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departments

681 The Associate Editor/Dentistry in 2100

685 Impressions

723 RM Matters/Managing Patients With HIV

727 Regulatory Compliance/Continuing Education Q&A 734 Tech Trends 685

f e at u r e s

691 Prosthodontic Treatment in Parkinson’s Disease Patients: Literature Review The aim of the article is to identify the treatment modalities that will be helpful during a patient’s dental rehabilitation procedure. Ajay Mootha, MDS; Snehal Sanjay Jaiswal, BDS; and Ramandeep Dugal, MDS

701 Periodontal Disease Contributes to Obstructive Sleep Apnea This study explores the comorbidity of periodontal disease, xerostomia and obstructive sleep apnea. Scott E. Schames, DDS; Orr Shauly, BS; Rita Y. Chuang, DDS; Kaitlyn Tarbert, RDH; Hila Robbins, DMD; and Michael Jordan, RN, MSN, MBA

707 Denture Group Visits: A Model To Improve Access to Care and Reduce Treatment Period for Dentures This study evaluates reduction in the number of days required for denture treatment utilizing a denture group-visit model. Siddardha G. Chandrupatla, BDS, MMSc; Lisa A. Thompson, DMD; Sirisha Kuna, BDS; and Brian J. Swann, DMD, MPH

715 Color Monitoring: Comparison Between Visual and Instrumental Methods With Do-It-Yourself Whitening This study evaluated by means of visual and instrumental color-assessment tools the whitening efficacy of activated charcoal slurry and coconut oil regimens promoted over the internet. Christina Chi, BA, DDS; Minna Chun, BA, DDS; Arfassa Gullo, BS, DDS; Darlene Teddy, BS, DDS; Emily Hwang, BS; Udochukwu Oyoyo, MPH; and So Ran Kwon, DDS, MS, PhD, MS

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Volume 46, Number 11 JournaCALIFORNIA DENTAL ASSOCIATION November 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 Ruchi K. Sahota, DDS, CDE Subscriptions 800.232.7645 December/General Topics ASSOCIATE EDITOR Subscriptions are available cda.org January/CAMBRA/PBRN only to active members of February/E-cigarettes Brian K. Shue, DDS, CDE the Association. The CDA Offi cers ASSOCIATE EDITOR subscription rate is $18 and Advertising Natasha A. Lee, DDS is included in membership PRESIDENT Gayle Mathe, RDH Sue Gardner dues. Nonmembers can SENIOR EDITOR ADVERTISING SALES [email protected] view the publication online [email protected] at cda.org/journal. R. Del Brunner, DDS Andrea LaMattina, CDE 916.554.4952 PRESIDENT-ELECT PUBLICATIONS MANAGER Manage your subscription [email protected] online: go to cda.org, log in Kristi Parker Johnson Permission and and update any changes to EDITORIAL SPECIALIST Richard J. Nagy, DDS Reprints your mailing information. VICE PRESIDENT Andrea LaMattina, CDE Email questions or other PUBLICATIONS MANAGER [email protected] Blake Ellington changes to membership@ TECH TRENDS EDITOR [email protected] cda.org. Judee Tippett-Whyte, DDS 916.554.5950 SECRETARY Jack F. Conley, DDS EDITOR EMERITUS [email protected] Manuscript Steven J. Kend, DDS Robert E. Horseman, DDS Submissions TREASURER HUMORIST EMERITUS www.editorialmanager. [email protected] com/jcaldentassoc 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 VICE PRESIDENT, MARKETING AND MEMBERSHIP Copyright 2018 by the California Dental Association. All rights reserved. help you get the results you need, faster than ever. Check it out for Alicia Malaby COMMUNICATIONS yourself at cda.org/classifieds. DIRECTOR

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680 NOVEMBER 2018 Assoc. Editor CDA JOURNAL, VOL 46, Nº11

Dentistry in 2100 Brian K. Shue, DDS, CDE

reat events in dental history occurred in 1895. That year, the nine-member Let’s continue this journey and use our San Diego County Dental imagination to travel forward in time Society may have been Gthe fi rst dental society ever to have a to the year 2100. woman president when it elected Emma T. Read, DDS. Also, the 115-member California State Dental Association — which became today’s CDA in colored restoration cements, capitation we have genetic insights early, we can 1973 — celebrated its 25th anniversary reimbursement checks, dental nurses “with suggest changes in where someone lives, in San Francisco with its annual four- good pay” who operated under general what they do and their diet.” He also day meeting of oral presentations and supervision, an oral rinse that “entirely stated: “There is likely to be a greater gulf clinic demonstrations. More than prevents tartar, stain” and — before between the haves and the have-nots.” 50 dentists attended its opening day, fl uoride put Grand Rapids, Mich., on The article also included comments including women for the fi rst time. the map — oral rinses that “harden the by David W. Chambers, EdM, MBA, According to a report published in teeth, obviating decay almost entirely.”2 PhD, then associate dean for academic the Pacifi c Stomatological Gazette, CDA’s Dr. Merriman said: “The prevention affairs at the University of the Pacifi c, fi rst woman member, Carolyn McElroy, of decay and disease is the great aim and Arthur A. Dugoni School of Dentistry, DDS, of Pescadero, Calif., gave a scientifi c is thought of and infl uenced even before who said: “Improvements in therapeutic presentation called “Children and the birth of the child,” and “The dentist, mechanisms, more user-friendly materials Dentistry,” which “was the fi rst ever read instead of being a hard-worked mechanical and procedures and other aspects will before the Association by a woman” and man, is purely scientifi c and guides all make it easier to practice dentistry,” as “the Doctor was made to feel that she had information pertaining to the oral cavity.” well as “Biological breakthroughs in presented a paper of superior merit.”1 Fast forward 100 years. In 1995, genetic engineering and therapeutic And future CDA president A.F. the CDA Journal Managing Editor interventions” outside of the dental Merriman Jr., DDS, of Oakland read his Susan Lovelace wrote an article that offi ce. However, Dr. Chambers also added paper “Dentistry in two thousand.”2 It was documented CDA’s past and present. For that organized dentistry needs to avoid a “breezy, enjoyable” 20 percent non-core her article, many dental leaders also shared divisiveness, such as that experienced in presentation, which “abounded in pleasing their vision of dentistry in 20 to 30 years medicine and law, otherwise the various fancies of the possible advancement that (which happens to be now), as well as facets of dentistry “will be pulled apart” will have occurred in the next 105 years ahead to the year 2100.3 They forecasted by infi ghting. “The profession can and in stomatological science and dental art.”1 clinical and offi ce advancements in the must make adjustments to forces as Some of Dr. Merriman’s predictions science and technology of dentistry, it recognizes and interprets them.” were quite far-fetched, if not tongue-in- the computerization and birth of the Let’s continue this journey and cheek. For example, the human mandible chartless offi ce, educational advancements use our imagination to travel forward did not evolve to allow “the wisdom and the disappearance of the line in time to the year 2100. Borrowing teeth more room to come through.” between medicine and dentistry. Ms. Lovelace’s concept, I asked dental But he correctly predicted Bay Area Of note, Harold C. Slavkin, DDS, leaders to once again look deeply into congestion in the shape of a metropolis then newly appointed director of the the crystal ball and share their insight. called “San Franoakland,” the BART National Institute of Dental Research, said Art A. Dugoni, DDS, MSD, dean railway system under the bay, the San in that article: “The knowledge of genetics emeritus at the University of the Pacifi c, Francisco-Oakland Bay Bridge and will be critical to dentists. We will be Arthur A. Dugoni School of Dentistry, intercontinental airline travel. And on able to design lives by genetic strengths, stated in his most recent prepared the dental front, he imagined tooth- acknowledging genetic liabilities. If speech: “Much effort is being devoted by

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the world’s scientists and engineers in will impact who enters health care Now more than ever, the truest addressing many of the key challenges professions, how they are educated to path we take as individuals and as that face humanity today, especially in meet the societal needs and how to a collective group can lead to great medicine, energy and the environment. increase quality and decrease costs.” accomplishments over the next 100 These efforts will result in impressive new Dr. Chambers, now professor of dental years. And as Dr. Dugoni reassured, solutions that will extend the lives of our education at the University of the Pacifi c, “I, for one, remain hopeful.” ■ descendants and improve their quality Arthur A. Dugoni School of Dentistry, of life and provide them the tools to also revisited the future, this time with REFERENCES overcome such threats as climate change.4 his gloves off: “Dentists’ fi xation on 1. California State Dental Association — 25th annual meeting. “The next 10 to 20 years will technology may kill the profession. Pacifi c Stomatological Gazette 1895; 3(7):294–302. 2. Merriman AF. Dentistry in two thousand. Pacifi c be an astounding time for medical U.S. News and World Reports lists Stomatological Gazette 1895; 3(12):509–516. achievements,” he continued. dentistry as a job, not a profession. The 3. Lovelace SE. A professional calling. J Cal Dent Assoc 1995 “Developments are happening right business model of dentistry is grounded 23(7):33–52. 4. Dugoni AA. A glimpse into the future. Speech, 2017. now that will extend the lives of our in transaction codes, not oral health 5. Slavkin HC. Private correspondence, 2018. children and grandchildren and very outcomes.” He went even further: “Here 6. Chambers DW. Private correspondence, 2018. likely free them from such debilitating is the danger. Dentists cannot control diseases like Parkinson’s and Alzheimer’s. the rise of technology and technology is Brian K. Shue, DDS, CDE, is the It’s fascinating to imagine that many replacing major aspects of what dentists dental director of a federally qualifi ed health of our grandchildren can realistically do. Dentists are no longer the major voice center. He is a certifi ed dental editor, the expect to remain active and mentally in patients’ attitudes regarding their oral San Diego County Dental Society editor engaged while they are celebrating health and what can be done about it. and is a fellow of the American College of their centennial birthdays.” That is now being done on the internet.”6 Dentists and the Pierre Fauchard Academy. Dr. Slavkin, now dean emeritus “How will the dentistry of 2018 begin and professor at the Ostrow School of to prepare for these profound challenges?” Dentistry of USC, agreed to participate in Dr. Slavkin asked. He looked at the The Journal welcomes letters this exercise and updated his vision. He big picture and said: “Essentially all of We reserve the right to edit all said industrial nations will “demonstrate the industrial nations of our present communications. Letters should discuss striking trends as to their aging world share a number of profound an item published in the Journal within populations and related prevention and societal issues including considerations the last two months or matters of general care for the ‘senior’ cohorts. The fastest- as to health in the year 2100.” interest to our readership. Letters must be growing cohort being those of us who “This is not a future that dentistry no more than 500 words and cite no more present into the ninth and 10th decades can control,” Dr. Chambers warned. than fi ve references. No illustrations will of life.” This is not far-fetched. He said: “Dentistry can certainly work with the be accepted. Letters should be submitted “Today, in Japan, that group represents 25 emerging forces of technology and have at editorialmanager.com/jcaldentassoc. By percent of the entire population with the a place at the table. But I sense that the sending the letter, the author certifi es that U.K., Germany, Italy, Scandinavia and the profession is more interested in a strategy neither the letter nor one with substantially U.S.A. all moving in the same direction.”5 of denial unless they can be in charge, similar content under the writer’s authorship But fi nances will enter the equation. than it is in working with others.” has been published or is being considered Dr. Slavkin said: “Health care expense “I realize that the future scares a lot for publication elsewhere, and the author as a percentage of GDP is also rising of people,” Dr. Dugoni said. “But when acknowledges and agrees that the letter and and threatens the economies of these you consider all the coming innovations all rights with regard to the letter become the nations. Quality as well as sustainability provided to us by science and technology, property of CDA. issues are now being addressed through there’s room for optimism.” His 21st- high-defi nition, precision health century insight echoes that of Dr. care. These and other major societal Merriman, who at the end of the 19th challenges will determine the quality century predicted a “future of dentistry and cost of oral health care and brimming with optimism and innovation.”

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Ethical Equipoise David W. Chambers, EdM, MBA, PhD

If ethics is valuable, we should expect to pay a little something for it. The ethics we get for free may not be the best quality. Value is a refl ection of what we are prepared to do, not what we want. Equipoise means being generally indifferent to any of the plausible alternatives in a situation. Some examples: The patient has no preference for full extractions and dentures or just pulling the one that hurts today; the practitioner says the same things in public about colleagues who do great work and those known to deliver gross or continuous faulty treatment; some see no need to belong to or participate in organized dentistry — “the profession will be the same with me or without me.” This does not mean that dentists are indifferent about outcomes. As a species, humans are exquisitely talented at forming preferences and having opinions. Have you noticed the polarization in America today? Few can watch a football game on television between two schools they have never heard of for more than fi ve minutes without picking a favorite. No dentists can look in a patient’s mouth without instantly “seeing” the treatability of the case. The confusion comes in correctly recognizing that one has clear and consistent preferences among outcomes but incorrectly equating this with ethics. All the outcomes one is prepared to do nothing about are of equal ethical weight. Whether we are ethical depends on the choices we made, not on whether we like the results. After the outcomes are revealed, we cheer or hiss or grumble. Before the outcomes The nub: are revealed, any courses of action about which we are 1. In ethics, you get what you are indifferent are considered to be in ethical equipoise. Discount ethics is quite the thing these days. The basic willing to pay for. idea is to spend as little as possible in hopes of still getting by. The cheapest form of discount ethics is to blame others 2. Being critical of what others do or to say they should be doing things the way we want. is not ethics; it is smugness. Good bargains are also to be had by writing codes and advertising them. Enforcing them is avoided because it is 3. All situations that are treated the expensive and drains the public-relations value of ethical same way are ethically indiff erent. posturing. A bargain is to be had and has been used by the dental trade by awarding publicized prizes for being ethical. There is an old saw in business advising that every

David W. Chambers, EdM, MBA, PhD, is a professor organization (or profession or individual) is perfectly of dental education at the University of the Pacifi c, Arthur designed to produce exactly the level of dysfunction it is A. Dugoni School of Dentistry, San Francisco, and the editor willing to accept. The principle of ethical equipoise says that of the American College of Dentists. a profession achieves exactly the level of ethics it is willing to pay for. This is usually not the same as the level it thinks it is entitled to, wants, enshrines in codes or editorializes about. ■

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Drug-Free Approach Detects, Treats Oral Plaque Researchers from the University of Illinois have devised a practical drug-free, Cross-section cut of liver cirrhosis under the microscope. nanotechnology-based method for detecting and treating the harmful bacteria that cause plaque and lead to tooth decay and other detrimental conditions. The Gum Disease Treatment May study was published online in July in the journal Biomaterials. “Presently in the clinic, detection of dental plaque is highly subjective and only Improve Cirrhosis Symptoms depends on the dentist’s visual evaluation,” said Bioengineering Associate Professor Routine oral care to treat Dipanjan Pan, PhD, head of the research team. “We have demonstrated for the first periodontitis may play a role in reducing time that early detection of dental plaque in the clinic is possible using the regular infl ammation and toxins in the blood intraoral X-ray machine which can seek out harmful bacteria populations.” (endotoxemia) and improving cognitive To accomplish this, Fatemeh Ostadhossein, a bioengineering graduate student in function in people with liver cirrhosis, Dr. Pan’s group, developed a plaque-detection probe that works in conjunction with according to a study published in common X-ray technology and is capable of finding Streptococcus mutans in a the American Journal of Physiology – complex biofilm network. The researchers also demonstrated that by tweaking the Gastrointestinal and Liver Physiology. chemical composition of the probe, it can be used to target and destroy the S. mutans Cirrhosis is the presence of scar tissue bacteria. The probe is made up of nanoparticles made of hafnium oxide (HfO2), a on the liver. Previous research shows nontoxic metal that is currently under clinical trial for internal use in humans. that people with cirrhosis have changes In practice, Dr. Pan envisions a dentist applying the probe on the patient’s teeth in gut and salivary microbiota, which and using the X-ray machine to accurately visualize the extent of the biofilm can lead to gum disease and a higher risk plaque. If the plaque is deemed severe, then the dentist would follow up with the of cirrhosis-related complications. In administering of the therapeutic HfO2 nanoparticles in addition, studies have found that people the form of a dental paste. with cirrhosis have increased levels of Learn more about this study in Biomaterials (2018); infl ammation throughout the body, which doi.org/10.1016/j.biomaterials.2018.07.053. is associated with hepatic encephalopathy. Researchers studied two groups of In this illustration, nanoparticles attach to or are taken volunteers who had cirrhosis and mild-to- up by the bacteria cells. (Credit: University of Illinois moderate periodontitis. One group received Laboratory for Materials in Medicine) periodontal care (“treated”), including teeth cleaning and removal of bacteria toxins from the teeth and gums. The other group was not treated for gum disease (“untreated”). The research team collected group, on the other hand, demonstrated minimize some of the symptoms of hepatic blood, saliva and stool samples before and an increase in endotoxin levels in the encephalopathy in people who are already 30 days after treatment. Each volunteer blood over the same time period. The receiving standard-of-care therapies for the took standardized tests to measure cognitive improvement in the treated group could be condition. This fi nding is relevant because function before and after treatment. related to a reduction in oral infl ammation there are no further therapies approved by The treated group, especially those leading to lower systemic infl ammation the U.S. Food and Drug Administration with hepatic encephalopathy, had or due to less harmful bacteria being to alleviate cognition problems in this increased levels of benefi cial gut bacteria swallowed and affecting the gut microbiota, population, the researchers said. that could reduce infl ammation, as well according to the research team. Learn more about this study in as lower levels of endotoxin-producing Cognitive function also improved in the the American Journal of Physiology — bacteria in the saliva when compared treated group, suggesting that the reduced Gastrointestinal and Liver Physiology (2018); to the untreated group. The untreated infl ammation levels in the body may doi.org/10.1152/ajpgi.00230.2018.

686 NOVEMBER 2018 CDA JOURNAL, VOL 46, Nº11

Tongue Microbiome Study Marks Importance of Dental Health Elderly individuals with poor Prior to this study, researchers dental health constantly ingest more knew that constant aspiration of saliva dysbiotic microbiota, which could be can lead to pneumonia, a major cause harmful to their respiratory health, of death among elderly adults with according to new research published swallowing impairments, and that in the journal mSphere. The fi ndings tongue microbiota are a dominant source come from a large, population-based of oral microbial populations that are of indigenous tongue microbiota is study that identifi ed variations in the ingested with saliva. Previous research associated with an increased risk of tongue microbiota among community- has also shown that in institutionalized death from pneumonia. “Fewer teeth, dwelling elderly adults in Japan. frail elderly adults, the dysbiotic shift poorer dental hygiene and more dental caries experience are closely related to dysbiotic shift in the tongue microbiota composition, which might be harmful to the respiratory health of elderly Bioengineered Tooth Leads to New Therapies adults with swallowing problems,” said author Yoshihisa Yamashita, PhD, While artificial dental implants are the existing standard tooth replacement DDS, of Kyushu University of Japan. therapy, they do not exhibit many properties of natural teeth and can be In the new study, Dr. Yamashita associated with complications leading to implant failure. But two studies published and colleagues investigated the tongue in September in the Journal of Dental Research highlight recent advances in microbiota status and dental conditions bioengineering teeth that could solve those problems. of 506 adults aged 70 to 80 years living Researchers from Tufts University School of Dental Medicine in Boston in the town of Hisayama, Japan, who explored new methods to create highly cellularized bioengineered tooth bud each received a dental examination constructs that include features that resemble natural tooth buds, such as the dental during a health examination of the epithelial stem cell niche, enamel knot signaling centers, transient amplifying cells town’s residents that was performed and mineralized dental tissue formation. The constructs were composed of in 2016. The scientists collected the postnatal dental cells encapsulated within a hydrogel material that were implanted tongue microbiota from the center area subcutaneously into immunocompromised rats. of the tongue dorsum using a modifi ed This is the first report that describes the use of postnatal dental cells to create electric toothbrush as a sampling device bioengineered tooth buds that exhibit evidence of these features of natural tooth and used next-generation sequencing development, pointing to future bioengineered tooth buds as a promising, clinically approaches to analyze the samples. relevant tooth replacement therapy, according to the study. The researchers found that Additionally, researchers from the French National Institute of Health and the total bacterial density was Medical Research developed a strategy where autologous mesenchymal cells independent of the conditions coming from bone marrow can be used to supply nerves to bioengineered teeth of teeth surrounding the tongue, without treatment that uses an immunosuppressor. The innervation of teeth is whereas the microbiota composition, essential for their function and protection but does not occur spontaneously after especially the relative abundances of injury. This new method provides innervation while avoiding predominant commensals, showed multiple side effects associated with immunosuppressors. an association with tooth conditions. Learn more about these studies in the September issue “Commensal microbiota composition, especially the relative abundances of the Journal of Dental Research (2018). of predominant commensals, showed an association with tooth Tooth bud in early bell stage. (Credit: Dozenist/Wikimedia Commons) conditions,” said Dr. Yamashita. Read more of this study in mSphere (2018); doi:10.1128/mSphere.00332-18.

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Study of 10th-Century Teeth Explores Diet, Health, Development Bone deficits treated with engineered exosomes Researchers from the University of Bradford in the U.K. found that analysis of (right) heal quicker when compared to deficits milk teeth of children’s skeletons from a 10th-century site in Northamptonshire, without exosome treatment (left). (Credit: UIC/ England, gave a more reliable indicator of the effects of diet and health than bone. Sriram Ravindran and Praveen Gajendrareddy) The study, published in September in the American Journal of Physical Anthropology, shows that by analyzing dentine from the milk teeth of the Anglo Researchers Seek Safer, Saxon children, a picture emerges of the development of these children from the More Promising Growth third trimester of pregnancy onward and is a proxy indicator of the health of the Regenerator mothers. This is the first time that secure in utero data has been measured, according to the study. Researchers from the University The skeletons analyzed came from a group known to have been undernourished. of Illinois at Chicago have received The effect of this undernourishment, or stress, is to limit the growth of bones. This can approximately $2 million in funding from limit the evidence available from analysis of bones alone, such as age. the National Institutes of Health to develop Researchers were also able to look at children of different ages to see a better way to regenerate bone or tissues whether those who survived the first 1,000 days from conception had different that have been lost to disease or injury. biomarkers for stress than those who died during this high-risk period. Currently, most treatments rely Teeth, unlike bone, continue to grow under such stress and, unlike bone, record on the use of growth factors or other high nitrogen values. This evidence gives a clearer picture of what is happening to chemical agents to stimulate stem cells the child from before birth. The teeth are, in effect, acting as to regenerate what has been lost. But an archive of diet and health of both the child and mother. this approach has many limitations, like Read more of this study in the American Journal of Physical side effects and uncontrolled abnormal Anthropology (2018); doi.org/10.1002/ajpa.23682. growths due to dosing and toxicity, which have caused complications and prevented CT scan of 5-year-old Anglo Saxon jawbone from Raunds regulatory organizations from approving Furnells. (Credit: University of Bradford) the treatments for use in humans. “We need a replacement for growth factor-based interventions so that we can reduce side effects and advance these therapies to the bedside,” said Sriram Ravindran, PhD, co-principal investigator of run a lab at the UIC College of Dentistry Dr. Gajendrareddy, associate professor of the project. “We need therapies that better that develops biomimetic tools — those periodontics. “Because these engineered mimic the body’s natural processes, so the that mimic natural biology — for tissue exosomes mimic nature, we are not body is better able to tolerate treatment.” regeneration. With this latest round reinventing the wheel, we are just making Bone is the second most transplanted of funding, they hope to evaluate and the wheel go a bit faster while better organ in the human body, after blood. characterize the use of engineered exosomes, controlling the direction it travels.” Grafting and regeneration procedures small vesicles in cells that carry cellular Drs. Ravindran and Gajendrareddy are performed by health care providers messages, as a safer and more clinically will use the new funding to further to treat anything from complex bullet promising alternative to growth factors. develop their exosomes to be, what they wounds and spinal injuries to gum disease. “Our preliminary research has call, functionally activated targeted Dr. Ravindran, research assistant demonstrated that engineered exosomes exosomes, or FATE, and will evaluate professor of oral biology, and his colleague, may aid regeneration faster than growth the exosomes’ effectiveness in healing Praveen Gajendrareddy, DDS, jointly factors, with fewer complications,” said critical-size skull defects in rodents.

