penicillin 600 000 U IM 30 to 60 minutes before surgery. For two days after, 200 000 to 250 000 U by mouth four times per day. 1960 Step I: Prophylaxis two days before surgery with procaine penicillin 600 000 IM on each day. Step II: Day of surgery — procaine penicillin 600 000 U IM supplemented by crystalline penicillin 600 000 U IM one hour before surgical procedure. Step III: For two days after surgery — procaine penicillin 600 00 U IM each day. 1965 Day of procedure: Procaine penicillin 600 000 U, supplemented by crystalline penicillin 600 000 U IM one to two hours before the procedure. For two days after procedures: Procaine penicillin 600 000 U IM each day. 1972 Procaine penicillin G 600 000 U mixed with crystalline penicillin G 200 000 U IM one hour before and once daily for two days after the procedure. 1977 Aqueous crystalline penicillin G (1 000 000 U IM) mixed with procaine penicillin G (600 000 U IM) 30 minutes to one hour before procedure and then penicillin V 500 mg orally every six hours for eight doses. 1984 Penicillin V 2 g orally one hour before, then 1 g six hours after initial dose. 1990 Amoxicillin 3 g orally one hour before procedure, then 1.5 g six hours after initial dose. 1997 Amoxicillin 2 g orally one hour before procedure.

IM indicates intramuscularly. * These regimens were for adults and represented the initial regimen listed in each version of the recommendations. In some versions, > 1 regimen was included. Adapted from AHA Guideline Prevention of Infective Endocarditis. Guidelines From the American Heart Association: A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 116:1736–1754.

is now only indicated for patients with nor hygienists consistently recommend infections (LPJIs) and dental procedures the highest risk of adverse outcomes prophylaxis for high-risk cardiac patients.17 during that same time period.31–36 from infective endocarditis and should Seto et al. reported that among physicians Prophylactic antibiotics were not be based on an increased lifetime antibiotic prophylaxis overuse among favored by the majority of orthopedic risk of acquiring infective endocarditis. negligible-risk patients and underuse surgeons and dentists.37,38 There was no In the report, the AHA recognizes the among moderate-risk patients was consensus as to the antibiotic, duration importance of optimal oral health and common.18 A survey of 878 dentists found and dose. In 1990, the ADA published hygiene as it relates to bacteremia from that 75 percent of those dentists had the results of a consensus conference daily activities (toothbrushing) and state patients who took antibiotic prophylaxis of orthopedic surgeons, dentists and that this is more important than antibiotic prescribed by their physicians even though infectious diseases specialists. The report prophylaxis in reducing the risk of IE.15 it was not indicated by the guidelines.19 stated that there was limited data to In spite of the guidelines, compliance support the use of antibiotic prophylaxis is a concern. Nelson and Van Blaricum Prosthetic Joint Replacement prior to dental procedures to reduce the reported that physicians and dentists had Historically, the guidelines with risk of LPJI.39 In 1997, the Infectious “extraordinarily” low rates of compliance respect to prophylaxis prior to invasive Diseases Society of America (IDSA), the with the AHA guidelines for prophylaxis dental procedures to prevent prosthetic ADA and the American Academy of against bacterial endocarditis.16 A random joint infections have also not been Orthopedic Surgeons (AAOS) published survey of 450 dental hygienists and 450 evidence based. Starting in the 1970s, an advisory statement on the issue.40 dentists in Alberta, Canada, published case reports and animal studies began This statement was slightly revised in October 2015 found that dental to appear in the literature that raised in 2003 by these same organizations. hygienists were more likely than dentists concerns about the risk of these types of These reports failed to justify the use of to recommend antibiotic prophylaxis for infections after dental procedures.20–30 antibiotic prophylaxis on the basis of risk/ low-risk cardiac patients. In addition, There was little scientifi c evidence for benefi t and cost/effectiveness ratios.41 the study found that neither dentists the relationship of late prosthetic joint In 2015, the ADA Council on

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Scientifi c Affairs published the erythematosus; and insulin-dependent In a review article for the March results of a 2014 panel of experts (type 1) diabetes mellitus. The authors 2000 Journal, Pallasch reported on studies and recommended that “in general, found no evidence that bacteremias after that have shown signifi cant resistance for patients with prosthetic joint dental procedures or antibiotic prophylaxis to the tetracyclines, clindamycin and implants, prophylactic antibiotics had a signifi cant effect on the other the newer macrolides (azithromycin are not recommended prior to dental medical conditions reviewed.43 Finally, a and clarithromycin) among viridans procedures to prevent prosthetic cost-effectiveness analysis published in streptococci. Beta-lactamase production is joint infection. The practitioner November 2015 showed that “on the basis common in oral Prevotella, Porphyromonas and patient should consider possible of available cost and clinical outcomes and Fusobacterium species in both children clinical circumstances that may suggest data, the results produced by our model and adults. His report cited studies that the presence of a signifi cant medical suggest that a general no-antibiotic showed that amoxicillin and doxycycline risk in providing dental care without prophylaxis strategy is more cost- resistance was found in approximately antibiotic prophylaxis, as well as the effective than prophylaxis strategies.”44 one-third of moderately advanced known risks of frequent or widespread periodontitis patients. Methicillin antibiotic use. As part of the evidence- resistant staph aureus has also been found based approach to care, this clinical to colonize not only appliances like recommendation should be integrated dentures but also natural dentition.50 with the practitioner’s professional The authors found no evidence Other studies document that judgment and the patient’s needs and that bacteremias after dental antibiotic resistance in oral fl ora is a preferences.” The panel noted the procedures or antibiotic worldwide problem. One study found potential adverse effects of antibiotics antibiotic resistant genes of gram- (for anaphylaxis, antibiotic resistance prophylaxis had a signifi cant negative facultative anaerobes associated and opportunistic infections) may eff ect on the other medical with in children exceed the benefi ts. Lastly, the panel conditions reviewed. who did not have previous dental stated that each patient circumstance care or preventative procedures.51 and preference should be considered by the dentist when making the Antibiotic Dosing for the Management decision to prescribe prophylactic Antibiotic Resistant Bacteria of Oral Infections antibiotics prior to dental procedures.42 It is well documented that there In the management of infections, are strains of Staphylococcus aureus, Pallasch wrote that successful Other Medical Conditions or Devices Enterococcus and others that are resistant to antibiotic treatment requires that In the past, antibiotic prophylaxis multiple antibiotics, including vancomycin. serum concentrations delivered to the has been recommended to patients with Methicillin-resistant S. aureus is one of the infected tissues have to be greater than other types of heart disease and other most common hospital-acquired pathogens. or equal to the antibiotics’ minimum medical conditions because of the risk In 2013, the CDC published Antibiotic inhibitory concentration (MIC) for of bacteremia. In a 2007 systematic Resistance Threats in the United States that the responsible bacteria. In order to review, Lockhart et al. studied eight included a list of 18 multidrug-resistant accomplish this, Pallasch recommends medical conditions looking for support organisms (bacteria, fungi and viruses) a loading dose at the beginning of for the use of antibiotic prophylaxis that represent an urgent or serious threat.45 antibiotic treatment followed by aggressive during invasive dental procedures. Documented high rates of resistant strains dosing for the shortest period of time. These conditions included heart valve of viridans streptococcus have also been According to Pallasch, there are disease, prosthetic heart valves and reported.46,47,48 A study of 43 U.S. medical three considerations in determining the pacemakers; hip, knee and shoulder centers conducted during 1993–1994 appropriate dosing interval. The fi rst are prosthetic joints; renal dialysis shunts; found high levels of penicillin resistance the post-antibiotic effects (PAEs) of the cerebrospinal fl uid shunts; vascular grafts; were noted in 13.4 percent of the strains drug. PAEs are defi ned as the continued immunosuppression secondary to cancer and 42.9 percent of the strains were suppression of antibacterial growth after and cancer chemotherapy; systemic lupus found to have intermediate resistance.49 the administration of the antibiotic has

