August 2015 Seattle Care Pathway Root Caries Aging Periodontium Apple Tree Dental JournaCALIFORNIA DENTAL ASSOCIATION

DENTISTRY FOR THE AGES: Part II Susan Hyde, DDS, MPH, PhD, FACD, and Dick Gregory, DDS Times change, but our promises remain the same.

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DEPARTMENTS

417 The Guest Editor/Collaborative Practice — Paving the Path to Success

419 Impressions

461 RM Matters/Accounting Controls Can Prevent Dishonest Behavior

467 Regulatory Compliance/Marketing and Advertising Rules 419 471 Periscope

476 Tech Trends

477 Dr. Bob/Aging Gracefully (and Other Indignities)

FEATURES

426 Dentistry for the Ages: Part II An introduction to the issue. Susan Hyde, DDS, MPH, PhD, FACD

429 The Seattle Care Pathway: Defining Dental Care for Older Adults This article describes the evidence for, and the details of, the Seattle Care Pathway to ensure older adults receive optimum dental care. Iain A. Pretty, BDS, MSC, MPH, PhD, FDSRCS(ED)

439 Root Caries in Older Adults Root caries is a major cause of tooth loss in older adults and the need for improved preventive efforts and treatment strategies for this population is acute. Dick Gregory, DDS, and Susan Hyde, DDS, MPH, PhD, FACD

447 Aging Periodontium, Aging Patient: Current Concepts This paper presents the current state of knowledge and opinion on approaches to periodontal diseases and periodontal treatment in the elderly with an emphasis on consensus, conclusions and future directions for dental practitioners. Mark Ryder, DMD

453 Apple Tree Dental: An Innovative Oral Health Solution Apple Tree Dental’s Community Collaborative Practice model illustrates a sustainable, patient-centered approach to overcoming barriers to care across the lifespan. Deborah Jacobi, RDH, MA, and Michael J. Helgeson, DDS

459 National Resources A listing of websites on the oral health of older adults submitted by the authors of this issue. Compiled by Susan Hyde, DDS, MPH, PhD, FACD

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Volume 43, Number 8 JournaCALIFORNIA DENTAL ASSOCIATION August 2015 CDA Classifieds.

Free postings. published by the Editorial Upcoming Topics Manuscript California Kerry K. Carney, DDS, CDE September/Radiology Submissions EDITOR-IN-CHIEF Priceless results. Dental Association October/The Dental Team www.editorialmanager. 1201 K St., 14th Floor [email protected] November/Pain com/jcaldentassoc Sacramento, CA 95814 Ruchi K. Sahota, DDS, CDE Management 800.232.7645 ASSOCIATE EDITOR Letters to the Editor cda.org Advertising www.editorialmanager. Brian K. Shue, DDS, CDE Doug Brown com/jcaldentassoc CDA Offi cers ASSOCIATE EDITOR ADVERTISING SALES Walter G. Weber, DDS [email protected] PRESIDENT Susan Hyde, DDS, MPH, 916.554.7312 Subscriptions [email protected] PhD, FACD Subscriptions are available Dick Gregory, DDS Tiff any Carlson only to active members of GUEST EDITORS ADVERTISING SALES Kenneth G. Wallis, DDS the Association. The PRESIDENT-ELECT Tiff [email protected] subscription rate is $18 and [email protected] Andrea LaMattina 916.554.5304 is included in membership PUBLICATIONS SPECIALIST Permission and dues. Nonmembers can Clelan G. Ehrler, DDS view the publication online VICE PRESIDENT Blake Ellington Reprints at cda.org/journal. TECH TRENDS EDITOR [email protected] Andrea LaMattina PUBLICATIONS SPECIALIST Manage your subscription Natasha A. Lee, DDS Courtney Grant [email protected] online: go to cda.org, log in SECRETARY COMMUNICATIONS 916.554.5950 and update any changes to [email protected] SPECIALIST your mailing information. Email questions or other Kevin M. Keating, DDS, MS Jack F. Conley, DDS changes to membership@ TREASURER EDITOR EMERITUS cda.org. [email protected] CDA classifiedsclassifieds wworkork harder to Robert E. Horseman, DDS Stay Connected cda.org/journal HUMORIST EMERITUS bringbring 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 Go Digital cda.org/apps SENIOR GRAPHIC DESIGNER James D. Stephens, DDS see the potential. IMMEDIATE PAST PRESIDENT Look for this symbol, noting additional video [email protected] Randi Taylor content in the e-pub version of the Journal. SENIOR GRAPHIC DESIGNER And if you’re hiring, candidates anywhere can apply right from Management Journal of the California Dental Association (ISSN 1043-2256) is published monthly by the Peter A. DuBois the site. Looking for a job? You can EXECUTIVE DIRECTOR California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal post that, too. And the best part— of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. Jennifer George it’s free to all CDA members. CHIEF MARKETING OFFICER The California Dental Association holds the copyright for all articles and artwork published herein. The Journal of the California Dental Association is published under the supervision of Cathy Mudge All of these features are designed to CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for VICE PRESIDENT any expression of opinion or statement of fact, all of which are published solely on the authority PUBLIC AFFAIRS help you get the results you need, of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition faster than ever. Check it out for Alicia Malaby that they are contributed solely to the Journal. COMMUNICATIONS yourself at cda.org/classifieds. DIRECTOR Copyright 2015 by the California Dental Association. All rights reserved.

416 AUGUST 2015 GuestEditor Editor CDA JOURNAL, VOL 43, Nº8

Collaborative Practice — Paving the Path to Success Susan Hyde, DDS, MPH, PhD, FACD

any Native American cultures teach that Inclusion of oral-systemic health data in risk caring for elders is a blessing path in which assessment and disease management plans the whole community have resulted in improved collaboration and Mshould participate. Like many of us with referrals between dental-primary care providers. aging parents, I have provided a lot of care to my parents, and oral health issues always arose. My experiences dealing with my father’s care-resistant behaviors dental care is one of the Leading Health health is an important population health as he battled Alzheimer’s and diffi culties Indicators for Healthy People 2020.2 issue for primary care providers.5 New in obtaining dental treatment for my Additionally, oral health disparities in York University has successfully integrated stepmother, who was paralyzed and older adults are now recognized to extend HEENOT in the comprehensive history unable to speak as the result of a stroke, beyond edentulism, as refl ected by the and physical examinations for nursing contributed greatly to my decision to new Healthy People 2020 objectives and medical student clinics and faculty specialize in geriatric dentistry. Thanks to reduce untreated coronal and root practices. Inclusion of oral-systemic to the geriatric training I received, caries in older adults, and decrease health data in risk assessment and disease when my mother moved into a long- the prevalence of moderate or severe management plans have resulted in term care facility, I immediately put her periodontal disease.3 Therefore, primary improved collaboration and referrals on a three-month schedule for home care providers must obtain training in oral between dental-primary care providers.6 visits with a dental hygienist. Similarly, health screening and referral, consider Dentists and dental hygienists also when my father-in-law’s face ballooned oral health in disease management and need to participate in the cycle of because of multiple periapical abscesses, collaborate with the dental community interprofessional collaborative practice. I was able to raise the awareness of his to develop home-based programs Healthy People 2020 objectives promote family, endocrinologist and orthopedic for older adults in order to achieve collaborative practice with two new oral surgeon that the needed dental treatment patient-centered, value-based care.1 health goals for increasing the proportion wasn’t elective but rather critical to the An article in the October 2014 issue of adults who receive tobacco cessation resolution of his poor wound-healing of the Journal of the California Dental information and who are tested or referred from a recent diabetic amputation. My Association described the National for glycemic control by a dentist or dental experiences are by no means unique. Interprofessional Initiative on Oral hygienist.3 Although previous studies Homebound and institutionalized older Health (NIIOH), established in 2008 to indicated both dentists and patients are adults lack access to dental care and launch a new standard of care for patient receptive to screening and managing endure a great deal of untreated oral oral health.4 The initiative espoused medical conditions in the dental disease, which affects their abilities to primary care providers becoming skilled setting,7,8,9 a survey of North Carolina eat and socialize, resulting in further at addressing the oral health needs of dentists expressed reservations for taking compromised overall health and function.1 their patients and effectively referring a more active role in the management Beginning with the Surgeon General’s to dentists. The traditional head, ears, of patients’ systemic conditions through Report on Oral Health in America, eyes, nose and throat (HEENT) physical risk behavior counseling, referral for through 15 years of compelling research assessment performed by primary care laboratory testing or in-offi ce diagnostic publications and two seminal Institute of providers excludes examination of the screening for medical conditions.10 ■ Medicine reports on oral health, dentistry oral cavity and omits consideration of has achieved national recognition oral-systemic linkages to overall health. REFERENCES 1. Ornstein KA, et al. Signifi cant unmet oral health that oral health is necessary for overall Incorporating the oral cavity into a revised needs among the homebound elderly. J Am Geriatr Soc health. For the fi rst time, access to HEENOT examination affi rms that oral 2015;63(1):151-7.

AUGUST 2015 417 AUG. 2015 GUEST EDITOR

CDA JOURNAL, VOL 43, Nº8

2. U.S. Department of Health and Human Services. Healthy People 2020: Leading health indicators. 2010. www. healthypeople.gov/2020/Leading-Health-Indicators. 3. U.S. Department of Health and Human Services. Healthy People 2020: Oral health objectives. 2010. www. healthypeople.gov/2020/topics-objectives/topic/oral-health/ objectives. Our archives 4. Garland T, Smith L, Fuccillo R. Addressing oral health needs through interprofessional education and practice. J Calif Dent Assoc 2014;42(10):701-9. 5. U.S. Department of Health and Human Services, are your archives. Health Resources and Services Administration. Integration of oral health and primary care practice. 2014. www. hrsa.gov/publichealth/clinical/oralhealth/primarycare/ Our archive is online for your research. Access every issue integrationoforalhealth.pdf. of the Journal from the past 16 years at cda.org/journal. 6. Haber J, et al. Putting the mouth back in the head: HEENT to HEENOT. Am J Public Health 2015;105(3):437-41. 7. Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Dentists’ attitudes toward chairside screening for medical conditions. J Am Dent Assoc 2010;141(1):52-62. 8. Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients’ attitudes toward screening for medical conditions in a dental setting. J Public Health Dent 2012;72(1):28-35. 9. Marshall S. Evidence from ElderSmile for diabetes and hypertension screening in oral health programs. J Calif Dent Assoc 2015;43(7). 10. Paquette DW, Bell KP, Phillips C, Off enbacher S, Wilder RS. Dentists’ knowledge and opinions of oral-systemic disease relationships: relevance to patient care and education. J Dent Educ 2014;79(6):626-35.

Susan Hyde, DDS, MPH, PhD, FACD, chairs the division of oral epidemiology and dental public health at the University of California, San Francisco, School of Dentistry. She is the dental director of UCSF’s multidisciplinary fellowship in geriatrics and faculty lead for interprofessional ed ucation for the School of Dentistry. Dr. Hyde received her dental degree from UCSF, Master of Public Health and doctorate of philosophy (epidemiology) from the University of California, Berkeley, and certifi cates in dental public health and geriatrics from UCSF.

418 AUGUST 2015 Impressions CDA JOURNAL, VOL 43, Nº8

Autonomy and Agency

David W. Chambers, EdM, MBA, PhD

Yogi Berra had it right: “If the people don’t want to come, nothing can stop them.” They are autonomous, in the literal sense of the term “self-governing.” Dentistry is one of the professions that has made quite a bit out of this principle. Patients get to choose … even if the choices are limited for their own good. Bioethicists ground informed consent in the norm of respect for autonomy. Sometimes informed consent is mistaken for a legal process. Sometimes it means little more than making certain patients have a generally favorable idea what is going to happen to them. The nub: Respect for autonomy is an ethical pillar in most professions. It just makes sense that when the professional sets up the ground 1. Respect for autonomy is rules, patients should be allowed the opportunity to opt out. But this is only half the story. What if we looked at it nice, but a bit paternalistic from the perspective of potential patients? It is plausible, if because either party alone a bit uncomfortable, for others to set their own conditions can make that determination. on whether or how they will participate (or not) in health care. This is a free choice and involves no necessary prejudice 2. Dentists and adult patients against the professional, even if it means a hit to prestige, and nonpatients are agents, income, lost time and a ding on the self-concept of serving the public. Others show “respect for autonomy” by not with the capacity to aff ect forcing conformity. Respect for autonomy loses some of each other. its nobility unless we accept that it works both ways. Agency is a sturdier moral concept. Agents have the 3. Morality requires that the capacity and responsibility to affect others by their actions. same moral status as agents Both dentists and patients are agents. Patients are agents when they refuse radiographs, choose less-than-ideal be accorded all concerned. treatment to remain within the limits of their insurance coverage or decide not to go to the dentist at all. Each dentist choice affects both the patient and the dentist; each patient choice affects both the dentist and the David W. Chambers, EdM, MBA, PhD, is professor of dental education at the University of the Pacifi c, Arthur patient. Dentists and patients are (potentially) reciprocal A. Dugoni School of Dentistry, San Francisco, and editor moral agents. The challenge is to fi nd a common way forward of the Journal of the American College of Dentists. that neither party would have any reason to change. In the traditional approach to ethics, dentists consider only what they understand to be in patients’ best interests and claim the moral high ground by reluctantly allowing them to elect less than ideal care. The dentist’s interests have been screened off from consideration as not belonging to the sphere of professional ethics. Not so, of course, for patients who judge their own and the dentist’s advantage. Morality requires more than one person deciding whether he or she has done right by private standards. Professionals justify their standards by roughly conforming to what their colleagues are doing. Morality requires that agents recognize the valid claim of other moral agents to affect them. ■

AUGUST 2015 419

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800.232.7645 or cda.org/sickleave AUG. 2015 IMPRESSIONS

CDA JOURNAL, VOL 43, Nº8

Cigarettes Linked to Half of Oral Cancer Deaths In 2011, there were more than 8,500 deaths in the U.S. from cancers of the oral cavity and pharynx. A recent study, published in JAMA Internal Medicine, estimated the number of deaths attributable to cigarette smoking for 12 smoking-related cancers and found that, among U.S. adults 35 years and older in 2011, almost half (47 percent) of the deaths caused by cancers of the oral cavity and pharynx were attributable to cigarette smoking. Additionally, in the multi-institution research letter, the authors report that Oral Surgery and the overall number of deaths from 12 smoking-related cancers was nearly Anticoagulant Therapy 346,000. Of those, 48.5 percent were attributable to cigarette smoking. Specifi cally, the researchers linked smoking with 80.2 percent of lung, Researchers recently assessed the bronchus and trachea cancer deaths, as well as 76.6 percent of deaths from incidence of postoperative bleeding in cancer of the larynx. Secondhand smoke exposure, which was estimated by patients who were highly anticoagulated the 2014 U.S. Surgeon General’s report to cause an additional 5 percent and in patients who underwent extensive of lung cancer deaths, was not included in the analysis. oral surgical procedures and who continued using oral anticoagulant therapy. Published In the research letter, the authors stated that 44.8 in The Journal of the American Dental percent of bladder cancer deaths, 19.6 percent of Association, the study found that, in stomach cancer deaths and 22.2 percent of cervical patients who are highly or therapeutically cancer deaths were linked to smoking. anticoagulated, dental extractions as For more details and specifi c well as more extensive oral surgical breakdowns within each category, see procedures can be performed safely without the full report published online ahead interruption or modifi cation of the therapy. of print in the journal JAMA Internal According to a summary of the Medicine, June 15, 2015. research, the authors divided 125 patients receiving anticoagulant therapy into three groups. Group A consisted of 54 patients who were highly anticoagulated (international normalized ratio (INR) ≥ 3.5) and who had three teeth extracted. For Group B, the authors stated that underwent surgical procedures similar be performed safely without interruption this group consisted of “60 patients with to those performed in Group A and or modifi cation of the therapy. INR 2.0 to less than 3.5 in whom higher- Group B made up the control group. “Tooth extractions and even more risk dentoalveolar surgery (extraction The authors reported that 3.7 extensive surgical procedures can of more than three teeth or other oral percent of Group A, 5 percent of be performed safely in patients who surgery procedure involving raising Group B and 18.2 percent of Group C continue using anticoagulant therapy a mucoperiosteal fl ap, osteotomy or experienced postoperative bleeding, if proper local hemostatic measures are biopsy) was performed.” Lastly, Group while a single bleeding event (1.2 used and if no other coagulopathies C consisted of 11 patients whose INR percent) occurred in the control are present,” the authors wrote. values were 3.5 or higher and who group. They concluded that dental For more, see the study in The Journal required higher-risk dentoalveolar extractions in patients who are highly of the American Dental Association, June surgery, and 85 healthy participants who or therapeutically anticoagulated could 2015, vol. 146, issue 6, pp. 375–381.

422 AUGUST 2015 CDA JOURNAL, VOL 43, Nº8

Nanostructures in Dentin Make Teeth Crack Resistant A team of international researchers become increasingly compressed. recently analyzed the complex structure “Our group was able to use of dentin and discovered that the mineral changes in humidity to demonstraterate particles are precompressed. The internal how stress appears in the minerall in the stress works against crack propagation and collagen fi bers,” said Paul Zaslansky,sky, increases resistance of the biostructure. Dr. med. dent., PhD, a researcherr at According to the study, published in Charité Berlin, in the news release.ase. the journal Nano Letters, the researchers “The compressed state helps to used in-situ stress experiments and prevents cracks from developing and examined the local orientation of the we found that compression takess pplacelace mineral nanoparticles. They discovered in such a way that cracks cannot easily that when the tiny collagen fi bers reach the tooth inner parts, which shrink, the attached mineral particles could damage the sensitive pulp.” The scientists also analyzed what happens if the tight mineral-protein link is destroyed by heating. They found that, in that case, dentin in teeth becomes much weaker. Four Out of 10 Pregnant Women Not “We therefore believe that the Seeing Dentist During Pregnancy balance of stresses between the particles and the protein is important for the While the importance of oral health during pregnancy extended survival of teeth in the mouth,” has been shown, a new survey out recently has found said scientist Jean-Baptiste Forien. that 42.5 percent of expecting mothers in the United According to the authors, their fi ndings States aren’t visiting a dentist during their pregnancy. may help explain why artifi cial tooth According to a news release about a recent dental replacements usually do not work as well insurance survey, visiting the dentist during pregnancy as healthy teeth do — they are simply is a crucial step and can help identify key health issues too passive, lacking the mechanisms appearing specifi cally during pregnancy. Additionally, found in the natural tooth structures, and the California Dental Association says improving oral consequently fi llings cannot sustain the health during pregnancy can prevent complications stresses in the mouth as well as teeth do. associated with dental diseases, may reduce preterm “Our results might inspire the and low birth weight deliveries and has the potential development of tougher ceramic structures for tooth repair or to prevent early childhood cavities in infants. replacement,” Zaslansky said. It is important for women who are pregnant or For more information, see the study planning to become pregnant to visit a dentist for routine published in the journal Nano Letters, examination, cleanings and guidance about specifi c May 2015, vol. 15:6, pp. 3729-373. oral health issues that may occur during pregnancy. For more information, see the June and September Illustration shows complex biostructure of dentin: The 2010 issues of the Journal, available at cda.org/journal. dental tubuli (yellow hollow cylinders, diameters appr. 1 micrometer) are surrounded by layers of mineralized collagen fi bers (brown rods). The tiny mineral nanopar- ticles are embedded in the mesh of collagen fi bers and not visible here. Image: JB Forien @ Charité

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Dental Implants in Osteoporotic Women With age, postmenopausal women with osteoporosis are at greater risk of losing their teeth. In a new study, researchers from Case Western Reserve University School of Dental Medicine suggest dental implants may provide postmenopausal women with osteoporosis with the highest degree of satisfaction in their work and social lives. “This investigation was initiated to incorporate oral health into women’s health promotion and to examine psychosocial outcomes associated with dental implant Families of Orofacial Clefting, supported rehabilitation,” the authors wrote. No Higher Risk for Dental In the study, researchers surveyed 237 osteoporotic women with one or more adjacent teeth missing. The survey consisted of 23 questions rating their satisfaction Anomalies with replacement teeth and how it improved their lives at work and in social Children with oral clefts show situations — specifi cally in regards to the work, health, emotional and sexual a wide range of dental anomalies, aspects of their lives. Of the 237 participants, 64 had implant retained prosthetic adding complexity to understanding restorations, 60 had traditional fi xed partial dentures, 47 had removable partial the phenotypic spectrum of orofacial denture and 66 had no restoration to restore missing teeth. No signifi cant clefting. In a recent study, researchers diff erence in age exists between groups, according to the study. characterized the spectrum of cleft-related The authors found that women with dental implants reported a higher overall dental anomalies and evaluated whether satisfaction with their lives, according to lead researcher Christine DeBaz, who families with clefting have a signifi cantly higher risk for such anomalies compared personally interviewed each participant. Fixed dentures scored next highest in to the general population. They found satisfaction, followed by false teeth and then women with no restoration work. that families of orofacial clefting are “In order to make decisions about the most not at higher risk for dental anomalies. appropriate treatment option in rehabilitation a dentist Published in the Journal of Dental must understand not only the prosthetic therapeutic Research, the study included 3,811 specifi cs such as chewing function and orofacial esthetics individuals — 660 cases with clefts, but also the patient-centered specifi cs of psychosocial 1,922 unaffected relatives and 1,229 and overall well-being,” the authors wrote. controls. Researchers identifi ed dental For more, see the study in the International Journal anomalies from in-person dental exams of Dentistry, vol. 2015, article ID 451923, 6 pages. or intraoral photographs and case-control differences were tested. This is the largest international cohort to date of children with nonsyndromic clefts, their Compared to controls, unaffected higher genetic risk for dental anomalies relatives and controls, according to a new siblings and parents showed a trend for than the general population and that release. The authors report that cases had increased anomalies of the maxillary the higher prevalence of anomalies higher rates of dental anomalies in the permanent dentition. Yet, these in cases is primarily a physical maxillary arch than controls for primary differences were nonsignifi cant after consequence of the cleft and surgical and permanent dentitions but not in the multiple-testing correction, suggesting interventions,” the authors concluded. mandible. They also reported fi nding genetic heterogeneity in some families For more information, see the study dental anomalies were more prevalent carrying susceptibility to both overt titled “Spectrum of Dental Phenotypes in cleft lip with cleft palate than other clefts and dental anomalies. in Nonsyndromic Orofacial Clefting,” cleft types and that more anomalies “Collectively, the fi ndings suggest published online fi rst in the Journal were seen on the same side of the cleft. that most affected families do not have of Dental Research, June 16, 2015.

424 AUGUST 2015 CDA JOURNAL, VOL 43, Nº8

Weight-Related Risk Factor for Periodontitis According to the Centers for Disease In the new study, the authors note Control and Prevention, more than that “previous reviews were primarily 90 percent of adults aged 20-64 have based on cross-sectional studies, with experienced tooth decay and one in every only a few longitudinal or intervention three adults is obese. In a recent systematic studies included.” For their study, the review, authors indicate that obesity may researchers examined the “time- be one of a number of weight-related risk dependent association” between obesity factors for development of periodontitis. and periodontitis and how changes

in weight may affect the development and progression of periodontitis in the Porcine Collagen Barrier Aids Bone Regrowth general population. Searching studies with overweight or obesity as exposure Researchers examined a new type of barrier membrane, called and periodontitis as outcome, the porcine collagen, to fi nd out how quickly a bone graft can develop with authors reviewed eight longitudinal this material placed over the grafted tooth socket. While they found bone and fi ve intervention studies that regeneration varied, the authors reported that porcine collagen showed assessed the association among potential for promoting new bone growth. overweight, obesity, weight gain, waist The study, which was published in the Journal of Oral Implantology, circumference and periodontitis. included 14 patients with a diagnosis of one or more unsalvageable “Two of the longitudinal studies found teeth and a treatment plan to replace them with implant-supported single a direct association between degree of crown restorations. After the teeth were removed, the sockets were fi lled overweight at baseline and subsequent risk with particulate allograft bone and covered with a layer of porcine of developing periodontitis, and a further three studies found a direct association collagen. According to the study, the porcine collagen membranes were between obesity and development of cut to overlap the facial and lingual (or palatal) socket rim by at least 5 periodontitis among adults,” the authors mm (or more if necessary) to cover bony wall fenestration or dehiscence summarized. Additionally, they found that defects. Sixteen weeks later, researchers checked the sites and dental two of the reviewed intervention studies implants were placed. on the infl uence of obesity on periodontal The formation of new bone in the treated sites averaged 11.2 percent, treatment effects showed that the response with a range of 1.8 percent to 43 percent, in bone biopsies trephined from to nonsurgical periodontal treatment was the center of the grafted socket sites, the authors explained in the report. better among lean than obese patients The authors concluded that “The resulting new bone regeneration varied while the remaining three studies widely, but the barrier membranes showed potentialal did not report treatment differences for promoting signifi cant bone regeneration.” between obese and lean patients. They suggest a larger sample of treated cases In conclusion, the authors stated that their systematic review suggests is needed to support their conclusion. overweight, obesity, weight gain and For more on this study, see the Journal increased waist circumference may be risk of Oral Implantology, June 2015, vol. 41, factors for development of periodontitis no. 3, pp. 293–297. or worsening of periodontal measures. For more, see the study in the Journal of Periodontology, June 2015, vol. 86, no. 6, pp. 766-776.