688 NOVEMBER 2018

treating pd patients

CDA JOURNAL, VOL 46, Nº11

Prosthodontic Treatment in Parkinson’s Disease Patients: Literature Review

Ajay Mootha, MDS; Snehal Sanjay Jaiswal, BDS; and Ramandeep Dugal, MDS

a b s t r ac t Parkinson’s disease (PD) is defined as a progressive, disabling neurodegenerative disorder characterized by resting tremors, slowness of movement (bradykinesia), muscle rigidity, postural instability and gait disturbance. The clinical symptoms worsen over time and affect the patient’s quality of life and ability to perform regular activities such as toothbrushing and hygiene maintenance. The aim of this article is to identify the treatment modalities that will be helpful during the patient’s dental rehabilitation procedure.

AUTHORS

Ajay Mootha, MDS,  Ramandeep Dugal, arkinson’s disease (PD) is most common cause of death by the earned his master of dental MDS, earned her defined as a progressive, year 2040.5 However, PD has a low surgery in prosthodontics master of dental surgery disabling neurodegenerative prevalence in India except for the and implantology. He in prosthodontics and is a reader at the M.A. implantology. She is disorder caused by a loss of small Parsi community where Bharucha 3,6 Rangoonwala Dental professor and head dopamine-producing cells in et al. found a high prevalence. College and Research of the department of Pthe substantia nigra. It is a movement Braak’s hypothesis postulates that the Centre in Pune, India. prosthodontics and principal disorder characterized by resting disease originates in the intestine then Conflict of Interest at the M.A. Rangoonwala tremors, slowness of movement spreads to the brain via the vagus nerve, Disclosure: None reported. College of Dental Sciences and Research Centre in (bradykinesia), muscle rigidity, postural a phenomenon that would involve other 1–3 Snehal Sanjay Jaiswal, Pune, India. instability and gait disturbance. neuronal types than the well-established BDS, earned her bachelor Conflict of Interest These symptoms negatively affect the dopaminergic population. There is a of dental surgery from Disclosure: None reported. patient’s quality of life and often result growing list of research work that shows Sharad Pawar Dental in loss of employment, inability to evidence supporting the hypothesis that College, DMIMSU, Sawangi (Meghe), India. drive and impairment in activities of nonmotor symptoms associated with PD, She is pursuing a master daily living, including the ability to especially gastrointestinal dysfunctions of dental surgery in perform bodily functions and maintain such as constipation, drooling, dysphagia prosthodontics from the adequate oral hygiene.3 The incidence and nausea, could be considered as early M.A. Rangoonwala College and prevalence of PD increases with biomarkers because they are frequently of Dental Sciences, Azam campus, in Pune, India. advancing age, being present in 1 found among PD patients and occur 4 Conflict of Interest percent of people over the age of 65. much earlier than the other motor Disclosure: None reported. PD, along with other neurodegenerative manifestations.7 Due to poor oral hygiene, diseases such as Alzheimer’s disease and there has been a rise in prevalence of motor neuron disorders, is expected dental caries and edentulism, further to surpass cancer as the second leading to an increasing number of

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TABLE 1 Hoehn and Yahr Scale: Five Stages of Parkinson’s Disease 20

Stages Symptoms I – Mild/early disease Unilateral involvement of the body with minimal or no functional impairment. II Bilateral involvement of the body. these patients attending dental clinics.3 Posture and balance remain normal. It is the aim of this article to acquaint III – Moderate Bilateral involvement of the body. dentists with the orofacial fi ndings, disease Mild postural imbalance while standing or walking but patient still remains different treatment modalities and independent. current prosthodontic rehabilitation IV – Advanced Bilateral involvement of the body. procedures for PD-affected patients. disease Disabling instability while walking or standing. V Severe, fully developed disease. Material and Methodology Patient is often cachexic, restricted to bed or wheelchair unless aided. A MEDLINE search using the key terms “Parkinson’s disease,” “Parkinson’s disease and oral cavity,” “Parkinson’s The behavioral manifestations of with progressive disability, however at disease and prosthodontics” and “Implants PD are mainly due to varied patterns a rate that varies greatly from person to in Parkinson’s patients” led to a list of of degeneration in dopaminergic and person. The increased mortality depends 361 articles. A combination of controlled nondopaminergic (noradrenergic and on disease duration and often results vocabulary and free-text words guided the serotonergic) neuronal systems.11,12 The from aspiration pneumonia, pressure search. Out of these, 30 articles providing clinical symptoms range from early sores and urinary tract infections.17 information regarding symptoms, general gastrointestinal symptoms, like dry management and dental treatment mouth, dysphagia and constipation, to Diagnosis in PD patients were selected. Twelve urinary retention, erectile dysfunction, The diagnosis is based on careful articles providing valuable information of decreased sweating and orthostatic history taking, physical examination treatment modalities related to implants hypotension.7,13,14 The vast majority of PD and, in some instances, a positive in PD patients were also included in cases are “idiopathic” or “sporadic” with sustained response to the administration this review. The bibliographies of the incidence of around 3–5 percent of cases of dopaminergic medications.18 references obtained were used to identify showing genetic predilection.8 It has been Laboratory tests and imaging studies pertinent secondary references. Review proposed that early symptomatic treatment are not routinely used19 but a defi nitive articles were also used to identify relevant improves motor control and quality of life diagnosis requires postmortem confi rmation articles. A defi nitive list of articles was in the short-term and benefi ts are sustained (based on the presence of intraneuronal screened to extract the qualitative data for longer periods, perhaps through a aggregates known as Lewy bodies).8 The and the information was derived. disease-modifying effect of compensatory Hoehn and Yahr scale as shown in TABLE 1, mechanisms.15 Others consider that it is based on the extent of motor symptoms, can Etiology better to delay initiation with dopaminergic assist a clinician in staging the disorder.20 PD has an incidence of 13 per 100,000 medications and would rather proceed people per year.8 It affects both genders with symptomatic treatments.16 The Clinical Manifestations equally.3 It is most prevalent in older medications used for the treatment of PD Parkinsonism is characterized by the people, affecting around 2–3 percent of are listed in TABLE 2.1 Dopaminergic drugs three cardinal motor signs — bradykinesia, those older than 65, but can begin as early like levodopa and dopamine agonists resting tremor and rigidity.21 The as the third or fourth decade, particularly help in improving bradykinesia and bradykinesia is the slowness of movement in people with familial history of PD. rigidity in PD. Levodopa is still the and the decrease in its amplitude. The The motor dysfunction arises due to potent dopaminergic drug but dopamine resting tremors (4–6 hz) generally start damage and loss of 60–70 percent of the agonists like monoamine oxidase B in the hand with a typical pill-rolling neurons that store and release dopamine inhibitors can also provide effective movement between the thumb and in the substantia nigra.9 The depletion of symptom control. MAO-B inhibitors fi ngers.1,21 The tremors may spread to the dopamine and norepinephrine is mainly are effective as monotherapy in early tongue, mandible, face and legs. These infl uenced by a combination of accelerated disease and as adjuvant therapy in more tremors are typically seen in the relaxed aging, genetic predisposition, exposure to advanced disease but are not as potent state and the amplitude of resting tremors pesticides or neurotoxins, head injuries as levodopa or dopamine agonists.1 decreases during purposeful movements. or an abnormal oxidative mechanism.10 The disease continues to be associated Along with bradykinesia, patients manifest

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TABLE 2 Medications: Properties, Action and Adverse Systemic Reactions1

Generic name Properties and actions Adverse systemic reactions (elderly and cognitively impaired patients are more susceptible to these adverse eff ects) Amantadine An antiviral agent, has properties to increase dopamine release, Confusion, hallucinations and a worsening of glaucoma and inhibit dopamine reuptake, stimulate dopamine receptors and congestive heart failure. also possibly exert central anticholinergic eff ects. Benztropine Used in treating tremor but less useful in alleviating muscle Confusion, blurred vision, worsening of glaucoma, urinary rigidity and bradykinesia. retention, cardiac dysrhythmia. Cabergoline Dopamine agonist and provides long-lasting direct stimulation Orthostatic hypotension, nausea, vomiting, confusion and of dopamine receptors bypassing the depleted neurons in the hallucinations; cabergoline, an ergot-related dopamine agonist, substantia nigra. known to be associated with the development of stiff fi brotic heart valve leafl ets, thereby increasing the risk of endocarditis. Levodopa Levodopa is a dopamine precursor that is taken up by the Nausea, orthostatic hypotension; 50–75 percent of patients remaining neurons in the substantia nigra and transformed become less responsive to the medication within fi ve years into dopamine, facilitating synaptic transmissions and helping of starting treatment and develop new involuntary movements eliminate bradykinesia and muscle rigidity, but postural instability (dyskinesias). and gait disturbances still remain. Levodopa and Carbidopa inhibits the conversion of levodopa to dopamine in No major signifi cance. carbidopa the systemic circulation and liver, thus increasing the amount of levodopa available to cross the blood-brain barrier, decreasing the adverse systemic eff ects of levodopa. Levodopa, carbidopa Entacaptone reduces O-methylation of levodopa in the No major signifi cance. and entacapone gastrointestinal tract, leading to an increase in the amount of levodopa available to cross the blood-brain barrier. Pramipexole Dopamine agonist, provides long-lasting direct stimulation of Orthostatic hypotension, nausea, vomiting, confusion, dopamine receptors. hallucinations. Rasagiline Rasagiline blocks monoamine oxidase B from metabolizing Patients develop dyskinesia and headache (less than dopamine in the brain, prolonging the eff ects of the co- 10 percent). administered levodopa. Ropinirole Dopamine agonist, provides long-lasting direct stimulation of Orthostatic hypotension, nausea, vomiting, confusion, dopamine receptors. hallucinations. Selegiline Selegiline blocks monoamine oxidase B from metabolizing Cardiac dysrhythmias and possible sensitivity to dopamine in the brain, prolonging the eff ects of the often sympathomimetics due to the presence of the amphetamine coadministered levodopa; selegiline gets metabolized in liver to byproducts. form amphetamine byproducts. Trihexyphenidyl An anticholinergic medication useful in treating tremor but less Confusion, blurred vision, worsening of glaucoma, urinary useful in correcting muscle rigidity and bradykinesia. retention, cardiac dysrhythmias.

the inability to initiate voluntary and resistance to passive movement of an is also seen and turning while walking involuntary movements, which is akinesia extremity around a joint (e.g., wrist and cannot be a single pivoting maneuver. characterized by reduced facial expression, elbow), known as cogwheel rigidity.1,21 Postural instability and gait disturbance reduced frequency of blinking, swallowing Patients also have a feeling of are the major disabling features leading or diffi culty with normal activities like imbalance or postural instability. They to falls that can cause injury and dressing, bathing or rising from a chair, walk with a stooped posture, head leaning hamper patients’ independence.1,3,21 resulting in an overall sense of weakness forward, knees and hips bent and reduced The other symptoms may include or fatigue. There is rigidity of skeletal arm swing. They fi nd it diffi cult to initiate variations in blood pressure, mostly muscles due to an increased tone and walking and have short and shuffl ing seen as orthostatic hypotension, cardiac is expressed as smooth or ratchet-like steps. The phenomenon of festination dysrhythmias, excessive sweating and

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TABLE 3 Dental Treatment Modifications and Drug Administration Precautions1

Dental treatment Modifi cation in treatment Appointing patients Patient’s physician consultation to determine stage of Parkinson’s disease (PD), patient’s cognitive ability to provide consent and to know presence of any comorbid illnesses which might require treatment modifi cation. Treatment planning Major dental interventions should be completed at the earliest in the course of disease because of the disease’s progressive debilitating nature followed by a conservative approach in later stages of disease. Schedule appointment Short appointments of about 45 minutes or less and should begin approximately around 90 minutes after administration of PD medication; patient should empty the bladder and should be assisted into dental chair. During treatment mouth prop can be used to keep mouth open, chair inclination should be 45 degrees, rubber dam and high-volume oral evacuation should be used to protect airway. Surgical treatment requiring For patients receiving levodopa and/or entacapone, LA administration should be limited to three cartridges of 2% lidocaine with administration of local 1:100,000 epinephrine per 30-minute period to prevent tachycardia and hypertension; avoid prescribing erythromycin anesthetic (LA) agent and ampicillin as they interfere with biliary excretion of entacapone. Patients receiving selegiline should not be administered agents containing epinephrine or levonordefrin because of adverse interaction, which may lead to severe hypertension. Administration of pain killers Patients receiving selegiline or rasagiline should not be prescribed meperidine hydrochloride because of a severe interaction that may result in severe hyperthermia, hypertension and tachycardia; however, other narcotic analgesics at one-half usual dosage may be prescribed. Maintenance of oral hygiene The patient, as well as the caregiver, should be given written instructions on good oral hygiene maintenance techniques as the cognitive impairment and loss of motor skills during the disease process may hamper the patient’s ability to maintain good oral hygiene. bladder, bowel and sexual dysfunction.3,21 mobility of the tongue and jaw, rigidity Management Sleep disorders like insomnia, sleep and muscle tremors complicate the The line of treatment for PD involves apnea and sleep fragmentation leading to formation and the placement of the the use of medications and symptomatic daytime drowsiness are common.21 Other food bolus followed by diffi culty with treatment to combat the disabling nature behavioral disturbances may include chewing and swallowing further leading of the disease. Surgical management depression, cognitive impairment and to dysphagia.3,22 The drooling saliva involving deep brain stimulation, dementia due to primary illness as well as from the corner of the mouth results in stereotactic thalamotomy, etc., may be psychosis due to the use of dopaminergic angular cheilitis, skin irritation and foul needed for the severe cases of disability. medications.1,21 The cognitive odor. Patients cannot close their mouths Physiotherapy and speech therapy also impairment can lead to dementia, fully, showing an anterior bowed-head play an important role. Speech therapists impaired visual motor skills and verbal position. Their voices becomes soft, teach the patients various strategies fl uency. Medication-induced psychosis monotonous, more like mumbling, and to overcome the diffi culties of slowed may also be seen in the form of visual they speak hurriedly. In advanced stages refl exes. Dietitians recommend cutting hallucination, which if not treated further of the disease, the speech is a whispering food into smaller pieces and altering its progresses to paranoid delusions.1,3,21 type due to increased muscle rigidity. texture and consistency to help in easy The orofacial muscle tremors can be bolus formation and swallowing.1,3,22 Oral Manifestations a prerequisite for bruxism, attrition or Swallowing management compensates PD patients show a typical mask- cracked teeth syndrome.1,3 Poor oral for diffi culties in the swallowing like appearance of the face with hygiene and the presence of xerostomia process and aims to maintain a safe lip-pursing. Other fi ndings include increase the chances of carious lesions oral feeding as long as possible.26 xerostomia or drooling saliva from the and periodontal diseases.3,23 Along with Some researchers have claimed corner of the mouth, angular cheilitis, these, around 24 percent of patients increased incidence of root caries orofacial muscle tremors and dysphagia. show manifestations of burning mouth in patients with PD.27 There is also The taste sensations are altered due syndrome, characterized by a burning signifi cantly greater incidence of to the anti-Parkinson’s medications. sensation of the hard palate, tongue, fl oor periodontal involvement in these patients, Masticatory functions are impaired of the mouth, cheek mucosa and the lips probably due to the decreased manual due to reduced speed and frequency irrespective of the patient being dentulous, dexterity and inability to maintain oral of the jaw movements.22 Reduced edentulous or a denture wearer.24,25 hygiene.28 Edentulism is commonly seen in

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these patients due to advanced periodontal cognitive abilities decline.36 The treatment head movements may interfere with disease.29 The orofacial musculature plan must take into account the patient’s the treatment procedure. To overcome tremors and the use of levodopa- prognosis with respect to immediate this, an intraoral rubber bite block or containing medications lead to bruxism. versus long-term dental needs.1,35 The extraoral ratchet type prop should be Dentists should examine the dentition of patient should be scheduled for early used. The chair should not be inclined these patients for excessive loss of tooth morning appointments as the symptoms more than 45 degrees to facilitate the structure.30,31 The dentist should consult are least bothersome for 60 to 90 minutes patient’s swallowing. Saliva can be the patient’s physician to discuss the after taking medicine. Duration of the aspirated regularly using an aspirating possibility of changing the medication or appointment should not be more than tip under the rubber dam, maintaining even fabricating a prosthetic appliance 45 minutes. The patient should be asked a dry fi eld and thereby avoiding to protect the dentition if necessary.32 to empty the bladder before entering the contamination of restorative material The ergot-derived dopamine agonist dental operatory to prevent incontinence and also protecting the tongue from cabergoline has been known to damage and urinary urgency.1,3,35 The dental injury.29,41,42 The rubber dam also provides heart valves and predispose patients chair should be raised slowly, allowing protection to the airway because patients to endocarditis.33 The dentist should with PD are in danger of aspiration enquire with the patient or the caregiver secondary to diminished cough refl ex.43 and physician regarding use of these medications. The American Heart It is best to complete Restorative Treatment Association criteria should be met for restoration of oral health as The optimum restorative materials for patients who have bacterial endocarditis early as possible because the carious lesions in these patients include or a prosthetic cardiac valve and require glass ionomers and resin-modifi ed glass an antibiotic prophylaxis regimen during patient’s ability to cooperate ionomers. They can also be used to restore dental procedures involving surgical decreases as functional and root surface caries as they bond well to intervention or manipulation of gingival cognitive abilities decline. the dentin as well as the cementum and tissue or the periapical region of teeth.34 release fl uoride.1,3,35 A case report has shown successful use of composite resins Dental Treatment to restore multiple decayed teeth.44 Dental treatment precautions and the patient to adjust in an upright sitting treatment modifi cations, if any, should position to avoid orthostatic hypotension Surgical Intervention be taken into consideration as shown in or possibility of syncopal episode.37,38 The dentist must take precautions TABLE 3.1 The dentist must consult with Patients with cognitive defi cits may show while administering local anesthetic the patient’s physician before starting anxiety or frustrated behavior due to agents containing epinephrine for dental treatment for any modifi cation unfamiliar circumstances, but this can be patients being treated with levodopa and in the current treatment plan and for avoided by using relaxation and diversion entacapone-containing medications as necessary information regarding stage methods.39 Therefore, the dentist must these patients may exhibit an exaggerated of the disease, the patient’s cognitive start by introducing himself to the patient. effect on blood pressure and heart ability to provide consent for treatment, Using short sentences and simple words rate.45 Therefore, it is very important to prognosis of the disease, drug regimen may help ease any of the patient’s anxiety. administer not more than 0.05 milligrams and identifi cation of any other systemic Direct eye contact, a smile and gentle of epinephrine as found in three conditions (for example, a history of touch can help to obtain maximum cartridges of 2% lidocaine with 1:100,000 endocarditis) that may infl uence the cooperation from the patient.1,35 The epinephrine at every 30-minute period, treatment plan.1,3,35 Informed written caregiver should be allowed to sit next with careful aspiration in order to avoid consent must be obtained from the patient to the patient to reduce stress, anxiety intravascular administration. It is highly or caregiver.35 It is best to complete or even distract the patient.40 Because recommended to monitor patient’s vital restoration of oral health as early as some patients cannot keep their mouth signs.46 Entacapone is excreted in bile and possible because the patient’s ability to wide open for long periods, the drooling the dentist must be cautious whenever cooperate decreases as functional and of saliva, poor control over tongue and prescribing erythromycin and ampicillin

