December 2018 Antibiotic Stewardship Third Molar Coronectomy Non-Hodgkin Lymphoma of the Maxilla JournaCALIFORNIA DENTAL ASSOCIATION

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DEPARTMENTS

741 Guest Editorial/Are We Doctors or Not?

744 Letter to the Editor

747 Thank You to 2018 Journal Reviewers

749 Impressions

779 RM Matters/Posttreatment Care Crucial in Foreign Object Aspiration Incidents

783 Regulatory Compliance/Mandated Reporting

786 Tech Trends 788 Index to 2018 Articles 749

FEATURES

755 Antibiotic Prescribing and Stewardship in Dentistry: A Public Health Perspective Antibiotic resistance is one of the most serious public health threats of modern times. Jane D. Siegel, MD, and Erin Epson, MD

757 The Core Elements of Antibiotic Stewardship in Dentistry This article offers suggestions for applying the four core elements of antibiotic stewardship in dentistry and dental practices. Peter L. Jacobsen, PhD, DDS

767 Coronectomy of Mandibular Third Molars: Our Experience With 250 Consecutive Patients Coronectomy of mandibular third molars has become an accepted alternative to extraction in cases where there is a close proximity of nerve and roots. Emily Ehsan; Paul Hauser, PhD; and David Ehsan MD, DDS

773 Recognition of Non-Hodgkin Lymphoma of the Maxilla This article discusses the importance of early recognition of the symptoms of this aggressive disease that can lead to earlier treatment and improved outcomes. Joel B. Epstein, DMD, MSD; Alexa Martin, DMD; Ali M.M. Sadeghi, DMD, MD; and Dimitrios Tzachanis, MD, PhD

DECEMBER 2018 739 CDA JOURNAL, VOL 46, Nº12

Volume 46, Number 12 JournaCALIFORNIA DENTAL ASSOCIATION December 2018 CDA Classifieds.

Free postings. published by the Editorial Production Letters to the Editor California Kerry K. Carney, DDS, CDE Randi Taylor www.editorialmanager. Priceless results. Dental Association EDITOR-IN-CHIEF SENIOR GRAPHIC DESIGNER com/jcaldentassoc 1201 K St., 14th Floor [email protected] Sacramento, CA 95814 Upcoming Topics Subscriptions Ruchi K. Sahota, DDS, CDE 800.232.7645 ASSOCIATE EDITOR January/CAMBRA/PBRN Subscriptions are available cda.org February/E-cigarettes only to active members of Brian K. Shue, DDS, CDE March/Opioids the Association. The CDA Offi cers ASSOCIATE EDITOR subscription rate is $18 and Advertising is included in membership Natasha A. Lee, DDS dues. Nonmembers can PRESIDENT Gayle Mathe, RDH Sue Gardner SENIOR EDITOR ADVERTISING SALES view the publication online [email protected] at cda.org/journal. [email protected] R. Del Brunner, DDS Andrea LaMattina, CDE 916.554.4952 PUBLICATIONS MANAGER Manage your subscription PRESIDENT-ELECT online: go to cda.org, log in [email protected] Permission and Kristi Parker Johnson and update any changes to EDITORIAL AND Reprints your mailing information. Richard J. Nagy, DDS COMMUNICATIONS SPECIALIST Andrea LaMattina, CDE Email questions or other VICE PRESIDENT PUBLICATIONS MANAGER changes to membership@ [email protected] Blake Ellington [email protected] cda.org. TECH TRENDS EDITOR 916.554.5950 Judee Tippett-Whyte, DDS SECRETARY [email protected] Jack F. Conley, DDS Manuscript EDITOR EMERITUS Submissions Steven J. Kend, DDS www.editorialmanager. TREASURER Robert E. Horseman, DDS com/jcaldentassoc HUMORIST EMERITUS [email protected] CDA classifiedsclassifieds wworkork harder to bbringring you resuresults.lts. SeSellinglling a practice Craig S. Yarborough, DDS, MBA Stay Connected cda.org/journal or a piece ooff equipment? Now you SPEAKER OF THE HOUSE [email protected] can include photos to help buyers Clelan G. Ehrler, DDS see the potential. IMMEDIATE PAST PRESIDENT Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the [email protected] California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. And if you’re hiring, candidates Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. anywhere can apply right from Management Peter A. DuBois The California Dental Association holds the copyright for all articles and artwork published the site. Looking for a job? You can EXECUTIVE DIRECTOR herein. The Journal of the California Dental Association is published under the supervision of post that, too. And the best part— CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for Carrie E. Gordon any expression of opinion or statement of fact, all of which are published solely on the authority it’s free to all CDA members. CHIEF STRATEGY OFFICER 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 Kristine Allington that they are contributed solely to the Journal. All of these features are designed to CHIEF MARKETING OFFICER Copyright 2018 by the California Dental Association. All rights reserved. help you get the results you need, Alicia Malaby faster than ever. Check it out for COMMUNICATIONS DIRECTOR yourself at cda.org/classifieds. Cris Weber CREATIVE AND UX DIRECTOR

740 DECEMBER 2018 Guest Editorial CDA JOURNAL, VOL 46, Nº12

Are We Doctors or Not? Robert S. Roda, DDS, MS

m I a doctor? I think I am, but there have been times when I have not been so sure. Yes, the status of someone’s oral preventive skills is When I was in dental school, personal, but it’s not the same as discussing sexual the med students reveled in Atheir status as “RDs” (real doctors) and behaviors that can result in picking up this STI. tended to throw it in our faces regularly. Back then, dentists were considered “ doctors,” with the implication that the mouth was somehow disconnected from rubber dam was precluded at that stage comfort, but I knew that once any doctor the rest of the body. As time has gone on, due to the confi guration of the section used the word “cancer,” anything said the realities of medicine and dentistry of bridge to be removed, and I feared after that was not heard by the shocked have forced us together, and there are that despite all precautions the bur had patient. This was, by far, the most diffi cult few in the medical profession who think been lost down the patient’s throat. interaction I had ever had with a patient. of me as less of a doctor than they are. I sat the patient up and she said Among all of the other emotions I was There is no doubt that I know my nothing went down her throat and dealing with, I was also heartbroken profession and my specialty inside and out. nothing had been swallowed or aspirated. because she was such a great person. I work very hard to keep up with the rapid A check of our operatory and suction traps I fi nished the root canal procedure changes in both medicine and dentistry showed no bur, so out of an abundance within a week or two and the patient had and the allied health fi elds by reading of caution, I advised my patient that entered the medical system by then. Tests extensively, by attending courses and she would need to get a chest X-ray were going to be performed the next week through the many personal contacts that and that I would pay for it. She wanted and she was certain that no matter what I have made over the years. My review of to fi nish the appointment fi rst so that it was, she was going to be cured. What medical histories is thorough and every was done uneventfully and she went to an optimist, I thought. She returned for a day I have to adapt my clinical procedures get the radiograph. I was called by the six-month re-evaluation and was cancer- to the medical needs of my patients. I radiologist at the imaging center that free. The tumor had been found at a very contact physicians routinely to discuss afternoon and he said it was a good- early stage, was surgically removed, and the medical status of mutual patients, news, bad-news situation: There was no with some radiation and chemotherapy, and I have enjoyed seeing many of these foreign object in her thorax or abdomen, the oncologists were as optimistic as she physicians enter my practice as patients. but she had a “spot” on her left lung was. I followed her root canal healing for Yet, there are still times that I struggle and he was afraid it was lung cancer. two more years and to that date, there with my role in the fi eld of health I was very concerned and told him the had been no recurrence of the cancer care. I had an incident occur about 20 name of her physician so he could contact She thanked me for saving her life. years ago when I had to section and her, but the radiologist stopped me in I think about how hard it was for remove part of an old fi xed bridge in my tracks. “You ordered the radiograph, me to make that call to tell her about preparation for a root canal procedure. doctor; you have to tell the patient,” he the radiographic fi ndings. I was already The bridge was made of mystery metal said. I was fl oored! He did not care that feeling bad that I had lost the bur. I was (a combination of chrome cobalt alloy I was a ; he said I had to tell her. worried she had swallowed or aspirated mixed with depleted uranium and forged Now I had to be a doctor, a real doctor. it already, and my brief relief that it was in the fi res of hell) and I had already I called her up and relayed the not inside of her was crushed by the used (and destroyed) fi ve very expensive news. I told her that the radiologist was report of the radiologist. Elation turned to burs that were made to cut hard metal. concerned that it may be lung cancer concern and turned to shock and then to I was using the sixth bur and started and that I was going to call her physician anxiety about having to make that call. cutting, but the bur suddenly fl ew out of to have her manage the appropriate There have been other times where I the handpiece and disappeared. Using a referral. I tried to say some short words of had to don the medical coat of our dental

DECEMBER 2018 741 DEC. 2018 GUEST EDITORIAL

CDA JOURNAL, VOL 46, Nº12

profession. The “infection” referred to oropharynx. That is, the posterior one- discomfort is secondary to the health of the me that turned out to be a lymphoma in third of the tongue, around the tonsillar people. My problem is that I don’t have the a patient’s jaw. My best friend’s father (a pillars and further down the throat. This experience of my physician colleagues in retired physician) who had a golf ball- is to be distinguished from oral cancers discussing these deeply personal issues with sized lesion under his tongue that was in the more anterior part of the mouth4 my patients. Yes, the status of someone’s another lymphoma. The squamous cell that are mainly considered to be related oral preventive skills is personal, but it’s not carcinomas, central giant cell granulomas, to tobacco and alcohol use. In addition the same as discussing sexual behaviors that three patient emergency transports to to those etiologies, infection with HPV can result in picking up this STI. I don’t hospital (one who went into a dangerous has been recognized as an independent want to make my patients or their parents arrhythmia after I told him he did not risk factor for oropharyngeal cancer. feel uncomfortable with this unprecedented need a root canal … go fi gure), the house In a recent study, among 557 invasive insertion of medical issues into my dental calls, and on and on. I guess I am a doctor. oropharyngeal squamous cell carcinomas, conversations. And in today’s social climate, Well, something new has come 72 percent were positive for HPV and 62 does a middle-aged male dentist run the risk up that will cause us all to put on our percent for vaccine types HPV 16 or 18.5 of being misunderstood when discussing medical coats once again: the human There is an HPV vaccine that is the risks of a patient’s sexual behavior? papillomavirus (HPV). The link between effective against the HPV 16 and 18 Then I think, Am I being selfi sh? HPV and cervical cancer has been known strains and the ADA says that, despite Am I worrying about myself and not my for many years, and young females have lacking solid scientifi evidence to date, patients? Does my personal belief system been encouraged by pediatricians and it may help to prevent oropharyngeal or personal discomfort at discussing STIs gynecologists to get the vaccine against cancers related to HPV. Data suggest prevent me from helping to address a strains 16 and 18 of the HPV for a long that oral HPV infection prevalence is real and expanding public health crisis? time. More recent news is the link lower in women who have received an And what if, as some public health between HPV and oropharyngeal cancer. HPV vaccine than those who have not. proponents argue, dentists should actually HPV is the most common sexually Clinical trials designed to answer these administer the vaccine? How deep transmitted infection (STI) in the United questions are currently underway.6 does the discussion have to go then? States. There are 100 strains of the virus The Centers for Disease Control As dentists, we need help with these with some creating a high risk for cancer. (CDC) does recommend that 11- and issues. Gynecologists and infectious During 2011–2014, prevalence of all oral 12-year-old boys and girls get two doses disease doctors have been discussing HPV among adults aged 18 to 69 was 7.3 of an HPV vaccine to prevent cervical these topics for years with their patients, percent and prevalence of high-risk oral and other less common genital cancers.7 and it is not unexpected by the general HPV was 4.0 percent. Genital infection If there is a chance that this vaccine public. Is the public ready for dentists with HPV is much more common at 42 could prevent approximately 11,000 to join the conversation? Are dentists percent.1 Most of the people who are cases of oropharyngeal cancer per year,6 ready? There is a study published in the exposed to it will clear the virus. Some then shouldn’t dentists help spread the January 2018 edition of the Journal of the will have the virus persist, however, and word to our patients about the vaccine? American Dental Association8 looking at those people have a risk of developing Well, of course we should, but it may dentists’ health literacy regarding HPV oropharyngeal cancer. The persistent virus not be so easy for some dentists. It’s not infection and prevention and the attitudes can remain in the throat or tongue for about informing oneself about the ins and of dentists toward discussing these issues decades before becoming cancerous. This outs of the disease and its prevention, since with their patients. Not surprisingly, is the same pattern that exists in HPV- that is what we do. And it’s not about the they found that many of the study related cervical cancer in women.2 If the uncertainty of promoting the vaccine for participants were uncomfortable having rise in incidence continues at its present preventing oropharyngeal cancer when its these discussions with their patients. The pace, the incidence of oropharyngeal only CDC-designated use is for preventing authors noted that “not being comfortable cancers among males will overtake that cervical cancer (although that is a real talking with adolescents and parents of cervical cancers by the year 2020.3 concern). The biggest problem for me about HPV and the HPV vaccine will Oropharyngeal cancers are mainly is discomfort at discussing STIs in detail continue to hinder efforts to increase HPV squamous cell carcinomas in the with patients. I can get over that, since my vaccine uptake in the United States.”8

742 DECEMBER 2018 CDA JOURNAL, VOL 46, Nº12

This fi nding should motivate the ADA Robert S. Roda, DDS, MS, is the and other public health entities to help Arizona Dental Association’s 110th president. alleviate this discomfort among dentists He is the former president of the American by educating them about HPV and its Association of Endodontists as well as a past clinical manifestations and prevention. CADS president and Inscriptions editor. He These educational efforts should include practices in Scottsdale, Ariz. training on how to have these discussions with patients and their parents, what to say and how to say it. In addition, The Journal welcomes letters public education efforts by federal, We reserve the right to edit all state and local public health groups communications. Letters should discuss could inform our patients before they an item published in the Journal within come in to see us so that the inevitable the last two months or matters of general discussions would not be unexpected. interest to our readership. Letters must be In the end, what matters is what it no more than 500 words and cite no more means to be a doctor. You must put your than fi ve references. No illustrations will personal fears and biases behind you and be accepted. Letters should be submitted determine what is best for the patient and at editorialmanager.com/jcaldentassoc. By then do that. Yes, you may need help with sending the letter, the author certifi es that overcoming your discomfort and you may neither the letter nor one with substantially need some more education about HPV, similar content under the writer’s authorship but if you save a life through your efforts, has been published or is being considered you can truly call yourself “Doctor.” ■ for publication elsewhere, and the author

Reprinted with permission. All rights reserved by Arizona acknowledges and agrees that the letter and Dental Association. all rights with regard to the letter become the property of CDA.

REFERENCES 1. McQuillan G. et al Prevalence of HPV in Adults Aged 18–69: United States, 2011- 2014. NCHS Data Brief. 280, April 2017. 2. Hilton L. The Rise of . Dermatology Times June 9, 2017. dermatologytimes.modernmedicine.com/dermatology- times/news/rise-oral-cancer. Accessed Jan. 21, 2018. 3. Chaturvedi AK, Engels EA, Pfeiff er RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol 2011;29(32):4294–301. 4. ADA Council on Scientifi c Aff airs. Statement on Human Papillomavirus and Squamous Cell Cancers of the Oropharynx. www.ada.org/en/about-the-ada/ada-positions-policies-and- statements/statement-on-human-papillomavirus-and-squamous- cel. Accessed Jan. 23, 2018. 5. Steinau M, Saraiya M, Goodman MT, et al. Human Papillomavirus Prevalence in Oropharyngeal Cancer before Vaccine Introduction, United States. Emerging Infectious Diseases. 2014;20(5):822-828. 6. ADA Oral and Oropharyngeal Cancer. www.ada.org/en/ member-center/oral-health-topics/oral-cancer. Accessed Jan. 21, 2018. 7. Head, Neck and Oral Cancers. www.mouthhealthy.org/en/ az-topics/h/hpv-and-oral-cancer. Accessed Jan. 21, 2018. 8. Vazquez-Otero, C. et al. Assessing dentists’ human papillomavirus — related health literacy for oropharyngeal cancer prevention J Am Dent Assoc 2018:149(1):9–17.

DECEMBER 2018 743 Letter CDA JOURNAL, VOL 46, Nº12

October 2018 Gingival Recession Autogenous Soft The Loyal Opposition Tissue Grafting Tissue Engineering JournaCALIFORNIA DENTAL ASSOCIATION

I want to commend Murray Levine, The Editor-in-Chief Responds DDS, for his letter “Et tu, CDA.” It is not Dr. Brucia makes an important that I agree or disagree with its contents but point, which I regret I failed to make it represents something more important. in my response to Dr. Levine. The Disagreeing with CDA policy and Journal is a forum for ideas. I apologize the majority can achieve enough to that my rebuttal did not begin with justify one’s position by arousing pro my personal thanks to Dr. Levine for

TO GRAFT OR NOT TO GRAFT? and con discussions. Members should taking the time to send his thoughts to AN UPDATE ON GINGIVAL GRAFTING DIAGNOSIS AND never hesitate being part of the “loyal us at the Journal. I want to make clear TREATMENT MODALITIES Richard J. Nagy, DDS opposition.” My “et tu, Brucia” resolution that whether or not a reader agrees for the unifi cation of our two associations, with the ideas expressed and the facts which I opposed, refl ects that concept. documented within these pages, we So keep it up, Murray. Whether appreciate the interest in organized you prevail or not, you will be dentistry and respect the intent of the contributing to CDA policies. reader to provide another perspective. FRANK A . BRUCIA, DDS Sincerely, San Francisco Kerry K. Carney, DDS, CDE

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Reviewers CDA JOURNAL, VOL 46, Nº12

Thank You to 2018 Journal Reviewers

The Journal is grateful for the many professionals who formally reviewed manuscripts in 2018 and offered their recommendations. We extend our thanks to those who are instrumental in helping us produce this award-winning scientifi c publication.

Ahmad Abdelkarim, DDS, MS, PhD, DMD, EdD Brigitte Higgins, DDS Gregory Olson, DDS, MS Elliot Abt, DDS, MSc, MS Robert A. Horowitz, DDS Joan Otomo-Corgel, DDS, MPH Maha Ahmad, PhD Jeremy Horst, DDS, PhD Udochukwu Oyoyo, MPH Tamer Alpagot, DDS, PhD Zsuzsa Horvath, PhD Mariela Padilla, DDS, MEd Elizabeth Andrews, DDS, MS Christopher V. Hughes, DMD, PhD John H. Paul, DDS Jane R. Barrow, MS Yuan-Lung Hung, DMD, MS Yawen Peng, DMD Moshe Benarroch, DMD Robert Isman, DDS, MPH Rajesh Raveendranathan, BDS Patrick Blahut, DDS, MPH Lisa Itaya, DDS Mark Reynolds, MA, DDS, PhD Wanda Borges, PhD, RN, ANP-BC Dmitriy Ivanov, DDS Giampiero Rossi-Fedele, BDS, MDS, PhD Donald L. Branam, BS, PharmD Richard Jackson, DMD Jeff rey A. Rossmann, DDS, MS Carolyn Brown, DDS Days Jangam, MDS Mark Ryder, DMD Jennifer Valinda Byrne, BA, CCPH Daniel Jenkins, DDS, CDE Gary Sabbadini, DDS Michael E. Cadra, DMD, MD Michael J. Kanellis, DDS, MS Mohammad Sabeti, DDS Paulo Camargo, DDS, MS, MPH Kian Kar, DDS, MS Erik Sahl, DDS, MSD David W. Chambers, EdM, MBA, PhD Cristin E. Kearns, DDS, MBA Elise Sarvas, DDS, MSD, MPH Kai Chiao Joe Chang, DDS, MS Reuben Kim, DDS, PhD Keerthana M. Satheesh, BDS, DDS, MS Elisa Chávez, DDS Gary D. Klasser, DMD Kyungsup Shin, BS, MS, PhD, DMD David A. Chernin, DMD, MLS Mark Koday, DDS Brian K. Shue, DDS, CDE Santos Cortez, DDS Clarice S. Law, DMD, MS Rebecca L. Slayton, DDS, PhD Darren P. Cox, DDS, MBA Irving Lebovics, DDS Andrew Sonis, DMD Jean L. Creasy, DDS Huong Le, DDS Vladimir Spolsky, DMD Yasmi O. Crystal, DMD, MSc Su-Min Lee, DDS, MSD, DScD Sotirios Tetradis, DDS, PhD Arthur Curley, JD William Lundergan, DDS Richard D. Trushkowsky, DDS Michael John Danford, DDS Cindy Lyon, RDH, DDS, EdD Alejandra Valencia, DDS, MPH, MS Lori L. Doran-Garcia, DDS Sanjay M. Mallya, BDS, MDS, PhD Suvendra Vijayan, BDS, MPH Scott L. Doyle, DDS Michael Marshall, DDS, HDS Jane A. Weintraub, DDS, MPH Irina Dragan, DDS, MS Melanie E. Mayberry, DDS, MS Kimberly G. Whippy, DMD Alan L. Felsenfeld, DDS Keith A. Mays, DDS, MS, PhD Jian Xu, PhD Charles M. Fischer, DDS, MS, EdD Michael Meharry, DDS Juan Fernando Yepes, DDS, MD, MPH, MS, DrPH Carlos Flores Mir, MDS Mike Meru, DDS Douglas A. Young, DDS, EdD, MBA, MS Steven Friedrichsen, DDS Roger A. Meyer, DDS, MS, MD Craig Yonemura, DDS, MS Desmond Gallagher, DDS, MA Diana Messadi, DDS, MMSc, DMSc Anthony J. Ziebert, DDS, MS Cherie Gentry, RDH Peter Milgrom, DDS Zhe Zhong, DDS, PhD Jane Gillette, DDS Carol Anne Murdoch-Kinch, DDS, PhD Anupama Grandhi, DDS Theodore A. Murray Jr., DDS Judith Haber, PhD, APRN, BC Asma Muzaff ar, DDS, MS, MPH Every eff ort was made to ensure the accuracy Mina Habibian, DMD, MS, PhD Stephen P. Niemczyk, DMD of the list of contributors. If you discover an error Edmond Hewlett, DDS Brian Novy, DDS or omission, please accept our apologies.