AUGUST 2015 425

introduction

CDA JOURNAL, VOL 43, Nº8

Dentistry for the Ages: Part II

Susan Hyde, DDS, MPH, PhD, FACD

GUEST EDITORS

Susan Hyde, DDS, Dick Gregory, DDS, is n this second of two issues that supports a collaborative practice MPH, PhD, FACD, the San Mateo Center dedicated to the oral health of approach to treatment decisions. chairs the division of director for Apple Tree older adults, the Journal presents Guest editors Dick Gregory, DDS, oral epidemiology and Dental. He completed possible resources for general and Susan Hyde, DDS, MPH, PhD, dental public health at the his dental degree at the dentists to consider when caring FACD, present alternative treatments University of California, University of California, San Francisco, School Los Angeles, School of Ifor older adults. Iain A. Pretty, BDS, for root caries that could be delivered of Dentistry. She is the Dentistry in 1980 and a MSC, MPH, PhD, FDSRCS(ED), bedside, such as silver diamine fl uoride dental director of UCSF’s two-year postgraduate writes about the Seattle Care cariostasis, partial caries removal and multidisciplinary fellowship multidisciplinary geriatric Pathway, which takes into glass ionomer restorations. Deborah in geriatrics and faculty fellowship at the University account the continuum of clinical Jacobi, RDH, MA, and Michael J. lead for interprofessional of California, San Francisco education for the School of in 2014. During the presentation of older adults, with the Helgeson, DDS, write about Apple Tree Dentistry. Dr. Hyde received intervening three decades, resultant need for dentists to provide Dental, a community collaborative her dental degree from he cared for his patients oral health anticipatory guidance practice model, that will soon be UCSF, Master of Public while in private general for patients, and if appropriate, providing comprehensive care to Health and doctorate of dental practice in Northern their caregivers, as well as increased vulnerable populations in the Bay philosophy (epidemiology) California. from the University of Confl ict of Interest communication with primary care Area and may become a statewide California, Berkeley, and Disclosure: None reported. providers when developing care model for delivering on-site dental certifi cates in dental public plans. Mark Ryder, DMD, reviews services within long-term care facilities. health and geriatrics from the roles of systemic disease, Finally, the contributing authors to the UCSF. pharmacological management, July and August issues of the Journal Confl ict of Interest Disclosure: None reported. immune response and functional have provided a national resource capacity in the development and section of organizations and websites progression of periodontal disease dedicated to the care of older adults. ■

AUGUST 2015 427 You are the reason people stand tall in front of the class, grin widely for the camera and never cover their mouths in shame. You are the champion of the smile and all the possibility it represents. The confidence you instill in your patients is one reason why CDA supports and protects your profession. Because the world is a better place when people are smiling, and that’s thanks to you.

800.232.7645 | cda.org ® seattle care pathway

CDA JOURNAL, VOL 43, Nº8

The Seattle Care Pathway: Defi ning Dental Care for Older Adults

Iain A. Pretty, BDS, MSC, MPH, PhD, FDSRCS(ED)

ABSTRACT It is well-recognized that the demographic shift in the population will result in a larger proportion of older adults and those adults will live longer than ever before. There is, therefore, a need to ensure dental services recognize this transition and plan for the management of older adults in primary care dental practices. This article describes the evidence for, and the details of, the Seattle Care Pathway to ensure older adults receive optimum dental care.

AUTHOR ACKNOWLEDGEMENT

Iain Pretty, BDS, MSC, The author would like n 2013, a group of interested The Shift MPH, PhD, FDSRCS(ED), to recognize and thank academicians, clinicians and There is no doubt Western countries is a professor of public the original authors of practitioners gathered in Seattle to are all experiencing a demographic shift health dentistry at the the pathway and their University of Manchester contribution to the Seattle discuss the issues surrounding the — a change in the population profi le School of Dentistry and conference: Roger P. dental care of older adults. Many that will see a greater proportion of older co-director of Colgate Ellwood, BDS, MSc, MDS, Irecognized that while research was adults who will be living longer than Palmolive’s Dental PhD; Edward C.M. Lo, available, it was diffi cult to consume ever before.2,3 Such a shift has a profound Health Unit, a 45-year BDS, MDS, PhD; Michael and there was little advice for dental impact on many aspects of society, not collaboration between the I. MacEntee, LDS(I), Dip. company and the university. Prosth., PhD; Frauke Müller, practitioners on how to manage least the fi nancial considerations, but Dr. Pretty is working Prof. Dr med dent; Eric this increasing proportion of their perhaps, one of the biggest concerns on caries management Rooney, BDS, MSc, DDPH population. In an effort to provide such is maintaining the health and well- programs for older people RCS; William Murray guidance, the Seattle Care Pathway for being of an aging population in an and, with international Thomson, BSc, BDS, MA, Securing Oral Health in Older Patients economically viable manner that does colleagues, developed the MComDent, PhD; Gert-Jan 4 Seattle Care Pathway, an Van der Putten, PhD; Elisa was produced. Readers can access not destabilize health care systems. evidence-based approach M. Ghezzi, DDS, PhD; all 12 papers, including the pathway Many could argue the shift is a perfect to assessing and planning Angus Walls, BDS, PhD; document1 itself, free of charge from storm – older individuals with greater the oral care of older and Mark S. Wolff , DDS. the Gerodontology website — simply and more complex health care needs people. search for “Seattle Care Pathway but no workplace medical insurance Confl ict of Interest Disclosure: None reported. Gerodontology” online. The purpose will strain health care systems while of this article is to summarize the key at the same time the proportion of fi ndings of the conference in a single working-age, tax-contributing individuals source that is accessible and relevant reduces. The obvious solution to these to general dental practitioners. issues would seem to be that prevention

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Drivers for vulnerability Drivers for vulnerability Skills of parent, access to dental services General health, presence of chronic with eff ective prevention policies, diseases,activities of daily living (ADL), deprivation, health care system. performance, medication, burden, Not vulnerable deprivation, access to services, luck.

Start of life End of life

Services Vulnerable Services Well-defi ned and integrated within Poorly defi ned, often highly variable, even national schemes, such as health within health care systems. Poor access to visiting, HeadStart, children’s centers, services and service specifi cations based nurseries and schools. Clear and on the treatment aspirations of younger consistent oral health promotion and Population 1 adults rather than directed by the oral prevention messages linked with eff ective health needs of the elder patients. Population 2 interventions, therapies and treatments. Research Population 3 Good access to care generally. Evidence base is poorer, fewer Research Line of vulnerability recommendations based on clinical trial Strong, evidence-based, with wide range evidence, often focused on settings rather of clinical trials and numerous systematic than delivery. reviews to provide guidance to health care systems. Evidence embodied within national recommendations and endorsed by governments and organized dentistry.

FIGURE. Life course and health.

is key. If individuals can be helped to Population 1. The fi rst population is Population 3. The third line is keep healthy for longer, and if chronic, our ideal, the life course we hope for our perhaps the most reflective of the debilitating diseases can be prevented, families and ourselves. It is an individual Western population experience. We then the burden on health and social born above a line of vulnerability, are born and are vulnerable for a care systems can be reduced, quality of who leads a long and healthy life and, period of time, and then, fortunately, life increased and the system maintained. toward the end of life, suffers some spend the majority of our lives fit Such an approach requires a loss of function but remains vital and and well, but with an end of life different contextual framework for the with a good sense of well-being. that may be affected by chronic delivery of health care services and Population 2. The second line is a conditions, loss of cognitive ability resources. The FIGURE demonstrates worst-case scenario and perhaps seen and other factors that impact quality a life course model of health care. today in those individuals born with of life and make us increasingly We can consider this model for any life-threatening and altering conditions dependent and vulnerable.2 aspect of health care, and dentistry is that cause severe disability and require What we know from dental and no exception. The three lines in the constant medical attention and assistance. medical attendance and resource model represent three hypothetical Such patients are likely to be managed allocation research is the vast majority individuals or populations: by specialists in secondary care facilities. of resource is spent on the “middle”

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TABLE 1 Dental Challenges of the Older Adult

Tooth loss While now far less common, incremental loss of teeth leading to the decision to render an individual edentulous is still a major challenge for many older adults. The provision of complete prostheses is becoming more complex as patients typically lose their teeth at an older age and have a reduced ability to cope with the challenges of managing a prosthesis.

Dental caries Perhaps the most common challenge, in community-dwelling older adults, caries rates are similar to those in young children at about one surface per year. While root caries are often considered the major issue in this age group, this appears to be largely a disease of adults in residential and nursing homes, with coronal caries remaining the site of increment for older adults. Those in nursing homes will typically experience a caries increment rate double that of their community-dwelling peers.

Periodontitis A highly prevalent condition in this cohort of patients but with most attachment loss being in the form of gingival recession rather than increases in probing depth. The concept of “health survivors” is apropos here — with teeth that remain into old age likely resilient to periodontal disease. The changes in the immune system also contribute to the altered progression of the disease in this group, although this must be set against the reduced ability to undertake some oral hygiene procedures that require fi ne motor skills.

Dry mouth Both xerostomia and salivary gland hypofunction are seen in older patients, either together or alone, and can have a devastating impact. Caries risk is increased either due to loss of the protective saliva or due to measures taken to stimulate salivary fl ow (often sucking candies), and dry mouth is associated with a decrease in quality of life, diffi culty eating and wearing a prosthesis. Dry mouth is often associated with polypharmacy.

Oral cancer/ Epidemiological data are scarce, but oral cancer and its precursors are generally seen in older populations and rates vary across developed Precancer and developing nations. Given its devastating impact, however, clinicians should be vigilant for oral lesions in all patients, especially those with recognized risk factors.

Access Many older adults fi nd it increasingly diffi cult to access care. This may be due to transport, cognitive ability or their own general health and mobility. Dental offi ces may not cater well to wheelchair users or may not be located close to public transport links. In patient surveys, the need to maintain access to dental care is often raised as older adults’ No. 1 concern with respect to their oral health.

Setting Older adults living in nursing and residential care may be especially diffi cult to treat, especially if they cannot be easily transported to a regular clinical setting. The need for mobile dental units and staff is clear but the provision of these is often sporadic.

Resources For many adults, dental insurance ceases or is reduced at retirement and, combined with a lower overall income level, resources become scarce. This is confounded by the fact that many of these patients will have received complex dental treatments that may require additional resource to maintain and protect.

section of this life course with some Dentistry and Vulnerability issue in children’s oral health, but the (increasing) emphasis on young The FIGURE also defi nes the current environment for change is present.2 children (those younger than age 3) position of dental services, resources and Looking at the older population, we and very little on end-of-life care.5 research. While this is a generalization, are not in the presence of such clarity. It should be noted that the life it is largely applicable to all Western The reasons for poor oral health are more course makes no reference to an health care models. For young children, complex, more interlinked and not as individual’s age. While it is clear there is a wealth of services, strong well understood. There is little robust individuals are aging, placing artifi cial clinical trial evidence upon which clinical trial evidence that has examined and arbitrary chronological metrics is to base such services and, generally, these populations in detail and it is often not helpful. We all know the 95-year- the political, social and professional necessary to extrapolate from studies old man who we see out jogging and will to see oral health care improve. undertaken on adolescents or children. we all, sadly, know of the 55-year- The reasons for poor oral health in Services are poorly defi ned, diffi cult to old man who has suffered a stroke young children are well understood, access and often restricted, for example, and is unable to walk. We must as are the means on individual and to older adults living in residential care. consider our patients as individuals population levels to address them. This It is important to remember that while and plan their care appropriately.2 is not to assert there is no longer an the media will often depict or report

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TABLE 2 Definitions of Dependency Used in the Seattle Care Pathway

No dependency Fit, robust people who exercise regularly and are in the most fi t group for their age. on the elderly living in nursing homes Predependency People with chronic systemic conditions, which could impact on oral health — less than 5 percent of older adults in that, at point of the presentation, are not currently impacting on oral health. Western populations are in such housing A comorbidity whose symptoms are well-controlled. — the vast majority is community dwelling, living either with caregivers Low dependency People with identifi ed chronic conditions that are aff ecting oral health but (often partners) or on their own. who currently receive or do not require help to access dental services or Speaking to older people, their maintain oral health. These patients are not frankly dependent, but their partners and caregivers, and third- disease symptoms are aff ecting them. sector organizations, the medical terms Medium People with an identifi ed chronic system condition that currently impacts on surrounding aging are often found dependency oral health and who receive or do not require help to access dental services to be pejorative, for example, frailty. or maintain oral health. This category would include patients who demand to Instead, the concept of dependency, or be seen at home or who do not have transport to a dental clinic. indeed independency, was recognized High dependency People with complex medical problems preventing them from going to receive as a more acceptable means of defi ning dental care at a dental clinic. They diff er from patients categorized in medium individuals as they age. This is important dependency because they cannot be moved and must be seen at home. for dentistry where we have the means of implementing prevention at an early stage to ensure that disease processes can be arrested or even reversed. In the Periodontal disease is complex from salivary gland hypofunction results in low context of the older adult, plans for this an epidemiological position, not least salivary fl ow rate, both can be a threat to approach need to be undertaken early in because of the multitude of defi nitions, oral health and quality of life. Those with a time best described as “predependent.” indices and reporting mechanisms. Aging low salivary fl ow rates have reduced salivary was traditionally considered a risk factor buffering and remineralization abilities Dental Challenges of Older Adults for periodontal disease, but the research and those with xerostomia will often seek These are well-described in a evidence is not clear.3 Longitudinal studies to reduce symptoms by sucking on sour multitude of publications and were suggest there is both a progression and candies or something similar that provides summarized by Thompson in his Seattle remission of the disease process over time a source of fermentable carbohydrates conference presentation3 and shown in and in older adults, attachment loss is and, therefore, increased caries risk. TABLE 1. The major dental issues faced often the result of gingival recession rather Oral precancer and cancer is also a by older people are broadly the same than increases in periodontal pocket disease associated with older adults with as those of younger individuals. Many depth.9 Nonetheless, plaque control and catastrophic consequences for those dentists are surprised, however, to learn the presence of fl orid, plaque-related affected. The ability to detect precancerous the caries increment in older adults is marginal gingivitis is often seen in older lesions early, confi rm diagnosis and the same as in younger children, about adults, especially those with cognitive or commence treatment (including risk factor one surface increment per year, and, motor impairments.10 There is a concept reduction) is key to positive outcomes.11 often surprising, too, is that this is mainly of “healthy survivors,” i.e., those teeth in coronal surfaces.6 Root caries, often present in older adults may be, for a Meeting the Challenges: A Pathway thought of as the major challenge of the variety of reasons, less susceptible to Approach elderly, is a disease entity largely confi ned the disease and hence the overall risk Pathways were originally developed in to those in residential and nursing care.7 of progression is reduced. Those teeth industry, particularly Japanese automobile Tooth loss is typically an incremental that were susceptible will have been production lines, where there was a focus process that tends to occur throughout life lost through incremental extraction. on clearly defi ned steps that resulted in and is more common than edentulism. Dry mouth is often cited as a a consistent and predictable outcome.12 Predicting it can be complex, and its consequence of age that is exacerbated by The adoption of care pathways in impact on the remaining dentition, the polypharmacy and other disease processes. medicine has been rapid over recent provision of prosthesis and its effect Remembering that xerostomia is the years and they aim to collate best on quality of life can be substantial.8 subjective feeling of dry mouth, whereas evidence and present this to clinicians

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in a supportive way so practitioners have the implicit rationale behind the work was One of the comments raised in the a more effi cient and predictable means older patients, and it became clear there conference was that this group was of treating patients. The care pathway had to be a “trigger age,” an age at which commonly seen in general practice, represents a journey — one that may patients should be considered against the but often “fell off the radar,” meaning be paused, for example, while specialist pathway to ensure a change in dependency they began to fail to attend and before tests are conducted or a caregiver is was not missed. An age of 55 years was long were lost to the practice. This was consulted, or one that may be deviated agreed upon, with the assumption that at recognized as an important place to from if clinical experience dictates it. this chronological time point almost every start considering the impact of aging. It is a journey that can be modifi ed patient would be in the “nondependent” For this group, the importance is to based on local, regional and nationally category. Despite this stated trigger start the conversation about what may available guidance and resources.13 point, dentists should remain vigilant to happen in the future. How can we keep Pathways should therefore be viewed the onset of dependency at any age.1 in touch in case things change? It was as enablers — documents or processes agreed that complex treatment plans that assist in clinical decision making Implementing the Pathway in this group were not contraindicated and, if followed correctly, can result in a The care pathway describes the but a conversation about implications predictable outcome as well as providing assessment, preventive regime, treatment on the maintenance of such treatments support for a clinician’s approach to a and communication recommendations should things change was important. particular patient presentation. The for each level of dependency (TABLE 3). These groups need, as all patients full Seattle Care Pathway considered While the table is designed to be easy to do, a good home-care/self-care plan individuals, populations, treatments, implement and understand, the authors with an emphasis on prevention. The prevention and communication issues of the pathway determined that clinical concept of “protecting the investment” for varying levels of dependency ranging vignettes or examples might help the was raised. These patients have spent from no dependency through high application. A series of examples were considerable fi nancial and time resources dependency. The dependency categories included in the article and some further on their oral health. As risk factors were described as shown in TABLE 21 and case scenarios, looking at no, pre- and may increase with age, we should the care pathway in full in TABLE 3. medium dependency, are described here. provide them with information and These dependency categories were The purpose is to place the pathway into guidance to help them maintain this. developed to ensure critical elements real-life context for dental practitioners, Frequently reviewing medical history within the life course could be captured. considering those patients who are most and medicine will be important. They were also felt to be “tipping likely to present. points” when approaches to care would Predependency change. All but the highest level of No Dependency These patients present with a dependency may represent patients These are older individuals who are fi t chronic systemic condition with seen in community dental practice. As and exercise regularly. An example of this potential impact on oral health, the defi nitions were discussed, many type of patient might be the following: which at point of presentation, is well in the group could identify these with “Arnold is a 75-year-old who lives controlled. An example of this type their own patients or family members. at home with his wife and three dogs. of patient might be the following: Once the categories of patients were He exercises regularly and is actively “Sarah is 66 years old and is a determined, the evidence base around involved in dog training for new dog widow living alone. She is active in their prevention and treatment options owners in his community. He attends her community and attends church could be collated. The pathway document six-month recalls at your practice regularly where she has an extensive was presented in tabular form with the and three-month cleanings with your social network. She sometimes uses a main supporting evidence provided.1 hygienist. When you review his chart, walking stick when she feels a little dizzy, Throughout the development of the the last treatment you provided was and is taking medications for diabetes guidance, the authors worked on the basis a replacement restoration two years and high blood pressure but both are of dependency rather than a particular ago. He is on a statin for cholesterol well controlled. She recently had an chronological age. However, it was clear but otherwise is on no medication.” CONTINUES ON 436

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TABLE 3 The Seattle Care Pathway

Dependency Level Assessment Prevention

No Dependency Routine processes in locality — U.K. National Dental Assessment. Locally derived guidance — U.K. Delivering Better Oral Health. Recall interval based on risk assessment (U.K. National Institute for Health and Care Excellence (NICE) guidance). Use of dependency checklist. Assessment of long-term viability of oral health.*

Predependency Condition identifi ed and risk assessment undertaken to inform any potential Based on assessment consider the following: 18 increased frequency of contact. Caries: High-fl uoride toothpaste, varnishes, gels and mouth rinses.22 19 Consideration of additional diagnostics (for example salivary fl ow rate). Perio: Antibacterial toothpaste, professional cleaning, Oral health care plan — Strategy — Treatment plan.20 chlorhexidine (not long-term use), oral hygiene instruction. Recognition that risk may be greater as result of increasing dependency. Oral cancer: Risk modifi cation and education.11 Assessment of long-term viability of oral health. Tooth service loss: Risk modifi cation, sensitivity products 23 Consideration of use of skill mix.21 as indicating. Production of daily oral care plan (home care).

Low Dependency Manifestation identifi ed and risk assessment undertaken and increased Assessment of the reason behind the impact — prevention frequency of contact unless compelling reasons to maintain current based on mitigation of factors.22 18 frequency. Defi nitive move to evidence-based prevention products.24 Recognition that risk may be greater as result of increasing dependency. Consideration of how these can be delivered — for example Assessment of long-term viability of oral health. high-fl uoride25 toothpaste now combined with electric 25,26 Oral health care plan — Strategy — Treatment plan.20** toothbrush or modifi ed brush. 27 Consideration of use of skill mix.21 Consider medication issues both in terms of systemic impact and sugar free.28 Consider recommending gum chewing and/or salivary substitutes if indicated.29 Production of daily oral care plan.

Medium Dependency Usage of support identifi ed and risk assessment undertaken and Ensure that the prevention routine is both adequate — increased frequency of contact unless compelling reasons to maintain i.e., move from high- to very-high fl uoride toothpaste; that current frequency.18 routine can be delivered by others if required.25 Recognition that risk may be greater as result of increasing dependency. Education of caregivers in delivery of prevention. Assessment of long-term viability of oral health. Consider increased use of professional applied products — Oral health care plan — Strategy — Treatment plan.20 utilization of increased patient contacts, i.e., nurse-applied varnishes.30 Consideration of use of skill mix.21 Consider recommending gum chewing and/or salivary substitutes if indicated.29 Production of daily oral care plan.

High Dependency Inability to receive care elsewhere identifi ed and risk assessment Focusing prevention on easily deliverable products and undertaken and increased frequency of contact† unless compelling therapies, emphasis on pain and infection management.14 18 reasons to maintain current frequency. Further move to professional products, including varnishes Recognition that risk may be greater as result of increasing dependency. and gels. Assessment of long-term viability of oral health. Consideration of prevention of disease complications — 30 Oral health care plan — Strategy — Treatment plan.20 i.e., chlorhexidine use to prevent respiratory infections. Consideration of use of skill mix.21 Production of daily oral care plan.

© 2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2014; 31 (Suppl. 1): 77–87.1 Reproduced with permission. * Consideration of the long-term success, impact and maintenance of current restorative condition, oral health and prevention. ** Development or modifi cation of this plan. † Contact is defi ned as an activity involving contact between patient and the wider dental team.

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Treatment Communication Based on an assessment of patient need to secure oral health. Speak to patient about long-term oral health issues especially when considering complex treatment modalities that require replacement and/or maintenance.

Based on patient needs but with greater consideration of long-term Identifi cation of the condition and its likely future impact on oral care — viability of treatments given assessment of likely dependency in the future education of patient. and impact on oral care. Communication with general care physician re: conditions.

Consideration of the strategic importance of retaining teeth.31 Discussion around care plans, caregivers, social circumstances as appropriate. Shortened dental arch, and longevity and maintenance of more complex Need for strategic approach to retaining functional occlusal contacts. procedures.32 Link in with wider health care team — around medication management (sugar Provision of implant support dentures where indicated.31 in medicines). Based on maintaining function and freedom from infection and pain — plan for failure.

Further consideration of strategic importance, repair rather than Establish link with source of support to ensure that daily oral health plan can replace, glass ionomer cement for fl uoride release in dry mouth, be delivered and that prevention modalities are appropriately implemented. adhesive bridgework. Minimal intervention to preserve health but consideration of long-term viability which may lead to more complex treatments being recommended, for example implants to support lower denture.31 Use of simple restorative techniques such as atraumatic restorative technique.33 Change attachment types on implant or tooth supported overdentures.34

Palliative treatment based on patient demand ensuring freedom from pain Ensure that the patient is at the center of discussions to ensure that what is being or infection, and esthetics where required.14 delivered is what is needed.

