November 2019 Fluoride Varnish Pediatric Pain Assessment Denture Fracture Strength

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A History of Water Fluoridation in California: Lessons Learned Vol 47 N o 9 SAVE MORE ON DENTAL SUPPLIES THAN YOU PAY IN DUES

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departments

697 The Associate Editor/Toothbrushes and Concentration Camps

701 Impressions

739 RM Matters/Before Recording, Protect Private Patient Information

743 Regulatory Compliance/Sales and Use Tax 747 Ethics/Ethically Reporting Substandard Treatment 701 750 Tech Trends

f e at u r e s 705 A History of Water Fluoridation in California: Lessons Learned This article examines the history, and lessons learned, of water fluoridation in California tracing referenda and decisions by administrative bodies. Ernest Newbrun, DMD, PhD

713 Review of Safety, Frequency and Intervals of Preventive Fluoride Varnish Application for Children This paper’s objective is to provide the rationale and guidance around the safety of frequent applications of fluoride varnish when provided in multiple (dental, medical and community) settings. Lisa H. Berens, DDS, MPH; Mimansa Cholera, BDS, MPH; Deborah Elam, MS, CAE; Susan A. Fisher-Owens, MD, MPH; Margaret Fisher, RDAHP; Stuart A. Gansky, DrPH, MS; Irene V. Hilton, DDS, MPH; Kara Lugtu, MPH; Robert Isman, DDS, MPH; Elaine Musselman, PhD, RN; Howard Pollick, BDS, MPH; and Ling Zhan, DDS, PhD

719 The Pain Assessment Practices of Pediatric Dentists This survey of active members of the American Academy of Pediatric Dentistry investigates the pain assessment beliefs of pediatric dentists in order to understand if those beliefs allow the dentist to decide how much pain a child is experiencing during procedures involving tissue trauma. Dennis Paul Nutter, DDS; Shahin Goddousi, MS; Sahand Soltani, DDS; and Colleen Gillen Azen, MS

729 Comparative Evaluation of Fracture Strength of Maxillary Denture Base in Different Arch Shape and Palatal Vault Configuration by Three Different Processing Techniques This manuscript investigates and compares the fracture strength of complete maxillary denture base in different arch shape and palatal vault configuration by three different processing techniques. Sushil Kar, MDS; Arvind Tripathi, MDS; and Sayida Khan, BDS

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Volume 47, Number 11 JournaCALIFORNIA DENTAL ASSOCIATION November 2019 CDA Classifieds.

Free postings. published by the Editorial Production Manuscript California Kerry K. Carney, DDS, CDE Randi Taylor Submissions Priceless results. Dental Association editor-in-chief senior graphic designer www.editorialmanager. 1201 K St., 14th Floor [email protected] com/jcaldentassoc Sacramento, CA 95814 Upcoming Topics Ruchi K. Sahota, DDS, CDE 800.232.7645 December/Dental associate editor Letters to the Editor cda.org Student Research

January/Importance www.editorialmanager. Brian K. Shue, DDS, CDE of Research in com/jcaldentassoc associate editor CDA Officers Dental Education R. Del Brunner, DDS February/Aesthetics Subscriptions Gayle Mathe, RDH president Annual subscriptions are [email protected] senior editor Advertising available to association members at a rate of $36. Richard J. Nagy, DDS Andrea LaMattina, CDE Sue Gardner To manage your printed publications manager advertising sales president-elect Journal subscription online, [email protected] [email protected] Kristi Parker Johnson 916.554.4952 log in to your cda.org account or email Judee Tippett-Whyte, DDS senior communications [email protected] for vice president specialist Permission and assistance. View the [email protected] Reprints Joie R. Harrison publication online at Andrea LaMattina, CDE cda.org/journal. communications and Ariane R. Terlet, DDS publications manager media relations specialist secretary [email protected] [email protected] 916.554.5950 Blake Ellington Steven J. Kend, DDS tech trends editor treasurer [email protected] Jack F. Conley, DDS CDA classifieds work harder to editor emeritus bring you results. Selling a practice Debra S. Finney, MS, DDS, speaker of the house Robert E. Horseman, DDS or a piece of equipment? Now you [email protected] humorist emeritus can include photos to help buyers Natasha A. Lee, DDS Connect to the CDA community by immediate past president see the potential. [email protected] following and sharing on social channels

And if you’re hiring, candidates Management anywhere can apply right from Peter A. DuBois @cdadentists executive director the site. Looking for a job? You can Journal of the California Dental Association (issn 1043–2256) is published monthly by the Carrie E. Gordon post that, too. And the best part— California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. chief strategy officer free Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal it’s to all CDA members. of the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814. Kristine Allington chief marketing officer All of these features are designed to The California Dental Association holds the copyright for all articles and artwork published herein. The Journal of the California Dental Association is published under the supervision of help you get the results you need, Alicia Malaby CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for communications any expression of opinion or statement of fact, all of which are published solely on the authority faster than ever. Check it out for director 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 yourself at cda.org/classifieds. Cris Weber that they are contributed solely to the Journal of the California Dental Association. The creative and ux director association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services. Copyright 2019 by the California Dental Association. All rights reserved.

696 NOVEMBER 2 01 9 Assoc. Editor CDA JOURNAL, VOL 47, Nº11

Toothbrushes and Concentration Camps

Brian K. Shue, DDS, CDE

he recent surge of adult and child migrants seeking asylum at our U.S. southern border The U.S. government called them “relocation overwhelmed U.S. Customs centers.” But President Roosevelt didn’t use and Border Protection euphemisms and called them concentration camps. T(CBP) and resulted in overcrowded So did President Harry S. Truman. detention facilities. Much debate ensued over the separation of families, the lengths of stays, facility conditions and the root cause of this surge. Through this chain of events, Because of this mass incarceration, Politicians were not the only ones who politicians and the press escalated their an estimated 80 Japanese-American raised concern. The Office of Inspector rhetoric. For example, U.S Rep. Alexandria dentists in California lost their practices, General, Department of Homeland Ocasio-Cortez (D-New York) offered her including Dr. Taniguchi, as well as about Security reported CBP did not follow opinion on the border patrol’s migrant 20 dentists from Washington and Oregon. its own detention standards. CBP held detention centers: “The U.S. is running Dental students were imprisoned too. migrant children (called “unaccompanied concentration camps on our southern Dr. Taniguchi and his wife, both U.S. alien children” (UAC)) longer than border, and that is exactly what they are.” citizens, arrived at the Poston Relocation permitted and did not provide clean Concentration camps? Let that Center in the remote Arizona desert with clothes, hot meals, showers and other comment sink in. only the permitted two luggage items basic necessities. This is despite a It is one thing to point out how these per person. They were prisoner numbers 1997 federal court ruling that ordered children in migrant detention centers 21271A and 21271B, respectively. They that “safe and sanitary” conditions are did not receive the required proper care lived in a sparse 20 feet by 20 feet section required for children in detention. and sanitary conditions while under of a barrack unprotected from the harsh To complicate matters, the Ninth temporary custody. But to call them desert elements, with only paper dividing Circuit Court of Appeals asked an concentration camps? In general, she their living space from others. They ate attorney from the U.S. Justice Department and others may not fully understand the at a central mess hall. Restrooms were if it was required to provide items to conditions that existed behind the use in a separate barrack down the block UAC like toothbrushes, toothpaste, of that term. To see my point, take a with rows of toilets with no stalls, near soap and blankets. In an effort to avoid look at the lives of two dentists: Frank the communal showers. Privacy did not adding specifics to the 1997 ruling, the Taniguchi and Benjamin Jacobs. exist. Even though Poston did not have attorney answered: “Those things may be Frank Kazuichi Taniguchi, DDS, much barbed wire fencing because of its …” Providing basic hygiene for children belonged to the San Diego County Dental remote location, other camps did, along “should be,” not “may be,” important Society and practiced in El Centro, Calif. with sentry posts and machine guns to in any situation. So the court rightfully — my hometown — just miles from the reinforce the fact that no one could leave. and soundly corrected the attorney. And U.S. southern border. His life changed Dr. Taniguchi was appointed chairman later, the Ninth Circuit Court of Appeals when 2,400 Americans were killed in of the three Poston dental clinics from returned with a ruling that stated that Japan’s surprise attack on Pearl Harbor the start, which by 1943 had 15 Japanese- basic hygienic necessities required for and the U.S. Pacific Naval Fleet, which American dentists who served the dental care of these unaccompanied migrant jolted our devastated country right into needs of their 15,000 fellow prisoners. The children “are without doubt essential World War II. President Franklin Delano dentists were only able to extract teeth to the children’s safety” and include Roosevelt enacted Executive Order 9066, and provide pain relief in the beginning items such as soap and toothpaste. which led to the forced incarceration because of a lack of instruments, It just makes sense. There should of more than 110,000 Americans of supplies and even local anesthetic. be no argument against this, regardless Japanese descent on the West Coast That was a concentration camp. of any previous or current ruling, without due process, even though The U.S. government called them in a great country like ours. almost two-thirds were U.S. citizens. “relocation centers.” But President

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Roosevelt didn’t use euphemisms and air greeted them as they arrived at their That was a concentration camp. called them concentration camps. So destination: Auschwitz. An SS guard Politicians and others will continue did President Harry S. Truman.1 flung Jacobs’ dental instruments to the to decry that the CBP operates Why is it important to discuss this? “I ground, to be lost forever. The prisoners concentration camps. That is incorrect. think that many people … do not know were lined up in front of Auschwitz Look at the lives of Dr. Taniguchi and that the U.S. once had concentration where Dr. Josef Mengele judged their Jacobs. There is no comparison. camps,” said 2003–2004 ADA President health and either passed a sentence of Postscript: Dr. Frank Taniguchi Gene Sekiguchi, DDS, who also served hard labor or immediate death. It was would become a captain in the U.S. as CDA’s president in 1996–1997 and the Holocaust. Jacobs was given life. Army with the most-decorated all the San Gabriel Valley Dental Society Jacobs was prisoner 141129, which Japanese-American 442nd Regimental president in 1987. During World War was tattooed deeply into his bleeding Combat Team and was the only II when Dr. Sekiguchi was a toddler, he arm. Jacobs struggled to survive, while Japanese-American dentist to serve was incarcerated with his mom and baby torture and murder occurred around in Europe during World War II. He sister (all U.S. citizens) in the Heart him. “My strength was slipping. There returned to California and practiced Mountain, Wyoming, concentration was not much flesh or muscle left on in Orange County. He died in 1990. camp. Dr. Sekiguchi said: “There is barely my body. Each day I feared the next,” Dr. Benjamin Jacobs survived the any mention of these camps in our history he said. The Nazis transferred him to Holocaust and continued to work books. For example, when I talked to a Fürstengrube, one of many branches as a dentist in Poland. He later young group from Arkansas, only one of Auschwitz, which held 1,500 moved to the U.S. and practiced person knew about the camps. The others prisoners. A guard recognized him as in Boston. He died in 2004. n were not aware and somewhat ignorant “the dentist” from a former location, 2 references of the (existence of the) camps.” and he was sent to work on prisoners 1. Miller M. Plain Speaking: An Oral Biography of Harry S. Let’s look at another example. In in the camp’s dental clinic. But he Truman. Berkeley Publishing Corp., New York, 1974. World War II, Nazi Germany occupied noticed there was no equipment or 2. Sekiguchi E. Broader lessons learned from my incarceration in the U.S. as an American of Japanese Descent during Poland and forced first-year dental student supplies. The next day it was completely World War II. Facets, San Diego County Dental Society, May Benjamin Jacobs (Bronek Jakubowicz) stocked; the Nazis simply raided an 2019:14–15. and other Jewish men into labor camps in unlucky dental office nearby. Life was 3. Jacobs B. The dentist of Auschwitz: A memoir. University Press of Kentucky. 1994. 1941. He was allowed to pack two bundles still a nightmare for him; his office and took his set of dental instruments manager physically tortured him Brian K. Shue, DDS, CDE, is the at his mom’s insistence. It would save every single morning for months. dental director of a federally qualified his life, as he wrote in his memoir.3 Jacobs also became the dentist for health center. He is a certified dental editor, Even with his minimal dental the Nazi guards. A Nazi dentist later president-elect of the American Association experience, the Nazis chose Jacobs joined him. But when this dentist of Dental Editors and Journalists and editor to provide dental care in the camps found there was no gold to provide of the San Diego County Dental Society. to his fellow prisoners. “The inmates’ crown and bridgework for the Nazi main problem was bleeding gums, a guards, he commanded Jacobs to do result of vitamin deficiency and the the unimaginable. Jacob painfully complete absence of toothbrushes and described the horror as he opened the ERRATA dentifrice,” Jacobs said. He provided door of the morgue and saw the fresh Errors were made in name spelling and extractions and pain relief, which was of and decayed bodies piled on the floor. academic degrees in the Community/ little consolation in the camp’s hellish In order to survive, but with a heavy Education Dental Student section on environment of pain and suffering. sadness, he pulled all the gold work page 560 in the September 2019 issue. Then he and thousands of other from their mouths. There would be a The winners were Alexandra Barsotti, MS, prisoners were packed in locked cattle cars never-ending supply of gold. Another BS, and Reisa Rara, BS. The Journal of the California Dental Association apologizes and transported by train for three days. Nazi dentist told Jacobs matter-of-factly for the errors. They arrived exhausted and half dead. that there were 10 dentists in the main An unnatural stench and a smoke-filled Auschwitz camp doing this same thing.