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ceased and serum concentrations have rates for nonhospitalized patients Sweeney et al. published a review fallen below the minimum inhibitory dropped by about one-fourth in the examining the antibiotic prescribing concentration. Antibiotics like 1990s. Unfortunately, the CDC found habits of general dentists in the United erythromycin, clindamycin and tetracycline during the same time an increase Kingdom. Their review found numerous have PAEs that last between two to seven in the number of prescriptions for studies that in general, dentists were hours because they act within the microbial broad-spectrum antibiotics. The prescribing antibiotics as treatment cytoplasm. The second consideration unnecessary use of these antibiotics before resorting to appropriate surgical is merits of continuous or pulse dosing. will likely lead to more antibiotic procedures. This is in spite of the fact Pulse-dosed antibiotics are given at higher resistance. Finally, they reported that that dental students are taught that doses on a regular schedule that allows the antibiotic prescription rate did management of dental infections the serum concentration of the drug to not change in emergency departments should be primarily through surgical or drop below the MIC for the pathogen. and outpatient clinics.53 This is an mechanical means, not by the initial Metronidazole and the quinolones act by important fi nding for dentistry because use of antibiotics. They found wide suppressing nucleic acid synthesis. For this due to decreasing reimbursements and inconsistencies in the frequency and reason, these drugs can be used at higher duration of antibiotic prescriptions. doses and at more widely spaced dosing The authors concluded that these intervals. Lastly, antibiotics like penicillin, practices contributed signifi cantly to amoxicillin and the cephalosporins work by Even though most oral facial the development of antibiotic resistance interfering with cell division. Bacteria have infections resolve in three to in oral fl ora.55 A study of the antibiotic different division rates and times; therefore, seven days, 16.7 percent prescribing practices of general and steady-state levels must be maintained. pediatric dentists in the management of A steady-state condition is achieved after of the respondents routinely odontogenic infections in children in an adequate number of doses of a drug is prescribed antibiotics for more North Carolina found a low adherence given so that a continuous blood level of than seven days. to accepted guidelines. In their the drug is reached. This requires that the summary, the authors concluded that drug be taken at an adequate dose, at the more specifi c clinical guidelines may prescribed interval and without missing improve adherence to the guidelines.56 a dose. In deciding whether antibiotics access to care issues, larger numbers General dentists’ perceptions of are necessary, Pallasch states that there of patients with dental problems antimicrobial use and resistance in are six possible outcomes of the use of are being seen in these locations. the U.K. was studied by Cope et al. antibiotics to treat infection. Of those, the A November 2000 survey of dentists They found that dentists were aware of only positive outcome is when antibiotic in Canada reported that there was resistant bacteria such as methicillin- treatment supports the patient’s immune confusion among the dentists about resistant staph aureus (MRSA), but system in resolving the infection. The prescribing antibiotics and found that there were differences of opinions negative outcomes include toxicity, inappropriate prescribing practices. as to whether antibiotic resistance was allergy, superinfection, chromosomal Even though most oral facial infections a problem in dental alveolar infections. mutations leading to resistance, gene resolve in three to seven days, 16.7 Some U.K. dentists recognized that transfer to vulnerable organisms and percent of the respondents routinely the antibiotic failure could be due to expression of dormant resistant genes.52 prescribed antibiotics for more than antibiotic resistance. Though the U.K. seven days. The authors also found that dentists in the study linked prescribing Stewardship 17.5 percent of the respondents were practices with a risk of increased It is recognized that some of the most not using the current guidelines for antibiotic resistance, most felt that important ways to reduce increases in prophylaxis against endocarditis and the prescribing practices of dentists antibiotic resistance are stewardship artifi cial hip prosthesis. Further, they had less of an impact on antibiotic and improving prescribing practices. found that antibiotics were prescribed resistance than those of physicians. The CDC reported in December 2001 postsurgically when there was no evidence Some said that the decision to prescribe that among physicians prescription for these drugs improving outcomes.54 antibiotics was infl uenced by clinical

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pressures, such as a waiting room full The council recommended that dentists Future of Infection Control of patients. Dentists who practiced educate the patients regarding the use of Current culturing methods and in the National Health Service these medications and completing the antibiotic sensitivity techniques may (NHS) suggested greater incentives full course of therapy as prescribed.59 not be sensitive enough to identify all to provide operative treatment On June 2, 2015, the American microorganisms responsible for oral might result in fewer prescriptions. Dental Association announced that infections. These methods are also time Providers primarily in private practice it was one of 15 health professional consuming and delay effective and felt raising awareness of the public organizations that participated in a directed antibiotic therapy. Since the about resistance and the appropriate White House forum on antibiotics late 1990s, molecular methods such as management of dental conditions stewardship. The forum discussed plans polymerase chain reactions, fl uorescence would reduce patients’ expectations to implement changes in antibiotics in situ hybridization, sequencing of the of the need for antibiotics.57 stewardship over the next fi ve years to 16S rRNA gene and other phenotypic The American Dental Association has reduce the development of antibiotic methods have been developed.61 Studies clarifi ed its position on whether dental resistant bacteria. In commenting utilizing these techniques have appeared prescribing practices are responsible for in the periodontal, oral and maxillofacial the development of antibiotic resistance surgery and endodontic literature.62–67 in oral fl ora. In a 1997 report, the ADA Genotyping of patients may help to Council on Scientifi c Affairs noted that The council recommended identify individuals at risk for infections.68 antibiotic resistance was a signifi cant that dentists obtain a worldwide problem, but felt that the thorough knowledge of the Conclusions prescribing practices of dentists had been Patients have clearly benefi ted from the “relatively conservative” and did not side eff ects and drug use of antibiotics for the prevention and contribute signifi cantly to the problem.58 interactions of antibiotics management of infection. It is also clear A 2004 report stated that the council before prescribing them. that the miracle cures of antibiotics are not “recommends the prudent and appropriate without personal and population risk and use of antibacterial drugs to prolong cost. The indiscriminate and inappropriate their effi cacy and promotes reserving use of antibiotics in health care and their use for the management of active about the meeting, Daniel Meyer, DDS, agriculture has led to antibiotic resistance infectious disease and the prevention of chief science offi cer for ADA’s Science yielding multidrug-resistant organisms, hematogenously spread infection, such Institute and the association, said that many with life-threatening consequences. as infective endocarditis or total joint a CDC-U.S. Department of Health Approximately 10 percent of antibiotic infection, in high-risk patients.” The and Human Services partnership will prescriptions are written by dentists. council went on to provide guidelines provide data about antibiotic use and As with other health care providers, it for the use of antibiotics that included prescribing trends to “help physicians has been shown that, at times, dentists making an accurate diagnosis, using and providers improve antibiotic use prescribe antibiotics inappropriately.69 appropriate antibiotics and dosing and cut inappropriate prescribing by Antibiotics are not a replacement for schedules and using narrow spectrum 50 percent in practices and 20 percent appropriate surgical management. Scaling antibiotics for simple infections. The in hospitals.” In a statement, the ADA and root planing, endodontics, incision recommendations also called for the pledged to “provide appropriate scientifi c and drainage and/or extraction should appropriate use of antibiotics solely and clinical expertise to fully assess and be considered as fi rst-line treatment. for bacterial infections and revision of respond to antibiotic health care issues, Dentists are fortunate in the fact that antibiotic treatment regimen based on the offer continuing education at professional most odontogenic infections are sensitive patient’s response and any microbiological meetings and provide systematic reviews to penicillin. In selecting the use of an test results. The council recommended and current scientifi c information on antibiotic, clinicians must remember that dentists obtain a thorough knowledge the proper use of antibiotics in online that there are many considerations that of the side effects and drug interactions resources.” The ADA’s position on the must be addressed. Before prescribing of antibiotics before prescribing them. use of antibiotics is posted on ada.org.60 a drug, a complete history and clinical