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CONTINUED FROM 433 anterior tooth extracted following a With assistance, he can attend the should be commenced with frequent persistent periapical infection and this practice, but these appointments recalls that should be facilitated between was added to her partial denture. She need to be scheduled carefully and his the dental offi ce and the residential fi nds the additional tooth uncomfortable caregiver must accompany him. John home. Restorative treatment should and wants to know what can be done.” has mild dementia and can consent to be designed with easy maintenance in Sarah is considered predependant his treatment but has poor short-term mind and it may be inappropriate to as her diabetes and high blood pressure memory and often repeats his questions. consider complex work that may become could, if they became unstable, adversely He is on a range of medications that increasingly diffi cult to clean in the affect her oral health. She is struggling have caused salivary hypofunction future. Consideration could be given to with her adapted denture, which may and he complains of a dry mouth. treatments that might be adapted in the be affecting her ability to socialize or John consumes a large number of future, for example, fi xed implant work eat. The care pathway for predependant candies in an attempt to stimulate that might be changed to removable.14,15 individuals advocates a candid approach saliva and he has an extensively Patients in the medium dependency to communicating with the patient. It is restored dentition in which there is group, when questioned in focus important to articulate the risks of poor groups, placed access to care as their disease management with the patient, top priority, followed by a pain-free, in this case the polypharmacy, and this functional dentition. They fear their should impact on the recall interval Prevention should be the loss of independence will prevent them for Sarah. Prevention should be the centerpiece of a detailed home- from going to the dentist to receive the centerpiece of a detailed home-care plan care plan and consideration care they need, therefore, assuring them and consideration should be given to the of continued access and facilitating this inclusion of high-fl uoride dentifrices, gels should be given to the inclusion are key. The importance of oral hygiene or mouth rinses. In terms of the treatment of high-fl uoride dentifrices, measures should be made clear to care offered to Sarah, this must be considered gels or mouth rinses. personnel and a written plan is essential. in the context of her potentially increasing The full care pathway document dependency and therefore should be easy provides further examples of the to maintain but may need adaptation management of patients with over time. Efforts should be made to evidence of new carious lesions and increasing dependency and should ensure that, within her care record, the failing extracoronal restorations. He be consulted by those practitioners contact details for her family, or perhaps doesn’t report any pain at present.” who serve such populations.1 someone in her church group, are recorded John is a patient who is on the so they may be contacted if Sarah fails “tipping point.” His medications are Cultural/Generalizability to attend her recall appointments. having a direct impact on his oral Care pathways, such as the Seattle health and he requires an immediate Pathway, are designed to be generalizable Medium Dependency and aggressive preventive approach. to a range of populations, health service These are patients with an identifi ed Given his cognitive diffi culties, organizations and cultures. They should chronic systemic condition that is these need to be coordinated with be consistent with, or enable the currently impacting oral health and who his caregiver and should include incorporation of, local, regional and receive or require support in managing high-fl uoride products, for example, national guidance and regulations. They access to dental services or maintaining 5000 ppm toothpaste. Plaque control should be operable in insurance and oral health. This category would include measures should be discussed with him state-funded systems. It is therefore a patients who demand to be seen at home and his caregiver, and his physician requirement of practitioners to assess the or who cannot get transportation to a should be contacted to see if it is guidance and consider its implementation dental clinic. An example of this type possible to alter his medication regime within their practice population. of patient might be the following: to reduce the dry mouth symptoms. The impact of culture should not “John is living in residential care in Professional prevention, for example, be ignored when considering the needs the same town as your dental practice. the application of fl uoride varnish, of patients in this group. Lo described

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Gerodontology of root caries: A literature review of primary and secondary education and continuing professional 2014 31 Suppl 1: 25-30. 17 preventive agents. Spec Care Dentist 2013. 33(3): 133-40. education courses address these concerns. 11. Hunter KD, Yeoman CM An update on the clinical 31. Heath MR, Wright PS. The teaching of prosthodontic care pathology of oral precancer and cancer. Dent Update 2013. for older people: a non-rote philosophy. Gerodontology 1997. Summary 40(2): 120-2, 125-6. 14(2): 113-8. 12. Vanhaecht K, Panella M, van Zelm R, Sermeus W. An 32. Kanno T, Carlsson GE. A review of the shortened dental The purpose of this article has been overview on the history and concept of care pathways as arch concept focusing on the work by the Kayser/Nijmegen to present and describe the rationale complex interventions. Int J Care Pathw 2010. 14: 117-23. group. J Oral Rehabil 2006. 33(11): 850-62. behind the Seattle Care Pathway. The 13. Rooney E. Developing care pathways — Lessons from the 33. Gil-Montoya JA, Mateos-Palacios R, Bravo M, Gonzalez- Steele Review implementation in England. Gerodontology Moles MA, Pulgar R. Atraumatic restorative treatment and authors recognize the pathway may be 2014. 31 Suppl 1: 52-9. Carisolv use for root caries in the elderly: Two-year follow-up a fi rst step to providing an evidence- 14. Beck JD, Ettinger RL. Rational dental care in the long-term randomized clinical trial. Clin Oral Investig 2013. based approach to the management care facility. J Am Health Care Assoc 1981. 7(3): 22-4, 34. Andreiotelli M, Att W, Strub JR. Prosthodontic complications 29-30. with implant overdentures: A systematic literature review. Int J of this increasingly complex group of 15. Ettinger RL. Rational dental care: Part 1. Has the concept Prosthodont 2010. 23(3): 195-203. patients who are destined to become an changed in 20 years? J Can Dent Assoc 2006. 72(5): 441-5. ever-greater proportion of our practice 16. Lo EC, Tan HP. Cultural challenges to oral health care THE AUTHOR, Iain A. Pretty, BDS, MSC, MPH, PhD, FDSRCS(ED), implementation in elders. Gerodontology 2014. 31 Suppl 1: can be reached at [email protected]. populations. The overarching advice 72-6. is that prevention, both self care and 17. Wolff MS, Schenkel AB, Allen KL. Delivering the evidence — skill mix and education for elder care. Gerodontology 2014. professional, is key for these patients 31 Suppl 1: 60-6. and the practitioners should be vigilant 18. Steele JG, Walls AW. Strategies to improve the quality of about changes in the health and social oral health care for frail and dependent older people. Qual Health Care 1997. 6(3): 165-9. circumstances of their older adult patients. 19. Cunha-Cruz J, Scott J, Rothen M, Mancl L, Lawhorn T, While products and therapies exist for Brossel K, et al. Salivary characteristics and dental caries: this cohort of patients, there is a need for Evidence from general dental practices. J Am Dent Assoc 2013. 144(5): e31-40. robust clinical trials in this population, 20. Jenson L, Budenz AW, Featherstone JD, Ramos-Gomez as well as further consideration of how FJ, Spolsky VW, Young DA. Clinical protocols for caries dental service funding, either public or management by risk assessment. J Calif Dent Assoc 2007. 35(10): 714-23. private, can be leveraged to support the 21. Gallagher JE, Lim Z, Harper PR. Workforce skill mix: implementation of effective prevention. ■ modelling the potential for dental therapists in state-funded

AUGUST 2015 437 Read this issue on your iPad.*

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CDA JOURNAL, VOL 43, Nº8

Root Caries in Older Adults

Dick Gregory, DDS, and Susan Hyde, DDS, MPH, PhD, FACD

ABSTRACT Older adults are retaining an increasing number of natural teeth, and nearly half of all individuals aged 75 and older have experienced root caries. Root caries is a major cause of tooth loss in older adults, and tooth loss is the most signifi cant negative impact on oral health-related quality of life for the elderly. The need for improved preventive efforts and treatment strategies for this population is acute.

GUEST EDITORS

Dick Gregory, DDS, is the Susan Hyde, DDS, MPH, ental caries is a transmissible Carious lesions are termed either San Mateo Center director PhD, FACD, chairs the infection caused by specifi c primary (new lesions on previously for Apple Tree Dental. He division of oral bacteria (Streptococcus unrestored surfaces) or secondary (new completed his dental epidemiology and dental degree at the University of public health at the mutans, Streptococcus sobrinus, caries around existing restorations). California, Los Angeles, University of California, San Lactobacilli and others) They occur on the crowns of teeth and School of Dentistry in 1980 Francisco, School of Dthat colonize tooth surfaces, feed on exposed root surfaces. Periodontal disease and a two-year post- Dentistry. She is the dental carbohydrates and produce acids as waste results in loss of gingival attachment and graduate multidisciplinary director of UCSF’s products. These acids dissolve the mineral exposure of the tooth’s root surface. Root geriatric fellowship at the multidisciplinary fellowship University of California, San in geriatrics and faculty content of the tooth, and if not halted surface cementum and dentin are more Francisco in 2014. During lead for interprofessional or reversed, a carious lesion is formed.1 susceptible to cavitation because they are the intervening three education for the School of The risk for dental caries persists less mineralized than enamel and begin decades, he cared for his Dentistry. Dr. Hyde received throughout life. A dynamic balance to demineralize at a higher salivary pH. patients while in private her dental degree from exists between pathological factors Older adults are retaining an general dental practice UCSF, Master of Public in Northern California. Health and doctorate of that promote caries and protective increasing number of natural teeth, and Confl ict of Interest philosophy (epidemiology) factors that inhibit it. Pathological nearly half of all individuals aged 75 and Disclosure: None reported. from the University of factors include acid-producing bacteria, older have experienced root caries. Root California, Berkeley, and frequent consumption of fermentable caries is a major cause of tooth loss in certifi cates in dental public carbohydrates, poor oral hygiene, as older adults, and tooth loss is the most health and geriatrics from UCSF. well as subnormal salivary fl ow and signifi cant negative impact on oral health- Confl ict of Interest composition. Protective factors include related quality of life for the elderly.2 Disclosure: None reported. normal salivary function, fl uoride, A false perception exists among dental daily thorough oral hygiene, casein professionals and policy makers that dental phosphopeptide-amorphous calcium caries is, for the most part, only active in phosphate paste (GC’s Tooth Mousse, younger people. Several of the clinical, MI Paste and Recaldent) and extrinsic social and behavioral changes common to topical antibacterial substances.1 aging predispose older adults to the highest

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multiple medications. More than 500 care modalities (chlorhexidine and medications have the potential to fl uoride rinse or varnish) can be used decrease salivary fl ow, which leads to proactively to prevent carious lesions xerostomia and subsequently dental and therapeutically to remineralize early caries. Other social and behavioral carious lesions. Restorative procedures factors that contribute to the higher for more advanced lesions can be FIGURE 1. Primary root caries under heavy plaque frequency of root caries in older adults conservative, preserving tooth structure accumulation: Teeth Nos. 22–27. include lack of a perceived need for and benefi ting patient oral health.9 dental treatment and a history of CAMBRA has proven to be a practical smoking and alcohol consumption.7,8,9 caries risk assessment methodology and rates of decay are discussed below. The Good oral hygiene is also compromised a systematic and effective approach need for improved preventive efforts and by existing dental restorations and the to caries management. Targeted treatment strategies for this population presence of oral prostheses and appliances. antibacterial and fl uoride therapy based is acute. Better clinical surveillance by Wearing a removable partial denture is on salivary microbial and fl uoride levels public health agencies will drive decisions associated with higher rates of dental has been shown to favorably alter the about oral health policy and education.3,5 caries. It is unclear whether this is due to balance between pathological and the initial high caries rate which resulted protective caries risk factors. Caries risk Prevalence and Risk Factors in tooth loss or if the denture has a role assessment with aggressive preventive The prevalence of untreated root in causing caries due to increased root measures and conservative restoration caries is 12 percent for adults aged surface exposure on the abutment teeth, has been shown to result in a reduced 65-74 and 17 percent for those aged food impaction and plaque accumulation.4 two-year caries increment compared 75 and older.5 African Americans and to traditional, nonrisk-based dental Mexican Americans experience more Caries Risk Assessment treatment. Altering the caries balance oral health problems, including dental Understanding factors and behaviors by reducing pathological factors and caries, throughout the life course. that directly or indirectly impact caries enhancing protective factors, namely Lower educational attainment is also pathogenesis offers opportunities to antimicrobial and fl uoride rinses, reduced strongly associated with increased reduce the caries burden of the aging caries risk and resulted in fewer carious oral health problems at all ages population. Caries management by lesions. Readers are encouraged to and across all races (FIGURE 1). risk assessment (CAMBRA) is a further familiarize themselves with this Aging is often associated with changes conservative and effective approach research and CAMBRA methodology.1 in oral morphology, chronic systemic to prevention and treatment of the For the older adult population the disease such as diabetes and decreasing disease across the life course.9 Caries etiology and pathogenesis of dental caries dexterity, making personal oral hygiene pathogenesis is recognized as a balance are known to be multifactorial, but the more diffi cult, particularly for the oldest between protective factors (fl uoride, interplay between intrinsic and extrinsic and most frail individuals. The pain calcium phosphate paste, suffi cient factors is still not fully understood. Caries of arthritis and neuropathies make it saliva and antibacterial agents) and research commonly tests an intervention diffi cult to grasp or manipulate a manual pathological factors (cariogenic bacteria, for a single pathological factor; however, toothbrush. Patients with dementia inadequate salivary function, poor oral it is observed that effective caries control experience a higher prevalence of caries hygiene and dietary habits — especially requires a comprehensive and coordinated than those without dementia, and the frequent ingestion of fermentable approach. The predictors of root caries rates are related to dementia type and carbohydrates).9 Correctly assessing caries most frequently reported in the literature severity. Individuals needing assistance risk can identify a therapeutic treatment are caries history, number of teeth with oral hygiene and whose caregivers regimen for effectively managing the and plaque index.10 In addition to the have diffi culties providing effective oral disease by reducing pathological factors pathological factors mentioned in the care experience the highest rates.6 and enhancing protective factors, introduction to this chapter, patients with Another risk factor that often resulting in fewer carious lesions.9 With one or more existing carious lesions are accompanies aging is patients taking accurate risk assessment, noninvasive at risk for additional new carious lesions

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There is questionable evidence that to caries is limited. Utilizing the xylitol and sorbitol gum can be used human genome sequence to improve as an adjunct for caries prevention.15 understanding of a genetic contribution Cariogenic bacteria prefer six-carbon to caries pathogenesis will provide a sugars or disaccharides and are not able foundation for future research.18 to ferment xylitol, depriving them of FIGURE 2. Tooth No. 11 shows secondary caries an energy source and interfering with Saliva apical to a root carious lesion previously restored growth and reproduction. Systematic Saliva contains many important caries- with amalgam. reviews of clinical trials have not protective components, such as calcium, provided conclusive evidence that phosphate and fl uoride, which are essential in the future. Simply restoring a single xylitol is superior to other polyols such to tooth surface remineralization. Salivary lesion does not reduce the bacterial loads as sorbitol 16 or equal to that of topical proteins and lipids form a protective in the rest of the mouth (FIGURE 2). fl uoride in its anticaries effect.17 pellicle on the tooth surface, while other Dental plaque is a complex biofi lm proteins bind calcium, maintaining saliva constantly forming and maturing. Pathological Factors Versus Protective as a supersaturated mineral solution. It consists of microorganisms and Factors Diet Bicarbonate, phosphate and peptides extracellular matrix including cariogenic A lifetime of caries and/or periodontal in saliva provide a critical pH-buffering acid-producing bacteria. In high caries disease frequently results in tooth loss. function. With age, the amount of saliva risk individuals the bacterial challenge In addition to the reduced masticatory remains stable, however, saliva becomes must be lowered to favorably alter the function accompanying tooth loss, thicker due to a reduction in serous caries balance. Patients with moderate it is also common for older adults to fl ow relative to the mucous component, to high levels of mutans streptococci experience a diminished ability to taste resulting in decreased lubrication or and lactobacilli require targeted food. The resultant dietary shift from perceived decreased moistness. antibacterial treatment and fl uoride to complex to simple sugars promotes caries. combat growth and remineralize tooth Cariogenic bacteria metabolize sucrose, Fluoride surfaces.1 Recommended regimens are glucose, fructose and cooked starches to Other than the pre-eruptive described in the next paragraph. produce organic acids that dissolve the mineralization of the developing Evidence-based clinical mineral content of enamel and dentin. dentition, systemic benefi ts of fl uoride recommendations generally favor fl uoride- The amount, consistency and frequency are minimal. The anticaries effects of containing caries preventive agents, of consumption determine the rate fl uoride are primarily topical in adults. however, chlorhexidine-thymol varnish and degree of demineralization. Some The topical effect is described as a has also been shown to be effective in the medications and dietary supplements constant supply of low levels of fl uoride treatment of root caries.15 A 38% solution containing glucose, fructose or sucrose at the biofi lm/saliva/dental interface of silver diamine fl uoride (SDF) applied also contribute to caries risk.15 being the most benefi cial in preventing annually (Saforide, Bee Brand Medico dental caries. Therapeutic levels of Dental, Toyko), or 5% sodium fl uoride Genetic Susceptibility fl uoride can be achieved from drinking varnish applied every three months,11 or There appears to be variation in fl uoridated water and the use of fl uoride 1% chlorhexidine varnish applied every individual susceptibility to caries. Intrinsic products (toothpaste, rinse, gel, varnish). three months,12 have all been found more host factors related to the structure Fluoride can inhibit plaque bacterial effective in preventing new root caries of enamel, immunologic response to growth, but more signifi cantly, fl uoride than giving oral hygiene instruction cariogenic bacteria and the composition inhibits demineralization and enhances alone.13 Recent recommendations for the of saliva play key roles in modulating the remineralization of the tooth surface.1 prevention of primary root caries called for initiation and progression of the disease. The most widely used forms of fl uoride the professional application of 38% SDF Genetic variation of the host factors delivery have been the subject of several solution annually and 22,500 ppm sodium may contribute to an increased risk for systematic reviews, providing strong fl uoride varnish applications every three dental caries. However, the evidence evidence supporting the use of dentifrices, months to prevent secondary root caries.14 supporting an inherited susceptibility gels, varnishes and mouth rinses for the

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control of caries progression. Dentifrices of the likelihood of dark staining of new caries than fl uoride varnish, and with fl uoride concentrations 1,000 their teeth during chlorhexidine use, may be a valuable caries-preventive ppm and higher have been shown to be and that the staining is easily removed intervention. Possible mechanisms clinically effective in caries prevention during a dental prophylaxis. Bacterial for SDF’s clinical success include its when compared to a placebo treatment. testing should be used to monitor antimicrobial activity against a cariogenic More evidence is needed to determine the clinical success of chlorhexidine biofi lm of S. mutans or A. naeslundii the benefi ts of the combined use of therapy.20 Better antibacterial therapies formed on dentin surfaces and slowing two modalities of fl uoride application for high caries risk individuals are down the demineralization of dentin.21 as compared to a single modality.19 needed, and they must be combined While SDF is available from international Considering the currently available with remineralization by fl uoride.1 chemists online and has been shown to evidence and risk-benefi t aspects, Chlorhexidine is effective at be as safe as fl uoride varnish, effective brushing twice daily with a dentifrice reducing the bacterial challenge in for treating carious lesions and is containing fl uoride is one of the most high caries risk individuals even when widely used in other countries, it does effective ways to control caries. However, compliance is problematic. In the not currently have FDA approval. brushing alone does not overcome a high bacterial challenge, and additional Clinical Decision Making fl uoride therapy should be targeted toward Diagnosis of a carious lesion on a individuals at high caries risk. Frequent Brushing alone does not root surface raises ethical and practical topical application of fl uoride appears to overcome a high bacterial questions. Can the lesion be remineralized be a successful treatment for incipient challenge, and additional with fl uoride therapy or does it require root caries lesions by remineralizing a restoration? Is it an active or arrested decalcifi ed structure, irrespective of fl uoride therapy should be carious lesion? Is the root caries causing the type of fl uoride treatment used.1 targeted toward individuals or likely to cause pain? How do the at high caries risk. risks and benefi ts to the patient of not Chlorhexidine treating a carious lesion compare to those The use of chlorhexidine for caries associated with restoring it? Does the prevention has been a controversial topic patient have access to follow-up care? among dental educators and clinicians. absence of regular professional teeth If the lesion is to be restored, what Chlorhexidine rinses, gels and varnishes or cleaning and oral hygiene instruction, technique and material will result in combinations of these items with fl uoride chlorhexidine varnish may provide the best outcome for the patient? What have variable effects in caries prevention, a benefi cial effect for frail elders and is the patient’s ability to maintain the and the evidence is regarded as “suggestive patients with xerostomia.20 Cervitec Plus restoration and what is the future caries but incomplete.” The most persistent (Ivoclar Vivadent Inc., Amherst, N.Y.), risk? Systemic disease burden, xerogenic reductions of mutans streptococci have a chlorhexidine-thymol varnish, may medications, diet quality, salivary function, been achieved, in order of more effective help to control established root lesions manual dexterity, cognitive ability, the to less effective, by chlorhexidine varnish and reduce the incidence of new root need for caregiver assistance and access followed by gels and, lastly, mouth rinses. caries among institutionalized elderly. to care all contribute to caries risk. While chlorhexidine had been widely used It is the only nonfl uoride caries agent The literature suggests that there is in Europe before gaining FDA approval, to receive a favorable recommendation a fair agreement between visual/tactile the only chlorhexidine-containing from a panel for caries prevention.13 appearance of caries and the severity/ products currently marketed in the depth of the lesion. No single clinical United States are 0.12% chlorhexidine Silver Diamine Fluoride predictor is able to reliably assess the mouth rinses. The preferred dosage Recent interest in the antimicrobial activity of a carious lesion.10 However, a regimen for rinsing is once a day with 5 use of silver compounds suggest that silver combination of predictors increases the cc of a 0.12% chlorhexidine gluconate nitrate (SN) and silver diamine fl uoride accuracy of lesion activity prediction for solution for one week every month for (SDF) are more effective at arresting both primary coronal and root lesions. a year.1 Patients should be informed active carious lesions and preventing Three surrogate methods have been used

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for evaluating lesion activity (construct restorations.22 When pulpal exposure is a caries lesions at or near the gingival validity); all have disadvantages. If concern in treating deep lesions, partial margin where most occur. Self- construct validity is accepted as a “gold caries removal is the preferred approach.22 etching adhesives provide decreased standard,” it is possible to assess the In the absence of clinical symptoms clinical application time and reduce activity of primary coronal and root of pulpal involvement, stepwise caries the risk of saliva contamination.25 lesions reliably and accurately at one excavation to stained but fi rm dentin A 2009 Statement on Dental examination by using the combined followed by the placement a thin liner Amalgam released by the American information obtained from a range of of calcium hydroxide or antimicrobials Dental Association Council on indicators, such as visual appearance, such as chlorhexidine-thymol varnish Scientifi c Affairs remains consistent location of the lesion, tactile sensation or polycarboxylate cement combined with a more recent review of the during probing and gingival health.10 with a tannin-fl uoride preparation, international literature on amalgam Treating root caries can be technically are all effective in reducing bacteria toxicity. Various anecdotal complaints challenging. The location of the root and promoting remineralization of systemic toxicity because of mercury caries may be diffi cult to access. It often of any carious dentin that remains release from dental amalgam do not may extend below the gingival margin, after the stepwise excavation.23 justify the discontinuation of amalgam making it necessary to retract the gingiva There is limited scientifi c evidence use from dental practice or the with a clamp, pack retraction cord to for laser treatment being as effective replacement of serviceable amalgam expose the cervical margin of the lesion, as a rotary bur for removing carious fi llings with alternative restorative or utilize laser or electrosurgery to tissue. However, treatment time with dental materials.26 Available scientifi c recontour the gingiva and obtain access lasers is prolonged compared to using a data show that the mercury released to the lesion. One important and relevant traditional handpiece, and to date no from dental amalgam restorations does diagnostic consideration is, “What is conclusions can be drawn regarding not contribute to systemic disease the clinician’s ability to successfully biological or technical complications or or systemic toxicological effects. No restore a particular carious lesion?” The the cost-effectiveness of the method.24 signifi cant effects on the immune location of the carious lesion on the system have been demonstrated with tooth, the tooth’s location in the mouth Restorative Materials: Amalgam, the amounts of mercury released and the patient’s ability to cooperate all Composite and Glass Ionomer from dental amalgam restorations, contribute to the challenge of placing a The longevity (failure rate, median and only very rarely, have there successful restoration. How extensive and survival time, median age) of silver been reported allergic reactions to close to the pulp is the carious lesion? amalgam fi llings has been compared to mercury from amalgam restorations.26 How likely is a pulp exposure and the direct composite fi llings in permanent No evidence supports a relationship subsequent need for root canal therapy? teeth. Amalgam fi llings have been between mercury released from dental Will the operator be able to achieve a shown to have greater longevity than amalgam and neurological diseases.26 dry fi eld and have adequate visualization composite fi llings. However, composites Glass ionomer, resin-modifi ed glass and access with a handpiece and/or and their adhesives are frequently ionomer and composite resin have been instruments? Will conservative caries replaced by the next generation of compared in high caries risk patients. removal result in a better outcome for materials with improved properties, Both glass ionomer and resin-modifi ed the patient than aggressive treatment? making periodic revisions of these glass ionomer restorations contain conclusions necessary.25 Economic fl uoride and release it into the saliva Caries Removal analyses report lower costs for amalgam and adjacent tooth structure. While Partial caries removal has been fi llings because of the higher complexity no signifi cant difference in caries found to greatly reduce the risk of pulp of and time needed to place composite prevention between the two materials exposure.22 For asymptomatic teeth, partial fi llings. Resin bonding to dentin or has been observed, reduction in new caries removal generally results in no enamel requires adequate isolation caries formation for glass ionomer and detriment to the patient from increased and saliva contamination control. resin-modifi ed glass ionomer restorations pulpal symptoms, decay progression This is time consuming and often was more than 80 percent greater under restorations or premature loss of diffi cult to achieve in restoring root than for composite resin restorations

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FIGURE 3A.