DECEMBER 2018 747 FACING QUESTIONS ABOUT REGULATORY COMPLIANCE?

WE HAVE ANSWERS. Keep on top of the compliance process with resources and guidance from dedicated analysts.ts. As a CDA member, you’ve got access to online tools and unlimited phone support to navigate CURESS and opioid pain management, amalgam separation,ation, infection control and more.

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Fibbing David W. Chambers, EdM, MBA, PhD

Some wag said that the fi rst casualty in war is truth. But fi bbers will tell you dentistry is not war, so bending the truth is acceptable if it serves a purpose. That is fl at-out false logic, but it is certainly not uncommon to hear people reason this way. Why do any dentists sell treatment that is patently or even arguably not needed without disclosing alternatives? Why do they fail to mention a big overhang or incomplete endo they left in hopes that it might not cause a problem or, if it does cause a problem, they expect to negotiate proportional responsibility with the patient? Why are more and more dentists offering standardized treatment plans to mass markets? Why does the most recent Gallup poll of trust in the professions show dentists at the bottom of health care providers and neck and neck with police offi cers, with a 5 percent drop in public trust in the profession during the past six years? We have had quite enough editorializing about why it is wrong to fi b (with certain qualifi cations). We are getting tired of this “moralizing.” We are now numb to fi bbing and in danger of ceasing to care about it. Perhaps we have overlooked the opportunities opened by allowing multiple truths. The nub: Telling the truth means saying only what one knows to be the case. Lying is saying things one knows not to 1. Fibbing is about who benefi ts be so. Fibbing means enhancing one’s prospects by saying from twisted truth, not whether truth what it is hoped others will accept as being fact. This is a creative blending of misfocused facts and motivation. is twisted. Fibbing turns on believability not veracity. The fabulous 2. It is always possible to concoct fi bber cares less about what is the case and more about whether others will accept a claim (or strategic silence) from a backstory to justify a claim about which the fi bber benefi ts. We all create worlds we prefer to what one needs to believe. believe in. Fibbers offer others believable alternatives that depend to some extent on perceived expertise and largely 3. Fibbing is good for business but on fear and fantasy. Mendacity can be smoked out by fact- corrodes relationships. checking. Not so for fi bbing. There the test is who benefi ts and who is harmed by accepting an offered version of reality. Overtreatment is a fi b because there will always be “evidence” or an “expert for hire” who confi rms the need for David W. Chambers, EdM, MBA, PhD, is a professor the care while at the same time the patient loses and the of dental education at the University of the Pacifi c, Arthur A. Dugoni School of Dentistry in San Francisco and the dentist benefi ts from the motivated misstatement. It is just editor of the American College of Dentists. business and some justifi cation can be found if needed. Patients want to trust dentists, so they usually avoid looking too deeply into anything other than cost. As one patient said recently in a focus group, “If I think the dentist is overselling, overcharging or has even committed malpractice, I will simply walk away. They can always prove that they are right, even when it hurts the rest of us.” ■

DECEMBER 2018 749 DEC. 2018 IMPRESSIONS

CDA JOURNAL, VOL 46, Nº12

1 M Stem Cells From Baby Teeth Stimulate Regrowth Nearly half of children suffer some injury to a tooth during childhood. When that trauma affects an immature permanent tooth, it can hinder blood Paranthropus robustus fossil from South Africa SK supply and root development, resulting in what is essentially a “dead” tooth. 46 and the virtually reconstructed first upper molar Until now, the standard treatment has entailed apexification to encourage used in the analyses. (Credit: Kornelius Kupczik, Mas Planck Institute for Evolutionary Anthropology) further root development, but it does not replace the lost tissue from the injury and may result in abnormal root development. New results of a clinical trial jointly led Research Gets to the Roots by researchers from the University of Pennsylvania and the Fourth Military Medicine University in Xi’an, China, suggest a more promising treatment for children with of Ancient Diets these types of injuries: Using stem cells extracted from the patient’s baby teeth. Food needs to be broken down in According to the study published in the journal Science Translational Medicine, the mouth before it can be swallowed the treatment gives patients sensation back in their teeth. “If they are given a warm and digested further. The mechanical or cold stimulation, they can feel it; they have living teeth again,” researchers said. properties of the foods and the The Phase I trial, conducted in China, enrolled 40 children who had each morphology of the masticatory apparatus injured one of their permanent incisors and still had baby teeth. Thirty were play a large role in the process. assigned to human deciduous pulp stem cells (hDPSC) treatment and 10 to the Paleoanthropologists reconstruct control treatment, apexification. Those who received hDPSC treatment had the diets of our ancestors in order to tissue extracted from a healthy baby tooth. The stem cells from this pulp were help understand our evolutionary allowed to reproduce in a laboratory culture and the resulting cells were history. Research published recently in implanted into the injured tooth. The Royal Society Publishing explored Upon follow-up, the researchers found that patients who received hDPSCs the diet of South African hominins had more signs than the control group of healthy root development by using noninvasive high-resolution characterized by thicker and an increase in blood flow. computed tomography technology At the time the patients were initially seen, all had little sensation in the and shape analysis to deduce the main tissue of their injured teeth. After one year, only those who received hDPSCs direction of masticatory forces from the had regained some sensation. orientation of the tooth roots within Learn more about this study in Science Translational Medicine (2018); the jaw. By comparing the virtual reconstructions of 30 hominin fi rst doi:10.1126/scitranslmed.aaf3227. molars from South and East Africa, researchers found that Australopithecus Stem cells extracted from baby teeth were able to africanus had much wider splayed roots regenerate dental pulp (shown, with fluorescent than both Paranthropus robustus and labeling). (Credit: University of Pennsylvania) the East African Paranthropus boisei. Paranthropus robustus, unlike any of the other species analyzed in this study, exhibited an unusual orientation, or structure of the enamel also points toward what hominins ate and how hard they “twist,” of the tooth roots, which might a complex, multidirectional loading, bit that determined skull morphology, suggest a slight rotational and back- while their unusual microwear pattern but also the way in which the jaws were and-forth movement of the might conceivably also be reconciled being brought together during chewing. during chewing. Other morphological with a different jaw movement rather Read more about this study in traits of the P. robustus skull support than by mastication of novel food sources. The Royal Society Publishing (2018); this interpretation. For example, the According to the researchers, it is not only doi:10.1098/rsos.180825.

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Periodontal Disease Bacteria May Kick-Start Alzheimer’s A study led by researchers at neurons in mice that is similar to the the University of Illinois at Chicago effects of Alzheimer’s in humans. suggests that could Over the course of 22 weeks, play a factor in the development of researchers used two groups of mice to Micrograph of brain tissue with Alzheimer’s disease. The fi ndings, which conduct the study, exposing only one Alzheimer’s disease. are published in the journal PLOS of the groups to ONE, claim that long-term exposure bacteria. They found that mice who accumulated amyloid beta — a senile to periodontal disease bacteria causes were repeatedly exposed to the bacteria plaque found in the brain tissue of infl ammation and degeneration of brain had signifi cantly higher amounts of Alzheimer’s patients. The effected mice also had more brain infl ammation and fewer intact neurons due to degeneration. “Other studies have demonstrated a close association between periodontitis Antibiotics Destroy ‘Good’ Bacteria, Worsen Infection and cognitive impairment, but this is New research shows that the body’s own microbes are effective in maintaining the fi rst study to show that exposure immune cells and killing certain oral infections, according to a study published in the to the periodontal bacteria results journal Frontiers in Microbiology. in the formation of senile plaques A team of Case Western Reserve University School of Dental Medicine that accelerate the development of researchers found that antibiotics actually kill the “good” bacteria keeping infection neuropathology found in Alzheimer’s and inflammation at bay. patients,” said Keiko Watanabe, DDS, Scientists have long known that overuse of antibiotics can do more harm than MS, PhD, professor of periodontics good. For example, overuse can cause antibiotic resistance. But research into this at the UIC College of Dentistry and phenomenon in oral health was uncharted territory. corresponding author on the study. Pushpa Pandiyan, PhD, an professor of biological sciences, led the team Not only does this data demonstrate the movement of the bacteria from of researchers to examine “resident” bacteria, their fatty acids and their effect on the mouth to the brain, but according certain types of white blood cells that combat infections in the mouth. Specifically, to researchers, it also indicates that researchers looked at the “short-term maintenance” of Tregs and Th-17 cells in fighting chronic infection leads to neural fungal infections, such as candida, in a laboratory setting. effects similar to Alzheimer’s. The study found that those natural defenses were very effective in reducing “ is an important infection and unwanted inflammation and antibiotics can prevent such natural defenses. predictor of disease, including diseases “We set out to find out what happens when you don’t have bacteria to fight a that happen outside of the mouth,” fungal infection,” Dr. Pandiyan said. “What we found was that antibiotics can kill said Dr. Watanabe. “People can do short-chain fatty acids produced by the body’s own good bacteria. We have good so much for their personal health bacteria doing good work every day, why kill them? As is the case with many by taking oral health seriously.” infections, if you leave them alone, they will leave on their own.” Researchers believe that Dr. Pandiyan said the study could have broader implications on protective effects understanding potential factors that could of “resident microbiota” in other types of infections. cause Alzheimer’s is important to the Learn more about this study in Frontiers in Microbiology development of treatments, specifi cally (2018); doi.org/10.3389/fmicb.2018.01995. sporadic or late-onset disease, which makes up more than 95 percent of cases Gut bacteria. (Credit: Fawcett/Wikimedia Commons) and has largely unknown causes. Learn more about this study in PLOS ONE (2018); doi.org/10.1371/ journal.pone.0204941.

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Study: Water More Popular Than Soda for U.S. Children More children are choosing water over soda, according to a new study released by the U.S. Centers for Disease Control and Prevention and conducted by a research team from the National Center for Health Statistics. Researchers led by Kirsten Herrick, PhD, studied data from the National Health and Nutrition Examination Surveys from 2013 to 2016. The surveys Connection of ‘Chalky Teeth’ are organized by the CDC’s National Center for Health Statistics and designed to provide nationally representative data about the health status of and Bisphenol A Unlikely children and adults in the U.S. The survey asked NHANES participants, U.S. An evaluation conducted children aged 2 to 19, what they had to drink within the past 24 hours. recently by the German Federal The research team studied the total drink consumption habits of the survey Institute for Risk Assessment of a participants and found that 43 percent chose water first. Milk came in second 2013 study that reported a possible with 21 percent and soft drinks, which include a wide variety of beverages connection between molar-incisor such as regular soda, diet soda and fruit drinks with added sugar, accounted hypomineralization (MIH), also for 20 percent of total beverages consumed by youths. known as “chalky teeth,” and exposure Researchers not only looked at what the children drank, but also to Bisphenol A (BPA) found that investigated how their beverage consumption habits varied by age and there is currently no scientifi c reason sex. According to the study, older children were more likely to drink water to assume a connection between the and soda than were younger children, while younger children were more uptake of BPA and the occurrence likely to drink milk. Boys were also more likely to drink soda, while girls of MIH in children. Among a wide were more likely to drink water. range of various products, BPA can Race and ethnicity also had a significant impact on the results. Non- also occur in food contact materials. Hispanic Asian youths were significantly more likely to drink water than The 2013 study by Jedeon et al. children of any other race, and non-Hispanic black youths were more likely examined the connection between to consume soft drinks. Soft drinks accounted BPA exposure and mineralization for almost one-third of total beverage intake defects of in rats. In for non-Hispanic black youths, significantly subsequent publications, the authors reported that the mineralization more than all other race and Hispanic-origin disturbances occurred mainly in groups, according to the study. male rats (up to 71 percent) and Learn more about this study at cdc.gov. less frequently in female rats (only up to 31 percent) and identifi ed selected hormone-controlled signaling pathways as potential molecular percent, with a worldwide occurrence (possibly also connected to high fever). targets. A direct connection between of 2 to 40 percent. Various reasons Altogether, it appears that MIH is BPA and MIH therefore appears are assumed to contribute to this caused by a variety of factors and thus unlikely in humans under conditions occurrence. Epidemiological studies has to be considered a multifactorial of expectable real-life exposure, point, for example, to maternal diseases condition, according to the study. according to the evaluation. during the last quarter of pregnancy, Learn more about the The condition of MIH occurs in complications during birth or frequent German Federal Institute for Risk Europe with a frequency of 3 to 22 illness in the fi rst year of the child Assessment at bfr.bund.de.

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Burning Mouth Syndrome Associated With Skin Diseases A recent study conducted by the population and mainly middle-aged Sahlgrenska Academy at the University and elderly women, according to the of Gothenburg in Sweden found that study. The pain is experienced as patients with burning or stinging, with the tongue A generic schematic of the interrelationship between chronic pain, anxiety, depression and other emotions in (BMS) suffer more from skin diseases most often affl icted followed by the patients with BMS. (Credit: University of Gothenburg ) and skin problems than those who are , and . Other common not affected by the chronic oral pain symptoms include dry mouth and condition. The study was published on altered taste sensation, such as a bitter gender- and age-matched control group. the university’s website in August 2018. or metallic taste in the mouth. Shikha Acharya, PhD, lead author BMS in the oral cavity affects The study followed 56 women with of the study, also connected clinical approximately 4 percent of the Swedish BMS and compared their results with a fi ndings and self-reported fi ndings from questionnaires from patients with BMS about their symptoms and background along with -related factors. Smoking Weakens Immune Systems The researchers found that in addition to skin diseases, a higher Researchers at the Case Western Reserve University School of Dental incidence of other types of diseases was Medicine found that in addition to lung cancer, emphysema and heart disease, also reported. BMS patients also used smoking also weakens the ability for pulp in teeth to fight illness and disease. more medications, were more prone to The results of the study were published in the Journal of Endodontics. grinding their teeth and reported more “That might explain why smokers have poorer endodontic outcomes and allergies than the control group. Also, delayed healing than nonsmokers,” said Anita Aminoshariae, DDS, MS, 45 percent of the BMS patients reported associate professor of endodontics and director of predoctoral endodontics. to have altered taste sensations. “Imagine TNF-a and hBD-2 are among the soldiers in a last line of defense Health experts on the quest to fi nd fortifying a castle. Smoking kills these soldiers before they even have a a better diagnosis and treatment for chance at mounting a solid defense.” BMS believe this new discovery could Prior to this study, little research was done that explored the endodontic be a breakthrough. “Our hope is that effects of smoking, Dr. Aminoshariae said. Scientists have known that smokers the new fi ndings will contribute to the had worse outcomes than nonsmokers with greater chances of developing development of objective diagnostic gum disease and nearly two times more likely to require a root canal, so the criteria and effective individualized Case Western research set out to explain the possible contributing factors. treatment both that are currently lacking,” Thirty-two smokers and 37 nonsmokers diagnosed with endodontic said Dr. Acharya, who has a doctorate in and immunology were included in the cross-sectional study. at the Institute of Odontology that “We began with a look at the dental pulp of smokers compared with the University of Gothenburg. nonsmokers,” Dr. Aminoshariae said. “We hypothesized that the natural Researchers are optimistic that these defenses would be reduced in smokers; we didn’t expect them to have them new pieces of information will help completely depleted.” characterize BMS and the persistent One interesting find Dr. Aminoshariae noted was that for mouth pain associated with it. The study two patients who quit smoking, those natural defenses returned. is a part of a bigger effort aimed at fi nding Read more of this study in the Journal of Endodontics a model for BMS that can facilitate (2018); doi.org/10.1016/j.joen.2017.08.017. diagnosis and treatment in the future. Learn more about this study at the University of Gothenburg website (2018); hdl.handle.net/2077/55387.

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oFO

Antibiotic Prescribing and Stewardship in Dentistry: A Public Health Perspective

Jane D. Siegel, MD, and Erin Epson, MD

AUTHORS

Jane D. Siegel, MD, is Erin Epson, MD, is the ntibiotic resistance is one by provider and geographic location.4 a public health medical medical director and of the most serious public Dentists are the third highest group of offi cer III in the California assistant chief of the health threats of modern prescribers of antibiotics by volume in the Department of Public Health California Department of 5 Healthcare-Associated Public Health Healthcare- times. More than 2 million U.S. U.S. data from 2011 and 2014 show Infections Program. She is Associated Infections illnesses and 23,000 deaths that dentists prescribe 10 percent and 9 board certifi ed in pediatrics Program. She is clinically Adue to antibiotic-resistant infections percent, respectively, of all antibiotics and pediatric infectious trained and board certifi ed occur in the United States each year; this in outpatient settings. The total number diseases and was a faculty in internal medicine translates to an estimated 260,000 illnesses of prescriptions written by U.S. dentists member in the division of and infectious diseases 6 pediatric infectious diseases and completed medical and nearly 3,000 deaths in California. was unchanged from 2014 to 2016. at the University of Texas epidemiology training as Antibiotic-resistant infections are more Southwestern Medical an epidemic intelligence diffi cult to treat and are associated with Challenges Dentists Face Center in Dallas for 36 service offi cer with the increased morbidity and mortality. Dentists have little opportunity to years. The focus of her Centers for Disease Control There are few antibiotics left to treat observe fi rst-hand the adverse events career has been caring and Prevention. Dr. Epson for children with infectious also provides consultation resistant infections and even fewer new associated with antibiotic prescribing, 7–10 diseases and leading and epidemiologic drugs in the development pipeline. such as adverse reactions and CDI. infection prevention and assistance to local public Antibiotic use is the primary driver of In a Minnesota study of CDI from 2009 control activities. health agencies regarding antibiotic resistance and is associated with to 2015, 15 percent of people with Confl ict of Interest health care-associated Clostridioides diffi cile infections (CDI) and community-associated CDI had taken Disclosure: None reported. infections (HAI) and antibiotic-resistant (AR) emergency department visits for adverse antibiotics, most commonly clindamycin, 1,2 9 outbreaks and breaches in drug events in adults and children. for a dental procedure. A study of infection control. university-affi liated dental clinics in Confl ict of Interest Antibiotic Prescribing in Dentistry Utah from 2014 to 2016 reported that Disclosure: None reported. Most antibiotic prescribing occurs 6.1 percent of dental encounters were in outpatient settings. An estimated associated with antibiotic prescribing, 30 percent of outpatient antibiotic but only 10 percent of prescriptions were prescribing is inappropriate, such as, consistent with preprocedure prophylaxis for example, antibiotics not prescribed guidelines. The average duration of according to guidelines for indication, nonprophylactic antibiotics was 8.3 drug and duration.3 Publications from days. CDI occurred more frequently many countries demonstrate substantial after antibiotic-associated encounters.10 inappropriate antibiotic prescribing Although published guidelines limit the among dentists with broad variability number of cardiac conditions requiring

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antibiotic prophylaxis for prevention of the community, such as infectious- 9. Bye M, Whitten T, Holzbauer SM. Antibiotic Prescribing infective endocarditis and recommend disease physicians, cardiologists for Dental Procedures in Community-Associated Clostridium diffi cile cases, Minnesota, 2009–2015. Abstract #78. ID against routine antibiotic prophylaxis and orthopedic surgeons. Work Week 2017. to prevent prosthetic joint infections, to increase access to preventive 10. Spivak E, Winkler JR, Dixon B, et al. Evaluation of Antibiotic there are no national guidelines for oral health services. Prescribing at University-Affi liated Dental Clinics Abstract #255, ID Week 2018. treatment of specifi c dental infections. ■ Collect data to track trends in 11. Stivers T, Mangione-Smith R, Elliott MN, et al. Why do Providers may overestimate patient antibiotic prescribing within physicians think parents expect antibiotics? What parents demand for antibiotic prescriptions individual dental practices. Evaluate report versus what physicians believe. J Fam Pract 2003; 52:140–148. PMID:12585992. and underestimate the effectiveness of the use of electronic billing to 12. Koppen L, Suda KJ, Rowan S, et al. Dentists’ prescribing informed communication.11 Patients facilitate data collection. Audit of antibiotics and opioids to Medicare Part D benefi ciaries: visiting hospital emergency departments prescribing data and provide Medications of high impact to public health. J Am Dent Assoc 2018; 149(8):721-730. PMID:29929728. for dental-related conditions are often feedback to dental providers 13. Okunseri C., Okunseri E, Thorpe JM, et al. Medications treated with antibiotics and opioids,12,13 to improve appropriateness of Prescribed in Emergency Departments for Nontraumatic Dental refl ecting a lack of access and decreased antibiotic prescribing.14,15 Condition Visits in the United States. Med Care 2012; 50:508- 512. PMID:22584886. utilization of preventive dental care. The California Department of Public 14. Elouafkaoul P, Young L, Newlands R, et al. An Audit and Health is pleased to partner with the Feedback Intervention for Reducing Antibiotic Prescribing Actions Dentists Can Take California Dental Association to promote in General Dental Practice: The RAPiD Cluster Randomized Controlled Trial. PLoS Med 2016 Aug 30;13(8):e1002115. In addition to the recommendations in measures to improve and track the PMID:27575599. this issue’s articles, we suggest the following: appropriateness of antibiotic prescribing, 15. Palmer NA and Dailey YM. General Dental Practitioners’ ■ Prioritize antibiotic resistance also known as antibiotic stewardship. Experiences of a Collaborative Clinical Audit on Antibiotic Prescribing: A Qualitative Study. Br Dent J 2002; 193:46–49. and prescribing when planning We encourage all dentists and dentistry PMID:12171207. continuing education programs stakeholders to plan a targeted action and developing criteria for for the next annual U.S. Antibiotic THE CORRESPONDING AUTHOR, Jane Siegel, MD, can be reached at [email protected]. recertifi cation of dentists. Include Awareness Week in November 2019. ■ updates on antibiotic prophylaxis for preventing bacterial endocarditis REFERENCES and infection of prosthetic joints 1. Shehab N, Lovegrove MC, Geller AI, et al. U.S. Emergency Department Visits for Outpatient Adverse Drug Events, following dental procedures, new 2013–2014. J Am Dent Assoc 2016; 316:2115–2125. data on preventing infection PMID:27893129. of adjacent tissue and diagnosis 2. Lovegrove MC, Geller AI, Fleming-Dutra KE, et al. U.S. Emergency Department Visits for Adverse Drug Events from and treatment of established oral Antibiotics in Children, 2011–2015. J Pediatr Infect Dis Soc infection and behavioral science- 2018 Aug 23. Epub ahead of print. PMID:30137509. based strategies for improving 3. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among U.S. communication with patients. Ambulatory Care Visits, 2010-2011. J Am Dent Assoc 2016; ■ Continue to work with local, 315(17):1864–73. PMID:27139059.4. state and national professional 4. Stein K, Singhai S, Marra F, et al. The Use and Misuse of Antibiotics in Dentistry. J Am Dent Assoc 2018; 149:869– organizations to develop evidence- 884. PMID:30261952. based guidelines for treatment of 5. Durkin MJ, Hsueh K, Sallah YH, et al. An Evaluation of specifi c dental conditions based Dental Antibiotic Prescribing Practices in the United States. J Am Dent Assoc 2017; 148: 878-886. PMID:28941554. on rigorously performed studies. 6. Roberts RM, Bartoces M, Thompson SE, Hicks LA. Antibiotic ■ Determine which physicians Prescribing by General Dentists in the United States, 2013. J other than dentists are prescribing Am Dent Assoc 2017; 148: 172–178. PMID:28126225. 7. Bombassaro AM, Wetmore SJ, John MA. Clostridium diffi cile antibiotics as prophylaxis or Colitis following Antibiotic Prophylaxis for Dental Procedures. J treatment of dental conditions. Can Dent Assoc 2001; 67:20–2. PMID:11209501. Engage and promote consistency 8. Dantes R, Mu Y, Hicks LA, et al. Association Between Outpatient Antibiotic Prescribing Practices and Community- of practice among antibiotic- Associated Clostridium diffi cile Infection. Open Forum Infect prescribing stakeholders within Dis 2015; Aug 11;2(3):ofv113. PMID:26509182.