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TOGETHER WE ARE LIMITLESS Impressions CDA JOURNAL, VOL 47, Nº11

Daily Soft Drinks Linked to Early Death Risk

A global study by scientists from the World Health Organization of more than 450,000 adults in 10 countries found that daily consumption of all types of soft drinks was linked with a higher chance of dying young. The research, published in JAMA Internal Medicine, is the largest study to examine links between soft drink consumption and mortality. Previous smaller studies have suggested a link but have not found such dramatic differences. Researchers found that those who consumed two or more 250 ml glasses of diet drink a day had a 26% increased risk of dying within the next 16 years. And deaths from cardiovascular disease went up 52%. Costs, controlled. “The striking observation in our study was that we found positive associations for both sugar-sweetened and artificially Member-exclusive savings from sweetened soft drinks with risk of all-cause deaths,” said study leader Neil Murphy, PhD. The Dentists Supply Company He said it is unclear exactly why this is but pointed to through a shopping site designed previous studies that suggest the artificial sweeteners in diet to help your practice be competitive drinks may induce glucose intolerance and trigger high blood insulin levels. and efficient. Just one of the limitless Similar studies in the past have been criticized because member benefits atcda.org . some experts said people who drink diet products are more likely to be unhealthy to start with. But the new study found the link between diet drinks and death rates persisted among those of a healthy weight. The study also raised concerns about policies that drive people from sugary drinks to diet drinks. Reformulation of CDA. THIS IS sugar-sweetened soft drinks, in which sugar is replaced with low- or no-calorie sweeteners, is being driven by consumer awareness and fiscal instruments, such as taxes, according WHERE VISION to the study. But while artificially sweetened soft drinks have few or no calories, their long-term physiological and health implications have been largely unknown. “Additional studies are now needed to examine the MEETS VALUE. long-term health consequences of specific artificial sweeteners that are commonly used in soft drinks, such as aspartame and acesulfame potassium,” Dr. Murphy said. Experts such as Jeremy Pearson, PhD, associate medical director at the British Heart Foundation, said it would be ® “prudent” to cut out all soft drinks and to drink water instead. “We’re all too familiar with the fact that sugary drinks are not only bad for our teeth, but the excess calories can also make us put on weight, increasing our risk of a heart attack TOGETHER or stroke,” he said. “Where you can, stick with water and WE ARE unsweetened tea or coffee and keep soft drinks as a treat.” LIMITLESS Learn more about this study in JAMA Internal Medicine (2019); doi:10.1001/jamainternmed.2019.2478. n

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U.K. Study Says Snack Tax May Fight Obesity Better Than Soda Tax Taxing high sugar snacks may be more effective at reducing obesity than taxing sugary drinks, according to a new study published in the BMJ. The modeling Poor Oral Health in Older study demonstrated that a snack tax on food — which would increase prices by Chinese Americans Linked 20% — would be twice as effective as the same price rise on sugary drinks. While sugar-sweetened beverages often make up a substantial part of sugar to Cognitive Decline intake and as such have been a major focus of policy to date worldwide, in the U.K. Two recent studies took a closer look high-sugar snacks make a greater contribution to intakes of free sugars than at the relationship between poor oral sugar-sweetened beverages. The U.K. introduced its Soft Drinks Industry Levy in April health and the psychological well-being of 2018, and since then, calls have been made to extend the tax to sugary foods. older adults. The studies, published in the The study conducted by researchers from the London School of Hygiene Journal of the American Geriatrics Society, and Tropical Medicine and the universities of Oxford, Cambridge and Exeter reviewed the links between poor oral examined food purchases made by 36,324 U.K. households and National Diet health and cognitive decline and the effects and Nutrition Survey data for 2,544 adults. The results estimated the change in of perceived stress and social support on dry weight and prevalence of obesity over one year, with data grouped by mouth among older Chinese Americans. household income and body mass index (BMI). More than 2,700 Chinese Americans, Researchers say the results suggest that for all income groups combined aged 60 and older, were part of the increasing the price of cookies, cakes, chocolates and sweets by 20% would studies. In the first study, nearly 50% of reduce annual average energy intake by around 8,900 calories, leading to an participants self-reported experiencing average weight loss of about 2 pounds over one year. In contrast, a similar price tooth symptoms. Researchers found that increase on sugary drinks would result in an average those who reported tooth symptoms weight loss of just one-half pound over one year. The experienced declines in cognition model also suggests the impact would be highest in and episodic memory, which are often precursors to dementia. In the second low-income households with higher rates of obesity. study, 25.5% reported dry mouth, which is Read more of this study in the BMJ (2019); reportedly triggered by stress and leads to doi.org/10.1136/bmj.l4786. poorer overall oral health. The relationship between dry mouth and medications was not taken into account in this study. “Minorities have less access to made to increase social support to alleviate Researchers emphasize the preventive dental care that is further stress and the resulting dry mouth issues importance of examining immigrant exacerbated by language barriers and low reported by participants, Dr. Dong said. oral health outcomes later in life socioeconomic status,” said XinQi Dong, “Examining current oral health to understand the specific type of MD, director of Rutgers University’s practices among older Chinese outcomes of different cultural groups. Institute for Health, Health Care Policy Americans is crucial for developing “The studies further serve as a call and Aging Research. “Older Chinese culturally tailored interventions to to action for policymakers to develop Americans are at particular risk for promote oral health and ultimately programs aimed at improving oral health experiencing oral health symptoms mitigate cognitive decline,” said preventative and dental care services in due to lack of dental insurance or not Darina Petrovsky, PhD, RN, co- this high-risk population,” said Dr. Dong. visiting a dental clinic regularly.” author of the study and a postdoctoral Read more of this study in the To help preserve the health and research fellow at the University of Journal of the American Geriatrics Society well-being of older adults, efforts must be Pennsylvania School of Nursing. (2019); doi.org/10.1111/jgs.15748.

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Periodontal Disease Bacteria Love Colon and Dirt Microbes Research led by the Georgia Institute shared food and assistance more stingily of Technology found that common with gum infector Aggregatibacter mouth bacteria responsible for acute actinomycetemcomitans (Aa). periodontitis fared better overall when The study was conducted by Georgia Aggregatibacter actinomycetemcomitans. paired with bacteria and other microbes Tech’s School of Biological Sciences (Credit: Derren Ready/Creative Commons license) that live anywhere but the mouth, and published in the Proceedings of including some commonly found in the National Academy of Sciences. peacefully in the mouth and certain the colon or in dirt. Bacteria from the Like many bacteria known for circumstances turn them into infectors. oral microbiome, by contrast, generally infections they can cause, Aa often live The researchers and their sponsors at the National Institutes of Health wanted to know more about how Aa interacts with other microbes to gain insights that may eventually help fight Athletes Have High Rate of Oral Disease acute periodontitis and other ailments. Top athletes are more likely to have poor oral health despite brushing their Researchers manipulated and teeth twice a day, according to a recent study. The findings, published in the British tracked nearly all of Aa’s roughly Dental Journal, surveyed the dental check-ups of 352 Olympic and professional 2,100 genes using an emergent gene athletes across 11 sports, including cycling, swimming, rugby, football and hockey. tagging technology while pairing Aa with 25 other microbes — about half Along with measuring their tooth decay, gum health and acid erosion, from the mouth and half from other researchers asked the athletes what they did to keep their mouth, teeth and body areas or the environment. gums healthy. Ninety-four percent of participants reported brushing their teeth The findings are surprising because at least twice a day and 44% reported regularly flossing — more frequently bacteria in a microbiome have evolved than the general population where 75% reported brushing twice daily and intricate interactions making it seem 21% for flossing. logical that those interactions would The dental check-ups revealed that nearly half of participants had untreated stand out as uniquely generous, tooth decay, the large majority showed early sings of gum inflammation and according to the study. Some mouth almost a third reported that their oral health had a negative impact on their microbes even have special docking training and performance. sites to bind to their partners, and “We found that a majority of the athletes in our survey already have good much previous research has tightly oral health-related habits in as much as they brush their teeth twice a day, visit the focused on their cooperations. But dentist regularly, don’t smoke and have a healthy general diet,” said researcher this new study went much further. Julie Gallagher, a PhD student at the University College London Eastman Dental “We asked a bigger question: How Institute Centre for Oral Health and Performance. “However, they use sports do microbes interact with bugs they drinks, energy gels and bars frequently during training and competition.” co-evolved with as opposed to how they Researchers contribute the high levels of tooth decay and acid erosion found would interact with microbes they had during the check-ups to the sugar found in these products. hardly ever seen. We thought they would This study builds on previous findings that suggest elite not interact well with the other bugs, athletes may also face an elevated risk of oral disease from but it was the opposite,” said Marvin a dry mouth during intensive training. Read more in the Whiteley, PhD, a professor in Georgia British Dental Journal (2019); dx.doi.org/10.1038/ Tech’s School of Biological Sciences s41415-019-0617-8. and the study’s principal investigator. Learn more about this study in the Proceedings of the National Academy of Sciences (2019); doi.org/10.1073/pnas.1907619116.

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A History of Water Fluoridation in California: Lessons Learned

Ernest Newbrun, DMD, PhD

a b s t r ac t Water fluoridation is the most effective measure in preventing caries. This article examines the history, and lessons learned, of water fluoridation in California tracing referenda and decisions by administrative bodies. Progress was slow until a breakthrough when Assembly Bill 733, the fluoridated drinking water act, became law in 1995, thanks to the courage and persistence of then Assemblymember Jackie Speier (D-Burlingame). More recently, administrative bodies have exerted their authority to direct water agencies to fluoridate, thereby avoiding expensive and divisive referenda.

AUTHOR

Ernest Newbrun, DMD, hen Americans Early History of Water Fluoridation PhD, is a professor think of California, in California emeritus of oral biology they conjure From 1945 to 1947, four independent and periodontology at the University of California, up images of clinical trials were undertaken in North San Francisco, School of Hollywood, America to determine if adding fluoride Dentistry. He received a Wthe Golden Gate Bridge or even to public water supplies to an optimum bachelor of dental surgery Silicon Valley. The most populous level (then 1.00 ppm) would reduce the from the University of state in the U.S., California has an prevalence and severity of dental caries Sydney, a master of science 1 from the University of economy ranking fifth in the world, similarly to naturally occurring fluoride Rochester and a doctor of raised automobile emission standards (TABLE 1). These trials were planned to run dental medicine from the earlier than other states and on for 15 years, but after 6.5 years, the caries University of Alabama in health issues was one of the leaders in prevalence in 4- to 6-year-olds residing Birmingham. He obtained a banning smoking in work areas and in test cities was already about half of PhD and specialty training in periodontology at UCSF. public places. Yet when it came to that in the control nonfluoridated cities. Conflict of Interest community water fluoridation, one of Accordingly, two of the control cities, Disclosure: None reported. the 10 great public health measures Muskegon, Mich., and Oak Park, Ill., of the 20th century,2 California sadly did not wait for these trials to finish and lagged behind most other states until started fluoridating.3 California was in the quite recently. This is the story of the vanguard; in the spring of 1951, the San fight for fluoridation in California. Francisco Board of Supervisors unanimously

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TABLE 1 TABLE 2 North American Clinical Trials To Test Efficacy of Controlled Water Fluoridation 10 Years’ Dental Caries Experience in Children Aged 12–14 of Children in Antioch, Calif., 1952–1962 City/state Fluoride status Year DMFT/child Percentage difference Age Year Deft or Percentage DMFT reduction Grand Rapids, Michigan No F 1945 9.5 5 1952 4.13 F 1959 4.26 55.5 1962 1.86 55% Evanston, Illinois No F 1946 9.03 6 1952 1.04 F 1959 4.66 48.8 1962 0.17 84% Sarnia, Ontario No F 1959 7.46 8 1952 3.14 Brantford, Ontario F 1959 3.23 56.7 1962 1.13 64% Kingston, New York No F 1959 12.46 10 1952 4.36 Newburgh, New York F 1959 3.73 70.1 1962 1.74 60% After 6.5 years, the control city for Grand Rapids, Muskegon, dropped out; similarly the control for Evanston, Oak Park, dropped out.3 12 1952 6.79 TABLE 3 1962 3.60 47% California Water Systems Fluoridating in the 1950s* 14 1952 10.39 Water system County Starting date Population served 1962 5.04 51%

