August 2016 Antifungal Activity of Alkaloids Third Molar Enamel Markings Nonodontogenic Dental Pain JournaCALIFORNIAC A LIFORN I A DEDENTALN T A L ASSOCIATIONA SSOCIA TION

DENTAL STUDENT RESEARCH Parish P. Sedghizadeh DDS, MS You are not a statistic.

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DEPARTMENTS 481 The Associate Editor/Dentistry’s Pay Gap

483 Impressions

515 RM Matters/Data Backup: What’s Your Risk Tolerance?

521 Regulatory Compliance/Basic Life Support Course, AEDs and Medical Emergency Kits

526 Tech Trends 483

FEATURES 491 Dental Student Research An introduction to the issue. Parish P. Sedghizadeh, DDS, MS

493 Antifungal Activity of Alkaloids Against Candida albicans The aim of this study was to evaluate the antifungal activity of several alkaloids against Candida albicans in vitro and to determine the cytotoxicity on oral fibroblast cells. Juliana Noguti, DDS, MS, PhD; Mersedeh Rajinia; Bruna Raquel Zancope, DDS, MS; Maria Carolina Salome Marquezin, DDS, MS; Dalia Seleem, DDS; Vanessa Pardi, DDS, MS, PhD; and Ramiro M. Murata, DDS, MS, PhD

499 Prevalence of Enamel Markings on Third Molars The purpose of this study was to measure the prevalence of enamel markings in routinely extracted third molars. Rassilee Sharma, BA; Sapna Lohiya, DDS; Pardis Rajabi, DDS; Kelly Nguyen, BS; Albert Ngo; Elizabeth Lee, BS; Afsaneh Shahrokhi Rad, DMD; Hongfei Chen, DDS, PhD; Rodrigo S. Lacruz, PhD; and Shane N. White, BDentSc, MS, MA, PhD

507 Nonodontogenic Sources of Dental Pain This paper discusses nonodontogenic sources of dental pain and the importance of proper diagnosis to ensure that treatment is directed toward the source of the pain rather than the site of the pain. Scott E. Schames, BS; Michael Jordan, RN, MSN, MBA; Hila Robbins, DMD; Lenard Katz, BA; and Kaitlyn Tarbert, RDH

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Volume 44, Number 8 JournaCALIFORNIA DENTAL ASSOCIATION August 2016 CDA Classifieds.

Free postings. published by the Editorial Upcoming Topics Letters to the Editor California Kerry K. Carney, DDS, CDE September/Pathology www.editorialmanager. EDITOR-IN-CHIEF Priceless results. Dental Association October/Sugar com/jcaldentassoc 1201 K St., 14th Floor [email protected] November/Regulatory Sacramento, CA 95814 Ruchi K. Sahota, DDS, CDE Issues Subscriptions 800.232.7645 ASSOCIATE EDITOR Subscriptions are available cda.org Advertising only to active members of Brian K. Shue, DDS, CDE the Association. The CDA Offi cers ASSOCIATE EDITOR Doug Brown subscription rate is $18 and ADVERTISING SALES is included in membership Kenneth G. Wallis, DDS [email protected] PRESIDENT Parish P. Sedghizadeh, dues. Nonmembers can 916.554.7312 [email protected] DDS, MS view the publication online GUEST EDITOR at cda.org/journal. Clelan G. Ehrler, DDS Permission and PRESIDENT-ELECT Andrea LaMattina Manage your subscription SENIOR PUBLICATIONS Reprints [email protected] online: go to cda.org, log in SPECIALIST Andrea LaMattina and update any changes to SENIOR PUBLICATIONS your mailing information. Natasha A. Lee, DDS SPECIALIST VICE PRESIDENT Blake Ellington Email questions or other TECH TRENDS EDITOR [email protected] [email protected] changes to membership@ 916.554.5950 cda.org. R. Del Brunner, DDS Courtney Grant COMMUNICATIONS SECRETARY Manuscript SPECIALIST [email protected] Submissions www.editorialmanager. Kevin M. Keating, DDS, MS Jack F. Conley, DDS TREASURER EDITOR EMERITUS com/jcaldentassoc [email protected] CDA classifiedsclassifieds wworkork harder to Robert E. Horseman, DDS HUMORIST EMERITUS Stay Connected cda.org/journal bbringring you resuresults.lts. SeSellinglling a practice Craig S. Yarborough, DDS, MBA SPEAKER OF THE HOUSE or a piece ooff equipment? Now you Production [email protected] can include photos to help buyers Val B. Mina SENIOR GRAPHIC DESIGNER Walter G. Weber, DDS Go Digital cda.org/apps see the potential. IMMEDIATE PAST PRESIDENT Look for this symbol, noting additional video [email protected] Randi Taylor SENIOR GRAPHIC DESIGNER 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— Jennifer George California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. it’s free to all CDA members. CHIEF MARKETING OFFICER Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. Cathy Mudge The California Dental Association holds the copyright for all articles and artwork published All of these features are designed to VICE PRESIDENT herein. The Journal of the California Dental Association is published under the supervision of PUBLIC AFFAIRS help you get the results you need, CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority faster than ever. Check it out for Alicia Malaby of the author whose name is indicated. The association reserves the right to illustrate, reduce, COMMUNICATIONS revise or reject any manuscript submitted. Articles are considered for publication on condition yourself at cda.org/classifieds. DIRECTOR that they are contributed solely to the Journal. Copyright 2016 by the California Dental Association. All rights reserved.

480 AUGUST 2016 Assoc. Editor CDA JOURNAL, VOL 44, Nº8

Dentistry’s Pay Gap Ruchi K. Sahota, DDS, CDE

ay inequality is more than trending. Famous actors like Jennifer Lawrence, tennis stars like In dentistry, a CBS MoneyWatch article Serena Williams and executives states that female dentists earn only like Sheryl Sandberg raise our Pawareness every day. It’s an issue in this 72 percent of what male dentists earn. year’s presidential election. We cheered when Patricia Arquette challenged “ … every woman who gave birth …” to fi ght for wage equality.Newsweek reports that a female professional soccer hours. However, it also brought a new fi nd the answers to these questions. player is paid 38 percent of her male appreciation that I had chosen a great The U.S. Equal Employment counterpart. And, although Serena profession. We can set our own hours Opportunity Commission has a proposal Williams is acknowledged as the highest and still ensure that we see patients to collect data about employees’ pay paid female athlete in the world, she still and maintain production. My mother, beginning in 2017 for employers with earns 15 percent less, per victory, than who is also a dentist, set her hours more than 100 employees. Adding her male counterpart, Novak Djokovic. around our schedules. She drove us pay data to existing employer reports The Institute for Women’s Policy to school every morning. On the way, that report race, gender and ethnicity, Research states that women earn we ran through our multiplication they say, will provide a tool to 79 percent of the income of men. tables, recited our memorized prayers identify discriminatory pay practices. In dentistry, a CBS MoneyWatch and practiced our vocabulary words. Last year, Fortune reported, in an article states that female dentists She came to our soccer games, tennis interview with Salesforce CEO Marc earn only 72 percent of what male tournaments and piano recitals. She Benioff, that he addressed this issue dentists earn — compare that to also worked hard, spending many hours by spending about $3 million to bring female physicians who earn 82 in the offi ce. But as the boss, she could the salaries of female employees up to percent of their male counterparts. also bring her kids into the offi ce after the level of their male counterparts. This is all just so hard to take. school. She was a rock star at both If the economists are right that Women are almost half of the new roles — dentist and mother. She was in the future, most dentists will dental workforce, and 40 percent of all able to provide a beautiful life for us, transition out of private practice women are the breadwinners in their even as a single parent. She has always and into being employees, such a families. A study out of the National credited her choice of profession as the proposal may benefi t us as well. Bureau of Economic Research tried to reason for being able to balance it all. Venus Williams shed an introspective make sense of this disparity in wages, Like my mother, most of my female light on gender wage disparity, “Imagine reviewing data over the last 30 years. colleagues have a strong desire to you’re a little girl. You’re growing up. It found that the time women take off, succeed, are fi nancially astute and You practice as hard as you can, with whether it is a long leave or a shortened do well. So where does this pay gap girls, with boys. You have a dream. You daily schedule, in order to care for their come from? Are female dentists less fi ght, you work, you sacrifi ce to get to families, is a large contributing factor. aggressive at presenting treatment this stage. You work as hard as anyone Other studies have suggested that plans? Do we make less per hour you know. And then you get to this pay may be affected because females because we spend more time with more stage, and you’re told you’re not the may not be the best negotiators, or patients? Do fewer female dentists own same as a boy. Almost as good, but not in health care professions, they may their practices or are they employee quite the same. Think how devastating choose lower paying specialties. dentists who possibly earn less? Are and demoralizing that could be.” It’s true. At fi rst, my beautiful male dentists better at negotiating Our dental school classes are baby resulted in decreased offi ce contracts with dental plans? We must comprised of more and more women.

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Eventually, the gender gap within our profession will close. We will rise to more leadership positions. We will lean in. We will band together. And, we will soon arrive at a day where the pay gap narrows enough to just Our archive disappear. Sure, we cannot have it all, but the fl exibility of our profession allows us to have a lot. And for is your archive. that, I cannot be more grateful. ■

CDA’s archive is online for your research. Access every issue Ruchi K. Sahota, DDS, CDE, practices of the Journal from the past 17 years at cda.org/journal. family dentistry in Fremont, Calif., and serves as faculty at the University of the Pacifi c, Arthur A. Dugoni School of Dentistry. She is also a certifi ed dental editor, a consumer advisor for the American Dental Association, past president of the Southern Alameda County Dental Society and a fellow of the American College of Dentists, International College of Dentists and the Pierre Fauchard Academy.

The Journal welcomes letters We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than fi ve references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/ jcaldentassoc. By sending the letter, the author certifi es that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

482 AUGUST 2016 Impressions CDA JOURNAL, VOL 44, Nº8

Small Stuff

David W. Chambers, EdM, MBA, PhD

Before there was Watson that blitzed the experts on “Jeopardy,” and even before computers regularly humbled chess masters, there was Arthur Samuel and his checker-playing computer. That was 1949, and Samuel probably had to hand- crank his machine. Samuel started by giving his gadget some great tactics, such as jumping an opponent or getting to the king row. He had the computer assign high point values to the big payoff moves. At each move, the computer searched a modest range of available options and picked the one with the most points. The machine was allowed to adjust the point distribution. Following each move and the opponent’s response, the computer would re-evaluate the approach and adjust point values. That was the learning part. At fi rst, Samuel pretty regularly beat the computer. But it got better and eventually Samuel had to give up the contest as being hopeless. What did the computer learn that made it so effective? Mostly it was the small stuff. Open a space toward the middle rather than the edge of the board, reduce the opponent’s possible moves, that sort of thing. Most checkers games are won or lost in the scrum at the beginning, based on slight adjustment in balance. After establishing control of the territory with multiple very small wins, even a 6-year-old child can run the board with kings and triple jumps. The nub: And so it is with dental ethics. Disciplined licenses, lawsuits against unfair practices, Medicaid fraud and the like may get the 1. The small stuff matters the most headlines. But it is the daily, nuanced decisions — winking at a in dental ethics. colleague’s questionable dealings or causal depreciation of the aspirations of auxiliaries — that establish the tone of the profession. 2. It is easier to bend a green twig A few years ago, I tested this idea, and the results have than move a mighty oak. been published. I looked to see what effect we could get by having enforcers, such as state boards, clamp down on devious 3. There is something everyone practitioners. I also looked at the relationship between can do this afternoon to improve dentists who are ethically upright and unafraid to point out the behavior of the few bad apples and the dentists who are the ethical tone of dentistry. ethically upright but decline to get involved. Like Samuel’s checker-playing computer, the real action depended on the small stuff. The relationships among good David W. Chambers, EdM, MBA, PhD, is professor practitioners and how willing they are to put the details of of dental education at the University of the Pacifi c, Arthur good practice on the table were more important than what A. Dugoni School of Dentistry, San Francisco, and editor was done to the devious few. The effect is many orders of of the Journal of the American College of Dentists. magnitude in favor of daily details. The next time someone tells you not to sweat the small stuff in dental ethics and wait until something really big and important comes along, you can be pretty sure the person you are talking with has been waiting a lifetime for the right opportunity to do something ethical. ■

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Photos on Cigarette Packages May Be Strong Smoking Deterrent Tobacco Smoke Houses Photos related to the dangers of smoking on cigarette packages are a Pathogens in the Mouth strong deterrent and provoke more users to quit, according to researchers at the Tobacco smoke is a proven University of North Carolina at Chapel Hill. A clinical trial, which was recently environmental stressor by allowing bacteria published by JAMA Internal Medicine, was conducted over four weeks and colonization and “immune invasion” in the included 2,149 smokers (1,901 completed the study). Those enrolled received mouth, according to a new study from the warnings either through text or photos. According to the results, 40 percent University of Louisville School of Dentistry. of the participants who were exposed to pictures attempted to quit. Among Specifi cally, smoke, which is comprised the smokers who received only a text warning, 34 percent attempted to quit. of thousands of chemical components, acts Further, 5.7 percent of the photo group quit for at least a week. as an environmental stressor to which oral “Implementation of pictorial cigarette pack warnings in the United States bacteria respond by altering the expression is on hiatus. Our trial fi ndings provide timely and important information as of multiple genes and proteins, including the United Sates and other countries consider requiring pictorial cigarette virulence factors that promote colonization pack warnings. The World Health Organization Frameworkork ConventionConven on and immune evasion. Recent evidence has demonstrated that tobacco smoke and Tobacco Control now recommends pictorial warnings butt components alter the bacterial surface stops shorts of requiring them. Our trial fi ndings support and promote biofi lm formation in several strengthening the treaty to require pictorial warnings on important human pathogens, including cigarette packs,” the study concludes. Staphylococcus aureus, Streptococcus mutans, The limitations of the study include not having an Klebsiella pneumonia, Porphyromonas understanding of what long-term exposure to photos gingivalis and Pseudomonas aeruginosa. may have and whether the participants coming into University of Louisville School of the study may have been more inclined to quitting Dentistry researcher David A. Scott, Ph.D, than the general population. explained his fi ndings in a press release. “Once a pathogen establishes itself within Stock image of a cigarette pack from Brazil, where a biofi lm, it can be diffi cult to eradicate images on cigarette packs are required. as biofi lms provide a physical barrier against the host immune response, can be impermeable to antibiotics and act as a reservoir for persistent infection,” Scott said. “Furthermore, biofi lms allow for the transfer Health show that 90 percent of smokers dependence, tooth discoloration and bad of genetic material among the bacterial start as teens. In California, 21,000 kids get breath. Danger signs of oral cancer include community and this can lead to antibiotic hooked on smoking every year, and half of a sore that does not heal; a lump or white resistance and the propagation of other them will die from tobacco-related illnesses. patch; a prolonged sore throat; diffi culty in virulence factors that promote infection.” California has approximately 3.4 million chewing; restricted movement of the tongue Of course, dental plaque is a adult smokers and 200,000 youth smokers. or jaws; and a feeling of something in the biofi lm and it can lead to gingivitis Dental patients can be reminded that throat. According to the National Institute and chronic periodontitis. smokeless tobacco use puts them at risk of Dental and Craniofacial Research Kentucky ranks No. 2 for cigarette use not only for oral cancer, but also cancer of (NIH), the fi ve-year survival rate for those among adults, according the Centers for the pharynx, larynx and esophagus, as well with localized disease at diagnosis is 83 Disease Control and Prevention. Studies as may lead to tooth abrasion, increased percent compared with only 36 percent from the National Survey on Drug Use and tooth decay, gum recession, nicotine for those whose cancer has metastasized.

484 AUGUST 2016 CDA JOURNAL, VOL 44, Nº8

Study Describes Damage Caused to Mouth From Exploding E-Cigarette A report has been published in addictive as cocaine, producing a scientific literature that describes vapor that users inhale. The U.S. Fire the extent of damage an exploding Administration has been evaluating e-cigarette can cause to the mouth. The the safety of e-cigarettes after reports of University of Cincinnati studied the explosions and fires have increased. mouth of an 18-year-old who had an The authors of the study state e-cigarette explode while using it. The that multiple procedures will need to report, published in the Journal of Oral take place to “reconstruct lost tissue, and Maxillofacial Surgery, describes the and to re-establish functional and burns, lacerations and lost and fractured cosmetically acceptable results.” Initial presentation of patient in study. Upper labial teeth that resulted from the explosion. In addition to fire risk, e-cigarettes mucosa. (Image courtesy of the Journal of Oral and E-cigarettes work by heating carry a variety of health risks for users Maxillofacial Surgery with permission from Elsevier.) up liquid nicotine, the neurotoxin and those around them. E-cigarette derived from tobacco that is as aerosol contains formaldehyde and lead, as well as at least 10 toxic chemicals on California’s Proposition 65 list of chemicals known to cause cancer and birth defects. E-cigarette use among middle and high school students Facial Blueprint Studied Through Stem Cells tripled from 2013 to 2014, according A new study has identified the role of molecular signals in the development to the Centers for Disease Control and of facial structures. Specifically, USC stem cell researchers looked at two types Prevention and more than a quarter of of molecular signals — Jagged-Notch and Endothelin1 (Edn1). These two signals a million youth who had never smoked are critical when the face is shaped. The researchers discovered that the Jagged- a cigarette used e-cigarettes in 2013. Notch and Edn1 “work in tandem to control where and when stem cells turn into Ninth graders who use e-cigarettes are facial cartilage.” eight times more likely to later smoke traditional cigarettes than their peers Edn1 signals speed up the formation of cartilage in the early stages of who have never tried e-cigarettes. development in the lower face and Jagged-Notch signals stop the development E-cigarettes are widespread with 450 of cartilage until later in the upper face. This timing is critical for the development brands currently available and some of the regions of the face, according to the authors. 7,600 flavors. E-cigarettes are sometimes In a press release, USC Stem Cell researcher and lead author Lindsey Barske touted as the healthy alternative to said, “We’ve shown that the earliest blueprint of the facial skeleton is set up by traditional cigarettes, but some reports spatially intersecting signals that control when stem cells turn into cartilage or bone. have cited negative effects of the vapors. Logically, therefore, small shifts in the levels of these signals throughout evolution The National Institute of Dental could account for much of the diversity of shapes we see within the skulls of and Craniofacial Research has awarded different animals, as well as the wonderful array of facial shapes seen in humans.” more than $2 million in first-year funding Interestingly, many of the genes required to shape the facial skeleton in fish to seven research grants centered on and man are the same. The researchers used the zebrafish studying the effects of e-cigarettes on oral and craniofacial tissues. The timing of system to understand the skeletal components of the face. the awards is critical as research shows an increasing number of high school A three-day-old zebrafish head skeleton with newly students, approximately 13.4 percent, differentiated cartilage cells (magenta) emerging from a pool of skeletal progenitor cells (green). (Image by Lindsey Barske) are now using e-cigarettes. Additionally, evaluating the risks of e-cigarettes has been challenging due to the lack of research regarding their harmful effects.