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as both medications are known to Overdentures provide better are present adjacent to labial, buccal, interfere with biliary excretion. In patients masticatory effi ciency when compared to lingual and palatal surfaces of the denture taking monoamine oxidase inhibitors patients wearing conventional complete and incorporating them into the denture.51 (MAOIs), selegiline administration dentures. The abutments for overdentures The linear occlusion concept is one where of epinephrine may result in severe must be self-cleansing to prevent plaque the masticatory surfaces of the mandibular hypertension and hence it is prudent accumulation. Magnets can also be used posterior artifi cial teeth have a straight, to skip a vasoconstrictor containing for easy placement of these dentures.3,35 long, narrow occlusal form resembling local anesthetic in such patients.47 A study has indicated a very good that of a line, usually articulating with Also the dentist should not prescribe satisfactory impact on oral-health- opposing monoplane teeth.50 This concept meperidine hydrochloride to patients related quality of life in PD-affected can be used for teeth arrangement to taking MAOIs selegiline and rasagiline to fi xed partial denture wearers.49 The prevent a combination syndrome where avoid potentially toxic drug interaction margins of the prepared teeth should an edentulous maxillae is opposed leading to severe hyperthermia, be kept supragingival or equigingival. by supraerupted natural mandibular hypertension and tachycardia.48 They Full coverage design should be followed anterior teeth and a mandibular bilateral also increase the potency of other extension-base removable partial narcotic analgesic agents, therefore the denture.50 Nonanatomic teeth for the dentist must prescribe only one-half the maxillary arch and blade form of teeth 1 usual dosage of the narcotic agent. Flexible dentures like on the mandibular arch can be selected to help to stabilize the occlusion in the Partial Dentures (Removable valplast for removable maximal intercuspal position and also to and Fixed) partial dentures can be improve mastication.52 Selective grinding Patients with PD face diffi culty in used to obtain good can be done to remove the occlusal controlling and retaining dentures, interferences and obtain the maximum thereby compromising denture retention, retention and stability. stability and retention of the dentures.3,35 stability and support due to rigidity and Researchers recommend that the denture tremors of the orofacial musculature and be fabricated with metal denture base drooling of saliva.1,3,35 It is advisable to or high-impact denture base resin. The record impressions with quick-setting for maximum retention and resistance. glass-fi ber reinforced denture base can impression materials especially in severe Avoid over contouring as it may cause have 1 percent glass fi ber as chopped cases of PD. Wax or compound can be plaque accumulation followed by gingival strands of 3 mm to increase impact used to record jaw relations due to its hyperplasia. If the patient shows signs strength and also transverse strength so fast setting time.3 Monoplane teeth can of bruxism, resin fused to metal or gold that dentures will not break easily even if be used to establish stable occlusion bridge are advocated. The contacts and the patient drops the denture accidently.52 and reducing the vertical dimension contours of the pontic and retainers slightly helps to accommodate for the should be self-cleansing. Resin cement Complete Dentures jerky mandibular movements.44 should be used for cementation for Stress exacerbates the tremor and For removable partial dentures, the metal copings and fi xed partial dentures uncontrolled movement during treatment. major connectors of smaller design should as it reduces the microleakage.35 Therefore, a compassionate and caring not be used to prevent aspiration and The neutral zone technique and approach with these patients is very choking. Denture retainers should be fl ange technique can be used for making important to overcome the anxiety. designed to provide adequate retention. fi nal impressions. The neutral zone is Implant or tooth-supported overdentures Precision attachments aren’t advocated the potential space between the lips and are known to be more advantageous for as the patients do not have the required cheeks on one side and the tongue on the better proprioception and controlled stable movement for insertion of a other; positioning teeth in this area helps jaw movement.23,53 The patient should prosthesis. Flexible dentures like valplast to equalize the forces between the tongue be taught jaw exercises that will help for removable partial dentures can be used and cheeks or lips.50 The fl ange technique in recording the maxillomandibular to obtain good retention and stability.3 involves recording the soft structures that relationship. Bilateral manipulation

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technique can be used to guide the fi t over a coping, another crown or a to be convenient due to its slow onset mandible to centric relation in patients bar connector or any other suitable of action, retrograde amnesia and with reduced neuromuscular control.54 rigid support for the removable dental prolonged postanesthetic recovery.65 It has been observed that arrangement prosthesis may be an indication.50 Shortened dental arch concept suggests of teeth in the neutral zone enhances Furthermore, the Oral Hygiene Index that at least four occlusal units should the denture stability and retention. needs to be assessed with these patients remain, one unit corresponding to a Researchers have also observed that to determine their ability to carry pair of occluding premolars and a pair of the teeth within the neutral zone do out sufficient implant maintenance.63 occluding molars corresponding to two not interfere with involuntary muscular The implant-prosthodontic treatment units.66,67 The principles of the “shortened movement.55 Cuspless or monoplane teeth with telescopic attachments has dental arch” should be adhered to, keeping are indicated for the patients who exhibit subjectively shown to increase patients’ in mind restoration of anterior aesthetics poor muscular control to compensate for chewing ability. It has also shown to and function. The provision of removable irregular mandibular movement. The enhance oropharyngeal predigestion prostheses to restore the missing posterior lingualized occlusion scheme was fi rst that is necessary in these patients.61 teeth should be avoided, as these have described in 1941 by prosthodontist S. shown to cause higher incidences of caries Howard Payne. This form of denture and periodontal damage.68–71 Mandibular occlusion articulates the maxillary lingual implant overdentures in people with PD cusps with the mandibular occlusal Cuspless or monoplane teeth have shown to have a positive impact surfaces in centric occlusion, working and on gastrointestinal symptoms.60 The nonworking mandibular positions.50 This are indicated for the patients antiparkinsonian medication induces concept can be utilized for the patient who exhibit poor muscular dystonia manifesting as clenching.72 to have the combined advantages of control to compensate for Post-insertion, the prostheses pose better masticatory effi ciency,56,57 limited challenges, such as difficulty in removing lateral movement of denture and lesser irregular mandibular movement. overdentures, fracture of overdentures, distortion of the oral musculature.58,59 It deterioration of remaining natural teeth is also reported to be suitable for patients in the opposing arch and maintenance with involuntary teeth grinding.60 of oral hygiene mainly due to dexterity PD patients are usually prescribed problems as a result of PD.61 Complications Implants levodopa. It is necessary to maintain of overloading due to mandibular Dental implants can provide great a stress-free environment, as stress is parafunction must also be expected along benefi ts to severely handicapped PD known to elevate blood pressure to with an unexpected high level of alveolar patients, mainly by improving chewing dangerous levels. Anesthetic agents like resorption or fi brous replacement of the and predigestion capacity.61 Muscular 3% prilocaine hydrochloride can be used edentulous alveolar ridge. These changes equilibrium is normally required to in combination with vasopressin as it may be seen where a dentate arch opposes stabilize removable prosthesis in static does not produce hypertension during an edentulous arch, mainly due to overload and dynamic conditions. However, surgery combined with intravenous caused by dystonia-induced clenching.72 due to motor system dysfunction, midazolam to reduce anxiety.64 Midazolam Bar retainers have been associated muscular equilibrium is highly reduced also helps in patients who have a severe with gingival hyperplasia.73 Therefore, in PD patients.62 These patients exhibit gag refl ex that may be aggravated ball retainers can be used. They difficulty with precise movements that during an impression procedure in the are easier to clean and will help to pose problems for the insertion, removal maxilla and mandible. It also produces avoid the problem of plaque-induced and cleaning of dental prostheses. The cardiovascular stability during implant gingival hyperplasia. The LOCATOR use of overdenture retaining systems placement surgery performed with overdenture implant system (LODI) can requires a high level of manual dexterity, regional anesthesia, causing minimal be used, though not without problems. which is reduced in these patients. respiratory changes and reducing The use of higher retentive inserts can Telescopic attachments where an artifi cial neurovascular effects. For patients with make it diffi cult for patients with PD to crown or framework is constructed to systemic illnesses, midazolam seems remove the overdenture, while lighter

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Management

Physiotherapy Symptomatic Surgical Dental Medical Medical and speech treatment

Deep-brain Reduce rigidity Fixed Dopamine Orthostatic stimulation of the and correct Antidepressants Antipsychotic prosthodontic precursors hypotension motor components abnormal treatment of the subthalamic posture nucleus

Electrical stimulation Selective results in inhibition Help in Dopamine serotonin Reduction in Dosage Shortened of movement dysphonia and agonist reuptake dosage modifi cation dental arch and sustained dysarthria inhibitors improvement

Atypical Tricyclic Support Stereotactic neuroleptic All-on-4 antidepressants stockings thalamotomy agents

Implantation Increased of the fetal LOCATOR intake of fl uids midbrain cells system and sodium into basal ganglia

Stem cell therapy

FIGURE. Oral hygiene maintenance tree diagram. retentive inserts can displace it during the magnetic assembly and thus has cantilever arm, improved interimplant function and allow accumulation of an added advantage that allows use in distance as well as improved anchorage food debris in the recess at the top of limited interocclusal space. They can in the bone.74 Liu et al. recommended the LODI abutment, preventing the also be used in cases where angulation the use of the All-on-4 concept for seating of the central “post” of the nylon and position of implants is not ideal.53 successful mandibular rehabilitation. insert into the abutment. This problem Paulo Malo, DDS, PhD, developed It is a minimally invasive, time- and can be overcome by training caregivers the All-on-4 concept where the straight cost-effective technique and has on how to replace the inserts.73 and angled multiunit abutments are used shown no complication in the one- Implant-supported, magnet-retained to provide an immediately loaded full year follow-up period and improved overdentures can be used in patients arch restoration with only four implants ability of mastication and quality of with poor muscular control as magnets in edentulous patients. This method life.75 Beech and Farrier reported in provide adequate retentive force for the advocates tilting of distal implants a study that the use of intermaxillary prosthesis. When compared with the bar in edentulous arches that enable the fi xation screws can serve as an or ball attachments, the vertical height placement of longer implants, improved alternative to dental titanium implants required is only 2–3 mm to accommodate prosthetic support with a shorter for complete denture retention.76

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Implant treatment for the patient agents such as chlorhexidine gluconate Medicine 2016; 44(9):542–546. in the early stages of PD would improve should not be prescribed as many of the 9. Schapira AH. Treatment options in the modern their quality of life and overall contribute patients may not be able to swish and management of Parkinson disease. Arch Neurol 2007 Aug;64(8):1083–1088. 52 to improved general management of PD. expectorate to minimize ingestion. The 10. Ciarrocca KN, Greenberg MS, Garfunkel A. Dyskinesia being less severe in early stages dentist should provide a thorough clinical Neuromuscular diseases. In: Greenberg MS, Glick M eds. of PD allows for greater surgical precision examination and oral prophylaxis, including Burket’s oral medicine: Diagnosis and treatment. 10th ed. Harcourt (India) Private Limited 2003:597–598. followed by subsequent improvement application of topical fl uorides like 5 11. Hilker R, Thomas AV, Klein JC, et al. Dementia in Parkinson in successful implant integration, better percent fl uoride varnish, at follow-up visits disease: Functional imaging of cholinergic and dopaminergic mobility making it easier for the individual every three months.79 This management pathways. Neurology 2005 Dec 13;65(11):1716–1722. 12. Frisina PG, Haroutunian V, Libow LS. The neuropathological to cope with the implant surgery and the is summarized as seen in the FIGURE. basis for depression in Parkinson’s disease. Park Relat Disord follow-up dental appointments required 2009 Feb;15(2):144–148. to provide the prostheses, limitation of 13. Truong DD, Bhidayasiri R, Wolters E. Management of Conclusion nonmotor symptoms in advanced Parkinson’s disease. J Neurol denture discomfort and better denture Keeping in mind these challenges, Sci 2008 Mar 15;266(1–2):216–28. Epub 2007 Sep 4. control. This can lead to an improved clinicians should prioritize to preserve the 14. Korchounov A, Kessler KR, Yakhno NM, Damulin quality of life that can further help the dentition of patients with PD.73 Fiske and IV, Schipper H. Determinants of autonomic dysfunction in idiopathic Parkinson’s disease. J Neurol 2005 patient and reduce the depression that Hyland have recommended that clinicians Dec;252(12):1530–6. is often associated with progressive should intervene early after the diagnosis 15. Schapira AH, Obeso J. Timing of treatment initiation in neurological disorders. Studies suggest that of PD and initiate a preventive regimen Parkinson’s disease: A need for reappraisal? Ann Neurol 2006; 59(3):559–562. implant retained/supported prostheses as a fi rst priority with professional support 16. Aminoff MJ. Treatment should not be initiated too soon in should be considered as a first line of to patients and caregivers to maintain an Parkinson’s disease. Ann Neurol 2006 Mar;59(3):562–564. treatment for people with PD to overcome optimum level of oral hygiene. This will help 17. de Lau LM, Schipper CM, Hofman A, Koudstaal PJ, Breteler M. Prognosis of Parkinson disease: Risk of dementia future denture problems as their PD the clinician to provide simple, high-quality and mortality — the Rotterdam Study. Arch Neurol 2005 progresses.23 Klineberg recommended an restorations to maintain the dentition Aug;62(8):1265–1269. occlusal design with narrow occlusal table and arrange for regular follow-ups.27 ■ 18. Clark CE, Davies P. Systematic review of acute levodopa and apomorphine challenge tests in the diagnosis of idiopathic and central fossa loading in intercuspal Parkinson’s disease. J Neurol Neurosurg Psychiatry 2000 contact and also low cusp inclination. REFERENCES Nov;69(5):590–594. Occlusal canine guidance instead of 1. Friedlander AH, Mahler M, Norman KM, Ettinger RL. 19. Tolosa E, Wenning G, Poewe W. The diagnosis of Parkinson disease systemic and orofacial manifestations, Parkinson’s disease. Lancet Neurol 2006 Jan;5(1):75–86. group function has also been proposed medical and dental management. J Am Dent Assoc 2009 20. Hoehn MM, Yahr MD. Parkinsonism: Onset, progression in patients with oral parafunction.77 Jun;140:658–669. and mortality. 1967. Neurology 1998 Feb;50(2):318 and 16 2. Suchowersky O, Reich S, Perlmutter J, Zesiewicz T, Gronseth pages following. G, Weiner WJ, et al. Practice parameter: Diagnosis and 21. Postuma RB, Berg D, Stern M, Poewe W, Olanow CW, Oral Hygiene Maintenance prognosis of new onset Parkinson’s disease (an evidence-based Oertel W, et al. MDS clinical diagnostic criteria for Parkinson’s Moisture-based denture adhesives review): Report of the Quality Standards Subcommittee of the disease. Mov Disord 2015 Oct;30(12):1591–1601. or artifi cial salivary substitutes can be American Academy of Neurology. Neurology 2006; Apr 11 22. Zlotnik Y, Balash Y, Korczyn AD, Giladi N, Gurevich 66:968–975. T. Disorders of the oral cavity in Parkinson’s disease and prescribed depending on the patient’s 3. Rajeswari CL. Prosthodontic considerations in Parkinson’s parkinsonian syndromes. Parkinsons Dis 2015;2015:379482. requirements.78 Denture cleansers should disease. Abstract : Introduction: Orofacial fi ndings. Peoples J doi: 10.1155/2015/379482. Epub 2015 Jan 15. be prescribed to maintain proper denture Sci Res 2010;3(July):2–4. 23. Packer M, Nikitin V, Coward T, Davis DM, Fiske J. The 4. Singhal B, Lalkaka J, Sankhla C. Epidemiology and potential benefi ts of dental implants on the oral health quality hygiene. Oral hygiene instructions, such treatment of Parkinson’s disease in India. Parkinsonism Relat of life of people with Parkinson’s disease. Gerodontology as regular toothbrushing, fl ossing and Disord 2003 Aug;9 Suppl 2:S105–109. 2009 Mar;26(1):11–18. doi: 10.1111/j.1741- fl uoride application, should be explained 5. Goldman SM, Tanner C. 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Robbins J, Butler SG, Daniels SK, Gross RD, Langmore S, should be advocated to clean abutment Gastrointestinal Dysfunctions in Parkinson’s Disease: Symptoms Lazarus CL, et al. Swallowing and dysphagia rehabilitation: and Treatments. Parkinsons Dis 2016;2016:6762528. doi: Translating principles of neural plasticity into clinically teeth of the telescopic denture and to 10.1155/2016/6762528. Epub 2016 Dec 6. oriented evidence. J Speech Lang Hear Res 2008 35 Feb;51(1):S276–300. prevent plaque retention. Oral rinse 8. Gray W, Caroline H, Worth PF. Parkinson’s disease.

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27. Fiske J, Hyland K. Parkinson’s disease and oral care. Dent 45. Gansberg S. Neurological drugs. In: Ciancio SG ed. induced marginal tissue reactions of osseointegrated oral Update 2000 Mar;27(2):58–65. 3rd ed. ADA Guide to Dental Therapeutics. ADA Publishing implants: A review of the literature [Review]. Clin Oral Impl Res 28. Schwarz J, Heimhilger E, Storch A. Increased 2003;366–381. 1992 Dec;3(4):149–161. periodontal pathology in Parkinson’s disease. J Neurol 2006 46. Little JW, Falace DA, Miller CS, Rhodus NL. Dental 64. Sunada K. A study on vasoconstrictors contained in local May;253(5):608–611. Management of the Medically Compromised Patient. 6th ed. St anesthetic solutions — clinically safe dosage of felypressin in 29. Nakayama Y, Washio M, Mori M. Oral health conditions Louis: Mosby; 2002;432. essential hypertension [in Japanese]. J Jpn Dent Soc Anesth in patients with Parkinson’s disease. J Epidemiol 2004 47. Chen JJ, Swope DM. Clinical pharmacology of 1992; 20:521–532. Sep;14(5):143–150. rasagiline: A novel, second-generation propargylamine for 65. Kubo K, Kimura K. Implant surgery for a patient with 30. Byrne BE. Oral manifestations of systemic agents. In: Ciancio the treatment of Parkinson disease. J Clin Pharmacol 2005 Parkinson’s disease controlled by intravenous midazolam: SG, ed. ADA Guide to Dental Therapeutics. 3rd ed. Chicago: Aug;45(8):878–894. A case report. Int J Oral Maxillofac Implant 2004 Mar– American Dental Association; 2003:504–550. 48. Yagiela JA. Adverse drug interactions in dental practice: Apr;19(2):288–290. 31. Winocur E, Gavish A, Voikovitch M, Emodi-Perlman A, Eli Interactions associated with vasoconstrictors — part V of a series. J 66. Fernandes VA, Chitre V. The shortened dental arch concept: I. Drugs and bruxism: A critical review. J Orofac Pain 2003 Am Dent Assoc 1999 May;130(5):701–709. A treatment modality for the partially dentate patient. J Indian Spring;17(2):99–111. 49. Pullishery F. Oral health-related quality of life in patients with Prosthodont Soc 2008;8:134–139. 32. Durham TM, Hodges ED, Henry MJ, Geasland J, Straub P. Parkinson’s disease wearing fi xed partial dentures — A prospective 67. Kanno T, Carlsson GE. A review of the SDA concept focusing Management of orofacial manifestations of Parkinson’s disease study. Parkinsonism Relat Disord 2016 Jan;22:e62–63. on the work by the Kayser/Nijmegen group. J Oral Rehab 2006 with splint therapy: A case report. Spec Care Dent 1993 Jul– 50. The Glossary of Prosthodontic Terms. J Prosthet Dent 2017 Nov;33(11):850–852. Aug;13(4):155–158. Jun;117(5):e1–e105. 68. Käyser AF. Shortened dental arch: A therapeutic concept in 33. Kenangil G, Ozekmekçi S, Koldas L, Sahin T, Erginöz E. 51. Lott F, Levin B. Flange technique: An anatomic and reduced dentitions and certain high-risk groups. Int J Periodontol Assessment of valvulopathy in Parkinson’s disease patients on physiologic approach to increased retention, function, comfort Restor Dent 9(6):426–449. pergolide and/or cabergoline. Clin Neurol Neurosurg 2007 and appearance of dentures. J Prosthet Dent 1966 May– 69. Budtz-Jørgensen E, Insidor F. A fi ve-year longitudinal study May;109(4):350–353. Jun;16(3):394–413. of cantilevered fi xed partial dentures compared with removable 34. Wilson W, Taubert KA, Gewitz M, et al. IWG. Prevention 52. Tamin HZ, Angelia V. Management of Immediate Complete partial dentures in a geriatric population. J Prosthet Dent 1990 of infective endocarditis: Guidelines from the American Heart Denture, Overdenture and Telescopic Denture of Patient With Jul;64(1):42–47. Association — a guideline from the American Heart Association Parkinson ’s Disease (Case Report). IOSR J Dent Med Sci 2016 70. Isidor F, Budtz-Jørgensen E. Periodontal conditions Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Dec;5(12):56–65. following treatment with distally extending cantilever bridges Council on Cardiovascular Disease in the Young, and the 53. Chu FCS, Deng FL, Siu ASC, Chow TW. Implant-tissue or removable partial dentures in elderly patients. A fi ve-year Council on Cardiovascular Disease in the Young, and the supported, magnet-retained mandibular overdenture for an study. J Periodontol 1990 Jan;61(1):21–26. Council on Clinical Cardiology, Council on Cardiovascular edentulous patient with Parkinson’s disease: A clinical report. J 71. Jepson NJA, Moynihan PJ, Kelly PJ, Watson GW, Thomason Surgery and Anesthesia, and the Quality of Care and Outcomes Prosthet Dent 2004 Mar;91:219–222. JM. Caries incidence following restoration of shortened lower Research Interdisciplinary Working Group. J Am Dent Assoc 54. Kantor ME, Silverman SI, Garfi nkel L. Centric relation dental arches in a randomised controlled trial. Br Dent J 2001 2007;138(6):739–45,747–60. recording techniques — a comparative investigation. J Prosthet Aug;191(3):140–144. 35. Bashir U, Bathala L, Rajesh NaiduT N. Prosthodontic Dent 1972 Dec;28(6):593–600. 72. Diz P, Scully C, Sanz M. Dental implants in the medically Management in Parkinson’s Disease — A Review. IJSRST 55. Beresin VE, Schiesser FJ. The neutral zone in complete compromised patient. J Dent 2013 Mar;41(3):195–206. doi: 2016;1(1):51–53. dentures. J Prosthet Dent 1976 Oct;36(4):356–367. 10.1016/j.jdent.2012.12.008. Epub 2013 Jan 11. 36. Lobbezoo F, Naeije M. Dental implications of some common 56. Clough HE, Knodle JM, Leeper SH, Pudwill ML, Taylor DT. A 73. Packer ME. Are Dental Implants the Answer to Tooth movement disorders: A concise review. Arch Oral Biol 2007; comparison of lingualized occlusion and monoplane occlusion in Loss in Patients With Parkinson’s Disease? Prim Dent J 2015 52(4):395–398. complete dentures. J Prosthet Dent 1983 Aug;50(2):176–179. May;4(2):35–41. doi:10.1308/205016815814955091. 37. Collins R. Special considerations for the dental patient with 57. Inoue S, Kawano F, Nagao K, Matsumoto N. An in vitro study 74. Taruna M, Chittaranjan B, Sudheer N, Tella S, Abusaad M. Parkinson’s disease. Tex Dent J 1990 Mar;107(3):31–32. of the infl uence of occlusal scheme on the pressure distribution Prosthodontic Perspective to All-On-4 Concept for Dental Implants. 38. Alexander RE, Gage TW. Parkinson’s disease: An update for of complete denture supporting tissues. Int J Prosthodont 1996 J Clin Diagn Res 2014 Oct;8(10):ZE16–ZE19. dentists. Gen Dent 2000 Sep–Oct;48(5):572–80. Mar–Apr;9(2):179–187. 75. Liu FC, Su WC, You CH, Wu AY. All-on-4 concept 39. Corah NL, Gale EN, Illig SJ. The use of relaxation and 58. Ohguri T, Kawano F, Ichikawa T, Matsumoto N. implantation for mandibular rehabilitation of an edentulous distraction to reduce psychological stress during dental Infl uence of occlusal scheme on the pressure distribution patient with Parkinson disease: A clinical report. J Prosthet procedures. J Am Dent Assoc 1979 Mar;98:390–394. under a complete denture. Int J Prosthodont 1999 Jul– Dent 2015 Dec;114(6):745–750. doi:10.1016/j. 40. Dissanayaka NN, Sellbach A, Matheson S, O’Sullivan JD, Aug;2(4):353–358. prosdent.2015.07.007. Epub 2015 Sep 26. Silburn PA, Byrne GJ, Marsh R, Mellick GD. Anxiety disorders 59. Sutton AF, McCord JF. A randomized clinical trial 76. Beech A, Farrier J. The novel use of intermaxillary fi xation in Parkinson’s disease: Prevalence and risk factors. Mov Disord comparing anatomic, lingualized and zero-degree posterior screws as denture abutments in a Parkinson’s patient — case 2010 May15;25:838–845. doi:10.1002/mds.22833. occlusal forms for complete dentures. J Prosthet Dent 2007 report. Br J Oral Maxillofac Surg 2016;1–3. 41. Solomon NP, Robin DA. Perceptions of eff ort during handgrip May;97(5):292–298. 77. Lumetti S, Ghiacci G, Macaluso GM, et al. Tardive Dyskinesia, and tongue elevation in Parkinson’s disease. Park Relat Disord 60. Inada M, Yamazaki T, Shinozuka O, Sekiguchi G, Tamamori Oral Parafunction and Implant-Supported Rehabilitation. Case 2005 Sep;11(6):353–361. Y, Ohyama T. Complete denture treatments for a cerebral palsy Rep Dent 2016 Jan;1–7. 42. El Sharkawi A, Ramig L, Logemann JA, et al. Swallowing and patient by using a treatment denture. A case report. J Med Dent 78. Turner M, Jahangiri L, Ship JA. Hyposalivation, xerostomia voice eff ects of Lee Silverman Voice Treatment (LSVT): A pilot Sci 2002 Dec;49(4):171–177. and the complete denture — A systematic review. J Am Dent Assoc study. J Neurol Neurosurg Psychiatry 2002 Jan;72(1):31–6. 61. Heckmann SM, Heckmann JG, Weber HP. Clinical 2008 Feb;139(2):146–150. 43. Pitts T, Bolser D, Rosenbek J, Troche M, Sapienza C. Voluntary outcomes of three Parkinson’s disease patients treated with 79. Brailsford SR, Fiske J, Gilbert S, Clark D, Beighton D. The cough production and swallow dysfunction in Parkinson’s disease. mandibular implant overdentures. Clin Oral Implants Res 2000 eff ects of the combination of chlorhexidine/thymol- and fl uoride Dysphagia 2008 Sep;23(3):297–301. doi:10.1007/s00455- Dec;11(6):566–571. containing varnishes on the severity of root caries lesions in frail 007-9144-x. Epub 2008 May 16. 62. Soykan I, Sarosiek I, Shiffl ett J, Wooten GF, McCallum RW. institutionalised elderly people. J Dent 2002 Sep–Nov;30(7– 44. Al-Omari FA, Al Moaleem MM, Al-Qahtani SS, Al Garni Eff ect of chronic oral domperidone therapy on gastrointestinal 8):319–324. AS, Sadatullah S, Luqman M. Oral Rehabilitation of Parkinson’s symptoms and gastric emptying in patients with Parkinson’s Disease Patient: A Review and Case Report. Case Rep Dent disease. Mov Disord 1997 Nov;12:952–957. THE CORRESPONDING AUTHOR, Snehal Sanjay Jaiswal, BDS, can 2014;2014: 1–4. 63. Schou S, Holmstrup P, Hjorting-Hansen E, Lang NP. Plaque- be reached at [email protected].