Antioch Contra Costa August 1952 64,442 Stadt et al.4 California Water Service Butte April 1958 1,130 Citizens Utility Co. Sacramento December 1956 18,232 Among the other communities in Fresno Co. Waterworks 19 Fresno September 1954 2,006 California that fluoridated in the 1950s Gridley Butte May 1954 4,631 were Hayward, Healdsburg, Morgan Hill, Hayward WS Alameda March 1958 115,203 Palo Alto, Pleasanton and Vallejo — all in Northern California (TABLE 3).5 In Healdsburg Sonoma November 1953 9,454 the 1950s and early 1960s, there were Morgan Hill Santa Clara November 1956 25,180 36 referenda in California on CWF, in Palo Alto Santa Clara May 1956 56,000 which 11 communities voted favorably Placerville El Dorado October 1956 7,500 while 25 others rejected fluoridation.6 Pleasanton Alameda March 1954 51,900 The reason opponents were more successful in these referenda might San Francisco WD San Francisco and San Mateo August 1952 871,844 have been in part because the health San Luis Obispo San Luis Obispo August 1954 42,136 benefits, documented by statistics, were Vallejo Solano November 1954 121,600 not as emotionally compelling as the *Data from Fluoridation Census 1992, U.S. Department of Health and Human Services, Public Health Service and the Centers for opponents’ inaccurate portrayal of fluoride Disease Control and Prevention. as poison at only 1.0 ppm. Furthermore, the children who would gain the most requested that the water department take DMD, MPH, the dental health director from this public health measure were steps to fluoridate San Francisco water. of Contra Costa County, compared the not entitled to vote. Another reason The supervisors approved an enabling caries prevalence in Antioch school was that the main proponents of water ordinance and an appropriation of $40,000 children before fluoridation in 1952 to 10 fluoridation were health professionals of water department funds. In the fall of years later in 1962 (TABLE 2). The dental (dentists, physicians and public health 1951, a declaration of policy regarding findings showed greatly reduced tooth workers) who were inexperienced in communal water fluoridation (CWF) decay — a 55% reduction in the mean politics. The general public was mostly was put before the voters, who voted to number of decayed, extracted and filled indifferent on the issue and politicians fluoridate the water (56% in favor and deciduous teeth (deft) in 5-year-olds and preferred not to get involved. 44% opposed). The San Francisco Water 84% reduction in the mean number of In April 1952, the Sonoma County District and Antioch in Contra Costa decayed, missing and filled permanent cities of Cloverdale, Santa Rosa and County were the first in California to do teeth (DMFT) due to caries in 6-year-olds Healdsburg held referenda on CWF. so, starting in August 1952. Zachary Stadt, and 60% to 64% in 8- and 10-year-olds.4 Cloverdale and Santa Rosa rejected

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TABLE 4 TABLE 5 Healdsburg, Calif., Fluoridation California Water Systems Fluoridating in the 1960s* Referenda Water system County Starting date Population served Year In favor Opposed Contra Costa WD Contra Costa May 1965 225,000 1952 604 (63%) 348 (37%) Crescent City Del Norte November 1969 11,246 2014 2,184 (66%) 1,113 (34%) Fairfield Solano December 1967 72,000 2016* 3,223 (57%) 2,433 (43%) Fresno Co. Waterworks 11 Fresno October 1963 641 *Backwardly worded referendum (a no vote indicated Fresno Co. Waterworks 14 Fresno October 1968 977 support for CWF). Loyalton Sierra May 1968 1,070 fluoridation TABLE( 4).7 In Santa Rosa, Martinez Contra Costa January 1965 28,500 57% of the voters opposed it and only 43% Merced City WS Merced June 1966 57,645 voted in favor. It was defeated by only 421 Pittsburg MW Contra Costa April 1965 48,700 votes; the reason, according to one reporter, Roseville Placer October 1967 47,000 was “shear apathy” as less than 3,000 San Jose Santa Clara September 1965 70,000 of the city’s 9,658 registered voters cast ballots.8 The public utilities board dodged Scotia-Pacific Humboldt October 1962 1,000 responsibility by merely recommending *Data from Fluoridation Census 1992, U.S. Department of Health and Human Services, Public Health Service and the Centers that it be placed on the ballot, but there for Disease Control and Prevention. were no open hearings. The city council TABLE 6 was completely passive on the matter.8 In California Water Systems Fluoridating in the 1970s* nearby Healdsburg, voters approved (63% for, 37% against) and the city commenced Water system County Starting date Population served fluoridation in November 1953. East Bay MUD Alameda and Contra Costa 1976 1,100,000 During the 1960s, 12 water systems serving 516,779 persons were added to the Eureka Humboldt February 1972 25,000 population served by fluoridated water in Fountain Valley Orange June 1973 53,691 California (TABLE 5). The largest water Fresno Co. Waterworks 27 Fresno March 1971 1,225 system by far was the Contra Costa Water Fresno Co. Waterworks 28 Fresno November 1979 250 District with a population at that time of Huntington Beach Orange July 1973 185,000 225,000. In the 1960s, California ranked Long Beach WD Los Angeles June 1971 425,000 near the bottom (~ 46th) of all states in the percentage (~ 12%) of the population Marin Municipal Marin December 1973 170,000 benefiting from community water Stanford University Santa Clara April 1970 23,000 fluoridation, with only Utah, Hawaii, New Vacaville Solano February 1975 76,200 Hampshire, New Jersey and Oregon ranked lower. How could this be remedied? One way Alameda WD** Alameda June 1971 275,000 was to educate the public by starting with *Data from Fluoridation Census 1992, U.S. Department of Health and Human Services, Public Health Service and the Centers for future dentists and dental hygienists who Disease Control and Prevention (except data from East Bay MUD). **Serves Fremont, Newark and Union City. would then be able to inform their patients. The public perceives the advice of their dentist or physician as the most trustworthy safety issues and the benefits, costs, risks the 1975 referendum on CWF, students source of information about fluoridation.9 At and environmental impact of communal helped distribute brochures. Students at the the University of California, San Francisco, water fluoridation. Some students even University of the Pacific, Arthur A. Dugoni School of Dentistry, students were taught the volunteered as campaign workers during School of Dentistry reviewed an online physiology, pharmacology and toxicology of the East Bay Municipal Utility District module on CWF, followed by a two-hour fluorides as well as clinical epidemiological (EBMUD) water fluoridation referendum seminar where this and other topics related evidence of the benefits in terms of caries in 1980, a practical learning experience. to community oral health were discussed. reduction using a small group seminar At the University of California, Los At the Ostrow School of Dentistry of format (~ 12–15 students) including a final Angeles, School of Dentistry, students USC, the principles of fluoridation were fluoridation debate that proved very popular. heard lectures and were examined on taught using problem-based learning (PBL) In the process, the students learned about the health issues and benefits of CWF. In in a case, with such cases held in the first

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100%

80% 57 53 49.5 45.1 60% AIDS as an infectious disease.19 By 1983, 40% a causative retrovirus had been isolated from the lymph node of an AIDS patient 43 47 50.5 54.9 20% by a team of virologists at the Pasteur Institute in Paris. In 1984, a nearly 0% identical virus was isolated by a team led 1960 1964 1974 1980 by Robert Gallo, MD, at the National n Anti-fluoridation n Pro-fluoridation Institutes of Health in Bethesda, Maryland, with evidence that it caused FIGURE 1. East Bay Municipal Utility District fluoridation referenda 1960 to 1980. AIDS; this virus was later named human immunodeficiency virus (HIV). CWF opponents, led by Nelder, attempted to two years and cut across all disciplines. against the measure, influenced the city pressure the city’s board of supervisors to At the Loma Linda University School council and the voters. John Yiamouyiannis, stop San Francisco’s 34-year-old practice of Dentistry, CWF was incorporated in PhD, a biochemist, was hired by the of fluoridating its water supply. Although both the teaching of pediatric dentistry National Health Federation in Monrovia to the local press and radio widely publicized and general dentistry, each devoting stop fluoridation.13 He succeeded using scare the opponents’ unsubstantiated claims about 15 minutes to this topic. tactics, falsely alleging higher than average that fluoridation renders people During the 1970s, the biggest cancer rates in fluoridated communities.14,15 susceptible to AIDS by destroying the fluoridation victory was the EBMUD The studies cited by Dr. Yiamouyiannis, body’s defense mechanisms, with rare serving 30 cities in two counties, including according to one reviewer, were more like exception the media were supportive of Oakland, Berkeley, Richmond and Walnut “a propaganda flyer than serious scientific CWF. Political leaders dismissed Nelder’s Creek, with a total combined population effort.” It took some time to disprove such call for an investigation into the health of 1,100,000 (80% residing in Alameda claims, by which time the referendum effects of water fluoridation; then Mayor County and 20% in Contra Costa County) was already over.16,17 Opponents of water Dianne Feinstein denounced Nelder’s (TABLE 6). This followed two embarrassing fluoridation won that referendum handily charges as “off the wall.” The board voted referenda defeats in 1960 and 1964. In by 213,573 (56%) votes to 166,549 (44%) to continue to support CWF20 based on 1974, a fluoridation referendum won votes. Thereby about 9 million people the city health department’s report on narrowly, 50.5% to 49.5%,10 and in 1980 were denied the benefits of communal the benefits and safety of fluoridation.21 voters reapproved fluoridation by 54.9% water fluoridation for another 24 years. The safety and dental benefits of CWF to 45.1%11 as shown in FIGURE 1. Usually, were reconfirmed in an updated review once a community has been fluoridated, Recent History of Water Fluoridation of the medical literature by the San voters are less likely to reject it in a recall in California Francisco Department of Public Health referendum or to believe all the dire Dental health experts voiced in 2011.22 Nelder served on the board of predictions of the fluoridation opponents. amazement when San Francisco supervisors from 1981 to 1991. As top In the 1970s, in spite of some major Supervisor Wendy Nelder suddenly vote-getter in the 1982 election, she successes such as EBMUD and the city of renewed the fight against fluoride in became president of the board from 1983 Long Beach in Southern California, the city water on Sept. 5, 1984.18 Dentists said to 1985. During this time, she pushed of Los Angeles was a big disappointment. the water treatment had saved children’s her antifluoride campaign but could In 1974, the L.A. City Council adopted a teeth from millions of cavities and not muster sufficient support from the fluoridation ordinance by a 10-4 vote; the had proven to be inexpensive and safe board to place it on the ballot. Five years ordinance was signed by the acting mayor for more than 30 years. The reaction later, she tried again but was blocked shortly afterward.12 Subsequently, the L.A. to her charge that fluoridation of San again. She did not seek reelection in City Council lost courage and reversed its Francisco’s water — begun in 1952 — 1990 but ended her political career after decision, leaving it to the voters to decide. might cause AIDS was scathing. In running unsuccessfully for assessor.23 Her Two prominent state legislators, Art Torres 1981, the Centers for Disease Control outspoken opposition to CWF possibly and Richard Alatorre, who had turned and Prevention (CDC) had recognized contributed to her political demise.

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In 1992, only 15.7% of California’s In 1995, Speier termed out as an 58% of L.A. County’s population receive population on public water systems assemblymember and her political future optimally fluoridated water, 5% near received fluoridated water,5 ranking 48th was unclear; conventional wisdom would optimal, 19% partial and 17% no fluoride.28 among states just ahead of Hawaii, Utah have been to avoid so-called “controversial” In February 2003, the board of the and Nevada. By 2014, the percentage issues such as water fluoridation. Speier Metropolitan Water District of Southern climbed to 63.7% and the number of saw it as a health issue and did not hesitate California (MWD), which supplies water Californians receiving fluoridated water to persist in promoting passage of this to about 18 million consumers, heard was almost five times higher, increasing statewide bill; therein lies an important testimony concerning water fluoridation. from less than 5 million in 1992 to 24.7 lesson. Clearly it did not hinder her The board consisted of 55 representatives million in 2014. The turning point was political career; in 1998, she was elected to from various communities and convincing when the California Legislature and the the California State Senate, and in 2008, them to move on fluoridation was no small governor enacted AB 733 in 1995 at the following the death of Congressman Tom task. Proponents of water fluoridation had a initiative of Assemblymember Jackie Speier Lantos, she was overwhelmingly elected to “dream team” of dentists, physicians, public (D-Burlingame), “a legislator known for succeed him as the U.S. representative for health officials, school teachers and nurses her courage under fire and her penchant California’s 14th Congressional District. and parents all conveying the message of for hard-hitting bills,” who pressed on with safety, efficacy and the need for this proven a statewide fluoridation bill because of public health measure. The MWD board the dental needs of children.24 In order to voted to accept the recommendation, get the bill passed, she enlisted bipartisan Speier saw it as a and in September 2003, $5.5 million in support from members of the state Assembly health issue and did grant monies was made available from and Senate as well as the influential Speaker the California Endowment; as a result, of the House Willie Brown as co-authors. not hesitate to persist California no longer lagged behind most The bill underwent further transformation in promoting passage other states. In November 2007, the MWD to garner the necessary support of some of this statewide bill. started bringing fluoridation systems online wavering legislators; the capital costs at its five massive filtration plants, the for the equipment and building had to largest fluoridation project in the U.S. be funded from nonstate sources. The In the case of San Diego, both the day-to-day operating expenses could be Following the passage of AB 733 California attorney general and the passed onto the customers who would be and with the efforts of a broad-based city attorney’s office opined that when saving money on their dental bills. This California Fluoridation Task Force, in sufficient funding became available act required water systems with 10,000 1998, the California Endowment provided state law would preempt San Diego or more service connections to fluoridate $15 million dollars in grants to water Municipal Code Section 67.0101 dating once; funding from an outside source was utilities through the CDA Foundation back to 1954, which prohibited the city provided. The California Endowment, to leverage the state law. More recently, from fluoridation. Accordingly, state a private foundation, contributed $15 other sources of grant support have law preempts this old city ordinance. In million25 and First 5 California contributed assisted additional communities to June 2008, the San Diego City Council varying amounts, depending on the county, cover initial implementation costs. voted unanimously to accept $3.9 to fund capital costs to initiate CWF using The city of Los Angeles fluoridated million to fund the city’s fluoridation money obtained through the state cigarette its water supplies in 1999 by action of the program. As a result of state law and the tax.26 The Dental Health Foundation and city council after several public hearings availability of funding, the city began the California Dental Association (CDA) but without the kind of public outcry from fluoridating its public water supply in Foundation were instrumental in distributing 25 years earlier. However, it has taken February 2011. San Diego not only these funds. The ongoing expense of CWF is longer to fluoridate Los Angeles County, delivers water to its citizens, it also low, ranging from about 50 cents per person which includes 88 cities, because of the supplies treated water to the cities of per year for communities with more than many water suppliers and the vast area Del Mar, Coronado and Imperial Beach. 20,000 residents to $3 per person per year in covered. According to Maritza Cabezas, More than 1.36 million people receive communities with 5,000 or fewer residents.27 DDS, MPH, the county dental director, fluoridated water treated by San Diego.