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Strength of Dentin Tested Dentin is a strong material. The reason as to why teeth in humans can come into contact so often (some 5,000 per times day) and rarely break is largely considered to be because of dentin. Researchers at Charité — Universitätsmedizin Berlin have found that “it is the mechanical coupling between the collagen protein fi bers and mineral nanoparticles that render dentin capable of withstanding extreme forces.” To test this, the researchers enhanced compressive stress on the inside of dentin samples and put it under heat as high as 125 degrees Celsius. The result was the discovery that dentin has the same yield strength of construction-grade steel. A gradual reduction in the size of the cHAP crystal lattices toward the inner part of the tooth was present. Paul Zaslansky is from the Charité’s Julius Wolff Institute. Chemicals in Plastics and “Tissue found near the dental pulp, which is formed during the later Fungicides Could Harm stages of tooth development, contains mineral particles that are made up Children’s Teeth of smaller cell units,” Zaslansky said in a press release. Bacteria related to dental decay can soften the mineral, destroy collagen Chemicals commonly found in fi bers and cause breakdowns in teeth. The researchers said that dentists plastics and fungicides could be harming should make sure to keep teeth moist when performing dental procedures. the teeth of children. This happens “Avoiding dehydration may very well prevent build- when the chemicals disrupt hormones up of internal stresses, the long-term eff ects of which that promote growth of dental enamel, remain to be studied,” Zaslansky said. according a new study by the French National Institute of Health and Medical Research. According to a press release, Dentin’s biological structure: tubules and mineral nanoparticles “Endocrine disruptors are chemicals that embedded in a network of collagen fi bers. (Image: Jean- interfere with mammalian hormones. Baptiste Forien, © Charité — Universitätsmedizin Berlin) Bisphenol A (BPA) is one of the most prevalent, found in everyday items, including refi llable drink bottles and food storage containers. Vinclozolin is another endocrine disruptor that was commonly used as a fungicide in vineyards, golf and vinclozolin are known to block the tooth enamel.” Another part of the courses and orchards.” The study analyzed effect of male sex hormones, the fi ndings experiment led to the discovery that how permanent fi rst molars and incisors reveal a potential mechanism by which a mechanism by which endocrine in children between the ages of 6 and 9 endocrine disruptors are weakening teeth.” disruptors are weakening teeth. have sensitive areas that can be prone Rats were used in the study and Katia Jedeon, lead author of to cavities. This is referred to as molar received a daily dose of BPA either by the study warned pregnant women incisor hypermineralization (MIH). itself or with vinclozolin. The dosage to avoid endocrine disruptors. Researchers “cultured and studied rat was the same as an average dose a “Tooth enamel starts at the third ameloblast cells, which deposit enamel human would have every day from trimester of pregnancy and ends at during the development of teeth. They the time they are born to when they the age of 5, so minimizing exposure found that the presence of sex hormones are 30 days old. Cells from the teeth to endocrine disruptors at this stage like estrogen and testosterone boosted the of the rats were collected. The doses in life as a precautionary measure expression of genes making tooth enamel, had changed the “expression of two would be one way of reducing the especially male sex hormones. As BPA genes controlling the mineralization of risk of enamel weakening.”

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Correlation Found Between Marijuana Use and Poor Periodontal Health Marijuana use can have a long-term daily and 675 had ever used cannabis. affect on oral health, according to a The researchers labeled the topic new study by Arizona State University. important because after major policy The study, which collected data from changes in the U.S., policymakers, 1,037 individuals who were born in health care professionals and the New Zealand in 1972 and 1973 and general public are looking for followed until they were 38 years old, information on if cannabis use is found that “Cannabis was associated related to physical health problems with poorer periodontal health at age 38 later in life. The specifi c goal of the but was not associated with the other study, which was discussed in an article physical health problems.” Among the published by JAMA Psychiatry, was to participants, 484 had ever used tobacco determine if marijuana use from the ages of 18 to 38 had a correlation with physical health problems at 38 years old. The researchers obtained laboratory measures of physical health (periodontal health, lung function, systemic Cells Around Vital Organs Speed Tissue Repair infl ammation and metabolic health), Cells that live in the cavities surrounding various organs (such as the heart, and self-reported physical health. lung and liver) play a signifi cant role in rapid tissue repair, according to a A press release on the topic stated, new study from the Cumming School of Medicine. The study, published in the “This study has a number of implications. journal Cell, specifi cally looked at macrophages. Macrophages “patrol within First, cannabis use for up to 20 years the cavity, and upon organ damage, adhere themselves to the damaged area is not associated with a specifi c set of physical health problems in early midlife. for quick repair,” according to a press release. The sole exception is that cannabis use Jing Wang, PhD, is the lead author of the study and member of the Snyder is associated with periodontal disease. Institute for Chronic Diseases. Second, cannabis use for up to 20 years “The traditional thought of how organs are repaired after injury is that monocytes is not associated with net metabolic (a type of immune cell found in the blood) are recruited to the site of injury, move out benefi ts (i.e., lower rates of metabolic of blood vessels and mature into macrophages in two to three days,” Wang said. syndrome). Third, our results should “In our study, the mature macrophages are already in the cavity and can infi ltrate the be interpreted in the context of prior injury site in visceral organs directly, thereby initiating immediate and rapid repair.” research showing that cannabis use is The cells were viewed in real time after experiencing thermal and toxin- associated with accidents and injuries, induced injury. “The cells behaved in the same way for both types of injury. bronchitis, acute cardiovascular events, Further to the observation, when the macrophage supply was depleted in the and, possibly, infectious diseases and abdominal cavity, tissue repair did not take place as quickly. When the cells cancer, as well as poor psychosocial and mental health outcomes.” were reinfused back into the animal models, they resumed their role,” the According to the study, “Unlike press release stated. cannabis use, tobacco use was associated Wang believes the fi ndings may change how clinical procedures and with worse lung function, systemic surgeries are performed. “Washing out” a cavity infl ammation and metabolic health at to clear out foreign pathogens could be “hindering age 38 years, as well as within individual the healing process.” decline in health from ages 26 to 38 years.” A little more than half of the Electron microscope image of a macrophage in participants were male. Some limitations of the alveolus, showing the nucleus and cytoplasmic organelles, such as golgi and mitochondria. the study were self-reported marijuana use and the fact that physical health in all of the candidates was assessed in early midlife.

AUGUST 2016 489 introduction

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Dental Student Research

Parish P. Sedghizadeh, DDS, MS

GUEST EDITOR

Parish P. Sedghizadeh, ental research not only what is required of them in their training DDS, MS, is an assistant advances the fi eld of dentistry or curriculum to make dedicated time for professor on the tenure and oral health care, it directly conducting research. We also recognize track at the Herman Ostrow School of Dentistry of impacts patient management their mentors who foster student inquiry USC. Dr. Sedghizadeh is a and informs medicolegal and help maintain a pipeline of dental diplomate of the American Dstandards of care. Our understanding investigators. As an educator and Board of Oral and of the pathogenesis of oral diseases, the mentor, I know that student research is Maxillofacial Pathology. risk factors for disease in our patients challenging and involves higher-order Confl ict of Interest Disclosure: None reported. and therapeutic guidelines all come learning in the cognitive domain for from peer-reviewed research fi ndings. these students; they are challenged to Whether basic science or clinical generate data, synthesize information research, both are often required for or apply analytical and problem-solving ultimate translation of research fi ndings skills. What these student researchers to patient care. Therefore, dental research and their mentors do is by no means easy in its entirety is necessary to safeguard and involves commitment and sacrifi ce. the well-being of our patients and to Despite the challenges, the research ensure the growth of our profession in efforts of our young investigators can a rapidly evolving health care fi eld. also be rewarding as evidenced by the Naturally, the future of dental peer-reviewed publication of their work, research rests in the hands and minds which is highlighted in this issue. of young and new investigators. They I would like to thank our student must carry the torch to assure a bright researchers and their mentors for their future for dentistry and dental research. hard work and diligence in writing these Therefore, in this issue of the Journal we articles. I am thankful for the opportunity celebrate and recognize the work of young to be the guest editor for this issue, and dental researchers and their mentors. I hope you will enjoy (as I did) seeing We pay homage to the fact that student the scholarship and research efforts of investigators often go above and beyond our young dental investigators. ■

AUGUST 2016 491 You are the protector of the smile. You enable people to laugh without shame, eat their favorite foods and experience the dignity of aging with grace. That’s why this association tirelessly advocates for the profession and stands up for those in need of care. Because the world is a better place when people are smiling, and that’s thanks to you.

Join today. cda.org/member

® antifungal activity

CDA JOURNAL, VOL 44, Nº8

Antifungal Activity of Alkaloids Against Candida albicans

Juliana Noguti, DDS, MS, PhD; Mersedeh Rajinia; Bruna Raquel Zancope, DDS, MS; Maria Carolina Salome Marquezin, DDS, MS; Dalia Seleem, DDS; Vanessa Pardi, DDS, MS, PhD; and Ramiro M. Murata, DDS, MS, PhD

ABSTRACT Candida albicans is a pathogen in the mouth responsible for opportunistic infections that are usually harmless. Natural products have been used to develop several drugs, mostly anticancer and anti-infective agents. Among these, alkaloids have been studied for their medicinal properties. In this study, we examined their antifungal activity against C. albicans in vitro. Among the alkaloids studied in this work, berberine hydrochloride showed the best activity against C. albicans.

AUTHORS

Juliana Noguti, DDS, Bruna Raquel Zancope, Dalia Seleem, DDS, is a Ramiro M. Murata, DDS, mong infections observed in MS, PhD, is a research DDS, MS, is a doctoral doctoral candidate in the MS, PhD, is an assistant patients, especially when there associate in the division of student and visiting scholar division of periodontology, professor of dentistry in the is an imbalance in the normal periodontology, diagnostic from the State University diagnostic sciences and division of periodontology, 1,2 sciences and dental hygiene of Campinas, Piracicaba dental hygiene at the diagnostic sciences and fl ora, Candida albicans is the at the Herman Ostrow Dental School, department Herman Ostrow School of dental hygiene and most prevalent human fungal School of Dentistry of USC. of pediatric dentistry, in São Dentistry of USC. biomedical sciences at the Apathogen.3 Its ability to form single biofi lms Confl ict of Interest Disclosure: Paulo, Brazil. Confl ict of Interest Herman Ostrow School of increases exponentially the virulence4 None reported. Confl ict of Interest Disclosure: Disclosure: None reported. Dentistry of USC. as well as the resistance to antimicrobial None reported. Confl ict of Interest Disclosure: 5 Mersedeh Rajinia is an Vanessa Pardi, DDS, MS, None reported. drugs. Oral candidiasis vary from the large undergraduate student in the Maria Carolina Salome PhD, is an assistant professor white plaques of pseudomembranous layers division of periodontology, Marquezin, DDS, MS, of dentistry in the division of on the tongue and buccal mucosa to the diagnostic sciences and is a doctoral student and periodontology, diagnostic palatal erythematous lesions of chronic dental hygiene at the Herman visiting scholar from the State sciences and dental hygiene atrophic candidiasis and moreover, to Ostrow School of Dentistry University of Campinas, at the Herman Ostrow 6 of USC. Piracicaba Dental School, School of Dentistry of USC. angular cheilitis on the labial commissures. Confl ict of Interest Disclosure: department of pediatric Confl ict of Interest Generally, C. albicans biofi lm can be None reported. dentistry, in São Paulo, Brazil. Disclosure: None reported. present in those who have dentures and Confl ict of Interest Disclosure: implants.7 When systemic diseases or None reported. immune defi ciencies affect the individual, this opportunistic fungus promotes very uncomfortable infections,8 thereby decreasing the patient’s quality of life.9 In light of these pathologies from C. albicans,

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there is a growing need to research and Microbial Growth Conditions obtained by comparing biofi lm density develop new approaches that might be C. albicans MYA-2876 (ATCC- over a fi ve-day period. Analyses were both used against this pathogen.10 In addition, American Type Culture Collection, qualitative, done by examining biofi lm limitations of the currently available Manassas, Va.) was used in this study. It morphology microscopically, as well as antifungal agents present a challenge was the selected strain based on its proven quantitative, performed by comparing in the treatment of oral candidiasis.11 virulence and genomic sequencing.16-18 the biomass or total dry weight of the Natural products are still major C. albicans strains were subcultured on biofi lms collected over the fi ve-day period. sources of innovative therapeutic agents BBL Sabouraud’s dextrose agar (BD, for infectious diseases.12 Alkaloids are Sparks, Md.) and incubated at 37 degrees Minimum Inhibitory Concentration and secondary metabolites found in many Celsius with 5% CO2 for 36 hours. Minimum Fungicidal Concentration plants and microorganisms13 that have The culture medium of C. albicans was The minimum inhibitory shown several pharmacological activities, replaced once daily during the 36-hour concentration (MIC) and minimal including antimicrobial activity.14,15 incubation period. The inoculum strain fungicidal concentration (MFC) The aim of this study was to concentration was standardized according were performed according to evaluate the antifungal activity of the CLSI guidelines.17,18 several alkaloids against Candida The MIC was determined by the albicans in vitro and to determine the microdilution broth method using 96-well cytotoxicity on oral fi broblast cells. plates.17,18 Initial C. albicans inoculum was Limitations of the currently prepared and adjusted to 5.0 × 102 − 2.5 × 3 Material and Methods available antifungal agents 10 colony forming units (CFU)/ml. Stock solutions of the compounds were prepared Antimicrobial Compounds present a challenge in the in 100% DMSO followed by a serial two- In this in vitro study, we performed a treatment of oral candidiasis. fold dilutions in Roswell Park Memorial screening using several natural alkaloids. Institute (RPMI) 1640 medium. The A library of 131 FDA-approved drugs tested compounds’ drug concentrations was purchased (Selleck Chemicals, were in the range 0.01-100 to μM in 1% Houston). Compounds were stored DMSO. The plates were incubated at 37 as 10 μM stock solutions in dimethyl to the microdilution broth method.17,18 degrees Celsius for 24 hours. The MIC was sulfoxide (DMSO) at 4 degrees Celsius The initial stock suspension was obtained determined as the lowest concentration until use. Berberine hydrochloride, by suspending fi ve colonies of C. albicans of the compound that inhibited cinchonidine, cytisine, gramine, from 24-hours-old cultures in saline. The microorganism growth. The MIC results lappaconite hydrobromide, matrine, cell density of the initial stock suspension were compared to the vehicle control (1% oxymatrine, palmatine chloride, piperine, was in the range of 1 × 106 − 5 × 106 cells DMSO), positive control (fl uconazole; rotundine, sinomenine, sophocarpine per mL, which was determined using a fl uconazole concentration of 32.65 μM was and synephrine were selected for further spectrophotometer (DU-650, Beckman used in this experiment based on its MIC analysis based on their antimicrobial Coulter, Fullerton, Calif.), by measuring against C. albicans established from our activity as determined by minimum the absorbance of 0.08-0.1 at 625 nm previous experiments) and negative control inhibitory concentrations (MIC) using wavelength. The working suspension of (RPMI 1640). The MFC was performed the microdilution broth method (Clinical the inoculum used in this experiment by subculturing 20 μl of the samples from and Laboratories Standards Institute was standardized to 5.0 × 102 − 2.5 × each of the microplate wells on agar (CLSI), 2002). The concentrations 103 colony forming units (CFU)/ml by Sabouraud plates, which were incubated tested for all compounds used were in diluting the initial stock solution in for 48 hours. MFC was determined as the the range 0.01-100 μM dissolved in medium 1:2.000. The 36-hour biofi lm lowest concentration of the compound 1% DMSO. All in vitro tests included was established based on our preliminary to show no fungal growth. Results were the following tested groups: 1-negative data (not published), illustrating the peak compared to the vehicle control (1% control, 2-vehicle (1% DMSO v/v) and mature phase of C. albicans biofi lms. Our DMSO), the positive control (fl uconazole) 3-positive control (fl uconazole 32.65 μM). preliminary results on such fi ndings were and the negative control (RPMI 1640).

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TABLE Minimum Inhibitory Concentration (MIC) and Minimum Fungicidal Concentration (MFC) of Alkaloid Compounds

Substance Molecular formula/ Molecular Antimicrobial activity weight (g/mol) structure Co-Culture Model Berberine hydrochloride C20H18ClNO4 /371.81 C. albicans SC5314 MIC: 20 μm Cytotoxicity Test MFC: 90 μm Cytotoxicity assays were performed on Cinchonidine C H N O/294.39 C. albicans SC5314 fibroblast cells (ATCC:CRL2014), grown 19 22 2 in Dulbecco’s Modified Eagle’s Medium MIC: >100 µM (DMEM)/10% FBS (Lonza, Walkersville, MFC: >100 µM

Md.) at 37 degrees Celsius in 5% CO2. Cytisine C11H14N2O/190.24 C. albicans SC5314 Based on the initial antifungal screening, MIC: >100 µM the alkaloids were added simultaneously MFC: >100 µM with the C. albicans and the fibroblasts at day two of the experiment, after Gramine C11H14N2 /174.24 C. albicans SC5314 the initial 24-hour period of seeding MIC: >100 µM the fibroblasts on the wells. Prior to MFC: >100 µM adding the yeast, the morphology of the Lappaconite hydrobromide C H BrN O /665.61 C. albicans SC5314 fibroblasts was examined in an optical 32 45 2 8 MIC: >100 µM microscopy to ensure cell viability. The MFC: >100µM alkaloids remained incubated in the well plates of C. albicans and fibroblasts Matrine C15H24N2O/248.36 C. albicans SC5314 with medium in a volume ratio of MIC: >100 µM 1:10 for 72 hours in order to allow for MFC: >100 µM adequate exposure to the treatment as Oxymatrine C H N O /264.36 C. albicans SC5314 well as maturation of biofilm. Tested 15 24 2 2 compounds at concentrations in the MIC: >100 µM range of 0.01-100 μM were dissolved in MFC: >100 µM 1% DMSO and added to the plates. Palmatine chloride C21H22ClNO4 /387.85 C. albicans SC5314 After the screening of the alkaloids MIC: >100 µM selected for this study, berberine MFC: >100µM hydrochloride (BER–HCl) was selected for further in vitro tests using a co-culture Piperine C17H19NO3 /285.33 C. albicans SC5314 model and colony forming unit (CFU). In MIC: >100 µM addition, a toxicity test was performed with MFC: >100µM fibroblast cells. The fibroblast suspension Rotundine C H NO /355.43 C. albicans SC5314 was prepared and adjusted to 1.0 × 105 21 25 4 MIC: >100 µM cells/ml and plated in 96-well plates. The MFC: >100 µM plates were incubated at 37 degrees Celsius in 5% CO for 24 hours, which were then 2 Sinomenine C19H23NO4 /329.39 C. albicans SC5314 replenished with fresh medium. Toxicity MIC: >100 µM tests performed with BER HCl were MFC: >100 µM repeated with higher concentrations up to Sophocarpine C H N O/246.35 C. albicans SC5314 500 μM. The plates were then incubated 15 22 2 at 35 degrees Celsius for 24 hours. Cell MIC: >100 µM viability analysis was performed by adding MFC: >100 µM CellTiter-Blue (CellTiter-Blue Viability Synephrine C9H13NO2 /167.20 C. albicans SC5314 Assay, Promega Corp., Madison, Wis.) MIC: >100 µM to the cells and incubating the plates for MFC: >100 µM three-and-a-half hours. Fluorescence was

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Negative Vehicle Positive Berberine HCl Berberine HCl Berberine HCl Berberine HCl control control 20 μM 50 μM 100 μM 200 μM microscopy Phase contrast Phase contrast staining LIVE/DEAD

FIGURE 1. Co-culture fl uorescence microscopy (fourfold magnifi cation scale bar is set at 1,000 μm) stained with Calcofl uor White Stain (blue: Candida albicans) and Viability/Cytotoxicity Assay Kit for Animal Live and Dead Cells (green: live fi broblast cells; red: dead fi broblast cells).

read using the DU-650 spectrophotometer (Sigma-Aldrich, St. Louis) was used to Results plate reader with excitation at 550nm stain C. albicans. The fl uorescence images and emission at 585nm. Cytotoxicity only provided qualitative examination of Susceptibility Test of the tested groups was compared the fi broblasts, both live and dead, as well The TABLE shows the MIC and MFC to those of the vehicle control (1% as C. albicans distribution. However, the values of 13 alkaloid compounds against DMSO), positive control (fl uconazole) cytotoxicity test was used to measure the C. albicans. Based on the initial MIC and negative control (RPMI 1640). percentage of cell viability by incubating and MFC screenings, BER HCl had the plates with CellTiter-Blue added to the a strong antifungal potential with the Fluorescence Microscopy and Colony cells and then measuring the fl uorescence lowest MIC in the range of 20-50 μm Formation Unit using a spectrophotometer. The percentage and was, therefore, selected for further A co-culture model was conducted by of cell viability for each sample tested was in vitro analysis using a co-culture model culturing fi broblast cells and C. albicans normalized to the vehicle control group, and colony-forming unit (CFU) together in a sterile 48-well plate. First, oral which was set to have 100 percent viability. assessment of biofi lms. fi broblast cells (ATCC: CRL2014) were Fluorescent images of the double staining seeded in DMEM with 10% fetal bovine were captured using fl uorescence microscopy Co-Culture Model Fluorescence serum (FBS) at 37 degrees Celsius in 5% (EVOS microscope, Life Technologies, Microscopy

CO2 for 24 hours. The medium was then Carlsbad, Calif.). After 72 hours of After treatments of berberine replaced with an inoculum of 5 × 102 to treatments, colony formation unit (CFU) hydrochloride (20-200 μM), C. albicans 2.5 × 103 CFU/ml C. albicans (ATCC: was determined by suspending each sample growth was inhibited (FIGURE 1). To SC5314) grown in DMEM without FBS. of biofi lm in 1 ml of PBS and plating 20 μl rule out the possibility of cytotoxicity Fibroblast cells and C. albicans were treated of the suspension on Sabouraud dextrose in the bioassay, gingival fi broblasts were daily with 20μM, 50μM, 100μM and 200μM agar plates, which were incubated at 37 exposed to various concentrations of of BER HCl. The plate was then incubated degrees Celsius in 5% CO2. After 24 hours BER HCl at varying concentrations, FIGURE 1 at 37 degrees Celsius in 5% CO2 for 24 of incubation, the number of C. albicans as indicated in . At a fourfold hours. The vehicle control tested was 1% colonies was counted and the data was dilution, all dilutions of the compound DMSO, positive control was fl uconazole transformed in Log 10. All procedures were inhibited Candida formation. However, and negative control was pure DMEM. repeated at least twice for reproducibility. when compared to the negative control The distribution of dead and live fi broblast group, higher concentration of BER HCl cells was examined using the Viability/ Statistical Analysis of 200μM had a visible adverse effect on Cytotoxicity Assay Kit for Animal Live All results were expressed as the mean fi broblast cells. In regard to C. albicans and Dead Cells (Biotium, San Francisco), ± SEM, using one-way analysis of variance formation, the positive control group which contains a mixture of Calcein AM (ANOVA) and Tukey test. The level of and all concentrations of BER HCl and EthD-III. Calcofl uor White Stain statistical signifi cance was set at 0.05. were able to reduce fungus growth.