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CDA JOURNAL, VOL 46, Nº12 oFO The Core Elements of Antibiotic Stewardship in Dentistry

Peter L. Jacobsen, PhD, DDS

AUTHOR

Peter L. Jacobsen, PhD, he Core Elements of Outpatient Following are suggestions for the DDS, lectures extensively Antibiotic Stewardship1 was application of these four core elements on dental pharmacology developed as a framework for within dentistry and dental practices: as well as over-the- the judicious and appropriate Commitment: This is the foundation counter dental drugs and products. He directed use of antibiotics in the various for achieving change. It requires a the Clinic Toutpatient settings in which antibiotics are clear vision of the desired change and at the University of the prescribed for patient use. In 2015 alone, proactive behavior. In dental offi ces, Pacifi c, Arthur A. Dugoni approximately 269 million antibiotic commitment may take the form of School of Dentistry for prescriptions were dispensed from a written offi ce policy on antibiotic more than 25 years. Dr. Jacobsen is a diplomate outpatient pharmacies in the United States, prescribing that is shared with patients of the American Board of enough for fi ve out of every six people when antibiotics are being considered Oral Medicine and past to receive one antibiotic prescription or are requested. It is essential that chairperson of the Council each year. At least 30 percent of these the entire dental team understand the on Dental Therapeutics antibiotic prescriptions were unnecessary.2 dentist’s prescribing policies and their of the ADA. He is the author of The Little Dental The four core elements of rationale as patients often consult with Drug Booklet, a succinct antibiotic stewardship are: or ask questions of dental team members handout and reference on ■ Commitment. because they feel comfortable doing commonly prescribed dental ■ Action for policy and practice. so and often do not want to “bother” medications. ■ Tracking and reporting. the dentist with their questions. Team Confl ict of Interest Disclosure: None reported. ■ Education and expertise. members who understand the reasons These elements are crucial in any behind the management of oral setting to support and improve prescribing infections can be very helpful in allaying habits and actions intended to: patients’ concerns and supporting ■ Measure antibiotic prescribing. and reinforcing proper compliance. ■ Improve clinician prescribing and Action for policy and practice: For patient use so that antibiotics are only individual clinicians, this is where staying prescribed and used when needed. current with clinical knowledge and ■ Minimize misdiagnoses or adherence to best practices come into delayed diagnoses leading to play. While antibiotic use in dentistry is the underuse of antibiotics. not complex, recommendations change ■ Ensure that the right drug, dose over time as new drugs become available and duration are selected when and traditional approaches to care are an antibiotic is needed.1 evaluated for effectiveness. Dentists’ When antibiotic prescribing prescribing practices should follow practices are evaluated based on the national or state practice guidelines four core elements, the principles and should be responsive to relevant of antibiotic stewardship become local data, including disease incidence a practice and practical reality. and pathogen susceptibilities.

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Tracking and reporting: Tracking and Considerations for Optimal Antibiotic Prescribing in Dentistry1 reporting functions are often considered the purview of large organizations and care Pretreatment ■ Consider antibiotics if there are systems where data can be collected in Correctly diagnose an oral bacterial signs of a systemic spread of the amounts suffi cient for analysis. However, infection. infection, such as fever and/ solo or small group dental practices may ■ Oral bacterial infections or malaise, or if the patient is be able to fi ne-tune prescribing practices may present as: immunosuppressed or otherwise by closely monitoring prescribing behavior ● Pain, swelling and/or redness medically compromised. and outcomes. Thorough documentation in the tissue around the Weigh potential benefi ts and risks is of particular importance to this element, tooth or along the bone (i.e., toxicity, allergy, adverse effects, as accurate assessment requires complete supporting the teeth. Clostridium diffi cile infection) of information, including the diagnosis, ● Pain and swelling below the antibiotics before prescribing. rationale for antibiotic treatment, specifi cs jaw in the upper neck region ■ All drugs have risks. Be aware of of the prescription and eventual outcomes. or in the facial structures the risks of the primary antibiotics Education and expertise: Adhering to under the eyes and nose. used to treat dental infections: best practices for antibiotic prescribing are ● Purulent exudate coming from penicillins, azithromycin and often not enough to achieve antibiotic some part of the swollen area especially clindamycin. stewardship goals. External pressures too or from the space around the ■ Clostridium diffi cile infection often intervene in clinician decision- infected teeth or gums. (pseudomembranous colitis) making, from patients who express strong ■ The signs and symptoms of an oral associated with clindamycin and preferences for antibiotic “protection” bacterial infection differ in key ways other broad-spectrum antibiotic or medical colleagues with differing from oral infections resulting from use is the most common serious prescribing philosophies. Dentists must viral, fungal or traumatic causes side effect of antibiotic use. This educate not only themselves, but also (discussed in more detail below). can occur with a single oral dose. their staff and patients on responsible Consider therapeutic management ■ Penicillin allergy is also a serious antibiotic use: when antibiotics are interventions, which may be suffi cient to risk, though true allergic reactions needed and when they are not needed, control a localized oral bacterial infection. are less than 0.01 percent. including the reasons for these differences ■ Focus on eliminating the ■ Closely monitor patients with as well as the risks associated with that led to the infection. extensive medical problems and antibiotic use without medical necessity. ● Use radiography to identify the those taking multiple medications. Further, all clinicians managing a correct tooth or gingival area. ■ Antibiotic use when not needed patient’s care should use similar protocols ● Clean the area if it is a puts patients at risk for adverse for antibiotic use. Sharing disease periodontal infection. reactions without any benefi t. management and treatment ideas among ● Provide endodontic treatment In almost all situations where clinicians reduces confusion for the or tooth extraction if an an oral infection shows signs of patients and is an important source of odontogenic infection. systemic spread, however, proper continuing professional education. ■ ■ Incise and drain abscess if local management and initiating an abscess has formed. antibiotic use is of benefi t and REFERENCES 1. Centers for Disease Control and Prevention. Core Elements ● Consider limited incise and drain likely outweighs the risk. of Outpatient Antibiotic Stewardship, 2016. www.cdc. if the swelling is very swollen and Prescribe antibiotics only for patients of gov/antibiotic-use/community/pdfs/16_268900-A_ taut and may be transitioning record and only for bacterial infections CoreElementsOutpatient_508.pdf. 2. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence from a cellulitis into an abscess you have been trained to treat. of Inappropriate Antibiotic Prescriptions Among US to ensure that there is no abscess ■ Clinicians must know and Ambulatory Care Visits, 2010–2011. JAMA 2016 May and to provide a focus for abscess understand the patient’s medical 3;315(17):1864–73. doi:10.1001/jama.2016.4151. formation and drainage (the history and be familiar with THE AUTHOR, Peter L. Jacobsen, PhD, DDS, can be reached at incision point) if the cellulitis their dental history for safe [email protected]. evolves into an abscess. and effective patient care.

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■ Familiarity and experience describe the discomfort as a ■ In 2012, the American Academy with managing bacterial dental “burning” sensation, which is of Orthopaedic Surgeons5 and infections in the oral cavity an uncommon word relative the ADA issued a joint report and adjacent tissues are also to describing oral pain from relative to the need for prophylactic essential for the best perspective any other oral infection. antibiotics for patients with and decision-making. ■ Ulcerations related to aphthous prosthetic joints undergoing dental ● Consultation with or referral to ulcers or autoimmune diseases, procedures, followed in 2017 by the a specialist is appropriate when such as , ADA’s release of a chairside guide an infection shows signs that and , usually hurt when for dentists titled Management it is outside the clinician’s area exposed to acid like orange or of Patients with Prosthetic Joints of training and experience. tomato juice and salty foods. Undergoing Dental Procedures.6 For example, altered eye ■ Traumatic ulcers are generally ● The American Academy movement, suggesting it recalled by the patient, are not an of Orthopaedic Surgeons has entered into the cranial infection and do not commonly offers an online support space, or diffi culty swallowing, become infected unless the tool (Appropriate Use suggesting it is spreading patient is immunosuppressed Criteria7) to assist when into deep neck tissues. or has a medical problem that making prophylactic Do not prescribe antibiotics for oral compromises their ability to heal. antibiotic decisions relative viral infections, fungal infections or Implement national antibiotic to any specifi c patient. ulcerations related to trauma or aphthae. prophylaxis recommendations for the ● In most cases, prophylactic ■ Oral bacterial infections have a medical concerns for which guidelines antibiotics are NOT predictable presentation in the exist (e.g., cardiac defects). recommended for patients oral cavity – usually redness, ■ Proper use of antibiotics to with prosthetic joints. pain and swelling in the tissues prevent oral organisms from ■ Severely immunosuppressed around a tooth; advanced infecting body sites other than patients, such as those undergoing infections will often be associated the oral cavity is sometimes chemotherapy, are at an increased with an exudate (pus). appropriate and clinicians risk of systemic infection from an ■ Viral and fungal infections and should be familiar with national oral source. Clinicians may elect ulcerations associated with trauma guidelines for these situations. to be more aggressive in initiating or an immunologic response also ■ The American Heart Association2 antibiotic use in such patients have unique characteristics. and the ADA3 have developed and may elect to use antibiotics ● Viral infections (usually herpes guidelines for the prophylactic prophylactically to prevent an simplex virus) manifest as use of antibiotics to prevent infection if the intended dental blisters and constant pain infective endocarditis in procedure may cause a bacteremia. at the site of the blister/ patients with specifi c cardiac Assess the patient’s medical history ulcer. Inside the mouth, conditions that put them at a and conditions, pregnancy status, drug blisters usually overlay hard higher risk of such infections.4 allergies and potential for drug-drug tissue like the roof of the ● Cardiac conditions interactions and adverse events, any of mouth or attached gums. warranting antibiotic which may impact antibiotic selection. ● Fungal infections usually prophylaxis include but are ■ All medications have risk; the present with redness and some not limited to prosthetic antibiotics commonly used white areas that can be rubbed cardiac valves, prosthetic in dentistry — penicillins, off and are scattered around material used for cardiac clindamycin and azithromycin the mouth, in the vestibule valve repair, history of — are no exception. and on the dorsal tongue. endocarditis and specifi c heart ■ A thorough health history should ● Patients experiencing a transplant and congenital reveal any allergies or adverse fungal infection typically heart defect patients. responses to antibiotics.

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● Evaluate the patient for true ■ Social or other non-evidence-based Prescribe only when clinical signs and penicillin allergy (IgE-mediated) pressures may try to infl uence symptoms of a bacterial infection suggest by obtaining details of the nature the clinician’s decision-making systemic immune response, such as fever and timing of the reaction. in situations where antibiotic use or malaise along with local oral swelling. ● The health history should is not indicated. It is important ■ A local oral bacterial infection also reveal any medications to avoid such pressure, as it may is best and effectively handled that may risk drug-drug lead to inappropriate antibiotic with mechanical interventions to interactions, though the use and result in a poor clinical eliminate the irritant or foreign primary drugs used to treat outcome for the patient. body causing the infection. dental bacterial infections are ■ Patient and staff education on ● Common treatments include not commonly associated with antibiotic prescribing protocols, extraction, endodontic such adverse drug responses. the signs and symptoms of an oral therapy and cleaning/ ■ Drugs that inhibit liver cytochrome bacterial infection, the proper irrigation of the infected site. P450 enzymes are most sequence of care and the rationale ■ Once effective cleaning and commonly associated with drug- for initiating antibiotic therapy removal of the irritation is drug interactions. In dentistry, and its duration are all important accomplished, the body’s these are metronidazol and steps in minimizing the risk of immune system should clear erythromycin, both antibiotics, poor antibiotic decision-making up any remaining infection. and ketoconazole, an antifungal. related to external pressure. Antibiotics are seldom necessary. ● Avoid using these drugs ■ Periodic discussion of antibiotic ■ Antibiotic therapy is appropriate, in patients taking specifi c prescribing protocols between however, if there are signs and medications metabolized in the referring clinicians will ensure use symptoms, such as fever and liver and those taking multiple of the most up-to-date protocols malaise, that the body’s immune medications because many and reduce confl icts or confusion system is not containing the are metabolized in the liver. associated with antibiotic use infection and the patient is starting ■ The clinician should consult when sharing a patient’s care. to experience a systemic response.8 an authoritative reference, the Make and document the diagnosis, ● Antibiotic therapy in these patient’s physician or pharmacist, treatment steps and rationale for situations is used to control before prescribing an antibiotic antibiotic use (if prescribed) in the the infection while the local when there is any concern patient chart. infection-control measures of drug-drug interaction. ■ Thorough documentation used to remove the cause of the is essential. infection (extraction, drainage, Prescribing ● Clearly and completely irrigation and/or endodontic Ensure evidence-based antibiotic document the diagnosis of treatment) can be carried out references are readily available during an oral bacterial infection, and be given time to work. patient visits. the treatment steps and Use the most targeted (narrow- ■ While most clinicians are well- the rationale for treatment spectrum) antibiotic for the shortest versed in the antibiotic choices decisions, including duration possible (two to three days after for oral bacterial infections, the decision to initiate the clinical signs and symptoms subside) it is prudent for the clinician antibiotic therapy. for otherwise healthy patients. to have at least one of several ● Documentation shortcuts, ■ Most bacterial organisms associated recognized prescribing reference understandably common with oral infections are sensitive resources readily available. among busy practitioners, to penicillins, making it the fi rst Avoid prescribing based on non- may be a source of confusion drug of choice, as follows: evidence-based historical practices, or concern when records are ● Penicillin VK, 500 mg patient demand, convenience or pressure later reviewed for treatment given 4Xday or amoxicillin, from colleagues. decisions and rationale. 500 mg given 3Xday.

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● If there is no response in 48 be appropriate as well as a culture ■ Clinicians should instruct patients to 72 hours, then amoxicillin and sensitivity test to ensure the to dispose of unused drugs protected from beta-lactamase correct antibiotic has been chosen. immediately upon completion of with clavulanic acid Discuss antibiotic use and prescribing treatment and provide guidance (Augmentin) can be tried or protocols with referring specialists. on drug disposal options. switch to clindamycin 300 mg ■ All clinicians managing a patient’s ● The Food and Drug given 4Xday. If the patient has care should utilize similar evidence- Administration provides a true (IgE mediated) allergy based resources and protocols, guidance on drug disposal,10 to penicillins, then the drug including the fi rst, second and which indicates that antibiotics of choice is clindamycin, third drugs of choice, at the proper may be harmful to others 300 mg given 4Xday.9 dosage for the proper duration. if fl ushed down the toilet. ● Patients unable to take ■ The use of similar protocols Guidance for household clindamycin may be improves the care of shared trash disposal, which is prescribed azithromycin, patients and decreases the risk of appropriate, is as follows: 500 mg given 1Xday. confl ict for the clinicians and the ◆ Remove the drugs from ■ The number of pills prescribed risk of confusion for the patient. their original containers should be enough for 10 days and ■ Sharing disease management and mix them with the patient should be instructed to and treatment ideas among something undesirable, take the antibiotic as prescribed for clinicians is an important source such as used coffee grounds, two to three days after all clinical of continuing education. dirt or cat litter. This signs and symptoms are gone. makes the medicine less ■ Clinicians should disposal of Patient Education appealing to children and unused drugs immediately upon Educate your patients to take pets and unrecognizable completion of treatment and antibiotics exactly as prescribed, to to someone who might counsel patients on drug disposal take antibiotics prescribed only for intentionally go through options (see the following Patient them and to not save antibiotics for the trash looking for drugs. Education segment for more detail). future illness. ◆ Put the mixture in Revise empiric antibiotic regimens on ■ Antibiotics are complex drugs with something you can close the basis of patient progress and, if different absorption rates, half- (a resealable zippered needed, culture results. lives and elimination mechanisms, storage bag, empty can ■ All patients taking an antibiotic all of which infl uence the dose or other container) to for a bacterial infection should be prescribed, the dosing frequency prevent the drug from followed closely to make sure the and the duration of its use. leaking or spilling out. infection is resolving and that there ■ Antibiotics must be taken as ◆ Throw the container are no adverse effects occurring. prescribed to be effective; many in the garbage. ■ A patient taking an antibiotic antibiotic failures can be traced ◆ Scratch out all your as prescribed following a proper back to the fact that the patient personal information incise and drain should start to did not comply with the clinician’s on the empty medicine see a positive response in 48 to recommended dosage and, most packaging to protect your 72 hours. Patients not improving important, dosing frequency. identity and privacy and in that time frame or who are ■ Clinicians should clearly and throw the packaging away. experiencing adverse responses unequivocally inform patients of ■ Patients who refuse to take a to the antibiotic should be re- the need to take their medication prescribed antibiotic as directed, for evaluated and their antibiotic as directed for two to three any reason, must be instructed to changed to the next drug of choice. days after the clinical signs immediately inform the prescribing ■ For poorly responding patients, a (fever, swelling, redness) and clinician so an alternative treatment consultation with a specialist may symptoms (pain) have resolved. approach can be identifi ed.

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Staff Education REFERENCES 7. American Academy of Orthopaedic Surgeons. 1. Centers for Disease Control and Prevention. Checklist for Appropriate Use Criteria: Management of Patients With ■ All members of the dental team Antibiotic Prescribing in Dentistry. www.cdc.gov/antibiotic- Orthopaedic Implants Undergoing Dental Procedures should be educated about oral use/community/downloads/dental-fact-sheet-FINAL.pdf. (2016). www.orthoguidelines.org/go/auc/default. bacterial infections, the offi ce 2. Infective Endocarditis. American Heart cfm?auc_id=224995&actionxm=Terms. treatment protocols, the rationale Association. www.heart.org/HEARTORG/ 8. American Association of Endodontists. AAE Guidance on Conditions/CongenitalHeartDefects/ the Use of Systemic Antibiotics in Endodontics. www.aae. for the steps in the infection TheImpactofCongenitalHeartDefects/Infective-Endocarditis_ org/specialty/wp-content/uploads/sites/2/2017/06/ protocol and the criteria used UCM_307108_Article.jsp#.WyFSrKdKiUk. aae_systemic-antibiotics.pdf. to initiate antibiotic therapy. 3. Sollecito T, Abt E, Lockhart P, et al. The use of 9. American Association of Endodontists. AAE Guidance prophylactic antibiotics prior to dental procedures in on Antibiotic Prophylaxis for Patients at Risk of Systemic ■ Staff training improves the patients with prosthetic joints: Evidence-based clinical Disease. www.aae.org/specialty/wp-content/uploads/ probability of patient a dherence practice guideline for dental practitioners — a report of the sites/2/2017/06/aae_antibiotic-prophylaxis.pdf. to antibiotic prescriptions. American Dental Association Council on Scientific Affairs. J 10. U.S. Food and Drug Administration. Where and how to Am Dent Assoc 2015;146(1):11–16. dispose of unused medicines. www.fda.gov/ForConsumers/ ● Patients often consult with 4. Wilson W, Taubert KA, Gewitz M, et al. Prevention ConsumerUpdates/ucm101653.htm#steps. or ask questions of dental of infective endocarditis: Guidelines from the American team members because they Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki feel comfortable doing so Disease Committee, Council on Cardiovascular Disease in and often do not want to the Young, and the Council on Clinical Cardiology, Council “bother” the dentist with their on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working questions. Team members Group. J Am Dent Assoc 2008 Jan;139 Suppl:3S–24S. who understand the reasons 5. AAOS–ADA Clinical Practice Guideline on the behind the management of oral Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. www.aaos.org/Research/ infections can be very helpful guidelines/PUDP/PUDP_guideline.pdf. in allaying patients’ concerns 6. American Dental Association. Management of patients and supporting and reinforcing with prosthetic joints undergoing dental procedures. www. ada.org/en/~/media/EBD/Files/ADA_Chairside_Guide_ proper compliance. ■ Prosthetics.