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examination must be performed. A evolving infections to aid in the 9. Caldwell JB. The Use of Antibiotics in Oral Surgery. J Am bacterial etiology must be confi rmed and selection of an appropriate antibiotic. Dent Assoc 1953 Feb;46(2):135–8. 10. Oslander FD. The use of antibiotics in periodontics and the source of the infection identifi ed. Lastly, fi nancial cost must be considered. endodontics. J Am Dent Assoc 953 Feb;46(2):139–144. Patient-related factors including health The use of antibiotics in the 11. Dever LA, Dermody TS. Mechanisms of status, other medications, allergies or management of infectious disease and Bacterial Resistance to Antibiotics. Arch Intern Med 1991;151(5):886–895. previous adverse events must be addressed. antibiotic prophylaxis is evolving. 12. Lewis T, Grant RT. Observations relating to subacute If empiric antibiotic therapy is planned, Clinicians should make decisions on infective endocarditis. Heart 1923;10:21–99. likely pathogens, their characteristics and the management of infections in an 13. Chung M. Prescription of Antibiotics for Prophylaxis to Prevent Bacterial Endocarditis. J Am Dent Assoc 2009 replication patterns must be known. evidence-based manner. Guidelines Aug;140(8):1025–6. The clinicians must be familiar can be used to assist practitioners in 14. Dayer MJ, Jones S, Prendergast B, et al. Incidence of with pharmacodynamics and potential those decisions, but should not be infective endocarditis in England, 2000–13: A secular trend, interrupted time-series analysis. Lancet 2015 adverse side effects of the drugs. considered a cookbook approach to Mar 28;385(9974):1219–28. doi: 10.1016/S0140- The dosages prescribed need to patient care. Unfortunately, they are 6736(14)62007–9. Epub 2014 Nov 18. deliver the highest and safest loading not necessarily evidence based. By 15. Prevention of Infective Endocarditis: Guidelines From the American Heart Association — A Guideline dose of the antibiotic at the beginning defi nition, guidelines are meant for the From the American Heart Association Rheumatic Fever, of treatment. The antibiotic should have management of the majority of patients Endocarditis and Kawasaki Disease Committee, Council the narrowest spectrum and be used for and therefore serve as a starting point on Cardiovascular Disease in the Young and the Council on Clinical Cardiology, Council on Cardiovascular Surgery 70 the shortest period of time. The selection to individualize care. The use of and Anesthesia and the Quality of Care and Outcomes of an antibiotic should take into account guidelines should take into account each Research Interdisciplinary Working Group. Circulation compliance related factors including the patient’s health status and comorbidities 2007;116:1736–1754. 16. Nelson CL, Van Blaricum CS. Physician and dentist ease and frequency of administration. and may require consultation with compliance with American Heart Association Guidelines Patients who are prescribed antibiotics the patient’s physicians. As part for prevention of bacterial endocarditis. J Am Dent Assoc must be followed closely. An antibiotic of the health care system, dentists 1989 Feb;118(2):169–73. 17. Jain P, Stevenson T, Sheppard A, Rankin K, Compton should be used for the shortest period of need to recognize their responsibility SM, Preshing W, Anderson R, Islam S, Mackie AS. time and only as an aid to the patient’s in limiting the proliferation of Antibiotic prophylaxis for infective endocarditis. Knowledge own host defenses. Once the patient’s multidrug-resistant organisms by and implementation of American Heart Association Guidelines among dentists and dental hygienists in Alberta, signs and symptoms improve, the appropriate use of antimicrobials. ■ Canada. 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PRACTICE SALES • PARTNERSHIPS • MERGERS • VALUATIONS/APPRAISALS • ASSOCIATESHIPS • CONTINUING EDUCATION

NORTHERN CALIFORNIA SACRAMENTO:  VT IW RIILFH Z SOUTHERN CALIFORNIA 25$1*(&2817<: FKDLU2UWKR BERKELEY: (TXLS 2SV  DGG¶O 3OXPEHG 'HQWDO0DWH SUDFWLFH2SV&RQVXOWURRP3DSHUOHVV VTIW2SV'HQWUL[ ALISO VIEJO: 7XUQNH\/HDVHKROGV 6RIWZDUH'LJLWDO;5D\/DVHU*5 VRIWZDUH*5&$ 'LJLWDO3DQ&HSK*5RI.DQG 6DOH2SV(TXLSSHG5HWDLO3OD]D*UHDW .$GM1HW&$ DGMXVWHGQHWIHH 6$&5$0(172: New Listing! VT 6LJQDJHPRYHLQUHDG\,QFOXGHV : IRUVHUYLFH&$ IW2SVLQWUDRUDOGLJLWDO[UD\2SHQ FRPSXWHUV[UD\V LQVWUXPHQWV&$ 2;1$5' 2SV3DSHUOHVV'HQWUL['H[LV 'LJLWDO[UD\VGD\VRI+\JLHQHSHUZHHN : 'HQWDOVRIWZDUH+02SUDFWLFH*5 %5(17:22' VTIW2SV .ORZRYHUKHDG&$ $1$+(,0)$&,/,7<21/< New 6HOOHUUHWLULQJ)DYRUDEOHOHDVH*5RI 'HQWUL['LJLWDO;UD\3DQR,QWUD2UDO Listing! 2SV0RYHLQUHDG\ZLWK .&$ &DPHUD(QGR2UDO6XUJHU\ LPSODQWV 6$&5$0(172: New Listing! 2SRIILFH HTXLSSHG2SV;UD\V3UDFWLFH:HEZLWK : New Listing! UHIHUUHGRXW*5.&$ LQSURIHVVLRQDOEXLOGLQJGHVLUDEOHORFDWLRQ FRPSXWHUVDQGGLJLWDO[UD\V&$ 3$/0'(6(57 2SV (DJOHVRIWVRIWZDUH$YDJHRIHTXLSPHQW VTIW*50'LJLWDO[UD\V &+,&2: New Listing! 2SV'LJLWDO \HDUV6HOOHU5HWLULQJ&$ %$.(56),(/': New Listing! 2SV QLFHORFDWLRQEXLOGLQJKDVVLJQDJH2ZQHU 'HQWUL[3DQR3UDFWLFHKDVEHHQHVWDEOLVKHG (VW\HDUV'HQWUL['LJLWDO;UD\V SOXV$VVRFLDWHVZRUNLQWKHSUDFWLFH 6$&5$0(172: New Listing! VTIW \HDUVZLWKORQJWHUPRZQHUVGD\V $YJ(TXLS$JHLVa\HDUVROG*5 3$/0'(6(57: New Listing! 2SV +\JZN*5.&$ Z2SV,QWUD2UDOFDPHUD 3DWLHQW%DVH .6HOOHUUHWLULQJ&$ VRIWZDUH3UDFWLFHHVWDEOLVKHG\HDUV (TXLSSHG+LJKHQGEXLOGRXWZLWK'HQWUL[ CONTRA COSTA COUNTY:2S(QGR RZQHUUHWLULQJ&$ BEVERLY HILLS:2SV(DJOH6RIW 'LJLWDO;UD\V3DQRDQG/DVHUV6HOOLQJ RI¿FHZ'LJLWDO;UD\0LFURVFRSHVDQG 'LJLWDO&(5(&/RQJWHUPVWDIIQHZHU GRFWRUZRUNVGD\VZN*500DQG SAN FRANCISCO: )LQDQFLDO'LVWULFWRI¿FH $GM1HWRI.&$ 3%6(QGRLQDSSUR[VTIW*5 2SVURRPIRUWKVTIW*5 HTXLSPHQW*50&$ .&$ PLO$GM1HW&$ PALM SPRINGS: 2SV \HDUVRI BURBANK:*HQHUDO3URVWK,PSODQW JRRGZLOO*RRGORFDWLRQ'RFWRUZDQWVWR EL DORADO COUNTY: VTIWZ SAN FRANCISCO: 3HULRGRQWDO3UDFWLFH  SUDFWLFH\HDUVRIJRRGZLOOUHWDLOFHQWHU UHPDLQDQGZRUNSDUWWLPHLISRVVLEOH 2SVLQWUDRUDOFDPHUDGLJLWDO[UD\3UDFWLFH &RQGR8QLWVTIWZ2S*5 2SVHTXLSSHG(DV\'HQWDO'LJLWDO *5.&$ .Z.$GM1HW&$ *5..$GM1HW&$ :RUNVVRIWZDUH*5.&$ SANTA BARBARA: 2SVHVWIRU SAN JOSE: CAN’T RENEW LEASE!  &2$67$/25$1*(&2817<: New \HDUVGD\V+\JLHQHZHHNORQJWHUPVWDII (/'25$'2&2817<: VTIW *5.RQòGD\ZHHN(TXLSSHGRSV Listing! 3HULR3UDFWLFHIHDWXUHVHTXLSSHG ))6*5RI.&$ 2SVZLWK3DQR(=VRIWZDUH DGG¶O3OXPEHG6T)W(='HQWDO RSVDGG OSOXPEHGZLWK\HDUVRI 9$/(1&,$: New Listing! 2SVDGG¶O *5.RQGD\ZHHN&$ 'H[LV¿OPEDVHG3DQRUDPLF&$ JRRGZLOO*UHDWORFDWLRQ&RPSXWHU$JH Some equipment also for sale! SOXPEHG(''HQWUL['LJLWDO3DSHUOHVV (/.*529(±)$&,/,7<21/< New VRIWZDUHDQG3DQR*5RI.RQD \UV*RRGZLOOGD\V+\JLHQHSHUZN Listing! )XUQLVKHGRSVWRWDO IXUQLVKHG  6$1-26()$&,/,7<:IXOO\HTXLSSHG GD\ZRUNZHHN&$ *5.ZLWK.$GM1HW 6LJQDJHRQ(ON*URYH%OIDVWJURZLQJDUHD 2SVVTIW3DQR'LJLWDO6FDQQHU ENCINO: 2SV(VW\HDUV(DJOH6RIW &$ UHDG\WRPRYHLQVHSDUDWHSDQR&$ 'LJLWDO6HQVRU'HQWUL[306VRIWZDUH 'LJLWDOLQWUDRUDOFDPHUD*5RI :(67(516$1)(51$1'29$//(<: +RXVHGGHQWDOSUDFWLFH\HDUV&$ .DQG.$GMXVWHG1HW&$ *5($7(5$8%851 New Listing! VTIW New Listing! 3HGR3UDFWLFHLQXSVFDOH Z RSV GLJLWDO [UD\V 2UWKR SKRV ;* ' GLJLWDO SDQ SAN RAMON-FACILITY: 2SIDFLOLW\ GREATER LOS ANGELES: 3HULR ORFDWLRQ2SV(DJOH6RIW,QWUD2UDO &HUHF /DVHU DQG 'HQWUL[ VRIWZDUH   FROOHFWLRQV ZKLJKHQG3HOWRQ &UDQH(TXLSPHQW 3UDFWLFH2SV