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8 150 a 6 100 4 c d b b b 50 2 Log 10 (CFU/mL)Log % of viable cells

0 0 VehicleVehVehih cle PositivePositive BerberineBerberine BerberineBerberine BerberineBerberine BerberineBerberine VehicleVehhih cle 500 200200 90 70 50 20 control HCl HCl HCl HCl 20 μM 20 μM 20 μM 20 μM Concentrations of berberine HCl (μM)

FIGURE 2. Candida albicans co-culture expressed in Log 10/mL after each FIGURE 3. Cytotoxic eff ects of berberine HCl on oral fi broblast cells. respective treatment. Values denote means with standard deviation. Values followed by the same letter are not signifi cantly diff erent from each other (p > 0.05).

Colony Forming Unit in order to evaluate their potential and MFC were determined to be at The TABLE shows that the number antifungal activity against C. albicans. concentrations greater than 100 μM. Future of colony forming unit (Log 10) of the Numerous studies with alkaloids support research is needed to confi rm matrine’s tested groups was signifi cantly reduced the benefi ts of this group of compounds. potential and its possible mechanism in comparison to that of the negative Vindoline I-IV were isolated from the of action against Candida albicans. control group (p < 0.001). Moreover, Catharanthus roseus, an herbal plant Palmatine, an alkaloid found in a plant the inhibition of Candida formation was used by folkloric medicine in countries called Phellodendron amurense (commonly signifi cantly higher in groups treated such as India, South Africa, China and known as the Amur cork tree), has shown with fl uconazole or in those treated Malaysia to treat diabetes.19 A study antifungal activity against Microsporum with BER HCl at high concentrations performed with breast cancer stem cells canis, a fungus that causes dermatitis in of 100 and 200 μM (p < 0.0010). showed antiproliferative activity from two humans and other animals.26 However, it alkaloids: noscarpine and papaverine.20 did not show strong antifungal potential on Toxicity Test Moreover, antibacterial activity was C. albicans, as our results illustrate a high The cytotoxicity result of BER HCl found in vasicine, an alkaloid extracted MIC/MFC greater than 100 μM. However, showed nontoxic effects on fi broblast from Adhatoda vasica Nees, a plant in further studies are necessary to confi rm its cells, up to 90μm with 100 percent Ayurveda and Unanni medicine, against antifungal activity against C. albicans. cell viability (FIGURE 3). At higher E. coli. Antifungal properties against BER HCl is an isoquinoline alkaloid concentrations up to 500μm, cell viability C. albicans were also demonstrated.21 commonly used in Chinese medicine was slightly greater than 50 percent. Some studies showed that alkaloids with broad bioactive properties against extracted from plants exhibited potential a large number of diseases, including Discussion antifungal activities,24 which was in fungal and infl ammatory diseases.26,27-29 A new spectrum of human fungal agreement with our results. However, from Our study provided new information infections is increasing because of the the natural compounds library used in on the antifungal potential of BER systemic diseases responsible for the this study, only BER HCl demonstrated HCl against C. albicans. Nakamoto et immunocompromised system failure.19 promising antifungal activity against C. al. (1990) investigated the antifungal Historically, natural products have albicans. Among the natural products effects of BER HCl in comparison to been a rich source of antifungal drugs, described so far in the literature that possess amphotericin B and determined that and among them, alkaloids from some antifungal activity, another example is MIC values of BER HCl were higher plants have already been reported to matrine, which at 1 mg/ml was shown to when compared to amphotericin B.30 affect fungus’ biological functions at inhibit nearly 80 percent of planktonic Other studies have illustrated a strong very low concentrations.20-23 In this growth.25 However, our results did not synergistic effect of berberine and study, we reported an antifungal activity show the same potential when compared fl uconazole, as the combinatorial effect provided from a screening of alkaloids to the negative control, as both MIC resulted in the inhibition of C. albicans

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growth.21,22 Our results showed that BER In conclusion, a screening of alkaloids 2nd ed., vol. 22. 2002. 17. Pasetto S, Pardi V, Murata RM. Anti-HIV-1 activity of fl avonoid HCl (100 and 200 μM concentrations) against C. albicans was performed to myricetin on HIV-1 infection in a dual-chamber in vitro model. PLoS decreased CFU/ml to similar values as identify natural products with antifungal One 2014; 9(12):e115323. those of the positive control treated with activity. Berberine hydrochloride 18. Jones T, et al. The diploid genome sequence of Candida albicans. Proc Natl Acad Sci U S A 2004; 101(19):7329-34. fl uconazole 32.65 μM (FIGURE 2). (BER HCl) has shown activity against 19. Arif T, et al. Natural products — antifungal agents derived from Gu et al. suggested that berberine at C. albicans at low concentration. plants. J Asian Nat Prod Res 2009;11(7):621-38. high dosage (> 0.05 mg/ml) exhibited Furthermore, studies in order to evaluate 20. Singh S, et al. Antifungal activity of the alkaloids from 22 Eschscholzia californica. Folia Microbiol 2009; 54(3):204-6. cytotoxicity on fi broblasts. Our study its cytotoxicity and antimicrobial activity 21. Iwazaki R, et al. In vitro antifungal activity of the berberine and also demonstrated that the cytotoxicity must be explored, thus, guiding the its synergism with fl uconazole. Antonie Van Leeuwenhoek, 2010; result of BER HCl showed nontoxic effects clinical and pharmaceutical intentions 97(2):201-5. 22. Li L, et al. Synergistic antifungal activity of berberine derivative on fi broblast cells, up to 90μm with 100 in a secure and safe manner. ■ B-7b and fl uconazole. PLoS One 2015; 10(5):e0126393. percent cell viability. Berberine is usually 23. Pandey M, et al. Inhibitive Eff ect of Fuyuziphine Isolated From well-tolerated by humans, however, higher ACKNOWLEDGMENTS Plant (Pittapapra) (Fumaria indica) on Spore Germination of Some Research reported in this publication was supported by the Fungi. Mycobiology 2007; 35(3):157-8. doses might cause nausea, diarrhea and National Center for Complementary and Integrative Health of the 24. Ata A, et al. Triterpenoidal alkaloids from Buxus hyrcana and allergies.23 Nevertheless, in this study, National Institutes of Health under award number R00AT006507. their enzyme inhibitory, antifungal and antileishmanial activities. at higher concentrations up to 500 μM, Phytochemistry 2010; 71(14-15):1780-6. REFERENCES 25. Shao J, et al. Matrine reduces yeast-to-hypha transition and cell viability was slightly greater than 50 1. Vachot L, et al. Candida albicans-induced DC activation partially resistance of a fl uconazole-resistant strain of Candida albicans. J percent. Morphological changes were restricts HIV amplifi cation in DCs and increases DC to T-cell spread Appl Microbiol 2014; 117(3):618-26. of HIV. J Acquir Immune Defi c Syndr 2008; 48(4):397-407. observed in human promonocytic U937 26. Xiao C, et al. Antifungal activity of berberine hydrochloride 2. Rodrigues CR, et al. Candida albicans delays HIV-1 replication and palmatine hydrochloride against Microsporum canis-induced cells with 75 mcg/ml(–1) of berberine for 24 in macrophages. PLoS One 2013; 8(8):e72814. dermatitis in rabbits and underlying mechanism. BMC Complement hours leading to apoptosis.24 It is necessary 3. Cabral V, et al. Targeted changes of the cell wall proteome Altern Med 2015; 15:177. infl uence Candida albicans ability to form single- and multistrain to test and regulate berberine dosage 27. Zhang Y, et al. Berberine hydrochloride prevents postsurgery biofi lms. PLoS Pathog 2014; 10(12):e1004542. intestinal adhesion and infl ammation in rats. J Pharmacol Exp Ther according to safe levels and further to 4. Cuéllar-Cruz M, et al. Candida species: New insights into biofi lm 2014; 349(3):417-26. ensure its use for pharmaceutical purposes. formation. Future Microbiol 2012; 7(6):755-71. 28. Wang L, et al. Enhancing the antitumor activity of berberine 5. Mukherjee P, et al. Candida biofi lm: A well-designed protected Recently, an in vitro study reported that hydrochloride by solid lipid nanoparticle encapsulation. AAPS environment. Med Mycol 2005; 43(3):191-208. PharmSciTech 2014; 15(4):834-44. berberine treatment had detrimental effects 6. Scully C, El-Kabir M, Samaranayake L. Candida and oral 29. Chen C, et al. A Randomized Clinical Trial of Berberine on the cell wall integrity of C. albicans.31 candidosis: A review. Crit Rev Oral Biol Med 1994; 5:125-157. Hydrochloride in Patients With Diarrhea-Predominant Irritable Bowel 7. Ferreira G, et al. Does scientifi c evidence for the use of natural In addition, berberine was able to interfere Syndrome. Phytother Res 2015; 5475. products in the treatment of oral candidiasis exist? A systematic 30. Nakamoto K, Sadamori S, Hamada T. Eff ects of crude drugs with the calcineurin pathway, leading to review. 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Prevalence of Enamel Markings on Third Molars

Rassilee Sharma, BA; Sapna Lohiya, DDS; Pardis Rajabi, DDS; Kelly Nguyen, BS; Albert Ngo; Elizabeth Lee, BS; Afsaneh Shahrokhi Rad, DMD; Hongfei Chen, DDS, PhD; Rodrigo S. Lacruz, PhD; and Shane N. White, BDentSc, MS, MA, PhD

ABSTRACT The purpose of this study was to measure the prevalence of enamel markings in routinely extracted third molars. One hundred donated third molars were examined. All had some marking(s). Caries was almost universal; white snowcapping of cusps and ridges was extremely common; pit and valley defects were very common; spots and bands were very common, most were white; horizontal grooves were common; linear enamel hypoplasia, considered to be a true developmental defect, was rare.

AUTHORS

Rassilee Sharma, BA, Kelly Nguyen, BS, is Afsaneh Shahrokhi Rad, Rodrigo S. Lacruz, nce formed, tooth enamel is a dental student at the a dental student at the DMD, is an advanced PhD, is an assistant is incapable of active University of California, University of California, clinical trainee at the professor, basic science repair. Hence, its markings Los Angeles, School of Los Angeles, School of University of California, and craniofacial biology, Dentistry. Dentistry. Los Angeles, School of at New York University can provide a unique Confl ict of Interest Confl ict of Interest Dentistry. College of Dentistry. immutable record of Disclosure: None reported. Disclosure: None reported. Confl ict of Interest Confl ict of Interest Oinherited, developmental and acquired Disclosure: None reported. Disclosure: None reported. markings or defects. Inherited genetic Sapna Lohiya, DDS , Albert Ngo is a student at defects of enamel are extremely rare. is a dental student at the the University of California, Hongfei Chen, DDS, Shane N. White, University of California, Los Angeles, College of PhD, is a visiting scholar at BDentSc, MS, MA, For example, amelogenesis imperfecta Los Angeles, School of Letters and Science. the University of California, PhD, is a professor in the occurs in only one in 700 to 14,000 Dentistry. Confl ict of Interest Los Angeles, School of endodontics section at the births.1 Developmental defects are Confl ict of Interest Disclosure: None reported. Dentistry and a staff University of California, more common than genetic defects.2 Disclosure: None reported. dentist in the department Los Angeles, School of Developmental defects may occur Elizabeth Lee, BS, is a of prosthodontics at Dentistry. Pardis Rajabi, DDS, is student at the University Guanghua School of Confl ict of Interest through stress from systemic disease a dental student at the of California, Los Angeles, Stomatology at Sun Yat-sen Disclosure: None reported. affecting ameloblastic function, trauma University of California, College of Letters and University in Guangdong, to the tooth bud, excessive ingestion of Los Angeles, School of Science. China. fl uoride during amelogenesis or other Dentistry. Confl ict of Interest Confl ict of Interest disturbances of normal development and Confl ict of Interest Disclosure: None reported. Disclosure: None reported. Disclosure: None reported. biomineralization. Acquired markings are also extremely common. Carious demineralization, initially producing white spots and later producing surface loss, is extremely widespread.3,4

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Wide varieties of markings appear as being a developmental defect of enamel The purpose of this study was to on human tooth enamel. Some are of (DDE).7 Reported prevalence rates of create a third molar model for evaluating shape, others are of color or texture. Pit MIH have varied widely, from 2 percent enamel markings and to measure the and valley defects may be produced by to 75 percent.8-17 The etiology of MIH, prevalence of enamel markings in perturbation to ameloblastic function developmental or acquired, remains a routinely extracted third molars. or they may simply be a variation of contentious issue. One recent systematic anatomic form. Linear enamel hypoplasias review found that DDE was associated Materials and Methods (LEHs) are generally thought to with caries.18 However, it is not clear that represent severe systemic stress events, the enamel markings ascribed as being Patient Population affecting an entire cohort of ameloblasts DDE were actually of developmental Patients presenting for extraction contemporaneously during mineralization. origin. It is possible that white markings of lower wisdom teeth were recruited LEHs are generally reported to be ascribed to be DDE were in fact acquired at the University of California, Los narrow horizontal grooves consistent through demineralization after eruption. Angeles, School of Dentistry, Oral with a group of contemporaneous Without either longitudinal evaluation and Maxillofacial Surgery Clinic. All ameloblasts being affected by a consenting patients requiring third stressor, but vertical LEHs have also molar extractions between June 2011 been reported. Wide rounded grooves and September 2013 were included. This may refl ect a period of ameloblastic clinic has a socioeconomically diverse hypofunction, but they may simply be Caries is one of the most patient population because it provides a variation of normal anatomy. White prevalent acquired diseases specialty services to patients covered by spots may refl ect hypomineralization Medi-Cal and is located in an extremely during tooth formation, acquired carious worldwide, with enormous affl uent part of Los Angeles. Census data demineralization, fl uorosis or rare genetic impact, suff ering and cost. has indicated that the proportion of Los defects. Brown spots are considered to be Angeles city and county residents from less common and can be associated with disadvantaged backgrounds and racial and fl uorosis or caries. Likewise, white or brown ethnic diversity is higher than California bands may refl ect a period of ameloblastic or national averages. Some selection hypofunction or acquired carious of affected surfaces from the time of biases may have occurred. A sample size of demineralization. Cusps and cuspal slopes eruption or of destructive subsurface 100 was attained. Given prior prevalence of newly erupted molars are often marked histological evaluation, defi nitive data, this was suffi cient to measure the by white markings or “snowcapping.” It knowledge of the etiology of enamel major types of enamel markings.19 Most is unclear as to whether these markings markings cannot be understood. wisdom teeth are extracted from adults are of developmental or acquired origin Standard dental anatomy texts 18 years or older. Our subjects in this and what is normal or abnormal. describe the most common anatomical age group were 18 years old or older and Caries is one of the most prevalent variants rather than attempting to able to provide informed consent. In acquired diseases worldwide, with capture the wide range of human tooth order to ensure patient confi dentiality, enormous impact, suffering and cost.3,4 enamel form and color. Furthermore, no personal identifi ers were collected. Caries begins as reversible white spot markings that appear to be similar Although the city of Los Angeles has demineralization lesions in enamel. These clinically may have very different origins. long provided fl uoridated water, many may remain static, progress slowly or Knowledge of the types and prevalence smaller communities in Southern progress rapidly. The term molar-incisor of enamel markings would assist California still receive mixtures of hypomineralization (MIH), a clinical clinicians in distinguishing the normal fl uoridated and nonfl uoridated water. syndrome, has been used to describe the from the abnormal and in identifying Hence, the fl uoridation status, even presence of acquired, demarcated opacities those patients affected by or at risk for for subjects who grew up in Southern and posteruptive enamel breakdown in developmental or acquired defects, as California, cannot be certain. Essentially, the permanent incisors and fi rst molars.5,6 well as in advancing understanding of this investigation was an observational However, MIH has also been described the etiologies of enamel markings. study of a convenience sample.