Antibiotic Use in Dentistry Antibiotic stewardship assists health care providers with the judicious and appropriate use of antibiotics for patient use. Appropriate clinical decision-making with regard to antibiotic use requires the clinician to evaluate the needs of the individual patient and provide the best treatment for that patient. At the same time, the clinician should consider what is best for the long-term sustainability of antibiotics as an eff ective means of patient care. This dual responsibility is at the core of “antibiotic stewardship.” The TABLE is intended as guidance for dental professionals prescribing antibiotics in outpatient settings for certain common conditions. It is not the result of a systematic review of evidence nor the consensus of an expert panel, but rather utilizes professionally developed resources and best-available practices and as such should be considered in conjunction with other available resources. Dental professionals should consult emerging science and practice guidelines as these become available.

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TABLE Antibiotic Use in Dentistry

Managing active infections Condition/Concern Epidemiology Diagnosis Acute oral bacterial infection Many patients at some time in their life, depending Oral bacterial infections usually present as pain, (cellulitis or abscess) on their level of dental care, will get an oral bacterial swelling and/or redness around the tooth or along infection within the bone or under the gingival and the bone supporting the teeth. periodontal tissue surrounding their teeth. They may also present as pain, swelling below the jaw in the upper neck region or in the facial structures under the eyes and nose. As an infection progresses, there may be a purulent exudate coming from some part of the swollen area or from the space around the infected teeth or gums. Management Management should focus on eliminating the pathology that leads to the infection and should include a radiograph to identify the correct tooth or gingival area, cleaning of the area if it is a periodontal infection or the extraction or endodontic treatment of the tooth if it is an odontogenic infection. Management may also require the incision and drainage of the abscess if an abscess has formed. Limited incision and drainage may be considered if the swelling is hard, even if it might still be a cellulitis, to ensure that there is no abscess and to provide a focus for abscess formation and drainage (the incision point) if the cellulitis evolves into an abscess. Depending on the extent of the infection and any signs of a systemic spread of the infection, such as fever and/or malaise or if the patient is immunosuppressed or otherwise medically compromised, antibiotics should be considered. (Primary treatment is the surgical resolution of the dental problem. Antibiotics are considered secondary to that process.) The types of bacterial organisms associated with oral infections are relatively limited and most are sensitive to penicillins. Based on that, the drugs of choice are: ■ Penicillin VK and amoxicillin. If there is no response in 48 to 72 hours, then amoxicillin protected from beta-lactamase with clavulanic acid (Augmentin) can be tried or switch to clindamycin. If the patient is allergic to penicillins, the drug of choice is clindamycin. ■ If the patient is unable to take clindamycin, the drug of choice is azithromycin. Depending on the severity of the infection and its response to therapy, if the above sequence is not eff ective the dentist may want to consider consultation with or referral to a specialist or antibiotic sensitivity testing to identify an eff ective antibiotic. Condition/Concern Epidemiology Diagnosis Chronic periodontal disease Periodontal disease is common in the U.S. adult Periodontal disease, especially the early stages, can population, with estimates suggesting that nearly be diffi cult for the patient to detect because there may 50 percent or 65 million American adults have mild, be no pain and few outward signs that the subgingival moderate or severe periodontitis. In adults 65 and infl ammation and subsequent bone loss are occurring. older, prevalence rates increase to more than Periodontal disease is usually initially detected by a 70 percent. dentist or and is characterized by bleeding on probing, periodontal pockets of 5 mm or more and, at more advanced stages, bone loss and gingival recession. Radiographs are useful to evaluate for bone loss. Management Chronic periodontal disease is not amenable to antibiotic management. Though it has a bacterial component to it and short-term management may include antibiotic use, long-term management is focused on altering the oral environment by appropriate mechanical cleaning of the tooth and root surfaces to eliminate the pathogenic organisms. Treatment approaches, beyond eff ective mechanical cleaning, may include using disinfectants such as chlorhexidine or essential oil-based mouthwashes to assist in eliminating the pathogenic organism associated with the disease. Locally delivered antibiotics can also be used, adjunctively to mechanical methods, to support or improve periodontal health. Maintaining a long-term healthy oral environment is essential to managing chronic periodontal disease. Chronic periodontal disease may manifest into an acute abscess. In that situation, antibiotics may be needed to control the infection, though they should only be instituted after meticulous professional cleaning and irrigation of the teeth in the infected area and re-evaluation. Proper mechanical cleaning of infected areas is usually adequate to alter the local environment and eliminate the infection without the need for an antibiotic and is the only way to prevent the infection from continuing or returning.

CONTINUES ON 764

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TABLE (CONT) Condition/Concern Epidemiology Diagnosis Sinus infection that presents with Acute sinusitis is the second most common infectious Acute or chronic sinusitis usually manifests as dental symptoms disease seen by general practice physicians. Most pressure and pain in the maxillary sinus area under acute sinusitis is caused by the same viruses that the eyes and beside and behind the nose. cause the common cold. Infrequently, it can also manifest as diff use dental Though there is evidence that acute bacterial pain and sensitivity in the posterior maxillary teeth sinusitis does occur in the adult population, it is a with cold sensitivity, throbbing and a general sense small percentage of total sinusitis cases. of discomfort. Antibiotic trials fi nd that 75 percent or more of Patients may refl exively clench their teeth to patients with sinusitis in the placebo groups get counteract the pain that can lead to more maxillary better spontaneously within seven to 10 days. tooth pain and sensitivity and start to cause the lower teeth to become sensitive as well. Due to the proximity of the sinuses to the dentition and the shared innervation of that area, the dentist must rule out dental pathology as a cause of or coincidental to a sinus infection. Management A detailed dental examination of the maxillary teeth in the aff ected area should be conducted to look for dental decay, external or internal root resorption, periodontal infection or any other dental pathology that could explain the dental pain. Appropriate periapical radiograph(s) should be used to look for periapical pathology and for root proximity to the maxillary sinus. If there is no evidence of dental pathology, then it is unlikely the sinus pain is coming from a dental source. Potentially confounding this process is that the normal tests for , such as cold or hot sensitivity and pain on biting, are not good discriminators of dental versus sinus infection pain because sinus infections can cause teeth to respond in the same way. Treating sinus pain with antibiotics as a means of ruling out a dental etiology is not appropriate. Sinus infections are complex and using antibiotics is not eff ective in discriminating between a dental versus a nondental source. If the dentist determines that dental pathology is an unlikely source of the sinus/pain problem, the patient should be directed to their physician for further evaluation and treatment. Prophylaxis to prevent local infections or distant site infections Condition/Concern Epidemiology Diagnosis Prophylaxis to prevent local or proximal/ All surgical procedures carry a risk of infection A thorough medical history is required to determine adjacent surgical-site infection (primary either from pathogens existing in the surgical site or the presence of a medical condition or medication prophylaxis) by the introduction of bacteria during the surgical that may compromise the patient’s immune system procedure. That risk may be increased if the or ability to respond to infection. patient’s immune system is compromised, such as Depending on the situation, consultation with the in those taking immunosuppressing drugs, patients patient’s physician may be warranted. with leukemia or those undergoing chemotherapy. The risk of infection is also increased if the patient has a compromised ability to heal, such as those with severe or uncontrolled diabetes. Management In general, the literature does not support the use of antibiotics prophylactically to prevent local infections in tissues adjacent to a surgical or dental procedural site, such as a , endodontic procedure or an implant placement. An exception may be the surgical extraction of third molars, especially in situations where there is . The clinician is encouraged to use their clinical judgement to evaluate the patient’s health and the extent of the procedure relative to antibiotic use in such situations. The prophylactic eff ect of antibiotics occurs within the fi rst one or two doses and antibiotic use may be of detriment if continued for the next three to seven days, especially if there are no signs of infection at the surgical site. Best practices and responsible antibiotic stewardship suggest antibiotics should be reserved to manage an infection were it to occur, rather than used in hopes of preventing the infrequent infections that may be associated with such procedures in healthy immunocompetent patients.

RESOURCES org/specialty/wp-content/uploads/sites/2/2017/06/ Association Council on Scientifi c Aff airs. J Am Dent Assoc American Association of Endodontists Guidance on the Use aae_antibiotic-prophylaxis.pdf. 2015;146(1):11–16. of Systemic Antibiotics in Endodontics aae.org/specialty/wp- Sollecito T, Abt E, Lockhart P, et al. The use of prophylactic Wilson W, Taubert KA, Gewitz M, et al. Prevention of content/uploads/sites/2/2017/06/aae_systemic-antibiotics.pdf. antibiotics prior to dental procedures in patients with infective endocarditis: Guidelines from the American American Association of Endodontists Guidance on Antibiotic prosthetic joints: Evidence-based clinical practice guideline Heart Association: A guideline from the American Heart Prophylaxis for Patients at Risk of Systemic Disease. aae. for dental practitioners — a report of the American Dental Association Rheumatic Fever, Endocarditis and Kawasaki

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TABLE (CONT) Condition/Concern Epidemiology Diagnosis Prophylaxis to prevent distant site infection Patients with certain cardiac conditions, such as Pathogens in the oral cavity are a potential source (secondary prophylaxis) prosthetic valves, a history of endocarditis and of bacteremia whenever the oral tissues are specifi ed congenital heart defects, are at higher risk compromised. While this may occur during daily of infection from a bacteremia and the outcome of brushing and fl ossing, it most certainly occurs during such an infection can be life-threatening. dental procedures that elicit bleeding. Patients with large prosthetic joints may also be The spread of the infecting organisms is through the candidates for prophylactic antibiotics under certain blood (hematogenous spread) to a site or sites in circumstances, such as previous joint infection, the body that are vulnerable to bacterial infection. immunosuppression or uncontrolled diabetes. The American Heart Association (AHA) and the American Dental Association (ADA) have published guidelines for identifying the cardiac conditions for which prophylactic antibiotics are indicated. ADA developed a chairside clinical recommendation guide for the management of patients with prosthetic joints undergoing dental procedures and the American Academy of Orthopaedic Surgeons off ers online access to Appropriate Use Criteria for assistance determining at-risk dental patients who may benefi t from prophylaxis. Management There has been an evolution over the last 50 years in dentistry regarding the effi cacious and appropriate use of antibiotics to prevent infections at a distant site from bacteremia as a result of dental treatment. Over that time, antibiotic use has been reduced from multiple days before and after the dental procedure of concern to a single dose of an antibiotic 30 to 60 minutes before the dental procedure with no follow-up dosage. Current evidence indicates that generally, for healthy patients, prophylactic antibiotics are not recommended prior to dental procedures except for the AHA- defi ned higher-risk patients. Antibiotics are appropriately used prophylactically in dentistry to prevent the spread of infection to a distant site in the body from organisms in the oral cavity under situations where the patient is identifi ed as vulnerable to infection. Medical conditions for prophylactic antibiotic consideration are: ■ Specifi c cardiac conditions (see AHA guidelines). ■ Prosthetic joints in specifi c patients (see ADA chairside guide or the American Association of Orthopedic Surgeons’ Appropriate Use Criteria online decision support tool). ■ Patients taking chemotherapeutic or immunosuppressing drugs or who have a medical condition that creates a compromised immune response, such as leukemia. Drug recommendations: ■ Amoxicillin, 2,000 mg. ■ If amoxicillin or other penicillin is not an option, clindamycin, 600 mg, is the drug of choice for cardiac patients and cephalexin, 2,000 mg, is the drug of choice for prosthetic-joint patients. ■ If the patient is unable to take clindamycin, then azithromycin, 500 mg, is the drug of choice. Dose timing: ■ If prophylactic antibiotics are needed, give 30 to 60 minutes before the dental procedure begins. ■ At the high doses recommended, this time interval is considered adequate for enough drug to be absorbed so that bactericidal blood levels are reached. Where published guidelines exist, no subsequent dose of antibiotics is recommended. In situations where specifi c guidelines do not exist, such as severely immunosuppressed patients, the patient’s physician should be consulted relative to subsequent doses of antibiotics past the initial dose. Antibiotic prophylaxis to prevent infections at distant sites, even in medically complex patients, has evolved over time and still remains controversial, as there is lack of a solid evidence base for the effi cacy of such a practice.

Disease Committee, Council on Cardiovascular Disease in of Orthopaedic Implant Infection in Patients Undergoing Assoc 2015 Jul;146(7):525–35. the Young and the Council on Clinical Cardiology, Council Dental Procedures. aaos.org/research/guidelines/PUDP/ Stein K, Farmer J, Singhal S, et al. The use and misuse of on Cardiovascular Surgery and Anesthesia, and the Quality dentalexecsumm.pdf. antibiotics in dentistry: A scoping review. J Am Dent Assoc of Care and Outcomes Research Interdisciplinary Working Smiley C, et al. Evidence-based clinical practice guideline on 2018 Oct;149(10):869–884.e5. doi:10.1016/ Group. J Am Dent Assoc 2008 Jan;139 Suppl:3S–24S. the nonsurgical treatment of chronic periodontitis by means of j.adaj.2018.05.034. AAOS–ADA Clinical Practice Guideline on the Prevention scaling and root planing with or without adjuncts. J Am Dent

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Coronectomy of Mandibular Third Molars: Our Experience With 250 Consecutive Patients

Emily Ehsan; Paul Hauser, PhD; and David Ehsan MD, DDS

ABSTRACT Extraction of third molars is a common and safe surgical procedure in the United States. However, injury to the inferior alveolar nerve (IAN) during the extraction of impacted mandibular third molars in close proximity to the mandibular neurovascular canal is a complication frequently encountered by the oral and maxillofacial surgeon. We report our experience with 369 consecutive coronectomy procedures in 250 patients performed by one surgeon in a private-practice setting at a metropolitan locale.

AUTHORS

Emily Ehsan is a student at David Ehsan, MD, DDS, xtraction of third molars is Once a controversial procedure, Cornell University in Ithaca, is an oral and maxillofacial a common and safe surgical coronectomy of mandibular wisdom N.Y., and a clinical research surgeon in private practice procedure in the United States. teeth has become an accepted intern at the San Francisco and the surgical director of Implant Institute. the San Francisco Implant However, injury to the inferior alternative to extraction in cases where Confl ict of Interest Institute. alveolar nerve (IAN) during there is a close proximity of nerve and Disclosure: None reported. Confl ict of Interest Ethe extraction of impacted mandibular roots. In 2011, the American Dental Disclosure: None reported. third molars in close proximity to the Association approved a procedure Paul Hauser, PhD, is a mandibular neurovascular canal is a code (D7251) for coronectomy and postdoctoral fellow at the University of California, complication frequently encountered since 2012 it has been listed by the Berkeley, and a science by the oral and maxillofacial surgeon. American Association of Oral and educator at San Francisco The published incidence of injury to Maxillofacial Surgeons ParCare 2012 as University High School. the IAN is 0.5 to 8 percent1–3 where a standard treatment option for surgical Confl ict of Interest 1 percent of the injury is permanent.3,4 management of third molars.17 Most Disclosure: None reported. The incidence may reach up to 20 articles in peer-reviewed literature are percent in high-risk cases.5 To minimize either case reports or small case series. the risk for nerve injury, coronectomy We report our experience with has become an alternative surgical 369 consecutive coronectomy procedure. The technique was fi rst procedures performed by one reported by Ecuyer and Debien in surgeon in a private-practice 19846 and continues to be studied.7–16 setting at a metropolitan locale.

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FIGURE 1B. Three-dimensional cone beam computed tomography (CBCT) scan image.

FIGURE 1A. Preoperative panoramic radiograph of a 32-year-old patient with impacted third molars. Mandibular third molar roots appear to be in close proximity to the inferior alveolar canal.

FIGURE 1C. Axial slice of CBCT showing the intimate contact of the third molar roots with the inferior alveolar canal.

FIGURE 1D. Immediate postoperative panoramic radiograph after extraction of maxillary third molars and coronectomy of mandibular third molars.

FIGURE 1E. Six-months postoperative panoramic radiograph showing slight FIGURE 1F. Seven-years postoperative panoramic radiograph showing no further superior movement of coronectomy roots but with excellent overlying bone. movement of coronectomy roots with excellent bony healing overlying the roots and distal to the second molars.

Methods ■ Patient underwent preoperative week and six-months postoperative We conducted a retrospective clinical examination including evaluation with panoramic review of 250 consecutive patients who panoramic radiograph radiograph. The exclusion criteria underwent a coronectomy procedure and cone beam computed were patients whose panoramic at the San Francisco Implant Institute tomography scan (CBCT). radiograph or CBCT scan did not from 2010 to 2016 performed by the ■ CBCT showed intimate contact of show close proximity of wisdom same surgeon (D.E.). Patient clinical the inferior alveolar nerve (IAN) teeth roots to IAN, patients with records and follow-up data were and roots defi ned by absence of the active fascial space infection where reviewed. The inclusion criteria were: cortical wall of the mandibular canal. the source was the mandibular ■ Patient needed coronectomy of at ■ Patient cooperated with follow-up third molar and caries of the least one mandibular third molar. care that consisted of at least three mandibular third molar to very near postoperative visits — one-week, six- or within the pulp of the tooth.

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FIGURE 2B. Axial CBCT showing the right inferior alveolar canal crossing between the roots of tooth No. 32 and in direct contact with the roots of tooth No. 17.

FIGURE 2A. Preoperative panoramic radiograph of a 34-year-old patient with impacted third molars. Mandibular third molar roots appear to be piercing the inferior alveolar canal.

FIGURE 2C. Immediate postoperative panoramic radiograph after extraction of FIGURE 2D. Three-years postoperative panoramic radiograph showing coronectomy maxillary left third molar and coronectomy of mandibular third molars. roots with excellent bony healing overlying the roots and distal to the second molars.