FIGURE 3B. FIGURE 3C. FIGURES 3A—C. Root caries are clinically detectable on most remaining teeth. The clinical crown on tooth No. 11 is completely missing due to caries. The arrow points to an example of root caries.

caries.30 ART uses a high-viscosity glass ionomer restoration to restore single- surface lesions in permanent posterior teeth, including root carious lesions. There appears to be no difference in the survival of single-surface, high-viscosity glass- ionomer ART restorations and amalgam restorations in permanent posterior teeth including Class V root surface lesions.30

Clinical Scenario The director of nursing in a local residential care facility requests a consultation with a dentist for Mrs. Switzer, who is 86 years old and has a fractured maxillary left lateral incisor. Mrs. Switzer was admitted to the facility three weeks previously with moderate Alzheimer’s disease, depression and FIGURE 4. Radiographs taken to determine the extent of the carious lesions (see clinical scenario for details). severe hypertension. Mrs. Switzer attended her dentist one month before in the treatment of cervical caries for as demonstrated by radiographic quality entering the facility but did not follow head and neck radiation patients with is the single most important predictor for the dentist’s recommendations for xerostomia who did not adhere to a caries- restoration survival.23,28 When compared periodontal debridement, intracoronal preventive fl uoride rinse protocol.26,27 to amalgam, signifi cantly less secondary restorations and a fi xed partial denture. Glass ionomer is particularly suitable caries has been observed at the margins of Before this appointment, Mrs. Switzer for restoring root carious lesions. It single-surface glass ionomer restorations had not been to the dentist in two years, has good esthetic and anticariogenic in permanent teeth after six years.29 although she claimed to have visited her properties, allows for chemical bonding to dentist frequently over the years before teeth and has gained wide acceptance in Atraumatic Restorative Treatment then. Consequently, she is referred to restoring carious lesions on the accessible Atraumatic restorative treatment the care facility’s dentist for further buccal and lingual root surfaces. Minimally (ART) is an essential caries management assessment and treatment of the fractured invasive techniques for restoring more technique for improving access to oral tooth. The dentist examines Mrs. diffi cult to access interproximal root care. The approach, initiated 25 years Switzer to confi rm that the maxillary surfaces with glass ionomer have been ago in Tanzania, has evolved into a caries left canine has an asymptomatic but developed demonstrating a survival rate management concept for improving complete coronal fracture due to root of 77.4 percent at 80 months. Caries quality and access to oral care globally. caries (FIGURES 3A–C). He notes also removal, complete fi lling of the resulting Local anesthesia is seldom needed and that there is copious plaque and food cavity preparation and marginal integrity only hand instruments are used to remove debris throughout the teeth and mouth.

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On questioning, Mrs. Switzer reveals rates of 90 percent with no signifi cant chlorhexidine varnish on root caries: a systematic review. Caries Res 2011; 45(2):162-73. Epub 2011 Apr 27. that she drinks tea sweetened with difference between ART restorations 14. Rosenblatt A, et al. A Critical Summary of: Silver sugar constantly “for energy” and to using high-viscosity glass ionomer and diamine fl uoride: a caries “silver-fl uoride bullet.” J Dent Res be sociable in the facility, and she those produced through the traditional 2009;88(2):116-25. 15. Tan HP, et al. A randomized trial on root caries prevention takes multiple medications for blood approach of complete caries removal in elders. J Dent Res 2010 Oct;89(10):1086-90. Epub 2010 pressure, depression and occasional using rotary instruments, resulting in a Jul 29. memory loss. The dentist requests the higher risk of pulp exposure.31 Anecdotal 16. Gluzman R, et al. Prevention of root caries: A literature review of primary and secondary preventive agents. Spec Care radiographs be taken before she enters clinical reports of dentists and expanded Dentist 10 Dec 2012. the facility to determine the extent function hygienists and assistants 17. Mickenautsch S, Yengopal V (2012). “Eff ect of xylitol of the carious lesions (FIGURE 4). providing on-site care for nonambulatory versus sorbitol: A quantitative systematic review of clinical trials.” Int Dent J 62 (4): 175-88. A diagnosis of extensive root caries older adults provide support from the fi eld 18. Shuler, C.F. J Dent Educ. Inherited risks for susceptibility to involving all previously restored teeth for this clinical approach. More research dental caries. 2001 Oct;65(10):1038-45. is made. A treatment plan of extraction is needed in a clinical randomized- 19. Pessan JP, et al. Topical use of fl uorides for caries control. Mono Oral Sci 2011; 22:115-32. of the fractured maxillary left lateral controlled trial environment to provide 20. Autio-Gold J. The Role of Chlorhexidine in Caries incisor and replacement using an systematic evidence for this approach. ■ Prevention. Oper Dent November 2008, vol. 33, no. 6, pp. acrylic removable partial denture is 710-716. 21. Chu CH, et al. Eff ects of silver diamine fl uoride on made. The carious lesions are scheduled Reprinted from Geriatric Dentistry: Caring for Our Aging Population (9781118925454/1118925459) with dentine carious lesions induced by Streptococcus mutans and Actinomyces naeslundii biofi lms. Int J Paediatr Dent 2012 for restoration using resin-modifi ed permission from John Wiley and Sons. glass ionomer material. The patient’s Jan;22(1)2-10. 22. Walls AW, Meurman JH. Approaches to caries prevention REFERENCES daughter is warned that excavation and therapy in the elderly. Adv Dent Res 2012 Sep;24(2):36- 1. Featherstone JDB, et al. 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Longevity of dental amalgam 4. Thomson WM. Dental caries experience in older people in comparison to composite materials. Int J Dent would be needed for the mandible. over time: What can the large cohort studies tell us? Br Dent J 2011;2011:981595. GMS Health Technol Assess 2008 Nov Personalized diet and daily mouth care 2004 Jan 24;196(2):89-92. 13;4:Doc12. Epub 2011 Nov. 5. Dye BA, et al. Trends in oral health status: United States, counseling is provided to the patient, 26. Uçar Y, Brantley WA. Biocompatibility of dental amalgams. 1988-1994 and 1999-2004. National Center for Health Int J Dent 2011;2011:981595. Epub 2011 Nov 23. daughter and nursing staff. Daily use Statistics. Vital Health Stat 11. 2007; Apr(248):1-92. 27. McComb D, et al. A clinical comparison of glass ionomer, of 0.2% neutral sodium fl uoride is 6. Rethman MP, et al. Nonfl uoride caries-preventive resin-modifi ed glass ionomer and resin composite restorations agents: Executive summary of evidence-based clinical prescribed for prevention of root caries. in the treatment of cervical caries in xerostomic head and neck recommendations. Dental Association Council on Scientifi c radiation patients. Oper Dent 2002 Sep-Oct;27(5):430-7. Aff airs Expert Panel on Nonfl uoride Caries-Preventive Agents. J 28. Gilboa I, et al. A longitudinal study of the survival of Future Directions Am Dent Assoc 2011;142;1065-71. interproximal root caries lesions restored with glass ionomer 7. Featherstone JDB, et al. Caries risk assessment in practice for age ART is expected to play a signifi cant cement via a minimally invasive approach. Gen Dent 2012 6 through adult. J Calif Dent Assoc 35(10):703-7,710-3, 2007. Jul-Aug;60(4):e224-30. part in essential caries management for 8. ten Cate JM, Featherstone JD. Mechanistic aspects of the 29. Mickenautsch S, et al. Absence of carious lesions at the frail elderly, especially as additional interactions between fl uoride and dental enamel. Crit Rev Oral margins of glass-ionomer cement (GIC) and resin-modifi ed GIC Biol Med 1991;2:283-296. scopes of practice are more widely restorations: a systematic review. J Prosthodont Restor Dent 9. Featherstone JD. The caries balance: the basis for caries 2010 Sep;18(3):139-45. included in an expanded clinical care management by risk assessment. Oral Health Prev Dent 30. Frencken JE, et al. Twenty-fi ve year atraumatic restorative team. One of the indications for the 2004;2(suppl 1):259-264. treatment (ART) approach: A comprehensive overview. Clin 10. Topping GV, et al. Clinical visual caries detection. Monogr appropriate use of the ART approach Oral Investig 2012 Oct;16(5):1337-46. doi: 10.1007/ Oral Sci 2009; 21:15-41. Epub 2009 Jun 3. s00784-012-0783-4. Epub 2012 Jul 24. is for the elderly who are homebound 11. Synopsis of Fluoride Varnishes (Project 06-16) (2/07). 31. Honkala S, Honkala E. Atraumatic dental treatment among or living in institutions. More studies www.airforcemedicine.af.mil/shared/media/document/AFD- Finnish elderly persons. J Oral Rehabil 2002;29:435–440. 130327-445.pdf. are needed to investigate the potential doi: 10.1046/j.1365-2842.2002.00903.x. 12. Cervitec Plus. www.ivoclarvivadent.com/en/competences/ of ART in providing essential caries all-ceramics/prevention-care/cervitec-plus. management in this population. However, 13. Slot DE, Vaandrager NC, Van Loveren C, Van Palenstein THE CORRESPONDING AUTHOR, Dick Gregory, DDS, can be fi eld trials report two-year survival Helderman WH, Van der Weijden GA. The eff ect of reached at [email protected].

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CDA JOURNAL, VOL 43, Nº8

Aging Periodontium, Aging Patient: Current Concepts

Mark Ryder, DMD

ABSTRACT A functioning natural dentition is essential to maintaining overall health in the elderly patient. While age-related alterations in periodontal tissues and the immune system may make an elderly patient more susceptible to periodontal breakdown, age itself is not a major risk factor for periodontal diseases. Rather, individual age-associated factors such as systemic diseases, medications and changes in behavior, motor function and cognitive function should be considered for each elderly patient when making treatment decisions.

AUTHOR

Mark Ryder, DMD, is n the U.S. and most of the developed life for the elderly is the maintenance of a the chair of the division of and developing world, there is an healthy and functional natural dentition. periodontology and director increased proportion of the population Maintenance of a healthy dentition of the postgraduate program in periodontology at the that is considered elderly. Numerous requires an understanding of the causes, University of California, factors, including declining birth rates diagnosis, risk assessment and timely San Francisco, School of Iand longer life spans because of improved treatment of the two primary causes of Dentistry. treatment and prevention measures, have tooth loss, periodontal disease and caries. Confl ict of Interest played a major role in this demographic This paper presents the current state of Disclosure: None reported. shift.1 Along with this demographic knowledge and opinion on approaches shift there has been a physiological, to periodontal diseases and periodontal psychological and philosophical shift treatment in the elderly with an emphasis among practitioners and the public with on consensus, conclusions and future the perception of what is considered “old directions for dental practitioners. age.” Such changes are apparent in the The central question in addressing emergence of concepts of “healthy aging”2 the role of aging in periodontal disease and the goal of “adding life to years” rather is whether aging itself is a risk factor for than “years to life.”3 Part of these new the incidence, severity and progression attitudes in improving the quality of the of periodontal disease. In other words,

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is periodontal disease a “risk factor” for the elderly may refl ect in large part ■ The effects of aging on motor periodontal disease initiation and/or these differences in attitudes in their function, cognitive function and disease progression? By risk factor we mean younger years with an accumulated behavioral changes that could a condition or factor that is associated effect toward their current condition. affect the ability to remove with the disease after adjusting for other Thus, the prevailing opinion among bacterial plaque deposits. contributing factors, such as tobacco use, the periodontal research community is Aging and the periodontal tissues. It is plaque levels and systemic conditions, and that age alone is not a major risk factor well-known that with aging, the ability has been demonstrated in longitudinal for the incidence of new destructive of tissues in the body to regenerate and studies. While it has been demonstrated periodontal disease or in its rate of repair diminishes over time.12,13 This is from large epidemiological surveys that progression. In a periodontally healthy due in part to the reduced ability of cells the elderly have a higher prevalence elderly patient some gingival recession to divide, leading to a reduction in the and severity of periodontal diseases,4-6 and slight horizontal bone loss may be number of cells in the full range of tissues particularly among African-Americans observed as part of the normal aging in the body. These changes have been and Hispanics,7 as measured by level of process. However, the susceptibility observed in periodontal tissues including loss of periodontal support when compared the gingival epithelium, connective to a younger cohort, these observations tissues and bone that form the need to be interpreted with caution. periodontal complex.12,13 In particular, Firstly, employing levels of loss of support Age alone is not a major the reduction of numbers of fi broblasts of alveolar bone, clinical attachment to maintain and repair both gingival loss, recession, etc. for determining the risk factor for the incidence connective tissues and periodontal incidence and/or severity of periodontal of new destructive ligament may lead to an increase rigidity disease at a single observational time periodontal disease or and/or loss of elasticity in these tissues. point does not indicate the presence of This loss of elasticity could lead to active periodontal breakdown, or the in its rate of progression. a reduced ability of the periodontal rate of periodontal breakdown itself. tissues in general and the periodontal Determination of active disease or ligament complex in particular to absorb rate of breakdown would be the most both natural and nonphysiological accurate measures of the presence of of an individual elderly patient to occlusal forces. In addition, the natural periodontal disease itself. Rather, these periodontal breakdown from infl ammatory longer-term exposure of collagen in measures from surveys of larger general periodontal diseases is more dependent periodontal connective tissues to free populations at a single time point refl ect on that individual patient’s biological, radicals could lead to damage, reduced the long-term cumulative effects of past behavioral, medical and pharmacological function and/or death of epithelial periodontal infl ammation from bacterial considerations that accompany aging. cells and to fi broblasts, osteoblasts plaque, as well as the cumulative effects Specifi cally, the dental practitioner should and cementoblasts of the periodontal of physiological and nonphysiological consider four broad areas when assessing tissues,13,14 as well as cross linking of occlusal forces, psychological stress, oral periodontal risks in the elderly patient: collagen fi bers with reduced elasticity habits and hygiene techniques, tobacco ■ The effects of aging on the in the periodontal ligament support. use, medications, compensation for integrity and function of the These normal aging changes may occlusal wear, continued tooth eruption periodontal tissues themselves. contribute to a small and gradual and gingival recession.8-10 Secondly, ■ The effects of aging on the local and reduction in the periodontal support the attitudes toward the importance of systemic response to periodontal in the elderly, even in the absence of oral hygiene and importance of both plaque biofi lm and how this may a history of periodontal infl ammation maintenance by the patient and regular manifest in clinical signs of disease. due to plaque infl ammation. maintenance by the dental practitioner ■ The effects of systemic conditions Aging and host response in periodontal have improved over successive generations and medication associated with diseases. As with other tissues of the of patients.11 Therefore evidence of aging on the incidence, severity and body, periodontal tissues require a fully loss of periodontal support among progression of periodontal diseases. functional host defense in general,

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and immune response in particular, to patients is associated with a higher the individual aging patient should defend against microbial pathogens. incidence and prevalence of periodontal be taken into consideration.11 Self- A reduction in these host defenses, disease.19 Hormonal changes in elderly, effi cacy is defi ned as the self-perception or immunosenescence,15 has received postmenopausal women increase the of the individual patient to control considerable attention over the past incidence of osteoporosis, which has and modify his or her respective several decades. The rapid fi rst line also been observed in the alveolar behaviors to treat and prevent his or of defense against bacterial plaque supporting bone.20 It is associated with her respective conditions and diseases. known as the innate immunity system, an increased loss of alveolar bone For periodontal diseases, these include which includes the epithelial barrier support while other studies found no following plaque control regimens, and normal function of neutrophils to such association in this population. seeking dental care on a regular basis migrate, engulf and break down bacteria, Medications taken for a variety of and following through on proposed as well as the adaptive immune system, chronic conditions and diseases are treatments from the dental practitioner. which includes a variety of T and B associated with reduced salivary fl ow18 Several considerations should lymphocyte responses with production of and increased susceptibility to plaque be kept in mind when considering antibodies, cytokines and chemokines, changes in prevention and therapy of are reduced in the aging process itself.15,16 periodontal diseases for the elderly. However, it remains unresolved as Perhaps the most important of these to whether diminished function in The chronological age of is that the chronological age of the these two immune systems and other the elderly patient may not elderly patient may not refl ect the protective host responses in a medically refl ect the actual overall actual overall physical health, cognitive healthy elderly patient leads to more function and motor functions of that severe forms of periodontal disease. In physical health, cognitive particular patient. Some clinical thought addition, there are confl icting reports function and motor functions leaders have proposed a multiple- as to whether older patients have an of that particular patient. tiered system of the elderly patient, altered gingival infl ammatory response such as young-old aged, middle-old in experimental gingivitis studies when aged and old-old aged patient, based compared to a younger population.13,17 on specifi c age brackets and/or specifi c Systemic diseases, conditions and accumulation. Older patients may quality of life and quality of function medications in the elderly and implications also exhibit the accumulative effects measures. It is important to keep in for periodontal diseases. When considering of stress, which are associated with an mind from the previous discussion of that the prevalence of chronic increased loss of alveolar bone support other factors associated with aging, conditions and diseases in the elderly are and reduced immune function.21 In particularly medical and pharmacological higher and that most of these conditions addition, the increased prevalence considerations, that these should be and diseases require treatment by of depression in the elderly3 may be addressed in any periodontal treatment medication,3,18 it is understandable that associated with both reduced immune plan for the elderly patient. many of these conditions are associated function and poorer plaque control. Among these considerations are with a higher prevalence and severity of Motor function, dementia and maintaining adequate dietary and periodontal diseases in this population. periodontal disease. With the increase nutrient intake to prevent premature While a complete discussion of these of the proportion of very elderly in the loss of alveolar bone density and support associations would be beyond the general population, the prevalence of through recommended dietary intake scope of this review, several examples impaired mental and motor functions of calcium or calcium supplements can be discussed to demonstrate the can lead to both impaired physical and and vitamin D.22 In addition, for full range of these associations. mental abilities to practice effective postmenopausal women, there is For example, with increasing age, the plaque control measures. In addition suffi cient evidence that an estrogen prevalence of type II diabetes increases. to these objective declines in motor supplement has benefi cial preventive It is now well-established that less than and cognitive abilities in some elderly, effects for alveolar bone loss.20 However, optimal glycemic control with these the more subjective “self-effi cacy” of because of the risk of reported adverse

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side effects and events for estrogen, should focus on maintaining a functional It is widely accepted that the success estrogen supplementation should be dentition as opposed to restoring all of any form of nonsurgical and surgical determined for such patients at risk by teeth to full periodontal health.23,24 This treatment is primarily dependent on a their physicians. In addition, chronic treatment philosophy implies that given patient’s plaque control regimen. Use of medical conditions that increase a young and an old periodontal patient antimicrobial rinses with demonstrated in prevalence with aging and are with the same clinical levels of loss antiplaque and antigingivitis activity associated with increased periodontal of periodontal support, the treatment can be valuable adjuncts for elderly disease and loss of support should also approach of frequent debridement and patients, particularly those with reduced be controlled in collaboration with frequent maintenance would be the motor and/or cognitive function. the elderly patient’s physician. When preferred approach for the elderly patient Another major consideration for the considering the strong association of as opposed to debridement followed decision to perform periodontal surgery poor glycemic control with type II by some form of periodontal surgery on an elderly patient is whether that diabetes with periodontal disease,21 for the younger patient. However, this patient is currently taking or has taken appropriate measures should be taken to philosophy should be tempered by the some form of bisphosphonates to protect assure this condition is under control. against fractures associated with loss of As the prevalence of one or more bone mineral density. Such patients may chronic conditions requiring medication be at risk for postoperative osteonecrosis becomes increasingly common in this The dental practitioner of the jaw. As most periodontal population, the dental practitioner should be aware of potential surgical procedures are elective, special should be aware of potential adverse adverse eff ects some of these considerations and precautions should effects some of these medications have be taken in consultation with the on the oral cavity in general and the medications have on the oral patients’ physicians for those patients on periodontal tissues in particular.18,23 These cavity in general and the intravenous bisphosphonates or for those include the range of medications that periodontal tissues in particular. patients who are currently taking or have result in a reduced salivary fl ow, which taken bisphosphonates intravenously, would make the patient more susceptible have taken oral bisphosphonates over a to both periodontal diseases, and three year period or longer, have a history coupled with the increased prevalence fact that a healthy elderly patient may of diabetes or an immunosuppressive of gingival recession, root caries. High- have several more decades of a high condition or who are taking or fl uoride rinses, dentifrices and topical quality of life. Furthermore, consensus have taken corticosteroids or other application of fl uorides may have opinion from studies comparing the immunosuppressive medications.20 benefi cial preventive effects for both root healing response to periodontal surgical In conclusion, the diagnosis, caries and periodontal diseases. If the procedures between older and younger treatment planning and treatment patient is taking a medication such as patients is that the healing responses are decision for the elderly patient should some classes of calcium channel blockers comparable.24 Therefore age itself should take into consideration the known that are associated with the gingival not be a contraindication for performing risk factors for periodontal disease that enlargement, the dentist should also surgery, placement of implants, etc. are prevalent with higher frequency consult with the physician to explore Nevertheless, medications, oral in the elderly patient. At present, the alternative medications with the same habits, systemic factors associated with prevailing view is that age itself in a systemic benefi cial effect but with less the incidence and severity of periodontal medically healthy and functional elderly adverse effects on the periodontal tissues. disease in general, and the ability of the patient may be of minimal signifi cance A second major consideration for patient to perform regular and effective in the treatment of periodontal diseases. treatment decisions for the elderly mechanical plaque control regimens While the American Academy of patient is the actual treatment approach still need to be taken into consideration Periodontology (AAP) has published itself. Several practitioners have proposed for treatment decisions. These include statements and/or position papers on the concept that the principal goal of the elderly patient’s motor ability to periodontal considerations in the child periodontal therapy in the elderly patient maintain such a plaque control regimen. and adolescent population, no similar

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resources are currently available from the intersection of aging and disease. Periodontol 2000 Feb 21. Doyle CJ, Bartold PM. How does stress infl uence the AAP for periodontal treatment 2014;64(1):7-19. periodontitis? J Int Acad Periodontol Apr 2012;14(2):42-49. 15. McArthur WP. Eff ect of aging on immunocompetent and 22. Krall EA, Wehler C, Garcia RI, Harris SS, Dawson-Hughes considerations for the elderly. infl ammatory cells. Periodontol 2000 Feb 1998;16:53-79. B. Calcium and vitamin D supplements reduce tooth loss in the Nevertheless, for the individual elderly 16. Hajishengallis G. Too old to fi ght? Aging and its toll on elderly. Am J Med Oct 15 2001;111(6):452-456. patient, the dental practitioner should innate immunity. Mol Oral Microbiol Feb 2010;25(1):25-37. 23. Kamen PR. Periodontal care. Dent Clin North Am Oct 17. Fransson C, Berglundh T, Lindhe J. The eff ect of age on 1997;41(4):751-762. understand and assess the role of other the development of gingivitis. Clinical, microbiological and 24. Wennstrom JL. Treatment of periodontal disease in older age-related conditions such as systemic histological fi ndings. J Clin Periodontol Apr 1996;23(4):379- adults. Periodontol 2000 Feb 1998;16:106-112. diseases, concomitant medications 385. 18. Ciancio SG. Medications: a risk factor for periodontal THE AUTHOR, Mark Ryder, DMD, can be reached at mark. and reduced motor and/or cognitive disease diagnosis and treatment. J Periodontol Nov [email protected]. function as well as the overall goals or 2005;76(11 Suppl):2061-2065. therapy for that individual patient. Such 19. Boehm TK, Scannapieco FA. The epidemiology, consequences and management of periodontal disease in an understanding of these treatment older adults. J Am Dent Assoc Sep 2007;138 Suppl:26S- considerations for the elderly patient will 33S. help that patient maintain a functioning 20. Reddy MS, Morgan SL. Decreased bone mineral density and periodontal management. Periodontol 2000 Feb dentition for a higher quality of life. ■ 2013;61(1):195-218.