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Subject Recruitment individuals. Children younger than 18 Diagnostic criteria were based on Institutional Review Board approval were specifi cally excluded from eligibility. the Winter and Brook and Witkop and was obtained (UCLA IRB #10-001874). Additionally, subjects generally appeared Sauk classifi cations for use in general Subjects were recruited using a posted to be attending for extraction of purpose epidemiological studies.8-10 Those fl yer asking interested patients to partly erupted third molars following classifi cation systems were modifi ed in contact the clinic receptionist. Next, episodes of pericoronitis. No personal consideration of the defects actually seen recruiters used a short eligibility screening identifi ers, including date of birth, were in our tooth sample. Six main types of according to a standardized script to collected. The tooth specimens were enamel defects, namely pit and valley determine eligibility. Finally, completion solely identifi ed by bar codes. Some defects, LEH, grooves, spots, banding of informed consent occurred in a of the included teeth may have been and snowcapping were seen (FIGURE). private room. Study personnel provided misidentifi ed as being third molars by Pits included single, multiple and valley participants with instructions to apply the surgeons performing the extractions, defect variants (FIGURE). LEH included an anonymous coded sticker to a plastic however, all had anatomy consistent with horizontal and vertical subtypes. Grooves bottle containing thymol solution for third molars upon extraoral examination. included horizontal shallow rounded and their extracted teeth on the day of their vertical types. Spots contained the above extractions. Subjects were given a $10 subtypes, as well as single, multiple and gift card upon consent, whether or not translucent variants (FIGURE). Banding they later donated their extracted teeth. included diffuse, well-defi ned white Plastic bottles with extracted teeth The fl uoridation status, and brown subtypes. In addition, the were collected at the end of each day. even for subjects who prevalence of prominent perikymata was recorded. The International Caries Third Molars grew up in Southern Detection and Assessment System Wisdom teeth were used because California, cannot be certain. (ICDAS) was used to measure caries.22,23 their enamel forms during childhood The ICDAS scale is reproducible, valid and they are available. They are and correlates with histology.24-26 It is commonly extracted prophylactically possible that acquired demineralization or because of painful pericoronitis in prevented the identifi cation of some young adults. Thus, suffi cient quantities Tooth Evaluation developmental defects.27 Although of third molars, which would otherwise After extraction, each tooth was wear could also potentially prevent the be discarded, could be obtained for carefully cleaned to remove any gross identifi cation of some defects,27 none examination. This study was limited to plaque or debris and stored in a 0.1% of the teeth exhibited any faceting third molars, whereas most prior studies thymol solution. Enamel defects were upon observation or histology, again have focused upon the entire dentition analyzed using plain eyesight, 2.5x suggesting that these teeth had been or on selected groups of teeth. Third magnifi cation loupes and projected extracted shortly after eruption. molar enamel development starts at ~8 images made using macrophotography The prevalence of markings and their years of age and is typically completed with fi ve views per tooth (buccal, subtypes were calculated as percentages. three years later, representing key distal, lingual, mesial and occlusal). prepubertal developmental periods.20,21 A consensus decision of two trained Results In this study, all consenting patients and calibrated examiners described Unwanted extracted third molars had already been treatment planned each tooth. After calibration, levels were readily available for our study. for third molar extraction and were of interexaminer agreement for the Participating subjects donated 100 willing to donate their extracted teeth. assessment of each third molar were unwanted, freshly extracted third molars. The sample potentially included a substantial to almost perfect (kappa Many purported enamel defects were range of teeth from the unerupted to value = 0.81 − 0.95). If a patient very common in this sample (TABLE). the long exposed. However, subjects donated more than one wisdom tooth, All teeth had at least one marking; overwhelmingly appeared to be young the tooth with the largest number many teeth had multiple markings. Pit adults rather than middle aged or older of visible defects was included. or valley defects, snowcapping, spots

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TABLE Enamel Markings

Enamel Marking Type Prevalence % (100 teeth from individual 100 subjects) Pit and valley defects, total teeth 65% and banding were found in a majority Single pits (d<1mm) 6% of the teeth. Shallow rounded grooves were also quite common, but LEHs were Single pits (d>1mm) 9% rare. Acquired caries was common, Multiple pits (d<1mm) 21% being found in 95 percent of the sample. Multiple pits (d>1mm) 21% Prominent perikymata, a normal feature, Valley defects (d<1mm) 0% were no more common than some of Valley defects (d>1mm) 8% the purported anomalies or defects. Linear enamel hypoplasia (LEH), total teeth 8% Pits and valley defects were extremely common with almost two- Horizontal LEH 8% thirds of the sample exhibiting pitting Vertical LEH 0% (TABLE). Teeth with multiple pits were Grooves, total teeth 42% more common than teeth with single Horizontal shallow rounded groove (SRG) 40% pits. The size of the pits was evenly Vertical groove 10% split between those bigger or smaller than 1 mm. Linear valley defects were Spots: white, brown or translucent, total teeth 64% considerably less common than pits. Single white spot 30% LEH was rare, found in only 8 percent Single brown spot 1% of the sample (TABLE). All LEHs were Single translucent spot 3% horizontal; no vertical LEHs were identifi ed. Multiple white spots 42% Shallow rounded grooves were quite Multiple brown spots 2% common, exhibited by 40 percent of the sample (TABLE). Most of the shallow Multiple translucent spots 4% rounded grooves were located in the Banding, total teeth 64% cervical quarter of the crowns. However, White diff use banding 59% vertical grooves in positions unrelated to Brown diff use banding 5% cuspal form were rarer, being exhibited White well-defi ned banding 4% in just 10 percent of the sample. Spots were extremely common and Brown well-defi ned banding 3% were exhibited on almost two-thirds of the Snowcapping on cusps and slopes, total teeth 83% sample (TABLE). Teeth with multiple spots Snowcapping white 82% were more common than teeth with single Snowcapping brown 1% spots. White spots were approximately Caries, International Caries Detection and Assessment System 95% an order of magnitude more common (ICDAS), total teeth than brown or translucent spots. Sound, ICDAS 0 5% Banding was extremely common and was exhibited by almost two-thirds Early stage decay, ICDAS 1 and 2 21% of the sample, as was spotting (TABLE). Established decay, ICDAS 3 and 4 61% Diffuse banding was approximately Severe decay, ICDAS 5 and 6 13% an order of magnitude more common Prominent perikymata, total teeth 64% than well-defi ned banding. White banding was approximately an order of magnitude more common Snowcapping was also extremely Caries was extremely common, than brown banding. Banding was common at 83 percent (TABLE). All but affecting 95 percent of the sample; 61 generally located in the cervical one of the teeth exhibiting snowcapping percent of the sample had established third of the crown, often coincident also exhibited decay, having an ICDAS decay according to the ICDAS criteria with shallow, rounded grooves. score of 1 or more. (TABLE).

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AB C

White spot

Snowcapping Serial narrow white banding Translucent spot genetic etiology appears unlikely because snowcapping was only found on the cusps and their slopes, not over the entire tooth surface, which is all eventually DE F covered by last-formed enamel. The patterning of cuspal snowcapping Pits LEH could be explained by the pattern of eruption of these molars; the cusps erupt fi rst and have the longest exposure to the oral environment. If the oral environment had favored demineralization or caries, LEH LEH Diffuse banding these areas would have the longest exposure and could be more likely to show whiteness FIGURE. Macro photographs showing representative enamel markings: narrow white banding (A); white caused by demineralization. Little is yet snowcapping of cusp tips and cuspal ridges (B); white and translucent spots (C); linear enamel hypoplasia (LEH) (D, E and F); pits (E); and diff use white banding (F). known about snowcapping. It is possible that young adults included in this study had moved from a more nutritive home environment to independent living with Prominent perikymata were discerned exhibited snowcapping of cusp tips and behavioral and dietary habits that put them on approximately two-thirds of the sampled slopes (TABLE). Snowcapping almost at high risk to carious demineralization. teeth (TABLE). Perikymata are a normal universally presented as multiple bright Shallow rounded grooves were surface feature, the manifestation of striae of white areas on cusps and slopes (FIGURE). common, mostly being found in the Retzius as cohorts of ameloblasts reach the This study could not determine the cervical areas; all were horizontal. tooth surface and senesce. origin of this snowcapping whether Although shallow rounded grooves could Few subjects donated contralateral or developmental, acquired or normal. It be indicative of true enamel hypoplasia, opposing third molar teeth, but in those is possible that this white cuspal enamel they were so common as to be considered cases, like fi ndings were discerned. becomes worn away in the years after normal in this sample of third molars. eruption and that snowcapping might Spots and bands were common. Discussion become less evident over time. Banding of developmental origin in Enamel markings were extremely The ameloblasts forming the the horizontal plane can be indicative common. Pit and valley defects, outer snowcapped enamel cusp tips of stress affecting multiple ameloblasts grooves, spots, bands and snowcapping and ridges were at the end of their simultaneously.34-37 The vast majority were found on a majority of teeth, lives,32,33 whereas other ameloblasts were of spots were white and a few were whereas LEHs were much rarer. contemporaneously forming normal brown. Translucent spots were rare. No LEHs are considered to be a useful unaffected enamel. Therefore, a change translucent bands were identifi ed, but biomarker of severe stress in anthropologic in this outermost enamel cannot be in the cases with multiple translucent study.28-31 The high prevalence of enamel ascribed to developmental stressors spotting, the spots were generally formed markings in this population could be because other contemporaneously contemporaneously. It is unknown attributed to several factors. Unusual, formed enamel appeared normal. whether translucent enamel is inferior, these teeth were examined with great care Snowcapping may be related to equal or superior to normal enamel, using photography with indirect lighting cellular senescence and death, but it whereas it is widely believed that white and high magnifi cation. Small defects was generally localized to the cusp tips or brown enamel is less dense than that usually go uncounted or unseen and slopes and not to the other tooth normal enamel. Well-defi ned banding was may have raised the found prevalence. surfaces. Amelotin, a recently discovered considerably rarer than diffuse banding. Snowcapping was an extremely protein, is involved in the formation of Caries was extremely common in this common enamel marking. The vast the last-formed fi nal enamel33 and might cohort, with 95 percent of teeth being majority of the teeth in this sample be related to snowcapping. However, a affected. This estimate may appear high.

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socioeconomic status and water fl uoridation. Int J Paediatr ■ However, there is no doubt that almost Caries was extremely common, Dent 2012;22(4):250-7. [PMID: 22010979] three-quarters of the teeth had established almost universal. 11. Muratbegovic A, Zukanovic A, et al. Molar-incisor or severe decay. The probability of carious ■ Snowcapping was extremely common. hypomineralisation impact on developmental defects of enamel prevalence in a low fl uoridated area. Eur Arch Paediatr Dent ■ attack is the highest in the couple of years Pit and valley defects were very 2008;9(4):228-31. [PMID: 19054477] following eruption of fi rst and second common. 12. Correa-Faria P, Martins-Junior PA, et al. Developmental molars38 and the same is likely true for ■ Spots and bands were very common; defects of enamel in primary teeth: Prevalence and associated factors. Int J Paediatr Dent 2013;23(3):173-9. [PMID: third molars. Many teeth exhibited a most were white. 22548676] variety of defects, most often including ■ Horizontal grooves were common. 13. Cruvinel VR, Gravina DB, et al. Prevalence of enamel decay and snowcapping. Decay could have ■ Many marking types were so prevalent defects and associated risk factors in both dentitions in preterm and full-term born children. J Appl Oral Sci 2012;20(3):310- prevented identifi cation of other defects. that they may be considered to be 17. [PMID: 22858696] This study was limited to third molars. normal. 14. Ghanim A, Morgan M, et al. Molar-incisor Most prior studies have not focused on ■ Linear enamel hypoplasia, considered hypomineralisation: Prevalence and defect characteristics in Iraqi children. Int J Paediatr Dent 2011;21(6):413-21. [PMID: third molars, but on the entire dentition to be a true developmental defect, was 21689174] or on representative groups of teeth. rare. ■ 15. Martinez Gomez TP, Guinot Jimeno F, et al. Prevalence Most prior studies examined teeth in of molar-incisor hypomineralisation observed using ACKNOWLEDGMENTS transillumination in a group of children from Barcelona (Spain). vivo, whereas this study examined teeth The authors are very grateful for support from NIH NIDA grant Int J Paediatr Dent 2012;22(2):100-9. [PMID: 21883558] ex vivo using magnifi cation and optimal R21 DA031571. We are also grateful to the China Scholarship 16. Arrow P. Prevalence of developmental enamel defects of lighting conditions. Data on third molar Council and Dr. Cui Huang, Wuhan University, for facilitating the fi rst permanent molars among schoolchildren in Western the visit of Hongfei Chen to UCLA. We are most appreciative of Australia. Aust Dent J 2008;53(3):250-9. [PMID: 18782370] markings is rare, but these teeth are the eff orts of all the faculty, staff and residents of the UCLA Oral 17. Mackay T, Thomson W. Enamel defects and dental caries available for donation and their enamel and Maxillofacial Surgery Clinic in their gracious and invaluable among Southland children. N Z Dent J 2005;101(2):35-43. is formed during childhood. It is possible support of this study. We would also like to thank Chunling Ge, [PMID: 16011308] Peking University; Brian Lozano, UCLA; as well as Tim Bromage 18. Vargas-Ferreira F, Salas MM, et al. Association between that a similar study could be performed and Bin Hu, NYU, for their invaluable technical assistance. developmental defects of enamel and dental caries: A using unwanted premolars extracted systematic review and meta-analysis. J Dent 2015;43(6):619- from children for orthodontic purposes. REFERENCES 28. [PMID: 25862273] 1. Crawford PJ, Aldred M, et al. Amelogenesis imperfecta. 19. Suckling G, Herbison G, et al. Etiological factors Now that the high prevalence of a Orphanet J Rare Dis 2007;2:17. [PMID: 17408482] infl uencing the prevalence of developmental defects of dental wide variety of enamel markings has been 2. Needleman HL, Leviton A, et al. Macroscopic enamel defects enamel in 9-year-old New Zealand children participating in a established, further study is needed to of primary anterior teeth — types, prevalence and distribution. health and development study. J Dent Res 1987;66(9):1466- Pediatr Dent 1991;13(4):208-16. [PMID: 1886825] 69. [PMID: 3476618] differentiate the causative etiologies of 3. RA Bagramian, F Garcia Godoy, et al. The global increase 20. Liversidge HM. Accuracy of age estimation from markings that may appear to be similar, but in dental caries. A pending public health crisis. Am J Dent developing teeth of a population of known age (0–5.4 years). are of completely different origin. Surface 2009;22(1):3–8. [PMID: 19281105] Int J Osteoarchaeol 1994;4(1):37-45. 4. Dye BA, Li X, et al. Oral health disparities as determined by 21. Reid DJ, Dean MC. Variation in modern human enamel viewing at a single moment in time cannot selected healthy people 2020 oral health objectives for the formation times. J Hum Evol 2006;50(3):329-46. PMID: determine etiology. Unneeded, donated United States, 2009-2010. NCHS data brief 2012;(104):1-8. 16300817 third molars provided an ideal basis for [PMID: 23101968] 22. Pitts NB, Ekstrand KR. ICDAS Foundation. International 5. Weerheijm KL. Molar incisor hypomineralisation (MIH). Eur J Caries Detection and Assessment System (ICDAS) and its study because they can be obtained in Paediatr Dent 2003;4(3):114-20. [PMID: 14529330] International Caries Classifi cation and Management System suffi cient numbers and can be sectioned for 6. Chawla N, Messer LB, et al. Clinical studies on molar-incisor- (ICCMS) — methods for staging of the caries process and hard tissue histology to examine subsurface hypomineralisation part 2: Development of a severity index. Eur enabling dentists to manage caries. Community Dent Oral Arch Paediatr Dent 2008;9(4):191-9. [PMID: 19054472] Epidemiol 2013;41(1):e41-52. [PMID: 24916677] features microscopically for evidence of 7. Weerheijm KL, Mejàre I. Molar incisor hypomineralization: 23. International Caries Detection and Assessment System etiology without any harm to their donors. A questionnaire inventory of its occurrence in member countries (ICDAS) Coordinating Committee. Rationale and Evidence of the European Academy of Paediatric Dentistry (EAPD). Int J for the International Caries Detection and Assessment System Paediatr Dent 2003;13(6):411-6. [PMID: 14984047] (ICDAS II). www.icdas.org/home. Accessed June 1, 2015. Conclusions 8. Machiulskiene V, Baelum V, et al. Prevalence and extent 24. Jablonski-Momeni A, Ricketts DN, et al. Occlusal caries: We drew the following conclusions from of dental caries, dental fl uorosis and developmental enamel Evaluation of direct microscopy versus digital imaging used for our research: defects in Lithuanian teenage populations with diff erent fl uoride two histological classifi cation systems. J Dent 2009;37(3):204- exposures. Eur J Oral Sci 2009;117(2):154-60. [PMID: 11. [PMID: 19124186] ■ Freshly extracted third molars were 19320724] 25. Jablonski-Momeni A, Ricketts DN, et al. Eff ect of diff erent readily available for study. 9. Jalevik B. Prevalence and diagnosis of molar-incisor- time intervals between examinations on the reproducibility of ■ Enamel markings were universally hypomineralisation (MIH): A systematic review. Eur Arch ICDAS-II for occlusal caries. Caries Res 2010;44(3):267-71. Paediatr Dent 2010;11(2):59-64. [PMID: 20403299] [PMID: 20516687] common in the studied third molar 10. Balmer R, Toumba J, et al. The prevalence of molar incisor 26. Topping GV, Pitts NB. Clinical visual caries detection. cohort. hypomineralisation in Northern England and its relationship to Monogr Oral Sci 2009;21:15-41. [PMID: 19494673]

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27. Seow WK. Clinical diagnosis of enamel defects: Pitfalls and formation. Am J Phys Anthropol 2008;135(3):348-61. [PMID: 37. Witzel C, Kierdorf U, et al. Reconstructing impairment practical guidelines. Int Dent J 1997;47(3):173-82. [PMID: 18161846] of secretory ameloblast function in porcine teeth by analysis 9448804] 32. Escobar VH, Goldblatt LI, et al. A clinical, genetic and of morphological alterations in dental enamel. J Anat 28. Guatelli-Steinberg D. Macroscopic and microscopic ultrastructural study of snowcapped teeth: Amelogenesis 2006;209(1):93-110. [PMID: 16822273] analyses of linear enamel hypoplasia in plio-pleistocene imperfecta, hypomaturation type. Oral Surg Oral Med Oral 38. Carlos JP, Gittelsohn AM. Longitudinal studies of the natural South African hominins with respect to aspects of enamel Pathol 1981;52(6):607-14. [PMID: 6947186] history of caries. II. A life-table study of caries incidence in the development and morphology. Am J Phys Anthropol 33. Lacruz RS, Nakayama Y, et al. Targeted overexpression of permanent teeth. Arch Oral Biol 1965;10(3):739-51. [PMID: 2003;120(4):309-22. [PMID: 12627527] amelotin disrupts the microstructure of dental enamel. PloS One 5226906] 29. Hubbard A, Guatelli-Steinberg D, et al. Under restrictive 2012;7(4):e35200. [PMID: 22539960] conditions, can the widths of linear enamel hypoplasias be 34. Goodman AH, Armelagos GJ, et al. Enamel hypoplasias THE CORRESPONDING AUTHOR, Shane N. White, BDentSc, MS, MA, used as relative indicators of stress episode duration? Am J as indicators of stress in three prehistoric populations from PhD, can be reached at [email protected]. Phys Anthropol 2009;138(2):177-89. [PMID: 18711731] Illinois. Hum Biol 1980;52(3):515-28. [PMID: 7005071] 30. Guatelli-Steinberg D, Ferrell RJ, et al. Linear enamel 35. Rose JC. Defective enamel histology of prehistoric teeth hypoplasia as an indicator of physiological stress in great apes: from Illinois. Am J Phys Anthropol 1977;46(3):439-46. [PMID: Reviewing the evidence in light of enamel growth variation. Am 871151] J Phys Anthropol 2012;148(2):191-204. [PMID: 22610895] 36. Rose JC, Armelagos GJ, et al. Histological enamel indicator 31. Ritzman TB, Baker BJ, et al. A fi ne line: A comparison of childhood stress in prehistoric skeletal samples. Am J Phys of methods for estimating ages of linear enamel hypoplasia Anthropol 1978;49(4):511-6. [PMID: 367176]

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CDA JOURNAL, VOL 44, Nº8

Nonodontogenic Sources of Dental Pain

Scott E. Schames, BS; Michael Jordan, RN, MSN, MBA; Hila Robbins, DMD; Lenard Katz, BA; and Kaitlyn Tarbert, RDH

ABSTRACT Nonodontogenic sources of dental pain can be extremely challenging to diagnose. It is critical to establish a proper diagnosis to ensure that treatment is directed toward the source of the pain rather than the site of the pain.