Results distobuccal releasing component. follow-up visit included clinical and The sample was composed of The fl ap is elevated buccally with no radiographic (panoramic) examinations. 250 patients with the coronectomy manipulation of lingual soft tissues. Fourteen patients were seen at procedure. Mean patient age was 28.7 Ostectomy is performed with a fi ssure one- to fi ve-years postoperatively, years with 45 patients younger than bur on a surgical handpiece with usually for an unrelated oral surgical 25, 158 patients aged 25 to 35 years copious sterile irrigation to expose issue. Two patients are represented and 23 patients aged 35 and older. the tooth crown when necessary. The in FIGURES 1 and FIGURES 2. The male to female ratio was 1:1.48 fi ssure bur is used to transect the tooth There were four minor (101 male patients and 149 female at the cementoenamel junction in complications. Three patients patients). The study pool was healthy a buccolingual direction just short developed postoperative localized in general, with 226 patients meeting of the lingual cortical plate to avoid infections. Two patients were treated the criteria for the American Society injury to the lingual nerve. The with oral antibiotics and antimicrobial of Anesthesiology (ASA) I and 24 crown is transected again in order oral rinse and one required surgical patients meeting the criteria for ASA to obtain two small segments. The incision and drainage. One patient II. Of the ASA II patients, 13 were crown segments are gently removed developed an exposed lingual bony tobacco users and two had diabetes. with tissue forceps. Great care is taken spicule; using topical anesthesia, it A total of 369 coronectomy to avoid mobilization of the roots. was removed with cotton forceps. procedures were performed on 250 The residual roots are reduced with a In nine coronectomy procedures, patients by the same surgeon; 131 round bur to 3 mm below the buccal the residual roots were noted to patients underwent a unilateral bony crest. After thorough irrigation, be mobile during the surgery and coronectomy (78 left mandibular third the fl ap is reapproximated to obtain intentionally extracted at the same molar and 53 right) and 119 patients primary closure of the wound. time, as mobilization of a root can lead underwent bilateral coronectomy. All patients were seen for three to infection because of a disruption of The procedure consists of a postoperative visits at one week, six blood supply to the roots. These patients vestibular triangular fl ap with a weeks and six months. The six-months were all younger (< 25 years) and had

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conical or incomplete root formation. mandibular bony canal and third molar Incidence and evolution of inferior nerve lesions following lower third molar extraction. Oral Surg Oral Med Oral There was no neurological injury in these roots shows that coronectomy is an Pathol Ora Radiol Endod 2005;99:259–64. nine patients with root mobilization and extremely safe and effective surgical 5. Patel V, Moore S, et al. Coronectomy — oral surgery’s extraction. One patient was sent back procedure. In our review, there was no answer to modern day conservative dentistry. Br Dent J 2010; 209:111–114. fi ve-years postoperatively by the referring incidence of temporary or permanent 6. Ecuyer J, Debien J. Surgical deductions (French). Actual dentist to obtain a dental release for injury to the IAN. After surgical Odontostomatol 1984;38(148):695–701. overseas humanitarian work. The patient coronectomy, superior root migration 7. Knutsson K, Lysell L, et al. Postoperative status after partial removal of the mandibular third molar. Swed Dent J had undergone a bilateral coronectomy is common but slow and asymptomatic 1989;13(1–2):15–22. procedure where the left amputated with mean superior migration of 1.3 8. Pogrel MA, Lee JS, et al. Coronectomy: A technique to root was visible intraorally. The patient mm. Roots migrate more in younger protect the inferior alveolar nerve. J Oral Maxillofac Surg 2004;62(12):1447–1452. was completely asymptomatic but both patients compared to older patients. 9. Freedman GL. Intentional partial odontectomy: Report of residual roots had migrated superiorly The rate of root migration decreases case. J Oral Maxillofac Surg 1992;50(4):419–421. out of the IAN canal. Both retained after six months, likely due to bone 10. Freedman GL. Intentional partial odontectomy: Review of cases. J Oral Maxillofac Surg 1997;55(5):524–526. roots were extracted uneventfully. apposition coronal to the root fragment. 11. Zola MB. Avoiding anesthesia by root retention. J Oral There was no incidence of During the coronectomy Maxillofac Surg 1992;51(8):954. neurologic injury to the IAN in any procedure, the remaining roots were 12. O’Riordan BC. Coronectomy (intentional partial odontectomy of lower third molars). Oral Surg Oral Med of the 369 coronectomy procedures. noted to be mobile in nine patients Oral Pathol Oral Radiol Endod 2004;98(3):274–280. Root migration after coronectomy (2.4 percent). In these patients, the 13. Sencimen M, Ortakoglu K, et al. Is endodontic procedure was evaluated using entire root was extracted without treatment necessary during coronectomy procedure? J Oral Maxillofac Surg 2010;68(10):2385–2390. preoperative and postoperative neurological compromise. 14. Pogrel MA. Partial odontectomy. Oral Maxillofac Surg panoramic radiographs. There was an There were three cases of minor Clin North Am 2007;19(1):85–91. average of 1.3 mm of superior migration infection in 369 coronectomy 15. Dolanmaz D, Yildirim G, et al. A preferable technique for protecting the inferior alveolar never: Coronectomy. J of residual roots. Younger patients had procedures (0.81 percent). Oral Maxillofac Surg 2009;67(6):1234–1238. more superior root migration compared Patients who underwent extraction 16. Leung YY, Cheung LK. Safety of coronectomy versus to older patients (<25 years — 1.55 mm; on one side and coronectomy excision of wisdom teeth: A randomized controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 26–35years — 1.3 mm; >35years — on the other uniformly reported 2009;108(6):821–827. 0.95 mm). Of the 12 patients evaluated less postoperative pain on the 17. Lieblich SE, Kleiman MA, et al. Parameters of care: greater than one year after coronectomy, coronectomy side. We attribute less Clinical practice. Guidelines for oral and maxillofacial surgery. (AAOMS ParCare 2012). J Oral Maxillofac Surg 11 had no additional root migration and pain with coronectomy because there 2012;70:e50. one had 2 mm further root migration. is less surgery and invasiveness. Coronectomy is a safe and THE CORRESPONDING AUTHOR, David Ehsan, MD, DDS, can be reached at [email protected]. Conclusion effective procedure that should Coronectomy was fi rst proposed be considered as the standard in 1984 by Ecuyer and Debien to treatment if CBCT shows a direct avoid the risk of neurological injury relationship between the mandibular to the IAN in patients who had canal and third molar roots. ■ close proximity of the mandibular REFERENCES canal and roots of third molars. 1. Sisk AL, Hammer WB, et al. Complications following Case reports and small randomized removal of impacted third molars: The role of the experience of the surgeon. J Oral Maxillofac Surg 1986; clinical trials have shown positive 44:855–9. response and low incidence of nerve 2. Blondeau F. Paresthesia: Incidence following the injury compared to extraction. extraction of 455 mandibular impacted third molars. J Can Dent Assoc 1994;60:991–4. This review of 369 consecutive 3. Valmaseda-Castellon E, Berini-Aytes L, et al. Inferior coronectomy procedures in 250 patients alveolar nerve damage after lower third molar surgical who were at higher risk for neurological extraction: A prospective study of 1,117 surgical extractions. Oral Surg Oral Med Oral Pathol Ora Radiol injury to the IAN based on CBCT Endod 2000;92:377. demonstration of close proximity of 4. Queral-Godoy E, Valmaseda-Castellon E, et al.

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ENDORSED PROGRAMS oral cancer

CDA JOURNAL, VOL 46, Nº12

Recognition of Non-Hodgkin Lymphoma of the Maxilla

Joel B. Epstein, DMD, MSD; Alexa Martin, DMD; Ali M.M. Sadeghi, DMD, MD; and Dimitrios Tzachanis, MD, PhD

ABSTRACT Primary (extranodal) non-Hodgkin lymphoma (NHL) in the oral cavity is rare, but causes local morbidity and leads to mortality. Head, neck and oral involvement can be the fi rst site of presentation or it may occur in previously diagnosed cases. A thorough history, clinical evaluation, imaging, interdisciplinary consultation, biopsy and laboratory testing are all necessary to lead to diagnosis. Dentists must be aware that early recognition of this aggressive disease can lead to improved outcomes.

AUTHORS

Joel B. Epstein, DMD, Ali M.M. Sadeghi, ymphoma is a cancer of the blood Case Report MSD, is a diplomate of DMD, MD, is a certifi ed that affects the infection-fi ghting A 51-year-old female presented to the American Board of oral and maxillofacial Oral Medicine and a surgeon and the division cells of the immune system, the B her general dentist with a nine-month professor at the Samuel head of dentistry and and T lymphocyte cells. The two history of worsening pain and swelling Oschin Comprehensive oral surgery at Lions main types of lymphoma, which over the upper left lateral incisor (tooth Cancer Institute and Gate Hospital in North Linvolve abnormal and uncontrolled No. 10) and with awareness of a “sharp Cedars-Sinai Health Vancouver, British growth of the lymphocytes, are Hodgkin’s pointy ridge” above the upper left System in Los Angeles. Columbia. Confl ict of Interest Confl ict of Interest lymphoma that arises from abnormal B second molar (tooth No. 15). Tooth Disclosure: None reported. Disclosure: None reported. cells and non-Hodgkin lymphoma (NHL) No. 10 was root canal treated more than that may develop from either abnormal 20 years earlier. Due to the presenting Alexa Martin, DMD, is Dimitrios Tzachanis, B or T cells. Primary (extranodal) NHL symptoms and a diffuse radiolucency a former resident in the MD, PhD, is an assistant in the oral cavity is relatively rare, but adjacent to the tooth, endodontic general practice residency professor of medicine in the at Cedars-Sinai Hospital in bone marrow transplant can be locally destructive and lead to retreatment was completed by her Los Angeles. division at the University of mortality. Early detection is critical. Head, dentist and a second canal was found Confl ict of Interest California, San Diego, in neck and oral involvement can be the and treated. Due to a penicillin allergy, Disclosure: None reported. La Jolla, Calif. fi rst site of presentation of NHL or it may the patient was put on azithromycin Confl ict of Interest occur in previously diagnosed cases.1–6 and clarithromycin on separate Disclosure: None reported. A thorough history, clinical evaluation, occasions to treat the presumed dental imaging, interdisciplinary consultation, infection. Two weeks after endodontic biopsy and laboratory testing are all retreatment, the patient reported necessary to achieve diagnosis. Dentists that severe pressure sensitivity had Image above: CSF cytology of a diffuse large must be aware that early recognition of returned in the area of tooth No. 10. B-cell non-Hodgkin lymphoma. (Credit: Jensflorian/ this aggressive disease can lead to earlier She was then referred to an endodontist Wikimedia Commons) treatment and improved outcomes. for evaluation and treatment.

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FIGURE 1. Diff use radiolucency after endodontic FIGURE 2. Intraoperative photo of excision of necrotic segment of maxillary bone, including the retreatment and apicoectomy on tooth No. 10. area of labial and palatal bony plate, as well as extraction of teeth Nos. 9 and 11.

During consultation with the recurrent swelling of her left nasolabial necrotic segment including the area endodontist, the patient related a region and palate and eventually had of labial and palatal bony plate as history of an intermittent palatal tooth No. 10 extracted by her general well as extraction of teeth Nos. 9 and swelling adjacent to tooth No. 10 along dentist who noted pus expressed 11 were completed. Her pathology with a bump in the posterior hard from the socket. She was treated report described fi ndings consistent palate. An incision and drainage and intermittently with oral clindamycin, with osteomyelitis, however due to apicoectomy were performed and the azithromycin and moxifl oxacin by a comment in the previous biopsy patient was placed on clarithromycin various dentists and specialists with report indicating the inability to and metronidazole (FIGURE 1). During no resolution of her symptoms. A assess the infl ammatory cells due the surgery, the endodontist noted diagnosis of advanced osteomyelitis in to crush artifact, further evaluation that the periosteum seemed to be the anterior maxilla was made after a and differential staining of original stuck to the cortical bone. The bone cone beam computed tomography (CT) sections were requested by the OMS. was described as noncohesive in the was performed, which demonstrated The specimen was then re- area of teeth Nos. 9–12 compared extensive osteolysis of the anterior examined with immunohistochemistry to normal bone over tooth No. 8. maxilla and a periapical lesion on tooth staining that showed strong positivity The clinician noted that the lesion No. 9. She was then seen by an OMS for CD20, less intense CD3 and seemed abnormal. Suspicious of a who identifi ed mild facial asymmetry, reverse expression of Ig Kappa and malignancy, the endodontist submitted a fi rm, tender swelling in the left Ig Lambda consistent with B-cell a sample for biopsy. The initial nasolabial region including the left lymphoma. However, due to the report indicated malignancy, but an anterior mucobuccal fold and labial and extensive crush artifact, it was difficult addendum report issued a fi nal diagnosis palatal cortical expansion with crepitus to specify the lymphoma type. of “chronic apical periodontitis” suggesting altered cortical bone. Upon further work up, an underlying without evidence of malignancy. The OMS ordered a CT with low-grade lymphoma was identifi ed in On follow-up one week later with contrast, medical and laboratory testing the bone marrow in addition to the the endodontist, the soft tissue appeared and consultation with an infectious apparent intermediate-grade lymphoma to be healing and the swelling behind disease specialist. The new CT showed not otherwise specifi ed in the head tooth No. 10 was reported as indurated. extensive osteolysis reported consistent and neck causing bony destruction Tooth No. 9 tested nonvital, which with osteomyelitis. Laboratory results of the left maxillary bone and palate. had previously tested vital, and it was showed a normal hematologic panel. The fi nal diagnosis was stage IVA recommended the patient have a root The infectious disease specialist transformed non-Hodgkin B cell canal on tooth No. 9. The endodontist planned daily intravenous antibiotics lymphoma. The ertapenem therapy recommended a referral to an oral and (vancomycin and ertapenem). Soon after was continued to address the potential maxillofacial surgeon (OMS) for an antibiotics were initiated, the patient infectious component of the process and examination and biopsy of the persistent underwent a maxillary sequestrectomy. the vancomycin was discontinued. palatal swelling, which measured 1 cm in Intraoperatively, extensive lysis The patient was then referred to diameter. The endodontist suspected the of bone with gelatinous material an oncologist and she underwent six swelling was unrelated to the dentition. completely replacing the interseptal cycles of R-CHOP chemotherapy. Over the next few months, the bone between the maxillary teeth A PET/CT at the end of treatment patient saw multiple specialists for was noted (FIGURE 2). Excision of a showed resolution of all previously

774 DECEMBER 2018 CDA JOURNAL, VOL 46, Nº12

FIGURE 4. Panoramic radiograph showing CT- guided dental implants with fi xed implant- retained prosthesis after maxillary resection and reconstruction.

FIGURE 3. Reconstruction of anterior maxilla with iliac crest bone graft. identifi ed lymphoma lesions. She of most patients.2–4 A review of 40 diagnosis. Differentiating between reported no symptoms of recurrent cases of NHL involving the oral cavity lymphoma and infectious disease may disease or infection and was placed on revealed 28 percent involved the be diffi cult, but if a patient is not maintenance rituximab (375 mg/m2 maxilla or palatal bone.5 As the disease responding as expected to treatment q3mo for 8 cycles). Upon confi rmation progresses, intraoral signs suggestive of it is essential to review the working of full remission of her lymphoma, the NHL include unexplained dental pain, diagnosis, repeat or complete new testing patient had reconstructive surgery of her numbness, tooth mobility, swelling and refer to the appropriate specialists maxillary defect using an autogenous or ill-defined lytic osseous changes.6 to determine diagnosis and appropriate iliac crest bone graft (FIGURE 3). After The lymphoma in this case treatment.6 Delayed diagnosis may a six-month consolidation of the initially presented as a tender have led to a more advanced stage graft, multiple dental implants were swelling of the labial tissue in the of disease, as was seen in this case. placed using CT-guided technology area of tooth No. 10. Radiographic Testing for primary NHL requires and a fi xed implant-retained prosthesis evaluation showed a diffuse periapical immunohistochemistry and in situ in the maxilla (FIGURE 4). radiolucency and the incisional biopsy hybridization staining. Routine revealed erosive osseous changes. hematoxylin and eosin is not suffi cient Discussion The 20-year-old root canal for lymphoma diagnosis, and as seen Non-Hodgkin lymphoma is the in tooth No. 10 appeared intact with this case, hematologic and second most common neoplasm of the radiographically, despite diffuse bone biochemical profi les of the patients head and neck, even though overall loss seen in the anterior maxilla. are usually normal.7,8 Histological it accounts for only 3.5 percent of The patient did not respond to evaluation, including B and T cell oral malignancies.1 The oral cavity multiple antibiotic courses directed markers, is important in differentiating might be the first and/or only site of toward a possible dental infection, the types of cells involved and presentation even with disseminated yet multiple endodontic procedures differential diagnosis, and additional involvement. Most lymphomas are of were completed before lymphoma markers can help discern subtypes.5 B-cell origin followed by T-cell and the was considered in the differential In this case, A2 staining, CD20, NK/T cell. The most common subtype diagnosis. The history, diffuse bone CD3 and Ig Kappa and Ig Lambda is diffuse large B-cell lymphoma. destruction and the palatal swelling, were used to establish a diagnosis of It has an aggressive, fast-growing despite the radiographic appearance B-cell lymphoma. Unfortunately, the course but is curable, therefore early of the prior endodontic treatment, initial biopsy sample was not ideal recognition and treatment is of suggest a potential cause other in that there were many crushed paramount importance. Oral care than dental pathology. Differential cells due to the tissue obtained by providers must be aware that head, diagnosis is critical at this stage of curettage and the type of B-cell neck and oral involvement is common. care. Further, this case highlights the lymphoma could not be identifi ed. The most prevalent site is the tonsils challenges in histologic diagnosis Clinical, laboratory studies, imaging (32.7 percent) followed by the parotid and that defi nitive diagnosis requires to evaluate bony destruction and gland (16.1 percent).1 Clinical laboratory and clinical evaluation. positron emission tomography (PET) presentation of NHL often begins as , periodontal infection scan with 18F-fl uorodeoxyglucose an asymptomatic, slowly growing mass and benign reactive hyperplasia should (FDG) may be used for staging and and this is usually the first complaint all be considered in the differential evaluation of therapeutic response.8

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CDA JOURNAL, VOL 46, Nº12

Treatment for oral NHL involves and eight cycles of maintenance REFERENCES 1. Epstein JB, Epstein JD, Le ND, Gorsky M. Characteristics of primarily chemo-immunotherapy therapy of rituximab, a monoclonal oral and paraoral malignant lymphoma: A population-based and may include radiation therapy antibody directed to the CD20 review of 361 cases. Oral Surg Oral Med Oral Pathol Oral with bone marrow/hematopoietic antigen.8 Reconstructive maxillary Radiol Endod 2001;92:519–25. 2. van der Waal RI, Huijgens PC, van der Valk P, van der Waal stem cell transplant reserved mainly surgery was completed three I. Characteristics of 40 primary non-Hodgkin lymphomas of the for relapsed and refractory cases. The months after negative PET scan. oral cavity in perspective of the new WHO classifi cation and overall three-year survival rate is still Extranodal NHL should be included International Prognostic Index. Int J Oral and Maxillofac Surg 2005 Jun;34(4):391–395. only around 65 percent, and after as a rare differential diagnosis when a 3. Jacobs C, Hoppe RT. Non-Hodgkin’s lymphomas of the head salvage therapy, two-year survival is patient presents with gingival swelling and neck extranodal sites. Int J Radiat Oncol Biol Phys 1985 only about 55.3 percent.9,10 Our patient that cannot be explained by more Feb;11(2):357–64. 4. Shindoh M, Takami T, Arisue M, et al. Comparison between achieved a complete remission with common causes. It is important for submucosal (extranodal) and nodal non-Hodgkin’s lymphoma six cycles of R-CHOP chemotherapy, dentists to be aware of this due to the (NHL) in the oral and maxillofacial region. J Oral Pathol Med which is a 21-day course of rituximab, aggressive nature of the malignancy 1997 Jul;26(6):283–9. 5. Kemp S, Gallagher G, Kabani S, Noonan V, O’Hara C. cyclophosphamide, doxorubicin, so that diagnosis can be achieved and Oral non-Hodgkin’s lymphoma: A review of the literature and vincristine and prednisone per cycle treatment initiated as early as possible. ■ World Health Organization classifi cation with reference to 40 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008 Feb;105(2):194–201. Epub 2007 Jun 29. 6. Angiero F, Stefani M, Crippa R. Primary non-Hodgkin’s lymphoma of the mandibular gingiva with maxillary gingival recurrence. Oral Oncol Extra 2006;42:123–8. 7. Kolokotronis A, Konstantinou N, Christakis I, Papadimitriou P, Matiakis A, et al. Localized B-cell non-Hodgkin’s lymphoma of oral cavity and maxillofacial region: A clinical study. Oral Surg Oral Medi Oral Pathol Oral Radiol Endodo 2005 Mar;99(3): 303–310. 8. Vinoth P, Selvan S, Sahni L, Krishnaratnam K, Rajendiran S, et al. Primary extranodal non-Hodgkin’s lymphoma of the oral cavity in a young girl. Natl J Maxillofac Surg 2012 Jul–Dec; 3(2):187–189. doi:10.4103/0975-5950.111377. 9. Alinari L, Gru A, Quinion C, Huang Y, Lozanski A, et al. De novo CD5+ diff use large B-cell lymphoma: Adverse outcomes with and without stem cell transplantation in a large, multicenter, rituximab treated cohort. Am J Hematol 2016 Jun;91(4):395–399. doi:10.1002/ajh.24299. LIMITLESS 10. Matsumoto T, Hara T, Shibata Y, Nakamura N, Nakamura H. A salvage chemotherapy of R-P-IMVP16/CBDCA consisting MEMBER of rituximab, methylprednisolone, ifosfamide, methotrexate, etoposide and carboplatin for patients with diff use large B cell BENEFITS lymphoma who had previously received R-CHOP therapy as fi rst-line chemotherapy. Hematol Oncol 2017 Sep;35(3):288– 295. doi: 10.1002/hon.2285. Epub 2016 Mar 21.

THE CORRESPONDING AUTHOR, Alexa Martin, DMD, can be reached at alexa.martin.dmd@.com.

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CONTACT US FOR A FREE CONSULTATION WWW.CALPRACTICESALES.COM Phone: (800) 697-5656 CA BRE #00283209 RM Matters CDA JOURNAL, VOL 46, Nº12

Posttreatment Care Crucial in Foreign Object

Aspiration Incidents TDIC Risk Management Staff

he accidental aspiration or In another case, a 45-year-old A few months later, the patient failed ingestion of foreign objects patient presented for crown lengthening to show up for a recall appointment. during dental procedures can on a tooth that had been temporarily The offi ce was able to reach his occur on occasion. After all, restored. During the procedure, the wife, who said that the patient had introducing dental instruments, provisional crown dislodged and the developed complications following Trestorative materials and other small patient swallowed it. The patient his last visit and was hospitalized dental components into the oral cavity did not exhibit any signs of distress twice due to respiratory failure. It while a patient is in a reclined position or compromise of his airway during was during the second hospitalization naturally creates an element of risk. While the incident, so the dentist did not that a foreign object, which turned preventive measures may reduce the believe an X-ray was needed. He out to be the temporary crown, was number of incidents, communication about advised the patient to call the offi ce removed from his lungs. A few months proper posttreatment care can prevent if he developed any symptoms. later, the patient fi led a lawsuit. them from developing into a critical event. The Dentist Insurance Company’s Risk Management Advice Line reports a case in which a 75-year-old patient presented to his periodontist’s offi ce for a routine cleaning. While the hygienist was scaling his teeth, a gold crown dislodged and disappeared. The hygienist informed the periodontist, who assessed the patient and determined that because the patient wasn’t coughing after the incident, he most likely swallowed empowered the crown. She reassured the patient and advised that she didn’t anticipate any untoward complications, but recommended that he obtain an X-ray in the event the crown did not pass within a few days. Three months later, the patient’s daughter informed the offi ce that her father had been transported to the The Dentists Insurance Company is innovating and growing. hospital due to shortness of breath, With a heritage of 38 years and counting, TDIC now delivers dentist- coughing and chest congestion. She said focused protection to more than 19,000 dentists in 10 states – and we’re a radiograph revealed the presence of the growing to protect even more. Our success is due in no small part to the crown in the lower lobe of one his lungs. collective strength of our company, the trust of our policyholders and focus She stated that her father underwent of our dentist-led volunteer board. Together, we’re stronger than ever. a bronchoscopy procedure to retrieve the crown. Unfortunately, the patient developed complications following the ® procedure and was intubated due to Protecting dentists. It’s all we do. acute respiratory failure. Six months 800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783 later, the offi ce received word of her intent to sue on behalf of her father.