Well-Stocked Emergency Medical Kits Can Help Mitigate Risk TDIC Risk Management Staff

entists put their education, recommends dentists check with their skills and training into state dental boards. For example, action every day, but when The Dentists Insurance the California Dental Practice Act faced with a life-threatening Company recommends requires dentists to have both adult emergency, they are truly dental practices have and pediatric Magill forceps on hand Dput to the test. While dentists may not and be trained in their use to clear the like to think about the unfortunate two emergency kits: airway of foreign objects, according possibilities of medical emergencies, one for patients and to attorney Arthur Curley of Bradley, they should be prepared to handle Curley, Barrabee & Kowalski. anything that occurs under their one for employees. Dentists can refer to the American roof, whether it is a patient suffering Dental Association’s general an allergic reaction or a diabetic employee with low blood sugar. Emergency preparedness can sometimes mean the difference between life and death. Well-trained staff and clear emergency protocols are essential, as are regularly performed drills to ensure expediency should You are not an emergency occur. But one of the a sales goal. simplest ways to prevent an emergency from becoming a tragedy is a well- stocked and up-to-date emergency kit. While all dental practices are required to have emergency medical kits on hand, the type of kit and what it contains is determined by each practice’s type, patient base and level of training. The Dentists Insurance Company recommends dental practices You are a dentist deserving of an insurance company relentless have two emergency kits: one for in its pursuit to keep you protected. At least that’s how we see patients and one for employees. it at The Dentists Insurance Company, TDIC. Take our Risk Management program. Be it seminars, online resources or our Patient Kits Advice Line, we’re in your corner every day. With TDIC, There are no regulations governing what should be contained within an you are not a sales goal or a statistic. You are a dentist. emergency kit for patients; however, dental practices that contract with ® dental plans should be aware that many Protecting dentists. It’s all we do. plans have specifi c requirements. In 800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783 addition, individual states may have their own requirements, so TDIC

MAY 2017 255 MAY 2017 RM MATTERS

CDA JOURNAL, VOL 45, Nº5

recommendations on offi ce emergency ■ Nitroglycerin (sublingual and ends. Alternatively, practice kits at ada.org. TDIC’s kit content tablet or aerosol spray) owners can purchase commercial recommendations, which are aligned ■ Oxygen with positive-pressure emergency medical kits with refi ll with ADA’s, include the following: administration capability service options that automatically ■ Ammonia inhalants ■ Syringes send up-to-date medications when ■ Aspirin ■ Tourniquet existing medications are due to expire. ■ Antihistamine TDIC advises practice owners But simply having a comprehensive ■ Blood pressure monitoring equipment to designate a staff member to be medical emergency kit is not enough. ■ Bronchodilator (asthma inhaler) in charge of regularly checking Dentists and staff must know where ■ CPR pocket mask kits to ensure each is complete and it is located and how to use the items ■ Epinephrine 1:1,000 (injectable) medication contained within is not within it, especially medications. ■ Glucose (orange juice or expired. One helpful practice is to Many off-the-shelf kits come with sugar-sweetened soda) check the kit on the same schedule as instruction manuals or DVDs, and ■ High-volume suction and checking smoke detector batteries: on TDIC recommends dentists obtain aspiration tips or tonsillar suction the dates daylight saving time begins training in the administration of the emergency medications in their kits. Offi ces that provide general anesthesia or conscious sedation are required to have specifi c medications in their emergency kits. The requirements vary from state to state, so dentists should check with their state dental board or dental association for details. In California, emergency kits for offi ces that provide general anesthesia or conscious sedation are required to include the following: ■ Fifty percent dextrose or other antihypoglycemic ■ Antiarrhythmic (not required for conscious sedation) ■ Anticholinergic ■ Anticonvulsant ■ Antihistaminic ■ Antihypertensive (not required for conscious sedation) ■ Appropriate drug antagonist ■ Bronchodilator ■ Coronary artery vasodilator ■ Epinephrine ■ Intravenous medication for treatment of cardiopulmonary arrest (not required for conscious sedation)

CONTINUES ON 258

256 MAY 2017 “Matching the Right Dentist to CARROLL the Right Practice” C &COMPANY

4166 PALO ALTO GP 4151 MARIN COUNTY GP Well established practice serving young professionals and Well established and respected, quality general practice their families looking to transition to a confident dentist located in desirable Marin County location. Office has capable of handling a busy schedule. Remodeled 750 convenient ample parking, overlooking a beautiful park like square foot office with 3 fully equipped ops. Approximately setting adjacent to a peaceful creek. Office contains 5 ops 1,800 active patients. 8 hygiene days per week. $1M+ in ~1,300 sq. ft. Gross receipts average $1.2M annually average GR. Asking $800K. with 3 doctor days/week.

4127 MENLO PARK GP 4150 SANTA CRUZ COUNTY GP GP offering 35+ yrs of goodwill, this gem on the Peninsula is Seller retiring from successful 33 year general practice. Fee- truly a find. Incredible downtown location in upscale office for-service only practice. Fully-equipped 4 op facility in with ample onsite parking. 4 ops in 950 sq. ft. 2016-2014 beautiful, remodeled Seller owned building. Located in average GR $567K with average adj. net of $156K. Most desirable residential and commercial neighborhood. Asking services other than crown & bridge are referred out. 750+ 654K. Buliding also for sale. active patients. 4 hygiene days a week generate 40-45% of the revenue. Owner will help for a smooth transition. 4108 HUMBOLDT COUNTY GP Resume must be provided. Asking $417K. Well-established, high performing general practice boasts 6 fully equipped ops. in 2,900 sq. ft. free standing office w/ 4155 SAN MATEO GP Digital X- ray, 2 platinum Dexis sensors, & Cerec Omnicam General family and restorative practice with special & MCXL units. Loyal & stable pt. base in charming emphasis on esthetic dentistry. Established over 38 years in community, w/ a small town feel. Perfect for a dentist who desirable San Mateo neighborhood. 1,060 square foot has wants to escape the grind and live along the coastline. been continuously upgraded and has 3 fully-equipped ops 2016 GR $1.5M+. Seller willing to help for smooth transition. and 3 digital x-ray units. Average gross receipts $558K+ Asking $995K. with just 3 doctor days and 3 hygiene days per week. 100% of patients are private pay. Asking $379K. 4140 SAN FRANCISCO GP Seller offering 37 year family practice. Prime location in the LD 4103 SAN FRANCISCO GP heart of San Francisco'sO financial district. Modern 1,537 Vibrant downtown location in historic high-rise bldg. Retiring square footS office built out in 2005. Lease expires 2025 with doctor offering 30+ years of goodwill. 4.5 days of hygiene, option to extend. Asking $601K. Contact Carroll & Company 1,500+ active patients, 20-25 new patients/mo. Gorgeous, at (650) 362-7004 for details. spacious facility in approx. 2,500 sq. ft. 2015 GR $796K. 4093 SAN JOAQUIN ORTHO 2014 GR $768K. Average adjusted net income $274K+ Established over 35 years with a solid reputation, near Asking $599K. several referral sources in seller owned building. 2,500 sq. 4145 ROSEVILLE GP ft. office with 7 chair open bay in professional center on a Well-established GP offering 27+ years of goodwill. Owner well-travelled street with many retailers. Avg. Gross Receipts relocating out of the area. General & Cosmetic Practice with $763K. Seller retiring and willing to help for smooth 6 fully equipped ops. Lots of upgraded/newer equipment. transition. Asking $561K. The building is available to Opportunity to purchase single story 2,700 sq. ft. stand- purchase as well for $608K. alone professional bldg. Asking price for the Practice $520K. UPCOMING: NAPA COUNTY GP 4129 PETALUMA GP GP located in stunning 1,856 sq. ft. seller owned facility. State-of-the-art office includes 6 ops, staff lounge, reception Carroll & Company area, private office, business office, lab area, sterilization P (650) 362-7004 area, consult room, separate storage area, bathroom plus F (650) 362-7007 private bathroom. Asking $525K. [email protected] www.carrollandco.info 4091 SOUTH VALLEY - HOLLISTER GP & PEDIATRIC BRE #00777682 Country living at its best. Fully-equippedNG 1,600 sq. ft. office with 2 enclosed adult opsDI and 3 open pedo ops. Asking price only $125K. N Mike Carroll Pamela Carroll-Gardiner PE

www.carrollandco.info [email protected] P (650) 362-7004 F (650) 362-7007 MAY 2017 RM MATTERS