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Periodontal Disease Contributes to Obstructive Sleep Apnea

Scott E. Schames, DDS; Orr Shauly, BS; Rita Y. Chuang, DDS; Kaitlyn Tarbert, RDH; Hila Robbins, DMD; and Michael Jordan, RN, MSN, MBA

ABSTRACT Periodontal disease (PD) is associated with obstructive sleep apnea (OSA) by a postulated bidirectional causal-effect relationship of PD and OSA through systemic infl ammation. PD may contribute to OSA through aspiration of periodontal bacterial pathogens into the lungs, causing a decrease in lung function that consequently contributes to OSA. Xerostomia also plays a role in increasing the surface tension of the upper airway lining liquid and resultantly contributes to OSA.

AUTHORS

Scott E. Schames, DDS, Rita Y. Chuang, DDS, is a Kaitlyn Tarbert, RDH, is a Hila Robbins, DMD, is a eriodontal disease (PD) is a is in the orthodontic board-certifi ed orthodontist. registered dental hygienist, pediatric dentist, certifi ed chronic, complex, biofi lm-based specialty residency at She serves on the board of myofunctional therapist Gyrotonic/Gyrokinesis oral bacterial infection affecting the the Georgia School of the American Association and a clinical instructor at instructor, certifi ed Buteyko supporting structures of the teeth.1 Orthodontics in Atlanta. of Orthodontics and is a the Craniofacial Pain/TMJ breathing educator, Confl ict of Interest senior clinical instructor at Clinic at White Memorial myofunctional therapist and It is estimated that approximately Disclosure: None reported. the Craniofacial Pain/TMJ Medical Center in Los senior clinical instructor at P47.2 percent of the adult U.S. population Clinic at White Memorial Angeles. the Craniofacial Pain/TMJ is infected with PD.2 The oral cavity is Orr Shauly, BS, is a Medical Center in Los Confl ict of Interest Clinic at White Memorial an optimal environment for bacterial medical student (class of Angeles. She is a diplomate Disclosure: None reported. Medical Center in Los growth due to its high humidity and warm 2021) at the Keck School of the American Board of Angeles. She is also a 3 of Medicine of USC and Orthodontics and served as diplomat of the American temperature. As a result, periodontal is a medical researcher at the clinical director at the Board of Pediatric Dentistry. biofi lm is rich with many harmful aerobic the Craniofacial Pain/TMJ University of Pennsylvania Confl ict of Interest and anaerobic bacteria.1 These gram Clinic at White Memorial Dental Medicine’s Disclosure: None reported. negative and spirochete pathogens can Medical Center in Los department of orthodontics. enter the bloodstream and cause bacteremia, Angeles. Confl ict of Interest Michael Jordan, RN, Confl ict of Interest Disclosure: None reported. MSN, MBA, is the resulting in an infl ammatory response in 1 Disclosure: None reported. manager of the clinical the body. Risk factors for PD include, but research program at White are not limited to, poor oral hygiene, age, Memorial Medical Center in xerostomia, stress, lack of sleep, bruxism, Los Angeles. cortisol production and smoking status.4 Confl ict of Interest Disclosure: None reported. PD has been linked to cardiovascular disease, diabetes, stroke, preterm birth, COPD, cancer and renal failure. Most recently it has been linked to obstructive sleep apnea (OSA).1 Conventional treatment of PD includes mechanical debridement and antibacterial therapy.5

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Obstructive Sleep Apnea compounded six articles in a meta-analysis While this reasoning may be true, OSA is a breathing-related sleep to conclude that there is a plausible we assume that PD contributes to OSA disorder characterized by partial or association between PD and OSA.1 through the aspiration of periodontal complete collapse of the upper airway The association between PD and OSA pathogens directly into the lungs, during sleep, causing a reduction has been postulated to be a bidirectional creating a local infl ammatory infection, (hypopnea) or cessation (apnea) of causal-effect relationship through which decreases expiratory lung function airfl ow.6 OSA is diagnosed by a medical systemic infl ammation,1,13,16–22 where both and ultimately contributes to OSA. physician through a polysomnogram diseases are associated with an increase It is known that individuals with sleep study, using the apnea-hypopnea in systemic infl ammatory markers.15–18,21,22 PD have elevated levels of periodontal index (AHI), where the minimum The characteristic systemic infl ammatory pathogens and infl ammatory cytokines requirement for the diagnosis of OSA is cytokines correlated with OSA are within their periodontal tissues and at least an average of fi ve episodes per interleukin-B (IL-B), interleukin-6 (IL- in their saliva.15 Research shows hour of cessation of airfl ow.7 OSA affects 6), tumor necrosis factor-alpha (TNFα) that aspiration of a small amount of approximately 24 percent of adults and 1–4 and C-reactive protein (CRP).1 The saliva is normal even among healthy percent of children.8,9 OSA causes sleep subjects and that aspiration of PD fragmentation, an increase in sympathetic pathogens may cause damage to the activity and a decrease in oxygen airways.24,28 It is also important to note saturation in the blood.6 Risk factors for The association between that patients with OSA or snoring OSA include, but are not limited to, age, PD and OSA has been have an increased risk seven times 31,32 obesity and craniofacial abnormalities postulated to be a greater for swallowing disorders. of a high-arched palate leading to nasal Jaghagen et al. (2013) found that of 66 obstruction and mouth breathing.10 bidirectional causal-eff ect patients with OSA, 52 percent were OSA has been associated with daytime relationship through shown to have subclinical swallowing sleepiness, behavioral disorders in children, systemic infl ammation. dysfunctions compared to 7 percent of hypertension, diabetes, cardiovascular controls.31 This phenomenon increases disease, myocardial infarction, stroke the risk for OSA patients to aspirate and death.10–12 Routine treatment of harmful periodontal pathogens. PD is OSA includes CPAP, mandibular infl ammatory cytokines associated with associated with a decrease in expiratory advancement oral appliances and surgery.6 PD include but are not limited to IL-6, IL- volumes and overall lung function due B, IL-21, CRP and fi brinogen.15,19,20 Nizam to aspirated pathogens.25–29 During Periodontal Disease Is Associated et al. (2014) found an increase of IL-6 in apnea, the upper airway collapses upon With Obstructive Sleep Apnea patients with OSA regardless of severity, inhalation, which increases the pressure The link between PD and OSA was which refl ects the degree of subclinical needed to reopen the closed airway.30 If fi rst studied in 2009, when Gunaratnam infl ammation within periodontal tissues, a person’s lung function is compromised et al. found that PD was prevalent in identifying a possible correlation between due to concurrent diseases like PD, it 77 percent of patients with OSA.13 PD and OSA.15 More recently, Gamsiz- will suppress their ability to overcome In 2013, Seo et al. found a signifi cant Isik et al. (2017) found higher levels of an apneic episode. Therefore, it is with correlation of PD and OSA, where IL-B and CRP in the gingival crevicular reasonable medical probability that PD 60 percent of patients with OSA also fl uid in patients with OSA, indicating contributes to OSA through aspiration exhibited PD.14 Nizam et al. (2014) that OSA may increase the risk of PD.23 of PD pathogens into the lungs causing documented that there was a signifi cant Other studies found an increase of IL-B a resultant decrease in lung function, change in the composition of microbes within the saliva and gingival tissue of which inhibits an individual’s ability in the oral plaque, particularly in patients with PD, which may contribute to to overcome an apneic event. severe OSA patients, and concluded OSA.19,20 Overall, the studies hypothesized The pathogenesis between PD and that the incidence and duration of that comorbidity of PD and OSA are chronic obstructive pulmonary disease apnea events positively correlated with due to the overlap in the infl ammatory (COPD) similarly outlines our hypothesis PD severity.15 Al-Jewair et al. (2015) responses from both disorders.1,13,16–22 for PD as a contributing factor to OSA.

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Periodontal Disease and Chronic from PD directly into the lungs has been Kirkness et al. (2005) found no Obstructive Pulmonary Disease: shown to cause respiratory infl ammation, signifi cant difference in surface tension Connecting the Dots a decrease in expiratory volumes and between fl uid sampled from under the Chronic obstructive pulmonary disease an overall decrease in lung function, tongue and the posterior oropharyngeal (COPD) is a chronic obstruction of airfl ow subsequently leading to COPD.25–29 wall.48 This demonstrated that swallowing with excess production of sputum resulting Moreover, it is important to note coats the upper airway with saliva and that from chronic bronchitis-increased mucosa that the treatment of PD has been saliva is a primary constituent/surfactant in the airways and emphysema-distention shown to improve symptoms of COPD, of the UALL. Key fi ndings from Verma of the air spaces distal to the terminal where Zhou et al. (2014) conducted a et al. (2006) showed that there is a strong bronchiole with the destruction of alveolar two-year pilot study documenting that inverse correlation between oral mucosal septa.24 COPD affects approximately 10 60 patients with COPD had lowered wetness and UALL surface tension.49 percent of the world’s population and 25 exacerbations, increased forced expiratory Studies showed that reductions in salivary percent of U.S. adults over age 40.33,34 It volumes and an overall increase in lung fl ow rates or changes in the quality of the is the sixth leading cause of mortality in function after periodontal therapy.35 saliva cause increased surface tension of industrialized nations.24 Risk factors for the UALL, thereby contributing to upper COPD include smoking history and age.24 airway obstruction.50,51–58 Van der Touw et PD has recently been recognized as al. (1997) reported that patients with OSA a comorbidity of COPD as a result of Holtfreter et al. (2013) had signifi cantly higher surface tension of shared risk factors, infl ammatory markers found that in a study of 1,463 the UALL when compared to controls.53 4,25–29 and decreased lung function. Shen adults, PD was signifi cantly Many studies have documented that et al. (2015) associated PD with COPD, greater surface tension of the upper airway fi nding that the incidences of PD in associated with a decrease in lining causes the airway to collapse;51,53,55 patients who had diagnosed COPD lung function and airfl ow yet the inclination to collapse is sig- was 1.19-fold greater than in controls limitation in patients with COPD. nifi cantly reduced by the application of without COPD.25 Oztekinet et al. (2014) a surfactant.54,56,57 Kirkness et al. (2005) found that COPD is associated with PD concluded that patients with OSA showed and increased levels of infl ammatory a reduction in respiratory disturbance when cytokines.26 Of importance, Holtfreter et Xerostomia Contributes to Periodontal a surfactant was administered.54 Jokic et al. (2013) found that in a study of 1,463 Disease and Obstructive Sleep Apnea al. (1998) found that using a surfactant adults, PD was signifi cantly associated Xerostomia is characterized by an reduced the frequency of obstructive events with a decrease in lung function and individual’s feeling of a dry mouth due by up to 42 percent in OSA patients.57 airfl ow limitation in patients with COPD.4 to qualitative changes in saliva with or Overall, the research shows that salivary The most common route by which the without an actual decrease in salivary surface tension is correlated to obstructions oral cavity and PD infl uences respiratory volume.36–38 Xerostomia effects upwards of of the airway.50,51–58 Therefore, xerostomia’s function is through the aspiration of 46 percent of the population.38 It may be change in the quality and composition of saliva into the lungs.27 Research has caused by the anticholinergic side effect saliva also increases the surface tension found that aspiration of small amounts of of medications and or by an increase of the UALL and thereby contributes to saliva during sleep is very common even in sympathetic activity in response to nocturnal upper airway obstructions. among healthy individuals and may lead bodily stress or pain.39,40 Changes in to bacterial presence in the lungs.28 In salivary composition due to xerostomia Conclusions both healthy and affected individuals, has been shown to increase bacterial As discussed above, the scientifi c oral pathogens cause local damage to the plaque colonization, which aggravates literature documents the association of airways when aspirated.28 Individuals with and contributes to PD.38,41–47 Xerostomia PD and OSA,1,13–15 where it has been PD have elevated levels of periodontal also has a direct effect on OSA through postulated that the pathogenicity of pathogens and infl ammatory cytokines the increased surface tension of the PD and OSA includes the production in their saliva compared to healthy upper airway lining liquid (UALL), of similar infl ammatory mediators individuals.15 Aspiration of oral bacteria increasing upper airway obstruction. and resultant overall systemic

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infl ammation associated with both Overall, it is important for apnea syndrome and periodontal disease. J Periodontal 2014 disorders.1,13,16–22 While this may be dental professionals to recognize the Jul;85(7):e251–8. doi: 10.1902/jop.2014.130579. Epub 2014 Jan 13. true, we postulate that the aspiration comorbidity of PD, xerostomia and 16. Amabile N, Susini G, Pettenati-Soubayroux I, et al. of periodontal pathogens and OSA and the dental role of being Severity of periodontal disease correlates to infl ammatory infl ammatory cytokines into the lungs a member of the multidisciplinary systemic status and independently predicts the pressure and angiographic extent of stable coronary artery disease. J Intern decreases expiratory lung function team working with medical Med 2008 Jun;263(6):644–652. doi:10.1111/j.1365- and ultimately contributes to OSA. physicians to help manage the serious 2796.2007.01916.x. Epub 2008 Jan 16. PD is prevalent among patients breathing disorder of OSA. ■ 17. 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Lussi A, Schlueter N, Rakhmatullina E, et al. Dental reached at [email protected]. erosion — an overview with emphasis on chemical and histopathological aspects. Caries Res 2011;45 Suppl (1):2–12. doi:10.1159/000325915. Epub 2011 May 31. 44. Bekes K, Hirsch C. What is known about the infl uence of dentine hypersensitivity on oral health-related quality of life? Clin Oral Investig 2013 Mar;17 Suppl 1:45–S51. doi:10.1007/s00784-012-0888-9. Epub 2012 Dec 6. 45. Jenkinson HF, Douglas LJ. Interactions between Candida species and bacteria in mixed infections. In: Brogden KA, Guthmiller JA, eds. Polymicrobial Diseases. Washington, D.C.: ASM Press; 2002. 46. Zero DT, Lussi A. Erosion — chemical and biological factors of importance to the dental practitioner. Int Dent J 2005;55(4 Suppl 1):285–290. 47. Mandel ID. The functions of saliva. J Dent Res 1987 Feb;66:623–627 Spec No:623-7. 48. Kirkness JP, Christenson HK, Wheatley JR, Amis TC. 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CDA JOURNAL, VOL 46, Nº11

Denture Group Visits: A Model To Improve Access to Care and Reduce Treatment Period for Dentures

Siddardha G. Chandrupatla, BDS, MMSc; Lisa A. Thompson, DMD; Sirisha Kuna, BDS; and Brian J. Swann, DMD, MPH

ABSTRACT In this study, we evaluated reduction in the number of days required for denture treatment utilizing a denture group-visit model. Using this model, we reduced the number of days required to treat edentulism cases by 32 percent and drop-off rates by 9 percent. We demonstrated an innovative way to use group visits in clinical dentistry by opening up appointment space, reducing the waiting period for future patients, increasing patient retention and thereby increasing access to care.

AUTHORS

Siddardha G. Sirisha Kuna, BDS, is a he “group visit” is a format in dental cases can result in extraction. Chandrupatla, BDS, research assistant at the health care where treatment In the United States, periodontitis MMSc, is a faculty member Cambridge Health Alliance is delivered to a cohort of is the leading cause of edentulism in in the oral epidemiology in Cambridge, Mass. 5,6 department at the Harvard Confl ict of Interest patients who require similar elderly populations. Because the 1–3 School of Dental Medicine Disclosure: None reported. treatment. Group visits, also burden of tooth loss and edentulism in Boston. Treferred to as “cluster visits,” “shared is higher for patients with a low Confl ict of Interest Brian J. Swann, DMD, visits” or “group appointments,” are socioeconomic status or patients with Disclosure: None reported. MPH, is the chief of oral utilized to discuss treatment procedures disabilities,7,8 these patients may also health services at the Lisa A. Thompson, DMD, Cambridge Health Alliance and outcomes with health care providers seek treatment in community/hospital- is the head of the geriatric in Cambridge, Mass., and or auxiliaries in the presence of other based dental centers. Removable dentistry program and a an instructor at the Harvard patients. When necessary, individual dentures are the most economical clinical instructor at the School of Dental Medicine sessions may also occur during group way of restoring missing teeth. Harvard School of Dental in Boston. visits to discuss confi dential matters. Group visits are widely used Medicine in Boston. Confl ict of Interest Confl ict of Interest Disclosure: None reported. Group visits vary in length of time (a in medicine to treat patients with Disclosure: None reported. few minutes to hours) and frequency psychological disorders, diabetes, (single, biweekly or monthly visits).1,4 prenatal needs, chronic pain, etc.9–12 Most community/hospital-based Group visits are more useful in dental centers treat patients who cannot addressing chronic medical conditions, afford the cost of private care. Without wherein the patient not only receives prompt and timely intervention, many the treatment needed but has the

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15 15

10 10 Percent Percent

5 5

0 0 0 100 200 300 0 100 200 300 Number of days Number of days

FIGURE 1A. Group visits. FIGURE 1B. Individual visits. FIGURES 1. Distribution of the number of days, from initial impression to delivery of the denture, between group visits and individual visits.

ability to interact with patients with room by one dentist and two dental observe the procedure being performed similar medical dental needs.9,10,13 assistants. The room was arranged in a on others and communicate any queries These interactions may help motivate, rectangular fashion with three chairs regarding the treatment with the dentist. decrease anxiety and improve clinical and two tables positioned at the head Patients who did not show or canceled a outcomes. Group visits have been used of the room. Additional chairs were set group-visit appointment could choose the in dentistry for diabetes control and up behind the tables for the remaining next available group-visit appointment. children’s well visits, either alone or as patients. There was one large cart Because of this fl exibility in selecting the part of integrated medical services.14–16 with supplies and instruments and two next appointment date, patients usually smaller carts, one with paperwork and were at different treatment stages. For Denture Group-Visit Logistics the other with lab cases. In addition, example, one patient could be at the initial In 2011, the oral health the room was equipped with a built-in impression while another could be at the department (OHD) within the sink and a computer to access patient wax-bite. An individual appointment Cambridge Health Alliance (CHA) charts. All instruments and lab cases (in the dental operatory) was scheduled established a biweekly program for were opened in front of the patients to for any necessary denture adjustment patients needing removable dentures reduce concerns regarding sterilization procedures after denture delivery. using a group-visit model. The OHD and disinfection. Patient privacy The patient chose the type of visit initiated denture group visits with the was protected and all patients signed during their preliminary consultation for intent of increasing access to care by confi dentiality agreements,17,18 which prosthodontic needs. The dentist explained delivering treatment to more patients in were verifi ed by a dental assistant prior the advantages and disadvantages of group a shorter time, decreasing provider to the start of each group visit session. visits and individual visits and answered chairside time and reducing the Each session began with the dentist any questions that could help patients make overhead cost of denture fabrication. discussing the denture treatment process, an informed decision. The patients could The schedule was designed with answering any questions and educating switch between group visits and individual a biweekly (same day and time) the patients about their oral health. The visits at any time during the treatment 90-minute block for a denture group dentist then performed treatment on each process. Patients who chose individual appointment. Eight to 10 patients patient in the same conference room in the visits were given appointments based on were treated in a large conference order that they checked in. Patients could the availability in the schedule. At this