REFERENCES 1. Harper S. Economic and social implications of aging societies. Science Oct 31 2014;346(6209):587-591. 2. Cafi ero C, Matarasso M, Marenzi G, Iorio Siciliano V, Office of Bellia L, Sammartino G. Periodontal care as a fundamental step for an active and healthy ageing. Scientifi cWorldJournal CONTINUING EDUCATION 2013;2013:127905. 3. Sternberg SA, Gordon M. Who are older adults? Demographics and major health problems. Periodontol 2000 CONE BEAM COMPUTERIZED TOMOGRAPHY 2015: Feb 1998;16:9-15. 4. Locker D, Slade GD, Murray H. Epidemiology of Evaluating CBCT Images and Review of Concepts in Guided Surgery and periodontal disease among older adults: A review. Prosthetics Periodontol 2000 Feb 1998;16:16-33. 5. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. $495 for Prevalence of periodontitis in adults in the United States: SEPTEMBER 9-13, 2015 2009 and 2010. J Dent Res Oct 2012;91(10):914-920. 6 CEU’s 6. Renvert S, Persson RE, Persson GR. Tooth loss and Napa Valley, CA periodontitis in older individuals: Results from the Swedish National Study on Aging and Care. J Periodontol Aug Presented at the 2013;84(8):1134-1144. 7. Kim JK, Baker LA, Seirawan H, Crimmins EM. Prevalence of oral health problems in U.S. adults, NHANES 1999-2004: Exploring diff erences by age, education and race/ethnicity. Spec Care Dentist Nov-Dec 2012;32(6):234-241. 8. Burt BA. Periodontitis and aging: Reviewing recent evidence. J Am Dent Assoc Mar 1994;125(3):273-279. 9. Nunn ME. Understanding the etiology of periodontitis: An overview of periodontal risk factors. Periodontol 2000 2003;32:11-23. 10. Ajwani S, Ainamo A. Periodontal conditions among the old elderly: Five-year longitudinal study. Spec Care Dentist Course catalog on our website Mar-Apr 2001;21(2):45-51. 11. Kiyak HA, Persson RE, Persson GR. Infl uences on the http://unlvdentalce.com perceptions of and responses to periodontal disease among Or Contact: Roxane Santiago older adults. Periodontol 2000 Feb 1998;16:34-43. 12. Van der Velden U. Eff ect of age on the periodontium. J Ph: 702-774-2822 Clin Periodontol May 1984;11(5):281-294. 13. Huttner EA, Machado DC, de Oliveira RB, Antunes AG, Hebling E. Eff ects of human aging on periodontal tissues. We’re on unlvdentalce Spec Care Dentist Jul-Aug 2009;29(4):149-155. 14. Reynolds MA. Modifi able risk factors in periodontitis: At

AUGUST 2015 451 Be a part of the story.

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CDA JOURNAL, VOL 43, Nº8

Apple Tree Dental: An Innovative Oral Health Solution

Deborah Jacobi, RDH, MA, and Michael J. Helgeson, DDS

ABSTRACT The Surgeon General’s Report on Oral Health called attention to the “silent epidemic” of dental disease. Older adults and other vulnerable people continue to suffer disproportionately from dental disease and inadequate access to care. As a society and as dental professionals, we face multiple challenges to care for our aging patients, parents and grandparents. Apple Tree Dental’s community collaborative practice model illustrates a sustainable, patient-centered approach to overcoming barriers to care across the lifespan.

AUTHORS

Deborah Jacobi, RDH, Michael J. Helgeson, he July and August issues of the Driven by unsustainable costs and MA, is the policy director DDS, is the CEO and Journal highlight the multiple unsatisfactory health outcomes, the for Apple Tree Dental. She co-founder of Apple Tree holds degrees in sociology Dental. He completed challenges we face as a society three goals for health reform, often and public policy and his dental degree and a and as dental professionals to called the “triple aim,” are to: health administration from two-year postgraduate care for our aging patients, ■ Improve the experience of care. the University of Wisconsin, fellowship in geriatric Tparents and grandparents. We ■ Improve the health of populations. Madison. dentistry at the University undoubtedly possess suffi cient expertise ■ Reduce per capita costs Confl ict of Interest of Minnesota. 1 Disclosure: None reported. Confl ict of Interest to successfully prevent and treat dental of health care. Disclosure: None reported. diseases. And yet, older adults and other Achieving the triple aim for oral vulnerable people continue to suffer health depends on providing both disproportionately from dental diseases. appropriate dental care and effectively Apple Tree Dental’s (Apple Tree) infl uencing the key factors that produce “Community Collaborative Practice” and maintain health over the lifespan. model illustrates a sustainable, patient- These factors include common medical centered approach to overcoming conditions, health literacy of older adults barriers to care across the lifespan. and their caregivers and the effectiveness of daily mouth care routines. While Why Apple Tree Dental? children and pregnant women have Multiple national organizations long been the primary benefi ciaries of and initiatives have highlighted oral most publicly funded dental programs, health as essential to overall health and the value of a healthy start for and called for the development children is indisputable, there are of safe, effective, accessible and multiple reasons that a limited focus on affordable systems of care (TABLE). pediatric benefi ts is ultimately costly.

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TABLE Reports Calling for Action on Oral Health

Report Link Offi ce of the Surgeon General. National Call to Action to nidcr.nih.gov/DataStatistics/SurgeonGeneral/NationalCalltoAction/nationalcalltoaction.htm Promote Oral Health, 2003

A State of Decay: Are older Americans coming of age without b.3cdn.net/teeth/1a112ba122b6192a9d_1dm6bks67.pdf oral health care? Oral Health America

Dental Crisis in America, Report to the Subcommittee on Primary sanders.senate.gov/imo/media/doc/DENTALCRISIS.REPORT.pdf Health and Aging From Bernie Sanders

Improving Access to Oral Health for Vulnerable and hrsa.gov/publichealth/clinical/oralhealth/improvingaccess.pdf Underserved Populations. Institute of Medicine and National Research Council Policy Options to Increase Access to Oral Health Care and networkforphl.org/_asset/92jtkp/Access-to-Oral-Health-Care-Science-and-Law-Brief.pdf Improve Oral Health by Expanding the Oral Health Workforce Network for Public Health Law Oral Health Care Science and Law Brief

As baby boomers reach the age of 65, FIGURE 1. Apple there are many more elders who have Tree’s Centers for Dental kept more of their natural teeth and have Health also serve as much higher expectations regarding dental regional hubs for on- care in their old age than did previous site services and care coordination. generations.2 Older adults, particularly those who live in long-term care settings, suffer disproportionately from active and untreated mouth infections, aging and ill-fi tting dentures, and impairments in salivation and masticatory functions. Many are more dependent upon others for help with daily mouth care than children are. They are also more likely to have chronic conditions, such as diabetes and heart disease, which are negatively affected by mouth diseases. Aspiration pneumonia, a leading cause of hospitalization and death in elders, has been directly linked with bacteria from the mouth.3 For multiple reasons, institutionalized and community dwelling elders are often unable to access traditional dental offi ces and clinics to the same degree as younger and much healthier population groups.4 Such access disparities, in combination care delivery models that meet the needs What Is Apple Tree Dental? with the signifi cant health and nancialfi of underserved populations, including Apple Tree is a nonprofi t group dental consequences of untreated mouth diseases the rapidly growing population of older practice founded in 1985 to address the in vulnerable adults, have come to the adults and people with disabilities. The unmet dental needs of individuals living attention of policymakers and funders and following describes the development and in Minnesota. The mission of Apple resulted in calls for sustainable oral health impact of a successful, replicable approach. Tree is to improve the oral health of

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12,000 10,132 10,000 28,401 individual patients treated in 2014 79,943 dental visits and screenings provided 8,000 7,471 access legislation. Staff work collaboratively 6,000 5,059 within Apple Tree and create strong, long-lasting community partnerships to 4,000 3,135 achieve a common goal of strengthening 2,526 2,000 and creating healthy communities.

Number of patients — all programs Originally focused on nursing facility 0 78 residents, Apple Tree’s programs have < 21 21–44 45–64 65–84 85–99 >100 expanded to reach other underserved Age populations in response to requests from FIGURE 2. 2014 Patients’ age distribution. Originally founded to serve nursing facility residents, Apple Tree now local community leaders. In addition to serves patients of all ages. establishing its own regional programs in Minnesota, Apple Tree has assisted local leaders in Louisiana and North $25M Carolina to replicate aspects of its model.5 Apple Tree currently has more than $20M 200 paid employees who serve low-income children and families in rural and urban $15M areas, veterans, adults with disabilities, minorities and new immigrants, mental $10M health patients and elders living in nursing and long-term care facilities. Apple Tree Dollars in millions Dollars $5M provides dental care at regional Centers for Dental Health (Centers) in Mounds 0 View, Coon Rapids, Hawley, Madelia, 86 88 90 92 94 96 98 00 02 04 06 08 10 12 14 Fergus Falls and Rochester, Minn., and recently opened a Center for Dental Year Health in San Mateo, Calif. (FIGURE 1). FIGURE 3. Dental care value: 1986 to 2014. Sustained growth demonstrates the viability of Apple Tree’s Apple Tree also delivers on-site patient-centered approach to overcoming barriers to care across the lifespan. dental services year-round at more than 130 community oral health care sites including Head Start centers, all people, including those with special and maintain patients’ oral health schools, nursing facilities and other dental access needs who face barriers to and to share their interprofessional long-term care settings. With seamless care. Apple Tree’s staff works to achieve knowledge and experience. integration between care provided its mission by delivering education, A volunteer board of directors is at the Centers and on-site locations, prevention and restorative dental responsible for strategic planning to Apple Tree provides a comprehensive services to vulnerable populations and meet Apple Tree’s mission, contributing range of oral health care services by providing leadership and innovation expertise in health care administration and including diagnostic consultations, to transform the health care system. research, dentistry, public policy, nonprofi t preventive, educational and restorative Inspired by the Mayo Clinic’s governance, early childhood development services. Advanced services provided nonprofi t group medical practice model, and epidemiology. Apple Tree’s executive include periodontics, endodontics, Apple Tree’s interdisciplinary group and administrative staff has expertise prosthodontics and oral surgery. In dental practice includes clinical and in program planning, management and 2014, Apple Tree provided nearly support staff working together on the evaluation, fundraising, fi nance and 80,000 dental visits and screenings for patient’s behalf. These teams collaborate administration, implementing internal 28,400 patients (FIGURE 2). The value with teachers, nurses, physicians, family and external education programs, and of dental services delivered in 2014 members and other caregivers to restore promoting policy development and dental exceeded $22 million (FIGURE 3).

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Partnerships, Policy and Advocacy Partnership is a hallmark of Apple Tree’s approach to care delivery and policy development. Successful collaborations with long- term care facilities helped identify FIGURE 4. Dr. Michael Helgeson, Apple Tree’s FIGURE 5. Specially equipped trucks are used to a solution for long-standing barriers CEO, with a Mobile Dental Offi ce used to provide transport multiple Mobile Dental Offi ces to community comprehensive dental care in a variety of settings. sites. On-site care eliminates transportation barriers to dental care. For young children, common amongst older adults. a partnership with the Minnesota Dental Association, Minnesota Dental Hygienists’ Association and the ■ Administration for Community From its inception in 1985, Apple Minnesota Head Start Association Living (formerly the U.S. Tree has been recording diagnostic expanded the use of collaborative Administration on Aging) codes along with billing information practice and improved access to care Oral Health for Older Adults in its custom information systems. The for Head Start preschoolers statewide. Subject Matter Expert Group — result is an unprecedented longitudinal This effort helped federal offi cials developing best practice models. database, which has been used by recognize the need for new staffi ng ■ Special Care Dentistry Association researchers to understand the impact of and care delivery models and allowed — advocating for dental care for prevention and treatment on oral health local private dentists and hygienists people with disabilities, older outcomes for institutionalized elders.8 to establish collaborative practices adults and people requiring to serve local Head Start programs. hospital-based dental care. How Does Apple Tree Deliver Care? This effort increased the percentage Apple Tree has been recognized as Although often referred to as a of Head Start children obtaining a leading model by the American and “safety net” provider, Apple Tree is examinations statewide from less than California Dental Associations, in the not content to catch people who have 70 percent to nearly 90 percent.6 Surgeon General’s Call to Action and by already fallen into a dental access chasm. Apple Tree is actively involved national foundations including the Robert Instead, Apple Tree utilizes a proactive, in policy development at the state Wood Johnson and Kellogg Foundations.7 prevention-oriented, patient-centered and national levels including: practice approach, called community ■ California Dental Association’s Education and Research collaborative practice, to deliver dental Phased Strategies for Reducing Michael Helgeson, DDS, the CEO care and education. Apple Tree’s delivery the Barriers to Dental Care and co-founder, has lectured widely on system goal is to reach at-risk individuals in California Access Report geriatric and special needs dentistry as well when they are healthy and to provide — citing Apple Tree Dental as on the Apple Tree model. With support education, prevention and restorative as a potential solution. from multiple Minnesota Department care to keep them healthy. Apple Tree’s ■ Minnesota Dental Association — of Health Clinical Dental Education philosophy is to practice dentistry as an supporting legislation to improve Innovation grants, Apple Tree has offered integrated team of professionals focused public program reimbursement new learning experiences in partnership on meeting the needs of children, and workforce innovations. with the University of Minnesota School adults and elders across the lifespan. ■ Minnesota Oral Health Coalition of Dentistry, Minnesota State Colleges and Apple Tree employs unique workforce — raising awareness about the Universities and other dental education teams that include dentists, oral surgeons, importance of oral health. programs. Dental, dental therapy, dental nurse anesthetists, advanced dental ■ American Dental Association’s hygiene, dental assisting and nursing therapists, dental hygienists, dental National Elder Care Advisory students have experienced interprofessional assistants, community care coordinators Committee — advancing care for elders and children, oral health and lab technicians. Through dental care delivery, education screening and assessment, safe patient collaborative practice, dental hygienists and research to improve the handling, dental laboratory procedures are able to serve as front line clinicians in oral health of older adults. and the use of telehealth technologies. community settings as described below.

456 AUGUST 2015 CDA JOURNAL, VOL 43, Nº8

FIGURE 6A. FIGURE 6B. FIGURE 6C.

FIGURES 6A–6C. Apple Tree’s Centers for Dental Health are equipped to serve people with special needs. Shown here is a ceiling lift used to transfer nonambulatory patients into a dental chair.

Delivering On-Site Care The Apple Tree Mobile Dental Offi ce on-site dental hygienist becomes part Apple Tree’s on-site services can is nearly identical ergonomically and of the nursing facility’s assessment team be delivered at a wide variety of functionally to the equipment in Apple and is responsible for completing the oral community sites within a 60-minute Tree’s Centers. One difference is that health portions of the MDS. In addition, travel time radius of each Center for the dental chair and other units are on the hygienist develops a personalized Dental Health (FIGURES 4 and 5). wheels so they can be spread out, making daily mouth care plan for each new Community partnerships allow Apple it easier to safely transfer patients to resident, coaches facility caregivers on Tree to co-locate on-site dental services and from wheelchairs. Dental treatment how to care for residents’ teeth and within long-term care facilities and other may also be provided at a Center, where dentures, triages residents needing settings where people live, learn and operatories are designed to accommodate follow-up care and provides periodic in- receive other health and social services. wheelchairs, have specialized lifts to service education for the facility’s staff. Sometimes described as a “hub and spoke” transfer patients into the dental chair For nursing facility residents choosing delivery system, the model creates an and are equipped for sedation if required Apple Tree as their dental provider, accessible care network linked via a fully for a successful visit (FIGURES 6A–6C). community care coordinators on staff certifi ed electronic health record (EHR) Long-term care residents in facilities at Apple Tree take all necessary steps and allows multiple points of accessible served by Apple Tree enter the to obtain consent for treatment from care for patients and communities. dental care system through a program the responsible party, facilitate and Apple Tree uses both lightweight established for all residents and managed document needed medical-dental portable equipment and heavier custom by a dental director. Similar to a nursing consultations and schedule on-site mobile units to provide on-site care in facility’s medical director, Apple Tree dental appointments for treatment. shared spaces within long-term care takes on the role of dental director, On-site dental treatment is scheduled facilities and other community settings. working closely with nursing facility staff on a regular basis throughout the year Portable dental units are transported to establish programs and processes that by a consistent team ensuring timely in a car or minivan and used by dental help ensure that every residents’ oral care and strong patient-provider hygienists to provide preventive services. health needs are met. The Minimum relationships. When residents have For restorative and surgical services, Data Set (MDS) is a standardized health extensive disease or special needs, specially designed trucks can transport assessment instrument used to assess the they may also be scheduled at a nearby multiple complete Mobile Dental overall health of older adults admitted Apple Tree center, where care can be Offi ces. In a carefully planned route, to nursing facilities. Research has seamlessly provided using the same EHR. staff truck drivers pick up and drop off documented that oral health conditions one or more complete Mobile Dental are typically underreported when the A Sustainable Solution Offi ces at each scheduled location in MDS is completed by nurses or aides, High levels of uncompensated care the afternoon and evening, outside of that the majority of dependent residents associated with Medicaid and uninsured normal business hours. On-site dental are resistant to daily oral care and also populations make it diffi cult or impossible care teams provide dental care at each suggests that most receive inadequate for most private practices to accept location for one or more days according oral health care.9 To provide accurate signifi cant numbers of public program to the number of patients due to be seen. oral health assessments, Apple Tree’s and low-income patients. In order to

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Fundraising Insurance $108,821 Veterans Grants and gifts Management 10% .8% 0.7% 10.7% $924,523 6.5% Private pay Insurance 9% 12.4% Veterans 0.8% Private 12.5% Medicaid Program Medicaid 80.3% $13,218,827 63.6% 92.7%

FIGURE 7A. 2014 gross revenues by source. FIGURE 7B. 2014 net revenues by source. FIGURE 8. 2014 expenses by category. Management and fundraising make up a small portion FIGURES 7A and 7B. Comparison of gross and net revenue sources reveals the low reimbursement levels paid of Apple Tree’s expenses. by public insurance programs.

serve these populations, Apple Tree has provide evidence-based care. 4. Dolan TA, Atchison K, Huynh TN. Access to Dental Care developed multiple funding streams to ■ Include collaborative and Among Older Adults in the United States. J Dent Educ 2005 69(9), 961-974. www.jdentaled.org/content/69/9/961.long. support a sustainable business model. multidisciplinary teams working Accessed April 30, 2015. Earned revenue, including insured across the health care system. 5. www.accessdentalcare.org/pages/More_About_Us_ and full-pay patients, is supplemented ■ Foster continuous improvement Page.html. Accessed April 30, 2015. 6. www.mnheadstart.org/HS08%20REPORT6%20KEYLINE. with federal, state and local foundation and innovation. pdf. grants, corporate support and individual All these markers of success are 7. U.S. Department of Health and Human Services. A gifts (FIGURES 7A and 7B). evident in Apple Tree’s founding National Call to Action to Promote Oral Health. Rockville, Md.: U.S. Department of Health and Human Services, Public Apple Tree’s nonprofi t status mission and the evolution of its model. Health Service, Centers for Disease Control and Prevention, and delivery model keep costs low With a culture of patient-centered National Institutes of Health, National Institute of Dental and and allow fundraising efforts to help innovation, Apple Tree has continually Craniofacial Research. NIH Publication No. 03-5303, May 2003. fi ll the uncompensated care gap. incorporated new providers, new 8. Smith BJ, Shay K. What predicts oral health stability in a Innovative collaborative practices technologies and evidence-based long-term care population? Spec Care Dentist 25(3): 150- allow services to be provided in shared services into its practice. The provision 157, 2005. 9. Thai PH, Shuman SK, Davidson GB. Nurses’ dental spaces, with shared staffi ng leveraging of on-site care by interdisciplinary assessments and subsequent care in Minnesota nursing community resources and eliminating teams eliminates transportation homes. Spec Care Dentist 1997 Jan-Feb;17(1):13-8. transportation barriers (FIGURE 8). barriers and helps integrate oral health 10. Institute of Medicine and National Research Council (2011). Improving Access to Oral Health for Vulnerable According to the Institute of with other health care services. ■ and Underserved Populations. The National Academies Medicine’s 2011 report, “Improving Press, Washington D.C. www.hrsa.gov/publichealth/clinical/ Access to Oral Health for Vulnerable oralhealth/improvingaccess.pdf. Accessed April 30, 2015. 10 REFERENCES Populations,” to be successful, an 1. Berwick DM, Nolan TW, Whittington J. The Triple Aim: THE CORRESPONDING AUTHOR, Deborah Jacobi, RDH, MA, can evidence-based oral health system will: Care, Health and Cost Health Aff (Millwood). 2008 May- be reached at [email protected]. ■ Eliminate barriers that contribute Jun;27(3):759-69. Institute for Healthcare Improvement (IHI), “The Triple Aim Initiative.” www.ihi.org/off erings/ to oral health disparities. Initiatives/TripleAim/Pages/default.aspx. Accessed April ■ Prioritize disease prevention 30, 2015. and health promotion. 2. CDC. Public health and aging: Retention of natural teeth among older adults – United States, 2002. MMWR ■ Provide oral health services 2003;52(50):1226-9. in a variety of settings. 3. van der Maarel-Wierink CD, Vanobbergen JN, ■ Rely on a diverse and expanded array Bronkhorst EM, Schols JM, de Baat C. Oral health care and aspiration pneumonia in frail older people: of providers who are competent, A systematic literature review. Gerodontology 2013 compensated and authorized to Mar;30(1):3-9.

458 AUGUST 2015 resources

CDA JOURNAL, VOL 43, Nº8

National Resources for the Oral Health of Older Adults

Compiled by Susan Hyde, DDS, MPH, PhD, FACD

Resource Link

FOR CLINICIANS

ADA’s Dentistry in Long-Term Care (LTC) Course ada.org/en/education-careers/continuing-education/long-term-care-course Online C.E. course on how to successfully practice in LTC facilities. Geriatric Oral Health geriatricoralhealth.org/topics/default.aspx Online learning and case studies on various geriatric oral health topics. Oral Health and the Older Adult dentalcare.com/media/en-US/education/ce8/ce8.pdf Online C.E. off ered by Crest and Oral-B. Nursing Home Oral Health www.uky.edu/NursingHomeOralHealth How to train caregivers to provide daily mouth care. Oral Care in Continuing Care Settings ahprc.dal.ca/projects/oral-care/default.asp Oral care for frail and dependent older adults. American Geriatrics Society Beers Criteria healthinaging.org/medications-older-adults Medications that older adults should avoid or use with caution. Cognitive Status: Legal Implications and Informed Consent toothwisdom.org/resources/entry/cognitive-status-legal-implications-and- Surrogate decision-makers with legal guardianship or durable health informed-consent care power of attorney. Incurred Medical Expense Regulations ada.org/en/member-center/member-benefi ts/practice-resources/paying- How to bill Medicaid for dental services for long-term care residents. for-dental-care-a-how-to-guide-incurred-med

FOR EDUCATORS

Smiles for Life: A National Oral Health Curriculum smilesforlifeoralhealth.com Interprofessional modules on oral health across the lifespan. Association for Prevention Teaching and Research aptrweb.org/?PHLM_15 Interprofessional modules on oral health across the lifespan. Portal of Geriatrics Online Education pogoe.org Interprofessional evidence-based educational materials for teaching geriatrics.