DECEMBER 2018 779 DEC. 2018 RM MATTERS

CDA JOURNAL, VOL 46, Nº12

TDIC Senior Risk Management Analyst ■ Stop treatment and assess the “An incident may seem minor to Taiba Solaiman said although the outcomes situation, even if the incident a dentist, but proper follow-up care is of the above cases are pending, the appears insignifi cant. essential,” Solaiman said. “Any delay in the common denominator is that each of the ■ Stabilize the patient and calmly proper management and timely intervention providers failed to properly follow up with explain what happened. of such accidents may cause severe and their patients. Taking a proactive stance ■ Check the immediate area in an even life-threatening complications.” rather than a “wait-and-see” approach is attempt to locate the object. TDIC emphasizes the importance essential when it comes to patient injuries. ■ Refer the patient to their of communication and compassion “An incident can happen even if physician for follow up in handling patient injuries. Showing the dentist is very careful,” Solaiman and referral for X-rays. compassion is not admitting guilt. Failing said. “But often, it is how the incident is ■ Document the incident and to recognize how the patient is feeling or managed after the event that determines note any witnesses with their minimizing the situation can often lead to the severity and outcome of the case.” contact information. patients becoming more upset. Often what TDIC recommends dentists take ■ Follow up with the patient to a patient wants is for the dentist to simply the following actions to help mitigate check on their recovery. express concern and acknowledge the injury. risks associated with suspected foreign ■ Contact your insurance carrier “A calm, caring attitude and clear object aspiration or ingestion: to fi le an incident report. communication is key when handling these incidents,” Solaiman said. A patient may simply expect that the dentist will offer to cover their copay or other minor expenses as a gesture of good will. However, dentists should contact the Risk Management Advice Line prior to offering any payments or reimbursements. Analysts can also help dentists navigate patient demands. However, if the analyst believes the situation could develop into more than a small monetary payment, he or she may recommend the dentist speak with a claims representative. TDIC’s professional liability policy provides coverage up to $10,000 under the medical payments provision for medical expenses related to dental treatment. Despite the utmost care and precautionary measures, accidents during routine clinical procedures can happen. When they do, it is better for dentists to be armed with the right information and tools that will lead to the most desirable outcome for patient health. ■

TDIC’s Risk Management Advice Line is a benefi t of CDA membership. To schedule a confi dential consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 800.733.0633.

780 DECEMBER 2018 CARROLL “Matching the Right Dentist to the Right Practice” V &COMPANY

4261 CAPITOLA GP Retiring doctor offering an established practice in 4216 SIERRA NEVADA FOOTHILLS 23 year practice located in the heart professional office complex built around a garden setting. Beautiful and of the Sierra Nevada foothills in modern building close to downtown area. modern 1,465 square foot facility with 4 fully-equipped operatories. Average 1,024 square foot office with 4 fully- equipped ops., upgraded major gross $743K+ with 3 doctor days and 6 hygiene days per week. equipment and digital radiography. Average Gross Receipts $890K+ with Approximately 1,800 active patients. Asking $562K. 56% average overhead. Asking price for practice $604K. Seller is offering real estate for sale to the buyer of his practice. 4172 NAPA GP Amazing opportunity to own the practice of your dreams in one of the world’s premier wine destinations! Situated in a prime 4324 SF GP Seller offering 33 years of goodwill in busy financial district neighborhood close to many amenities. 1,200 square foot office with 4 fully- bldg. Gorgeous 890 sq. ft. office with 3 fully equipped ops (plumbed for 4). equipped and updated operatories. Over 1,000 active patients. Average Incredible panoramic views with amazing natural light pouring into each annual gross receipts over $700K. Asking price for practice $484K. Building window. 500+ active patients. 2 days of hygiene/wk. Current average GR available for purchase. approx. $410K with adj net of $115K. Asking $199K.

4316 SARATOGA GP Vibrant and active practice located in beautiful 4 op, 4331 SF GP Downtown SF practice in gorgeous, remodeled 1,300 office fully-equipped, facility at upscale residential, professional, and commercial with panoramic views. Suite includes 4 fully equipped ops, reception area, neighborhood. 10 new pts./month. 4 doctor days & 4 hygiene days per business office, private office, staff lounge, lab area, and sterilization area. week. $464 avg. Gross Receipts. Asking $357K. Beautiful, modern cabinetry and equipment. 1,600 active patients with 15-20 new patients/mo. Owner/doctor works 3 days/wk with 5 hygiene days/wk. 4233 SF GP Seller offering 26+ year general practice in SF Financial district. Average gross receipts $738K with average adj. net of $305K. Asking Ground floor office with high volume foot traffic. Approx. 1,200 sq. ft. facility $495K. with 4 fully-equipped ops. $930K+ avg. annual GR. Seller willing to help for a smooth transition. Asking $640K. 4340 WEST SONOMA COUNTY GP Charming and growing community practice with over 40 years goodwill in seller owned building. Busy corner 4210 UNION CITY GP Retiring GP offering 40+ years of goodwill. 5 ops in location adjacent to several retailers. Well appointed, 4 op office with several 1,100 sq. ft. 350 active patients, all fee-for-service. Asking $85K. Recent leasehold improvements and upgrades. Approximately 1,000 active patients. Average Gross Receipts $788K with consistent growth. 2018 on 4326 SANTA CLARA GP Practice with an emphasis on Restorative schedule for $822K with 65% overhead and 3.5 doctor days per week. dentistry with over 1,000 active patients located in sought-after Primarily Restorative dentistry with no implant placement. Average 4 days of ING neighborhood close to major routes,ND shopping centers and hospitals. hygiene per week. Owner willing to help for smooth transition. Asking $538K. Approximately 850 sq. ft. facilityPE with 3 fully-equipped ops. pljus a seasoned and loyal staff. Avg. Gross Receipts $617K. 4338 PENINSUNSULA PROSTHO Preeminent 45 year Prosthodontic practice located in peninsula neighborhood, now available. State-of-the-art 4225 EUREKA GP & BUILDING Established since 1981 in charming 1,242 square foot facility with 5 operatories. Seller willing to help in the Northern California port city. Retiring doctor is offering practice and building. transition. Outstanding referral sources. Average Gross Receipts $1.3M with Practice has approximately 1,200 active patients with new patients accepted 4 doctor-days per week. Asking $884K. on a selective basis. Average Gross Receipts of $765K+ with 61% average overhead. Beautiful 1,400 square foot office with four (4) fully-equipped 4336 SAN BRUNO GP Legacy practice centrally located in a combined operatories. Asking price for practice $468K. commercial & residential neighborhood, convenient to highways 101, 280, and 380 and close to the BART station. Elegant, remodeled 1,463 sq. ft. 4178 SONOMA COUNTY PERIO Seller retiring from 21 year practice with office with 5 fully-equipped ops. & digital radiography. 5 year average Gross trained, seasoned staff and great location. Exceptional 2,100 sq. ft. ample Receipts $922K+. 1,000 active patients with an average of 10 new patients office with 6 fully equipped ops. Majority of equipment purchased in 2002. 4 per month. Asking $661K. doctor-days&3hygienedaysperweek.Averagegrossreceipts $1M+. Asking $677K. 4343 SANTA CRUZ COUNTY GP Ample 3,000 sq.ft. faciltiy w/5 fully- equipped operatories,. Terrific opportunity to own the facility and well- 4198 PETALUMA DENTAL BUILDING Condominiumized dental office. established community practice with quality and seasoned staff. Average Approximately 1,600+ square feet with five (5) fully-equipped operatories set Gross Receipts $870K+. Asking $643K. up for right hand delivery. There is a reception area, business office, consult room, staff lounge, lab, sterilization area, private office and separate storage COMING SOON: Fairfield GP, Santa Cruz GP area. Asking $495K.

4344 SF GP Prime & convenient location in Laurel Heights neighborhood. 9 Carroll & Company year practice averageing $500K+ with approx. 50% overhead in fully- 2055 Woodside Road, Suite 160 equipped 2 op. modern faciltiy. Motivated seller relocating out-of area. Redwood City, CA 94061 BRE #00777682 4214 FREMONT GP Retiring Seller is offering an established practice in ample 2,000 s.f. facility that includes 9 operatories, 2 bathrooms, a reception Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll area, private office, staff lounge, lab area, sterilization area and storage area. Average Gross Reciepts $681K+ Asking $275K.

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

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Mandated Reporting CDA Practice Support

ach person licensed by the Dental Document fi ndings it require a specifi c medical indication Board of California is a “mandated Document fi ndings in the patient chart. of abuse or neglect. Any “reasonable reporter.” State law requires Assess patient safety suspicion” is suffi cient to make a report. a mandated reporter who has Is the patient in immediate danger? Report by telephone known or knowledge of or observes a child Review, refer, report suspected cases to the county department Eor dependent adult whom the mandated A mandated reporter who has a for child protective services or adult reporter knows or reasonably suspects has reasonable suspicion of a patient’s abuse protective services or to local law been the victim of abuse or neglect to or neglect must report his or her fi ndings. enforcement. A written report must be make a report to local law enforcement or “Reasonable suspicion” means that it is submitted as soon as practicably possible, a local social services agency. Each dental objectively reasonable for a person to but no later than 36 hours after making professional can meet his or her professional entertain a suspicion, based upon facts the initial verbal report. Neither HIPAA obligation by taking the following steps. that could cause a reasonable person in a nor state privacy laws prevent a dental Routinely screen for and recognize like position, drawing, when appropriate, professional from fulfi lling this obligation. signs and symptoms of abuse or neglect on his or her training and experience, All mandated reporters must sign Signs of physical abuse may include: to suspect abuse or neglect. “Reasonable a statement acknowledging their ■ Bruises, welts or other injuries suspicion” does not require certainty that responsibility as mandated reporters. that cannot be explained or abuse or neglect has occurred nor does The statement and a copy of Penal Code do not match with the patient’s explanation. ■ marks that cannot be explained. ■ Injury marks that have a pattern, like from a hand, belt or other objects. ■ Injuries that are at different stages of healing. Individuals who have been physically abused may: ■ Avoid any kind of touch or physical contact. ■ Be afraid to go home. ■ Seem to always be on high alert. ■ Wear clothing that doesn’t match the weather — such as long sleeves on hot days — to cover up bruises. Note that the pregnancy of a minor is not, on its own, a basis for a reasonable suspicion of sexual abuse. Ask direct, nonjudgmental questions with compassion ■ “Please tell me about ______(injury).” ■ “Have you been , kicked, punched or otherwise hurt by someone within the past year? If so, by whom?” ■ “Do you feel safe in your current relationship?” ■ “Does a partner from a previous relationship make you feel unsafe now?”

DECEMBER 2018 783 DEC. 2018 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 46, Nº12

sections 11165.7, 11166 and 11167 are to A mandated reporter who makes a copy of Penal Code sections 11165.7, be provided by employers. Employers are report in accordance with the law has 11166 and 11167. The state Department encouraged, but not required, to provide protection from liability. A mandated of Social Services has an online directory employees with training associated with reporter may seek reimbursement of county offi ces for adult protective the responsibility of being a mandated from the state crime victims fund services and a form for reporting abuse reporter. Whether or not employers for legal expenses under certain or neglect of a dependent adult or elder, provide employees with training, the lack circumstances. A mandated reporter cdss.ca.gov/Adult-Protective-Services. of training does not excuse a mandated who fails to make a report may be The agency also maintains an online reporter from his or her responsibility to prosecuted for a misdemeanor. directory of county agencies to which report. No supervisor or administrator may “California State Mandated to report child abuse or neglect, impede or inhibit an individual’s reporting Reporting” is a CDA Practice Support cdss.ca.gov/reporting/report-abuse/child- duties or subject the mandated reporter to resource that includes a form that protective-services/report-child-abuse. ■ any sanction for making the report. The employers can provide to licensed staff for RESOURCE law, however, allows for establishment of signed acknowledgement of the reporting Possible Signs of Child Abuse. WebMD. webmd.com/ internal procedures to facilitate reporting. obligation. The resource also includes a children/child-abuse-signs#1. Accessed Oct. 3, 2018.

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784 DECEMBER 2018 (;3(5,(1&(7+(',))(5(1&( t Lee Skarin and Associates has been serving the dental profession since 1959. t Kurt Skarin has over 30 years experience in dental practice sales. t We have sold more practices than any broker in the state within the last 12 months. t Our experienced practice appraisals are backed with credentials unequaled among dental practice brokers. t We provide in-house legal counsel to advise you in all aspects of the sale and purchase, including the tax consequences of the sale. t Excellent financing is available, in most cases for 100% of the purchase price. t With a reputation for experienced, conscientious, and ethical performance, we give our clients personal attention in all aspects of the purchase.

/((6.$5,1 $662&,$7(6,1&

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Experience the difference. Call Lee Skarin and Associates  for responses to all of your questions - No obligation!  Visit our website for current listings: www.LeeSkarinandAssociates.com Dental Practice Brokers CA DRE #00863149 800.752.7461 Tech Trends CDA JOURNAL, VOL 46, Nº12

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

TrackR bravo ($29.99 per unit or $89.99 for fi ve pack, TrackR) Spend (Free, Microsoft) Working at multiple practice locations is a reality for many in the Tracking expenses on the go can be a colossal task for business dental profession. When transporting personal eff ects, items inevitably professionals and consumers alike. The usual process involves saving get misplaced. Surely I cannot be the only person who has made that receipts from purchases throughout the day, collecting them at home call from offi ce to offi ce asking the staff if they have seen my loupes. or in the offi ce and categorizing them later to create an expense Tracking these “tools of the trade”— whether endodontic equipment, report for reimbursement or tracking fi nances. Spend for iOS, a new digital cameras with macro lenses and ring fl ashes or a backpack Microsoft Garage app, aims to automate this entire process to save with a laptop — is a prudent idea for the traveling practitioner, if time and help people simplify their expense management. only for peace of mind. Enter the TrackR bravo, a small, lightweight, Spend requires users to sign up for a free account with their email Bluetooth-based tracking device that integrates with . This address or use an existing MileIQ account. Additionally, users must review is based on the iOS version of the TrackR app on an iPhone X. link at least one bank or credit card account to take advantage of Founded in 2009, the Santa Barbara-based TrackR company the features of the app. After the initial setup process is complete, produces the TrackR bravo, a device coupled with the TrackR mobile recent transactions from linked bank or credit card accounts will app for iOS and Android. Weighing in at 7 grams and having the appear on the screen. Users can fi rst organize their individual diameter of about a quarter, the battery-powered TrackR bravo purchases by grouping them into expense categories and assigning works by reporting its location (and emitting a high-pitched sound if tags through drop-down menus and custom fi elds, respectively. requested) to the TrackR app when prompted by the user. The TrackR Next, users can tap the camera icon on individual transactions app is easy to set up, but contains a handful of nonintuitive, frustrating to attach pictures of their receipts. Lastly, users can then swipe navigation quirks. Under frequent use (location is asked for once a individual transactions to the left for personal purchases and to day), the nonrechargeable battery lasts about three months. the right for business expenses. Users also have the ability to add descriptions and split purchases for each transaction. A custom As one would imagine with Bluetooth, range is limited: The device report spreadsheet or PDF can be generated and sent to the specifi cations indicated a 100-foot range, but when tested in a account email address by tapping on the report icon at the upper building behind multiple closed doors, the range approximately right of the screen. The reports are formatted to be easily read by halved. Fortunately, when a TrackR bravo moves out of the range major accounting and expense management software. The app has of the mobile device it is reporting to, the last known location is a simple with intuitive gestures that make it extremely automatically recorded and saved in the TrackR app. To further powerful and easy to use for anyone needing to track expenses on address this lack of range, TrackR users can voluntarily participate the go. in the “Crowd Locate” program, wherein any TrackR user who walks within the range of a TrackR bravo device reports the location to an Spend simplifi es daily expense tracking for anyone who struggles anonymized cloud network. The logic is that TrackR users will be able with organizing receipts and purchases. The ability to track to help each other locate their lost TrackR bravos; however, there expenses easily on a mobile device makes this a wonderful appears to be limited TrackR users even in highly populated areas, companion tool for business professionals and consumers. reducing the usefulness of this functionality. Its limited range, lack — Hubert Chan, DDS of users in the “Crowd Locate” function and battery life prevent the TrackR bravo from being an anti-theft device as those with malicious intent can easily and unwittingly defeat the system. For the traveling practitioner, however, the TrackR bravo is a low-cost, subscription-free, minimal-eff ort solution to fi nding misplaced items. — Alexander Lee, DMD

786 DECEMBER 2018 Specialists in the Sale and Appraisal of Dental Practices Serving California Dentists since 1966 Practices How much is your practice worth? Wanted PPS extends Our Wishes WR

NORTHERNNORT RN CALIFORNIACALIFORNIA SOUTHERN CALIFORNIA CALIF (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6155 LAKEPORTEPORT PPS knows practice well as we sold it to current Owner ALTA LOMA Great exposure. Grossing $700,000. Five opsZLWK in 1984. 5-days of Hygiene. Revenues of $800,000. Great location and nicely 3-equipped. equipped. BAKERSFIELD Will do $1 Million. $650includes EXLOGLQJ 0$5,1&2817<Sterling opportunity$QGKDUGWREHOLHYHEXWWKHUH BAKERSFIELD AREA Grossing $1.20LOOLRQOwner works 16- LVno competition. 1,400 different patients seen last 2-years. Strong Hygiene hRXUVSHUZHHNNets$300 Department. Well-liked DDS is limiting New Patients due to ZDQWLQJWRFRQWURO BAKERSFIELD AREA Grossing $40/mRQth on 2-days. 5-ops. schedule. Collects near $500,000. Can do more. ll insulated KLV 7KLVLVDZH  BELLFLOWER Part-time doing $100. Buyer should do opportunity. $350,000+. FXOO3ULFH$65 6152 SAN RAFAEL Across WKHstreet from Marin Academy. Collected COLTON Latino. Absentee. Grosses $350 . 5-ops. $520,000 in 2017. What makes this an extraordinary opportunity is stand-alone   building is also “For Sale” Nearby practitioner who desires their own building CORONA Near Capistrano Beach exit. Free standing building.Part- should vertically integrate their practice into this building and have DQinstant time grossing $200,000. FXOO3ULFH150,000. $1+ Million practice in Dgreat location.1RZ\RXRZQWZRDVVHWV DEL MAR -- ENCINITAS HMO grossing near $400. 4-ops. 02'(672 Located on WKHnorth end of Coffee Road where new DIAMOND BAR High identity Asian strip center. 5-ops. +XQGUHGV development is occurring. Attractive 3-op office. 2018 tracking $445,000 in RISHGHVWULDQVZDONE\IURQWGRRUHYHU\GD\Will do $1Million.&KHFN collections on part-time basis. Did $700,000+ in 2016 when Owner was full WKLVRXWDQGVHHIRU\RXUVHOI time with $240,000 in Profits. ENDODONTIST Join PerioGRQWLVWin Santa Clarita Only $35,000 6150 HAYWARD Strong Dental DNA. Well-designed 5-op office. Digital 2UGPwho wants a good reliable job. radiography & computers. 2018 trending $850,000+. 5-days of hygiene. Full GLENDALE / BURBANK Grosses $840. Includes apDUWPHQW. Price $200,000. INLAND EMPIRE DentiCal grossLQJnear $300. FP $150. 6149 NOVATO Stand-alone building at busy stop light intersection off INLAND EMPIRE Union Practice can do $1+ Million. 5-ops. Highway 101. All new MXVW2-years ago. 4-ops, digital, paperless, Pano with INLAND EMPIRE On 215 Exit. Two practices one mile apart. Ceph at cost of $180,000. At doorway to Hamilton neighborhood with 100s Merge and do $1 Million first year7DNHWR$1.5QG\HDU7 ops. ofKomes. No competition. Perfect for nearby 1RYDWRDDS who wants to own INLAND EMPIRE Includes EXLOGLQJ7+ ops, Adec equippedDQGKDV WKHLUbuilding DQGUHORFDWHWKHLUSUDFWLFHor Group seeking perfect location. cone beam. Gross $1.3 Full Price $2.5 6FRWW0F'RQDOGIURP'RFWRUDemographicVVWDWHV³:HOO,KDYHWRVD\WKDW  0LOOLRQ 0LOOLRQ \RXZHUHULJKW5D\7KLVLVDQLQWHUHVWLQJDQGYLDEOHORFDWLRQ´ 6FRWW VUeport IRVINE Female Grossing $1.2 Million. 5-ops. LVDYDLODEOHXSRQUHTXHVW LA MIRADA Like new 5-ops, 3-equipped. Grossing $450 6148 SAN LEANDRO Great location on Hesperian Boulevard. Absentee NORTH LONG BEACH Hi Identity. 50% Latino. Part-time. $VNLQJ owned. Shall collect $460,000 in 2018. Has done $670,000 in past with 2wner Rnly$85. here. Seller’s daughter shall provide transition assistance. NORTH PASADENA Million 'ROODUpractice. 5-opVLQfree-standing 6147 SAN FRANCISCO BAY AREA - “OUT-OF-NETWORK” buildingacross from Starbucks. 2018 tracking $2.15 Million. Hygiene produces $1+ Million. $600,000+ in OC BEACH 6-ops, Dentrix, digital, computerized. FP $150 profits. 9HU\XQLTXHLQVRPDQ\ZD\VSeller available for long transition. OC BEACH Absentee owned, grossing $550. 4-ops. New Doc $8%851 Highly regarded family community. 6-days of hygiene ZKRGHYRWHVIXOODWWHQWLRQVKRXOGGR$1 Million. evidences strong foundation. 2017 collected $880,000. 2018 projecting OC BEACH Grossed $100last month. )XOO3ULFH$900,000. $950,000. OC’S FASHION ISLAND Grossing $650. Rare opportunity. 6144 SACRAMENTO’S ELK GROVE 14-days of Hygiene. 2017 collected ORANGE COUNTY- INLAND-EMPIRE Two practices Grossing $1.85 Million. Strong staff. 7-ops. Great locationDFURVVIURP$SSOH $1.80LOOLRQRight Buyer does $30LOOLRQ. Gorgeous facilities. 'LVWULEXWLRQ&HQWHUCondo optional purchase. PEDO Chinese & Latino. Grosses $450,000. F $285,000. 6143 BERKELEY’S ALTA BATES VILLAGE Perfect for nearby Premier XOO3ULFH  Dentist to relocate their practice into stand-alone building on Webster Street. REDLANDS Once did $1 MillionOlder DDS QRZwants to retire. 3-day week collected $550,000 in 2017. 4-days of Hygiene. Lotsof potential. 6-ops. 6142 OAKLAND’S PIEDMONT - “OUT-OF-NETWORK” RIALTO Empty 9-op office in 10,000 sq.ft. building near 210. Did 3-ops, paperless and digital 3anR. Does mid $600,000 with YHU\strong Profits. $1+ MillionLQWKHSDVW Successor should be proficient in Ortho or willing to learn. Seller available for RIVERSIDE Female grossing $250K. 30-new pts/mth. FP $165,000. ORQJtransition. THOUSAND OAKS / AGOURA HILLS 5-ops, part-time grossing 6141 NAPA VALLEY’S ST. HELENA 3-day per week PPO practice. approximately $500,000. 3-days Hygiene. 2017 Collected $359,000. Attractive 3-op office. 15QHZ TORRANCE Entrance to PDlRs Verdes. Grossing $300,00SHU SDWLHQWVSHUPRQWKFull Price $100,000. \HDU FullPrice $290,000. 6139 S$1F5$1&,6&2BAY AREA PROS PRACTICE - “OUT-OF- UPLAND Grossing $135,000 part-time. 3-ops. Full 3rice $65,000. NETWORK”2017 billed $1.2 Million, collected $1.19 Million. 4-days of WEST COVINA Grossing $650,000. 2 days Kygiene. Refers lots of Hygiene. Owner available for ORQJtransitionLIGHVLUHG&RQGRLVDQRSWLRQDO work! SXUFKDVH 2018 Index CDA JOURNAL, VOL 46, Nº12