CDA JOURNAL, VOL 45, Nº5

CONTINUED FROM 256

■ Muscle relaxant (not required add to their kits accordingly. Some ■ One blanket (minimum) for conscious sedation) states, including California, require a ■ One package gauze roller ■ Oxygen doctor to sign off on medical emergency bandage at least 2 inches wide ■ Vasopressor (other than epinephrine) kits, while other states do not. ■ Resuscitation equipment Following are required emergency such as resuscitation bag, Employee Kits kit items as outlined by OSHA: airway or pocket mask The U.S. Department of Labor’s ■ Adhesive tape ■ Scissors Occupational Safety and Health ■ Box of adhesive bandages ■ Splint Administration requires employers to ■ Directions for requesting ■ Tweezers keep emergency medical kits on-site emergency assistance ■ Triangular bandages (two) should an employee be injured on ■ Elastic wraps (two) ■ Wound cleaning agent such as the job. In addition to the required ■ Gauze pads (at least 4 by 4 inches) sealed moistened towelettes items in the following list, employers ■ Gauze pads (two, at least Keeping offi ce medical emergency are advised to consider the types of 8 by 10 inches) kits stocked and up to date is a simple injuries likely to occur on the job and ■ Latex gloves way for dentists to keep their patients and employees safe and to protect themselves from liability. It is the responsibility of the practice owner to ensure emergency kits are regularly maintained and staff members understand their roles during emergencies. In addition, it is crucial to cda.org/social-hub make sure the entire team knows where the emergency kits are located. Preparing for the worst can go a long way in preventing tragedy and can help mitigate risk should an emergency occur. ■

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

258 MAY 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 Specialists in the Sale and Appraisal of Dental Practices Serving California Dentists since 1966 Practices How much is your practice worth?? Wanted Selling or Buying, Call PPS today! Visit PPS at CDA Booth #1157 NORTHERNNORT RN CALIFCALIFORNIAORNIA SOUTHERNSOUTHERN CALIFORNIACALIF (415) 899-8580 – (800) 422-2818 (714)( ) 832-0230832 0230 – (800)(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 6123 SANTATA ROSAROSA AREA Nice country setting. This ppractice CERRITOS  EMERGENC<6$/( Grossing $450,000. Digital is a community fixture. Relaxed schedule realized $590,000 in with Pano. Well-equipped for Implants. Full Price $350,000. collections in 2016. 4-days of Hygiene. Fully networked office. DENTAL LOCATION Previously grossed $1.5+ Million. Rebuild Practice housed in its own stand-alone building. & flip, or investment. Seller will stay and work. Great for MSO. 6122 SANTA CLARA Great exposure and fantastic curb appeal. FASTEST SO87+(51 CAL,)251,$ GROWTH AREA Office suite has just been remodeled. 5-ops. 2016 topped Proven location. 60,000 autos/day. 8-ops. Full Price $300,000. $700,000 on 4-day week. Perfect platform to operate 6-days a GLENDALE Practice and high identity Real Estate available. week. With focus and youthful enthusiasm, this practice easily Seller stays 1-day for transition. Associate stays if Specialist buys. tops $1+ Million/year in short order. GREAT MERGER CANDIDATE Recently renovated, gorgeous 6121 NAPA VALLEY FAMILY PRACTICE  Highly respected 5-ops, 6th available. Grossing $1 Million. Conservative Seller, community asset. Collections last 5-years has averaged $1.28 refers lots LQFOXGLQJDOO(QGR Million per year. Beautiful facility. Condo is optional purchase. INDO 4,000 sq.ft. dental building. Across from City Hall DQG Central location. College of Desert addition. FXOOPULFH $550,000. Great opportunity 6120 OAKLAND’S PIEDMONT AREA Highly coveted area. to build $1 Million practice. Right off Highway 13. 3-days of Hygiene. 4-ops with 5th INLAND EMPIRE - EMERGENCY SALE Shopping Center. available. 2016 collected $650,000+. Operated E\parttime$VVRFLDWH. Fantastic staff. Grossing $350,000. 6119 NORTH BAY ORTHO Perfectly positioned for Ambitious Owner/Operator will do $500,000+. Gorgeous office. Full Ortho. Desirable family community. Best technology, cone beam Price $350,000. and paperless. Owner works part-time. Revenue streams averaged L26A1*(/(6 BEACH CITY Grossing $2.4 Million. Private $775,000/year in past. Strong profits. Does no marketing to the DQGPPO. RE available. Seller works back. Full Price $2.4 Million. ORFDO'ental &ommunity. NEVADA – DENTURE PRACTICE Grossing $1 Million. Do 6118 SAN FRANCISCO’S EAST BAY  Forty percent equity implants and GP, grow to $2+ Million. Fantastic opportunity. stake in extremely well positioned and branded practice. 2016 ORANGE COUNTY BEACH CITY HMO grossing $4.4 produced $2.64 Million and collected $2.53 Million, reflecting a Million, two locations. Full 3rice $4.4 Million. Hands-on Owner 10% improvement over 2015. Full complement of specialties will do$5.5 Million. 300+ new patients in 2016. 6L[PRQWK7ULDO$VVRFLDWLRQZKHUHLQ PASADENA AREA - PEDO Grossing $450,000. Refers 30+ LQWHUHVWHGFDQGLGDWHVKDOOVHHDELOLW\WRPDNHSHU\HDU ortho cases/month. Bargain at $390,000. RHDOEVWDWH available. 6115 SAN FRANCISCO’S RUSSIAN HILL – CHINESE RIVERSIDE Location to share. 4-ops, nice corner suite. 6KDUH PRACTICE 2016 shall collect $300,000 with Profits of $145,000. PRQWKUHQWSeller willing to sell facility and work-back. Has been a $400,000 year performer. Full Price $90,000. Many options. Asking$90,000. 6112 HEALDSBURG Ideal as part-time practice in desirable SAN FERNANDO VALLEY Established 40-years. Recently locale or nice foundation to grow. 100% out-of-network. 2016 renovatedZLWKWKHEHVW. $EVROXWHO\JRUJHRXVAbsentee Owner topped $210,000 in collections. Full Price $30,000. 3reviously did $1 Million. RSVGrossLQJ $550,000. 6111 SANTA ROSA Perfectly positioned for next Owner. Best TORRANCE Strip Center on Hawthorne.  Gross $300,000. equipment, networked and digital including Pano. 3-days of Refers Hndo, OS, implants, perio, ortho. Close to Palos Verdes. Hygiene. 2016 collected $525,000+ with strong profits. Double WKHgross. FXOOPULFH $295,000. Conservative Owner. Great location. TORRANCE Grossing $150,000 part-time. 4-ops1o lease. 6107 EUREKA 100% out-of-network with insurance industry. Merger candidate or low cost to build up. Full Price $110,000. 2016 collected $930,000+ on Doctor’s 20-hour week. Doctor's TORRANCE Rare contract with Unions. Great fees. 100 s of schedule booked 3-months out. 7+ days of Hygiene. Highly members get free dentistry. Another PPS client with same contract calls 50+ members every day to schedule exams. Full Price $185,000. respected. Full Price $250,000. Condo is optional purchase. 6098 WEST PETALUMA Petaluma has become the business center of the North Bay! Business parks are growing and young MORE OPPORTUNITIES AVAILABLE Bellflower, Corona, families are drawn to this great family community per the unique Dana Point, East LA, LA HMO Grossing $1.5 Million, Ladera amenities of this historic river city. Collected $468,000 with Profits Ranch, Norco. of $212,500. 4-days of Hygiene. COMING UP La Jolla, Lake Elsinore with Seller to work back, 6089 MOUNT SHASTA Small town living renowned for outdoor Murrieta grossing $1.5 Million, Newport, Pasadena, Poway, San lifestyle. 3-day week collected $950,000. Very strong bottom line. Diego grossing $2.2 Million. Digital including Pano. Full Price $350,000. CALL Tom Fitterer 714-345-9659 Regulatory Compliance CDA JOURNAL, VOL 45, Nº5