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U.S. national 80% average 70% 60% 50% 40% Concluding Remarks It is worth noting that administrative 30% bodies such as the L.A. City Council, 20% the board of the MWD and the 10% San Diego City Council decided to 0% fluoridate (or continue fluoridation as 1961 1995 2000 2005 2008 2011 2015 2018 in the case of San Francisco Board of Supervisors) following open hearings FIGURE 2. Percentage of Californians served by community water systems receiving fluoridated water. thereby avoiding divisive and expensive referenda. This should be a guide as Healdsburg has remained fluoridated salmonids that occur in local streams. The to how to proceed in implementing since 1952 in spite of two attempts by report was presented to the Fluoridation community water fluoridation by opponents to stop the process by referenda. Advisory Committee (appointed by the the Sonoma County Water Agency In 2014, Healdsburg voters again approved Sonoma Department of Health Services) in Santa Rosa and the surrounding fluoridation by a margin of 2:1 (2,184 that met for more than two years (2013– communities, the last holdouts of votes to continue water fluoridation; 2015). This committee recommended major-sized communities in California. 1,113 votes to stop water fluoridation). overwhelmingly (19 in favor, two opposed) In a review of the outcome of decisions In that referendum, the local Healdsburg in support of fluoridation.30 Sadly, those regarding CWF throughout the U.S., Tribune strongly supported continued water recommendations languished without any Easley found a substantial difference fluoridation as did a local dentist, Shawn action by the Sonoma Board of Supervisors, between the results of decisions by Widick, DDS. Undeterred by the vote the Sonoma County Water Agency nor governing body when compared to to continue fluoridation in Healdsburg the Santa Rosa City Council. The Sonoma results subject to voter referenda. Over in 2014, another referendum was held County Water Agency supplies drinking a 10-year period from 1980 to 1989, in 2016, based on 709 valid signatures water to more than 600,000 consumers in 78% of governing body decisions were gathered by anti-fluoridationists on a nine cities and water districts in northern in favor of CWF, while only 37% of proposed ordinance intended to stop Marin County, as well as Cotati, Petaluma, referenda on CWF were successful.34 fluoridation. The measure was again Rohnert Park, Santa Rosa, Sonoma and Looking at the percentage of defeated, this time by 57% in favor of Windsor in Sonoma County, of which Californians served by community water continuing fluoridation in a backwardly Santa Rosa is the largest customer. systems receiving fluoridated water35 worded ballot where a no vote meant The current tactic of antifluoridationists (FIGURE 2), one sees that for 34 years, continuing fluoridation, which may have has been to focus on fluoride not as a between 1961 and 1995, there was little confused some voters.29 Although no carcinogen but as a neurotoxin, claiming progress in bestowing this proven public survey has been undertaken to determine that fluoride presents a risk under Section health measure to the California public why voters in Healdsburg consistently 21 of the Toxic Substances Control Act because of apathy, lack of political support supported fluoridation, one might (TSCA).31 The Fluoridation Action and a small but determined opposition. speculate that they were more trusting of Network, representing fluoridation Over those 34 years, the population of the medical/dental profession than they opponents, has filed a lawsuit in the California doubled from 15.7 million to were worried about chemical additives.9 U.S. District Court, Northern District of 31.7 million, yet those with CWF changed Other communities in Sonoma County, California seeking a ban on fluoridation very little, from 12% to 17%. However, such as Sebastopol, Cloverdale and Santa additives.32 A court hearing was expected 1995 was the year that Speier introduced Rosa, lack the benefits of communal water to take place in San Francisco in August Assembly Bill 733, after which things fluoridation. A fluoridation preliminary 2019. Challenges to communal water improved. Based on the most recent engineering design report, costing about fluoridation based on religious freedom, survey (2014), 63.7% of Californians on $113,000, and an environmental impact due process and claims of harm have a long community water systems benefited from study on aquatic marine life, costing history. The legal validity of fluoridation drinking optimally fluoridated water, $66,766, concluded that fluoridation has been repeatedly tested and affirmed by slightly below the 74.4% for the nation was unlikely to harm federally listed courts of last resort in the United States.33 as a whole.36 California is not in the top

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TABLE 7 Lessons Learned ■■ Dentists, dental hygienists, physicians and public health personnel need to know the scientific basis of CWF and have the ability to communicate clearly concerning its benefits. ■■ For successful adoption of CWF, one must be perceptive and shrewd about politics and be able to identify political leaders who care about health. Mortal Wkly Rep 1981 Jun 5;30(21):250–252. ■■ State legislators need to create the legislative backbone, such as in enabling ordinances and 20. Löe H. The fluoridation status of U.S. public water supplies. providing appropriations. Public Health Rep 1986 Mar–Apr; 101(2):157–162. 21. Werdegar D. San Francisco Department of Health Reply ■■ If CWF becomes subject to a referendum, pay attention to wording of ballots in order not to confuse voters. to Board of Supervisors on Questions About Fluoridation. July 26, 1985. ■■ Nurture the dental professional pipeline by preparing and involving dental students. 22. Fluoride: Updated Review of the Medical Literature 2000– ■■ Address new tactics of opponents on risk issues such as fluoride being a neurotoxin rather than 2005. www.sfdph.org/dph/files/EHSdocs/ehsWaterdocs/ a carcinogen. Fluoride_Document_Collection.pdf. 23. Supervisor revives fluoride concerns. San Francisco ■■ Keep the local media, especially science writers, informed on issues related to CWF; be responsive Examiner p. A7, June 6, 2000. to their inquiries. 24. Boyd J. Anatomy of a campaign. J Calif Dent Assoc 1997 25(1):29–36. 25. The California Endowment. 20 for 20. www.calendow. org/were-20. 26. First 5 California. www.ccfc.ca.gov/about/about.html. 10 states in terms of percentage,37 but it references 1. Cooper JJ. California Now World’s 5th Largest Economy, 27. Wisconsin Dental Association. How much does community leads in having more people in California Surpassing U.K. Associated Press May 4, 2018. water fluoridation cost? www.wda.org/wp_super_faq/how- receiving fluoridated water than in any 2. Ten Great Public Health Achievements — United States, much-does-community-water-fluoridation-cost. other state, almost 25 million. California 1900–1999. MMWR Morb Mortal Wkly Rep 1999 Apr 28. Cabezas M. Water fluoridation status in Los Angeles 2;48(12):241–3. County cities over a 23-year period, National Oral Health has come a long way thanks to the efforts 3. Newbrun E. Water fluoridation and dietary fluoride. Conference April 29, 2014; Fort Worth, Texas. of many dedicated public health workers, In: Newbrun E, ed. Fluorides and Dental Caries. 3rd ed. 29. Healdsburg, California, fluoridation of water supply, dentists and a few courageous politicians. Springfield, Ill.: C.C. Thomas; 1986:12. Measure T (November 2016). ballotpedia.org/Healdsburg,_ 4. Stadt ZM, Blum HL, Kent GW, et al. Contra Costa County California,_Fluoridation_of_Water_Supply,_Measure_T_ The history of water fluoridation Fluoridation Report Antioch, California, after 10 years of (November_2016). in California is a story of perseverance, fluoridation. California’s Health 1964;21:24. 30. County of Sonoma. sonomacounty.ca.gov/Search- strategy and commitment to the oral 5. Fluoridation Census 1992. U.S. Department of Health and Results/?q=fluoridation%20advisory%20committee. Human Services, CDC. 1993; National Center for Prevention, 31. Connett M. Citizen petition under section 21 of TSCA: health of the population. Some of the Services Division of Oral Health, Atlanta. Regarding the neurotoxic risks posed by fluoride chemicals lessons learned from this history are 6. Meuller JE. The politics of fluoridation in seven California in drinking water. www.epa.gov/sites/production/ files/2017-02/documents/tsca_fluoride_petition.pdf. summarized in TABLE 7. One lesson from cities. West Polit Q 1966 Mar;(1); 19:54–67. 7. Fluoridation in Healdsburg OK’d. The Press Democrat Santa 32. FAN sues EPA to end fluoridation. fluoridealert.org/ the Healdsburg referenda of 1952, 2014 Rosa, Calif., April 9, 1952. articles/fan-sues-epa-to-end-fluoridation. and 2016 is that, though we may win 8. Bauers U. Vote against S.R. fluoridation disheartening 33. Frazier PJ, Newbrun E. Legal, social and economic aspects some battles, the dispute over communal election result. The Press Democrat Santa Rosa, Calif., April of fluoridation. In: Newbrun E ed. Fluorides and Dental Caries. 9, 1952. 3rd ed. Springfield, Ill.: C.C. Thomas; 1986:117–123. water fluoridation never ceases. Historian 9. Arcus-Ting R, Tessler R, Wright J. Misinformation and 34. Easley MW. The status of community water fluoridation Donald McNeil13 has described the fight opposition to fluoridation. Polity (Winter) 1977; 10:281–289. in the United States. Public Health Rep 1990 Jul–Aug; over fluoridation as “America’s longest 10. Boriskin JM. The winning of a large fluoridation campaign 105(4):348–353. using minimal manpower and budget. J Calif Dent Assoc 1979 35. Centers for Disease Control and Prevention. Populations war,” which is still continuing because Jun;7(6):53–63. receiving optimally fluoridated public drinking water — United the issue is “almost tailor-made for endless 11. Boriskin JM, Fine JI. Fluoridation Election Victory: A Case States, 1992–2006. MMWR Morb Mortal Wkly Rep 2008 controversy.” Some Americans mistrust Study for Dentistry in Effective Political Action. J Am Dent Assoc Jul 11;57(27):737–41. 1981 102(4):86–491. 36. Centers for Disease Control and Prevention. authority, government and science, and 12. Nathan H, Scott S. Fluoridation in California: A new look Community water fluoridation. www.cdc.gov/fluoridation/ people are prone to resist scientific claims at a persistent issue. Bull Inst Govt Studies Oct. 1974; vol.15, statistics/2014stats.htm. in spite of thorough testing and factual no. 5. 37. Pew Charitable Trust. Community Water Fluoridation: the 13. McNeil DR. America’s longest war: The fight over Top 10 and the Bottom 10. www.pewtrusts.org/en/research- observation when they clash with their fluoridation, 1950. Wilson Q Summer, 1985;9(3):140–153. and-analysis/data-visualizations/2014/fluoridation-by-the- intuitive beliefs. Atul Gawande38 points 14. Yiamouyiannis JS. Fluoride and Cancer. Nat Health Fed numbers. out that even where the knowledge Bull April 1975;21:9. 37. Gawande A. The mistrust of science. The New Yorker June 15. Yiamouyiannis J, Burk D. Congressional Record 191, 10, 2016. provided by science is overwhelming, H7172–7176, July 21, 1975; ibid, H 12731–12734, Dec. people often resist it — and sometimes 16 1975. the author, Ernest Newbrun, DMD, PhD, can be reached at outright deny it. That is the reason why 16. Hoover HC, McKay FW, Fraumeni JR. Fluoridated drinking [email protected]. water and the occurrence of cancer. J Natl Cancer Inst 1976 the fight for communal water fluoridation Oct;57(4):757–768. has continued now for nearly 70 years. n 17. Newbrun E. The safety of water fluoridation. J Am Dent Assoc 1977 94(2):301–304. acknowledgment 18. Perlman D. Fluoride, AIDS experts scoff at Nelder’s idea. The author is indebted to Howard Pollick, BDS, MPH, for his San Francisco Chronicle pp. 1, 18. Sept. 6, 1984. insightful comments and suggestions concerning this manuscript. 19. Pneumocystis Pneumonia — Los Angeles. MMWR Morb

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CDA JOURNAL, VOL 47, Nº11

Review of Safety, Frequency and Intervals of Preventive Fluoride Varnish Application for Children

Lisa H. Berens, DDS, MPH; Mimansa Cholera, BDS, MPH; Deborah Elam, MS, CAE; Susan A. Fisher-Owens, MD, MPH; Margaret Fisher, RDAHP; Stuart A. Gansky, DrPH, MS; Irene V. Hilton, DDS, MPH; Kara Lugtu, MPH; Robert Isman, DDS, MPH; Elaine Musselman, PhD, RN; Howard Pollick, BDS, MPH; and Ling Zhan, DDS, PhD

a b s t r ac t Fluoride varnish is supported by the United States Preventive Services Task Force and several professional organizations as an effective cavity preventive treatment, especially the earlier it is applied after tooth eruption, particularly on high-risk young children. It does not replace the essential early routine dental visit. This paper’s objective is to provide the rationale and guidance around the safety of frequent applications of fluoride varnish when provided in multiple (dental, medical and community) settings.