AUTHORS

Scott E. Schames, BS, Lenard Katz, BA, is a onodontogenic dental recreate and mimic the chief complaint of is a dental student at the dental student at New pain can be a major source pain during the examination; otherwise, University of San Francisco, York University College of frustration for patients the diagnosis may be incorrect and School of Dentistry and was of Dentistry and was a a medical researcher at medical researcher at the and dentists. Dentists suspect. If the source of the dental pain the Craniofacial Pain/TMJ Craniofacial Pain/TMJ are trained to detect is not identifi ed during the examination, Clinic at White Memorial Clinic at White Memorial Nthe source of a patient’s dental and the dentist must search for other causative Medical Center in Los Medical Center in Los orofacial pain based on the description factors. It is critical to establish a proper Angeles. Angeles. and clues provided by patients and diagnosis to ensure that treatment Confl ict of Interest Confl ict of Interest Disclosure: None reported. Disclosure: None reported. results of diagnostic tests. Odontogenic is directed toward the source of the causes of dental pain — decay, abscess, pain rather than the site of the pain. Michael Jordan, RN, Kaitlyn Tarbert, RDH, is cracked tooth, periodontal disease, sinus Until the source of the pain is found, MSN, MBA, is the a myofunctional therapist infection, etc. — can be challenging, the diagnosis is actually a differential coordinator of the clinical and a clinical instructor at but are part of the routine examination diagnosis, which can only be verifi ed research program at White the Craniofacial Pain/TMJ Memorial Medical Center Clinic at White Memorial process in determining a proper diagnosis with further testing, consultation with in Los Angeles. Medical Center in Los to ensure a successful treatment plan. other medical specialties and ultimately Confl ict of Interest Angeles. However, when the dental pain is of confi rmed by successful treatment. Disclosure: None reported. Confl ict of Interest a nonodontogenic origin, the route to Disclosure: None reported. discovery may be less straightforward. Not Myofascial Odontalgia From Facial Hila Robbins, DMD, is a pediatric dentist and is a only can nonodontogenic dental pain be Muscles senior clinical instructor at extremely painful, but such pain can also Myofascial causes of pain should the Craniofacial Pain/TMJ be indicative of other, sometimes serious be investigated during an examination Clinic at White Memorial health problems. Therefore, it is important of dental pain. Myofascial pain from a Medical Center in Los to identify the cause of pain as quickly as muscle trigger point (TrP) usually causes Angeles. She is a diplomate of the American Board of possible, even when the source of the pain patients to feel a regional, dull ache at the Pediatric Dentistry. is located in another part of the body. muscle site, but it can also refer pain to Confl ict of Interest The key to proper diagnosis of distant ipsilateral sites, including teeth.1,2 Disclosure: None reported. nonodontogenic dental pain is to try to According to Travell and Simons, pain

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referral patterns vary based on the muscle.2 ultimately lead to the formation of TrPs Travell noted, the soleus muscle in the leg For example, TrPs in the masseter muscle that directly refer pain to the teeth.3 near the calf refers pain into the orofacial can refer pain ipsilaterally to maxillary Therefore, restrictions of the tongue area. Schames et al.12 also showed that not and/or mandibular posterior molar teeth, should be examined when searching for only is there a pain referral pattern to the the temporalis muscle can refer pain nonodontogenic sources of tooth pain. orofacial region from a TrP in the pectoralis ipsilaterally to each of the maxillary teeth Additionally, ear infections may refer muscle located in the armpit, but also there and the anterior digastric muscle can refer and mimic dental pain. In some cases, appears to be an association between the pain to mandibular anterior incisors.2,3 orofacial pain that is associated with soleus and the pectoralis referral patterns. In a case reported by Mascia et al.,1 a the eruption of molars (primary and/or Dental pain can also be referred from patient complained of pain in the upper permanent) may actually be caused by the diaphragm, the thin, dome-shaped and lower left quadrants of her teeth, an ear infection that has referred pain to sheet of muscle and tendon that separates radiating to the ear and temporal region. that region.10 The area around the ear has the chest from the abdomen.13 The phrenic A thorough examination did not return an multiple nerve innervations including the nerve innervates the diaphragm to control odontogenic cause; therefore, a myofascial trigeminal, facial, glossopharyngeal and the movements that produce breathing. examination was performed. Palpation Bordoni and Zanier discuss that the phrenic of the left masseter at the angle of the nerve can affect the spinal trigeminal mandible duplicated the patient’s pain. By ganglia, stimulating “the last two branches isolating the TrP in the muscle between Restrictions of the tongue of the trigeminal nerve, reaching the teeth the middle and index fi nger, a diagnosis and periodontal ligaments through the of myofascial pain was established. should be examined alveolar nerves,”14 resulting in dental pain. The patient was treated with a non- when searching for Body posture, specifi cally of the head epinephrine-containing injection near nonodontogenic sources and cervical area, should be evaluated the trigger point, which was successful in during patient examination for orofacial eliminating the pain. Mascia et al.1 note of tooth pain. pain. Examples of poor posture include, that epinephrine is not used because of its but are not limited to, kyphosis of the vasoconstrictive action on muscle, which thoracic spine, anterior rotation of the can be toxic to muscle and fat tissue. shoulders and forward head position. The tongue is another organ/muscle vagus nerves, as well as superfi cial sensory Alterations of craniocervical posture may that can be the source of nonodontogenic branches from the cervical plexus.11 develop from trauma (including birth tooth pain. Ankyloglossia or tongue-tie is The referral pattern of pain is due to trauma), thoracic breathing patterns, commonly characterized as a short lingual the overlapping sensory innervations of mouth breathing, habitual poor posture frenum that limits tongue mobility.4-6 The the trigeminal nerve around the mouth and epigenetic factors such as the Western tongue, which has origin and insertion and ear during development.10,11 diet and modern technology.9,15-17 For points ranging from the internal portion example, Lee et al. 17 reported that subjects of the mandible down to the hyoid Myofascial Odontalgia From Muscles maintained a head fl exion of 33-45 degrees bone, has many myofascial and muscular Beyond the Head from vertical while texting on their attachments to the cervical muscles.7 Muscles in the neck and torso can smartphones. Such a forward disposition Olivi et al.8 report that ankyloglossia also cause orofacial pain. Travell and produces a posterior rotation of the is associated with hyperactivity of the Simons described that masseter muscle cranium, straightens the lordotic curvature suprahyoids and forward displacement TrPs may originate as satellites from of the neck and overworks cervical of the head. The restricted tongue TrPs in the trapezius muscle as well as muscles such as the sternocleidomastoid requires the use of accessory muscles to the sternocleidomastoid muscle, both of (SCM).9 Overactivation of the SCM perform functions such as breathing, which can refer pain to the facial area can lead to malocclusions, compression breastfeeding, chewing and swallowing.4-6 and restrict the opening of the mouth.2 of the temporomandibular joints, This hyperactivity of the cervical As counterintuitive as it may seem, orofacial pain9 and as documented, muscles causes shortening of the muscles, muscles distant from the head and neck the creation of TrPs that directly refer induces forward head posture9 and may area can also produce dental pain. As pain to the mandibular teeth.2,3

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Cardiac Odontalgia ■ Have daily pain. produced pain in the maxillary teeth. As many case studies have shown, ■ Experience disruption of Stimulation of the lower lateral wall of orofacial pain can be of cardiac origin. daily activities and sleep. the maxillary sinus resulted in pain in the Heart problems such as angina pectoris ■ Make an emergency room maxilla and posterior maxillary teeth. or acute myocardial infarction can visit for orofacial pain. Dr. Wolff also applied electrical refer pain to teeth and facial areas, The study concluded that nociceptive stimulation to patients’ teeth to determine with or without chest or arm pain.18 pain is exacerbated by diabetes, if pain was referred to other areas of One of the fi rst signs of cardiac particularly where diabetic patients the upper body. He documented that distress can be pain on either side of the can have a subjective experience of stimulation of a maxillary premolar face due to stimulation of the trigeminal increased orofacial pain. According referred pain in the temporal region, nerve. Rothwell explains that referral of to the study results, the frequency of forehead and scalp on the same side of the ischemic pain to the face and mandible orofacial pain is more prevalent and more head in which the tooth was stimulated. may stem from connections between the frequent among adults with diabetes Stimulation of a premolar in the mandible vagus and the trigeminal nerve nuclei.19 than among those without diabetes. caused pain throughout the maxilla If a patient presents with dental or and mandible as well as the areas over orofacial pain, and odontogenic, myofascial the zygoma, temple and top of the ear. and nasal causes have been ruled out, it is When a maxillary molar was stimulated, prudent to consider that the pain could be One of the fi rst signs of headache was induced in the temporal of cardiac origin, particularly if the patient region, forehead and up to the vertex, has one or more cardiac risk factors, such as cardiac distress can be with erythema (redness) occurring on advanced age, high blood pressure, obesity, pain on either side of the the side of the face, mandible and neck. etc. Anecdotally, there have even been cases face due to stimulation of in which young people have had dental and Bruxism orofacial pain that was cardiac in origin. the trigeminal nerve. Bruxism is a common cause of dental According to Kreiner and Okeson, and facial pain. The excess pressures can improper diagnosis of cardiac-related cause stress, not only in the teeth, but also dental pain frequently leads to unnecessary in the surrounding periodontal ligaments dental treatment or, more signifi cantly, Nasal Sinus Lining Odontalgia and facial musculature.24 To diagnose delayed treatment of underlying cardiac Harold Wolff, MD, a pioneer in the bruxism, dentists generally examine for disease, such as myocardial infarction.20 fi eld of neurology, performed experiments dental wear facets from grinding, but it uncovering referral patterns of pain is also important to check for evidence Diabetic Odontalgia between other parts of the cranium and the of clenching by looking for scalloping While periodontal infections, ulcers teeth. Dr. Wolff demonstrated that dental (indentations on the sides of tongue) or and inadequate wound healing are pain could originate from the sinuses. In linea alba (bite mark lines on the inside of known issues associated with diabetes his experiments, Dr. Wolff pressed a probe the cheeks). Stress or pain can contribute mellitus (DM),21 DM can also increase or faradic electrode against the wall of the to bruxism, and some antidepressant the sensation of dental pain. Because it nasal cavity at various trigger points.23 Dr. medications can also have the side effect affects the vascular system, DM causes Wolff demonstrated that the nasal sinus of contributing to bruxism.25 Schames reduced circulation in the tiny blood vessels lining, which is innervated by trigeminal et al.26 discussed that nocturnal bruxism entering the apices of the teeth, which afferents, has trigger points that refer pain is a result of airway obstructions during in turn affects the exchange of nutrients, to specifi c teeth. Dr. Wolff documented sleep, so due diligence must be exercised oxygen and waste, impairing healing.22 that stimulation in the superior nasal when patients have evidence of dental In a study examining the infl uence cavity produced pain ipsilaterally in or facial pain originating from bruxism. of adult-onset diabetes on orofacial pain, the upper teeth, including the canine, Most recently, in January 2015, Rahim-Williams et al.22 reported that the premolars and the fi rst molar, with Kloeffl er wrote, “The tightened diabetic patients were more likely than pain also felt in the maxilla above those muscles of the jaw narrow the airway nondiabetic orofacial pain sufferers to: teeth. Stimulation of the sphenoid sinus during nocturnal bruxism, creating

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intermittent hypoxia to the brain.”27 and facial muscles, and to promote proper ■ Air bubbles within fi llings Therefore, we can infer that bruxism physiology of the orofacial complex that expand and contract causes obstructions of the airway and during functions such as breathing, eating, next to vital dentin.38,39-41 must be treated appropriately. speaking, sleeping and swallowing.37 ■ Nociceptive pain referred down Traditionally, dentists treat bruxism Any patient who has bruxism should from the maxillary sinus.38,41-43 with an oral appliance, generically be referred to a sleep physician for ■ Stimulation of nerve endings in called a night guard appliance. However, more detailed polysomnographic sleep chronically infl amed pulp.38,44-46 it has been documented that when a studies to determine the exact type Kollman concluded that the majority regular bruxism night guard appliance of additional defi nitive care that the of the perceived pain was due to an is given to a patient to wear during patient may require for nocturnal airway infl amed pulp affected by altitude pressures.38 sleep, this appliance can exacerbate obstructions, such as the use of continuous The nonodontogenic phenomenon of nighttime obstructions of the airway.28,29 positive airway pressure (CPAP), barodontalgia should be considered when Therefore, the standard of care is that myofunctional therapy and/or surgery. seeking to identify the source and cause of a patient cannot use a daytime bruxism the patient’s pain complaint. oral appliance while sleeping, day or night. Rather, patients must use an oral Neuropathic Pain sleep appliance, such as a mandibular Neuropathic pain can be triggered by advancement or tongue-retaining When a regular bruxism various factors, but when developed, the appliance during sleep. The oral sleep night guard appliance is given pain experienced is generally different appliance serves not only to protect the to a patient to wear during from myofascial pain. As indicated above, patient from the ill effects of bruxism, myofascial pain in usually experienced as a but it also serves to bring the patient’s sleep, this appliance can regional, dull, aching pain, while patients mandible and tongue forward, thereby exacerbate nighttime with neuropathic pain often report an promoting the opening of the airway. obstructions of the airway. electrical, burning, shooting or stabbing pain, Signs and symptoms of bruxism which can be felt for several seconds when are also present in children with the trigger point (if known) is touched.47 obstructive sleep apnea, with a variable prevalence of 3.5 to 40.6 percent.30 Bariodontalgia Trigeminal Neuralgia Tonsilloadenoidectomy is often rendered Frequent air travelers are aware of Trigeminal neuralgia (TN) is the most as the fi rst line of treatment, but recent the phenomenon of a potato chip bag common cause of facial neuralgia. It affects research has documented that signs and expanding during fl ight then contracting four to fi ve people per 100,000 and affects symptoms of obstructive sleep apnea upon landing. During fl ight, a similar women older than 40 years of age48 more were retained in a large percentage of change in pressure can occur within the often than men. Experiencing severe, pediatric patients following the removal dental pulp chamber as well as within shocking pain18 that can last seconds to of tonsils and adenoids.31-33 Furthermore, the bony trabeculae within the mandible. minutes, the TN patient will generally recent studies describe the importance Barodontalgia is the occurrence of a be pain-free between occurrences.47 of restoring continuous nasal breathing toothache, maxillary sinus ache and/or Although the source of the pain is through the use of myofunctional mandibular bone ache due to the sudden internal, the patient may report seemingly therapy, as a solution to managing increase or decrease of atmospheric innocuous sources of pain such as when pediatric obstructions of the airway long pressure.34 Barodontalgia can be brought brushing teeth, shaving or eating.18,47 term.34,35 Nasal breathing is associated on by changes in cabin pressure during Because patients with TN can with a reduction in the infl ammation airline fl ights, climbing to higher suffer from similar symptoms to those of oral tissues, a more favorable growth altitudes and/or by the changes in water caused by pulpitis, dentists should pattern of the face and a reduction pressure while diving in water. Kollman34 differentiate by administering dermal in the apnea hypopnea index.33,34,36 describes three possible reasons that a topical surface anesthesia with an 8% Myofunctional therapy aims to promote number of patients experienced tooth xylocaine spray at the trigger zone to neuromuscular repatterning of the oral pain due to the changes in pressure. observe whether this reduces the pain.48

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Of signifi cant clinical importance, ■ May be triggered by placing the patient experiences hearing loss trigeminal neuropathic pain may be the pressure on the periauricular or tinnitus (ringing in the ears). An fi rst sign of multiple sclerosis (MS).49 region at the level of the tragus. MRI should be used to determine if Therefore, if a patient has a complaint of In the case described by Murayama et an intracranial tumor is present. neuropathic pain, an MRI of the brain al.,50 a patient presented with intense pain In a case documented by should be performed to rule out MS. As of short duration near the left external ear Mehrkhodavandi et al.,56 a patient was Lummel et al. wrote, “retrospective studies and in the ipsilateral maxillary second molar. initially treated for trigeminal neuralgia have noted that MS-related TN tends to Pain could be triggered by touching his face after reporting pain radiating from the present at younger ages compared with and the region of the ear helix. During the lower lip to the teeth in the lower left neurovascular compression (NVC)-related examination, a shocking pain was triggered quadrant, without an apparent odontogenic TN (48 versus 57 years, respectively).”50 by touching the ear helix region, which source. The patient also experienced Classical TN originates from referred to the maxillary left second molar ringing sounds and a congested left ear, compression of the trigeminal nerve and caused a burning pain in the ipsilateral as well as numbness, pain and tingling root.50 Secondary TN may be caused temporal region. Though palpation of in arms, hands and fi ngers on both by demyelinating disorders (e.g., MS, sides. When treatment for TN was autoimmune disorders) or pressure on unsuccessful, the patient was referred for the nerve from tumors (see Neoplasias MRI, which revealed a “moderate-size below), which, according to Matwychuk, Of signifi cant clinical lobular left cerebellopontine angle mass lead to “abnormal transmission and lesion consistent with acoustic neuroma processing of impulses along the importance, trigeminal with compression of the left trigeminal trigeminal nerve.”47 An MRI should help neuropathic pain may nerve secondary to the lesion.” to determine if blood vessels, tumors be the fi rst sign of multiple or evidence of MS are the source. Central Sensitization sclerosis (MS). Dentists should be aware of central Auriculotemporal Neuralgia sensitization, which is of particular Unlike TN, which generally importance in cases of chronic pain. After occurs without an obvious trauma, a traumatic event such as a heavy blow to auriculotemporal neuralgia (AN) is usually the TMJ and masticatory muscles caused the masseter muscle, or after repeated heavy caused by a traumatic event, such as a no pain, palpation of the region of the bruxism, the perceived pain can become root canal or extraction.47 The source of auriculotemporal nerve triggered a burning centrally sensitized due to central nervous pain from AN is believed to be irritation pain radiating toward the temporal region. system hyperexcitability leading to long- (whether by compression, friction or term changes in the nervous system. Central traction) of the auriculotemporal nerve, Acoustic Neuroma sensitization occurs when nociceptive particularly where the nerve pathway Acoustic neuroma, also referred to afferent nerve fi bers branch extensively to crosses muscles, the temporal artery or as vestibular schwannoma, is a benign terminate via synapses on many neurons, other anatomical structures.52,53 Patients tumor composed of Schwann cells on as opposed to just one synapse.57 Murray with AN may experience moderate the eighth cranial nerve between the explains that effective synaptic connections to severe pain in the following areas: brain and the inner ear, which can cause result in the activation of neurons in temporal region, the temporomandibular dental pain through compression of the higher centers of the brain for the correct joint, the parotid and also in the auricular trigeminal nerve. Bisi et al.54 report that perception of pain. However, there are and retro-orbital region.51 Where pain in patients presenting with TN symptoms, ineffective synapses in which nerve impulses from TN is experienced as quick fl ashes approximately 6-16 percent have do not activate the next neuron in the of shocking pain, Murayama et al.53 intracranial tumors (the most common of pathway. If there is prolonged or intense report that the pain from AN is often: which is acoustic neuroma). In making a pain stimulation, some of the ineffective ■ Continuous, with exacerbations differential diagnosis, early impairment of synapses can become effective connections perceived as stabbing pains. auditory activity is a common indicator for other origins by central sensitization ■ Unilateral. of acoustic neuroma,55 particularly if and neuroplasticity.58 In his example,

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Murray57 states that a source of noxious stabbing, aching, burning, prickling, consider the details of the pain and stimulation in the region of the temporalis tingling or [an] itching sensation.” patient history and try to recreate the muscle could activate neurons that typically If a patient presents with severe chief complaint of pain. If the source of receive noxious input from the forehead or neuropathic-type facial or dental pain, and the dental pain is not recreated during tooth pulps of the maxillary molars through imaging and other diagnostic tests have the examination, the dentist must search previously ineffective connections. This ruled out tumors and other neuropathic for other causative factors that may be means that the brain, and thus the patient, sources, the dentist should inquire if the the source of the perceived pain. ■ will perceive the pain source as the tooth patient has had chickenpox in the past to pulps or forehead, when the pain is actually determine if ZSH is a possibility and then REFERENCES 1. Mascia P, Brown BR, Friedman S. Toothache of Nonodontogenic produced from the temporalis region. proceed with a serological examination. Origin: A Case Report. J Endod 2003; 29(9):608-10. It is important for dentists to realize It is important to note that a patient may 2. Travell JG, Simons DG. Myofascial pain and dysfunction — the that muscular and/or dental pain caused have unknowingly had the original VZV trigger point manual. Baltimore, Md.: Williams and Wilkins, 1983. 3. Wright EF. Referred craniofacial pain patterns in patients with by repeated heavy bruxism may no longer infection without the main symptom temporomandibular disorder. J Am Dent Assoc 2000; 131:1307- respond only to treatment modalities (chickenpox), so if the pain is consistent 1315. focused toward the effect of bruxism, but with shingles, it may make sense to consider 4. Klockers T. Familial ankyloglossia (tongue-tie). Int J Pediatr Otorhinolaryngol 2007, 71:1321-1324. may also require neurological treatment it even if the patient states that he or she 5. Horton CE, Crawford HH, Adamson JE, Ashbell TS. Tongue-tie. for the neuropathic component of the has not had chickenpox. If the patient is Cleft Palate J 1969; 6:18-23. centrally sensitized pathways.57 diagnosed with ZSH through a serologic 6. Lalakea ML, Messner AH. Ankyloglossia: Does it matter? Pediatr Clin N Am 2003; 50:381-397. examination, oral antiviral drugs should 7. Fehrenbach M, Herring S. (2007). Illustrated Anatomy of the Shingles be prescribed by the appropriate health Head and Neck (3rd ed.). St. Louis: Saunders Elsevier. Another cause of nonodontogenic care professional to treat the disorder. 8. Olivi G, et al. Lingual frenectomy: Functional evaluation and new therapeutical approach. Euro J Paediatr Dent 2012; 2:101-106. pain is shingles (herpes zoster), the 9. Correa E, Berzin F. Temporomandibular disorder and syndrome that affects nearly one-third of Neoplasias dysfunctional breathing. Braz J Oral Sci 2004; 3: 498-502. all Americans at some point in their lives Some tumors, aneurisms or cancers 10. Silverglade D. Dental pain without dental etiology: A manifestation of referred pain from otitis media. J Dent Child 1980; according to the CDC, usually after the can also cause facial pain. While these 47:358-359. age of 50.59 Varicella-zoster virus (VZV) scenarios are rare, they are extremely 11. Kim D, et al. Dental otalgia. 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Wolff ’s Headache and Other describe ZSH pain as “deep, or as a boring, pain may not be obvious, dentists must Head Pain. New York: Oxford UP, 2001.