Cal/OSHA Citations of Dental Practices CDA Practice Support Staff

review of Cal/OSHA screening patients for ATDs and the dental facility inspection management of patients suspected of data from October 2011 to having an ATD. A sample injury and September 2016 provides The most common illness prevention plan is available useful information to dentists on cda.org/practicesupport as part of citation issued to dental Awho seek to reduce compliance risk. A the Regulatory Compliance Manual. total of 81 dental practices were inspected facilities was for not The second most common violation during that period and 49 of them were having a written injury was failure to have a written exposure- cited. Most of the cited facilities had and illness prevention plan. control plan. Fourteen facilities did between one and three citations. The most not have this plan as required by the citations given to one facility was 13. Blood-Borne Pathogens regulation. A sample plan also is available as part of Most Common Citation the Regulatory Compliance Manual. The most common citation issued to dental facilities was for not having a written injury and illness prevention plan. Twenty-six facilities did not have a written plan that must: 1. Identify the person(s) who has the authority and responsibility Your future. for implementing the injury and illness prevention program. Your practice. 2. Describe a system for ensuring employees comply with safe Our trusted work practices, such as a recognition program, disciplinary expertise. actions and training. 3. Describe how safety information is communicated to employees

If a dental practice claims Approved PACE Program Provider 866.898.1867 FAGD/MAGD Credit Approval does not imply acceptance exemption of the Cal/OSHA Aerosol [email protected] by a state or provincial board of dentistry or AGD endorsement paragon.us.com 4/1/2016 to 3/31/2020 Transmissible Disease (ATD) regulation, Provider ID# 302387. the plan must include procedures for

MAY 2017 261 MAY 2017 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 45, Nº5

Serious Citations closeable containers constructed place contaminated sharps in Cal/OSHA categorizes its to prevent spillage and leaks. a sharps container after use. citations by factors such as whether All containers of regulated waste ■ Failure to immediately report a violation was willful and by the shall be labeled as biohazardous. to Cal/OSHA an employee’s extent and severity of the violation. ■ Make HBV vaccination serious work-related injury. The Violations of the following Cal/OSHA available to occupationally hospitalization of an employee due regulations were deemed “serious” exposed employees. to a work-related incident also rather than “regulatory” or “general” ■ Carry out prescribed post- requires reporting to Cal/OSHA. and resulted in proposed penalties exposure evaluation and Most Cal/OSHA citations of dental ranging from $1,575 to $5,400 each. follow-up procedures. facilities are due to violations of the ■ Contaminated sharps shall not ■ Take safe measures to neutralize Blood-Borne Pathogens regulation. be bent, recapped or removed or dispose of spills and overfl ows As dental employers are required from devices. Cal/OSHA does promptly where a corrosive to provide annual training on this allow contaminated sharps to substance is handled in an regulation to employees, the mandatory be bent, recapped or removed open container or drawn from training session is a good opportunity from devices if the employer can a reservoir or pipe line. to review the violations described here demonstrate, and document in Appropriate precautions should and ensure appropriate procedures the Exposure Control Plan, that be taken when employees continue to are followed in the facility. ■ no alternative is feasible or that work while on-site construction projects such action is required by a specifi c are underway. A dental facility was Regulatory Compliance features medical or dental procedure that cited when an employee fell through a resources about laws that impact dental is performed using a mechanical temporary opening on a second fl oor. practices. Visit cda.org/practicesupport device or a one-handed technique. Both the dental facility and contractor for more than 600 practice support ■ Immediately or as soon as were cited for not securing a cover resources, including practice management, possible after use, contaminated to the opening and for not posting employment practices, dental benefi ts sharps shall be placed in sharps a warning sign. The initial penalty plans and regulatory compliance. containers. Sharps containers shall amount was greater than $10,000, be easily accessible to personnel but later was reduced on appeal. and located as close as is feasible to the immediate area where sharps Other Signifi cant Citations are used or can be reasonably Other violations, while not anticipated to be found. Sharps deemed “serious,” did result in the containers should be placed in assessment of signifi cant initial each operatory. Sharps containers penalties. These include: must be disposed within 30 days ■ Failure to maintain a sharps of contents reaching the fi ll line. injury log. The log is a record of ■ Handling, storage, treatment each exposure incident involving and disposal of all regulated a sharp. The log must contain waste shall be in accordance information specifi ed in the Blood- with the California Medical Borne Pathogens regulation. Waste Management Act. Sharps ■ Failure to handle contaminated containers must be constructed sharps using effective patient- and closed to prevent spillage handling techniques and or protrusion of contents during other methods designed to handling. Containers of nonsharps minimize the risk of a sharps regulated waste shall be in injury and to immediately

262 MAY 2017 Ethics CDA JOURNAL, VOL 45, Nº5

Life Outside the Operatory and Dental Ethics Kenneth Jacobs, DDS

hat is the essence that We as dentists must avoid responsibilities. While balancing harms separates a profession the misconception that we and benefi ts, dentists are expected to from an occupation? minimize harms and maximize benefi ts Of course as can separate an ethical life for the patient. Similarly, having the professionals, we in the operatory from life outside good sense to practice utilizing the Whave committed ourselves to lifelong concept of “doing no harm” readily learning and service to the public, but of dentistry and vice versa. translates to our lives outside of the division between routine work and clinical dentistry. Thus, driving under professional endeavors is deeply rooted the infl uence can certainly do great in the concept of self-governance. In harm beyond the practice of dentistry, exchange for a commitment in seeking Within the practice of dentistry, and a criminal conviction for such the greater good for society, we as a dentist must be well informed to an act would initiate notifi cation and professionals have been granted the ensure compliance with expected legal investigation by the dental board and ability to set many of our own rules of and ethical standards. Malpractice ultimately a violation of Section 4 of the conduct within dentistry. We have been and negligence obviously breach code. Furthermore, the ethical principle given the opportunity to be leaders not intended clinical standards. Material of integrity exemplifi es that the dentist only within dentistry itself, but have also misrepresentations and false claims to who practices with honor and decency been given the responsibility to be legal, the public occur in violation of stated affi rms the core values and recognizes moral and ethical examples throughout regulations. Misuse of dental auxiliaries when words, actions or intentions are society. With this great privilege comes and inappropriate prescription of in confl ict with one’s own values and enormous expectations. When we fail medications violate state and federal conscience. Living a life with integrity to uphold this privilege, not just within laws. Yet, upon closer reading of Section shows us that clinical excellence in our professional community, but equally 4 of the code, we see it extends beyond dentistry on one hand and the blatant important in our basic societal endeavors, merely the practice of dentistry. By virtue violation of societal laws (such as the ramifi cations can be devastating. of our covenant with society, this section spousal abuse) on the other hand are in Section 4 of the CDA Code of of the code dictates that we are obligated confl ict and thus a Section 4 violation. Ethics plays a central role in emphasizing to comply with state and federal laws When making decisions in potentially the essential nature of the elevated and not engage in activity for which we murky waters, the professional ethical expectations placed on each of us. This could be prosecuted. Therefore, we place principles of the CDA Code of Ethics section sets the bar so that each member our livelihood in jeopardy by committing can certainly play a valuable role. ■ of the association is expected to abide by illegal acts that one might feel are ethical and legal standards accepted by unrelated to the practice of dentistry. We Kenneth Jacobs, DDS, is a general the profession and society. Section 4 of as dentists must avoid the misconception dentist in Beverly Hills, Calif. He is a the code specifi cally states, “A dentist has that we can separate an ethical life in the member of the CDA Judicial Council. the obligation to comply with all state and operatory from life outside of dentistry and federal laws and regulations. It is unethical vice versa. For example, conviction of tax For more information or further for a dentist to violate any law of the evasion or operating a motor vehicle while guidance, contact your local ethics state of California relating to the practice under the infl uence could profoundly committee or Brittney Ryan, CDA Judicial of dentistry or to engage in activity for affect the status of your membership in Council manager, at 800.232.7645. which the dentist may be reprimanded, organized dentistry, and more important, disciplined or sentenced by fi nal action of the standing of your dental license. any court or other authority of competent So what are the ethical principles we jurisdiction, when such action refl ects can look toward for guidance to better unfavorably on dentists or the dental understand Section 4 of the code? As profession. It is also unethical for a dentist health care professionals, the principles to engage in unprofessional conduct as it of benefi cence and nonmalefi cence is defi ned by the Dental Practice Act.” are fundamental, publicly entrusted