FOR PATIENTS

Patient Education for the Older Adult toothwisdom.org/resources/category/importance-of-oral-health Age-related mouth changes, oral-systemic connections, access to care, caregiver oral hygiene instructions.

AUGUST 2015 459 Specializing in selling and appraising dental practices for over 40 years!

LOS ANGELES COUNTY ORANGE COUNTY SAN DIEGO COUNTY

CANOGA PARK (GP) – Price Reduced!! Seller is ANAHEIM – Leasehold Improvements & Equipment VISTA - 35 years of goodwill. 4 fully computerized currently working 1 day/wk with ½ day of hygiene. 2 Only! 4 equipped operatories in a 1,680 sq office. equipped operatories. Grossed approximately equipped operatories. Property ID #4357. Property ID #4535. $883K in 2013. Has monthly revenues of $73K. CHATSWORTH (GP) – Price Reduced!! 5 equipped ALISO VIEJO (Pedo) – 3 chairs in open bay, 1 Property ID #4507. operatories. Grossed $918K in 2013. Projecng plumbed not equipped op. Grossed approximately approx. $948K for 2014. Buyer’s net of $398K. $340K in 2014. Great pracce. Property ID #5031. EL CENTRO (GP) – This pracce is located in a Property ID #4537. single story building. Building is for sale. 5 FULLERTON (GP) – Established in 2002. Projecng equipped operatories. Grossed approximately LOS ANGELES – 65 years of goodwill Grossed ap- $304K for 2014. Buyer’s net of $132K. Property ID proximately $350K in 2013. Buyer’s net of $71K. $554K for 2014. Buyer’s net of $189K. Property ID #5023. Please contact your CPS Agent for more details. #5010. Property ID #5008. SAN DIEGO COUNTY - Mul-Specialty pracce. 7 FULLERTON – Leasehold Improvement and Equip- equipped operatories in an approximately 4,464 LOS ANGELES - This pracce with over 30 Years of ment! On one the busiest intersecons of Fullerton. office. Grossed $1,700,000 in 2013 and projecng goodwill, and approximately 60% of it's income 3 equipped operatories. Some paent charts includ- approximately $1,900,000 for 2014 with monthly comes from capitaon. Property ID #5012. ed. Property ID #5028. revenues of $165,000. Property ID #4231. LOS ANGELES (GP) - 3 equipped operatories with GARDEN GROVE – 4 equipped ops and 1 plumbed digital x-rays in a 1,000 sq . office. The recepon (not equipped) op. Grossed approximately $436K in area was recently remodeled. Grossed approxi- 2014 Property ID #5043. mately $277,130 in 2014. Property ID #5040. HUNTINGTON BEACH - Leasehold Improvement and RIVERSIDE & SAN BERNARDINO COUNTY MISSION HILLS - Leasehold Improvements & Equip- Equipment Only! Modern Design. 3 equipped ops, 1 APPLE VALLEY (GP) – 3 equipped ops . Has monthly ment Only! 8 equipped Property ID #5014. plumbed not equipped. Was built in June 2014. revenues of $42K. Property ID #5044. Property ID #5032. MONTEREY PARK (GP) – Leasehold Improvements APPLE VALLEY - 8 equipped operatories. Seller is & Equipment Only! 3 equipped operatories. IRVINE - Leasehold Improvement and Equipment! working 3 days/wk, Associate 1 day/wk and O.S. 1x/ Property ID #4449. 10 equipped ops and 2 recepon areas. Property ID #5030. mo. Grossed $707K in 2013 and Projecng $722K PASADENA (GP) - 3 equipped ops. Grossed approx- for 2014. Property ID#5009. imately $335K for 2014. Property ID #5035. LAGUNA HILLS – 2 equipped ops. Approximately 20- 25 new paents/mo. Ins/Cash/Cap (~$500/mo). HESPERIA (GP) – 4 equipped operatories. Seller RESEDA – 3 equipped operatories (stand up dens- Grossed approximately $319,024 in 2014. Property works 3 days/wk with 3 days of hygiene Grossed try). Projecng approximately $292,796 for 2014 ID #5033. with monthly revenues of $24K. Property ID#5017. $260K in 2013 and projecng approximately $336K ORANGE COUNTY PERIO – Price Reduced!! Grossed for 2014. Property ID #5007. ROSEMEAD – 2 equipped operatories, lab/ approximately $972K in 2013 and projecng approx- sterilizaon room, x-ray room, dark room and imately $1,016,000 for 2014 with a Buyer’s net of INDIAN WELLS – Leasehold Improvements and private office in a 790 sq suite. Projecng approxi- $260K. Please contact your CPS Agent for more Equipment Only!! Great opportunity for a TMJ, mately $119K for 2014. Low Sale Price! Property ID details. Property ID #5005. Sleep Apnea and GP. 4 equipped ops. Property ID #5019. #5041. RANCHO SANTA MARGARITA – Leasehold Improve- SANTA CLARITA (GP) – This turn-key pracce ment Only!! 4 plumbed not equipped operatories. PALM DESERT— 5 equipped ops. Have monthly Reestablished the pracce in September 2013. Property ID #4483. revenues of approximately $28K/mo. Property ID Great opportunity for a 1st me buyer. Property ID #4331. #5013. PALM SPRINGS – 3 equipped operatories with SANTA MONICA - 3 equipped operatories. Grossed Pracce Web soware and digital x-ray. Major $265,485 in 2013 and projecng approximately VENTURA, SANTA BARBARA & KINGS COUNTY equipment is approximately 2 years old. Suite is $265,796 for 2014. Property ID #5022. 1,200 sq . Seller is working 5 days/wk and sees SAN LUIS OBISPO COUNTY – 6 equipped ops. Has approximately 8-10 paents/day. Income source is TORRANCE – 3 equipped operatories, Grossed monthly revenues of $90K. Property ID #5037. approximately 25% insurance, 65% cash and 10% $321,051 in 2013. Pracce is averaging $28K in Den-cal. Does lile adversing. Please contact monthly revenue. Property ID #4477. VENTURA (GP) - 4 fully equipped operatories in a 1,862 (+ free bonus room) sq suite. Each operatory your CPS Agent for more informaon. Property ID TORRANCE – 5 equipped ops. Grossed approxi- has floor to ceiling windows for plenty of natural light . #4487. mately $493K for 2014. Property ID #5036. Grossed approximately $423K in 2014. Property ID RIVERSIDE – 6 ops. Projecng approximately $550K #5039. for 2014. Property ID # 5006.

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CONTACT US FOR A FREE CONSULTATION WWW.CALPRACTICESALES.COM Phone: (714) 639-2775 CA DRE #00491323 RM Matters CDA JOURNAL, VOL 43, Nº8

Accounting Controls Can Prevent Dishonest Behavior TDIC Risk Management Staff

mbezzlement is typically “The prototypical thief is a long- defi ned as the theft of money time employee who is extremely or property by a person trusted The employee is viewed familiar with the fi nancial aspects with those assets. It usually of your business. He or she interacts occurs in employment settings, within the practice as with clients and vendors, and may Eand small businesses suffer more losses a loyal, trusted, giving handle or process accounts receivable, from fraud than larger organizations, individual and would be accounts payable or banking according to the Association of last on a list of people functions for the practice,” she said. Certifi ed Fraud Examiners. The employee is viewed within the Analysts with The Dentists you might suspect. practice as a loyal, trusted, giving Insurance Company say dentists may individual and would be last on a inadvertently put their practices at risk list of people you might suspect. for fraud by trusting a single employee with sole fi nancial responsibility or by not reviewing accounts payable and receivable. However, this vulnerability can be reduced through awareness of “red fl ag” behaviors and a few key accounting protections. You are not a policy number. Fraudulent activity can happen in a number of ways, and TDIC case studies show instances of employees And at The Dentists Insurance Company, we won’t treat you like deleting appointment and ledger entries, one because we are not like other insurance companies. We were endorsing patient checks to personal accounts, forging payroll checks, started by, and only protect, dentists. A singular focus that leads modifying payroll, misappropriating to an unparalleled knowledge of your profession and how to best a credit card and using a signature protect you. It also means that TDIC is in your corner, because with stamp without authorization. us, you’re never a policy number. You are a dentist. Jennifer Duggan, a Northern California attorney specializing in business and employment law, says there are also more sophisticated Contact the Risk Management Advice Line at 800.733.0634. schemes in which employees fabricate fi ctitious vendors, create nonexistent employees, receive kickbacks from patients or from vendors for awarding company contracts or actually coerce Protecting dentists. subordinate employees to carry out theft. ® “Sometimes employees forge It’s all we do. signatures on checks and sometimes thedentists.com the employees are authorized signatories,” said Duggan. Duggan notes that the thief is more often than not a highly trusted employee.

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CDA JOURNAL, VOL 43, Nº8

This creates a delicate situation cross-train coworkers. Analysts say “Simply reviewing your book- for practice owners, but experts say one red fl ag is not typically cause keeping structure and implementing basic awareness of red-fl ag behavior for alarm, but a combination of accounting measures will greatly keeps employers from having to be these behaviors warrants concern. reduce the probabilities of falling unnecessarily suspicious. Red fl ags TDIC analysts say practice victim to employee theft,” she include an “ever-present” employee owners lose more than money when said. “Instituting controls also who comes in early or stays to close fraud shatters the “family feeling” communicates to employees that you up after everyone else has gone home and trust in the offi ce. “When an are paying attention and discourages or someone who regularly refuses to employee steals from the practice even the thought of stealing.” take a vacation. Illicit activity may owner, the owner feels betrayed and Accounting controls for dental surface if the employee is required to can have a hard time recovering practice owners include: be away from work for a week or two from that,” notes a senior analyst. ■ Avoiding single-person control and is not able to cover up the trail By implementing accounting of all of the practice’s fi nancial of fraud. Other things to be aware of controls, small business owners dealings. Separating tasks, are fi nancially frustrated employees can signifi cantly reduce the such as opening incoming mail who are always short on cash or chances of becoming a victim of and data entry for deposit and territorial employees who refuse to employee theft, Duggan says. receivable information, minimizes the possibility of an employee manipulating account information. ■ Separating job functions of reviewing monthly bank statements and preparing monthly bank reconciliations. If you have multiple authorized signers, separating the job functions of preparing the checks and signing the checks reduces risk. If you use online banking, separating the job functions of entering payments and reconciling monthly activity is key. ■ Requesting that the bank mail statements to your home or personal email address and reviewing statements regularly for unusual accounts payable names or other inconsistencies. ■ Securing company checks in a location accessible only to authorized employees. ■ Requiring supporting documentation (a vendor invoice or credit card statement, for example) for every check you sign and reviewing supporting documentation to ensure the expenditure is justifi ed. CONTINUES ON 464

462 AUGUST 2015 QUESTIONS MOST OFTEN ASKED BY SELLERS:

1. Can I get all cash for the sale of my practice?

2. If I decide to assist the Buyer with financing, how can I be guaranteed payment of the balance of the sales price?

3. Can I sell my practice and continue to work on a part time basis?

4. How can I most successfully transfer my patients to the new dentist?

5. What if I have some reservation about a prospective Buyer of my practice?

6. How can I be certain my Broker will demonstrate absolute discretion in handling the transaction in all aspects, including dealing with personnel and patients?

7. What are the tax and legal ramifications when a dental practice is sold? QUESTIONS MOST OFTEN ASKED BY BUYERS:

1. Can I afford to buy a dental practice?

Can I afford not to buy a dental practice? LEE SKARIN 2. INC. & ASSOCIATES

3. What are ALL of the benefits of owning a practice?

4. What kinds of assets will help me qualify for financing the purchase of a practice?

5. Is it possible to purchase a practice without a personal cash investment?

6. What kinds of things should a Buyer consider when evaluating a practice?

7. What are the tax consequences for the Buyer when purchasing a practice? 2IÀFHV Lee Skarin & Associates have been successfully assisting Sellers and Buyers of Dental Practices for nearly 30 years in providing the answers to these and other 805.777.7707 questions that have been of concern to Dentists. 818.991.6552 Call at anytime for a no obligation response to any or all of your questions Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461 CA DRE #00863149 AUG. 2015 RM MATTERS

CDA JOURNAL, VOL 43, Nº8

CONTINUED FROM 462

■ Running an accounts payable statements should also be suspect. of fraud should also be prepared to call history to review invoice ■ Noticing any increase in patient the police. TDIC offers identity theft numbers and amounts. complaints regarding their recovery for the individual dentist ■ Providing specifi c instructions accounts, which could indicate under its Professional Liability policy. or guidelines to your bank fraudulent activity or a need The business owners’ property policy including a list of your approved to develop a policy clarifying covers employee dishonesty. In order vendors and authorized signers. account procedures with patients for coverage to be effective, practice ■ Watching for an increase in and staff. Reviewing and owners must fi le a police report and patient refunds, adjustments or responding to patients’ concerns submit it to the claims department. ■ bad-debt write-offs. An unusual personally is recommended. number of accounts turned over to If you discover facts indicating Contact TDIC’s Risk Management a collection agency and a decline that you are the victim of employee Advice Line at 800.733.0634. in the gross income or profi tability fraud, call TDIC immediately. Trained of the practice is suspicious. analysts will discuss the situation with Discrepancies between accounts you, including documentation of the receivable records and patient fraud. Practice owners with evidence

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464 AUGUST 2015 Specialists in the Sale and Appraisal of Dental Practices Serving California Dentists since 1966 Practices How much is your practice worth?? Wanted Selling or Buying, Call PPS today! Visit us at CDA Booth #1414 NORTHERNNORT RN CALIFORNICALIFORNIAA SOUTHERNSOUTHERN CALIFORNIACALIF (415) 899-8580 – (800) 422-2818 (714)( ) 832-0230 832 0230 – (800) (800 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6090 SANTA ROSA Entry level opportunity includes 1,200 sq.ft. condo. ANAHEIM HILLS Group member wanted. Hi identity. GP has On relaxed schedule, PPO practice collected $274,000 in 2014 with Profits space to share with Specialist. Pedo, Ortho or ? of $154,000 with no rentH[SHQVH. Near Memorial Hospital. ARROWHEAD Great mountain practice. Hi identity location. 6089 MOUNT SHASTA Small town living renowned for mountain Conservative part-time owner with Associate grosses $4250,000. 3,000 recreation, lakes & streams, fishing, golfing and abundant culture. Perfect patients. 4-ops. Digital x-rays. Practice $350K and RE $250K. escape from the Rat Race and corporate intrusion. On 3-day week, BAKERSFIELD AREA Small town. 4-op practice with building. Full revenues topped $800,000 in 2014. Price $350,000 includes real estate. Renovations make property look 6088 SANTA CRUZ Well established, lots of patients. Strong Hygiene new. Department with 6.5 days of hygiene per week. Collected $600,000 in 2014. 2015 trending $675,000+. Full Price $375,000. BAKERSFIELD Lady DDS grosses $800,000. Low overhead. Full 6087 LAKE TAHOE - NEVADA'S STATELINE Located adjacent to Price $550,000. California's South Lake Tahoe. “Out-of-Network” practice. Collections CLAREMONT-UPLAND Gross $500,000+. Refers $250,000 in last year topped $600,000 with Available Profits of $220,000. 3.5 days of Ortho, OS, Endo. Hi identity. Seller can work back if acquired by hygiene per week. Escape California income taxes! Specialist. 6085 PERIO PRACTICE – SAN FRANCISCO BAY AREA 2014 grossed DENTAL LOCATIONS Bell and Bell Gardens. $2 Million. 7 Doctor days per week. Seller can work back. Beautiful 8-Op office. DENTURE PRACTICE Sees 30 denture patients per day. Perfect 6081 SANTA CLARA El Camino Real location. 2014 collected for Prosthodontist. $687,000. Available Profits of $305,000. 2-days of Hygiene. 5-ops in DIAMOND BAR Part-time practice. Grosses $400,000. Great 1,700 sq.ft. Extend hours and revenues shall increase. opportunity. Full Price $360,000. 6080 SAN RAMON 8+ days of Hygiene. $450,000 invested in 6-Op HAWTHORNE Located in strip center at busy intersection. 6-ops, office. Consistent $900,000+ per year performer. Attractive transition  arrangements available. 2 equipped in 1,600 sq.ft. suite. Full Price $95,000. 6079 BERKELEY’S ALTA BATES MEDICAL VILLAGE – “SOLD” IRVINE Part-time practice is grossing $400,000. Beautiful office. Strong performer on Owner’s 24 hour week. 2014 collected $676,500. Full 3rice $360,000. Patient foundation anchored by 4-days of Hygiene. Endo and OS referred. LAKE FOREST 7 ops across street from major employer in Renowned Medical Village has regional draw. Orange County. 6078 FRESNO Strip center practice on West Shaw Avenue. 2014’s LOS ANGELES HMO practice doing $4.15 Million. $33,000 per Collections totaled $383,000 with Profits of $192,000. Practice will do better month in cap checks. Includes real property. with Successor who devotes full attention here. 4-Ops. Full Price $245,000. MISSION HILLS Grossed $350,000, nets 50%. Senior DDS wants 6077 PERIO PRACTICE – SAN FRANCISCO’S NORTH BAY to work-back 2.5 days. Seller will finance. Highly regarded and located in desirable family area. On 3.5 day week, REDLANDS Full rice $35,000. 25-year phone number and fictitious revenues were $1 Million in 2014 with profits of $400,000. Beautiful facility  3 business name. Great rehab opportunity which will grow with TLC. with 4-Ops. 6075 MONTEREY BAY AREA – “SOLD” Digital, paperless and well REDLANDS Low overhead. 5- Ops. Should do $300-to-$400K first positioned for future. 2014 collected $1.47 Million with Profits of year with little marketing. Great Lease at $1.00 sq. ft. FP $250,000. $690,000. 7+ days of Hygiene. First Quarter of 2015 collected $449,000. RIALTO Dental building on 2.3 acres. Land shall soon have Extremely unique opportunity. $8,000SHUmonth in rental income. 6071 CHICO Strength is 4-day Hygiene schedule. Retiring DDS focuses RIVERSIDE Walmart Location. on restorative. Endo, OS, Perio & Pedo referred. 2014 collected $450,000. SAN DIMAS HMO $8,000 month in cap checks. Hi Identity Beautiful 4-Op office. Full Price $150,000. shopping center. Refers a lot. Specialist OK. 6070 VISALIA Strong foundation and well-positioned for ambitious TORRANCE Grosses $300,000 with older DDS. 3-ops plumbed, successor. Strong Hygiene Department, beautiful facility, well equipped. 2 equipped. Beautiful A Class building. Full Price $250,000. Digital throughout. Not a Delta Premiere practice. 6067 MONTEREY - ADVANCED RESTORATIVE PRACTICE TUSTIN Free standing dental building with 5 ops. Full Price $1.4 Strong foundation for DDS desiring quality restorative practice. $310,000 Million. invested here. Digital and paperless. 2014 collected $400,000. 2XWRI TUSTIN Best Location in city Hi identity corner. Double your volume. Network” practice. Considerable transition assistance available. Full VICTORVILLE “Coming Up” Price $185,000. WEST L26$1*(/(6 Grosses $1.2 Million. Seeks Korean Lady DDS for specialty team. Plan to grow to $2 Million per year. Quality **FOUNDERS OF PRACTICE SALES** office. Full Price for 1/3 of goodwill $350,000. 120+ years of combined expertise and experience! YUCCA VALLEY Hi identity location. Small office. Used to do 3,000+ Sales - - 10,000+ Appraisals $500,000. Needs TLC. Full Price $150,000 includes building. **CONFIDENTIAL** PPS Representatives do not give our business name when returning your calls. 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 SACRAMENTO: 7 equip Ops in 2,400 CYPRESS: NEW LISTING! General TORRANCE: General Dentistry. 3 Ops, sq. ft., 1 add’l Op Plumbed. Pano, Softdent, Practice, 5 Ops, 35 years of Goodwill.7 days 2 Equipped. Est 19+ years. 2013 GR of BAY AREA: Perio Practice. 2,120 sq. ft. Digital. 2014 GR $626K+. #CA250 Hygiene per week, most spec. work referred. $333K with $176K adj. net. #CA213 w/6 Ops, Digital, Endoscope, Piezosurgery, $948K GR. #CA257 Dentrix. #CA167 SAN FRANCISCO: Practice and UPLAND: NEW LISTING! General &RQGRPLQLXPVTIWRI¿FH2SV Practice. 4 Ops, 3 Equipped. 25+ years of CASTRO VALLEY: Practice & Building. GREATER LOS ANGELES: Perio Practice. Eaglesoft software. 2014 GR $650K. 5 Ops. 34 Years of Goodwill. Dentrix, Digital, Goodwill. 2014 GR of $221K with room to Approx. 1,800 sq. f.t, 3 Ops, 1 add’l #CA261 grow. #CA254 Plumbed. 2014 GR $373K, 4 day week. Laser, great referral base. #CA173 #CA251 VICTORVILLE: General Practice. 3 SANTA CRUZ COUNTY: General HUNTINGTON BEACH: NEW Dentistry. 3 Ops, 1,100 Sq. Ft., Schick Ops, 3 Plumbed, 2,150 sq. ft. Est. 34 Years, FOLSOM: FACILITY ONLY, 1,200 sq. LISTING! 5 Ops, 28 years of Goodwill, Digital. Dentrix. GR $338K #CA550 SoftDent. 2014 GR $273K. #CA149 ft. w/3 Ops, Digital X-rays & Pano, new Digital, GR of $1.1MM+. #CA263 compressor #CA209 SANTA ROSA: General Dentistry & WEST COVINA: General Practice with HUNTINGTON BEACH: General Practice., 4 Ops in a retail center location. Dentrix, GREATER SACRAMENTO: General Building. 3 Ops. 2013 GR $542K w/Adj. Net $182K #CA200 3 Ops. Dentrix, Digital, Laser, Intra-Oral. Est. Digital, 35 years of goodwill. 2014 GR of Practice. 7 Ops, 3,079 Sq. Ft. (Shared w/2nd 23 Years. #CA194 IN ESCROW! $402K #CA233 DDS – Separate Practices), 2013 GR $974K. WALNUT CREEK: PRICE REDUCED! WEST LOS ANGELES: General Practice, #CA140 Prosth Practice. 3 Ops, Full Lab. 2013 GR LOS ANGELES: General Dentistry, 6 Ops, 5 Equipped, Est. 50+ years, SoftDent, Digital. 4 Ops, newly built-out suite, desirable high GREATER SAN JOSE: Perio Practice. $399K w/Adj.SOLD Net $143K #CAM540 2014 GR $591K. #CA255 rise. 50+ years goodwill. FFS. 2014 GR Fiscal-year GR $1.3MM. 5 Ops, 2 add’l $651K. #CA226 Plumbed, in same loc. 28 years. #CA219 CENTRAL CALIFORNIA LOS ANGELES: NEW LISTING! Endo WEST HOLLYWOOD: General Practice, MARIN COUNTY: Mill Valley 1,260 sq. CENTRAL COAST: 6 Ops, 8 days of practice, 4 Ops, Cone Beam, 2014 GR of 4 Ops, Mediadent, Intra-Oral Camera, ft. 3 Ops, 1 add’l Plumbed. Dentrix, Digital, hygiene/wk. 2013 GR of $2.3M and $804K $360K on 21 hours/week. #CA259 Digital, Laser, 5 yr old equip. 2014 GR of in adj. net. Dentrix, Digital, Paperless. Intra-Oral. #CA224 IN ESCROW! $613K . #CA212 IN ESCROW! #CA208 LOS ANGELES: General Practice. 4 Ops, MENDOCINO COAST: General Practice. 3 Equipped, Est. 60+ years in prof. bldg. 2013 SAN DIEGO 4 Ops, 2,376 Sq. Ft. Dentrix, CAD/CAM. FRESNO: General Dentistry Partnership. GR of $824K with $355K adj. net. #CA211 2013 GR $1M+. #CA181 2013 Partnership GR $4.7M. Selling Partner CENTRAL SAN DIEGO: NEW 2013 Net Inc $368K. #CA196 N. ORANGE COUNTY: General Practice. LISTING! Very busy 6 Op General Practice MILLBRAE:6T)WOHDVHGRI¿FH 7 Ops, 6 Equipped, EagleSoft, Digital, Seller with room to expand to 9 Ops. PPO, Dentrix, FRESNO: 5 Ops, 4 Equipped, 1,400 sq. with 5 Ops, 1 additional Plumbed, state-of- works 2½ days with GR of $542K. #CA248 Digital. 2014 GR 1.7M. #CA231 the-art equipment. 2014 GR $670K. #CA262 ft. w/Pano, Dentrix, all digital. 3 years GR averaging $409,000.SOLD Priced to sell. #CA243 CHULA VISTA: General Practice, est. 50+ N. COAST: Endo Practice. 6 Ops, 5 N. ORANGE COUNTY: General Practice. 4 Ops, Beautiful design, great location near years. 4 Ops, 3½ days of Hygiene, Dentrix. Plumbed 3,300 sq. ft. Digital, Microscopes, KINGS COUNTY: NEW LISTING: 4 $493K GR in 2013. #CA109 EndoVision. #CA214 Ops, Pano, established for 50+ years. GR of freeway & shopping #CA234 IN ESCROW! $246K in 2014. #CA265 DOWNTOWN: NEW LISTING! N. EAST BAY: PRICE REDUCED $77K! ORANGE COUNTY: NEW LISTING! Leasehold sale. Modern and chic downtown General Practice + Bldg. 7 Ops. 2,324 Sq. Ft. PORTERVILLE: General Dentistry, 6 Ops. Perio Practice. Easy freeway access. 30 years RI¿FHLQSULPHORFDWLRQ2SVURRPWR 2012 GR $885K. #CA108 2014 GR $555K, 7 year old equipment, retail of Goodwill. 6 Ops, 5 equipped. 2014 GR of expand. #CA232 center. #CA223 $468K. #CA264 NORTHERN CALIFORNIA: Perio LA MESA: General Practice. 4 Ops. Practice, Partnership Position. 6 Ops, 1,500 SOUTHERN CALIFORNIA PALM DESERT: NEW LISTING! Perio/ 3 Equipped, FFS/PPO, Dentrix, Digital. Sq. Ft. Dentrix. Owner Financing Available. Implant Practice. 6 Ops, 5 Equipped, Dentrix, 2014 GR $340K. #CA227 IN ESCROW! #CA168 ANAHEIM: General Practice & Bldg. Digital, Pano, 20+ years of goodwill. 2014 6 Ops, 3 Equipped, 3 Plumbed. Near GR $805K with $386K Adj. Net #CA245 N. COUNTY COASTAL: NEW NORTHERN CALIFORNIA: Endo Disneyland. Est. 39 years. #CA186 LISTING! General Practice, 3 Ops, Digital, Practice. 3 Ops, 1 Plumbed, 1,200 Sq. Ft. PALM DESERT: NEW LISTING! Dentrix, FFS/PPO. 2014 GR of $530K with 2 Microscopes, Digital. 2013 GR $319K+ ANAHEIM: 4 Ops, 5 add’l available, General Practice, 5 Ops, Est. for 32 years, $228K adj. net. #CA253 #CA158 SoftDent, Digital X-Rays and Digital Pano. 6 days of hygiene/week/ GR of $824K and 2013 GR 237K. #CA207 $339K adj. net. #CA245 N. COUNTY INLAND: NEW LISTING! NORTHERN CALIFORNIA: Endo General Practice & Bldg, 4 Ops, PPO/FFS, Practice. 4 Ops, 1 Add’l Available, 1,021 Sq. BAKERSFIELD: General Practice. 4 Ops. Digital, Pano, Cerec. GR over $1M. #CA216 Ft. 2013 GR $337K #CA169 PICO RIVERA: NEW LISTING! General Pano. Est. 20+ Years. 2013 GR $521K. Dentistry, 6 Ops, Est. in 1960. DentiSoft, #CA193 SAN DIEGO: General Practice. 3 Ops. N. OF SACRAMENTO:VTIWRI¿FH Pano, 4½ days of hygiene per week. 2014 FFS, PracticeWorks. Located in Central San w/4 Ops. Intra-Oral, Digital X-ray, Pano, BALDWIN PARK: General Practice. 5 GR of $690K. #CA258 Diego. 2014 GR $187K. #CA161 Laser, CAD-CAM, Dentrix software. Ops, 4 Equipped. 2014 GR $276K. #CA176 2014 GR $1M. #CA260 S. ORANGE COUNTY: Pedo Practice with SANTEE: NEW LISTING! General FFS/ BANNING: General Practice. 6+ Ops. 4 Ops, 1 year new equipment, digital, Pano/ PPO Practice, 6 Ops, retail center, Dentrix, PLEASANTON: Facility Only, Former Paperless, Digital, EagleSoft. 8 Days Hyg/ $236K GR with room to grow. #CA222 Digital, $780K GR in 2014. 7 days of hyg/ Endo Ofc, Good GP Startup. 2 Ops, 1 Week. 2014 GR $1.4MM+. #CA183 week, long-term staff. #CA228 Plumbed & Partially Eq. 975 Sq. Ft. #CA195 SOUTH BAY, LOS ANGELES: General BEVERLY HILLS: Small boutique S. BAY AREA, SAN DIEGO: General SACRAMENTO: 7 Equip Ops in 2,400 Dentistry. 4 Ops, Dentrix, Dexis, Pano, practice, 2 Ops, 1 Equipped, Open Dental, Dentistry, 3 Ops, 4 days hyg/wk. Retail sq. ft., 1 add’l Op Plumbed. Pano, Softdent, mostly FFS, 8 days hyg/week. $1.1M+ GR in Digital, 2014 GR $120K on 3 days/wk.. center, Dentrix, Digital Pano, PPO & FFS. Digital. 2014 GR $626K+. #CA250 2014. #CA218 #CA215 GR 2014 $524K. #CA206 SACRAMENTO: Prosth. Practice. OWNER SOUTH PASADENA: NEW LISTING! OUT OF CALIFORNIA DECEASED. 4 Ops, 2,075 sq. ft. w/Digital BEVERLY HILLS: 5 Ops, EagleSoft, General Dentistry. 4 Ops, 3 Equipped, Pano & Mac Practice software. 2014 GR Digital, CEREC. Long-term staff, newer paperless, digital, est. 37 years. 2014 GR HAWAII (MAUI): PRICE REDUCED! $960K+. #CA247 equipment. 2014 GR 1.07MM, Adj. Net of $856K with $271K adj. net. #CA244 General Practice. 4 Ops, Approx. 1,200 Sq. $406K. #CA210 Ft. GR $636K #20101