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24. Shetty S, Pitti V, Satish Babu CL, Kumar GP, Deepthi BC. 2011. 48. Matwychuk MJ. Diagnostic Challenges of Neuropathic Tooth Appl Oral Sci 2006 Dec; 14(6):476-81. Bruxism: A Literature Review. J Indian Prosthodont Soc. 3:141-148. Pain. J Can Dent Assoc 2004; 70(8): 542-46. 55. Matsuka Y, Fort E, et al. Trigeminal neuralgia due to an acoustic 25. Milanlıoglu A. Paroxetine-induced severe sleep bruxism 49. Lummel N, Mehrkens JH, et al. Diff usion tensor imaging of neurinoma in cerebellopontine angle. J Orofac Pain 2000; successfully treated with buspirone. Clinics 2012; 67(2):191-192. the trigeminal nerve in patients with trigeminal neuralgia due to 14:147-51. 26. Schames SE, Schames J, et al. Sleep Bruxism, an Autonomic multiple sclerosis. Neuroradiology 2015 Mar;57(3):259-67. doi: 56. Mehrkhodavandi N, Green D, et al. Toothache Caused by Self-Regulating Response by Triggering the Trigeminal Cardiac 10.1007/s00234-014-1463-7. Epub 2014 Nov 18. 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Int J Morphol 2004; a review of the literature. J Orofac Pain 2003; 17(3):262-7. breathing symptoms in young children: A six-year population cohort 22(4):327-30. study. Sleep 2011. 34:875-884. 54. Bisi MA, Selaimen CM, et al. Vestibular schwannoma (acoustic THE CORRESPONDING AUTHOR, Michael Jordan, RN, MSN, MBA, 32. Bonuck K, et al. Sleep-disordered breathing in a population- neuroma) mimicking temporomandibular disorders: A case report. J can be reached at [email protected]. based cohort: Behavioral outcomes at four and seven years. Pediatrics 2012; 129:857-865. 33. Lee SY, Carillo O, Guilleminault C. Nasal disuse and persistence of sleep-disordered breathing during sleep post adenotonsillectomy in children. Sleep 2014; 37. 34. Guilleminault C, Sullivan S. Towards Restoration of Continuous Nasal Breathing as the Ultimate Treatment Goal in Pediatric Obstructive Sleep Apnea. Enliven: Pediatr Neonatol Biol 2014; 1:1-5. 35. Guilleminault C, Huang YS, et al. Critical role of myofacial reeducation of in pediatric sleep-disordered breathing. Sleep Med 2013; 14:518-525. 36. Moeller J, Coceani Paskay L, Gelb M. Myofunctional Therapy: A Novel Treatment of Pediatric Sleep-Disordered Breathing. Sleep Med Clinic 2014;9: 235-243. 37. Guimaraes K, et al. Eff ects of Oropharyngeal Exercises on Patients With Moderate Obstructive Sleep Apnea Syndrome. Am J Respir Crit Care Med 2009; 179:962-966. 38. Kollmann W. Incidence and Possible Causes of Dental Pain During Simulated High Altitude Flights. J Endod 1993; 19:1-6. 39. Schneider H. Klinische Befunderhebungen und experimentelle Unterdruckkammer- Testuntersuchungen zur Klarung der Pathogenese sogenannter Aerodontopathien. Z Mil Med 1966; 7:148-156. 40. Freitag W. Zur Veranderungdes Leftdruckes und ihr Ein fl u auf MAKE SURE YOUR das Zahnsystem des Menschen. Luftfahrtmed 1944; 9:49-56. REPUTATION IS PROTECTED 41. Halm T, Saghy E. The eff ect of changes in air pressure during fl ight on teeth in jawbones. Int Dent J 1963; 13:569-672. WITH MALPRACTICE 42. Shiller WR. Aerodontalgia under hyperbaric condition — an analysis of 45 case histories. Oral Surg Oral Med Oral Pathol INSURANCE FROM PSIC. 1965; 20:694-697. 43. Reynolds OE, Hutchins HC. Reduction of central hyperirritability following block anesthesia of peripheral nerve. Am J Physiol 1948; Get a quick rate quote at 152:658-662. www.psicinsurance.com/dentists 44. Harvey W. Dental pain while fl ying or during decompression Scan or visit www.psicinsurance.com/ tests. Br Dent J 1947; 82:113-118. dentists to learn 45. Orban B, Ritchey BT. Toothache under conditions stimulating more about PSIC. Call 1-800-718-1007, ext. 9191 high altitude fl ight. J Am Dent Assoc 1945; 32:145-180. www.psicinsurance.com/dentists 46. Kennebeck GR. Symposium on problems of aviation dentistry. J Am Dent Assoc 1946; 33:827-844. Malpractice insurance is underwritten by Professional Solutions Insurance Company. 47. Park HO, Ha JH, et al. Diagnostic challenges of nonodontogenic 14001 University Avenue | Clive, Iowa 50325-8258 ©2016 PSIC NFL 9663 toothache. Restor Dent Endod 2012; 37(3):170-174.

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   RM Matters CDA JOURNAL, VOL 44, Nº8

Data Backup: What’s Your Risk Tolerance? TDIC Risk Management Staff

companies require documentation for e’ve all heard the claim reimbursement, he had to retake horror stories. “If you don’t perform patient radiographs. He also had to cross The parents who his fi ngers and hope that his patients were lost their child’s regular backups, and you honest enough to pay what they knew baby pictures. The don’t check to make sure they owed, as he had no billing records. Wcorporate executive who lost an those backups are “There was a chance he would have important sales presentation. The new functioning, you run the risk to write off a signifi cant amount of bride who lost video of her big day. The income, should patients refuse to pay college student who lost his entire thesis of losing everything.” their bills. Most people are understanding and had to start all over from scratch. when it comes to computer glitches, Data loss can happen to anyone, at but it’s still a risk,” Davis said. any time. Even those on the cutting edge of technology are at risk. The creators of “Toy Story 2” nearly lost the fi lm mid- production when a Pixar employee accidentally deleted data fi les and the backups failed. Luckily, a technical director had saved portions of the fi lm on her home computer, and Buzz and You are not a sales goal. Woody were brought back to life. Data loss can even happen to dentists. The Dentists Insurance Company reports one Bay Area dentist lost all of his patient records when his hard drive crashed. When he attempted to restore the data by accessing his backups, he discovered his system hadn’t been backing up for two years. “Having a backup system for storing You are a dentist deserving of an insurance company relentless information is critical, but it is also in its pursuit to keep you protected. At least that’s how we see critical to check those systems,” said it at The Dentists Insurance Company, TDIC. Take our Risk Sheila Davis, assistant vice president, Management program. Be it seminars, online resources or our Claims and Risk Management, TDIC. Advice Line, we’re in your corner every day. With TDIC, “If you don’t perform regular backups, and you don’t check to make sure you are not a sales goal or a statistic. You are a dentist. those backups are functioning, you run the risk of losing everything.” In the case above, the dentist did ® Protecting dentists. It’s all we do. lose everything — and then some. Not only did he have to spend thousands of 800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783 dollars to rebuild his system, he also had to recreate patient fi les. Because insurance

AUGUST 2016 515 AUG. 2016 RM MATTERS

CDA JOURNAL, VOL 44, Nº8

Whether from human error, John Christopher, senior manager are functioning properly and all copied viruses, technical malfunctions, of marketing communications at data is corruption-free and useable.” natural disasters or theft, data loss DriveSavers Data Recovery, said one Cost is one of the major reasons can have a huge impact on any of the biggest mistakes small business business owners fail to back up their business. In fact, nearly half of all owners make is failing to monitor the computers. There are upfront costs, such small businesses have experienced performance of their backup systems. as hardware, and ongoing costs, such as some form of data loss, according to “Backups are not routinely evaluated monthly monitoring fees and storage fees. online backup provider Carbonite. for effectiveness,” he said. “Often, data But the costs associated with a data loss are Luckily, there are ways to avoid is lost when the administrator of a much greater, so it is a small price to pay. complete devastation. Topping the computer system believes the backup “Dentists with up-to-date backups can list is making sure your backups are system is functioning when it is not. be back to work within a few days,” Davis run regularly and accurately. Then, when the primary system fails, said. “Those without can spend weeks “Too often, people forget to there isn’t a backup. Backup systems must trying to get up and running again.” check their backups,” Davis said. be regularly maintained and fi les that Another reason dentists fail to “Backups are a fail-safe. But even fail- have been backed up must be regularly back up their data simply comes safes should be double-checked.” reviewed to ensure that scheduled backups down to time. According to the 2016 Backup Awareness Survey conducted by cloud storage provider Backblaze, 24 percent of computer users never back up their systems, and 42 percent only do it once a year. “What could be more time consuming than having to rebuild your entire system and reconstructing all of your patient records?” Davis asked. Most experts recommend real-time backups, also known as continuous backups, in which changes are automatically saved as they are made. That way, should a data loss occur, there will be no gaps in data recovery. Other options include conducting a full back up at a set point in time, such as once a day or once a week. “The real question is, ‘what’s your risk tolerance?’” Davis asked. “How much data are you willing to lose? A week’s worth? A month? A year?” Another consideration is where to store your backups. Many practice owners use external hard drives, but these can also fail if connected to a network and a virus strike or a malfunction occurs. Some use thumb drives or portable drives, which can be stored offsite. Many are now opting for cloud-based storage, which allows continuous backup and access

516 AUGUST 2016 SELL YOUR PRACTICE ...... to the right buyer! Knowing how, means doing all of the following - with precision:

1. Valid practice appraisal.

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

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

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

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

6. Lease negotiations.

All six of these services costs no more.

LEE SKARIN Maybe even less! INC. & ASSOCIATES Lee Skarin & Associates is Cali- fornia’s leading Dental Practice Broker. Their in-house attor- Lee Skarin & Associates ney, Kurt Skarin, PhD., J.D., has scores of Buyers in their specializes in these matters. He does all of the above, and more. database. The Buyers’ profiles He is the catalytic agent that personal desires and financial makes the sale happen - quick- ability have been categorized to ly and smoothly. expertly select the right Buyer for your practice. Expert Buyer selection solidifies a deal. Lee Skarin & Associates services Dental Practice Brokers 2IÀFHV all of Southern California. CA DRE #00863149 805.777.7707

Your calls are invited. Put our thirty years of experience to work for you! 818.991.6552 Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461 AUG. 2016 RM MATTERS

CDA JOURNAL, VOL 44, Nº8

to data at any time. It should be noted that there are HIPAA considerations when choosing cloud storage, and dentists should sign a Business Associate Agreement with any cloud service provider. To access a sample agreement, visit www.cda.org/member-resources/ Paul Maimone practice-support/resource-index and under Broker/Owner It is a Great Time to Sell! Inventory & the tab Regulatory Compliance, click

Rates are Still Low & Buyer Demand is “HIPAA Business Associate Agreement”

High! Call for a Free in Office Valuation! in the Privacy/HIPAA section. “We advise dentists who perform ARCADIA – (4) op comput G.P. Located in a well known Prof. Bldg. on a main thoroughfare. hard backups to disconnect the drive Cash/Ins/PPO pt base. Annual Gross Collect $300K+ on a (3) day week. REDUCED BAKERSFIELD #31 - Free Stand. Bldg. & Pract. (4) op comput G.P. w excell. exposure & and store it offsite in a secure location. signage. (3) ops eqt./4th plumbed. Annual Gross Collect $325K+ Cash/Ins/PPO. Better yet, we recommend investing CLAIREMONT – (3) op comput G.P. w newer eqt. 2015 Collect $265K Cash/PPO. SOLD GROVER BEACH - (3) op Turnkey Office w included charts (not guaranteed). (2) ops eqt’d w in a HIPAA-compliant, cloud-based newer eqt. 3rd plmbed. Digital Pano & x-ray. Dentrix. In a strip ctr. LL incentives. PENDING data backup service,” Davis said. MONTEBELLO - (4) op comput G.P. (2) ops eqt’d. Located in a busy shop. ctr. w exposure & visibility. Annual Gross Collect. $200K on a p.t. schedule. Cash/Ins/PPO. Seller retiring. Christopher said it’s best to OXNARD #9 - (3) op comput G.P. & a Prof Office Condo for sale. Located on a main have multiple backups, stored thoroughfare. (3) ops eqt’d. Annual Gross Collect $200K+ p.t. Cash/Ins/PPO/HMO $4.5K/mos in multiple locations. Cap Cks. Digital x-rays. Low overhead. Buy & Combine or open a satellite. NEW SANTA BARBARA COUNTY – (3) op comput G.P. & a 1,900 sq ft Bldg. that houses the “Keep one backup offsite in case practice & a residential unit that can be rented or lived in. “Fee for Service.” No PPO, HMO or some type of accident or disaster Denti-Cal. 2015 Gross Collections ~ $275K on a relaxed 3½ day week. Seller refers all O.S., Perio, Ortho, Endo & implant placement. Seller retiring but will assist w transition. occurs,” he said. “Automate your backup So. EAST KERN COUNTY - (5) op comput. G.P. located in a free stand bldg. w exposure/ system so there is less likelihood of visibility & signage. VERY LIMITED COMPETITION. 2015 Collect $600K. Cash/Ins/PPO. Digital x-rays & CT Scan. (6) sensors, Bldg. also available. Seller retiring. NEW human error. Regularly check the data SAN FERNANDO VALLEY #9 - (8) op comput. G.P. w modern eqt. In a prof. bldg. on a main on your backup devices to ensure it thoroughfare. Cash/Ins/PPO/HMO. Cap Ck approx $7K/mos. 2015 Collect $1.4M+ PENDING SAN FERNANDO VALLEY #10 - Located in an exclusive area of the Valley. (5) op comput is useable and to ensure that backups G.P. w high end buildout. Digital x-ray and CT Scan, Laser, Dentrix s/w & (5) year old eqt. Gross are performing as expected.” Collect $1M+/yr. Cash/Ins/PPO pts. Reasonable overhead, high Net! NEW Whether personal or professional, SAN GABRIEL VALLEY - (4) op comput G.P. w newer P&C Chairs/Eqt, All the toys & whistles. Paperless, Schick digital x-rays, Solaris Steril Ctr, Soprocare Intra Oral Camera, a data loss can lead to unwanted Velscope Cancer Screen, The Wand, Air Abrasion, Electric Hand Pieces, Laser, etc. FFS, 2015 expense, headache and stress. But Gross Collect. $881K+ on a 3½ day week. (4) days of Hygiene. Seller retiring. NEW SANTA ANA - absentee owned (6) op fully eqt’d G.P. First floor street front location on a main by assessing your risk tolerance and thoroughfare. Exposure/visibility/signage. Cash/Ins/PPO. No HMO & No Denti-Cal. Pano eqt’d taking a few preventative measures, & Comput. Annual Gross Collect. $400K- $500K on a (3) to (4) day week. BACK ON MARKET THOUSAND OAKS (4) ops/(2) eqt’d comput. Turnkey Office w included charts. Chart included it is possible to avoid catastrophe and but not guaranteed. Sirona Eqt. Located in a condo in a Prof. Bldg. PENDING get back up and running sooner. ■ WESTLAKE VILLAGE - Turnkey Office. (4) ops/(3) eqt’d. Located in a smaller prof. bldg. Very reasonable Lease terms. Newer build out & some newer eqt. Comput. & digital. NEW UPCOMING PRACTICES: Bakersfield, Beverly Hills, Central Coast, Covina, Downey, TDIC’s Risk Management Advice Line Duarte, Goleta, Oxnard, Pomona, San Gabriel, Palm Desert, Van Nuys, Visalia & West L.A.. at 800.733.0634 is staffed with trained D&M SERVICES: analysts who can answer data backup and Q Practice Sales and Appraisals Q Practice Search & Matching Services other questions related to dental practice. Q Practice and Equipment Financing Q Locate and Negotiate Dental Lease Space Q Expert Witness Court Testimony Q Medical/Dental Bldg. Sales & Leasing Q Pre - Death and Disability Planning Q Pre - Sale Planning P.O. Box #6681, WOODLAND HILLS, CA. 91365 Toll Free 866.425.1877 Outside So. CA or 818.591.1401 www.dmpractice.com Serving CA Since 1994 CA BRE Broker License # 01172430

CA Representative for the National Association of Practice Brokers (NAPB)

518 AUGUST 2016 Specialists in the Sale and Appraisal of Dental Practices Practices Serving California Dentists since 1966 How much is your practice worth?? Wanted Selling or Buying, Call PPS today!