AUTHORS

Lisa H. Berens, DDS, UCSF School of Medicine Irene V. Hilton, DDS, Howard Pollick, BDS, ental caries impacts the MPH, is an associate and a clinical professor of MPH, is a staff dentist at the MPH, is a clinical professor overall health of children,1 professor at the University preventive and restorative San Francisco Department of and director of the their school attendance and of California, San Francisco, dental sciences in the UCSF Public Health and a clinical accredited dental public School of Dentistry and School of Dentistry. She instructor at the UCSF School health residency program, their resultant academic 2 co-lead of the CavityFree chairs the CavityFree SF of Dentistry and School of department of preventive success as well as increases SF collaborative. integration team and is a Medicine. and restorative dental Dthe lifetime risk for dental and health member of the steering sciences at the UCSF School problems.3 It is a disease that has Mimansa Cholera, BDS, committee. Kara Lugtu, MPH, is a of Dentistry. long been recognized as having many MPH, is a dental student at health coach and project the University of Washington, Margaret Fisher, RDHAP,  administrator for the Ling Zhan, DDS, PhD,  influencing factors, including social, School of Dentistry and a is a former oral health CavityFree SF collaborative. is an associate professor in economic, genetic/biologic and individual former oral health consultant with the San the orofacial sciences health behaviors. San Francisco’s low- epidemiologist at the San Francisco Department of Robert Isman, DDS, MPH,  department at the UCSF income children and children of color Francisco Department of Public Health: Child Health is a former dental consultant School of Dentistry and a experience two to three times the rate Public Health. and Disability Prevention for the California Department practicing pediatric dentist Program and co-lead of the of Health Care Services in the UCSF Pediatric of dental caries as their white and more 4 Deborah Elam, MS, CAE,  CavityFree SF collaborative. (DHCS). Dental Clinic. affluent peers. Low family income is is the executive director of a significant risk factor for poor dental the San Francisco Dental Stuart A. Gansky, DrPH, Elaine Musselman, PhD, Conflict of Interest health5,6 with Medi-Cal eligibility Society and a member MS, is a professor at the RN, is an assistant professor Disclosure for all authors: being a proxy for low-income status. of the CavityFree SF UCSF School of Dentistry, and the associate director of None reported. steering committee. director of the UCSF Center the School of Nursing at San Although fluoride varnish does to Address Disparities in Francisco State University. not address all these determinants Susan A. Fisher-Owens, Children’s Oral Health and a She is the chair of the of health, it is a prevention strategy MD, MPH, is a clinical member of the CavityFree SF CavityFree SF access that is both effective (especially for professor of pediatrics in the steering committee. implementation team. high-risk children with two or more

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TABLE 1 Professional Associations’ Recommendations for Frequency and Intervals of Fluoride Varnish

Agency Caries risk Frequency Intervals Link American Dental Association (ADA) Moderate At least 6 months jada.ada.org/article/S0002-8177(14)64961-8/fulltext#cesec280 or high biannually doi.org/10.14219/jada.archive.2006.0356 Centers for Disease Control (CDC) CDC recommends that parents: “Talk to your cdc.gov/oralhealth/basics/childrens-oral-health/fl_caries.htm dentist, pediatrician, family doctor or nurse webcitation.org/78LjTe39x about putting fluoride varnish on your child’s teeth as soon as the first tooth appears.” American Academy of Pediatrics (AAP) At tooth 2 to 4 times/ 3 to 6 aap.org/en-us/about-the-aap/aap-press-room/pages/AAP- emergence in year months Recommends-Fluoride-to-Prevent-Dental-Caries.aspx primary care webcitation.org/75ox588E9 setting pediatrics.aappublications.org/content/134/3/626 doi: 10.1542/peds.2014-1699. American Academy of Pediatric Low Not needed Not needed ndhealth.gov/oralhealth/Publications/AAPD%20Caries%20Risk%20 Dentistry (AAPD) Moderate 2 times/year 6 months Assessment%20Tool.pdf to High webcitation.org/75oyvVRTM

High 4 times/year 3 months aapd.org/media/policies_guidelines/g_cariesriskassessment.pdf webcitation.org/75oyvVRTM aapd.org/media/Policies_Guidelines/P_FluorideUse.pdf webcitation.org/75p0HdXp4 Association of State and Territorial Follows ADA and CDC recommendation astdd.org/www/docs/fl-varnish-research-brief.pdf Dental Directors (ASTDD) www.webcitation.org/75otycSCt U.S. Department of Health and Human All children 9 4 or more 3 months ihs.gov/doh Services — Indian Health Service (IHS) to 24 months times webcitation.org/75p10Bc5a of age ihs.gov/HeadStart/documents/FluorideVarnishInitiativeFebruary16.pdf webcitation.org/75pADtLMb American Association of Family Based on risk 2 to 4 times/ 3 to 6 aafp.org/afp/2015/0801/p174.html Physicians (AAFP) year months webcitation.org/75p1fcOr7 U.S. Preventive Services Task Force Apply fluoride varnish to the primary teeth of uspreventiveservicestaskforce.org/Page/Document/ (USPSTF) all infants and children starting at the age of RecommendationStatementFinal/dental-caries-in-children-from-birth- primary tooth eruption. through-age-5-years-screening webcitation.org/75p2LCZfT U.S. Health Resources Services High 3 to 4 3 to 6 astdd.org/www/docs/fl-varnish-research-brief.pdf Administration (HRSA) Maternal Child times/year months webcitation.org/75otycSCt Health Bureau (MCHB) mchoralhealth.org/PDFs/TopicalFluorideRpt.pdf webcitation.org/75p3beBmb World Health Organization (WHO) High 2 to 4 3 to 6 allianceforacavityfreefuture.org/en/us/technologies/fluoride-varnish times/year months webcitation.org/75nmY7HUq applications per year7) and inexpensive to see primary care physicians (PCPs) Early and frequent fluoride varnish at 79 cents to $1.50 per packet for one far more frequently than dentists. In the applications provide proven results, application.8 Until all children have United States, the American Academy especially for high-risk children.7,11,12 easy and early access to preventive of Pediatrics (AAP) recommends The Association of State and Territorial dental care and guidance and parents that a child see PCPs 11 times for a Dental Directors (ASTDD) and the have the knowledge, time and support checkup by age 2.10 Early application American Dental Association (ADA) to provide healthy nutritional choices, of fluoride varnish and parental oral agree that at least biannual fluoride health care providers (in medical and health guidance, together with a dental varnish applications should be applied dental spaces) should offer fluoride referral during a routine primary care to prevent dental caries in primary varnish as one of many needed disease medical visit by a PCP, are important or permanent teeth for moderate or prevention tools.9 Young children tend approaches to caries prevention. high-risk children.13,14 The United

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TABLE 2 Dose Range — Safe to Lethal35

Threshold daily dose least likely to Possible mild dental fluorosis Probable toxic dose (PTD) — Certainly lethal dose (CLD) be associated to dental fluorosis daily dose acute toxicity 0.04 mg F/kg body weight > 0.06 mg F/kg body weight 5 mg F/kg body weight (range 3 mg 32–64 mg F/kg body weight F/kg body weight to 8 mg F/kg)

States Preventive Services Task Force Addressing Concerns to 5 years old receiving three fluoride (UPSTF) and AAP both recommend Although fluoride is safe when varnish applications within two weeks that fluoride varnish should be applied applied topically in small quantities, at baseline, there were no adverse during a young child’s pediatric medical ingestion of high levels of fluoride can events or complaints reported by any visits.15,16 While the decision to provide lead to two types of complications: of the subjects or their parents.20 fluoride varnish should always be based acute fluoride toxicity (can occur Fluoride varnish does not cause acute on caries risk level, on higher-risk from a single ingestion of very high toxicity: There is not enough fluoride in populations such as Medi-Cal/Denti-Cal levels of fluoride) and the potential one packet of fluoride varnish to cause (California’s dental Medicaid program) for development of dental fluorosis acute toxicity. In order to experience beneficiaries, three to four or even more (as a complication of daily chronic acute toxicity, a child would have to applications per year may be needed to ingestion of high doses of fluoride). swallow 5 mg of fluoride per kilogram obtain optimal effectiveness17 (TABLE 1). of their body weight in a single sitting, Acute Toxicity more than six times the age-appropriate Purpose Fluoride varnish (FV) is not premeasured amount (5.65 mg F) for a We sought to establish clear guidelines associated with acute toxicity. One 6-month-old (16 pounds or 7 kilograms) to ensure that children at high risk for high dose (TABLE 2) exposure to baby.21 With only a few teeth, it is caries can receive the maximum benefit ingested fluoride (not fluoride varnish rare to use even one-half of a packet from fluoride varnish treatment without application) can result in acute fluoride (2.8 mg F) on a 6-month-old baby. undue risk when applied multiple times in toxicity. Early symptoms include dental, medical and community settings. gastric pain, nausea, vomiting and Chronic Exposure We hope here to clarify that applying burning or cramp-like abdominal pains. Dental fluorosis is a condition resulting fluoride varnish is safe and that concerns Neurological symptoms are rarely from prolonged chronic exposure to about multiple and more frequent present. There are several ways that a elevated levels of fluoride to the developing applications, such as those exceeding child may be exposed to elevated levels enamel during the critical period of tooth current guidelines for the pediatric of fluoride: excessive swallowing of development (from birth to age 8).22 Visible population (TABLE 1), are unwarranted. fluoride toothpaste, excessive ingestion effects of fluorosis on the teeth are present Parents might express concern or worry of prescription fluoride tablets or even in its mildest forms, seen as teeth about children receiving multiple drops and/or excessive application of with white flecks, occasional white spots, applications of fluoride varnish. It is acidulated phosphate fluoride (APF) frosty edges or fine, lacy, chalk-like lines.23 important that both medical and dental foams and gels in a dental office. There These are often barely noticeable and providers have adequate information is minimal risk of acute fluoride toxicity difficult to see except by a dental health to allay unsubstantiated parental fear. from the small amount (0.25 ml of FV care professional. In moderate and severe This article, which represents = 5.65 mg fluoride) of fluoride in each forms of dental fluorosis, the teeth show consensus between the San Francisco fluoride varnish packet. The “probable larger white or stained areas and, in the rare, Department of Public Health, UCSF toxic dose” of fluoride has been set severe form, rough, pitted surfaces (TABLE 3). School of Dentistry, UCSF School at 5 mg F/kg body weight.18 Thus, Fluoride varnish application is of Medicine and San Francisco the toxic dose of fluoride ingestion not associated with fluorosis: Enamel State University School of Nursing, is estimated at 75 mg for an average formation takes about three years (less hopes to answer two questions: sized 3-year-old child weighing 15 for primary teeth).24 To cause fluorosis, ■■ How many fluoride varnish kilograms (33 pounds); this is the the tooth would have to be exposed applications can be provided equivalent of a toddler swallowing much more frequently, for a longer safely annually? more than 10 whole packets of fluoride period of time and at levels higher than ■■ What is a safe interval varnish at one time.19 In a 2001 study recommended here during the three between applications? of 156 low-income children aged 3 years in which enamel is forming.