NORTHERN CALIFORNIA OFFICE NEW SOUTHERN CALIFORNIA OFFICE 1.800.519.3458 www.henryscheinppt.com 1.888.685.8100

Henry Schein Corporate Broker #01230466 Regulatory Compliance CDA JOURNAL, VOL 43, Nº8

Marketing and Advertising Rules CDA Practice Support

Marketing and advertising are key to practice, or any printing or writing on “lowest prices” or words or phrases of the success of any dental practice. Dentists novelty objects or dental care products. similar import. Any advertisement that and their marketing consultants need to Advertising does NOT include (1) any refers to services, or costs for services, be aware of marketing and advertising printing or writing used on buildings or and that uses words of comparison shall rules to ensure their ventures are uniforms where the purpose of the writing be based on verifi able data substantiating compliant. The state Dental Practice Act is for identifi cation or (2) any printing the comparison. Any advertising shall (DPA), Health Insurance Portability and or writing on memoranda or other be prepared to provide information Accountability Act (HIPAA) and state communications used in the ordinary suffi cient to establish the accuracy of that privacy laws apply, and dentists also should course of business other than solicitation comparison. Fee advertising shall not keep the CDA Code of Ethics in mind. or promotion of the dentist’s practice. be fraudulent, deceitful or misleading, including statements or advertisements How does the state Dental Practice Act What are the rules for advertising fees of bait, discount, premiums, gifts or (DPA) affect marketing and advertising? and discounts? any statements of a similar nature. In In general, the DPA: Any fee advertisement shall be exact, connection with fee advertising, the ■ Defi nes “advertising” without the use of phrases, including, fee for each product or service shall be or “advertisement” and but not limited to, “as low as,” “and up,” clearly identifi able. The fee advertised states what dental practice advertising may include. ■ Prohibits the use of false, misleading or deceptive statements, images or claims. When Looking To Invest In Professional ■ Prohibits the advertisement of a guarantee of any dental service. Dental Space Dental Professionals Choose ■ Prohibits compensation (including thank-you gifts) and inducements for patient referrals. ■ Requires a permit if the dental practice uses a name other Linda Brown than the name under which a dentist is licensed to practice 30 Years of Experience Serving (fi ctitious name permit). the Dental Community Proven ■ Establishes rules for group advertising and referral services. Record of Performance ■ Establishes rules for advertising fees, discounts and dentures. • Dental Office Leasing and Sales

What is considered advertising? For your next move, • Investment Properties The DPA defi nes “advertising” contact: LINDA BROWN • Owner/User Properties or “advertisement” as any written or • Locations Throughout printed communication for the purpose Direct: (818) 466-0221 of soliciting, describing or promoting Southern California a dentist’s licensed activities, or any Office: (818) 593-3800 directory listing caused or permitted Email: [email protected] by a dentist that indicates his or her Web: www.TOLD.com licensed activity, or any radio, television, Cal BRE: 01465757 or airwave or electronic transmission that solicits or promotes the dentist’s

AUGUST 2015 467 AUG. 2015 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 43, Nº8

for products shall include charges for any related professional services, including dispensing and fi tting services, unless the advertisement specifi cally and clearly indicates otherwise. Fee advertising for a dental service must fully disclose all services customarily included by the dental profession as Paul Maimone part of the advertised service, including NOW IS THE BEST TIME IN YEARS Broker/Owner but not limited to necessary diagnoses, TO BUY OR SELL A PRACTICE! radiographs, restorative treatment, drugs,

ARCADIA – (4) op comput G.P. Located in a well known Prof. Bldg. on a main thoroughfare. local anesthesia or analgesia, materials, Cash/Ins/PPO pt base. Annual Gross Collect $300K+ on a (3) day week. NEW laboratory fees and postoperative BAKERSFIELD #29 - (4) op comput G.P. (3) ops eqt’d, (1) add. plumbed. Located in a free care. The advertisement must also stand bldg. Cash/Ins/PPO. Digital x-rays. Annual Gross Collect $300K+ p.t. Seller moving. disclose any additional services, not CULVER CITY – (3) op Turnkey Office with included charts. In free standing Bldg. NEW LOS ANGELES - (3) op computerized G.P. located in a Landmark Medical/Dental Bldg. on a part of the procedure but for which main thoroughfare. Cash/Ins/PPO pt base. No HMO & No Denti-Cal. Digital X-rays. Annual the patient will be charged, together Gross Collections $600K+. NEW MONTEREY PARK – (6) op comput G.P. located in a street front suite on a main thoroughfare with the fees for such services. w exposure & visibility. Cash/Ins/PPO & small % Denti-Cal. Annual Gross Collect $250K+ p.t. The advertisement of Seller retiring but will assist with Transition. NEW a discount must: PASADENA – Nearly New Turnkey Office w some charts. Newer eqt. Gorgeous! RANCHO CUCAMONGA - (4) op comput. G.P. in a strip ctr. w visibility. (3) ops eqt’d (4th) op ■ List the dollar amount of the plumbed. Annual Gross Collect $185K+ on 2.5 days/wk. Cash/Ins/PPO pts. Seller moving. nondiscounted fee for the service. SANTA BARBARA COUNTY – (3) op comput G.P. & 1,900 sq ft Bldg. Cash/Ins/PPO pts. No ■ List either the dollar amount of the HMO and No Denti-Cal. 2015 Projected Gross Collections $250K on a very relaxed 3½ day week. Seller refers all O.S., Perio, Ortho and Endo. Also refers implant placement. Seller is discount fee or the percentage of retiring but will assist with a short transition prior to moving out of state. NEW the discount for the specifi c service. SHERMAN OAKS – (3) op comput G.P. in a well known, easily accessible Med/Dental bldg. ■ Inform the public of the length of Cash/Ins/PPO. Annual Gross Collect $180K+ p.t. Great Starter or Satellite. Seller retiring. So. KERN COUNTY – (6) op comput. G.P. located in a Bakersfield suburb in a small strip ctr. w time the discount will be honored. exposure/visibility. Pano eqt’d. Limited competition. Cash/Ins/PPO pts. Annual Gross Collect. ■ List verifi able fees. Approx. $350K p.t. Seller is moving and is motivated. ■ SANTA ANA - absentee owned (6) op fully eqt’d G.P. First floor street front location on a main Identify specifi c groups that qualify thoroughfare. Exposure/visibility/signage. Cash/Ins/PPO. No HMO & No Denti-Cal. Pano eqt’d for the discount or any other & Computerized. 2014 Gross Collect. of $549K+ on a (3½) to (4) day Associate run week. NEW terms, conditions or restrictions SOUTHWEST RIVERSIDE COUNTY - (5) op comput. G.P. (4) ops eqt’d/5th plumbed. 2015 Project Gross Collect $400K+. Cash/PPO. Located in a smaller prof. bldg. in a condo which can for qualifying for the discount. be purchased or leased. Seller giving up private pract. to accept institutional position. NEW th TUSTIN - (4) op comput. G.P. (3) eqt’d/4 plumbed. Located in a busy shop ctr. on a main What about programs that reward thoroughfare. Exposure, visibility & signage. Digital x-rays & CEREC. Annual Gross Collect $460K+ on an easy 4½ day week. Cash/Ins/PPO. No Denti-Cal or HMO. Growth potential. NEW patients or others for referrals of new WEST SAN FERNANDO VALLEY - (4) op comput. G.P. w modern equipt. Located in a patients to the practice? smaller prof. bldg. on a main thoroughfare. Cash/Ins/PPO pts. Annual Gross Collect $750K+ on a This question comes up a lot in (4) day week. Excell. long term lease, outstanding signage, & great off street parking. SOLD UPCOMING PRACTICES: Bakersfield, Beverly Hills, Central Coast, Covina, Montebello, CDA Practice Support. Dentists Oxnard, Pomona, San Gabriel, SFV, Temecula, Thousand Oaks, Torrance, Visalia & Valencia. and other health care providers are D&M SERVICES: required to comply with Business and Q Practice Sales and Appraisals Q Practice Search & Matching Services Professions Code Section 650(a), Q Practice and Equipment Financing Q Locate and Negotiate Dental Lease Space which states, “Except as provided Q Expert Witness Court Testimony Q Medical/Dental Bldg. Sales & Leasing Q Pre - Death and Disability Planning Q Pre - Sale Planning in Chapter 2.3 (commencing with P.O. Box #6681, WOODLAND HILLS, CA. 91365 Section 1400) of Division 2 of the Toll Free 866.425.1877 Outside So. CA or 818.591.1401 www.dmpractice.com Health and Safety Code, the offer, Serving CA Since 1994 CA BRE Broker License # 01172430 delivery, receipt, or acceptance by any

CA Representative for the National Association of Practice Brokers (NAPB) CONTINUES ON 470

468 AUGUST 2015

“Matching the Right Dentist CARROLL to the Right Practice” &COMPANY CComplete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions

4069 SOUTH BAY PERIO Well established Perio practice in desirable South Bay location. Approx. 1,700 sq. ft. facility w/4 fully-equipped ops. in a professional dental building. 2014 GR $800K+. 3 doctor days per week. Practice sees 30-40 new pts. per month. Cone beam scanner & panoramic x-ray purchased recently. Seller willing to help in the transition. Asking $460K. 4076 MORGAN HILL GP Absolutely beautiful and modern; established practice in well-known Professional Center. State- of-the-artSOLD office in approx. 1,000 sq. ft. 3 fully equipped ops, with room for a 4th op. 300+ active Mike Carroll & Pamela Carroll-Gardiner patients. Gross Receipts approx. $245K. Ideal turn-key operation. Asking $215K. 4075 PETALUMA GP Established GP located in Petaluma in stunning 4071 SAN MATEO GP 1,856 sq. ft. seller owned facility in class A, 2 story, Well-est. GP in single story professional dental 10 year-old professional building. State-of-the-art building located on a heavily traveled main artery office includes 6 ops, staff lounge, reception area, between downtown San Mateo and downtown private office, business office, lab area, sterilization Burlingame. 4 fully-equipped ops in modern office area, consult room, separate storage area, w/digital x-ray, inter-oral camera, laser & Cerec. bathroom plus private bathroom. 4 doctor-days & 2014 GR $673K+ w/adjusted net of $232K+. 4 hygiene days/wk. Avg. GR $640K. Asking Asking $459K. $440K. 4081 HAYWARD GP 4077 SAN JOSE GP Seller retiring from successful GP with well- Seller re-locating out of state.

Offering turn-key trained, seasoned staff. 4 fully-equipped ops. w/ GP in San Jose's Willow Glen neighborhood.
4 several equipment upgrades in seller owned fully equipped ops with 2 additional ops (plumbed building. Practice averages over $1M/year w/ but not fully equipped) in approx 2,000 sq. ft.
adjusted net of $334K+ averaging 4 doctor days Plentiful parking and easy freeway access from per week & 6 hygiene days per week. All fee-for- Hwy 280.
Approx 300+ active patients. 2014 GRs service. Asking price for practice only $732K. $167K.
Asking price for practice only $100K. Building is also available for purchase. 4051 CENTRAL COAST PROSTHO 4043 SANTA ROSA GP Well-established practice located in California’s Well-established, well respected general dental gorgeous Central Coast area. Beautifully practice located within a lovely professional center appointed, spacious 1,568 sq.ft. office with 4 fully in the heart of town.

Beautifully landscaped equipped ops, pros lab and other amenities. grounds with ample parking, Condo is also SOLD Situated just minutes from the ocean and <5 Carroll & Company available for purchase.

Gross receipts average miles away from one of California’s historic 2055 Woodside Road, Ste 160 $750-$800K every year.
Asking price for practice Mission Cities, this practice is nestled in a highly Redwood City, CA 94061 only $495K. desirable community. 2013 gross receipts were $1.2M+ and 2014 is annualized at $1.3M+ on a Phone: 4019 SF GP 4 day doctor workweek, w/4 days of hygiene/ 650.362.7004 Retiring owner offering well-established, hygiene week. Approx. 15 new patients a month and driven GP w/focus on Restorative care.
Excellent ~1,500 active patients (all fee-for-service). Email: location in the Marina/Cow Hollow Owner/doctor is willing to help Buyer for [email protected] neighborhood.
3 fully equipped ops in approx. PENDING smooth transition. 700 sq. ft.

2014 GR $426K with adj. net of Website: $175K.
Well-trained & seasoned staff.
Asking UPCOMING: www.carrollandco.info $285K. SF GP, San Jose GP, Marin County GP CA DRE #00777682 AUG. 2015 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 43, Nº8

CONTINUED FROM 468 person licensed under this division or to, gifts, fees, payments, subsidies my profession?” The rationale for the the Chiropractic Initiative Act of any or other economic benefi ts, from a standard is protection of the public; rebate, refund, commission, preference, third party for making any marketing, a dentist’s advertising should contain patronage dividend, discount, or treatment or health care operations any information that a patient would other consideration, whether in communication, the practice must consider necessary to make informed the form of money or otherwise, as obtain authorization from the patient choices about practitioners and compensation or inducement for prior to making that communication. services. The CDA Code of Ethics, referring patients, clients, or customers Additionally, state law requires Advisory Opinion 1.G.1, also advises to any person, irrespective of any the dental practice to: dentists that, in many circumstances, membership, proprietary interest, or ■ Notify the individual receiving promotional activities on school co-ownership in or with any person the marketing communication in grounds are considered unethical. to whom these patients, clients, or typeface no smaller than 14-point Information on additional marketing customers are referred is unlawful.” type of the fact that the practice and advertising rules can be found in has been remunerated and the the article, “Dental Practice Marketing What are the limitations established source of the remuneration. and Advertising 101.” The article and by HIPAA and state privacy laws? ■ Provide the individual with sample patient authorization forms are State and federal laws overlap in an opportunity to opt out of available at cda.org/practicesupport. ■ the regulation of a dental practice’s use receiving future remunerated of patient information for marketing communications. Regulatory Compliance appears monthly purposes. The federal HIPAA Privacy ■ The communication must contain and features resources about laws and Rule and the state Confi dentiality of instructions in typeface no smaller regulations that impact dental practices. Visit Medical Information Act (CMIA) than 14-point type describing cda.org/practicesupport for more than 600 require a dental practice to obtain how the individual can opt out of practice support resources, including practice a patient’s authorization prior to receiving further communications management, employment practices, dental using patient health information to by calling a toll-free number of benefi t plans and regulatory compliance communicate about a product or service the dental practice making the that encourages a recipient of the remunerated communications. communication to purchase or use the No further communication may product or service, or to give to another be made to an individual who entity to market its product or service. has opted out after 30 calendar Patient authorization is not required for days from the date the individual the following types of communications makes the opt-out request. for which the practice is not fi nancially remunerated by a third party: How does the CDA Code of Ethics ■ Making a patient aware of a govern dental marketing and advertising? health-related product or service Section 6 of the CDA Code of (or payment for such product or Ethics advises that dentists have the service) that is included in the obligation to represent themselves in a patient’s dental benefi t plan. manner that contributes to the esteem ■ Providing patient treatment. of the profession. The standard for ■ Coordinating care with other judging the ethical propriety of any providers, such as nursing homes. dentist’s advertisement to the public ■ Providing inexpensive items is whether the ad, taken as a whole, with the practice name and is false or misleading in any material contact information. respect. A dentist should always ask, ■ Face-to-face communication. “Could my ad be misinterpreted or If a dental practice receives fi nancial potentially misleading to someone who remuneration, including, but not limited knows nothing about my practice or

470 AUGUST 2015 Periscope CDA JOURNAL, VOL 43, Nº8

Periscope off ers synopses of current fi ndings in dental research, technology and related fi elds

PEDIATRICS Parents in the operatory and children’s parents wanted to be present for the dental procedures mentioned above. Only 38 percent of parents would let the dentist decide dental procedures whether they should be permitted to remain during treatment. Shroff S, Hughes C, Mobley C. Attitudes and Preferences of Statistically signifi cant fi ndings included the following: female Parents About Being Present in the Dental Operatory. Pediatr Dent and parents who were 31-40 years old stated that their child’s 2015;37(1):51-5. well-being was the reason they wanted to be present during Purpose: The purposes of this study were to determine if the type treatment. Parents with a high school education or greater chose of dental procedure being performed on children had an eff ect being unfamiliar with the dentist as a signifi cant factor in wanting on parents’ desire to be present in the operatory and to determine to be present. Married parents chose wanting to obtain more if the percentage of parents desiring to be present for their child’s information about the procedure so they could explain it to their treatment had remained consistent over the past two decades. spouse as a factor for being present in the operatory. Materials and methods: A survey was conducted with Conclusion: Most parents preferred to be present during parents of children who presented for dental appointments at their child’s treatment regardless of the dental procedure. three sites: a pediatric clinic at the University of Nevada, Las More than one-third of the parents do not want the dentist Vegas, School of Dental Medicine and two private practice to be the sole person to determine their involvement in their settings in southern Nevada. Parents or caretakers were asked child’s dental visit. Parental desire to be present during to complete a three-section, 20-item survey. The sections were dental treatment has not changed over the last 20 years. demographic information, past medical and dental history, and Reviewer’s comments: Parental presence is a behavior diff erent scenarios commonly associated with treatment in a guidance technique endorsed by the American Academy of pediatric offi ce (i.e., examination and radiographs, restorative Pediatric Dentistry. As parenting styles and societal attitudes treatment, exodontia, conscious sedation and protective change, more parents want to be involved with the treatment stabilization). The parents were asked whether they had decisions for their child. Parents want to be present to support observed the procedure before, would prefer to be present or and ensure that their child is comfortable during treatment. This absent during the procedure, if their opinion would change if study also confi rms that the more educated the parents are, their child were struggling or crying during the procedure and the more likely they want to be present if they are unfamiliar if they preferred that the dentist make the decision whether they with the dentist. Parental presence during treatment can be remained in the room during the procedure. The survey was fi eld a good practice builder but it will only work if the dentist tested and approved by the Institutional Review Board of UNLV. establishes expectations and builds trust with the parents. Results: Three hundred and thirty-nine parents completed the — Thomas S. Tanbonliong Jr., DDS survey. Demographic information was as follows: 73 percent female parent, 60 percent Hispanic, all between 25 and 40 years old and have a high school education. Majority of the responders had a household income less than $50,000 annually. More than half of the children were between 4 and 9 years old and healthy. Seventy-nine percent of parents said that their child had never had a bad experience with the dentist. Seventy-eight percent of parents would prefer to be present during their child’s treatment. Sixty-two percent of the parents indicated that the primary reason they want to be present is they feel their child is more comfortable with their presence. The majority of the