NORTHERNNORT CALIFORNIA SOUTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (888) 440-5957 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 346937 6109 &$/,)251,$ 6,)251,$ 6 NORTNORTHHLAKE LAKE TAHOE “Best-of-“Be ANTELOPE VALLEY Has grossed $1.8 Million. Fantastic location. the-best!” 6ROLG foundation anchored by 8.5 days of Hygiene. 60,000 autos pass by per day. 8 ops. Partnership for $250,000 or buy all. &RQVLVWHQWMillionSHUyear performer. Beautiful office with ARCADIA Facility only. 3-ops equipped. $65,000 or $95,000 with Ortho. unsurpassed views. (QMR\JUHDW$OSLQHOLIHVW\OH BAKERSFIELD AREA 5-ops, next to McDonalds. 1,800 sq.ft. includes building. Grosses $40,000/month. Full Price with building $350,000. 6107 (85(.$ 100% out of network with insurance industry.  Produced $918,000 and collected $895,000 on 20-hour week. BAKERSFIELD Established 55 years. 5-ops in 3,000 sq. ft. Will do $1 Million. Full Price $300,000. Building available for $350,000. 7+ days of Hygiene.:HOOUHVSHFWHG)XOOSULFH BELLFLOWER Established 60-years. Grossing $350,000. Full Price 6106 6$&5$0(172 6(/'25$'2+,//6 No rush and $240,000. no chaos here. Staff is Dream Team. Beautiful facility. 2015 EAST LOS ANGELES One million Latinos in service area. PPS sold collected $640,000. 8&5)HHV9HU\VSHFLDORpportunity to Seller in 1985. Will do $1 Million in 18 months. Full Price $300,000. 0HGLDQKRXVHKROGLQFRPHLQZDV*UHDW EAST SAN FERNANDO VALLEY Absentee Owner. $8,000SHU VFKRROVJURZLQJEXVLQHVVSDUNVDQGYHU\XSVFDOHFRPPXQLW\ month Cap Check. 4-ops. Do a Million within a year. 6105 MODESTO Collected $430,000+ on 3-day week. 3- INDIO 4,000 sq.ft. dental building. Full Price $650,000. days of Hygiene. 5-ops. Central location. Successor should LADERA RANCH Grossing $650,000. Shopping center location. open 4th day. LAGUNA NIGUEL Location, location, location! 4-ops with Panorex. 6104 SANTA CLARA – CUPERTINO AREA Restorative Full Price $185,000. practice. 2015 collected $1.55 Million with Profits of $6,000. LA JOLLA  Established 20-years. 3-ops. Grossed $150,000. Super PaperlessDQGGLJLWDO. Beautiful office. 8&5)HHVExtremely opportunity with immediate growth. Full Price $150,000. attractive selling features DYDLODEOHto retain WKHgoodwill. LAWNDALE Hi identity. 2 ops . Full price $125,000. 6103 SAN FRANCISCO’S UNION SQUARE Opportunity LOS ANGELES HMO Grossing $1.2 Million. 5-ops. Full Price $1.2 Million. to acquire highly regarded practice with condo. Beautiful 5-ops, LOS ANGELES HMO Does $4 Million. SOLD digital and paperless. 6th op available. 2015 collected $658,000. NORCO – CORONA Will do $1.5 Million. 8-ops. Exquisite. Full Price $1.2 Million. 6102 0$5,1&2817< 6SAN RAFAEL *UHDWORFDWLRQ NORWALK Fantastic high identity location. 5 ops. Full Price QHDUVKRSSLQJPDOO&ROOHFWHGLQRQGD\V'LG $250,000. SOLD LQ$YHUDJHVQHZSDWLHQWVSHUPRQWKRSV ORAL SURGERY PRACTICE – LOS ANGELES Established 40 years. LQVTIWVXLWH)XOOSULFH ORANGE Beautiful 10 operatory office ready for merger. 6100 SANTA CLARA Phenomenal launching pad forQH[W Fantastic location, 5-op facility. Management not taking PASADENA Established 60 years. 7-ops. Always $1+ Million. Full 2ZQHU Price $600,000. advantage of what is possible even though 2015 collected REDLANDS Shopping center. Grosses $350,000. Full Price $250,000. $758,000 with Profits of $323,000. PHUIHFWO\Sositioned to be D $1 Million+ year performer immediately!1HHGV\RXQJ''6 RIVERSIDE  Facility only. 4 ops. Full Price $50,000. SOUTH ORANGE COUNTY BEACH CITY Grosses $650,000. 6099 FAIRFIELD CollectedSOLD $500,000 in 2015. 3-days of 4 ops. Beautiful! Hygiene. 4-ops with digital radiography. PERIO PRACTICE - PRESTIGIOUS BEACH CITY Established 6098 WEST PETALUMA Petaluma KDVEHFRPH7+( 40 years. business center RI the North Bay! %XVLQHVV SDUNV DUH JURZLQJ TORRANCE Established 12 years. 5 star building. 3-opHUDWRULHV DQG \RXQJ SURIHVVLRQDOV DUH EHLQJ GUDZQ WR WKLV JUHDW IDPLO\ Grossing $250,000. Full Price $195,000. FRPPXQLW\ SHU WKH XQLTXH DPHQLWLHV RI WKLV KLVWRULFULYHU TUSTIN  Dental building. Full Price $1.5 Million. FLW\Collected $468,000 with Profits of $199,000 3-days of VENTURA - OXNARD 5-ops. Grossing $850,000. High identity. Hygiene with 4th GD\starting SeptHPEHU.)XOOSULFH Full Price $685,000. 6089 MOUNT SHASTA Small town living renowned for YUCCA VALLEY 8/10th of an acre. Great highway visibility. Full  Price $250,000. outdoor lifestyle. %HVWDLUDQGZDWHUEscape 5at Race and corporate intrusion. 3-day week collected $. $YDLODEOH Seeking Senior Dentists wishing to have more time to enjoy life, be free 3URILWVWRWDOHG'LJLWDOUDGLRJUDSK\LQFOXGLQJ3DQR of management & overhead to join a Dental Cooperative. Call Tom )XOOSULFH Fitterer at 714-832-0230 or cell 714-345-9659. 6070 VISALIA 7KLVSUDFWLFHLVZHOOSRVLWLRQHGIRULWVQH[W **FOUNDERS OF PRACTICE SALES** FDUHWDNHUStrong Hygiene Department, beautiful facility, well 120+ years of combined expertise and experience! equipped. Digital throughout. Collected $727,000 on part-time 3,000+ Sales - - 10,000+ Appraisals scheduleLQ. Extend hours and be busier. Best location! **CONFIDENTIAL** PPS Representatives do not give our business name when returning your calls.

“Matching the Right Dentist CARROLL to the Right Practice” &COMPANY

CComplete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions

4117 SAN JOSE GP 4096 MENDOCINO COUNTY GP Incredibly desirable location at the corner of two major intersections in Seller offering well est. 48 year practice. Located in outdoorsman's West SJ near the Saratoga border. Offering 40+ yrs of goodwill. 3 paradise. Just 2 hours North of SF surrounded by redwood forest, ops in 1,200 sq. ft. Practice grossing btwn $175K - $215K. Approx vineyards and mountains. 950 sq. ft. office in single level building w/ 4 175+ active patients. 2 days of hygiene. Seller will help for a smooth fully equipped ops. 2014 GR $565. Asking $300K. transition. Asking $125K. 4110 SANTA ROSA GP 4103 SAN FRANCISCO GP Don’t miss this opportunity ~ absolutely gorgeous, state of the art Vibrant downtown location in historic high-rise bldg. Retiring doctor office located within two major thoroughfares in the heart of Santa offering 30+ years of goodwill. 4.5 days of hygiene, 1,500+ active Rosa. Practice generating $2.1M+ in GR. Asking $1,436K. patients, 20-25 new patients/mo. Gorgeous, spacious facility in approx. 2,500 sq. ft. 2015 GR $796K. 2014 GR $768K. Average 4093 SAN JOAQUIN VALLEY ORTHO adjusted net income $274K+ Asking $599K. Established over 35 years with a solid reputation, near several referral sources in seller owned building. 2,500 sq. ft. office with 7 chair open 4085 SANTA ROSA GP & BUILDING bay in professional center on a well-travelled street with many retailers. Practice and R/E are offered for sale in a well-established medical/ Avg. Gross Receipts $763K. Seller retiring and willing to help for dental complex conveniently located near Memorial Hospital. 3 fully smooth transition. Asking $561K. The building is available to purchase equipped ops in 1,200 sq. ft. Approx 750 active patients. Average as well for $608K. Gross Receipts of $264K with adj. net of approx. $116K. Seller willing to help for a smooth transition. Price reduced to $125K for the 4065 LAKE COUNTY GP practice and $245K for the real estate. Seller retiring from general practice located in a slower paced, relaxed community. Plenty of hunting and fishing and out door activities for the 4108 HUMBOLDT COUNTY GP enthusiast. Approx. 1,600 square foot office with 4 fully-equipped Well-established, high performing general practice boasts 6 fully operatories. Over 2,000 active patients, average $697K+ in Gross equipped ops. in 2,900 sq. ft. free standing office w/Digital X- ray, 2 Receipts with an overhead of just 56%, and 4 doctor days per week. platinum Dexis sensors, & Cerec Omnicam & MCXL units. Loyal & Asking $463K. stable pt. base in charming community, w/ a small town feel. Perfect for a dentist who wants to escape the grind and live along the 4105 STANISLAUS COUNTY GP coastline. Avg. GR $1.4M+, 2016 on schedule for $1.5M+. Seller Get away to a less demanding commuter friendly town. Seller retiring willing to help for smooth transition. Asking $1,041K. from practice est. over 30 years ago with loyal patient base in charming community with historic small town feel. 3 fully-equipped 4091 HOLLISTER GP & PEDIATRIC ops. in 1,200 sq. ft. office. Approx. 1,400 active pts. w/4 doctor days/ Country living at it’s best ~ small town feel with affordable housing, in week. 5 year avg. GR $647K+ w/approx. 50% overhead. Seller willing quaint bedroom community to Silicon Valley. Fully equipped 1,600 sq. to help for smooth transition. Asking $428K. ft. office with 2 enclosed adult ops and 3 open pedo ops, near Hazel Hawkins Hospital. Turn-key practice, great opportunity for a pediatric 4120 SF GP dentist. Approx. 565 active patients. 2015 GR $219K. Seller is Well est. downtown family practice grossing over $1M with an avg. relocating but will help for a smooth transition. Asking price $125K. overhead of 61%. 5 fully equipped ops., in remodeled office. Retiring seller works 3.5 Dr. days/week. Seasoned, dedicated staff & loyal 4114 CONCORD GP patient base. Terrific opportunity for experienced & confident dentist. Well-established practice offering 30+ yrs of goodwill. Concord is on Asking $806K. the verge of redevelopment of the old Naval Weapons Base later this year, which will cover 2,300 acres and include 12,000 housing units. 4122 SANTA ROSA GP & BUILDING The project will include Residential/Commercial/Recreational and Open Retiring owner/doctor has est. GP in gorgeous 1,500 sq. ft. office Space. This practice opportunity is strategically located for growth w/4 fully equipped ops. & state-of-the-art equipment. Avg. GR potential due the slotted re-development. Office has 3 fully equipped $739K+, avg. overhead 60%. Selling building w/practice. Asking ops in 836 sq. Average GR $360K+ on 2 doctor days. Asking $224K. $438K building & $544K practice. 4121 NAPA GP Gorgeous, state-of-the-art office available in beautiful wine Carroll & Company country! Incredible location with super high visibility on the corner 2055 Woodside Road, Ste 160 of two major cross streets near Queen of the Valley Hospital. 7 Redwood City, CA 94061 ops in 3,250 sq. ft. facility. Seller retiring but would like to transition P (650) 362-7004 with buyer after the sale. 2,100+ active patients, 9 days of F (650) 362-7007 hygiene, 15-20 new patients/mo. 2015 GR $1.56M, 2014 GR [email protected] $1.62M. Average Adjusted net income of $513K. Asking www.carrollandco.info $1,151K. BRE #00777682 Mike Carroll Pamela Carroll-Gardiner

www.carrollandco.info [email protected] P (650) 362-7004 F (650) 362-7007 Regulatory Compliance CDA JOURNAL, VOL 44, Nº8

Basic Life Support Course, AEDs and Medical Emergency Kits CDA Practice Support Staff

he Dental Board of California with state law governing ownership An individual or entity that acquires requires that licensees and of these devices. Recent changes an AED shall do all of the following: unlicensed dental assistants to the law became effective Jan. 1, ■ Comply with all complete a basic life support 2016. California state law (Civil regulations governing the (BLS) course and maintain Code §1714.21) excludes from civil placement of an AED. Tcertifi cation. No more than four units of liability the individual or entity that ■ Notify an agent of the local continuing education credit for license acquires an AED for emergency use if emergency medical services (EMS) renewal are allowed for a BLS course. the individual or entity has complied agency of the existence, location The mandatory course requirement with specifi c requirements contained and type of AED acquired. must be met by completion of either: in Health & Safety Code §1797.196. ■ Ensure that the AED is ■ An American Heart Association (AHA) or American Red Cross (ARC) BLS course. ■ A BLS course taught by a provider approved by the AHA, ARC, American Dental Association’s When Looking To Invest In Professional Continuing Education Recognition Program (CERP) Dental Space Dental Professionals Choose or the Academy of General Dentistry’s Program Approval for Continuing Education (PACE). For the purpose of C.E. credit, a BLS course shall include all of the following: Linda Brown ■ Instruction in both adult and pediatric CPR, including 30 Years of Experience Serving two-rescuer scenarios. the Dental Community Proven ■ Instruction in foreign-body airway obstruction. Record of Performance ■ Instruction in relief of choking for adults, children and infants. • Dental Office Leasing and Sales ■ Instruction in the use of automated external For your next move, • Investment Properties defi brillation with CPR. contact: LINDA BROWN • Owner/User Properties ■ A live, in-person skills practice session, a skills test • Locations Throughout and a written examination. Direct: (818) 466-0221 Southern California Office: (818) 593-3800 Automated External Defi brillators Email: [email protected] Dental practices in California Web: www.TOLD.com are not required to have automated Cal BRE: 01465757 external defi brillators (AED), but if a practice has one then it must comply

AUGUST 2016 521 AUG. 2016 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 44, Nº8

maintained and tested of an emergency is not liable 1043.3 of the Dental Practice Act). according to the operation and for any civil damages resulting Cal/OSHA requires employers to maintenance guidelines set from any acts or omissions in maintain adequate fi rst aid materials, forth by the manufacturer. rendering the emergency care. approved by a consulting physician ■ Ensure that the AED is A medical director or other and readily available for employees. tested at least biannually physician and surgeon are not required Cal/OSHA does not specify what and after each use. to be involved in the acquisition or fi rst aid materials are adequate. ■ Ensure that an inspection is made placement of an AED. A manufacturer One method of obtaining physician of all AEDs on the premises at or retailer supplying an AED must approval of a medical emergency least every 90 days for potential provide all information governing the kit is to fi rst write a description of issues related to operability of use, installation, operation, training the types of injuries that can be the device, including a blinking and maintenance of the AED to the anticipated in a dental practice then light or other obvious defects that purchaser or owner of the AED. list the contents of the kit. Provide may suggest tampering or that The protections specifi ed above the list to a physician and request a another problem has arisen with do not apply in the case of personal signature approval on the list. ■ the functionality of the AED. injury or wrongful death that result ■ Maintain records of required from the gross negligence or willful Regulatory Compliance appears monthly maintenance and testing. or wanton misconduct of the person and features resources about laws that Building owners are not required who renders emergency care or impact dental practices. Visit cda.org/ to place AEDs in buildings. treatment by the use of an AED. practicesupport for more than 600 practice However, when an AED is placed support resources, including practice in a building, the building owner Medical Emergency Kits management, employment practices, dental must do all of the following: Dental practices are required by benefi ts plans and regulatory compliance. ■ At least annually notify tenants contract with dental benefi ts plans of the location of the AED to have medical emergency kits. The units and provide information contents of the kits may be dictated by about who tenants can contact the plan, although one of the largest if they want to voluntarily plans requires the items recommended take AED or CPR training. by the ADA Council on Scientifi c ■ At least annually offer a Affairs (J Am Dent Assoc March demonstration to at least one 2002). The council recommends a person associated with the kit contain oxygen, blood pressure building so that the person monitoring equipment, epinephrine, can be walked through how an antihistamine such as Benadryl, a to use an AED properly in quick source of glucose, nitroglycerin an emergency. The building and a CPR pocket mask. The drugs owner may arrange for the should be checked periodically to demonstration or partner with a ensure they have not expired. A nonprofi t organization to do so. pharmacy can fi ll a prescription for ■ Next to the AED, post an epipen or nitroglycerin if the instructions, in no less prescription indicates it is for the offi ce than 14-point type, on medical emergency kit. Provide the how to use the AED. pharmacist with a copy of the ADA Any person who, in good faith article if necessary. For offi ces where and not for compensation, renders general anesthesia is used, the Dental emergency care or treatment by Board of California requires specifi c the use of an AED at the scene equipment (CCR Title 16 Section

522 AUGUST 2016 DENTAL PRACTICE BROKERAGE Making your transition a reality.

Dr. Lee Dr. Thomas Dr. Dennis Dr. Russell Jim Kerri Mario Jaci Steve Thinh Maddox Wagner Hoover Okihara Engel McCullough Molina Hardison Caudill Tran LIC #01801165 LIC #01418359 LIC #0123804 LIC #01886221 LIC #01898522 LIC #01382259 LIC #01423762 LIC #01927713 LIC #00411157 LIC #01863784 (949) 675-5578 (916) 812-3255 (209) 605-9039 (619) 694-7077 (925) 330-2207 (949) 566-3056 (949) 675-5578 (949) 675-5578 (951) 314-5542 (949) 675-5578 25 Years in Business 40 Years in Business 36 Years in Business 33 Years in Business 42 Years in Business 35 Years in Business 35 Years in Business 26 Years in Business 25 Years in Business 11 Years in Business