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TABLE 3 Fluorosis Photos

Normal Very mild Mild Moderate Severe

Stronger teeth Weaker teeth Centers for Disease Control and Prevention (2016), Community Water Fluoridation, 2016, Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, cdc.gov/fluoridation/faqs/dental_fluorosis/index.htm. Photos courtesy of Levy SM, Broffitt B, Marshall TA, Eichenberger-Gilmore JM, Warren JJ. Associations between fluorosis of permanent incisors and fluoride intake from infant formula, other dietary sources and dentifrice during early childhood. J Am Dent Assoc 2010;141:1190–201 ncbi.nlm.nih.gov/pmc/articles/PMC5538250.

Dental fluorosis formation is highly level was seen within two hours of In 2016, the Canadian Agency dependent on the dose, duration and treatment and was far below established for Drugs and Technologies in Health timing of fluoride exposure. Fluorosis toxic levels.28 A nested-cohort study published a review of the clinical risk appears to be related to total compared the prevalence and severity effectiveness, cost-effectiveness cumulative fluoride exposure to the of fluorosis in permanent maxillary and guidelines relating to fluoride developing dentition.25 Fluoride dose incisors of children who participated varnish use. The review included 326 at any one time is also important to in a two-year randomized placebo- citations, 19 of which ultimately met enamel fluorosis formation. “Evidence controlled clinical trial on fluoride the study’s stringent inclusion criteria. suggesting fluorosis can result from peak varnish application at ages 1 through These citations tested various fluoride levels of fluoride in the plasma after a 4. It found no significant differences in application schedules: two applications, high single dosage exposure has only fluorosis between the fluoride varnish four months apart; two applications, been seen with rats, when they were and the placebo groups.29 At the levels six months apart; three applications, injected (a different mode of intake) and intervals being considered for use in four months apart; four applications, with different doses of fluoride.”26 San Francisco or anywhere else, fluoride one week apart; five applications, six However, a single fluoride varnish varnish will not increase fluorosis risk. months apart; six applications, one application does not result in the month apart; two to four times per year; pathologically high-plasma fluoride (or Intervals and every three to 12 months.31 No high single-dose exposure) sufficient to Biological effects of fluoride studies found any association between cause fluorosis, as cited above. In fact, depend on the amount, the duration of number or frequency of varnish one study that examined peak plasma exposure and the metabolic handling applications and any adverse effects. fluoride postvarnish application in six of ingested fluoride. After ingestion, A 2018 review of three toddlers aged 12 to 15 months found fluoride is first absorbed in the stomach, prospective fluoride varnish trials that retained fluoride was 253 times followed by its distribution through reported that “fluorosis is unlikely lower than the acute toxic dose of 5 soft and hard tissues and excretion if not impossible to occur.” After mg/kg, which means plasma fluoride in the urine and feces. The fluoride fluoride varnish application, plasma after varnish placement was within one plasma peak is quickly reached after fluoride concentrations peak within standard deviation of control levels.27 ingestion, as a result of rapid pH- two hours and then rapidly decrease. The dosage of fluoride varnish per dependent absorption in the stomach. The plasma fluoride concentrations package for children younger than age 6 Plasma fluoride levels decrease reached and the kinetics were is 5.56 mg. Even if absorbed completely rapidly due to fluoride uptake in hard similar to those found after brushing systemically, the dosage will still be tissues and renal excretion, while with fluoridated toothpaste.32 The about 17 times lower than the dosage the nonabsorbed fluoride is excreted Centers for Disease Control and that resulted in fluorosis in the study in feces.301 Because the mean plasma Prevention (CDC) states: “No where fluoride was injected into rats. fluoride level after varnish placement published evidence indicates that Another study examined plasma is within one standard deviation of professionally applied fluoride fluoride levels following fluoride control levels, the risk of any residual varnish is a risk factor for dental varnish application in children aged 4 fluoride mixing with subsequent fluorosis, even among children to 14; the highest peak plasma fluoride fluoride applications is minimal. younger than 6 years of age.”33

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There is no risk of fluorosis with during medical visits and three times www.webcitation.org/75nK1bCPK. Accessed Jan. 29, 2019. periodic application of fluoride varnish. during dental visits). The consensus 5. Report to Congressional Request. Oral Health: Dental Disease Is a Chronic Problem Among Low-Income However, there is a risk due to daily of oral health experts from the San Populations. Washington, D.C.: U.S. General Accountability exposure to swallowing excessive Francisco Department of Public Office (2000), U.S. GAO (HEHS-00-72). www.gao.gov/ amounts of fluoridated toothpaste. Health, the UCSF Schools of Dentistry products/GAO/HEHS-00-72. 6. Yang A J, Gromoske AN, Olson MA, et al. Single and While applying fluoride varnish and of Medicine and San Francisco cumulative relations of social risk factors with children’s multiple times per year at various State University School of Nursing, dental health and care-utilization within regions of the intervals cannot cause fluorosis, the after reviewing the current fluoride United States. Matern Child Health J 2016; 20(3) 495– 506. doi: 10.1007/s10995-015-1847-2. link.springer. following routes are the most common varnish studies, is that six applications com/article/10.1007%2Fs10995-015-1847-2. ways excessive chronic fluoride exposure per year is both safe and effective. 7. Marinho VC, Worthington, HV, Walsh T, et al. Fluoride occurs and could result in severe dental Although there is insufficient varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2013 fluorosis during tooth development years: empirical evidence testing four to six Jul 11;(7):CD002279. doi: 10.1002/14651858. ■■ Regular use of drinking water annual FV applications, calculations CD002279.pub2. with high concentrations of extrapolating dosages indicate exposure 8. Plaksmacker, VarnishAmerica Natural Varnish. www. plaksmacker.com/Product/07-0030-07-0031-07-0032. > 2 ppm (mg/l) of fluoride. levels would be well below problematic SmartPractice. Medical DuraShield CV 5% Sodium Fluoride ■■ Daily eating or swallowing large levels. It is safe to offer more than one Varnish. www.smartpractice.com/shop/wa/style?id=SP24 amounts of fluoridated toothpaste. fluoride varnish application within a 1268&m=SPM&cid=524921. Accessed 2018. 9. Fisher-Owens S, Gansky S, Weintraub J, et al. Influences short time interval, such as within a on Children’s Oral Health: A Conceptual Model. Pediatrics Guidance for Health Care Providers: week or a month, without risk of harm. 2007 Sep;120(3):e510–20. doi: 10.1542/peds.2006- What To Tell Parents While it is highly unlikely that 3084. 10. Committee on Practice and Ambulatory Medicine, For children younger than any child in San Francisco will be Bright Futures Periodicity Schedule Workgroup. age 6 (or until they can spit): so fortunate, providers can offer Recommendations for Preventive Pediatric Health Care, ■■ Parents/guardians should apply this preventive treatment with no Pediatrics 2017 Apr;139(4). pii: e20170254. doi: 10.1542/peds.2017-0254. Epub 2017 Feb 17. (Updated an appropriate amount of fluoride hesitation due to safety concerns. We Recommendations for Preventive Pediatric Health Care toothpaste to an appropriately hope dental and medical providers — Periodicity Schedule, American Academy of Pediatrics sized toothbrush (younger than consider the benefit of providing a August 2018www.aap.org/en-us/Documents/periodicity_ schedule.pdf.) age 3: rice grain-sized amount; child’s parent the home care guidance 11. Weintraub JA, Ramos-Gomez F, Jue B, et age 3 and older: pea-sized and providing the child with one of al. Fluoride varnish efficacy in preventing early amount), applying twice a day. our most effective preventive dental childhood caries. J Dent Res 2006;85(2):172–176. doi:10.1177/154405910608500211. ■■ Encourage the child to spit out treatments: fluoride varnish. n 12. Colak H, Dülgergil CT, Dalli M, Hamidi MM. Early extra toothpaste minimizing the childhood caries update: A review of causes, diagnoses fluoride that the child may swallow. references and treatments. J Nat Sci Biol Med 2013;4(1):29–38. 1. Oral Health in America: A Report of the Surgeon doi:10.4103/0976-9668.107257. ■■ No use of prescription-strength 5000 General. Atlanta: U.S. Department of Health and Human 13. Association of State and Territorial Dental Directors ppm of sodium fluoride toothpaste. Services, Centers for Disease Control and Prevention, 2015, Fluoride Varnish Policy Statement. www.astdd. ■■ No use of fluoride rinse. 2000. www.nidcr.nih.gov/sites/default/files/2017-10/ org/docs/Varnish-Policy-Statement-12-15-2015.docx. hck1ocv.%40www.surgeon.fullrpt.pdf. ASTDD Dental Public Health Resources Committee. www. ■■ Fluoride varnish can be applied 2. Guarnizo-Herreño CC, Lyu W, Wehby GL. Children’s Oral webcitation.org/75otycSCt. up to six times a year (three Health and Academic Performance: Evidence of a Persisting 14. Weyant RJ, Tracey SL, Anselmo T, et al. Topical fluoride times at dential visits and three Relationship Over the Last Decade in the United States. for caries prevention: Executive summary of the updated J Pediatr 2019 Jun;209:183–189.e2. doi: 10.1016/j. clinical recommendations and supporting systematic review. times in the medical office). jpeds.2019.01.045. Epub 2019 Mar 26. J Am Dent Assoc 2013 Nov;144(11):1279-91. doi. 3. Bernabé E, Sheiham A. Age, Period and Cohort Trends org/10.14219/jada.archive.2013.0057. Conclusion in Caries of Permanent Teeth in Four Developed Countries 15. U.S. Preventive Services Task Force. Final Currently, if a low-income child 2014. Am J Public Health 2014 Jul;104(7):e115–21. doi: Recommendation Statement Dental Caries in Children 10.2105/AJPH.2014.301869. Epub 2014 May 15. from Birth Through Age 5 Years: Screening, 2014. www. insured by Medi-Cal was offered 4. San Francisco Health Improvement Partnership. San uspreventiveservicestaskforce.org/Page/Document/ all the possible fluoride varnish Francisco Community Health Needs Assessment 2016 RecommendationStatementFinal/dental-caries-in-children- applications reimbursed by Medi-Cal/ Appendices 89–95. San Francisco Department of Public from-birth-through-age-5-years-screening. www.webcitation. Health. 2019-01-29. www.sfdph.org/dph/files/MCHdocs/ org/75p2LCZfT. Denti-Cal, they would only receive Epi/Data-Brief-Childrens-Oral-Health-SFHIP-Community- 16. Clark MB, Slayton RL. Fluoride Use in Caries six applications annually (three times Health-Needs-Assessment-2016.pdf. Archived by WebCite at Prevention in the Primary Care Setting. Pediatrics 2014