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TABLE 1 Descriptive Characteristics of the Patients Who Received Dentures at the Cambridge Health Alliance

Variables All (n = 290) Denture group visits Individual visits (n = 206, 71%) (n = 84, 29%) Sex Male 130 (44.83%) 93 (45.11%) 37 (44.05%) P = 0.86 Female 160 (55.17%) 113 (54.85%) 47 (55.95%) Mean age 63.78 (62.38–65.18) 63.85 (62.2–65.5) 63.6 (60.9–66.29) P = 0.87 Race P = 0.08 White 114 (47.3%) 85 (49.7%) 29 (41.43%) African American 76 (36.51 %) 64 (37.43%) 24 (34.28%) descendants Others 39 (16.18%) 22 (12.88%) 17 (24.29%) Insurance Public 223 (79.08%) 159 (79.1%) 64 (79%) P = 0.98 Private 59 (20.92%) 42 (20.9%) 17 (21%) Provider Dentist 1 151 (52.07%) 102 (49.5%) 49 (58.37%) P = 0.19 Dentist 2 128 (47.93%) 104 (50.5%) 35 (41.63%)

Showing totals and proportions, except age mentioned in mean (95% CI).

practice, individual denture appointments Chart Selection and Data Collection ■ Complete data or no ambiguity in were scheduled for 30 minutes per session. CHA transitioned from paper the data for the treatment provided. Patients were given only one appointment charts to electronic health records ■ Patients who received only at a time, regardless of group or individual (EHR) in late 2013; therefore, only complete or partial dentures. visit status. This approach of one records from January 2014 through ■ Patients who were treated appointment at a time was warranted due August 2016 were selected. Current exclusively by one of the two to the high rate of missed appointments in Dental Terminology (CDT) codes dentists for all the steps required community dental practices. The amount and internal procedure codes were to complete treatment. of time needed by the lab to complete used to identify the patients who Patients who switched between group each stage of the denture was the same for received treatment for traditional and individual visits for any of the denture both group visits and individual visits. The complete and removable partial procedures and those who received fl ippers clinic has four dentists — only the two dentures. CDT codes and procedure and immediate dentures were excluded dentists who provided dentures in both codes used were: initial impression because these procedures may not require group and individual visits were included. (IMP), master impression (MIMP), all the fabrication steps mentioned earlier. wax-bite (WBITE), try-in (TRYIN) Methodology and denture delivery (using the Variables Collected This study was approved by the appropriate CDT code). Denture group The type of visit, dental provider, CHA Institutional review board. visits were identifi ed in the patient number of calendar days for treatment, Data were collected by conducting a record using the code (SHARED). number of patient visits for treatment retrospective review of patient charts. Two trained reviewers collected the from initial impression to denture For comparison purposes, the study pool data. The reviewers initially reviewed delivery and number of postdelivery was limited to patients who were treated 30 patient charts for calibration denture adjustment visits were collected. by the two senior dentists. The patients and training. These criteria were The dental provider was denoted as selected for the fi nal analysis received established for inclusion in the study: either “Dentist One” or “Dentist Two” for complete treatment (initial impression ■ Patients who participated exclusively the two senior dentists referenced earlier. to delivery) and were treated exclusively in either group or individual The type of visit was dichotomized as in either group or individual visits. visits for all appointments. group or individual. The patients who

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TABLE 2 Mann-Whitney U Test Results for the Comparison of Mean Number of Days To Finish the Entire Denture Treatment of a Patient Comparing Group and Individual Visits Group visits (95% CI) Individual visits (SD) P-value Median number of days 71 (43–155) 93.5 (42–253) <0.002 Mean number of days* 82.49 (77.09–87.88) 108.80 (95.72–121.89) *Mean given for easier interpretation purpose. P-value Mann-Whitney U test.

TABLE 3 Comparison of Drop-Off Rates, Number of Total Visits and Postinsertion Visits for Denture Adjustment Between Group Visits and Individual Visits Group visits (95% CI) Individual visits (95% CI) P-value Drop-off rate 7.62% 16.83% 0.03* Mean number of visits per person*** 4.98 (4.79–5.16) 4.76 (4.51–5.01) 0.19** Mean postdelivery denture adjustment visits*** 1.12 (0.93–1.30) 1.24 (0.9–1.58) 0.51**

*P-value Chi2. **P-value Mann-Whitney U test. ***Mean given for easier interpretation.

completed some of the steps for dentures conducted to analyze the association public insurance and 20 percent had but who ultimately did not get the of the number of days taken for the private. Of the patient charts included dentures were collected as the variable treatment and the type of appointment in the fi nal analysis, 151 (52.07 percent) “drop off.” The patients who dropped and other covariates. We utilized a were treated by Dentist One and 139 off the treatment were not included in modifi ed Park test to predict the square (47.93 percent) were treated by Dentist the analysis for a shorter delivery time; of the residuals as a function of the log Two. Chi2 and test of mean results for instead, they were analyzed separately of the dependent variable and identifi ed all the variables in TABLE 1 showed to check patient retention rates in that GLM gamma family was more no statistically signifi cant difference both of the groups. Type of denture and appropriate. The inter-rater kappa was between the population subgroups. number of dentures were collected as a 0.82. Statistical analysis was performed TABLE 2 shows the results of the Mann- combination of either complete dentures using STATA version 13 (STATACorp Whitney U test for the number of days, (CD) or removable partial dentures LLC, College Station, Texas). from the fi rst appointment until denture (RPD) and if the patient was receiving delivery. The median number of days treatment for one denture or two Results for group visits (71 days) for the entire dentures at the same time. Demographic TABLE 1 shows the descriptive statistics treatment period (initial impression to information was also collected (age, of the patient pool selected for this denture delivery) is statistically signifi cantly gender, race and type of insurance). analysis. We identifi ed 346 patients who different (p < 0.002) than the median needed dentures — 34 patients dropped number of days in individual visits (93.5 Statistical Analysis off before denture delivery and an days). The medians along with the means Descriptive statistics of the additional 22 were excluded because they for the number of days are also represented. distribution of the subjects in the switched between group and individual TABLE 3 contains the comparison two visit categories were calculated visits. A total of 290 patients were of the drop-off rates for patients who and compared using the Chi2 test for selected for the fi nal analysis — 206 (71 discontinued the treatment in each signifi cance testing. For each group, percent) belonged to group appointments group. The total number of patients comparison between the median days and 84 (29 percent) belonged to who got treatment for dentures in elapsed for the entire denture treatment, individual appointments. The mean age either of the two visit types until they from initial impression to denture was 63.85 years (95% CI; 62.21–65.5) discontinued the treatment were included delivery, was investigated using a Mann- for group visits and 63.6 years (95% CI; in this analysis. The Chi2 test shows a Whitney U test because the number of 60.9–66.29) for individual visits. About signifi cant difference in the observed days for the treatment was positively 55 percent of the patients were female count and expected count for drop-off skewed (FIGURES 1). Generalized linear (113 in group and 47 in individual). rates — 7.62 percent (n = 17) in group model (GLM) regression analysis was Nearly 80 percent of the patients had visits versus 16.83 percent (n = 17)

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TABLE 4 GLM Log Link Regression Model: The Number of Days It Takes To Deliver the Denture and Its Association With Group Visits Number of days for denture Exponential coeffi cients (95% CI) P-value (initial impression to delivery) Group visits Reference patients and patients with chronic Individual visits 1.32 (1.16–1.5) <0.0001 diseases.9,10,23–27 Other group visits Number of and type of denture that have been established at the Single RPD Reference CHA include infant/toddler, prenatal, Two RPDs 0.99 (0.84–1.17) 0.98 diabetic and new patient orientation. At the CHA, the addition of group Single CD 1.14 (0.95–1.38) 0.14 visits did not cause any disruption to Two CDs 1.08 (0.92–1.26) 0.31 the daily work schedule of the dentist. RPD and CD combination 1.28 (1.06–1.53) 0.007 After the 90-minute denture group-visit Intercept 76.3 (68.03–85.56) session, the dentist had appointments set for regular patients. The mean number Exponential coeffi cients are shown. of visits each patient had for a denture was 4.91 (95% CI 4.76–5.06). The mean number of visits for the group appointment was 4.98 when compared to 4.76 for the in individual (p = 0.03). The Mann- Discussion individual. The number of days needed to Whitney U test showed that the median To our knowledge, this is the fi rst deliver a combination of CD and RPD was number of visits required for dentures time that a group-visit model has been 27 percent days more when compared to to be delivered to each patient was not applied to a clinical dental procedure a single RPD denture and was statistically signifi cantly different (p = 0.19) between for dentures. The philosophy of denture signifi cant (p = 0.007). This statistic may the two groups. The postdelivery denture group visits is that patients with similar be attributed to some cases involving adjustment visit was also not signifi cantly dental needs are scheduled together. removable partial dentures that did not different between the two groups. These patients develop a mutually require all fi ve steps as outlined from initial TABLE 4 contains the results of the supportive unit that can help reduce impression to delivery and faster delivery of multivariable GLM regression model. The anxiety, reduce negative social and the denture from the lab after fabrication. number of days required for treatment psychological effects and provide moral Patient drop-off (discontinued was taken as the response variable and support to each other. A dentist with treatment) and no-shows (missed the type of appointment as a primary good leadership skills and chairside appointments) produce a negative impact, predictor variable. Log link GLM manner can further initiate constructive especially in community health centers — regression with gamma family has been changes in an individual patient while lost revenue is associated with high patient used in similar studies that had positively engaging all members of the group. drop-off and lost production is associated skewed dependent variables.19–22 The Discussions about oral and systemic with high no-show rates. It is important exponential coeffi cients of signifi cant health conditions within the group to note that Medicaid regulations require variables are displayed in TABLE 4, are encouraged, which can improve that a denture must be delivered before along with the 95% CI and p-values. the health literacy levels among the reimbursement is requested. Our study Variables, other than the type of visit patients. Patients have an opportunity has shown improved retention of patients (group or individual) and the type and to experience peer learning about in the group-appointment model when number of dentures (complete, partial oral health, tooth loss and potential compared to the conventional individual or both), did not show any statistical complications encountered during or appointment. Group-visit programs in signifi cance for the number of days after the treatment through discussions medicine have demonstrated improved for treatment. Delivery of dentures in with other patients and the dentist retention and patient adherence the individual visits took 32 percent during the group appointment. In the to the treatment process and lower more days when compared to group group visit, dental tasks are streamlined hospitalization rates.11,23,28 The number visits. Treating a patient who required a relative to the target patients and of drop-offs between the groups was combination of a CD and an RPD at the the treatment methods.23 Group signifi cantly different (TABLE 3). In this same time required 28 percent more days visits have shown to improve access study, 17 out of 101 patients in individual compared to a single RPD (p = .007). to medical care,24 monitor high-risk visits (16.83 percent) and 17 out of 223

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patients in shared visits (7.62 percent) the new appointment spaces are given health center setting; therefore, the dropped. The best predictors of a patient’s to patients of all types of treatments results may not be generalized to private satisfaction with removable denture are and not just limited to dentures. When practices, but we expect similar results, appearance and retention.29 Postdelivery three or more patients are treated in if not better. Because CHA transitioned visits are used to address these issues if a group visit, the loss of revenue due to EHR in fourth quarter of 2013, they exist. As the number of postdelivery to no-show is signifi cantly diminished denture treatment information prior to visits and the median number of visits (three patients equals 90 minutes). Over group-visit initiation was unavailable. were not signifi cantly different between the study period, more patients were Consequently, we were unable to compare the two visit types, we believe patients in treated under the group model when the changes in the length of the treatment the group visits were as satisfi ed as and the compared to an individual appointment, period for individual visits before and quality of denture was comparable to those thereby generating more revenue. after group-visit project initiation. receiving care in the individual visits. Providing a large volume of denture Access to dental care has been a cases also allowed the clinic to receive Conclusion longstanding problem among low- reduced rates from the dental labs. The denture group visit is an income populations that comprise a innovative model to improve access to higher number of the rural and inner- dental care by reducing the treatment city populations in the United States. period to deliver dentures. Using Access to dental care has many facets this model, we successfully reduced — the inability to see a dentist due The best predictors of a the number of days needed to treat a to long wait periods is one important patient’s satisfaction with patient by 32 percent when compared reason. Many community health centers to individual visits. Group visits are are established on the noble mission of removable denture are feasible in the dental setting and can providing care for all, but unfortunately, appearance and retention. result in decreased treatment length, in dentistry the need and demand for improved access to care, increased dental services are high, often resulting treatment retention rates and increased in long wait times. On average, it took revenue, while at the same time 32 percent more days for an individual maintaining the quality of care. ■ visit when compared to the group. Delivering dentures faster may also

Group visits demonstrate the ability of have a positive impact on the patient’s REFERENCES the dentist to engage and treat multiple satisfaction and social acceptance. The 1. Noff singer EB. Introduction to Group Visits. In: Running Group Visits in Your Practice. New York: Springer; 2009. patients in a single session, deliver transient nature of the surrounding 2. Noff singer E, Sawyer DR, Scott JC. Group Medical Visits: A dentures in fewer days, increase patient community, the dependency on public Glimpse Into the Future? Enhancing Your Practice. Patient Care retention rates and potentially open up transportation and the complex medical 2003;37(3):27. 3. Scott J, Gade G, McKenzie M, Venohr I. Cooperative health additional chair time. This additional histories make it imperative to deliver care clinics: A group approach to individual care. Geriatrics chair time increases utilization for dentures timely to use the momentum that 1998;53(5):68–70. individualized procedures for new and has been established in the denture group. 4. Noff singer EB. DIGMAs: Strengths, Weaknesses and Real- Life Examples. In: Running Group Visits in Your Practice. New existing patients. For example, treating Our study was conducted utilizing York: Springer; 2009. doi:10.1007/b106441_3. 10 patients in a 90-minute group session a retrospective review of patient charts 5. National Institute of Dental and Craniofacial Research. versus the fi ve hours needed for these same and may have been impacted by missing Dental diseases among adults. www.webcitation. org/6ou2GqIe4. patients nets 3 1/2 hours of additional information and potential confounders. 6. Natto ZS, Aladmawy M, Alasqah M, Papas A. Factors chair time. We believe the additional The patients were not randomized into contributing to tooth loss among the elderly: A cross sectional chair time created by the group visits the two treatment groups. Although study. Singapore Dent J 2014;35:17–22. 7. Wu B, Liang J, Plassman BL, Remle C, Luo X. Edentulism may also decrease the number of days not randomized, the correlates of the trends among middle-aged and older adults in the United for denture delivery for individual visits. characteristics of the patients were not States: Comparison of fi ve racial/ethnic groups. Community This hypothesized decrease in number statistically signifi cant between the two Dent Oral Epidemiol 2012;40(2):145–153. doi:10.1111/ j.1600-0528.2011.00640.x. of days to denture delivery in individual groups. This study was conducted in a 8. Seeriga LM, Nascimento GG, Peres MA, Horta B, visits may not be signifi cantly large, as community/hospital-based community Demarco FF. Tooth loss in adults and income: Systematic

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review and meta-analysis. J Dent 2015;43(9):1051–1059. Group Visits Into Practice. 2012. www.massgeneral.org/ 2017. doi:10.1111/hex.12525. doi:10.1016/J.JDENT.2015.07.004. stoecklecenter/assets/pdf/group_visit_guide.pdf. 26. Heyworth L, Rozenblum R, Burgess JF, et al. Infl uence 9. Loney-Hutchinson LM, Provilus AD, Jean-Louis G, Zizi F, 19. Stucki G, Sabariego C, Brach M. Determinants of of shared medical appointments on patient satisfaction: Ogedegbe O, McFarlane SI. Group visits in the management major direct medical cost categories among patients with A retrospective three-year study. Ann Fam Med of diabetes and hypertension: Eff ect on glycemic and blood osteoporosis, osteoarthritis, back pain or fi bromyalgia 2014;12(4):324–330. doi:10.1370/afm.1660. pressure control. Curr Diab Rep 2009;9(3):238–242. undergoing outpatient rehabilitation. J Rehabil Med 27. Egger G, Binns A, Cole M-A, et al. Shared medical 10. Trotter K, Schneider SM, Turner BS. Group appointments 2011;43:703–708. doi:10.2340/16501977-0845. appointments — an adjunct for chronic disease management in in a breast cancer survivorship clinic. J Adv Pract Oncol 20. Le TK, Montejano LB, Cao Z, Zhao Y, Ang D. Health Australia? Aust Fam Physician 2014;43(3):154. 2013;4(6):423–431. care costs in U.S. patients with and without a diagnosis of 28. Sadur C, Moline N, Costa M, Michalik D. Diabetes 11. Jaber R, Braksmajer A. Group visits: A qualitative review of osteoarthritis. J Pain Res 2012;5:23–30. doi:10.2147/JPR. management in a health maintenance organization. current research. J Am Board Fam Med 2006;19(3):276–290. S27275. Effi cacy of care management using cluster visits. Diabetes 12. Trento M, Passera P, Tomalino M, Bajardi M. Group 21. Kanzaria HK, Probst MA, Ponce NA, Hsia RY. The 1999;22(12):2011–2017. visits improve metabolic control in Type 2 diabetes. Diabetes association between advanced diagnostic imaging and ED 29. Ettinger RL, Jakobsen JR. A comparison of patient 2001;24(6):995–1000. length of stay. Am J Emerg Med 2014;32(10):1253–1258. satisfaction and dentist evaluation of overdenture therapy. 13. Weinger K. Group Medical Appointments in Diabetes doi:10.1016/j.ajem.2014.07.038. Community Dent Oral Epidemiol 1997;25(3):223–227. Care: Is There a Future? Diabetes Spectr 2003;16(2). 22. Desai PR, Lawson KA, Barner JC, Rascati KL. Identifying doi:10.1111/j.1600-0528.1997.tb00930.x. 14. Nakre PD, Harikiran AG. Eff ectiveness of oral health Patient Characteristics Associated With High Schizophrenia- education programs: A systematic review. J Int Soc Prev Related Direct Medical Costs in Community-Dwelling Patients. J THE CORRESPONDING AUTHOR, Siddardha G. Chandrupatla, BDS, Community Dent 2013;3(2):103–115. Manag Care Pharm 2013;1919(66):468–477. MMSC, can be reached at [email protected]. 15. Alsada LH, Sigal MJ, Limeback H, Fiege J, Kulkarni G V. 23. De Vries B, Darling-Fisher C, Thomas AC, Belanger- Development and testing of an audio-visual aid for improving Shugart EB. Implementation and outcomes of group medical infant oral health through primary caregiver education. J Can appointments in an outpatient specialty care clinic. J Am Acad Dent Assoc 2005;71(4):241, 241a–241h. Nurse Pract 2008;20(3):163–169. doi:10.1111/j.1745- 16. Vachirarojpisan T, Shinada K, Kawaguchi Y. The process and 7599.2007.00300.x. outcome of a programme for preventing early childhood caries in 24. Bronson DL, Maxwell RA. Shared medical appointments: Thailand. Community Dent Health 2005;22(4):253–259. Increasing patient access without increasing physician hours. 17. Steven R G. Legal issues to be considered for Group Medical Cleve Clin J Med 2004;71(5):369–370. Visits. underbergkessler.com/sites/default/fi les/article_docs/ 25. Housden L, Browne AJ, Wong ST, Dawes M. Attending Legal Issues to be Considered for Group Medical Visits_0.pdf. to power diff erentials: How NP-led group medical visits can 18. Eisenstat S, Siegel AL, Carlson K, Ulman K. Putting infl uence the management of chronic conditions. Heal Expect

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CDA JOURNAL, VOL 46, Nº11

Color Monitoring: Comparison Between Visual and Instrumental Methods With Do-It-Yourself Whitening

Christina Chi, BA, DDS; Minna Chun, BA, DDS; Arfassa Gullo, BS, DDS; Darlene Teddy, BS, DDS; Emily Hwang, BS; Udochukwu Oyoyo, MPH; and So Ran Kwon, DDS, MS, PhD, MS

ABSTRACT There has been a signifi cant cultural movement that is embracing organic or more natural ways to whiten teeth. This study evaluated by means of visual and instrumental color-assessment tools the whitening effi cacy of activated charcoal slurry and coconut oil regimens promoted over the internet. Activated charcoal and coconut oil were not effective as whitening agents. Instrumental measurements with the VITA Easyshade and a digital camera-based software correlated well with each other.