MAY 2017 263

BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED

Largest AC-566 SAN FRANCISCO: Spectacular views BN-679 ANTIOCH: Established for more than EC-531 GREATER SACRAMENTO: GN-399 REDDING: of Washington Square. 3ops +2 add’l, 1400sf 50 years W/ Large paent base! 3,600 sf w/ 9 $800k for Pracce & Real Estate $150k Price Reduced to $200k Ops. $1.1mil/RE $1.2mil EG-673 SACRAMENTO: GN-606 BUTTE COUNTY: Broker in AC-578 SAN FRANCISCO Patient Charts: near CC-611 SO. MARIN CO: Desirable, well- Reduced $125k Union Sq., 7 Doctor pts/day and 8 Hygiene established neighborhood, 20npts/mo 3ops, EG-685 LINCOLN/ROCKLIN: GN-641 YUBA CITY: Building available Northern pts/day $190k 1100 sf Price Reduction $625k $570k for purchase! $475k AC-624 SAN FRANCISCO: Wonderful Patients, CC-632 SAN RAFAEL: Small town life, vibrant- EN-625 SACRAMENTO: GN-656 NO. TEHAMA CO: Great Locaon! solid income in great stand-alone bldg. $475k growing city, 6-8 pts/day, 3ops in 800sf office $450k $275k California AC-640 SAN FRANCISCO: On 23rd Floor of in beautiful bldg $165k EN-626 CARMICHAEL: GN-667 OROVILLE: Great place to work & play! Prestigious SF Bldg, 2ops in 700sf. Seasoned CC-661 SAN RAFAEL: Starter Practice in beauti- $300k $325k Staff, Seller Retiring $175k ful location w/ like-new Equipment hardly EN-628 ORANGEVALE: GN-668 BUTTE COUNTY: AC-649 SAN FRANCISCO Facility Only: Rich- used, 3 ops, 900sf $250k 375k $95k mond District, 3 ops+1 add’l, Equipment less CC-676 NOVATO: Located at busiest location in EN-627 CARMICHAEL: HN-213 ALTURAS: Collected Extensive Buyer than 5yrs old $155k a well-known retail center in, 12+/- npts/mo, 4 $268k ~$760 in 2016! $195k AG-645 SAN FRANCISCO: Low Overhead, com- ops in 1,90sf $600k EN-634 ROSEVILLE: HN-280 NO EAST CA: RE- Database & pact practice ready for expansion or reloca- CG-616 NAPA: State of the Art Practice - Seller $235k DUCED! ONLY $60k tion. Retail/Commercial area. 2nd Floor $125k moving out of state! $425k EN-660 ROSEVILLE: HN-618 SIERRA FOOTHILLS: Unsurpassed AG-669 SAN FRANCISCO: RARE opportunity in DC-480 SILICON VALLEY: Multi-Specialty Prac- $995k $95k the heart of the City! 2 ops LOW OVERHEAD! tice, 14+ops in 7500 sf, Owner Financing avail- EN-654 CITRUS HEIGHTS: IG-687 TURLOCK: $88k Terms $1.075M $150k $298k Exposure allows AN-513 REDWOOD CITY: The pracce of your DC-671 SAN JOSE: Desirable neighborhood, 6 EN-651 SACRAMENTO: dreams! 900 sf w/ 4 ops + 2 add’l Now $350k npts/mo, 3ops in 900sf $150k $150k CENTRAL VALLEY us to offer you AN-642 SAN BRUNO: Don’t miss this one! FFS, 5 DN-631 CAMPBELL: Rare Opportunity! 1100 EN-664 SACRAMENTO Facility: ops 1950 sf $740k (Real Estate $1.2M) sf w/ 3 ops, busy retail center $249k $55k IC-468 SAN JOAQUIN VALLEY AN-686 SAN FRANCISCO: The office designed DG-519 SANTA CLARA Facility: Move In Ready! EN-680 GREATER SACRAMENTO: $425k

IN-569 MADERA: w paent flow and maximum office efficiency. 2240 sf w 6 fully equipped ops $225k $295k 1,000 sf w/ 4 ops. $825k DG-635 CASTRO VALLEY: Excellent Locaon & EN-689 SACRAMENTO Facility: $634k BC-520 HAYWARD Facility: Located in Down- Stellar Reputaon! Solo Group Pracce $650k $150k JN-690 LINDSAY town, 1500 sf, 4 equipped ops, X-Rays in 3 DG-643 SAN JOSE: Seller Movated! 3,300 sf w/ FC-489 CLEARLAKE: $150k/ RE 150k ops. $65k 4 ops + 2 add’l available! Call for Details! Only BC-662 HAYWARD: Starter Practice in the $65k $470k SOUTHERN CALIFORNIA “Heart of the Bay”, near Hospital, 3ops in DN-665 SANTA CRUZ AREA: Loyal, stable, mul- FC-650 FORT BRAGG: KC-678 LOMPOC & SANTA MARIA: 1056sf ONLY $75k -generaonal paent base. FFS. 1,460 sf w/ $350k for the Pracce & $400k for the Real Estate $240k BC-681 WALNUT CREEK: Recently remodeled 4 ops. $540k FC-677 FORT BRAGG: office located in this semi-rural community in a DG-691 SAN JOSE: One of the most unique $500k SPECIALTY PRACTICES serene environment. 1000sf w/ 4 Ops. $432k pracces you will ever see! 1450 sf w/ 5 ops GC-472 ORLAND: BC-682 CONCORD: located in desirable, bus- $985k $160k BC-600 CONCORD Ortho/Pedo Charts Only: tling community w/ seasoned, caring staff. DN-688 MONTEREY: Equipped with state-of- GG-453 CHICO: $400k 836sf w/ 3 Ops. $224k the-art equip& latest technology! 1,900 w/ 5 $325k FN-536 LAKE COUNTY Pedo: BN-504 RICHMOND: Established Practice & ops. $1.4mil/RE $795k GG-454 PARADISE: before $225k Real Estate! 1450 sf w/ 2 ops + 2 add’l DN-693 SAN JOSE Facility: Aracve & Spa- $525k IC-543 CENTRAL VALLEY Ortho: $100k /RE $700k cious! Faces one of the city’s major thorough- GN-244 OROVILLE: $125k fares. 1,080 sf w/4 ops. $150k $315k

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 NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED

Largest AC-566 SAN FRANCISCO: BN-679 ANTIOCH: EC-531 GREATER SACRAMENTO: Beauful 1750 sf w/ 4ops + 1 GN-399 REDDING: Loyal patient base & relaxed workweek schedule, add’l office, 8npts/mo. $800k for Pracce & Real Estate 1440 sf w/3 ops $150k Price Reduced to $200k $1.1mil/RE $1.2mil EG-673 SACRAMENTO: Beauful established dental pracce lease GN-606 BUTTE COUNTY: Hesitate & you’ll miss out on this one-of-a- Broker in AC-578 SAN FRANCISCO Patient Charts: CC-611 SO. MARIN CO: opportunity! Call for Details! kind opportunity! 1700 sf w/ 4 ops Reduced $125k EG-685 LINCOLN/ROCKLIN: Perfect Locaon in amazing community! GN-641 YUBA CITY: Fantasc signage & visibility. Building available Northern $190k Price Reduction $625k Retail Shopping Center w/ 4 ops $570k for purchase! 2,400 sf w/ 5 ops $475k AC-624 SAN FRANCISCO: CC-632 SAN RAFAEL: EN-625 SACRAMENTO: Looking for a HMO pracce in a great Loca- GN-656 NO. TEHAMA CO: Great Locaon! Ideal place to work, live $475k on? 2,500 sf w/5 ops $450k and raise a family! 2,468 sf w/ 5 ops $275k California AC-640 SAN FRANCISCO: $165k EN-626 CARMICHAEL: Lifestyle you just can’t be beat! HMO 1,250 sf GN-667 OROVILLE: Great place to work & play! Constant growth CC-661 SAN RAFAEL: w/ 3 ops $300k aracng an influx of residents! 1000 sf w/ 3 ops $325k $175k EN-628 ORANGEVALE: Great place to work, play & live. HMO 1,310 GN-668 BUTTE COUNTY: Remodeled in 2010! In a well-maintained, long- AC-649 SAN FRANCISCO Facility Only: $250k sf w/ 4 ops + 1 add’l $3375k established Professional complex. 1,200 sf w/ 2 ops. $95k CC-676 NOVATO: EN-627 CARMICHAEL: Remarkable HMO opp. awaits your talent & HN-213 ALTURAS: Well managed, consistent revenues! Collected Extensive Buyer $155k skill! 1,200 sf w/3 ops + 1 add’l $268k ~$760 in 2016! 2200 sf w/ 3 ops + 1 add’l. $195k AG-645 SAN FRANCISCO: $600k EN-634 ROSEVILLE: Beaufully designed, well-appointed and fully HN-280 NO EAST CA: Only Practice in Town 900 sf w/ 2 ops RE- Database & CG-616 NAPA: digital! 2352 sf w/4 ops + 2 add’l $235k DUCED! ONLY $60k $125k $425k EN-660 ROSEVILLE: Highly-esteemed, well-respected, fee-for-service HN-618 SIERRA FOOTHILLS: Seller Retiring! Much room for growth by Unsurpassed AG-669 SAN FRANCISCO: DC-480 SILICON VALLEY: pracce w/ loyal paent base. 2,950 sf w/ 5 ops $995k increasing office hours! 750 sf w/ 2 ops $95k EN-654 CITRUS HEIGHTS: Well-Established, & loaded with 30+ years IG-687 TURLOCK: Established quality pracce is a remarkable oppor- $88k $1.075M of goodwill! 1300 sf, 3 ops + 2 add’l. $150k tunity for you! 2,000 sf w/ 5 Ops. $298k Exposure allows AN-513 REDWOOD CITY: DC-671 SAN JOSE: EN-651 SACRAMENTO: Well-known for delivery excellent & compas- Now $350k $150k sionate care. 1750 sf, w/ 4 ops. $150k CENTRAL VALLEY us to offer you AN-642 SAN BRUNO: DN-631 CAMPBELL: EN-664 SACRAMENTO Facility: Great corner locaon, excellent visi- $740k (Real Estate $1.2M) $249k bility and easy access! 2,300 sf w/ 4 ops. $55k IC-468 SAN JOAQUIN VALLEY: High-End Restore Pracce! 6 ops in AN-686 SAN FRANCISCO: DG-519 SANTA CLARA Facility: EN-680 GREATER SACRAMENTO: Prisne in rural Northern Califor- 2500+ sf office. Call for Details! $425k

IN-569 MADERA: Stellar reputaon and load with goodwill! 2,900 sf $225k nia! Pracce denstry like it used to be! 1,500 sf w/ 4 ops. $295k $825k DG-635 CASTRO VALLEY: EN-689 SACRAMENTO Facility: Bring your talents, hang your sign & w/ 7 ops $634k BC-520 HAYWARD Facility: $650k make it your own! 2,000 sf w/ 4 ops. $150k JN-690 LINDSAY: Stable, mul-generaonal paent base who are DG-643 SAN JOSE: FC-489 CLEARLAKE: Great lifestyle. 2015 Gross $915k on 3 day loyal & appreciave. 1,700 sf w/ 3 ops. $150k/ RE 150k $65k Only week, 4ops. Real Estate 3600 sf shared, interest “Pride InsƟtute” BC-662 HAYWARD: $65k designed office $470k SOUTHERN CALIFORNIA DN-665 SANTA CRUZ AREA: FC-650 FORT BRAGG: Family-oriented Pracce, 5ops in 2000sf, 6 KC-678 LOMPOC & SANTA MARIA: Live and Price along the central ONLY $75k npts/mo $350k for the Pracce & $400k for the Real Estate coast, 10 npts/mo, plenty of room for growth, Call for Details! $240k BC-681 WALNUT CREEK: $540k FC-677 FORT BRAGG: Beauful, FFS Pracce, 4ops +1 add’l, in DG-691 SAN JOSE: 2375sf, Grosses over $1M annually $500k SPECIALTY PRACTICES $432k GC-472 ORLAND: Live & Practice in charming small town community. BC-682 CONCORD: $985k 1000 sf w/ 2ops, Seller Retiring. $160k BC-600 CONCORD Ortho/Pedo Charts Only: Continue treatment to DN-688 MONTEREY: GG-453 CHICO: 5000 sf w/ 7 ops Perfect for 1 or more dentists! these Ortho/Pedo patients Call for Details! $400k $224k $325k FN-536 LAKE COUNTY Pedo: Focusing on Prevent dental problems BN-504 RICHMOND: $1.4mil/RE $795k GG-454 PARADISE: 2550 sf w/ 9 ops, 40 yrs goodwill! Amazing Op- before they begin! 1750 sf w/ 3ops $225k DN-693 SAN JOSE Facility: portunity! $525k IC-543 CENTRAL VALLEY Ortho: 1650 sf w/ 5 chair bays & plumbed $100k /RE $700k GN-244 OROVILLE: Must See! Gorgeous, Spacious 2500 sf w/5 for 2 add’l, Strong Refs & Satisfied Pts Base $125k $150k ops! $315k

“ASK THE BROKER” CAN NOW BE FOUND AT WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 45, Nº5

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

Amazon’s Alexa Comes to iOS Asthma Study Relies on Smartphones Shopping App The idea that smartphones could play a big role in research was validated after a new study on asthma patients was conducted Alexa, the intelligent personal assistant developed by Amazon, has completely through iPhones. Mount Sinai Health System conducted only been available exclusively through Amazon Echo and Echo Dot its Asthma Mobile Health Study in 2015 using an app that was voice-controlled speakers, until now. Amazon recently updated its iOS downloaded by 50,000 people. The app included surveys and the shopping app to bring all the features of Alexa to the iPhone without participants needed to check in daily using an “electronic asthma the need to purchase additional hardware. diary.” The number of individuals who participated was 7,593, and Users of the Amazon shopping app may have noticed the 85 percent of those who participated completed at least one survey microphone icon in the upper right of the screen next to the search and 2,317 completed multiple surveys in a six-month span. As a result, fi eld. Previously, the microphone icon allowed users to perform researchers were able to link asthma symptoms to an outbreak of product searches, reorder items previously purchased and track wildfi res and pollen levels and heat. Learn more about this study in the orders. With the shopping app update, users can now tap the journal Nature Biotechnology, 2017; doi:10.1038/nbt.3826. microphone icon to activate Alexa directly from the iPhone without —Blake Ellington, Tech Trends editor the need for saying “Alexa” as a wake-word. Alexa accepts the same commands from the shopping app as with the Echo or Echo Dot, including controls for any enabled Smart Home skills. Alexa can Professionalism Course Changes Medical also be activated on the iPhone by using 3D Touch on the Amazon shopping app or through its app widget. Students’ Social Media Behavior To take advantage of Smart Home devices and other skills, users First-year medical students at George Washington University School must, in addition to the Amazon shopping app, download and setup of Medicine and Health Sciences altered how they were acting the Amazon Alexa app on their device. As confusing as it sounds, this online after taking a course about social media and professionalism. process is just like confi guring an Amazon Echo or Echo Dot to use The study included analyzing students who took the course between Alexa with the diff erence being only that the assistant resides in the 2012 and 2014. The results found that 94 percent of those students shopping app and not from a voice-controlled speaker that is sold who participated had an “increased awareness of their social separately. Once Smart Home device confi guration and enabling of media behavior.” This means they understood how it could tie into skills are complete, users can activate Alexa on their iPhones to take their careers. In addition, 64 percent of the students changed how advantage of all the features the assistant provides. Alexa has many they approached their social media use. The course delved into the abilities, from controlling lights and thermostats to simply asking it for challenges and opportunities of social media so students could use it to the latest news or weather forecast. their advantage professionally. For more information, see the study in the journal Teaching and Learning in Medicine, 2017; 1-9 dx.doi.org/ Bringing Alexa to the iPhone opens Amazon’s powerful voice- 10.1080/10401334.2016.1275971. controlled assistant to the masses. No longer tethered to speakers that reside in the home, Alexa can now be activated anywhere —Blake Ellington, Tech Trends editor that an iPhone can be used. Along with the many Smart Home and app integrations that support Alexa, Amazon has released a Would you like to write about technology? powerful combination of features and portability that make it a strong Dentists interested in contributing to this section should contact competitor to other digital personal assistants available today. Andrea LaMattina, CDE, at [email protected]. —Hubert Chan, DDS

266 MAY 2017 Get to the center of it all. Experience Discover your adventure. all the excitement during the convention and right outside its doors. See your talent, tools, inspiration and community in a new light at CDA Presents.

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