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

NORTHERN CALIFORNIA PASO ROBLES AREA: $2.25M GR, BELL: 2SV'HQWUL['LJLWDOLQD)UHH ORANGE COUNTY: (QGRSUDFWLFHZLWK RYHUKHDG%X\HUQHHGVWREHVNLOOHG VWDQGLQJ%XLOGLQJ332'HQWL&DO*5 6 Ops, Digital and Paperless, 5 year old BENICIA: Practice & Building. 1,545 sq. ft., LQUHVWRUDWLYHVXUJLFDOSURFHGXUHVLPSODQW .ZLWK.$GM1HW&$ HTXLSPHQW6WURQJUHIHUUDOEDVHIRU\HDUV 4 ops, Open-Dental software, digital X-ray & SODFHPHQW&$ &$ Pan, Laser. 2014 GR $550K. #CA298 BEVERLY HILLS: Perio practice. PINOLE:2S(QGRRI¿FHZ'LJLWDO;UD\ %HDXWLIXOO\GHVLJQHG2SV'HVLUDEOHSURI ORANGE COUNTY: 2SV(VW\HDUV BENICIA: VTIWRI¿FHRSV 0LFURVFRSHVDQG3%6(QGRLQDSSUR[ EOGJ'HQWUL[\HDUVRI*RRGZLOO 'HQWUL['LJLWDO*5RI.ZLWK *5.GD\ZHHN6LVWHUSUDFWLFH sq. ft. 2014 GR $672K. #CA284 *5RI. .$GM1HW&$ &$VDOHFRPELQHGRUVHSDUDWH&$ BEVERLY HILLS: ROSEVILLE:(TXLSSHG2SVDGG¶O 2SV(DJOH6RIW PALM SPRINGS: New Listing! 2SV CITRUS HEIGHTS: Prosthodontic practice SOXPEHGVTIWZ'LJLWDO;UD\ 'LJLWDO&(5(&/RQJWHUPVWDIIQHZHU years of goodwill. Good location, Doctor VWDQGDORQHEXLOGLQJIRUVDOH2SV /DVHU'HQWUL[VRIWZDUH*5. HTXLSPHQW*50&$ ZDQWVWRUHPDLQDQGZRUNSDUWWLPHLI *5RI&$ &$ BURBANK: New Listing! *HQHUDO3URVWK SRVVLEOH*5.&$ EL DORADO COUNTY: VTIWZ SACRAMENTO: VTIW(TXLSSHG ,PSODQWSUDFWLFH\HDUVRIJRRGZLOOUHWDLO PASADENA AREA: Practice & Building - 2SVLQWUDRUDOFDPHUDGLJLWDO[UD\3UDFWLFH VWDWLRQVLQED\DGG¶O3OXPEHG*5 FHQWHU2SVHTXLSSHG(DV\'HQWDO 2SV'HQWUL['H[LV&(5(&HVWDEOLVKHG :RUNVVRIWZDUH*5.&$ $590K. #CA269 'LJLWDO*5..$GM1HW for 50+ yrs. #CA282 &$ GREATER EL DORADO HILLS: SACRAMENTO:VTIWRI¿FHZ S. ORANGE COUNTY: Pedo Practice with New Listing! CARSON: VTIWRI¿FH2SV (TXLS2SVDGG¶O3OXPEHG'HQWDO0DWH 2SV3DSHUOHVV(DJOH6RIW 2SV\HDUQHZ(TXLSPHQW'LJLWDO3DQR 'LJLWDO3DQ'LJLWDO6HQVRUV(DJOHVRIW VRIWZDUH*5&$ 'LJLWDO3DQR$OO(TXLS \UVROG *5.ZLWKURRPWRJURZ&$ *5.&$ VRIWZDUH*5.&$ SACRAMENTO: New Listing! 8 Ops SANTA BARBARA: 4 Ops, est. for 40+ GREATER REDDING: VTIWZ Z6FKLFNGLJLWDO[UD\3DQR/DVHUDQG CENTRAL ORANGE COUNTY: 2SV Ops. Intra-Oral, Digital, Pano, Laser, CAD- (DJOHVRIWVRIWZDUH*50&$ \HDUVGD\V+\JLHQHZHHNORQJWHUPVWDII 3DSHUOHVVGLJLWDOEXV\UHWDLOFHQWHU*5 ))6*5RI.&$ &$0'HQWUL[*50&$ SAN FRANCISCO: Periodontal Practice & RI.ZLWK.$GM1HW&$ SANTA MARIA: GREATER ROSEVILLE/AUBURN: &RQGR8QLWVTIWZ2S*5 COASTAL ORANGE COUNTY: 2SVLQVTIW New Listing! Practice & Bldg, 1,600+ sq. ft. .Z.$GM1HW&$ VXLWH))6332GD\ZRUNZHHNZGD\RI 2SV(TXLSSHG'HQWUL['H[LV3URIEOGJ K\JLHQH*5.&$ Z2SV*5&$ SAN FRANCISCO: New Listing! )LQDQFLDO Z\HDUVRIJRRGZLOO*5RI. $GM1HWRI.&$ GREATER ROSEVILLE/ROCKLIN: 'LVWULFWRI¿FH2SVURRPIRUWK VICTORVILLE: 2SV3OXPEHG New Listing! VTIW*5PLO$GM1HW 6T)W(VW\UV6RIW'HQW*5 VTIW2SV,2FDPHUD &$ FULLERTON: New Listing! 6 Ops, 4 $277K. #CA149 Price Reduced! GLJLWDO[UD\VGLJLWDO3DQR06FDQQHU (TXLSSHG\HDUVRI*RRGZLOO'HQWUL[ 'HQWUL[VRIWZDUH*5.&$ SAN JOSE: 2015 GR $568K on 2½ day Digital, Paperless. Great location. 2015 GR WHITTIER: 2SV(TXLSSHG'HQWUL[ ZHHN(TXLSSHGRSVDGG¶O3OXPEHG RI.&$ 'H[LV(VWIRU\UVRQ0DLQ6WUHHW GREATER ROSEVILLE/ROCKLIN: 6T)W(='HQWDO'H[LV¿OPEDVHG GR $195K. #CA276 2SVZ,2'LJLWDO;UD\/DVHU'HQWUL[ 3DQRUDPLF&$ GREATER LOS ANGELES: Perio VRIWZDUH(VWDEOLVKHG\HDUV*5 SAN RAFAEL: New Listing! General & 3UDFWLFH2SV

BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED CENTRAL VALLEY

Largest AC-335 SAN FRANCISCO: Great Practice! CC-567 ST. HELENA: Live and Practice in beauti- EN-484 FOLSOM Facility: Fantastic Turn-Key Opportunity! IC-468 SAN JOAQUIN VLY 2100sf, 8ops in desirable location of SF. Call ful Wine Country, 5ops in 1842sf, single-story Now Only $125k $425k for Details $475k bldg. Price Reduced $790k EG-556 SACRAMENTO: IC-572 MODESTO: Broker in AC-566 SAN FRANCISCO: Spectacular views CG-537 MARIN COUNTY: Rare Opportunity in $389k $160k of Washington Square. 3ops +2 add’l upscale, highly desirable area. State of the art EN-534 ROSEVILLE Facility: IN-474 STOCKTON: Northern plumbed in 1400sf office $225k office. 2400 sf w/ 7 ops $1.1M $45k $95k AC-585 SAN FRANCISCO: Near Union Sq., 3ops, CG-583 SEBASTOPOL: Practice & Real Estate. EG-560 CARMICHAEL: IN-506 TURLOCK: 566sf. All reasonable offers considered! $270k Seller Willing to consider all reasonable offer. $130k $425k California for the Practice / $160k for the Goodwill Health Forces Sale PR $125/RE $750k EN-558 DAVIS: IN-512 MERCED: AG-564 SAN FRANCISCO: Over 25 yrs goodwill. DC-476 DUBLIN: Shared Facility. Great for Spe- $650k Now Only: $110k Large 5,600+ sf w/ 9 ops near Land’s End cialist - Endo, Pedo or Ortho. 1100 sf w/ 2 EN-573 SACRAMENTO: IN-554 TURLOCK: $2.225M ops+1 add’l $125k $93.1k $795k AG-576 SAN FRANCISCO: Part time practice w/ DN-497 PLEASANTON Facility: Great Location! EG-579 ROCKLIN Perio/Gen JC-541 FRESNO Facility Extensive Buyer Amazing Growth Potential. Perfect for 1-3 DDS 870 sf w/ 3 ops + 1 add’l. Owner Financing $325k Call for Details! 4 ops 1.400 sf $550k w/10% Down! Reduced! $95k FC-415 FT. BRAGG: JG-491 FRESNO: Database & AN-514 SAN FRANCISCO Facility: Located in the DG-519 SANTA CLARA Facility: Move In Ready! $425k REDUCED! $395k bustling financial district! 1,007 sf w/4 ops. 2240 sf w 6 fully equipped ops $225k FC-489 CLEARLAKE: JN-551 COALINGA AREA: Unsurpassed Reduced to $125k! DG-581 SAN JOSE: Must See to Appreciate! $470k / 50% interest in RE Also Available REDUCED! $395k! AN-565 SAN FRANCISCO: This remarkable op- Gorgeous Pracce, stable paent base & FN-527 TRINITY COUNTY: “Pride Ins- portunity could be your “dream come true”! loyal staff $570k tute” designed! $250k SPECIALTY PRACTICES Exposure allows 2,067 sf w/ 6 ops. $1.05M DG-582 SAN JOSE: Collecons over $900k! GC-472 ORLAND: BC-361 OAKLAND: Established for over 23+ 3000 sf w/8 ops. Top of the Line Buildouts! $160k BC-544 ALAMEDA COUNTY Pedo: us to offer you years! 2,200 sf w/ 7 ops. Seller is retiring. Now $675k GG-386 REDDING: $225k Only: $330k DN-542 FREMONT Facility: Spacious & beau- ONLY $260k BG-517 NORTH EAST BAY Endo: BC-509 SAN LEANDRO: Facility Only, 800 sf, fully equipped State-of-the-Art! 3,400 sf w/ 5 GG-453 CHICO: $325k $500k

3ops w/ xray in each op. Call for Details $60k ops + 4 add’l. $295k GG-454 PARADISE: CC-346 SO MARIN CO Perio: No reason- BC-520 HAYWARD Facility: Located in Down- DN-557 SALINAS: 3,000 sf w/ 7 ops and col- $525k able offer will be refused! Reduced $150k town, 1500 sf, 4 equipped ops, X-Rays in 3 lecng over $2.225M. Priced at only $1.4M GN-244 OROVILLE: CG-424 NAPA Prostho: ops. Call for Details $65k Only $315k BC-432 PITTSBURG: Own this family-oriented NORTHERN CALIFORNIA GN-399 REDDING: $690k Practice! 1,640 sf w/ 6 ops. Seller is Retiring $150k DC-459 SF PENINSULA Perio: $350k EC-525 SACRAMENTO: Great Location! Excel- GN-507 CHICO: $600k BC-549 LAMORINDA AREA Facility: Excellent lent Visibility! 1,500 sf w/ 3ops, 10-15 new pts/ Practice $535k Real Estate $750k EG-579 ROCKLIN Perio/Gen Location! Highly Visible, 900sf w/ 3ops +1 mo $220k GN-546 CHICO AREA: plumbed add’l. Reduced $75k EC-531 GREATER SACRAMENTO: Pracce and $350K $325k BG-570 SAN LEANDRO: 30+ yrs goodwill w/ Real Estate for Sale! 1,750sf w/ 4ops + 1 add’l, HC-461 SONORA: FN-536 LAKE COUNTY Pedo: focus on C&B. 2100 sf w 5 ops. Room for 6th 8npts/mo $800k Practice $700k & RE Also Available! before Now Only: $225k! op. Over $908k in 2015 $625k EN-464 ROCKLIN Facility: Don’t miss out on HN-213 ALTURAS: IC-543 CENTRAL VALLEY Ortho: BN-504 RICHMOND: Established Practice and this remarkable opportunity! 2,150 sf w/ 4 $115k $180k Real Estate! 1,450 sf w/ 2 ops + 2 add’l ops. Now Only: $100k HN-280 NO EAST CA: RE- JC-540 FRESNO Sleep Apnea $100k /RE $700k EG-479 FOLSOM: History is alive here with DUCED! ONLY $60k Call for Details! BN-575 PLEASANT HILL: 1,450 sf w/ 5 ops.. tributes to the past! 1,600 sf w/ 3ops.. $225k HN-539 Central Sierra/Tuolumne Co: $330k $175k

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 CONTINUED CENTRAL VALLEY

Largest AC-335 SAN FRANCISCO: CC-567 ST. HELENA: EN-484 FOLSOM Facility: Fantastic Turn-Key Opportunity! Come live, IC-468 SAN JOAQUIN VLY: High-End Restore Pracce! 6 ops in practice and grow here! 1,934 sf w/ 4 Ops. Now Only $125k 2500+ sf office. $425k $475k Price Reduced $790k EG-556 SACRAMENTO: Near CSUS Campus. Long-term 2nd genera- IC-572 MODESTO: In desirable Dental/Medical Professional building Broker in AC-566 SAN FRANCISCO: CG-537 MARIN COUNTY: tion office. 935 sf w/ 4 ops $389k of town, 3ops in 1300sf office. $160k EN-534 ROSEVILLE Facility: Locaon, Locaon, Locaon! Turn-key… IN-474 STOCKTON: Too good to be true? Absolutely not! 1,600 sf Northern $225k $1.1M just needs you! 2,000 sf w/4 ops. $45k w/ 3 ops. $95k AC-585 SAN FRANCISCO: CG-583 SEBASTOPOL: EG-560 CARMICHAEL: Focusing on the philosophy of treang pa- IN-506 TURLOCK: Practice in the heart of the Central Valley! All reasonable offers considered! $270k ents as family! 1,200 sf w/ 3 ops + 1 add’l. $130k 2,000 sf w/ 5ops + 1 add’l. $425k California for the Practice / $160k for the Goodwill PR $125/RE $750k EN-558 DAVIS: Designed for maximum office efficiency and paent IN-512 MERCED: This immaculate practice is an absolute jewel! AG-564 SAN FRANCISCO: DC-476 DUBLIN: flow! 1,487 sf w/ 4 ops + 1 add’l. $650k 1,200 sf w/ 4ops + 1 add’l. Now Only: $110k EN-573 SACRAMENTO: The goal and focus of this pracce is to pro- IN-554 TURLOCK: A small town feel but with “big city” amenies! $2.225M $125k vide excellent service! 1,075 sf w/ 2 ops. $93.1k 1,900 sf w/ 5ops. $795k AG-576 SAN FRANCISCO: DN-497 PLEASANTON Facility: EG-579 ROCKLIN Perio/Gen: Aracve, well-appointed pracce in JC-541 FRESNO Facility: 1,210 square feet and consists of 2 fully Extensive Buyer Owner Financing presgious Whitney Oaks area. 1,600 sf w/3 op + 1 add’l. $325k equipped ops and plumbed for add’l op Call for Details! $550k w/10% Down! Reduced! $95k FC-415 FT. BRAGG: Excellent Practice! Dr. avgs 18+ pts/day & 20+ JG-491 FRESNO: Well-established. 40-50 new Pt/mo. 1,452 sf w/ Database & AN-514 SAN FRANCISCO Facility: DG-519 SANTA CLARA Facility: npts/mo, 1,800 sf w/ 5 ops + 1 hyg. Op $425k 4 fully equipped ops. REDUCED! $395k $225k FC-489 CLEARLAKE: Located on “4-Corners” of Hwy 53, 4ops in JN-551 COALINGA AREA: Serving this community of working fami- Unsurpassed Reduced to $125k! DG-581 SAN JOSE: shared 3600sf facility. $470k / 50% interest in RE Also Available lies! Paperless Pracce. 1,200 sf w/ 3 ops. REDUCED! $395k! AN-565 SAN FRANCISCO: FN-527 TRINITY COUNTY: Be the only dentist in town! “Pride Ins- $570k tute” designed! 2350sf w/ 5 ops +1 add’l. $250k SPECIALTY PRACTICES Exposure allows $1.05M DG-582 SAN JOSE: GC-472 ORLAND: Live & Practice in charming small town community. BC-361 OAKLAND: 1,000 sf w/ 2ops. Seller Retiring. $160k BC-544 ALAMEDA COUNTY Pedo: 1,056sf w/ 4 chairs in growing, us to offer you Now $675k GG-386 REDDING: Amazing Practice. Lease or Buy Real Estate! revitalized community, Seller Retiring $225k Only: $330k DN-542 FREMONT Facility: 2,860 sf w/ 4 ops. Plumbed for 2 add’l! ONLY $260k BG-517 NORTH EAST BAY Endo: 2,750 sf w/ 8 ops! Strong Practice! BC-509 SAN LEANDRO: GG-453 CHICO: 5,000 sf w/ 7 ops Perfect for 1 or more DDS $325k $500k

$60k $295k GG-454 PARADISE: ~2,550 sf w/ 9 ops. 40 yrs goodwill! Amazing CC-346 SO MARIN CO Perio: Beautiful 1,142 sf w/ 3 ops. No reason- BC-520 HAYWARD Facility: DN-557 SALINAS: Opportunity! $525k able offer will be refused! Reduced $150k Priced at only $1.4M GN-244 OROVILLE: Must See! Gorgeous, Spacious. 2,500 sf w/5 CG-424 NAPA Prostho: Office has Digital X-ray & NEW 3D Imaging $65k ops! Collections over $450k in 2013. Only $315k Unit! Ready for Experienced, high-end Prosthodontist! On track to BC-432 PITTSBURG: NORTHERN CALIFORNIA GN-399 REDDING: Loyal patient base and relaxed workweek sched- collect just under $1m $690k ule. 1,440 sf w/3 ops. $150k DC-459 SF PENINSULA Perio: 50% Partnership Buy In! Call for De- $350k EC-525 SACRAMENTO GN-507 CHICO: It just doesn’t get any better than this! 3,000 sf w/ tails! $600k BC-549 LAMORINDA AREA Facility: 7ops. Practice $535k Real Estate $750k EG-579 ROCKLIN Perio/Gen: Aracve, well-appointed pracce $220k GN-546 CHICO AREA: Office is well-known for offering quality den- in the presgious Whitney Oaks area. 1,600 sf w/3 op + 1 add’l. Reduced $75k EC-531 GREATER SACRAMENTO: Pracce and stry with sedaon. 2,600sf w/ 4 ops. $350K $325k BG-570 SAN LEANDRO: Real Estate for Sale! HC-461 SONORA: In the beautiful Sierra Foothills, 4ops, 1350sf, free FN-536 LAKE COUNTY Pedo: Focusing on Prevent dental problems $800k -standing bldg.. Practice $700k & RE Also Available! before they begin! 1,750 sf w/ 3ops. Now Only: $225k! $625k EN-464 ROCKLIN Facility: HN-213 ALTURAS: This well managed pracce connues to have IC-543 CENTRAL VALLEY Ortho: 1,650 sf w/ 5 chair bays & plumbed BN-504 RICHMOND: consistent revenues! 2,200 sf w/ 3 ops + 1 add’l. $115k for 2 add’l, Strong Refs & Satisfied Pts Base $180k Now Only: $100k HN-280 NO EAST CA: Only Practice in Town 900 sf w/ 2 ops RE- JC-540 FRESNO Sleep Apnea: Movated Seller rering! Step right $100k /RE $700k EG-479 FOLSOM DUCED! ONLY $60k in and make yours! Call for Details! BN-575 PLEASANT HILL: . . $225k HN-539 Central Sierra/Tuolumne Co: The perfect Merger Op in a $330k rural Sierra Community! 2,000 sf w/ 5 ops. $175k

“ASK THE BROKER” CAN NOW BE FOUND AT WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 44, Nº8

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

Gboard (Google Inc., Free) More Than Half of U.S. Gets News iPhone users know the drill — when texting a friend or colleague about From Social Media the location of a meeting place, users leave their messaging app for Well above half of U.S. adults get their news on social media, another app to search and copy location information only to return to according to a report by the Pew Research Center and John their messaging app to paste and send. This process and other similar S. and James L. Knight Foundation. According to the study, ones are repeated constantly throughout the day. Google Gboard 62 percent of adults get their news on social media, up from is a third-party, add-on keyboard available for iPhone that brings the 49 percent in 2012. For the study, researchers completed a powerful Google search engine and commonly used iPhone features survey of 4,654 people. Reddit, not Facebook, is the leading together in one simple interface, making repetitive workfl ows a thing source of news on social media. In fact, 70 percent of Reddit of the past. Gboard is, fi rst and foremost, a swipe gesture keyboard. users get news on the platform, compared to 66 percent of Users swipe the words they want to spell out by connecting one letter Facebook users. In third is Twitter, where 59 percent of its users of a word to another without lifting their fi nger from the screen and get their news there. The study also found that 64 percent of the Gboard predictively inputs their word with amazing accuracy. Gboard participants get news on just one site, 26 percent get news on also has emoji and other word suggestions while users are typing two sites and 10 percent get news on three or more sites. in case they were looking for alternatives. The real distinction of this keyboard comes in its integration with search. Users can tap on the — Blake Ellington, Tech Trends editor Google button directly from the keyboard and a search fi eld appears without ever leaving the app. Search results appear as cards within the keyboard. Users can share the information to their app by simply Kids Getting Their First Smart Phone tapping on the card itself. Gboard knows what kind of information is contained in the cards, such as locations or websites, and shares at 10 Years Old pertinent information only, which is perfect for texting users. Users Remember when getting your first bike was the landmark can search for images and animated GIFs in the same manner, which moment of your childhood? Well, that may have been replaced further extends the usefulness of this keyboard. with a smartphone. The average age a child gets his or her first smartphone is 10.3 years old, according to a study conducted — Hubert Chan, DDS by Influence Central. While that may seem shocking to some, this one may get you even more: 31 percent of parents surveyed say their kids have sent them a text while in the same home Longhand Note-Taking Better for together. Kids are also using tablets more, as 55 percent said Learning Than Laptop Note-Taking tablets are a kids’ device of choice on car rides. The digital landscape has largely replaced many of the paper versions — Blake Ellington, Tech Trends editor of our world, but a new series of studies has found that there is some benefi t to sticking with a pen and paper over a laptop. Researchers Would you like to write about technology? at Princeton University and the University of California, Los Angeles, Dentists interested in contributing to this section should contact found that students who take notes on laptops performed worse on Tech Trends Editor Blake Ellington at [email protected]. conceptual questions than those who took longhand notes. Specifi cally, it was found that those who take notes on a laptop are more geared toward transcribing a lecture rather than processing information and paraphrasing with their own thoughts. — Blake Ellington, Tech Trends editor

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