AUTHORS

Christina Chi, BA, DDS, Arfassa Gullo, BS, DDS, Emily Hwang, BS, is a So Ran Kwon, DDS, MS, emand for white and bright is a recent graduate of is a recent graduate of senior dental student at PhD, MS, is a professor teeth has been growing among the Loma Linda University the Loma Linda University the Loma Linda University and director of the student the general public as a result School of Dentistry. School of Dentistry. School of Dentistry. research program at the of vigorous media emphasis Confl ict of Interest Confl ict of Interest Loma Linda University Disclosure: None reported. Disclosure: None reported. Udochukwu Oyoyo, School of Dentistry. on beauty and health. There MPH, is an assistant Confl ict of Interest Dhas also been a cultural movement Minna Chun, BA, DDS, Darlene Teddy, BS, DDS, professor and statistician at Disclosure: None reported. toward embracing organic or more is a recent graduate of is a recent graduate of the Loma Linda University natural ways to whiten teeth that are the Loma Linda University the Loma Linda University School of Dentistry. effective and safe. Most of these do- School of Dentistry. School of Dentistry. Confl ict of Interest Confl ict of Interest Confl ict of Interest Disclosure: None reported. it-yourself (DIY) whitening regimens, Disclosure: None reported. Disclosure: None reported. which use strawberries, charcoal, oil pulling and others, are promoted over the internet.1–3 The use of strawberries and apples is based on anecdotal evidence, with the rationale that these fruits contain malic acid.1 Activated charcoal has been utilized in human medicine for many years to eliminate poison from the gastrointestinal tract

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TABLE 1 Summary of Whitening Regimen Used by Group Group Regimen Batch No. NC Grade 3 water 60 minutes N/A COAL 3 minutes charcoal tooth brushing 20 times AC16194 and to suppress its absorption into the OIL 15 minutes coconut oil agitation 20 times 1045706 4,5 human body. Charcoal’s primary HP 20% HP Philips QuickPro 30 minutes 3 times at an interval of 3–5 days 15154032 value lies in its adsorptive power. The adsorptive mechanism has also been applied to stain removal in oral health care products, promoting the removal human eye, environment or light source assessment tools. Our null hypotheses of tannin, a colored substance found and that the results are reproducible.11 were that there would be no signifi cant in berries, chocolate and fruit juices.6 Currently, the only device on the market difference in color change among the Oil pulling originated as part of natural in the U.S. is a spot measurement device, four different groups and that there would healing practices in ancient Ayurvedic the VITA Easyshade Compact (VITA be no signifi cant correlation between medicine and involves swishing or Zahnfabrik), which provides extended the color-change parameters established holding oil in the mouth for a period of color information of L*C*h*a*b* color using different shade-assessment tools. time before spitting it out. It is believed coordinates in the CIEL*a*b* color space that oil pulling affects harmful bacteria for the measured area of the tooth.12 Methods and Materials and improves oral health. Improvements Shade-taking technology has also include teeth that appear whiter, advanced with new systems that combine Sample Selection and Preparation healthier gums and reduced malodor.7 digital photography with image shade- Extracted sound human teeth without Studies on the use of strawberry puree matching software (ShadeWave, Issaquah, identifi ers (n = 64) were collected and have not found any signifi cant effect on Wash.). The set-up consists of a single stored in 0.2% sodium azide solution at 4 whitening, and in fact, the strawberries calibrated shade tab, a digital camera and degrees Celsius. The Institutional Review may reduce the microhardness of an extension arm. The camera is attached Board (IRB) approved the use of the enamel. Despite the great interest in to the extension arm, which also holds the extracted human teeth with no identifi ers DIY whitening, there is only limited shade tab at the correct angle and distance as a non-human-subjects study. Teeth were information on the effi cacy and adverse from the camera and fl ash.13 Consequently, cleaned of gross debris and embedded in effects reported in the dental literature. the geometry of the camera lens, fl ash and typodonts (n = 8) (Columbia Dentoform, Kwon et al.3 were the fi rst to evaluate shade tab is kept consistent. Once the Long Island City, N.Y.) using light-body the whitening effect of a strawberry photograph is taken, the image is uploaded PVS (Examix NDS, GC America Inc., slurry regimen. However, there have on a custom portal, color corrected Alsip, Ill.). The typodonts were then been no studies on the use of charcoal according to an algorithm that accounts stored in artifi cial saliva for 24 hours and oil pulling for tooth whitening.1,8 for known hues, chromas and values on at 37 degrees Celsius before initiating While consumers are interested in the a black-to-white gray scale and matched the experiment. The artifi cial saliva effi cacy and safety of various whitening to a shade sample on the shade guide.13 was prepared from Fusayama solution modalities, a central issue that remains to With heightened consumer interest and adjusted to pH 6.0, as described be addressed in whitening studies is the in whiter teeth, the dental professional in ANSI/ADA Specifi cation 41.15 proper assessment of tooth color change is responsible for providing reliable to support and defi ne effi cacy. To facilitate information about the effi cacy and adverse Experimental Groups tooth-whitening monitoring, the VITA effects of different tooth-whitening TABLE 1 shows the regimen of the Bleachedguide 3D-Master (VITA modalities and for establishing valid whitening protocols used in the study. Zahnfabrik, Bad Säckingen, Germany) monitoring tools for the whitening The negative control (NC) group composed of 15 tabs was developed and progress.14 Based on a literature review, was treated with grade 3 water for 60 is recommended as the ADA standard.9,10 there is a lack of knowledge of whitening minutes at 35 degrees Celsius. The In addition, special instrumental regimens using natural ingredients. activated charcoal (COAL) group was methods for shade determination have Therefore, the purpose of this study was to brushed with a charcoal slurry (activated become available with advancements evaluate the effi cacy of two DIY whitening charcoal, Vivadoria Inc., Redmond, in technology. The main advantages methods, activated charcoal and coconut Wash.) for three minutes. This regimen of instrumental methods are that oil, as indicated measured by tooth color was based on a website that advocates measurements are not infl uenced by the change using three different shade- for brushing with activated charcoal

716 NOVEMBER 2018 CDA JOURNAL, VOL 46, Nº11

the middle third of the buccal surface using a contact-type intraoral spectrophotometer with a custom-fabricated clear jig for repeatable measurements.18 The overall color change was expressed as ΔE* from the FIGURE 1A. FIGURE 1B. Commission Internationale de l’Eclairage. The following equation was used: ΔE* = [(L*2-L*1)2 + (a*2-a*1)2 + (b*2-b*1)2]1/2 Digital Camera with Imaging Software (SW; Nikon D200 with Nikon Micro Nikkor 105 mm lens, Tokyo): This camera was used for picture taking and the images were processed using an imaging software (ShadeWave). The photograph was color corrected according to an algorithm that accounts FIGURE 1C. FIGURE 1D. for known hues, chromas and values of FIGURES 1. Shade-assessment tools used for color monitoring. Visual shade assessment (1A). Instrumental gray, black and white for shade sample on shade assessment with VITA Easyshade (1B). Digital camera-based shade assessment (1C). Shade mapping the shade guide. The software populates a with ShadeWave imaging software (1D). color map and identifi es the best matching VBG tab. Results of the software were also for three minutes.2 The coconut oil Tooth Color Change Assessment expressed as a difference of shade-guide units pulling (OIL; coconut oil, Kirkland, Tooth color was monitored with (ΔSGU) using the same formula as for VBG. Seattle, Wash.) group was agitated for three different shade-assessment methods 15 minutes7 in a Thermo-bath shaker (FIGURES 1). Measurements were performed Statistical Analysis at 37 degrees Celsius (Shak-R-Bath, at baseline (T0), one-day postwhitening Measurements of color change included Lab-Line Instruments Inc., Melrose (T1) and one-month postwhitening (T2). ΔVBG, ΔSGU, ΔL*, Δb* and ΔE*. Kruskal- Park, Ill.) to simulate swirling in the oral VITA Bleachedguide 3D-Master (VBG): Wallis procedure was used to determine cavity and brushed with a soft toothbrush Visual color assessment was performed by signifi cant differences in color change (Colgate Soft, Piscataway, N.Y.). The one evaluator with superior color-matching among the groups. Correlations between positive control (HP) group was treated competency under a color-controlled visual and instrumental measurements with an in-offi ce whitening product lightening box (MM 4e GTI Mini Matcher, were assessed with Pearson correlations. containing 20% hydrogen peroxide for GTI Graphic Technology, Inc., Newburgh, Testing of the null hypotheses was 30 minutes, three times at three to fi ve N.Y.) at CIE D65, a color temperature of two-sided with an alpha level of 0.05. day intervals (Philips QuickPro, Philips 6500K and a light intensity of ≈1200 lux.17 The analysis was conducted with SAS Oral Healthcare, Ontario, Calif.). The Each VBG shade tab is marked with an odd v 9.2 (SAS Institute, Cary, N.C.). latter regimen was based upon the number from one to 29 and “interpolated” manufacturer’s instructions. A previous even numbers are in between (FIGURE Results study that used the system with the 1A). Results were expressed as a difference same application frequency and interval of shade-guide units (ΔVBG), which VBG Assessment showed signifi cant whitening effi cacy,16 refl ects a change with respect to the The mean and standard deviation of which supported the use of this group baseline. A negative delta value indicated color measurements made with the VBG as the positive control. Any remaining a change toward the lighter direction. were 19.25 (2.98), 18.69 (3.99), 19.44 material following treatment was rinsed ΔVBG was calculated as VBG2-VBG1 (3.61) and 18.50 (2.83) for the NC, off with distilled water. Specimens were VITA Easyshade Compact Advance 4.0 COAL, OIL and HP groups, respectively. stored in artifi cial saliva at 37 degrees (VES, Zahnfabrik, Bad Säckingen, Germany): There were no signifi cant differences at Celsius throughout the experiment. Color measurements were performed on baseline among the groups (P = 0.841).

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TABLE 2 Summary of Color Change (ΔVBG, ΔL*, Δb*, ΔE* and ΔSW) Over Time by Group (Mean ± SD)

Color change NC COAL OIL HP P-value* ΔVBG_1 –0.19±1.22A –1.69±1.74A –1.31±1.14A –3.56±2.25B < 0.001 ΔL*_1 1.14±1.60A –0.07±2.56A 1.51±1.54A 5.54±1.71B < 0.001 Δb*_1 –0.65±1.19A –2.27±1.97A 0.26±0.90A –4.44±2.64B < 0.001 ΔE*_1 2.12±1.10A 3.77±1.56A 2.13±0.99A 7.63±2.11B < 0.001 ΔSGU_1 0.39±0.90A 0.13±1.02A –0.22±0.84A –3.18±1.27B < 0.001 ΔVBG_2 –1.50±2.58A –3.06±2.38A –3.75±2.23A –6.69±3.32B < 0.001 ΔL*_2 0.44±1.72A –1.00±2.71A 1.25±1.37A 3.75±1.80B < 0.001 Δb*_2 –1.30±1.79A –2.43±2.54A –1.00±1.06A –7.47±3.19B < 0.001 ΔE*_2 2.49±1.39A 4.13±2.06A 2.21±0.84A 8.81±2.97B < 0.001 ΔSGU_2 0.31±0.79A –0.19±0.65A –0.25±0.77A –3.25±1.34B < 0.001

* Independent-Samples Kruskal-Wallis test Same uppercase letters within the same row indicate no signifi cant diff erence. Signifi cance values have been adjusted by the Bonferroni correction for multiple tests.

VES Assessment The mean and standard deviation 12 NCN of baseline L*/b* made with the VES were 77.06 (6.05)/24.23 (7.05), 76.27 CoalC (7.44)/26.03 (8.06), 78.27 (6.04)/24.52 9 OOil (4.25) and 77.76 (5.59)/25.64 (3.92) for HPH the NC, COAL, OIL and HP, respectively. 6 There were no signifi cant differences for all ΔE*

baseline color parameters, L0*, a0* and b0* (P = 0.687, 0.980 and 0.868, respectively). 3

SW Assessment 0 The mean and standard deviation of 012 color measurements made with the SW Time points were 17.50 (2.66), 17.69 (1.70), 17.44 (1.03) and 17.75 (1.65) for the NC, FIGURE 2. Line plots of overall color change as measured with the VITA Easyshade by group over time. COAL, OIL and HP groups, respectively. There were no signifi cant differences at baseline among the groups (P = 0.958). TABLE 2 summarizes the color changes Time points at one-day and one-month postwhitening. 12NNC There were signifi cant differences at 1 CCoal T1 and T2 among the four groups, as 0 measured with VBG, VES and SW (P OOil < 0.001, in all instances). For all time –1 HHP points, HP had the highest color change, while other groups were not different from ΔSGU –2 each other. The overall color change, as determined with the VITA Easyshade –3 and changes in shade-guide units, as –4 measured with the ShadeWave software as well as visually with the VBG, are illustrated as line plots in FIGURES 2–4. FIGURE 3. Line plots of changes in shade-guide units as measured with the ShadeWave software by group over time.

718 NOVEMBER 2018 CDA JOURNAL, VOL 46, Nº11

Time points 1 12NNC 0 CCoal –1 OOil –2 –3 HHP assessment tools. The 50:50 percent acceptability threshold of ΔE*=2.7 was used

ΔVBG –4 to interpret the clinical relevance of tooth –5 color change results.19 This threshold relates –6 to a difference in color that is considered –7 acceptable by 50 percent of observers, –8 with the other 50 percent of observers

FIGURE 4. Line plots of changes in shade-guide units as measured visually with the VITA Bleachedguide replacing or correcting the restoration. Not 3D-Master by group over time. surprisingly, the highest color change was observed for the HP group, which served TABLE 3 as our positive control. Of note, the overall color change was in good accordance with Pearson Correlation by Color-Assessment Tool at One-Day and One-Month another study that used the same whitening Postwhitening agent for the same exposure time and ΔVBG_1 ΔE*_1 ΔSGU_1 ΔVBG_2 ΔE*_2 ΔSGU_2 frequency (current study: ΔE*=7.6 versus ΔVBG_1 1 –.563** .593** Park et al.: ΔE*=7.7, both at one-day 16 ΔE*_1 –.563** 1 –.695** postwhitening). Although there were no signifi cant differences among the NC, ΔSGU_1 .593** –.695** 1 COAL and OIL groups after adjusting for ΔVBG_2 1 –.494** .491** multiple comparisons, the COAL group ΔE*_2 –.494** 1 –.744** had an overall color change of 3.8 and ΔSGU_2 .491** –.744** 1 4.1 at T1 and T2, respectively, exceeding ** Correlation is signifi cant at the 0.01 level (2-tailed). the 50:50 percent acceptability threshold. The overall color change is a composite Correlation of change in lightness and chroma. The Pearson correlations (r) between the accessible to the public, affordable and largest contributing factor for ΔE of the color-assessment tools are summarized in potentially do not cause tooth sensitivity COAL group was the decrease in chroma TABLE 3. Correlation values range between or gum irritation, which are common side in the yellow-blue axis. This aligns well +1 and –1, where 1 relates to total positive effects of professionally supervised at- with the stain-adsorbing nature of activated linear correlation while –1 is total negative home or in-offi ce whitening procedures.1 charcoal reported in the literature. Studies correlation. The visual assessment by an Despite the fact that many practitioners have shown that activated charcoal acts observer was denoted as ΔVBG while receive inquiries on the fastest and safest best in an acidic environment.5 Controlling the electronic measurements from the way to whiten teeth, there is only limited the pH without creating adverse effects spectrophotometer were expressed as information on the whitening effi cacy of on tooth structure to boost the activity of overall color-change ΔE* and the results natural ingredients. The fi rst article on charcoal may be considered in the future. from the camera-based imaging software as DIY whitening concluded that strawberry While activated charcoal may be promising ΔSGU. There was a signifi cant correlation puree was not effective in tooth whitening.1 as a natural ingredient, the authors also for color-change measurements at T1 The current study aimed to provide more observed remaining charcoal particles in and T2 for all assessment tools (P < 0.05, evidence on other DIY whitening methods the occlusal pits and fi ssure areas that were in all instances). The correlations were to assist oral health care professionals diffi cult to remove by brushing. This may be higher with the VES versus SW than the and the general public in making wise a potential issue when using charcoal slurry visual versus digital assessment methods. decisions on how to best whiten teeth. in teeth with signifi cant irregularities and Based on the results, our fi rst null crack lines or in restorations with defects. Discussion hypothesis was rejected. There were The visual color determination with DIY whitening modalities with natural differences in color change among the shade guides is commonly used in restorative ingredients have been advocated over four groups at one-day and one-month and aesthetic dentistry.20 The process is the internet because they are readily postwhitening, as indicated by all color subjective and infl uenced by external light

NOVEMBER 2018 719 whitening efficacy

CDA JOURNAL, VOL 46, Nº11

conditions as well as the experience, age cleaning. However, extrinsic stains when modalities on microhardness, surface roughness and surface 10 morphology of the enamel. Odontology 2015;103(3):274–9. and fatigue of the examiner. However, accumulated for a prolonged time can 9. Paravina RD. New shade guide for tooth whitening monitoring: despite these limitations, the human eye become internalized, which makes the visual assessment. J Prosthet Dent 2008; 99(3):178–184. is very effi cient in detecting even small differentiation of extrinsic and subsurface 10. Paravina RD. Performance assessment of dental shade guides. 21 J Dent 2009;37s(suppl 1):e15–20. differences of color between two objects. stains challenging and necessitates different 11. Chu SJ, Trushkowsky RD, Paravina RD. Dental color matching Our second null hypothesis aimed to approaches for removal. The results of instruments and systems. Review of clinical and research aspects. J address the correlation between visual and our study indicate that the use of natural Dent 2010;38s(suppl 2):e2–16. 12. CIE (Commission Internationale de l’Eclairage). Colorimetry- digital shade-assessment tools. Based on ingredients may be more useful for the technical report. CIE pub. Bureau Central De La CIE 1986. the results, the hypothesis was rejected. removal of surface stains. Future studies are 13. Hu JC, Wang CH, Kuhns D. New algorithm in shade There were signifi cant correlations between warranted to distinguish between surface matching. J Cosmet Dent 2016;32(1):62–72. the visual and digital color-assessment and subsurface stains to evaluate the 14. Brambert P, Qian F, Kwon S. Erosion potential of whitening regimens as evaluated with polarized light microscopy. J Contemp tools. However, the correlation was higher effi cacy of different whitening regimens. Dent Pract 2015;16(11):921–925. with the two digital assessment tools. 15. American Dental Association. ANSI/ADA Specifi cation No. The VITA Easyshade system has a high Conclusions 41 for Recommended Standard Practices for Biological Evaluation of Dental Materials. Chicago: ADA 2005. measuring accuracy of 92.6 percent and a Within the limitations of this study, 16. Park S, Kwon SR, Qian F, Wertz P. The Eff ect of Delivery repeatability of 96.4 percent.22 Therefore, we conclude that DIY whitening with System and Light Activation on Tooth Whitening Effi cacy this system is often used as a reference activated charcoal and coconut oil and Hydrogen Peroxide Penetration. J Esthet Restor Dent 2016;28(5):313–320. instrument in diverse studies regarding was not effective. We also concluded 17. International Organization for Standardization. ISO/TR determination of tooth color.23–26 In the that instrumental measurements with 28642 Dentistry-Guidance on Color Measurement. Geneva: past few years, digital photography has the VITA Easyshade and with a newly International Organization for Standardization 2011. 18. Hemming M, Kwon S, Qian F. Repeatability in Color become a valuable tool in dentistry for developed digital camera-based software Measurements of a Spectrophotometer Using Diff erent Positioning record keeping and communication of correlated well with each other. ■ Devices. J Contemp Dent Pract 2015;16(11):933–938. information, especially with regard to tooth 19. Ragain JC Jr. Minimum color diff erences for discriminating mismatch between composite and tooth color. J Esthet Restor Dent 27 ACKNOWLEDGMENT color. The high correlation of the digital 2001;13(1):41–8. camera-based software with the Easyshade The study was funded by the Loma Linda University School of Dentistry Student Research Program fund. The authors convey 20. Van der Burgt T, Ten Bosch J, Borsboom P, Kortsmit W. A system is promising and warrants further special thanks to ShadeWave for kindly providing the software comparison of new and conventional methods for quantifi cation of evaluation of accuracy and repeatability. used for this study. tooth color. J Prosthet Dent 1990;63(2):155–62. 21. Paul S, Peter A, Pietrobon N, Hämmerle C. Visual and The topic of natural ingredients REFERENCES spectrophotometric shade analysis of human teeth. J Dent Res warrants a discussion of the nature of 1. Kwon SR, Meharry M, Oyoyo U, Li Y. Effi cacy of do-it-yourself 2002;81(8):578–82. superfi cial stain and subsurface stains. The whitening as compared to conventional tooth whitening modalities: 22. Kim-Pusateri S, Brewer JD, Davis EL, Wee AG. Reliability and accuracy of four dental shade-matching devices. J Prosthet Dent latter terms are often used interchangeably, An in vitro study. Oper Dent 2015;40(1):E21–7. 2. How to whiten your teeth with charcoal. www.prevention.com/ 2009;101(3):193–199. leading to confusion. Superfi cial stains beauty/charcoal-whitening-teeth. Accessed May 8, 2017. 23. Yuan JC, Brewer JD, Monaco EA Jr., Davis EL. Defi ning a are addressed by a mechanical approach 3. Six ways to naturally whiten your teeth. draxe.com/6-ways-to- natural tooth color space based on a three-dimensional shade system. J Prosthet Dent 2007;98(2):110–119. through the use of a toothbrush and naturally-whiten-your-teeth. Accessed May 8, 2017. 4. Lucas GH, Henderson VE. The value of medicinal charcoal 24. Paravina RD, Majkic G, Stalker JR, Kiat-Amnuay S, Chen JW. toothpaste that is readily available to (carbo medicinalis C.F.) in medicine. Can Med Assoc J Development of a model shade guide for primary teeth. Eur Arch the public. The removal of subsurface 1933;29(1):22–23. Paediatr Dent 2008;9(2):74–78. stains involves a chemical process with 5. Mináriková M, Fojtikova V, Vyskočilová E, Sedláček J, Šikut 25. Da Silva JD, Park SE, Weber HP, Ishikawa-Nagai S. Clinical M, Borek-Dohalska L, Stiborová M, Martinkova M. The capacity performance of a newly developed spectrophotometric system on peroxide-containing whitening products and eff ectiveness of diosmectite and charcoal in trapping the tooth color reproduction. J Prosthet Dent 2008;99(5):361–368. that is performed under the supervision compounds causing the most frequent intoxications in acute 26. Brandt J, Nelson S, Lauer HC, Von Hehn U. In vivo study for of an oral health care professional or medicine: A comparative study. Environ Toxicol Pharmacol tooth colour determination-visual versus digital. Clin Oral Invest 2017;17(52):214–220. doi: 10.1016/j.etap.2017.04.011. 2017; DOI 10.1007/s00784-017-2088-0. used by consumers at home. While [Epub ahead of print]. 27. McLaren, E, Figueira J, Goldstein RE. A technique using both approaches result in whitening of 6. Venkata Mohan S, Karrthikeyan J. Removal of lignin and calibrated photography and Photoshop for accurate shade teeth, the mechanism underlying the tannin and tannin color from aqueous solution by adsorption onto analysis and communication. Compend Contin Educ Dent activated charcoal. Environ Pollut 1997;97(1-2):183–187. 2017;38(2):106–113. 28 inherent processes is distinctly different. 7. Gbinigie O, Onakpoya I, Spencer E, MacBain MM. Eff ect 28. Kwon S, Wertz PW. A Review on the Mechanism of Tooth Despite the fact that stains may vary in of oil pulling on promoting oro dental hygiene: A systematic Whitening. J Esthet Restor Dent 2015;27(5):240–57. color, severity and location, all surface review of randomized clinical trials. Complement Ther Med 2016;26:47–54. THE CORRESPONDING AUTHOR, So Ran Kwon, DDS, MS, PhD, MS, stains can be easily removed by dental 8. Kwon S, Kurti SR, Oyoyo U, Li Y. Eff ect of various tooth whitening can be reached at [email protected].