February 2018 Silver Diamine Fluoride in Elder Care The Warm Springs Model Radiographic Changes After Silver Fluoride Treatment Index to 2018 Articles JournaCALIFORNIA DENTAL ASSOCIATION Journal of the California Dental Association Vol. 46, Nos. 1–12

PART II SILVER DIAMINE FLUORIDE ~ THE NEW OLD Author Index Cherissa Chong, primary Paul Reggiardo, DDS, and Gregory J. Sabino, DDS, PhD Tissue Engineering for Improving Paul V. Abbott Periodontal Phenotype Can We Regrow Pulps? Vol. 46, No. 10:653 Vol. 46, No. 4:249 Anne-Maree Cole Imran Ahmed, primary Understanding Normal Sleep, Respiration Child Misbehavior in the Dental Setting and Circulation Is Generally Assumed To Be Fear Vol. 46, No. 8:513 Vol. 46, No. 7:423 Yasmi O. Crystal, primary Debra S. Finney, primary Leif K. Bakland Use of Silver Diamine Fluoride for Dental Gingival Recession: What Is It All About? Evolving Aspects of Endodontic Treatment Caries Management in Children and Vol. 46, No. 10:617 Vol. 46, No. 4:221 Adolescents, Including Those With Special David T. Ford Tina M. Beck Health Care Needs Vol. 46, No. 1:45 Making eHealth Relevant to the Practice of The Pinhole Surgical Technique: A Clinical Dentistry: A Proposed Strategy Perspective and Treatment Considerations Erin Doughtery, primary Vol. 46, No. 5:293 From a Periodontist Factors Associated With Hispanic Children’s Vol. 46, No. 10:647 Dental Utilization in Imperial County: Jane Gillette Caries Arresting Approaches for Aging and James L. Borke, primary CA-CORD Project Vol. 46, No. 7:429 Medically Complex Patients Medication-Related : Vol. 46, No. 2:93 Update and Future Possibilities Emily Ehsan, primary Vol. 46, No. 5:301 Coronectomy of Mandibular Third Molars: Anupama Grandhi Our Experience With 250 Consecutive Patients Pathophysiology of Oral Cancer: An Overview Kerry K. Carney Vol. 46, No. 8:507 The Editor: Why We Change: Kirk vs. Spock Vol. 46, No. 12:767 Vol. 46, No. 1:5 Joel B. Epstein, primary Elissa Green, primary The Editor: Tooth Fairy Science Recognition of Non-Hodgkin Lymphoma Autogenous Soft Tissue Grafting for the Vol. 46, No. 3:141 of the Maxilla Treatment of Gingival Recession The Editor: The TDSC Marketplace and You Vol. 46, No. 12:773 Vol. 46, No. 10:625 Vol. 46, No. 4:209 James W.C. Fedusenko, primary Colleen Greene The Editor: Walter Clement Noel: Patient Zero Quality Improvement in Practice Leading How To Educate Millennials: Commentary Vol. 46, No. 6:345 to Remineralization Vol. 46, No. 6:359 The Editor: End First Exposure: Dentistry’s Vol. 46, No. 4:185 Markus Haapasalo Biggest Opportunity in the Opioid Crisis Can We Eliminate Microorganisms From Vol. 46, No. 7:405 the Root Canal System? The Editor: I’ll Drink to That Vol. 46, No. 4:227 Vol. 46, No. 8:473

The Editor: Nothing but the Tooth January 2018 Jeremy A. Horst, primary Silver Diamine Fluoride Vol. 46, No. 10:605 History and Use Radiographic Changes Following Treatment of Chronic Disease Management of Caries in Children Managing Caries With Silver Dental Caries With Silver Fluoride David W. Chambers JournaCALIFORNIA DENTAL ASSOCIATION Nitrate: Lessons Learned Vol. 46, No. 2:105 How Dentists Learn by Combining Evidence and Experience Josih T. Hostetler, primary Vol. 46, No. 5:315 Financial Considerations for Sustainability in Siddardha G. Chandrupatla, primary School-Based Oral Health Centers Vol. 46, No. 3:153 Denture Group Visits: A Model To Improve Access to Care and Reduce Treatment Period Peter L. Jacobsen for The Core Elements of Antibiotic Stewardship Vol. 46, No. 11:707 in Dentistry PART I SILVER DIAMINE Vol. 46, No. 12:757 FLUORIDE ~ Christina Chi, primary THE NEW OLD Paul Reggiardo, DDS, Color Monitoring: Comparison Between and Gregory J. Sabino, DDS, PhD Snehal Sanjay Jaiswal, primary Visual and Instrumental Methods With Prosthodontic Treatment in Parkinson’s Do-It-Yourself Whitening Disease Patients: Literature Review Vol. 46, No. 11:715 Vol. 46, No. 11:691

788 DECEMBER 2018 CDA JOURNAL, VOL 46, Nº12

April 2018 Bacteria and the Root Canal System Cone Beam CT and Endodontic Treatment Prospects of Regrowing Pulps JournaCALIFORNIA DENTAL ASSOCIATION

Daniel N. Jenkins Ruchi K. Sahota Craniofacial Physiology in Dentistry EVOLVING The Associate Editor: One-Stop Shopping Vol. 46, No. 8:485 ASPECTS OF Equals Savings and Support Michael J. Kanellis, primary ENDODONTIC Vol. 46, No. 2:73

LEIF K. BAKLAND, DDS The Associate Editor: Dentistry DIY: A Fading Fad? Managing Caries in the Primary Dentition TREATMENT Vol. 46, No. 9:537 With Silver Nitrate: Lessons Learned From a Clinical Trial Gabriela Saledo, primary Vol. 46, No. 1:37 Effects of an Educational and Outreach Haejin Kang, primary Intervention on Community Oral Health Workers Vol. 46, No. 7:413 Survey of Dental Students and Recent Graduates’ Knowledge, Attitudes and Practices Eric S. Salmon in Regard to Treating Patients With Special Statistics for Practicing Dentists Health Care Needs Vol. 46, No. 9:577 Vol. 46, No. 7:447 Elise Sarvas Steve Kirk Joan Otomo-Corgel, primary The History and Use of Silver Diamine Fluoride Searching for Research Articles on the Internet Acellular Dermal Matrix Allografts in in Dentistry: A Review Vol. 46, No. 9:555 Periodontal Therapy Vol. 46, No. 1:19 Vol. 46, No. 10:639 Kyle Luis Larsen Scott E. Schames, primary Health Care in the Middle of Nowhere: Arwa I. Owais, primary Periodontal Disease Contributes to Obstructive Millennials Who Practice in Small Towns: Silver Diamine Fluoride Chemical Mechanisms of Sleep Apnea Commentary Action as a Caries Arresting and Preventing Agent Vol. 46, No. 11:701 Vol. 46, No. 2:113 Vol. 46, No. 6:375 Terrence Shaneyfelt Kayhan L. Mashouf, primary T. Jaime Parado, primary How To Critically Appraise the Dental Literature Mixed-Dentition Orthodontic Treatment: A Four-Year Study on Risk-Based Vol. 46, No. 9:569 Recare Interval and New Cavitations in Outcomes and Timing Brian K. Shue Vol. 46, No. 5:307 Nontraditional Dental Clinics The Associate Editor: Run, Hide, Fight Vol. 46, No. 3:177 Eric Mediavilla, primary Vol. 46, No. 5:285 The Four Millennials You Meet in Dental Christian Piers The Associate Editor: Dentistry in 2100 School: Commentary Millennials in Dentistry: A Journey Toward Vol. 46, No. 11:681 Understanding Vol. 46, No. 6:369 Jane D. Siegel, primary Vol. 46, No. 6:355 Richard J. Nagy Antibiotic Prescribing and Stewardship in To Graft or Not To Graft? An Update on Francisco Ramos-Gomez Dentistry: A Public Health Perspective Gingival Grafting Diagnosis and Treatment Dental Student Research: Pediatric Oral Health Vol. 46, No. 12:755 and Vulnerable Populations Modalities Tory Silvestrin, primary Vol. 46, No. 10:615 Vol. 46, No. 7:413 Implant Dentistry and Endodontics: Can There Man Wai Ng, primary Paul Reggiardo, primary Be a Mutually Beneficial Relationship? Chronic Disease Management of Caries in Silver Diamine Fluoride — The New Old: Part I Vol. 46, No. 4:260 Children and the Role of Silver Diamine Fluoride Vol. 46, No. 1:15 Vol. 46, No. 1:23 Silver Diamine Fluoride — That Old Black Magic CONTINUES ON 792 Has Me in Its Spell

March 2018 Vol. 46, No. 2:83 May 2018 Financial Considerations Medication-Related for Sustainability Osteonecrosis Absence Rates and Dental Pain Lawrence D. Robertson Mixed-Dentition Orthodontics Barriers to Oral Health Care Clinical Judgement JournaCALIFORNIA DENTAL ASSOCIATION The Warm Springs Model: A Successful Strategy JournaCALIFORNIA DENTAL ASSOCIATION for Children at Very High Risk for Dental Caries Vol. 46, No. 2:97

MAKING eHEALTH RELEVANT TO THE PRACTICE OF DENTISTRY: Robert S. Roda A PROPOSED STRATEGY Can Use of Cone Beam Computed Tomography Have an Effect on Endodontic Treatment?

ADVANCING ORAL HEALTH EQUITY WITH Vol. 46, No. 4:237 INNOVATIVE DENTAL APPROACHES Stephen Rogers Dentists’ Almanac: Commentary

Marisa K. Watanabe DDS, MS Vol. 46, No. 6:363 Gary D. Sabbadini Silver Diamine Fluoride: A Clinical Perspective N Vol 46 o From a Pediatric Dentist 5 Vol. 46, No. 2:87

DECEMBERDECEMBER 20120188 789

Largest BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED CENTRAL VALLEY CONTINUED

AC-782 SAN FRANCISCO: Well maintained, mul-level DC-812 REDWOOD CITY Facility: Reasonable rent EG-788 ROSEVILLE: IN-764 STOCKTON: Broker in Professional Medical Complex. 1450 sf w/ 5 ops and great landlord! 740 sf w/ 3 fully equipped ops . $225k/ Real Estate Available Only: $180k! $195k $65k EG-849 AUBURN: IN-917 MERCED AREA: AC-886 SAN FRANCISCO (Facility): Unsurpassed DC-916 DUBLIN: Rare Opportunity to own pracce $350k $325k Northern visibility & locaon! Potenal here is limitless! 850 sf and real estate. 1220 sf w/ 4 ops & PRICED TO EG-887 FOLSOM Facility: JC-811 FRESNO COUNTY: w/ 3 ops $85k SELL! Priced for quick Sale! $50k $350k AC-893 SAN FRANCISCO (Facility): Amazing Move In DG-854 SUNNYVALE: Do your best denstry here. EG-910 MIDTOWN SACRAMENTO: JC-823 LOS BANOS: California Ready Facility in Union Square. 1000 sf w/ 3 ops Educated, diverse, family & business friendly! 782 sf $248k $80k

$30k w/ 3 ops $875k EN-831 SACRAMENTO JG-807 FRESNO: AG-852 SAN FRANCISCO: PRIME LOCATION! 600 sf DG-862 MID-PENINSULA: Rare gem with up to 7 Now Only: $650k Seller Movated $99k w/ 2 fully equipped, computerized ops. Reduced operatories in the Bay Area!! 2274 sf w/ 6ops + 1 EN-836 CITRUS HEIGHTS: Over $34.5M Price: $325k add’l. $475k $188k SOUTHERN CALIFORNIA AG-871 SAN FRANCISCO: The LOCATION of this DG-868 SUNNYVALE: Hesitate and you might lose out EN-858 ORANGEVALE: office is the envy of all! 600 sf w/ 2 ops $88k on the pracce of your dreams! 1350 sf w/ 5 ops. Priced to Sell Only $70k! KG-779 SAN CLEMENTE Ortho: in 2017 sales AG-880 SAN FRANCISCO: Seller rering aer 39 $725k EN-885 ROSEVILLE Facility: $325k/ Real Estate years! Remodeled in 2010. ~ 700 sf w/ 2 ops $350k DN-771 SOQUEL Facility: Sink down roots, raise a $85k Available!

AG-895 SAN FRANCISCO: Stellar reputaon and family & build an empire! 1100 sf w/2 ops + 1 EN-899 DIXON: KL-909 SAN DIEGO: delivers the highest quality of denstry! 1500 sf w/ 4 add’l. $38,500 $195k $1.05M Extensive Buyer ops $675k DG-785 SANTA CRUZ: Great price and cash flow for FC-650 FORT BRAGG: $350k KG-921 SANTA MARIA: AG-896 SAN FRANCISCO: Don’t less this opportunity only 3 days a week!! 1000 sf w/ 4 ops. Seller Mo- for the Pracce & $400k for the Real Estate Seller Movated $315k & pass you by! ~ 1300 sf w/ 2 ops $600k vated: $165k FG-841 ARCATA: AG-900 SAN FRANCISCO: State-of-the-art equip- DG-842 FREMONT: Imagine being able to live, $275k/Real Estate Also available SPECIALTY PRACTICES Unsurpassed ment/Primed for success. 2000 sf w/ 5 ops $695k pracce and play here! 3200 sf w/ 10 ops $395k FN-855 NO. HUMBOLDT: BC-741 DANVILLE (FACILITY): Move in Ready! Build DG-854 SUNNYVALE: This pracce is set to have its $275k BC-784 CENTRAL CONTRA COSTA CO Perio: Exposure allows the practice of your dreams! ~ 1600 sf w/ 3 ops best year ever! 790 sf w/ 3ops. Steal at $575k GN-799 PARADISE: $395k $150k DG-857 SAN JOSE: Do the math - this associate- Pracce $375k, Real Estate $325k BG-843 WALNUT CREEK Perio us to offer you BC-789 OAKLAND (Facility): Perfect for Pedo or driven pracce with profitability consistently! GN-904 CHICO AREA: Reduced Price: $595k Ortho. 2800 sf w/ 6 fully equipped ops. Plumbed 1709 sf w/5 ops $595k $310k DC-835 TRI-VALLEY Perio:

for 2 add’l $135k DG-892 SAN JOSE: Excellent locaon & stellar HG-815 SIERRA CO:

BN-891 PINOLE: This one won’t last! Build your den- reputaon in one-of-a-kind seng! 1500 sf w/ 3 Reduced Price: $165k/ Real Estate $437k $800k tal empire in this bedroom community! 1300 sf ops + 2 add’l. $295k HG-827 SO. LAKE TAHOE: DG-912 SUNNYVALE Ortho: w/3 ops. $425k DN-898 SAN JOSE: Built-out 2015 w/ locaon, visi- $310k $925k Better CC-798 PETALUMA: Partially equipped dental office bility, convenience in mind! 2,204 sf w/4ops + 2 HG-851 SO LAKE TAHOE: DN-908 SAN JOSE Pedo: for lease. Only $2500/mo for 1400 sf! Call for De- add’l. $500k $425k $275k tails! DN-907 PLEASANTON Facility: One of the “50 Best HN-618 SIERRA FOOTHILLS: EG-903 CARMICHAEL Oral Surgery: Candidate C C- 80 2 SA N TA ROSA: Retail shopping center w/ 1200 Cies to Live 2014” by Money Mag. 1,170 sf w/ $65k $450k sf and 4 fully equipped ops $220k or $260k w/CT 4ops. $95k HN-740 SHASTA CO: EN-821 DAVIS Perio: Scanner DN-914 SANTA CLARA: This beauful and compact $475k/ $385k CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 office produces a lot of denstry! 950sf w/ 3 ops. Real Estate $350k EN-822 SACRAMENTO Perio: ops 640 sf Collections $433k in 2017 $295k $210k HN-773 SUTTER CREEK: $790k Better CG-616 NAPA: State-of-the-Art practice and on track NORTHERN CALIFORNIA ! $175k JG-757 VISALIA Perio: to do $100k more in 2018. Seller is ready for retire- HN-879 SONORA: Steal at $350k ment! $425k EC-729 GREATER SACRAMENTO AREA: Seller rer- $275k CG-859 SONOMA: Priced below market value at only ing! FFS Pracce and Real Estate Available! Fit $395k! 2000 sf w/ 4 ops highly esteemed FFS Prac- EN-664 SACRAMENTO Facility: Great corner loca- CENTRAL VALLEY tice $395k on, excellent visibility & easy access! 2300 sf w/ 4 CN-878 VALLEJO: Highly desirable thriving communi- ops. $30k IG-832 OAKHURST: $235k/ ty! 2 story prof bldg. 2000 sf w/4 ops $315k EN-791 SO. SACRAMENTO CO: Highly esteemed Real Estate 375k CN-911 SANTA ROSA: “Quality Care & Paent well- pracce. Adoring & appreciave paents. 1950 sf IG-881 TURLOCK: Better being FIRST”. 2250 sf w/4 ops + 1add’l. $545k w/ 5 ops. $495k $360k

Price 800.641.4179 [email protected] “ASK THE BROKER” WWW.WESTERNPRACTICESALES.COM

Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD Largest BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED CENTRAL VALLEY CONTINUED

AC-782 SAN FRANCISCO: DC-812 REDWOOD CITY Facility: EG-788 ROSEVILLE: Do not pass up on this remarkable opportunity! 2700 IN-764 STOCKTON: Well-established, fully computerized, paperless, digital- Broker in sf w/ 6 ops.. $225k/ Real Estate Available ized. 5,000 sf w/10 ops. Only: $180k! $195k $65k EG-849 AUBURN: Imagine living in a peaceful, rural town w/ “big city” IN-917 MERCED AREA: Well established pracce with a stable, loyal pa- AC-886 SAN FRANCISCO (Facility): DC-916 DUBLIN: amenies nearby. 1400 sf w/ 4 ops $350k ent base! 1300 sf w/ 3 Ops. $325k Northern EG-887 FOLSOM Facility: Build the pracce of your dreams here! 1200 sf JC-811 FRESNO COUNTY: Amazing Opportunity! Considerable Goodwill in $85k w/ 2 ops Priced for quick Sale! $50k Community! 3,000 sf w/ 6 ops $350k AC-893 SAN FRANCISCO (Facility): DG-854 SUNNYVALE EG-910 MIDTOWN SACRAMENTO: Unlimited Potenal. Well-established JC-823 LOS BANOS: Heavy emphasis on hygiene. Growth potenal by increas- California ~ 1107 sf w/ 2 ops + 1 add’l. $248k ing DDS days. 1000 sf w/ 3 ops $80k

$30k $875k EN-831 SACRAMENTO: Wonderful locaon – Call for details! ~1600 sf w/4 JG-807 FRESNO: Reasonable Overhead, Stellar Reputaon, Excellent Loca- AG-852 SAN FRANCISCO: DG-862 MID-PENINSULA: ops. Now Only: $650k on! 1000 sf w/3 ops Seller Movated $99k Reduced EN-836 CITRUS HEIGHTS: Well-established, quality pracce. 30+ years of Over $34.5M Price: $325k $475k goodwill. 1300 sf w/3 ops + 2 add’l. $188k SOUTHERN CALIFORNIA AG-871 SAN FRANCISCO: DG-868 SUNNYVALE: EN-858 ORANGEVALE: Perfect for a 2nd locaon or satellite situaon! 850 $88k sf w/ 3 ops. Priced to Sell Only $70k! KG-779 SAN CLEMENTE Ortho: Huge growth potential by expanding in 2017 sales AG-880 SAN FRANCISCO: $725k EN-885 ROSEVILLE Facility: Ideal locaon, great visibility, and close to just relaxed work week! 2896 sf w/ 6 open bay chairs $325k/ Real Estate $350k DN-771 SOQUEL Facility: about anything! 1000 sf w/3 ops. $85k Available!