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Sep;134(3):626–33. doi: 10.1542/peds.2014-1699. versus_standard_fluoride_varnish_treatments_in_high_ single fluoride doses: A nuclear microprobe study. Caries 17. Moberg Sköld U1, Petersson LG, Lith A, et al. Effect of caries_children_aged_3-5_years. Res 1990;24(4):258–262. PMID: 2276162. doi: school-based fluoride varnish programmes on approximal 21. Whelan C. What’s the Average Baby Weight by 10.1159/000261279. caries in adolescents from different caries risk areas. Caries Month? Healthline Newsletter — Healthline Media. May 15, 27. Milgrom P, Taves, DM, Kim AS, et al. Res 2005 Jul–Aug;39(4):273–9. PMID: 15942186. doi: 201. www.healthline.com/health/parenting/average-baby- Pharmacokinetics of fluoride in toddlers after application 10.1159/000084833. weight. www.webcitation.org/78LoCE2nz. Accessed May of 5% sodium fluoride dental varnish. Pediatrics 2014 18. Whitford GM. Acute and Chronic Fluoride 13, 2019. Sep;134(3):e870–4. doi: 10.1542/peds.2013-3501. Toxicity. J Dent Res 1992 May;71(5):1249–54. doi: 22. National Research Council. Effects of Fluoride on Epub 2014 Aug 18. 10.1177/00220345920710051901. Teeth. In: Fluoride in Drinking Water: A Scientific Review of 28. Ekstrand J, Koch G, Petersson LG, et al. Plasma fluoride 19. Wright W, Turner S, Anopa Y, et al. Comparison of the EPA’s Standards. 1st ed. Washington, D.C.: The National concentration and urinary fluoride excretion in children caries-protective effect of fluoride varnish with treatment Academies Press; 2006:4,104. doi.org/10.17226/11571. following application of the fluoride-containing varnish as usual in nursery school attendees receiving preventive 23. Pollick H. The Role of Fluoride in the Prevention of Tooth Duraphat. Caries Res 1980;14:185–189. PMID: 6929729. oral health support through the Childsmile oral health Decay. Pediatr Clin North Am 2018 Oct;65(5):923–940. doi: 10.1159/000260452. improvement programme — the Protecting Teeth@3 Study: doi: 10.1016/j.pcl.2018.05.014. 29. Dos Santos AP, Malta MC, de Marsillac MW, et al. A randomised controlled trial. BMC Oral Health 2015 24. Reid DJ, Dean MC. Variation in modern human enamel Fluoride varnish applications in preschoolers and dental Dec 18;15:160. doi: 10.1186/s12903-015-0146-z. formation times. J Hum Evol 2006 Mar;50(3):329– fluorosis in permanent incisors: Results of a nested-cohort PMID:26681191. 46. Epub 2005 Nov 21. doi.org/10.1016/j. study within a clinical trial. Pediatr Dent 2016 Oct 20. Weinstein P, Riedy CA, Kaakko T, et al. Equivalence jhevol.2005.09.003. 15;38(5):414–418. PMID: 28206898. between massive versus standard fluoride varnish treatments 25. DenBesten PK. Mechanism and Timing of Fluoride 30. Peres Buzalaf C, de Lima Leite A, Buzalaf MAR, et in high caries children aged 3–5 years. Eur J Paediatr Dent Effects on Developing Enamel. J Public Health Dent 1999 al. Fluoride Metabolism. In: Preedy VR, ed. Fluorine: 2001; 91–96. ISSN (online): 2035-648X. admin.ejpd. Fall;59(4):247–51 PMID: 10682331. Chemistry, Analysis, Function and Effects. 1st ed. London: eu/download/2001-02-06.pdf. www.researchgate.net/ 26. Angmar-Månsson B, Lindh U, Whitford GM, et al. Royal Society of Chemistry; 2015:(4)54–74. doi: publication/319293678_Equivalence_between_massive_ Enamel and dentin fluoride levels and fluorosis following 10.1039/9781782628507-00054. 31. Fluoride Varnishes for Dental Health: A Review of the Clinical Effectiveness, Cost-Effectiveness and Guidelines [Internet]. Canadian Agency for Drugs and Technologies in Health. 2016. Summary of Evidence. PMID: 27929626. 32. Garcia RI, Gregorich SE, Ramos-Gomez F, et al. Absence of Fluoride Varnish–Related Adverse Events in Caries Prevention Trials in Young Children, United States. Prev Chronic Dis 2017 Feb 16;14:E17. doi: 10.5888/ pcd14.160372. PMID: 28207379. 33. Centers for Disease Control and Prevention 2016, Community Water Fluoridation, 2016, Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion. www.cdc.gov/fluoridation/basics/ fluoride-products.html faqs/dental_fluorosis/index.htm. Accessed Jan. 29, 2019. 34. Levy SM, Broffitt B, Marshall TA, Eichenberger-Gilmore JM, Warren JJ. Associations between fluorosis of permanent incisors and fluoride intake from infant formula, other dietary sources and dentifrice during early childhood. J Am Dent Assoc 2010;141:1190–201. PMC5538250. 35. Pollick H. Topical Fluoride Therapy. In: Harris NO, Garcia-Godoy F, Nathe CN, eds. Primary Preventive Dentistry. 8th ed. London: Pearson Education Inc.; 2014:248–272. ISBN: 9780133111408.

the corresponding author, Margaret Fisher, RDAHP, BS, can be reached at [email protected].

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pain assessment

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The Pain Assessment Practices of Pediatric Dentists

Dennis Paul Nutter, DDS; Shahin Goddousi, MS; Sahand Soltani, DDS; and Colleen Gillen Azen, MS

a b s t r ac t A survey of the active members of the American Academy of Pediatric Dentistry was undertaken to investigate the pain assessment beliefs of pediatric dentists in order to understand if those beliefs allow the dentist to decide how much pain a child is experiencing during procedures involving tissue trauma. The results reveal that as many as 92% of pediatric dentists hold beliefs about pediatric pain assessment that may lead to an underestimation of pediatric procedure pain.

AUTHORS

Dennis Paul Nutter, Sahand Soltani, DDS,  eliable and valid pain assessment achieved despite the need for “persistent DDS, is a diplomate of earned his dental degree is critical to the refinement use of restraint.”15 In opposition to this the American Board of from the University of of interventions to alleviate view, approximately one-fourth of the Pediatric Dentistry, a Pacific, Arthur A. Dugoni 1–3 fellow of the American School of Dentistry and is procedure pain. Unalleviated pediatric dentists did not believe that a College of Dentists, a past in private practice in San procedure pain can classically sedation can be termed “successful” or president of the California Francisco. Rcondition children to fear and avoid “acceptable” if immobilizing restraints Society of Pediatric Conflict of Interest necessary medical treatments.4–7 This fear were needed to complete treatment.15 Dentistry and is in private Disclosure: None reported. can increase a child’s pain perception The conflicting opinions that practice in Fairfield, Calif. Conflict of Interest Colleen Gillen Azen, MS,  during future medical treatments by dentists hold regarding the definition Disclosure: None reported. is a biostatistician with the focusing a child’s attention on the of sedation success was hypothesized Southern California Clinical procedure.8–12 Sedation is often undertaken by Vargas and Nathan et al. to be the Shahin Goddousi, MS,  Translational Science to improve pain outcomes by reducing result of a dentist’s expectations for the received his graduate Institute, Children’s Hospital procedural fear and the movement child’s behavior.15 This perspective was degree from Touro Los Angeles and is affiliated University California in with the University of associated with disruptive pain avoidance termed the authoritarian/disciplinarian 13,14 Vallejo, Calif. Southern California. behavior. A sedation may be termed style of behavior management. Its salient Conflict of Interest Conflict of Interest “successful” when it permits treatment to characteristic is that children are expected Disclosure: None reported. Disclosure: None reported. be completed in an efficient, qualitative to be “cooperative” and socially obedient manner that is well tolerated by the child. to the commands (“linguistic” requests) of In 2004, nearly half of pediatric adult authority.16–19 If the dentist had low dentists did not think that a successful expectations for child behavior, that is, sedation required disruptive distress low expectations for child obedience, then behavior to be reduced to a level that the dentist was said to have an advocate/ allowed the procedure to be well tolerated permissive management style.15 The by the patient.15 For “sedation success,” Vargas and Nathan et al. survey revealed they only required that treatment goals be that nearly half of the dentists identified

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TABLE 1 Demographic Characteristics of Respondents* Total number of usable surveys analyzed 1,149 Response rate (electronic + printed) 20% with the authoritarian/disciplinarian Underestimation of procedure pain can Primary type of practice style of behavior management and have dire consequences for children Private practice 73 Private practice with corporate 4 slightly more than half self-identified as undergoing invasive dental treatment. dental chain management 15 having an advocate/permissive style. If a clinician underestimates a child’s University 6 Authoritarian authors commonly pain, that child can experience suffering, Hospital 6 assert that much of children’s negative long-term sensitization (LTS) and classical University/hospital 6 procedural behavior is the result of fear conditioning (CFC).5,6,28–31 LTS Federally qualified health clinic 4 misbehavior that is manifested as defiance, can result in amplified pain experience Indian health clinic 1 16–20 Other community health clinic 2 aversion to authority or unruliness. for the same pain stimulus. Things that No longer actively treating children 1 29–32 When a child’s behavior exhibits these did not hurt before can now hurt. Not a dentist who treats children 0.2 characteristics, authoritarians reason CFC can debilitate a child’s ability Gender that protective stabilization is a justified to tolerate and later seek out future Male 52 4,5,31,33 intervention even when procedural tissue necessary medical treatments. Female 48 16,19 trauma is occurring. This behavior It has been demonstrated in rat models Years practicing assessment paradigm requires that dentists that growth hormone is endogenously 1–5 32 reliably discriminate between the behavior produced in the hippocampal region 6–10 16 that is the result of misbehavior and of the brain, a region associated with 11–15 13 that level of distress behavior that may learning and memory in humans.34–37 16–20 7 entail from three other possibilities: pain, Hippocampal growth hormone has been > 20 33 conditioned fear and noxiously perceived found to double in rats during periods *Numbers shown as percentage of respondent. nonpain sensory stimuli.3,21 This includes of acute distress.34 Consistent with the ability to differentiate misbehavior this discovery, when rats are exposed methodology can result in an assessment from a pain avoidance behavior that to pain stimuli their memory for that detour that leads to a diagnosis of is essentially motivated by fear but has pain event is doubled when growth misbehavior and not pain during been operantly conditioned by permissive hormone was placed in the hippocampal procedures involving tissue trauma. In parenting to manifest as defiance.3,5,22–24 region of their brain.38 Theoretically, this way, the decision to intervene in Protective stabilization-style restraints children’s neural plasticity responds to procedural movement is biased in favor are more difficult to justify if the negative pain events in a similar robust fashion of restraints because the risk of suffering behavior is driven by an operantly in the presence of growth hormone. LTS and CFC has been removed from conditioned, involuntary (implicit) fear Restraining the movement that the calculation of restraint risk.25,26,39 behavior.3,25 It is unknown if authoritarian is resulting from a child’s procedural Sensational news stories and a pediatric dentists believe that they distress is sometimes necessary when it U.S. Senate investigation of corporate have the experience and training to represents the least-risk alternative.25,39 dentistry serve as public reminders make these types of assessments. Such The alternative of general anesthesia that poor clinical pain practice with a belief would run counter to the well- may not be medically sound. The the use of immobilizing restraint is established finding that clinicians nature of the pathology may not lend a continuing problem in pediatric cannot reliably or accurately perform itself to treatment by less-invasive or dentistry.40–44 Authoritarian pain this type of assessment.21,26,27 noninvasive alternative techniques. In assessment methodology may be a factor Authoritarian behavior assessment these situations, the risk of suffering in poor distress management outcomes. methodology that permits the dentist LTS and CFC are weighed against A survey was designed to address two to downwardly revise a child’s clinical the risk valuations ascribed to other questions. Both questions seek to pain score will operate as a systematic alternative treatments and a decision is understand the factors that are involved error in pain assessment. Clinicians made about what modality of treatment in a pediatric dentist’s decision to use who cause procedure pain are not represents the least risk to the patient immobilizing restraint with children simply inaccurate when they gauge a while having the benefit of eliminating during procedures. First, do pediatric child’s pain intensity, they routinely or stabilizing the pathology.25,39 dentists hold the authoritarian belief underestimate their patient’s pain.21,26,27 Authoritarian behavior assessment that they, and not the child, should

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TABLE 2 Survey Questions Regarding Pain Assessment Practices Question Strongly or Neutral Strongly or generally agree generally disagree 4.* When uncooperative, negative or disruptive behavior occurs during an invasive procedure, my 87% 3% 10% experience and training with children permits me to discriminate between behavior that is the result of pain and behavior that is not the result of pain. N = 1,149 Dentist Mother Child 8. When a procedure involves the surgical removal of normal dentin (such as when the high-speed 46% 1% 53% dental bur is used to extend the margins of the dental restoration), who is the best person to decide how much pain the child is experiencing? N = 1,081 Behavior Anxiety Pain No formal scale used 9. In your management of a child’s behavior, for which factors do you routinely use 52% 3% 10% 35% formal measurement scales to rate intensity of the experience? N = 1,149

*This was the first nondemographic question asked. Some clinicians chose more than one answer. determine how much pain a child is Survey Questions holds both beliefs, they are termed a experiencing during procedures involving The data presented in this paper consistent authoritarian. If the clinician tissue trauma? Related to this, we also are limited to demographic data and holds only one of these beliefs, they are wanted to know if pediatric dentists the thought processes of how dentists termed a reluctant authoritarian. Reasons were targeting pain or behavior for assess behavior of children during for this are given in the discussion. measurement. Second, how do pediatric procedures that involve tissue trauma. Alternately, a respondent who believed dentists view the relative risk attending There were five demographic questions. that they did not have the experience and to alternate interventions in pain/ Only three were considered of interest training to differentiate pain constructs distress? Only the findings related to the in this presentation: practice type, from other distress constructs is expressing first question are reported in this paper. gender and years of experience. Type a belief that is logically connected to of training and practice location the belief that the child is best suited Methods are not presented at this time. to determine their own pain intensity. This research was approved by While the original survey involved Clinicians who hold both of these beliefs the Institutional Review Board of 10 questions regarding the respondent’s are termed consistent advocates. NorthBay Medical Center, Fairfield, behavior assessment practices, only Calif. A brief letter describing the six relate to this paper’s research Definitions study and its purpose was emailed to question. Three of the six questions To be certain there was no confusion 5,241 active members of the American were later found to have an ambiguity as to what was meant by the terms Academy of Pediatric Dentistry during that disqualified them from being used used in the questions, the following the fall of 2012. One hundred fifty- in the formulation of our conclusions. statement prefaced the behavior seven of these letters bounced and Their problems are discussed below assessment section of the survey. were undeliverable leaving a total of in the Limitations section. Two of “The manner in which behavior 5,084 delivered email surveys. Surveys the remaining three questions are is assessed in pediatric dentistry is were filled out anonymously online. essentially the same question asked controversial. Choose the answer that best Nonresponders were sent follow-up in different ways. Their answers have corresponds to your thoughts or feelings:” emails at four weeks and six weeks after logical connections with each other. ■■ Invasive procedure is one that the initial mailing. For those members is causing tissue trauma such who did not have email addresses (665), Logically Connected Beliefs as during an injection or a printed surveys were sent. Sixteen print A fundamental premise of this paper restorative procedure involving surveys were returned as undeliverable. is that a respondent who believed that removal of enamel or dentin. The total number of print surveys they had the experience and training to ■■ Negative, uncooperative or delivered was 649. There was no follow- differentiate pain from nonpain constructs disruptive behavior is movement up mailing for nonresponders of the is logically expected to believe that the of head, arms, legs or torso printed surveys. The total number dentist should decide the intensity of including general protest of surveys delivered was 5,733. a child’s pain experience. If a clinician with no compliance.”