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LOS ANGELES COUNTY ORANGE COUNTY SAN DIEGO— Price Reduced!! GP in med/ dent bldg. w/ 3 eq ops. Fee for service. Estab. CANOGA PARK— 25+ years of goodwill GP w/ FULLERTON—Leasehold Improvements and circa 1950. Grossed $301K in 2017. Net 4 eq ops and 1 plmbd not eq op. Located in a Equip Only!! This GP is located in a mul story $117K. Property ID # 5212. single story bldg. Proj. approx. $394K for professional building. Has 6 eq ops in a 1,941 2018. Property ID #5241. sq suite. Selling “as-is”. Property ID #5248. SAN DIEGO—Spacious GP located in a 3 story professional building. Has 5 eq ops in a 2,157 CARSON— Price Reduced!! Long established GARDEN GROVE - LH & Equip Only! Has 3 eq sq suite. Proj. approx. $645K for 2018. Prop- GP in a small shopping center. Grossed $277K ops, 1 plmbd not equip in a 2 story profession- erty ID #5233. in 2017. Net $132K. Has 3 eq ops & 2 plmbd al bldg. Great for a Perio or GP. Property ID not eq. Rering seller work 3 days/wk. Great #5239. RIVERSIDE & street visibility. Property ID #5181. IRVINE - Well established Cash Only GP w/ 5 SAN BERNARDINO COUNTIES COMPTON— (GP + Real Estate) Established in eq ops in a1,915 sq office . Grossed approx. CORONA— Beauful GP w/ 6 eq ops / 4 plmbd 1982 w/ 4 eq ops / 3 plumbed not eq. Gross. $482K in 2017. Property ID #5193. not eq for expansion in a 3,700 sq office. $581K in 2017. Net $262K. Property ID # LA PALMA— With 60 years of goodwill this GP Located on a one story free standing building 5209. pracce is located in 2 story dental bldg w/ 4 next to a busy shopping center. Grossed eq ops. Grossed $443K in 2017. Property ID # LANCASTER (GP + Bldg) Long established 5234. $346K in 2017. Great potenal for a full me pracce w / 4 eq ops in a 1,600 sq office. denst. Property ID #5224. ORANGE— LH & Equip Only! Beauful office Grossed $693K in 2017. NET $220K. Property w/ 4 eq ops in a 1,300 sq office in single free PALM DESERT— Beauful GP located in a ID #5222. standing bldg. Property ID #5229. single story corner building. Heavy traffic flow. SANTA CLARITA— Price reduced!! GP w/ 36 TUSTIN—Well established GP in a 2 story busy Consists of 4 eq ops in a 1,800 sq office. yrs of goodwill in prof. bldg. w/ 5 eq ops. shopping center. Projecng $1.8M in 2018. Reasonable rent. Monthly revenues of $132K. Grossed $449K in 2017. Property ID #5207. Has 3 eq ops in 1,222 sq suite. Property # Grossed $1.4M in 2017. NET $592K. Property 5236. TARZANA - Established in 1929 w/ 5 eq ops in ID #5217. a 1,552 sq suite. Delta Premier and Cash TUSTIN— LH & EQUIP ONLY! Beauful remod- Only! ProjecƟng approximately $698K. Buy- eled office with 3 eq op and 1 plmbd not eq. PALM SPRINGS – General pracce with 3 er’s Net $225K. Property #5226. Located in a single story professional building. equipped ops located in a free standing bldg. Has two price points. Property ID #5244. Established in 2005. Suite is approx. 1,200. WOODLAND HILLS - Well established GP in a 5 story med/dent bldg with 4 eq ops and 1 TUSTIN - GP + Real Estate. Established in Seller work 5 days/wk. BUYER’S NET OF plmbd not eq. ProjecƟng $1M for 2018. Prop- 1987w/ 4 eq ops in a 1,140 sq office. Proj. $311K. Property ID #4487. erty ID #5246. approx. $353K for 2018. Net $128K. Property RANCHO CUCAMONGA— GP established in KINGS & VENTURA COUNTIES 2004 in busy shopping center. Consists of 3 eq SAN ops in a 1,200 sqSOLD suite. Grossed $422K in GOLETA—GP w/ 27 yrs of gdwll in a 2 story 2017. Net $149K. Property ID #5169. mix bldg. 4 eq ops. Grossed $572K. Prop. SAN DIEGO COUNTY #5205. TEMECULA - Pedo and Ortho PracƟce + Real LA MESA— Beauful GP office in shopping Estate!! It’s located in a duplex single story LEMOORE— GP + Real Estate. 33 years of center w/ 5 eq ops & 1 plumbd not eq. Sees 80- 100 new paents/mo. Grossed $1.5M in 2017. building. ProjecƟng approximately $1.7M goodwill with 5 eq ops in a 1,655 sq office. Net $368K. Prop.#5228. with a Buyer’ net of $975K. PPO/Cash/Den- Averaging 35-40 new paents/mo. Grossed cal. Has 8 eq ops in a 3,500 sq office. Prop- $1.4M in 2017. Net $377K. Property ID # OCEANSIDE— Orthodonc pracce w/4 chairs in open bay in a 1,550 sq office. Grossed erty ID # 5243. 5232. SAN $263K in 2017. PropertySOLD ID #5225.

OXNARD—Est, in 1973 w/ 4 eq ops in a 1,100 sq suite. GrossedSOLD $585K Net $186K.

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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, Nº11

Managing Patients With HIV TDIC Risk Management Staff

n the early days of dentistry, not The patient informed the dentist much was known about the spread that he was not under the care of of disease. Dentists performed a physician and he did not agree their work without the protection Unlike the fl u or common with the dentist’s requirement to of gloves, sterilization or even cold, there is little, if any, contact a physician. He remained Ihand-washing, giving little thought risk of spreading the HIV adamant about having the tooth to infection control. As knowledge extracted and refused to move of bacteria and viruses expanded, so virus in the dental setting forward with the exam and X-ray. did the protocols for preventing their as long as appropriate The dentist explained that he could transmission in health care settings. precautions are taken. not complete the extraction without Unfortunately, there is still a great the necessary diagnostic information. misunderstanding about the spread of one The patient became upset and stated he of the most feared diseases in U.S. history felt he was being discriminated against — HIV. Unlike the fl u or common cold, there is little, if any, risk of spreading the HIV virus in the dental setting as long as appropriate precautions are taken. In California, patients with HIV are protected under the Unruh Civil Rights Act, which prohibits discrimination on the basis of medical condition, race, religion, You are not sexual orientation or disability, among a sales goal. other factors. The federal Americans With Disabilities Act offers similar protections by considering people with HIV, whether symptomatic or asymptomatic, to have a disability that impairs or substantially limits one or more life activities. According to The Dentists Insurance Company, refusing to treat a patient due to HIV status or perceived HIV status can be grounds for a discrimination claim. In a You are a dentist deserving of an insurance company relentless case reported to TDIC’s Risk Management in its pursuit to keep you protected. At least that’s how we see Advice Line, a dentist called to confi rm it at The Dentists Insurance Company, TDIC. Take our Risk whether he followed the right protocol Management program. Be it seminars, online resources or our when refusing to treat a patient with HIV. Advice Line, we’re in your corner every day. With TDIC, In this case, a new patient presented to his offi ce for an emergency visit, requesting an you are not a sales goal or a statistic. You are a dentist. extraction. The patient revealed he was HIV positive. The dentist told the patient ® that he should consult with his physician Protecting dentists. It’s all we do. prior to receiving treatment to discuss 800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783 whether the extraction would impact the patient’s overall physical health.

NOVEMBER 2018 723 NOV. 2018 RM MATTERS

CDA JOURNAL, VOL 46, Nº11

because of his HIV status. He left the The federal Centers for Disease confi dential and it will not affect your offi ce and warned that the dentist Control and Prevention details the willingness to provide treatment. Patients would be hearing from his attorney. minimum infection prevention practices should trust that their dental practice is Luckily, the case went nowhere, as that apply to patient care, both for a safe environment where they can be the dentist followed the appropriate bloodborne and airborne pathogens. truthful about their medical condition protocol of requiring an exam and Educating staff on these pathogens and without ramifi cation or judgement.” X-ray, a standard procedure regardless providing training on preventing their Practice owners should be aware of HIV status. Consulting a patient’s transmission is critical. The standard that they are obligated to follow physician is also a standard protocol precautions include the following: antidiscrimination policies as outlined in if the patient is under the care of a ■ Hand hygiene. state and federal law. Misunderstanding physician or is taking medication ■ Personal protective is no excuse for a discrimination claim, that may potentially impact dental equipment, including gloves, so brushing up on the requirements treatment, said senior TDIC Risk masks and eyewear. can go a long way in managing risk. Management analyst Taiba Solaiman. ■ Respiratory hygiene/cough etiquette. Assuming all patients are infectious and It should be noted that patients are ■ Sharps safety. employing standard infection precautions not required by law to disclose HIV ■ Safe injection practices. can avert a possible liability claim. ■ status, nor are practitioners prohibited ■ Sterile instruments and devices. from asking. However, dentists ■ Clean and disinfected TDIC’s Risk Management Advice should remind patients that various environmental surfaces. Line is a benefi t of CDA membership. medicines, including those used to In some cases, staff may be hesitant To schedule a confi dential consultation manage HIV, can affect oral health or may refuse to treat patients with HIV. with an experienced risk management and cause negative interactions. If this is the case, TDIC recommends analyst, visit tdicinsurance.com/RM Therefore, consulting with the attending trainings and classes that consult or call 800.733.0633. patient’s physician may be required address both the issue of HIV transmission and failing to ask the question may and the proper barrier procedures. Staff be considered practicing below the refusal to treat an HIV-positive patient standard of care. The TDIC form is no defense in a discrimination claim “Consultation Request for Dental against an employer. If staff members Treatment” can make quick work of continue to resist after being educated, scheduling a meeting with a patient’s consider taking disciplinary action. physician. TDIC policyholders can A patient’s HIV status bears special download the form and explore confi dentiality. Be sure not to release other helpful risk management this information unless you have express documents at tdicinsurance.com/ written permission from the patient risk-management/sample-forms. or the patient’s legal representative. Whether a patient is HIV positive, In some states, including California, dentists are reminded to use standard a general release or records form is infection control precautions at all times. not valid for release of HIV status In some cases, the patient may not be unless the release specifi cally states aware that he or she is HIV positive; “including HIV status.” Review and and in others, the patient chooses remind your staff of the offi ce’s privacy not to mark it on the medical history protocol so that they do not release this form out of fear of discrimination. information without your permission. “Standard precaution assumes “In order to ensure optimum care, all patients are infectious and a dentist must know about a patient’s protocols should be in place at health,” Solaiman said. “Reassure the all times,” Solaiman says. patient that his or her status will remain

724 NOVEMBER 2018 CARROLL “Matching the Right Dentist to the Right Practice” V &COMPANY

4261 CAPITOLA GP Retiring doctor offering an established practice in 4198 PETALUMA DENTAL BUILDING Condominiumized dental office professional office complex built around a garden setting. Beautiful and conveniently located close to Petaluma Valley Hospital and nearby shops, modern 1,465 square foot facility with 4 fully-equipped operatories. Average with easy access to Highway 101 and with ample, dedicated parking. gross $743K+ with 3 doctor days and 6 hygiene days per week. Approximately 1,600+ square feet with five (5) fully-equipped operatories set Approximately 1,800 active patients. Asking $562K. up for right hand delivery. There is a reception area, business office, consult room, staff lounge, lab, sterilization area, private office and separate storage 4172 NAPA GP Amazing opportunity to own the practice of your dreams in area. Asking $495K. one of the world’s premier wine destinations! Situated in a prime neighborhood close to many amenities. 1,200 square foot office with 4 fully- 4178 SONOMA COUNTY PERIO Seller retiring from 21 year practice with equipped and updated operatories. Over 1,000 active patients. Average trained, seasoned staff and great location. Exceptional 2,100 sq. ft. ample annual gross receipts over $700K. Asking price for practice $484K. Building office with 6 fully equipped ops. Majority of equipment purchased in 2002. 4 available for purchase. doctor-days & 3 hygiene days per week. Average gross receipts $1M+. Asking $677K. 4248 MENLO PARK FACILITY Remodeled, 930 sq. ft. dental facility with 2 fully equipped ops. andLD plumbed for 2 additional ops, reception area, 4225 EUREKA GP & BUILDING Established since 1981 in charming doctor's office, sterilization,SO lab, storage and restroom. Medical/Dental Northern California port city. Retiring doctor is offering practice and building. building in highly desirable location. Asking $135K. Practice has approximately 1,200 active patients with new patients accepted on a selective basis. Average Gross Receipts of $765K+ with 61% average 4233 SF GP Seller offering 26+ year general practice in SF Financial district. overhead. Beautiful 1,400 square foot office with four (4) fully-equipped Ground floor office with high volume foot traffic. Approx. 1,200 sq. ft. facility operatories. Asking price for practice $468K. with 4 fully-equipped ops. $930K+ avg. annual GR. Seller willing to help for a smooth transition. Asking $640K. 4216 SIERRA NEVADA FOOTHILLS 23 year practice located in the heart of the Sierra Nevada foothills in modern building close to downtown area. 4262 MOUNTAIN VIEW GP Desirable 1,700 square foot Mountain View 1,024 square foot office with 4 fully- equipped ops., upgraded major location. 5 fully equipped operatories.G Average Gross Receipts $886K+ with equipment and digital radiography. Average Gross Receipts $890K+ with DIN 4 doctor days and 6E hygieneN days. Practice with an emphasis on Restorative 56% average overhead. Asking price for practice $604K. Seller is offering and Preventative care.P Seller retiring. Great opportunity for a skilled dentist to real estate for sale to the buyer of his practice. take over a 35 year practice with seasoned staff and loyal patient base. Asking $619K. 4326 SANTA CLARA GP Practice with an emphasis on Restorative dentistry with over 1,000 active patients located in sought-after ING 4210 UNION CITY GP Retiring GP offering 40+ years of goodwill. 5 ops in neighborhood closeN toD major routes, shopping centers and hospitals. 1,100 sq. ft. 350 active patients, all fee-for-service. 2 yr average GR Approximately 850PE sq. ft. facility with 3 fully-equipped ops. pljus a seasoned $177K. Asking $85K. and loyal staff. Avg. Gross Receipts $617K.

4321 SANTA CLARA GP Incredible location on the corner of two major 4324 SF GP Seller offering 33 years of goodwill in busy financial district thoroughfares. Seller retiringIN afterG 20+ years. Solid, loyal staff and patient bldg. Gorgeous 890 sq. ft. office with 3 fully equipped ops (plumbed for 4). ND base. 1,200 activeP patientsE (Seller is contracted with Delta PPO & Premier) 4 Incredible panoramic views with amazing natural light pouring into each ops in 1,400 sq. ft. Seller works 4 days/wk with 4+ hygiene days. Average window. 500+ active patients. 2 days of hygiene/wk. Current average GR GR $739K with average adj net of $282K. Asking price $561K. approx. $410K with adj net of $115K. Asking $232K.

4269 SAN JOSE GP Well established practice offering 46 yrs of goodwill. 4331 SF GP Downtown SF practice in gorgeous, remodeled 1,300 office Excellent West San Jose location. 7ops, 5 fully equipped in 2,000 sq. ft with panoramic views. Suite includes 4 fully equipped ops, reception area, facility. Approx 3,000 active patients, all fee-for-service. 9 days of hygiene/ business office, private office, staff lounge, lab area, and sterilization area. LD week. OutstandingS staff.O Average annual GR $1.3M with an adjusted net of Beautiful, modern cabinetry and equipment. 1,600 active patients with 15-20 $473K. Asking price $1,015,000. Potential to purchase bldg interest, price new patients/mo. Owner/doctor works 3 days/wk with 5 hygiene days/wk. to be determined. Owner willing to help in the transition. Average gross receipts $738K with average adj. net of $305K. Asking $495K. 4271 SOUTH SF DENTAL FACILITY Turnkey facility in well known beautiful, professional building with dedicated parking lot. Incredible location with EZ freeway access to Hwys 280, 380 and 101. Asking only $30K. Carroll & Company 2055 Woodside Road, Suite 160 4267 SAN JOSE GP 36-year established 4 op practice near Willow Glen Redwood City, CA 94061 area grossing $650K average. 950+ active patients. Beautifully maintained D BRE #00777682 and updated 1,450 sq.OL ft. facility. 3-day doctor week, 3 hygiene days. Asking $450K. S Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll

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

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Continuing Education Q&A CDA Practice Support

any dentists and I fi nd value in taking the required Will any infection control course other licensees infection control course and Dental satisfy the requirement to complete learned earlier Practice Act course every year. Am two units in infection control? this year of I able to claim C.E. credit for the No. Only infection control courses their obligation second time I take those courses in (and Dental Practice Act courses) Mto retain records of continuing a renewal period if the instructors approved by the dental board will satisfy education for when the Dental are different from the fi rst time? the mandatory course requirement. You Board of California audited them Yes, you can get C.E. credit each can use the Department of Consumer for compliance. Dental licensees time you take the Dental Practice Act Affairs license search database (search. must retain continuing education course or infection control course as dca.ca.gov) to verify whether a provider’s records for a minimum of three long as there is a different instructor course is board-approved. See the FIGURE license-renewal periods and provide from the last time you took the course. for an example of what to verify. them to the board when audited. If a licensee fails to retain a C.E. certifi cate, he or she is required to contact the C.E. provider and obtain a duplicate certifi cate. Following are answers to other continuing education questions recently received by CDA Practice Support.

I took a clinical course outside of California. The course provider is not approved by the dental board, AGD PACE or ADA CERP. How can I obtain credit for attending this course? You can petition the dental board to grant credit. Complete and submit an “Application for Continuing Education Approval for Out-of-State Course Offered by an Unregistered California Provider” that is available for download from the board website. Include with the application the course content, course duration and evidence from the provider of course completion. Be certain to submit the application in sufficient time to allow the board to review and approve it before the end of your renewal period.

NOVEMBER 2018 727 NOV. 2018 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 46, Nº11

must include all of the following: I have a general anesthesia ■ Instruction in both adult and permit and therefore must complete pediatric CPR, including advanced cardiac life support FIGURE. How to verify a board-approved course. two-rescuer scenarios. certifi cation every renewal period. ■ Instruction in foreign-body Must I also complete a basic life Will an online CPR course satisfy airway obstruction. support certifi cate in the same the mandatory basic life support ■ Instruction in relief of choking renewal period or is the ACLS certifi cation requirement? for adults, children and infants. recertifi cation accepted as a basic No. To satisfy the requirement ■ Instruction in the use of automated life support-equivalent course? you must complete either: external defi brillation with CPR. The ACLS course will suffi ce 1. An American Heart Association ■ A live, in-person skills practice for the basic life support certifi cate or American Red Cross course session, a skills test and a requirement for the purpose in basic life support. written examination. of dental license renewal. 2. A basic life support course taught A maximum of 4 C.E. units by a provider approved by the ADA is granted for basic life support I know the dental board grants CERP or AGD PACE. The course certifi cate course completion. continuing education credit for accredited postdoc programs. How is the number of C.E. units calculated for a postdoc course? In other words, what is the C.E. unit equivalent for a 3-unit course? If you hold a license issued by the Dental Board of California or Dental Hygiene Committee of California and are enrolled full time in an educational program, such as a postdoctoral program, dental school, dental hygiene program or registered dental assisting in extended function program, approved by the dental board or ADA Commission on Dental Accreditation, 1 unit of continuing education credit is granted for every hour of contact instruction and may be issued in half-hour increments. Credit applies to either academic or clinical instruction. A maximum of 8 units per day can be credited. In case of an audit, a licensee should retain school transcripts or a letter from the residency program director that includes name, license number and dates of enrollment. CONTINUES ON 730

728 NOVEMBER 2018 SELL YOUR PRACTICE ...... to the right buyer! Knowing how, means doing all of the following - with precision:

1. Valid practice appraisal.

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

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

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

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

6. Lease negotiations.

All six of these services costs no more.

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

Your calls are invited. Put our thirty years of experience to work for you! 818.991.6552 Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461 NOV. 2018 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 46, Nº11

CONTINUED FROM 728 An RDA holds a specialty certifi cate. Is she required to obtain 25 continuing education credits for each license and certifi cate (total of 50 credits) or is 25 credits suffi cient for renewal of both license and certifi cate? The total number of C.E. units required for an individual with dual dental licenses and/or permit is the greatest number required for one license/ permit. In this example, the RDA need only complete 25 units to renew both the license and specialty certifi cate.

Is a live, interactive webinar considered live instruction? Yes, it is. Only one-half of a licensee’s required C.E. units may be earned through use of correspondence courses such as video-recorded courses, audio-recorded courses and home-study materials. All remaining units must be earned through live, interactive courses such as live lecture, live telephone conference, live video conference, live webinar, live workshop or live classroom.

I took a course on derma fi llers and Botox from an education provider approved by ADA CERP — can I claim C.E. credit for the course? It depends. If the course focuses on therapeutic purposes of those drugs, it may be possible to claim C.E. credit. If the course focuses on the cosmetic procedures that utilize these drugs, only a dentist who holds a facial cosmetic surgery permit may claim C.E. credit. ■

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

730 NOVEMBER 2018 Specialists in the Sale and Appraisal of Dental Practices Practices Serving California Dentists since 1966 How much is your practice worth?? Wanted Selling or Buying, Call PPS today!