AG-895 SAN FRANCISCO: EN-899 DIXON: State-of–the-art office, with all the “bells and whistles”! This KL-909 SAN DIEGO: Remarkable Opportunity. Long established in vi- $38,500 fantasc pracce has 3 ops. $195k brant North Park. 2400 sf w/ 5 ops & 2 Pedo chairs $1.05M Extensive Buyer $675k DG-785 SANTA CRUZ: FC-650 FORT BRAGG: Family-oriented pracce. 5 ops in 2000 sf $350k KG-921 SANTA MARIA: Live and pracce in this desirable collegiate coastal AG-896 SAN FRANCISCO: Seller Mo- for the Pracce & $400k for the Real Estate community! 930 sf w/ 3 ops Seller Movated $315k Database & $600k vated: $165k FG-841 ARCATA: Live In & own a little slice of heaven in this Collegiate AG-900 SAN FRANCISCO: DG-842 FREMONT: Coastal Town! 1114 sf w/3 ops $275k/Real Estate Also available SPECIALTY PRACTICES Unsurpassed $695k $395k FN-855 NO. HUMBOLDT: Seller relocang! Long-established, 100% FFS BC-741 DANVILLE (FACILITY): DG-854 SUNNYVALE: pracce! 1600 sf w/ 3ops + 1 add’l. $275k BC-784 CENTRAL CONTRA COSTA CO Perio: Seasoned Staff. Office runs like Exposure allows Steal at $575k GN-799 PARADISE: Remarkable opportunity – Call for Details! 1800 sf w/ 4 well-oiled machine! 3 ops $395k $150k DG-857 SAN JOSE: ops. Pracce $375k, Real Estate $325k BG-843 WALNUT CREEK Perio: Collecons over $1M! Great gross and profit us to offer you BC-789 OAKLAND (Facility): GN-904 CHICO AREA: Family-friendly, community-oriented, mul- for only 2 ½ days per week! 1085 sf w/ 4 ops Reduced Price: $595k $595k generaonal paent base. 880 sf w/ 3 ops. $310k DC-835 TRI-VALLEY Perio: Professional office bldg in highly desirable loca-

$135k DG-892 SAN JOSE: HG-815 SIERRA CO: Perfect location for outdoor enthusiast! 1000 sf w/ 3 ops tion. Owner available to work back to assist w/ transition. Collections

BN-891 PINOLE: This one won’t last! Reduced Price: $165k/ Real Estate $437k over $1.2M. 2,100 sf $800k $295k HG-827 SO. LAKE TAHOE: Ski, live, play and pracce here where your DG-912 SUNNYVALE Ortho: Premier ORTHO practice opportunity in the $425k DN-898 SAN JOSE: lifestyle can’t be ! 1200 sf w/4 ops. $310k Silicon Valley today! ~2030 sf w/ 5 chairs in open bay $925k Better CC-798 PETALUMA: HG-851 SO LAKE TAHOE: Projected Revenue on track to do $700k this year! DN-908 SAN JOSE Pedo: Amazing Location! Providing affordable pediatric $500k 2100 sf w/ 5 ops $425k denstry to families! 3600 sf w/ 4ops + 3 add’l. $275k DN-907 PLEASANTON Facility: HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by EG-903 CARMICHAEL Oral Surgery: Gross receipts $1.1M+ in 2017! Stable Candidate CC-802 SANTA ROSA: increasing office hours! 750 sf w/ 2 ops $65k paent base won’t be affected by transion! 2282 sf w/ 5 ops $450k $220k or $260k w/CT $95k HN-740 SHASTA CO: Beauful mountain community, well-established EN-821 DAVIS Perio: Live, pracce & play here! It’ll be the BEST deci- Scanner DN-914 SANTA CLARA: pracce, exceponal long-term staff. 2400 sf w/5 ops + 1 add’l. $475k/ sion you’ll ever make! 1700 sf w/4 ops + 1 add’l. $385k CC-846 SAN RAFAEL: Real Estate $350k EN-822 SACRAMENTO Perio: This pracce is known throughout Sacra- $295k $210k HN-773 SUTTER CREEK: Very qualified & credenaled Seller willing to show mento for its stellar reputaon! 2200 sf w/ 5 ops + 1add’l. $790k Better CG-616 NAPA: NORTHERN CALIFORNIA you how! 1536 sf w/4 ops + 1 add’l!! $175k JG-757 VISALIA Perio: 9 Hygiene days per week. On track to do almost Seller is ready for retire- HN-879 SONORA: Live and pracce in the capvang beauty of this family- 800k this year! ~ 2,000 sf w/ 5 ops Steal at $350k ment! $425k EC-729 GREATER SACRAMENTO AREA: oriented, scenic town. 2950 sf w/ 3 ops $275k CG-859 SONOMA: Fit EN-664 SACRAMENTO Facility: CENTRAL VALLEY We are a proud member of: * Western Practice Sales is a member of American Dental Sales (ADS Transitions), $395k a nationally recognized organization of dental practice brokers throughout the CN-878 VALLEJO: $30k IG-832 OAKHURST: Rare Opportunity. 2048 sf w/3 ops + 1 add’l. $235k/ United States. ADS members have a $315k EN-791 SO. SACRAMENTO CO: Real Estate 375k strategic alliance & combined marketing efforts with other practice brokerage CN-911 SANTA ROSA: IG-881 TURLOCK: Consistently growing pracce ~3500 sf w/ 10 Ops firms, financial companies & lending Better $545k $495k (shared). $360k organizations. All ADS companies are independently owned and operated.

Price 800.641.4179 [email protected] “ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM DEC. 2018 2018 INDEX

CDA JOURNAL, VOL 46, Nº12

CONTINUED FROM 789 July 2018 Oral Health Education Dental Anxiety Teledentistry

JournaCALIFORNIA DENTAL ASSOCIATION Harold C. Slavkin Can We Regrow Pulps? Lessons Learned as a Student of Craniofacial Paul V. Abbott Biology: What This Might Mean for Vol. 46, No. 4:249 Orthodontic Professional Education and Clinical Caries Arresting Approaches for Aging Practice in the 21st Century and Medically Complex Patients Vol. 46, No. 8:487 Jane Gillette Corey D. Stein, primary Vol. 46, No. 2:93 Leveraging Informatics To Relieve Barriers to Oral Case Report: Integrating Teledentistry To Health Care in Disadvantaged Communities Augment Clinical Outcomes in a School- Vol. 46, No. 3:171 DENTAL STUDENT RESEARCH: PEDIATRIC ORAL HEALTH AND VULNERABLE Based Setting Case Report: Integrating Teledentistry To Augment POPULATIONS Francisco Ramos-Gomez DDS, MS, MPH Corey D. Stein, Marisa K. Watanabe, Clinical Outcomes in a School-Based Setting Alexander Lee Vol. 46, No. 7:439 Vol. 46, No. 7:439 Norman R. Thomas, primary Child Misbehavior in the Dental Setting Inhibition of Collagen Crosslinking Produces Is Generally Assumed To Be Fear Significant Retardation of Impeded Imran Ahmed, Shannelle Shahery, and Unimpeded Eruption Rates Clarice S. Law Vol. 46, No. 8:497 Title Index Vol. 46, No. 7:423 Joe Vaughn Chronic Disease Management of Are Millennials Really That Different? Yes. No. A Four-Year Study on Risk-Based Caries in Children and the Role of Silver It’s Complicated: Commentary Recare Interval and New Cavitations in Vol. 46, No. 6:379 Nontraditional Dental Clinics Diamine Fluoride T. Jamie Parado, Shirley Y. Kang, Yesha M. Man Wai Ng, Rosalyn Sulyanto Marisa K. Watanabe, primary Patel, Keith R. Boyer, Marisa K. Watanabe Vol. 46, No. 1:23 Advancing Oral Health Equity With Innovative Vol. 46, No. 3:177 Dental Approaches Color Monitoring: Comparison Between Vol. 46, No. 3:149 Acellular Dermal Matrix Allografts in Visual and Instrumental Methods With The Impact of School-Based Oral Health Centers Periodontal Therapy Do-It-Yourself Whitening on Absence Rates and Dental Pain in a K–8 School Joan Otomo-Corgel, Chanook David Ahn, Allen Christina Chi, Minna Chun, Arfassa Gullo, Vol. 46, No. 3:161 Gunn Darlene Teddy, Emily Hwang, Udochukwu Vol. 46, No. 10:639 Oyoyo, So Ran Kwon Andrew Young, primary Vol. 46, No. 11:715 Enhancing Patient Care Through Evidence- Advancing Oral Health Equity With Based Dentistry Innovative Dental Approaches Coronectomy of Mandibular Third Vol. 46, No. 9:553 Marisa K. Watanabe Molars: Our Experience With 250 The Anatomy of a Clinical Study Vol. 46, No. 3:149 Consecutive Patients Vol. 46, No. 9:561 Antibiotic Prescribing and Stewardship in Emily Ehsan, Paul Hauser, David Ehsan Where the Rubber Meets the Road: Dentistry: A Public Health Perspective Vol. 46, No. 12:767 Incorporating Evidence-Based Dentistry Jane D. Siegel, Erin Epson Vol. 46, No. 9:583 Vol. 46, No. 12:755 Are Millennials Really That Different? Yes. No. It’s Complicated: Commentary Joe Vaughn June 2018 August 2018 Educating Millennials Vol. 46, No. 6:379 Tooth Eruption Practicing in Remote Areas Pathophysiology of Oral Cancer Confronting the Dental Generation Gap Autogenous Soft Tissue Grafting for the Sleep Physiology JournaCALIFORNIA DENTAL ASSOCIATION JournaCALIFORNIA DENTAL ASSOCIATION Treatment of Gingival Recession Elissa Green, Soma Esmailian Lari, Perry R. Klokkevold Vol. 46, No. 10:625 Can Use of Cone Beam Computed Tomography Have an Effect on Endodontic Treatment? Robert S. Roda

CRANIOFACIAL Vol. 46, No. 4:237 PHYSIOLOGY:Y WHAT MAKES US TICK? MILLENNIAL DENTISTS: DanielDanieele N. N Jenkins,Jenkins DDSDDS, CDE C How They Work, How They Learn and What It Means Can We Eliminate Microorganisms From for the Practice of the Future Christian Piers, DDS, MFA the Root Canal System? Markus Haapasalo Vol. 46, No. 4:227

792 DECEMBER 2018 CDA JOURNAL, VOL 46, Nº12

September 2018 Online Research Appraising Dental Literature Dental Statistics

JournaCALIFORNIA DENTAL ASSOCIATION Craniofacial Physiology in Dentistry Medication-Related Osteonecrosis of the Daniel N. Jenkins Jaw: Update and Future Possibilities Vol. 46, No. 8:485 James L. Borke, Jeffrey A. Elo, Ho-Hyun (Brian) Dental Student Research: Pediatric Oral Sun, Shirley Y. Kang Vol. 46, No. 5:301 Health and Vulnerable Populations Andrew Young, DDS, MSD Francisco Ramos-Gomez Millennials in Dentistry: A Journey Toward Vol. 46, No. 7:413 Understanding Dentists’ Almanac: Commentary Christian Piers Vol. 46, No. 6:355 Stephen Rogers Vol. 46, No. 6:363 Mixed-Dentition Orthodontic Treatment: Denture Group Visits: A Model To Improve Outcomes and Timing Access to Care and Reduce Treatment Kayhan L. Mashouf, Cameron K. Mashouf, Period for Dentures Sean Laraway Vol. 46, No. 5:307 Siddardha G. Chandrupatla, Lisa A. Thompson, Sirisha Kuna, Brian J. Swann Pathophysiology of Oral Cancer: An Vol. 46, No. 11:707 Overview Effects of an Educational and How To Educate Millennials: Commentary Anupama Grandhi Colleen Greene Outreach Intervention on Community Vol. 46, No. 8:507 Vol. 46, No. 6:359 Oral Health Workers Periodontal Disease Contributes to Vol. 46, No. 7:413 Implant Dentistry and Endodontics: Obstructive Sleep Apnea Can There Be a Mutually Beneficial Enhancing Patient Care Through Evidence- Scott E. Schames, Orr Shauly, Rita Y. Chuang, Relationship? Kaitlyn Tarbert, Hila Robbins, Michael Jordan Based Dentistry Tory Silvestrin, Charles J. Goodacre Vol. 46, No. 11:701 Andrew Young Vol. 46, No. 4:260 Vol. 46, No. 9:553 Prosthodontic Treatment in Parkinson’s Inhibition of Collagen Crosslinking Disease Patients: Literature Review Evolving Aspects of Endodontic Treatment Produces Significant Retardation of Snehal Sanjay Jaiswal, Ramandeep Dugal, Leif K. Bakland Ajay Mootha Vol. 46, No. 4:221 Impeded and Unimpeded Eruption Rates Norman R. Thomas, Daniel N. Jenkins Vol. 46, No. 11:691 Factors Associated With Hispanic Children’s Vol. 46, No. 8:497 Quality Improvement in Practice Leading to Dental Utilization in Imperial County: Lessons Learned as a Student of Remineralization CA-CORD Project Craniofacial Biology: What This Might James W.C. Fedusenko, Cindy Hannon, Erin Doughtery, Aarti Gupta, Tracy L. Finlayson, Cameron Fuller, Marcus Paulson, Brian B. Nový Shih-Fan Lin, Andrei Morales Cascaes, Mean for Orthodontic Professional Vol. 46, No. 4:185 Guadalupe X. Ayala Education and Clinical Practice in the 21st Vol. 46, No. 7:429 Century Radiographic Changes Following Treatment Harold C. Slavkin of Dental Caries With Silver Fluoride Financial Considerations for Sustainability Vol. 46, No. 8:487 Jeremy A. Horst, Steven Duffin, Sherrie Sanchez, in School-Based Oral Health Centers Michael Bratland Josih T. Hostetler, Huong H. Le, Marisa K. Leveraging Informatics To Relieve Vol. 46, No. 2:105 Watanabe, Jenny S. Tjahjono, Curtis H. Le, Barriers to Oral Health Care in Steven W. Friedrichsen Disadvantaged Communities Vol. 46, No. 3:153 Corey D. Stein, Marisa K. Watanabe, Alexander Lee October 2018 Gingival Recession Gingival Recession: What Is It All About? Autogenous Soft Vol. 46, No. 3:171 Tissue Grafting Debra S. Finney, Richard T. Kao Tissue Engineering JournaCALIFORNIA DENTAL ASSOCIATION Vol. 46, No. 10:617 Making eHealth Relevant to the Practice of Dentistry: A Proposed Strategy Health Care in the Middle of Nowhere: David T. Ford Millennials Who Practice in Small Towns: Vol. 46, No. 5:293 Commentary Kyle Luis Larsen Managing Caries in the Primary Dentition Vol. 46, No. 6:375 With Silver Nitrate: Lessons Learned From a Clinical Trial How Dentists Learn by Combining Michael J. Kanellis, Arwa I. Owais, John Evidence and Experience J. Warren, Deborah V. Dawson, Alberto David W. Chambers Gasparoni, Reem R. Oweis, Mary Akers, Derek TO GRAFT OR NOT TO GRAFT? AN UPDATE ON GINGIVAL Vol. 46, No. 5:315 GRAFTING DIAGNOSIS AND Blanchette, Matthew K. Geneser, Wei Liu, Mary TREATMENT MODALITIES Richard J. Nagy, DDS How To Critically Appraise the C. Skotowski, Karin Weber-Gasparoni Dental Literature Vol. 46, No. 1:37 Terrence Shaneyfelt Vol. 46, No. 9:569 DECEMBERDECEMBER 20120188 793 DEC. 2018 2018 INDEX

CDA JOURNAL, VOL 46, Nº12

December 2018 Antibiotic Stewardship Third Molar Coronectomy Non-Hodgkin Lymphoma of the Maxilla JournaCALIFORNIA DENTAL ASSOCIATION Recognition of Non-Hodgkin Lymphoma of The Associate Editor: Dentistry DIY: the Maxilla A Fading Fad? Joel B. Epstein, Alexa Martin, Ali M.M. Ruchi K. Sahota Sadeghi, Dimitrios Tzachanis Vol. 46, No. 9:537 Vol. 46, No. 12:773 The Associate Editor: Dentistry in 2100 Searching for Research Articles on the Internet Brian K. Shue Steve Kirk Vol. 46, No. 11:681 Vol. 46, No. 9:555 Antibiotic Prescribing The Associate Editor: One-Stop Shopping and Stewardship in Silver Diamine Fluoride: A Clinical Equals Savings and Support Dentistry: Perspective From a Pediatric Dentist Ruchi K. Sahota A Public Health Perspective Gary D. Sabbadini Vol. 46, No. 2:73 Vol. 46, No. 2:87 The Associate Editor: Run, Hide, Fight Silver Diamine Fluoride — That Old Black Brian K. Shue Magic Has Me in Its Spell Vol. 46, No. 5:285 Paul Reggiardo, Gregory J. Sabino The Core Elements of Antibiotic Vol. 46, No. 2:83 Stewardship in Dentistry The Pinhole Surgical Technique: A Clinical Silver Diamine Fluoride — The New Old: Peter L. Jacobsen Perspective and Treatment Considerations Part I Vol. 46, No. 12:757 From a Periodontist Paul Reggiardo, Gregory J. Sabino The Editor: End First Exposure: Dentistry’s Tina M. Beck Vol. 46, No. 10:647 Vol. 46, No. 1:15 Biggest Opportunity in the Opioid Crisis Silver Diamine Fluoride Chemical Kerry K. Carney The Warm Springs Model: A Successful Mechanisms of Action as a Caries Arresting Vol. 46, No. 7:405 Strategy for Children at Very High Risk for and Preventing Agent The Editor: I’ll Drink to That Dental Caries Lawrence D. Robertson Arwa I. Owais, Grace Lu, Khomson Kerry K. Carney Vol. 46, No. 2:97 Keratithamkul, Michael J. Kanellis, Amanda J. Haes Vol. 46, No. 8:473 Vol. 46, No. 2:113 The Editor: Nothing but the Tooth Tissue Engineering for Improving Statistics for Practicing Dentists Kerry K. Carney Periodontal Phenotype Eric S. Salmon Vol. 46, No. 10:605 Cherissa Chong, Yung-Ting Hsu, Paul Y. Lee, Vol. 46, No. 9:577 Richard T. Kao The Editor: The TDSC Marketplace and You Vol. 46, No. 10:653 Survey of Dental Students and Recent Kerry K. Carney Graduates’ Knowledge, Attitudes and Vol. 46, No. 4:209 To Graft or Not To Graft? An Update on Practices in Regard to Treating Patients Gingival Grafting Diagnosis and Treatment With Special Health Care Needs The Editor: Tooth Fairy Science Modalities Haejin Kang, Francisco Ramos-Gomez, Kerry K. Carney Richard J. Nagy Hamida Askaryar Vol. 46, No. 3:141 Vol. 46, No. 10:615 Vol. 46, No. 7:447 The Editor: Walter Clement Noel: Patient Zero Understanding Normal Sleep, Respiration The Anatomy of a Clinical Study Kerry K. Carney and Circulation Andrew Young Vol. 46, No. 6:345 Anne-Maree Cole Vol. 46, No. 9:561 The Editor: Why We Change: Kirk vs. Spock Vol. 46, No. 8:513 Kerry K. Carney Use of Silver Diamine Fluoride for Dental Vol. 46, No. 1:5 Caries Management in Children and November 2018 Periodontal Disease and Obstructive Sleep Apnea The Four Millennials You Meet in Dental Adolescents, Including Those With Special Denture Group Visits Color Monitoring and DIY Whitening School: Commentary Health Care Needs JournaCALIFORNIA DENTAL ASSOCIATION Eric Mediavilla, Christian Piers Yasmi O. Crystal, Abdullah A. Marghalani, Vol. 46, No. 6:369 Steven D. Ureles, John Timothy Wright, Rosalyn Sulyanto, Kimon Divaris, Margherita Fontana, The History and Use of Silver Diamine Laurel Graham Fluoride in Dentistry: A Review Vol. 46, No. 1:45 Elise Sarvas Vol. 46, No. 1:19 Where the Rubber Meets the Road: Incorporating Evidence-Based Dentistry The Impact of School-Based Oral Health Andrew Young, Des Gallagher Centers on Absence Rates and Dental Pain Vol. 46, No. 9:583 in a K–8 School PROSTHODONTIC TREATMENT IN PARKINSON’S DISEASE PATIENTS: Marisa K. Watanabe, Misa L. Yoshioka, Literature Review Jihae H. Cho Vol. 46, No. 3:161

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