AUGUST 2015 471 AUG. 2015 PERISCOPE

CDA JOURNAL, VOL 43, Nº8

MICROBIOLOGY PERIODONTICS Oral microfl ora eff ect on bone levels Surgical periodontal therapy — Irie K, Novince CM, Darveau RP. Impact of the Oral together is better Commensal Flora on Alveolar Bone Homeostasis. J Dent Res Aljateeli M, Koticha T, Bashutski J, Sugai JV,Braun TM,Giannobile 93(8): 801-806, 2014. WV, Wang HL. Surgical periodontal therapy with and without Background: It has long been known that the commensal oral initial scaling and root planing in the management of chronic microfl ora plays a role in homeostatic regulation of alveolar bone. periodontitis: a randomized clinical trial. J Clin Periodontol However, little is known regarding the underlying mechanisms of 2014, 41 (7): 693—700. alveolar bone loss mediated by the commensal oral microfl ora. Aim: To compare the outcomes of surgical periodontal Methods: Histomorphometric analyses of alveolar bone therapy with and without initial scaling and root planing. loss in specifi c-pathogen-free (SPF) mice and germ-free (GF) Methods: Twenty-four patients with severe chronic periodontitis mice were carried out. Immunohistochemical staining of were divided into two treatment groups, both who had modifi ed neutrophil markers, T-cell markers and receptor activator of Widman fl ap surgery but only one preceded the surgery with nuclear factor kappa B (RANKL) were conducted to identify scaling and root planing (control group). The test group had the cellular compositions within junctional epithelium (JE). surgery only. Clinical parameters evaluated included probing Tartrate-resistant acid phosphatase (TRAP) staining for the depths, attachment levels, bleeding on probing and radiographic identifi cation of osteoclastic cells was also carried out. evidence of bone level changes from base level to six months. Results/Discussion: SPF mice revealed increased alveolar bone Infl ammatory biomarkers of wound healing were also assessed. loss and increased numbers of both TRAP+ osteoclastic cells and Results: Both groups showed improvement in attachment RANKL+ cells at the alveolar bone surface than GF mice. This levels at three and six months compared to baseline. No was associated with increased numbers of neutrophils, CD3+, statistically signifi cant change in biomarkers was shown CD4+ and interleukin-17+ cells in the JE of SPF mice compared between the groups. There was a statistically signifi cant to GF mice. These results suggested that the host-commensal oral improvement in probing depth reduction in favor of microfl ora interactions result in the release of osteoclastogenic the control group at both three and six months. molecules from the host, leading to the alveolar bone loss seen in the clinically healthy periodontium. Since RANKL has been Conclusion: Combining scaling and root planing with known to be expressed by neutrophils and activated Th17 surgery yielded greater probing depth reduction than cells, it is possible that increased alveolar bone loss caused surgery without initial scaling and root planing. by the commensal oral microfl ora in SPF mice was due to the Clinical relevance: Scaling and root planing is an important activation of both innate and adaptive immune systems. component of periodontal therapy, helping to resolve Conclusions: An alveolar bone loss occurring in clinically healthy infl ammation, reduce pockets and gain clinical attachment, periodontium is mediated, at least in part, by the immunomodulately even if surgery needs to be performed. Based upon this eff ects of commensal oral microfl ora on host cells. study scaling and root planing might contribute to a more favorable outcome when performed prior to surgery in the — Takahiro Chino, DDS, MSD, PhD form of improved pocket depth reduction. Proponents of a “direct-to-surgery” approach should keep this in mind. — Gerald Drury, DDS

472 AUGUST 2015

800.641.4179 [email protected] WESTERNPRACTICESALES.COM

BAY AREA NORTHERN CALIFORNIA

What separates AC-335 SAN FRANCISCO: Two great practices for EN-340 SACRAMENTO: Large HMO pracƟce! 3,400 the price of one! Now Only $475! sf w/ 10 ops and Plumbed for 1 add’l $950k us from other AG-053 SAN FRANCISCO: 3,000 sf w/ 9 ops + 1 EN-350 SACRAMENTO: The Perfect Merger Oppor- add’l. PRIME LOCATION! $475k tunity! Old-fashioned values and philosophy! 674 brokerage firms? BN-183 HAYWARD: Kick it up a notch by increas- sf w/ 1 op. $85k ing the current very relaxed work schedule! EN-378 LINCOLN: quality pracƟce with a wonderful 1,300 sf w/ 3 ops $150k paƟent base! 1,369 sf w/ 2 op + 3 add’l. $170k BN-279 CONTRA COSTA COUNTY: Excellent Merger EN-379 ROSEVILLE: An amazing opportunity in the

Opportunity! 2-story. 1,350 sf w/ 3 ops +1 add’l locaƟon of your dreams! 1,040 sf w/ 3ops. $295k

$60k EN-423 FOLSOM Oral Surgery Facility: Primed for

BC-361 OAKLAND: Established for over 23+ years! success! 3,450 sf w/ 2 Lrg. Treatment Rooms. Now Our extensive buyer 2,200 sf w/ 7 ops. Now Only: $385k Only $50k! BC-381 PLEASANT HILL Facility: Open Floor Plan! EN-430 SIERRA FOOTHILLS: PracƟce in one of the database and 1,852 sf w/ 6 equipped ops! Move in Ready! $80k most desirable places to live in N. CA! 1,050 w/ 3 BG-407 SAN LEANDRO: Prof bldg. Great signage! ops. $475k unsurpassed exposure 1200 sf w/ 3 ops $140k FN-299 FERNDALE: Live and practice on the allows us to offer you a BN-426 BERKELY: Step into this quality pracƟce beautiful North Coast! 1,300 sf w/ 3 ops $195k and you’ll know you belong here! 1,386 sf w/ 3 (Real Estate: $309k) ops. $495k FC-334 NORTHERN CA: Emphasis on prevenƟon. BC-432 PITTSBURG: Own this family-oriented 1,200 sf w/ 4 ops $480k / Real Estate Also Availa- PracƟce! 1,640 sf w/ 6 ops. $350k ble! BG-444 FREMONT: PresenƟng a remarkable oppor- FC-343 NORTHERN CA: Quality & locaƟon are the Beer tunity and quality pracƟce! 3,200 sf w/ 10 ops. keys to success! 1,200 sf w/ 3 ops + 1 add’l & 1 hyg. $550k Op. $500k (Real Estate $375k) CC-390 SOLANO COUNTY: Near Travis AFB! High- FC-415 FT. BRAGG: An excellent pracƟce, located ly visible location! 950 sf w/ 3 ops REDUCED! in a peaceful, family-oriented community! 1,800 sf Candidate $180k w/ 5 ops + 1 hyg. Op. $425k CG-366 SONOMA CO.: Vibrant, growing commu- GG-320 CHICO: Large, Unique, Originally designed nity! 1,300+ sf w/ 4 ops. Over $760k in collec- for more than 1 dds! 5,000 sf w/ 7 ops (+2 add’l) tions! $450k $985k CG-449 SANTA ROSA: Vibrant, highly desired GG-386 REDDING: Practice & Real Estate! 2,860 sf Beer town! Prof Bldg 1860 sf w 4 ops + 1 a’ddl $250k w/ 4 ops. Plumbed for 2 add’l! PR: $330k / RE: DC-370 SAN JOSE Facility: Location, Location, $660k Location!! Move in Ready! Only $120k GN-201 CHICO: Beautiful practice, major thor- DG-341 SUNNYVALE/LOS GATOS Combined Sale: oughfare, stellar reputation! 1,400 sf w/ 4 ops & Fit Contact our office for details. $605k room for another $425k DG-396 SERRAMONTE AREA: Small Town Feel in GN-244 OROVILLE: Must See! Gorgeous, Spa- Heart of SF. 850 sf & 4 ops $485k cious. 2,500 sf w/5 ops! Collections over $450k in DN-312 LIVERMORE Facility: Don’t miss out on this 2013. Only $315k one! 1,070 sf w/ 3 ops. REDUCED! $75k GN-258 REDDING: PrisƟne and aƩracƟve! Conven- DC-403 SANTA CRUZ: Well-established, modern, iently located! 1,050 sf w/ 2 ops. $215k Beer quality pracƟce! 1,335 sf w/ 4ops. $725k GN-399 REDDING: Loyal paƟent base and relaxed DC-419 NEWARK Facility: LocaƟon, LocaƟon, Loca- workweek schedule. 1,440 sf w/3 ops. $150k Ɵon! 1,400 sf w/ 4 op. $140k GN-418 REDDING: Goodwill Galore! Established DC-406 SAN JOSE: Amazing opportunity in West- for ~37 years and the seller is reƟring! 3,200 sf w/6 Price gate Shopping Center. 6 ops + 80 mall hours per ops +2 add’l. $495k week $400k HG-298 REDDING FOOTHILLS: HEALTH FORCES DG-434 MENLO PARK: Well-Established. Near SALE! Includes Cerec! 2,000 sf w/ 5 ops. PracƟce Facebook, Stanford, Google and Tesla! 1702 sf w/ 5 $100k / Real Estate $250k We are a proud member of: ops. Excellent Opportunity! $1.2m HN-213 ALTURAS: Close to Oregon Border. FFS DN-447 SUNNYVALE: Quality, family-oriented practice is 2,200 sf w/ 3ops +1 add’l $115k opportunity awaits your talent and skill. 1,400 sf w/ HN-280 NORTHEASTERN CA: “Only Practice in 3 ops + 1 add’l. $395k Town” 900 sf w/ 2 ops $110k

Timothy G. Giroux, DDS is currently the Owner & ASK Broker at Western Practice Sales and a member of the nationally recognized dental organization, ADS Transitions. THE You may contact Dr Giroux at: [email protected] or BROKER 800.641.4179 NORTHERN CALIFORNIA CONTINUED Should there be a reduction in the value of What separates HN-290 PLACERVILLE: Excellent Merger Op! a “Delta Premier only” dental office? Embrace the lifestyle and build your success us from other story here! FFS. 1,400 sf w/ 4 ops $210k HG-448 S. LAKE TAHOE: 2 Story, Rustic dé- First, Let’s define the problem, as there is a great deal of misunderstanding on this cor. Upscale Family Practice. 3400sf w 6 ops issue. About four or five years ago, Delta decided that all new contracts with dentists brokerage firms? would include both the Premier and the PPO contract. There was no choice on the $725k matter from the dentist. On face value, this did not seem like a big deal in practice CENTRAL VALLEY transitions as the assumption was that the buyer would keep all the “premier patients” on the higher fee schedule and that he would acquire many more new patients on the IG-067 STOCKTON: Fully computerized, pa- PPO fee schedule, albeit at a lower fee schedule. In fact, it seemed like a good way to perless, digital. 5,000 sf w/10 ops Steal of grow the practice after the transition. Our extensive buyer the Century! Now ONLY $240k IG-367 MERCED: Newly Remodeled, Paper- The first time we discovered this assumption was incorrect, was upon listing a practice database and less. 1,550 sf w/4 ops REDUCED! $325k that voluntarily added the PPO product to his office. He also assumed that his current unsurpassed exposure IN-345 MODESTO: Long-standing tradiƟon of ”Premier” patients would keep their fee schedule. He soon found that Delta was paying quality care. 3016 sf w/ 5ops + 1 add’l. $495k 25 to 30 percent less on about 90% of his past Delta Premier patients. However, he allows us to offer you a IN-358 MODESTO: PracƟce nets over 50%! finished off that year with his highest production ever, due to the increased patient 1,200 sf, 3 ops+1 add’l. REDUCED! $275k flow! IN-397 FRESNO/MADERA: “the Perfect LocaƟon”! 2,000 sf w/5ops. NOW ONLY: What we did not fully comprehend is that Delta has not really sold any new “Premier” $440k plans for many years. Each year, the percentage of Delta Premier patients is reduced IN-429 TRACY Facility: “Move-in ready” compared to the PPO plans. Currently the percentage of Delta Premier patients is Beer Hesitate and you might miss out! 2,488 sf, 5 approximately 7%. Today’s current “Premier Only” doctors normally do not realize ops $245k/RE: $650k that as much as 93% of their “Delta Premier” patients are really what we refer to as JC-349 FRESNO Facility: Doctor is reƟring “PPO Plus”, meaning that Delta has agreed to pay the Premier fee schedule for the time and is moƟvated! Step right in and make being, but any change in the contract will reduce all of these patients to the standard Candidate yours! Call for Details! PPO fee schedule. SPECIALTY PRACTICES We have also witnessed transitions over the years where the practice’s gross receipts CG-431 FAIRFIELD Perio: Priced to sell! did suffer after the buyer was forced to take the lower fee schedule. However, since Beer 1400 sf w/ 3 ops. Plumbed for 2 add’l $60k 2011 when we began following this phenomenon, I can say that there is no direct I-7861 CENTRAL VALLEY Ortho: 2,000 sf, correlation to declining revenue just because of the Delta fee change issue. We recently open bay w/ 8 chairs. Fee-for-Service. sold a predominately Delta practice that had 1.7 Million in gross receipts. We expected $370k this practice would suffer as this practice did not need to grow their patient base with Fit I-9461 CENTRAL VALLEY Ortho: 1,650 sf w/5 the additional PPO patients. Six months after the sale the monthly collection numbers chairs/bays & plumbed for 2 add’l $180k DG-264 SAN JOSE Ortho: $300-400k in were actually greater!

build-outs alone! 1800 sf w/ 5 chairs. RE- It is imperative that buyers understand this issue and find out how much of the DUCED! $195k revenues are generated by a “Delta Premier only” office. However, it is just one of the CC-346 SO MARIN CO Perio: 1,142 sf w/ 3 many variables a buyer should understand in making a good decision to purchase a Beer ops. Meticulously maintained! REDUCED! practice. $199k BN-393 PINOLE Pedo: Streamlined pracƟce, where every child counts themselves lucky to Price be a paƟent here! 2,000 sf w/ 5 ops. $1.2m CG-424 NAPA Prostho: Ready for Experi- enced, high-end ProsthodonƟst! One track to collect just under $1m $725k CC-405 SOLANO CO. Endo: EndodonƟc Prac- Ɵce in a vibrant community! 1,250 sf w/ 4 ops. $485k

Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD Tech Trends CDA JOURNAL, VOL 43, Nº8

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

Google Photos (Google Inc., Free) HEALTHYDAY (McNeil-PPC Inc., Free) Google Photos for iOS provides all users with cloud storage backup HEALTHYDAY is a new app that uses crowdsourcing data to for photos and videos on mobile devices. The application and service provide real-time tracking status of health trends in any location. is also available for Mac, PC and Android devices. Once logged HEALTHYDAY works by gathering location and reports from its in with a Google account, Google Photos works seamlessly in the users. When the app determines its location, it asks the user simply, background by continuously backing up all photos and videos on the “How are you feeling today?” A color feeling indicator face can be iOS device through a Wi-Fi connection. When backups are complete, cycled through green (good), yellow, orange and red (bad). If a users are free to delete photos and videos from their camera rolls user is not feeling well, the app will try to determine what the user on their iOS devices. All photos and videos are available to view is most likely suff ering from using the trends of reports in the area. on the cloud through the Google Photos app. Within the Google If the app is incorrect in determining what a user is suff ering from, Photos app, users can view their photos sorted by date or collections he or she can choose from a list of common ailments that he or she based on photo location data. Tapping on any item enlarges it to thinks may be the cause of their illness. Each user report is combined full screen, where users can share, edit, view info or delete the item with reports from other users to create a local dashboard, which from cloud storage. Users can apply fi lters and use simple editing shows the trends and risks of allergies, colds and fl u in the area. tools for their photos and videos. Google off ers two storage options An “Illness Map” provides locations and reports of what is going for this service: Original and High Quality. The Original storage around in the neighborhood so that users can be on the alert when option backs up and syncs photos and videos at their full resolution common illnesses are on the rise. In addition to providing real-time and quality. This option counts against the standard storage quota reports and trends in the area, HEALTHYDAY provides “30-Second for a Google account, which is 15GB and is shared amongst other Solutions,” which are helpful tips and answers to the most common services such as Gmail and Google Drive. The High Quality storage health questions people ask. option provides unlimited storage for photos and videos that are — Hubert Chan, DDS equal to or less than 16MP or 1080p resolution. For most users, the High Quality option will more than suffi ce. — Hubert Chan, DDS Adding Photo Filters Boosts Social Interaction 70 Percent of World Using Adding fi lters to photos on social media is something amateurs and more advanced photographers do, but what does it do to Smartphones by 2020 enhance social interaction? Yahoo! Labs released a study aimed Smartphones have become part of most people’s day-to-day lives at determining how fi lters aff ect photo engagement such as likes, and that trend is expected to increase over the next fi ve years, comments and views. The study analyzed 7.6 million public photos according to a study by Ericsson Mobility Report. Specifi cally, 70 on Flickr, an online photo management and sharing application, percent of the world’s population will have a smartphone by 2020. which resulted in the fi nding that fi ltered photos saw a 21 percent The study went on to state that mobile traffi c in the fi rst quarter of increase in views and 45 percent increase in comments. “Filters 2015 was 55 percent higher than the fi rst quarter of 2014 and that that increase contrast and correct exposure can help a photo’s by 2020, 80 percent of mobile traffi c will be from smartphones. engagement, and fi lters that create a warmer color temperature are “Video continues to be the key growth factor, with 60 percent of more engaging than those with cooler color eff ects,” according to all mobile data traffi c forecast to be from online video by 2020,” the study. according to the study. The study also states that those who use — Blake Ellington, Tech Trends editor larger screens with their mobile devices (tablets) spend 50 percent more time watching videos. — Blake Ellington, Tech Trends editor

476 AUGUST 2015 Dr. Bob CDA JOURNAL, VOL 43, Nº8

Aging Gracefully (and Other Indignities)

The following Dr. Bob column was originally printed in the March 2010 issue of the Journal.

My knees, unlike some of When I pay one of my infrequent visits a twinge in my right shoulder and two my other body parts, had to my primary care guy, I make certain suspicious spots on my right forearm at to get my $10 co-payment’s worth by least 4 microns in width. In addition, not communicated with me saving up symptoms until I’m sure I have an annoying extra trip to the bathroom for more than eight decades. enough to command his attention for around 4:30 a.m. convinced me that at at least 10 minutes. These are carefully least one or two of these symptoms confi rm recorded on a list I bring with me. the presence of a fatal disease requiring My left knee has begun to hurt. My surgical intervention immediately. Time knees, unlike some of my other body to shell out the $10 co-pay. parts, had not communicated with me My instinctive distrust of general for more than eight decades. I compared anesthesia was intensifi ed by the Robert E. the ailing knee with its mate. Although probability of the operating surgeon they are both the same age and appear to assigned to save my life being revealed Horseman, be dimpled twins, the complainant had as a head case on the verge of going DDS taken on a life of its own, either refusing postal from stress and fatigue. “You to bend comfortably or threatening to fl ex need to make an appointment,” I told ILLUSTRATION both ways without advance warning. myself. I did — the following spring. BY VAL B. MINA After six weeks of ignoring it, I fi nally An overhead wide-angle shot of a managed to accumulate a qualifying surgical amphitheater overfl owing with number of unrelated complaints, including students and resident doctors forms clearly

AUGUST 2015 477 AUG. 2015 DR. BOB

CDA JOURNAL, VOL 43, Nº8

in my mind. Gathered from as far away as “What’s the matter with entrance of the doctor, an older man Rochester, the assemblage leans forward in radiating compassion and wisdom, sort hushed reverence to witness my surgeon’s your knee?” he asks. of like my grandfather, only richer. legendary expertise. I had just become Well, duh! At $10 I have In time (this is Doctor Time, different aware of two morgue attendants standing to do my own diagnosis? from Patient Time), the doctor breezes expectantly in the background beside their in. A substantial part of my wardrobe is gurney when I hear a female voice an- older than he. He gets right to the point, nounce, “Robert, you may come in now.” the meter is running. “What’s the matter I try to respond in kind by attempting percent errors and are meaningless except with your knee?” he asks. Well, duh! At to read her name tag pinned to her blouse to satisfy blank places on the chart. $10 I have to do my own diagnosis? just south of her left clavicle, but realize It seems under-the-tongue “It hurts when I do this,” I explain, that staring any longer to make out the thermometers are an anachronism. A fl exing my left leg gingerly. words would not be in my best interests. hand-held electronic probe is inserted “Then don’t do that.” His eyes Laying aside the article I had been reading three inches into my ear, beeps once and grow pensive. “How long?” in Woman’s Day on how to cope with immediately withdrawn. I assume this is “Six weeks.” He palpates the joint in a those pesky postpartum stretch marks, I a rejection because of the wax buildup, doctorly manner. “A stretched ligament or trail after the paisley-topped assistant into but Paisley dutifully notes the 98.6 on tendon,” he says, conserving unnecessary the inner sanctum. Young enough to be my chart and takes my blood pressure. words as if texting me. “Nothing to my granddaughter, she is preternaturally Blood pressure taken in an examination worry about. Take a while to disappear. cheerful as she confi des that we will room automatically initiates the white Couple of Advil or Aleve are OK.” pause for a moment to weigh me. coat syndrome and elevates itself to near “But, I …” It is too late. Obviously, At the end of the hall is the scale, fatal limits. I also believe if I hold my administering extreme unction to my impossible to circumvent. The drill is breath, close my eyes and roll my eyeballs knee is premature and the problem always the same and her buoyancy is upward in their sockets, then focus on is too intricate and inconsequential ill-suited for the occasion. “Hop on,” she arbitrary numbers like 120 and 75, I can to warrant recapitulating. trills cheerfully. Every time I have ever achieve any reading I please commensurate “You need a fl u shot and a pneumonia mounted one of these doctor scales it is with my age. Or better yet, some kid shot,” he states. “Take this form to obvious the patient before me could not about 25 who has matured in every way the lab. See you in two weeks.” have weighed more than 110 pounds. except for calling everybody “Dude!” He’s out the door and I am left sitting There follows a deliberate, prolonged and wearing a baseball cap incorrectly. on the crinkly paper-covered table, humiliation during which the weights are Paisley smiles benignly at me. Were as my list of assorted ailments fl utters slowly advanced along their tracks almost the room to be suddenly bathed in to the fl oor. Left knee, CHECK. to the end before balance is achieved. “My ultraviolet light, a little “thought bubble” What a nice man! Not once did he shoes weigh at least fi ve pounds each, you would appear over her head containing mention the fact that at my age it would know,” I always offer, feeling this should the words “What a porker!” In any event, be unrealistic to expect anything less be taken into account as a truer indication Paisley is satisfi ed with my BP, thinking, than a yard-long grocery list of physical of my poundage. I could be wearing a not bad for a geezer with one foot in. woes. Maybe I’ll come back next fall after full-length raccoon coat, pockets loaded She departs to fetch the doctor, a summer of reckless hedonism. I should with enough lead weights to anchor the taking my 2-inch thick folder with have a list to reckon with by then. ■ QE2 and the results would be carefully her lest I sneak a peak at my own recorded in my chart. Technically, one records that I couldn’t read anyway, We’re taking your requests should be weighed in the buff. If nothing written as they are in Physicianese! If you have a favorite Dr. Bob column else, the procedure would add interest to Modern medicine has streamlined the you want to see again, email Publications an otherwise dull day at the offi ce. If an whole medical appointment experience Specialist Andrea LaMattina at andrea. inaccuracy of this magnitude is tolerated, to the point where the doctor is the lamattina @ cda.org. We will oblige by the requisite recording of my vitals that last person encountered. When I was reprinting those requested favorites interspersed follows is subject to plus or minus 35 younger, the next step would be the with any new Dr. Bob submissions.

478 AUGUST 2015 Your convention.Your first look.

With approximately 400 companies showcasing their latest products and services, the exhibit hall at this year’s convention is the perfect place to see and try exciting innovations in dentistry for yourself. CDA Presents The Art and Science of Dentistry. Yeah, this is your convention.

Thurs.–Sat. Moscone Register today The Art August 20–22 South cdapresents.com and Science 2015 San Francisco of Dentistry I’M KIND OF A BIG DEAL

FAST 15- to 30-minute wear times EASY Ready to go right out of the package EFFECTIVE Award-winning Opalescence® professional teeth whitening gel

Before wearing UltraFit tray after UltraFit tray in just 10 minutes the mouth in the mouth

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