NORTHERNNORT CALIFORNIA SOUTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6151 MODESTODESTO Located on north end of Coffee Road where alla new ALTA LOMA *UHDWH[SRVXUH. Grossing $700. )LYHopV development is occurring. Attractive 3-op office. 2-days of Hygiene. 2018 3-equipped. tracking $445,000 in collections on part-time basis. Wants a full-time BAKERSFIELD Will do $1 Million. $650K includes RE. Owner. BAKERSFIELD $5($ Grossing $1.2. Owner works 16-hrs. 6150 HAYWARD Strong Dental DNA. Well-designed 5-op office. Digital radiography & computers. 2018 trending $850,000+. 5-days of Nets $300K. hygiene. Full Price $200,000. BAKERSFIELD AREA Grossing $40K/mth on 2-days. 5-ops. 6149 NOVATO Stand-alone building at busy stop light intersection off BELLFLOWER Part-time doing $100K. FP $65K. Highway 101. All new 2-years ago. 4-ops, digital, paperless, Pano with &2/721Latino. Absentee. Grosses $350. 5-ops. Ceph at cost of $80,000. At doorway into Hamilton neighborhood with CORONA Near Capistrano Beach exit. Part-time SUDFWLFH Vof homes. No competition. Perfect for nearby DDS who wants to grossing$200. own their building or Growing Group seeking perfect location. Building DEL MAR -- ENCINITAS HMO grossing near $400K. 4-ops. and turn-key office available for purchase. +DYHJUHDW5HSRUWIRUUHYLHZ 6148 SAN LEANDRO Great location on Hesperian Boulevard. DIAMOND BAR Million Dollar location-to-be. 4-ops, digital Absentee owned. Shall collect $40,000 in 2018. Has done $670,000 in pan. recent past with owner here. Associate relocating. Seller’s daughter shall DIAMOND BAR HiJKLdentity Asian VWULScenter. 5-ops. Will provide transition assistance. do $1 Million. 6147 SAN FRANCISCO BAY AREA – “OUT-OF-NETWORK” 2017 GARDENA Did $2 Million when Owner here. Doing $1.5QRZ. collected $2 Million. 2018 tracking $2.15 Million. Hygiene produces $1+ GLENDALE / BURBANK Grosses $840K. Includes apt. Million. Seller available for long transition. INLAND EMPIRE Adec, cone beam. Gross $1.3. Incl RE. 6146 LOWER SACRAMENTO FOOTHILLS Highly regarded INLAND EMPIRE DentiCal gross near $300K. FP $150K. family community. 6-days of hygiene evidences strong foundation. 2017 collected $880,000. 2018 projecting $950,000. INLAND EMPIRE Union Practice can do $1+ Million. 6144 SACRAMENTO AREA 14-days of Hygiene. 2017 collected INLAND EMPIRE 2 practices grossing $1.8. Right DDS does $1.85 Million. Strong staff. 7-ops. Great location. Condo optional $3. Gorgeous. purchase. IRVINE Grossing $1.2 Million. 5-ops. 6143 BERKELEY’S ALTA BATES VILLAGE Perfect for nearby LA MIRADA Like new 5-ops, 3-equipped. Grossing $450K. Premier Dentist to relocate their practice into stand-alone building on LANCASTER Successor will do $1.2. Area booming. Webster Street. 3-day week collected $550,000 in 2017. 4-days of NORTH LONG BEACH Hi Identity. 50% Latino. Only $75K. Hygiene. 1257+3$6$'(1$ Million $ practice. 5-ops across from 6142 OAKLAND’S PIEDMONT - “OUT-OF-NETWORK” 3-ops, paperless and Planmeca ProMax. 2017 collected $667,000. Profits Starbucks. $300,000+. Successor should be proficient in Ortho or willing to learn. OC BEACH 6-ops, Dentrix, digital, computerized. FP $150K. Seller available for transition. OC BEACH Absentee owned, grossing $550K. 4-ops. 6141 NAPA VALLEY’S ST. HELENA 3-day per week PPO practice. OC BEACH Grossed $100K last month. FP $900,000. 3-days Hygiene. 2017 Collected $359,000. Attractive 3-op office. OC BEACH Grossing $1 Million. 4-ops, cone beam. 15-NPs/mth. Full Price $100,000. OC’S FASHION ISLAND Grossing $650K. Rare opportunity. 6140 SAN RAFAEL Dentist retiring. Delta PPO provider. Has 3$/0635,1*6/$48,17$ Doing $1.5 0LOOLRQbut can averaged $390,000 in collections on 26.5-hour week. $223,000+ in do $2 Million. Profits in 2017. Full Price $125,000. PEDO Chinese & Latino. Grosses $450. FP $285,000. 6139 SF BAY AREA PROS PRACTICE - “OUT-OF-NETWORK” 2017 billed $1.2 Million, collected $1.19 Million. 4-days of Hygiene. REDLANDS Once did $1 Million. Grossing over $400. Owner available for transition. 5,$/72Empty 9-op office in 10,000 sq.ft. building near 210. 6138 SILICON VALLEY Best technology and well-designed suite. Did $1+ Million. 2017 collected $900,000+ with Profits of $420,000. Perfect for Dentist RIVERSIDE Grossing $250K. 30-new pts/mth. FP $165. wishing to create high-end brand. SANTA CLARITA 70,000 cars pass daily. 8-ops. FP $250. 6129 FOSTER CITY – “OUT-OF-NETWORK” Wish to infuse your THOUSAND OAKS / AGOURA HILLS 5-ops, part-time nearby practice with quality patients? Collected $500,000+ in 2017 on grossing DSSUR[LPDWHO\$500. part-time schedule. Seller and Hygienist shall relocate into Buyer’s practice to transition patients. Full Price $100,000. TORRANCE Entrance to Pales Verdes. Grossing $300+. 6122 SANTA CLARA Best exposure in beautiful strip center on El FXOOPULFH$290. Camino Real. 5-Ops. Delta PPO practice currently trending $1+ Million 83/$1' Grossing $135part-time. 3-ops. in Collections on 4-days. Perfect platform to operate 6-days a week. WEST COVINA Grossing $650. 2 days hygiene.

Largest BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED CENTRAL VALLEY

AC-782 SAN FRANCISCO: Well maintained, mul- CN-878 VALLEJO: Highly desirable thriving communi- EN-664 SACRAMENTO Facility: IG-832 OAKHURST: Broker in level Professional Medical Complex. 1450 sf w/ 5 ty! 2 story prof bldg. 2000 sf w/4 ops $315k Now Only: $30k ops $195k CN-911 SANTA ROSA: In the heart of wine country EN-791 SO. SACRAMENTO CO: $235k/ Real Estate 375k AC-886 SAN FRANCISCO (Facility): Unsurpassed this family-oriented pracce philosophy is “Quality $495k IG-881 TURLOCK: Northern visibility & locaon! Potenal here is limitless! 850 Care & Paent well-being FIRST”. 2250sf w/4 ops + EG-849 AUBURN: $360K sf w/ 3 ops $85k 1add’l. $545k IN-764 STOCKTON: AC-893 SAN FRANCISCO (Facility): Move In Ready DC-812 REDWOOD CITY Facility: Reasonable rent $350k Only: California Facility in Union Square. 1000 sf w/ 3 ops $50k and great landlord! 740 sf w/ 3 fully equipped ops EG-887 FOLSOM Facility: $225k!

AG-852 SAN FRANCISCO: PRIME LOCATION! 600 sf $65k Priced for quick Sale! $50k JC-811 FRESNO COUNTY: w/ 2 fully equipped, computerized ops. $325k DG-854 SUNNYVALE: Do your best denstry here to EG-910 MIDTOWN SACRAMENTO: $350k AG-871 SAN FRANCISCO: The LOCATION of this an educated, diverse, family-oriented, business- $248k JC-823 LOS BANOS: Over $34.5M office is the envy of all! 600 sf w/ 2 ops $88k friendly populaon! 782sf w/ 3 ops $875k EN-797 WOODLAND: $80k AG-880 SAN FRANCISCO: Seller rering aer 39 DG-862 MID-PENINSULA: Pracce is a rare gem with Pracce $575k/ Real Estate TBD JG-807 FRESNO: years! Remodeled in 2010. ~ 700 sf w/ 2 ops $350k up to 7 operatories in the Bay Area!! 1800sf w/ EN-831 SACRAMENTO Seller Movated $99k in 2017 sales AG-895 SAN FRANCISCO: This pracce has a stellar 6ops + 1 add’l. $475k “a cut above” Now Only: $650k reputaon and delivers the highest quality of den- DG-865 SANTA MARIA: Live and pracce in this de- EN-836 CITRUS HEIGHTS: SOUTHERN CALIFORNIA

stry! 1500 sf w/ 4 ops $675k sirable collegiate coastal community! 930sf w/ 3 $188k AG-896 SAN FRANCISCO: Don’t less this opportuni- ops $395k EN-858 ORANGEVALE: KG-779 SAN CLEMENTE Ortho: Extensive Buyer ty pass you by! ~ 1300 sf w/ 2 ops $600k DG-868 SUNNYVALE: Hesitate and you might lose Priced to Sell Only $70k! $325k/ Real Estate AG-900 SAN FRANCISCO: State-of-the-art equip- out on the pracce of your dreams! 1350sf w/ 5 EN-885 ROSEVILLE Facility: Available! Call for Details! Database & ment in this pracce, already primed for proven ops. $725k Now: $85k KL-909 SAN DIEGO: success at this locaon. 2000sf w/ 5 ops $695k DN-771 SOQUEL Facility: The perfect place to sink EN-899 DIXON: Unsurpassed BC-741 DANVILLE (FACILITY): Move in Ready facili- down roots, raise a family & build an empire! $195k $1.05M ty to build the practice of your dreams! ~ 1600sf 1100sf w/2 ops + 1 add’l. $38,500 FC-650 FORT BRAGG: Exposure allows w/ 3 fully equipped ops $150k DG-785 SANTA CRUZ: Great price and cash flow for $350k for the Pracce & $400k for the Real Estate SPECIALTY PRACTICES BC-789 OAKLAND (Facility): Perfect layout for only 3 days a week!! 1000sf w/ 4 ops. Seller Mo- FG-841 ARCATA: us to offer you Pedo or Ortho. 2800 sf w/ 6 fully equipped ops. vated: $165k $275k/Real Estate TBD AC-748 SAN FRANCISCO Perio: Plumber for 2 add’l $135k DG-842 FREMONT: Imagine being able to live, FN-855 NO. HUMBOLDT: $750k

BC-894 BRENTWOOD: Perfect locaon – Will be pracce and play here! 3200 sf w/ 10 ops $395k $275k BC-784 CENTRAL CONTRA COSTA CO Perio:

your best purchase ever! 1230 sf w/ 2 ops. DG-857 SAN JOSE: Do the math - this associate- GN-799 PARADISE: $395k Plumbed for 2 add’l $225k driven pracce with profitability consistently! Pracce $375k, Real Estate $325k BG-843 WALNUT CREEK Perio BG-734 ANTIOCH: The perfect place to work, live 1709 sf w/5 ops $595k GN-884 YUBA CITY Real Estate w/ Equip: Reduced Price: $595k Better and play! Located in desirable professional neigh- DG-892 SAN JOSE: Excellent locaon and stellar $400k DC-835 TRI-VALLEY Perio: borhood. 1,323 sf w/ 4 ops. $315k reputaon in a one-of-a-kind seng! 1500 sf w/ 3 GN-904 CHICO AREA: BN-891 PINOLE: This one won’t last! Build your ops + 2 add’l. $295k $310k $800k Candidate dental empire in this bedroom community! DN-845 FREMONT Facility: Build your dream HG-815 SIERRA CO: EG-903 CARMICHAEL Oral Surgery: 1300sf w/3 ops. $425k Pracce! Primed for success in this proven loca- Reduced Price: $165k/ Real Estate $437k CC-798 PETALUMA: Partially equipped dental office on! 1800sf w/3 ops + 2 add’l. $90k HG-827 SO. LAKE TAHOE: Amazingly Priced: $450k for lease. Only $2500/mo for 1400 sf! DN-898 SAN JOSE: Newly built-out in 2015, w/ $310k EN-821 DAVIS Perio: CC-802 SANTA ROSA: Retail shopping center w/ locaon, visibility, convenience, & comfort in mind! HG-851 SO LAKE TAHOE: $385k Better 1200 sf and 4 fully equipped ops $220k or $260k w/ 2,204sf w/4ops + 2 add’l. $500k $425k EN-822 SACRAMENTO Perio: CT Scanner DN-907 PLEASANTON Facility: Pleasanton one of HN-618 SIERRA FOOTHILLS: $790k CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 the “50 Best Cies to Live 2014” by Money Maga- $65k JG-757 VISALIA Perio: ops 640 sf Collections $433k in 2017 $295k zine. 1,170sf w/ 4ops. $95k HN-740 SHASTA CO: Steal at Fit CG-616 NAPA: State-of-the-Art practice and on $475k/ $350k track to do $100k more in 2018. Seller is ready for NORTHERN CALIFORNIA Real Estate $350k retirement! $425k HN-773 SUTTER CREEK: Seller Movated! CG-859 SONOMA: Priced below market value at only EC-729 GREATER SACRAMENTO AREA: Seller rer- ! $175k $395k! 2000sf w/ 4 ops highly esteemed FFS Prac- ing! FFS Pracce and Real Estate Available! HN-879 SONORA: Better tice $395k $275k

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

AC-782 SAN FRANCISCO: CN-878 VALLEJO: EN-664 SACRAMENTO Facility: Great corner locaon, excellent visibility & IG-832 OAKHURST: Have you ever dreamed of living and praccing by beau- Broker in $315k easy access! 2300sf w/ 4 ops. Now Only: $30k ful mountain ranges, surrounded by nature? 2048sf w/3 ops + 1 add’l. $195k CN-911 SANTA ROSA: EN-791 SO. SACRAMENTO CO: Highly esteemed pracce to an adoring & $235k/ Real Estate 375k AC-886 SAN FRANCISCO (Facility): appreciave paent base! 1950sfw/ 5 ops. $495k IG-881 TURLOCK: Offering a philosophy to provide “Nothing but the Very Northern EG-849 AUBURN: Imagine living in a peaceful, rural town that has an Best” in dental care! 10 ops $360K $85k $545k ideal climate and “big city” amenies less than an hour away. 1400 sf w/ IN-764 STOCKTON: Well-established, fully computerized, paperless, digital- AC-893 SAN FRANCISCO (Facility): DC-812 REDWOOD CITY Facility: 4 ops $350k ized pracce just waing for your talent & skill! 5,000sf w/10 ops. Only: California $50k EG-887 FOLSOM Facility: Build the pracce of your dreams here! 1200 sf $225k!

AG-852 SAN FRANCISCO: $65k w/ 2 ops Priced for quick Sale! $50k JC-811 FRESNO COUNTY: Amazing Opportunity! Considerable Goodwill in $325k DG-854 SUNNYVALE EG-910 MIDTOWN SACRAMENTO: Possibilies are endless for this well- Community! 3,000 sf w/ 6 ops $350k AG-871 SAN FRANCISCO: established pracce! ~ 1107 sf w/ 2 ops + 1 add’l. $248k JC-823 LOS BANOS: Unique opportunity. Heavy emphasis on hygiene. Growth Over $34.5M $88k $875k EN-797 WOODLAND: Do not hesitate or this enviable opportunity will fulfill potenal by increasing DDS days. 1000 sf w/ 3 ops $80k AG-880 SAN FRANCISCO: DG-862 MID-PENINSULA: someone else’s dream! 2316sf w/ 6 ops. Pracce $575k/ Real Estate TBD JG-807 FRESNO: Reasonable Overhead, Stellar Reputaon, Excellent Loca- $350k EN-831 SACRAMENTO: Locaon & pracce philosophy make this opportunity on! 1000 sf w/3 ops Seller Movated $99k in 2017 sales AG-895 SAN FRANCISCO: $475k “a cut above” others! ~1600sf w/4 ops. Now Only: $650k DG-865 SANTA MARIA: EN-836 CITRUS HEIGHTS: well-established, quality pracce comes loaded W/ SOUTHERN CALIFORNIA

$675k 30+ years of goodwill. 1300sf w/3 ops + 2 add’l. $188k AG-896 SAN FRANCISCO: $395k EN-858 ORANGEVALE: Perfect for a second locaon or satellite situaon! KG-779 SAN CLEMENTE Ortho: Huge growth potential by expanding Extensive Buyer $600k DG-868 SUNNYVALE: 850 sf w/ 3 ops. Priced to Sell Only $70k! relaxed work week! 2896 sf w/ 6 open bay chairs $325k/ Real Estate AG-900 SAN FRANCISCO: EN-885 ROSEVILLE Facility: Looking for the ideal locaon, great visibility, Available! Call for Details! Database & $725k and close to just about anything? Here it is! 1000sf w/3 ops. Now: $85k KL-909 SAN DIEGO: Remarkable Opportunity in proven location! Long $695k DN-771 SOQUEL Facility: EN-899 DIXON: State-of–the-art office, with all the “bells and whistles”! This established in vibrant North Park neighborhood. 2400 sf w/ 5 ops & 2 Unsurpassed BC-741 DANVILLE (FACILITY): fantasc pracce has 3 ops. $195k Pedo chairs $1.05M $38,500 FC-650 FORT BRAGG: Family-oriented pracce. 5 ops in 2000sf, 6 npts/ Exposure allows $150k DG-785 SANTA CRUZ: mo $350k for the Pracce & $400k for the Real Estate SPECIALTY PRACTICES BC-789 OAKLAND (Facility): Seller Mo- FG-841 ARCATA: Live and own a little slice of heaven, when you practice us to offer you vated: $165k here! 1114sf w/3 ops $275k/Real Estate TBD AC-748 SAN FRANCISCO Perio: Reputable PERIO practice with million dollar $135k DG-842 FREMONT: FN-855 NO. HUMBOLDT: Seller relocang! Quality 100% fee-for-service Bay views! 980 sf w/ 3 ops $750k

BC-894 BRENTWOOD: $395k pracce could be yours! 1600sf w/ 3ops + 1 add’l. $275k BC-784 CENTRAL CONTRA COSTA CO Perio: Seasoned Staff. Office runs like

DG-857 SAN JOSE: GN-799 PARADISE: This remarkable opportunity is undeniably too good to well-oiled machine! 3 ops $395k $225k be true! 1800sf w/ 4 ops. Pracce $375k, Real Estate $325k BG-843 WALNUT CREEK Perio: Collecons over $1M! Great gross and profit BG-734 ANTIOCH: $595k GN-884 YUBA CITY Real Estate w/ Equip: Designed specifically w/ paent for only 2 ½ days per week! 1085sf w/ 4 ops Reduced Price: $595k Better DG-892 SAN JOSE: flow &efficiency in mind. 1750sf w/ 5 ops. $400k DC-835 TRI-VALLEY Perio: Professional office bldg in highly desirable loca- $315k GN-904 CHICO AREA: Family-friendly, community-oriented, mul- tion. Owner available to work back to assist w/ transition. Collections BN-891 PINOLE: This one won’t last! $295k generaonal paent based pracce. 880sf w/ 3 ops. $310k over $1.2M. 2,100 sf $800k Candidate DN-845 FREMONT Facility: HG-815 SIERRA CO: Perfect location for outdoor enthusiast! 1000 sf w/ 3 ops EG-903 CARMICHAEL Oral Surgery: Gross receipts were over $1.1 million in $425k Reduced Price: $165k/ Real Estate $437k 2017! Stable paent base won’t be affected by transion! 2282sf w/ 5 ops CC-798 PETALUMA: $90k HG-827 SO. LAKE TAHOE: Ski, live, play and pracce here where your Amazingly Priced: $450k DN-898 SAN JOSE: lifestyle can’t be beat! 1200sf w/4 ops. $310k EN-821 DAVIS Perio: Live, pracce & play here! It’ll be the BEST deci- CC-802 SANTA ROSA: HG-851 SO LAKE TAHOE: Don’t wait another day to start living your dream of sion you’ll ever make! 1700sf w/4 ops + 1 add’l. $385k Better $220k or $260k w/ $500k a serene lifestyle! 2100 sf w/ 5 ops $425k EN-822 SACRAMENTO Perio: This pracce is known throughout Sacra- CT Scanner DN-907 PLEASANTON Facility: HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by mento for its stellar reputaon! 2200sf w/ 5 ops + 1add’l. $790k CC-846 SAN RAFAEL: increasing office hours! 750sf w/ 2 ops $65k JG-757 VISALIA Perio: 9 Hygiene days per week, this practice is a rare $295k $95k HN-740 SHASTA CO: Beauful mountain community, well-established gem! On track to do almost 800k this year! ~ 2,000 sf w/ 5 ops Steal at Fit CG-616 NAPA: pracce, exceponal long-term staff. 2400+sf w/5 ops + 1 add’l. $475k/ $350k Seller is ready for NORTHERN CALIFORNIA Real Estate $350k retirement! $425k HN-773 SUTTER CREEK: Seller Movated! Locaon known for beauful scen- CG-859 SONOMA: EC-729 GREATER SACRAMENTO AREA: ery, excellent wine & rich history! 1536sf w/4 ops + 1 add’l!! $175k HN-879 SONORA: Live and pracce in the capvang beauty of this family- Better $395k oriented, scenic town in Tuolumne County! 2950 sf w/ 3 ops $275k

Price 800.641.4179 [email protected] “ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 46, Nº11

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

Everlast (Rocketbook, $32) With amazing versatility and infi nite reusability, the Everlast Replication of handwritten notes to the digital realm continues to be notebook combines the best handwritten note experience with the an area of exciting innovation. While many mobile devices attempt advantages of a digital lifestyle to create a sustainable solution to replicate the pen-to-paper experience using sophisticated pencil without compromises. styluses to directly create notes on digital notebooks, there is no — Hubert Chan, DDS comparison to the actual physical experience. Rocketbook has developed Everlast, a notebook for the digital age. Everlast is a physical notebook that is perpetually reusable. Each 70 Percent of Employers Look Job page is made with a synthetic material and, combined with the use Candidates Up on Social Media of special pens from the Pentel FriXion line (one is included free Those who are looking for a job should consider what they with the notebook), gives its users a true pen-to-paper experience. are posting on social media. A new study from CareerBuilder A companion Rocketbook mobile application, available for iOS discovered that 70 percent of employers are now looking up job and Android, integrates with a plethora of cloud services, including candidates on social media. Further, 57 percent of those employers iCloud, Google Drive, Dropbox, OneNote and others. These decided not to hire candidates based on the social media presence integrations can be assigned to the various connection symbols of those candidates. The study, which involved more than 1,000 printed at the bottom of each page and users can simply mark hiring managers and human resources professionals across a wide the corresponding symbol of the cloud service they want to send range of industries, also found that 47 percent of employers are their page to. Once the connections are set up, the application is less likely to contact a candidate if they are unable to locate them used to scan each page, which contains a special QR code in the online. A good portion of those people said they would not contact lower corner to assist with identifi cation and orientation. The result them because of the value of collecting information on people prior is a high-quality digital scan with optimal orientation in PDF format to a call, and 20 percent of those expect candidates to have a seamlessly sent to the cloud connection marked by the user on each presence online. For more information, visit careerbuilder.com. page. Afterward, the page can be completely wiped clean using the included microfi ber cloth dampened with warm or hot water. — Blake Ellington, Tech Trends editor Notes written over two weeks may have a residual “ghosting” eff ect as the FriXion ink may leave a permanent residue on the page surface. Additionally, users who write hard may imprint the synthetic Study Details Best Times To Post on page coating and damage its surface, reducing its reusability. Any Social Media writing instrument used other than FriXion pens will permanently mark pages and should be avoided. Many dental practices likely have a presence on social media these days. For those that do, some interesting stats from a recent study Additional features can be enabled within the mobile application to may be of interest. Research recently published in the Harvard extend the usefulness of the notebook. Smart Titles allow the user to Business Review found that morning posts on Facebook got higher specify the name of the fi le containing their scanned page by writing click-through rates (8.8 percent more clicks than afternoon posts the title surrounded by double hashtag (##) symbols. Smart Search and 11.1 percent more than evening posts). That being said, uses optical character recognition (OCR) to help locate specifi c boosted posts earned more revenue in the afternoon hours. For words or phrases in handwritten pages. Email Transcription takes a more information, visit hbr.org. legible scan of a notebook page and creates an email containing a full transcript as the body, ready to be sent to recipients. — Blake Ellington, Tech Trends editor

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