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TABLE 3 Survey Questions Not Used To Form Conclusions for Reasons of Ambiguity or Lacking Specificity

Question Strongly or Neutral Strongly or generally agree generally disagree 5. I have at times judged that a child’s uncooperative, negative or disruptive behavior that 34% 9% 57% occurs coincident with an invasive procedure is really not the result of pain and I have used restraints (protective stabilization) to continue with treatment. N = 1,093 6. The emotional dimension of a preschool child’s pain expression generally contributes false 42% 23% 35% information to a clinician about the child’s true pain experience. N = 1,093 7. For children 3 years old and older, I would define sedation as successful if treatment 46% 16% 38% objectives are accomplished and general anesthesia is avoided despite the need for persistent use of restraint. N = 1,074

Statistical Analysis Associations Comments Survey data were collected in ■■ Those respondents who used a A comments window was SurveyMonkey and the data exported to pain scale were more likely to provided for the survey respondents the SAS/STAT v9.2 statistics software believe that the child was the best to comment on any aspect of the for analysis. Chi-square, Fisher exact tests person to decide how much pain survey. One hundred forty-four and Cochran-Armitage trend tests were they were experiencing rather respondents availed themselves conducted to assess associations between than the dentist, in contrast to of this opportunity. Most of the responses to survey questions on the use those who did not use a pain scale comments were directed at questions of selected behavior assessment beliefs, (64% versus 53%, p = 0.04). not reported in this presentation. measurement methodology of pain/distress ■■ Those respondents who used a Sixty-three comments can be intensity and demographic characteristics behavior scale were also more construed to possibly apply to the of respondents. Statistical tests were likely to believe that the child questions reported in this paper and two-sided at a 0.05 significance level. was the best person to decide how are summarized here. Most of them much pain they were experiencing broadly argued for a need for greater Results rather than to believe it was the detail in the questions before they Of the 5,733 surveys delivered, dentist, in contrast to those who can be adequately answered. “A lot a total of 1,013 email responses and did not use a formal behavior scale of the questions should ideally be 179 paper responses were collected. (58% versus 50%, p = 0.01). evaluated on a case-by-case basis” The total number of survey responses ■■ Respondents beliefs about their is an example. Other examples are: was 1,192. From these, the number of experience and training were not “Children’s behavior is multifaceted usable survey responses for the purposes significantly associated with who and can’t be narrowed to one of analysis was 1,149. Including both they thought was the better judge thing, pain.” “This survey is very printed and digitally delivered surveys, of pain, either child or dentist (p generalized. Sometimes I think the the usable response rate was 20%. = 0.08). Of the respondents who dentist is the best to know what level ■■ Demographic results are believed they had the experience of pain the child is experiencing and presented in TABLE 1. and training to differentiate pain other times I think it’s the child.” ■■ Frequency responses for pain from nonpain distress, 53% believed Six respondents pointed out assessment questions are presented that the child was the best person that the alternating reversal of the in TABLE 2 and FIGURES 1–3. in the procedure room to determine Likert answers choices — strongly ■■ Frequency responses for their pain intensity while 46% agree, generally agree, neutral, logically connected beliefs believed that it was the dentist who generally disagree, strongly disagree are presented in FIGURE 4. should decide. Of the respondents — was confusing and could result in ■■ Frequency responses for questions who believed they did not have unknowingly marking an answer that that were not used to form the experience and training to was the reverse of their opinion. For conclusions due to their ambiguity differentiate pain from nonpain this reason, only the response to the or lack of specificity are presented distress, 50% believed that the first Likert scale question is being in TABLE 3. The specific reasons child should be allowed to decide reported in this paper. Being the first, for not using these questions are their own pain while 50% believed it should not have any “reverse order” discussed in the Limitations section. that it should be the dentist. artifact associated with its data.

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Disagree Mother Anxiety scale Neutral 10% 1% 3% Pain scale 3% 10%

Behavior Dentist Child scale Agree 46% 53% 52% 87% No scale used 35%

FIGURE 1. Level of agreement with training and FIGURE 2. Who is the best person to decide how FIGURE 3. Formal measurement scales used by experience statement: “When uncooperative, negative much pain a child is experiencing during an invasive pediatric dentists. or disruptive behavior occurs during an invasive procedure? procedure, my experience and training with children permits me to discriminate between behavior that is the of this difficulty can be seen by the lack experience.45 However, while older result of pain and behavior that is not the result of pain.” of a significant association between children may hide much of their pain respondent beliefs about their experience expression in conformance to cultural Consistent and training in pain assessment and prohibitions against displaying pain Neutral advocate who they thought should be making distress, preschool children who have less 3% 5% that assessment — the dentist or the exposure to the influence of culture may child. When respondents were asked “symptom magnify” their pain experience logically connected questions about to convince an observer that they really 45–47 Reluctant pediatric pain assessment, respondents’ are experiencing some level of pain. Consistent answers were not logically connected Both of these age groups have alternate authoritarianauthoritarian Consistent authoritarian for the majority of respondents. interpretations of a child’s pain expression 40%52% Reluctant authoritarian40% A pilot study was not performed that could have been used by respondents 52% for this survey, which is likely reflected to answer the question making both in the issues associated with the agreement and disagreement with the following questions found in TABLE 3. statement correct. The word “expression” Question 5: This question is not should not have been in the question. specific as to time. It does not tell us Question 7: This question does not FIGURE 4. Distribution of logically connected beliefs. if the respondent is currently revising identify specific authoritarian beliefs Six respondents chose both “dentist” and “child” and one respondent chose all three possibilities. Because downward a child’s pain reports to about pain assessment. As described the choice of “dentist” was a factor in these selections justify the use of restraints or if this above, the decision to use restraints and could trump the declaration of the others, these is a practice that only occurred in involves more than an estimation of selections (0.65%) were counted as strictly “dentist” the distant past. It is also one of the the procedure pain involved. This selections. Those who selected “Mother” (1%) were questions that had its Likert answer question serves as a calibration with counted as “neutral.” order reversed and will suffer from a nearly identical question that was some “confusion” artifact. It has not asked in the Vargas and Nathan et Limitations been used to form our conclusions. al. survey eight years previously.48 At All surveys are limited in their Question 6: This question is also not that time, 47% of respondents were ability to generalize conclusions to the used to form our conclusions because in agreement — only 1% higher than survey’s target population by the response it has ambiguous interpretations. The this survey. However, this question did rate, which, in this case, was 20%. intent was to identify if respondents differ from Vargas and Nathan et al. by Another limitation is that we only understand that pain is defined as both excluding children aged 2 and younger investigated how dentists think. What an emotional and sensory experience from consideration. It also suffers from a people think and what people do are so that the emotional “dimension” of potential response artifact created by the not necessarily the same thing. A hint pain is not a false contribution to pain reverse order Likert scaling of answers.

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Discussion Targeting Pain Versus Targeting However, it is unclear if this method It is well known that pain is solely a Behavior of pain assessment will consistently construct of the mind, not a tangible thing; Pediatric dentists are frequently operate at the upper registers of pain genotypic and phenotypic factors make the source of pediatric procedure intensity. This is the area of pain each individual’s pain sensitivity unique so pain.33,56 When noxiously stimulating intensity in which clinicians are under that there is no uniform pain response for a children during procedures, pediatric the greatest pressure to “rationalize away given level of tissue trauma.49–56 Fifty years dentists know when, where and how pain they cannot alleviate.”60 It is human of research has documented that clinicians the pain stimulus is occurring. In the nature to want to blame something else cannot accurately and reliably estimate invasive, procedural context, the when confronted with our own clinical their patients’ pain experience.21,26,27 only problematic metric for them is failures. Seers and Derry et al. reported Despite this evidence, 87% of pediatric knowing the intensity of the child’s that the highest underestimation of a dentists indicate that they believe they pain experience.3 Measuring a child’s patient’s pain occurs during the highest have the experience and training to tell pain experience and documenting it is a intensity of a patient’s pain experience.26 the difference between behavior that is necessary step in refining one’s clinical It is in this clinical context that a the result of pain and behavior that is reluctant authoritarian who generally the result of other types of distress during follows a methodology in pain assessment procedures involving tissue trauma. that allows the child to determine Seers and Derry et al. their level of pain can convert to an Consistent Authoritarians reported that the highest authoritarian method that denies the Only 46% of pediatric dentists held the underestimation of a behavioral pain reports of young children. authoritarian belief that the dentist should be A systematic review of pediatric dental the one to determine how much pain a child patient’s pain occurs during sedations found that pediatric dentists was experiencing when procedural tissue the highest intensity of a do continue to treat children when trauma was occurring. Even fewer pediatric patient’s pain experience. children’s ostensible pain behavior is in dentists (40%) consistently held both the upper registers of distress.61 Out of 65 logically connected authoritarian beliefs. sedation studies included in the review, 66% of the clinician participants in those Reluctant Authoritarians pain interventions.3,57,58 Only 10% studies completed treatment regardless Fifty-two percent of pediatric dentists of pediatric dentists use formal pain of how much distress the child was hold conflicting pain assessment beliefs. scales to score the intensity of a child’s exhibiting during invasive treatment.61 When a child’s procedural distress intensity pain experience during procedures. The need to use immobilizing restraint runs outside the boundary of the dentist’s The majority of pediatric dentists to complete treatment indicates that usual experience with other children for (52%) utilize behavior scales to measure the child’s pain/distress was high.61 the same pain stimulus and the clinician a child’s procedural distress. Behavior Distress behavior during invasive is unable to alleviate the child’s pain is an ambiguous assessment target that procedures that requires immobilizing symptoms, these “conflicted” dentists may can be interpreted as a pain behavior or restraint in order to continue treatment feel justified in denying the authenticity something else.2,22,59 However, most dentists is, by inference, pain that is beyond of some or all of a child’s procedure pain who use a behavior scale, such as the a child’s pain tolerance threshold. expression. When a dentist allows the four-point Frankl scale, generally prefer to child to decide how much pain they are allow the child to determine how much Pain Assessment Bias or Knowledge experiencing only when the child’s pain pain they are experiencing. This makes Deficit in Sedation Pharmacology expression is in agreement with the dentist’s sense because the hand, leg, torso and One of the possible rationalizations assessment of pain intensity, this actually other distress movements that are being that dentists use to justify the use means that it is the dentist who is always scored with a behavior scale are virtually of restraint is unique to sedation. deciding the procedure pain intensity of identical to what would be identified as Anecdotally, it is known that some children. This is why “conflicted” clinicians pain movement when there is evidence dentists continue treatment during have been termed reluctant authoritarians. of procedural tissue trauma.3,57,59,60 pharmacologically failed sedations because

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they believe that midazolam has amnesia experience and training to differentiate or they believe that the dentist (and not properties that would prevent children the different mental constructs making the child) should decide how much pain from remembering their traumatic pain up a child’s procedural distress (an the child is experiencing, but not both. experiences. This idea is reflected in the advocate belief) paradoxically believe Forty percent of pediatric dentists online advertising of a popular midazolam that it is the dentist (an authoritarian consistently hold pain assessment sedation course that informs dentists belief) who should ultimately determine beliefs that make them vulnerable that they will learn how to “transform how much of a child’s pain behavior to an underestimation of pediatric multiple appointments and difficult cases is authentic and how much is false. pain. They believe that they can into a single ‘no memory’ appointment.”62 discriminate between pain and non- Additionally, a 2016 study of midazolam Dentists Who Do Not Use Formal pain constructs during procedures sedation effectiveness also promotes this Measurement Scales involving tissue trauma and they idea when it emphasizes that midazolam A large percentage of pediatric believe that, in this context, the dentist has the ability to make the patient “forget dentists do not use any formal (not the child) should decide how their unpleasant experience.”63 Both measurement scales to rate a child’s much pain a child is experiencing. of these statements about midazolam distress behavior (35%). If the Ninety-two percent of pediatric amnesic effects are only half right. clinician has been in practice for 16 dentists hold one or more pain Midazolam’s amnesia properties only apply years or more, this number increases assessment beliefs that make them in an imperfect, dose-related manner to to 50%. Anecdotally, it is understood vulnerable to a systematic error that explicit, declarative event memory.64–66 Its that many clinicians narratively tends to underestimate pediatric pain. effectiveness in producing explicit memory describe the quality of their patient’s Fifty-two percent of pediatric dentists amnesia is sometimes as low as 73%.67 The distress (e.g., crying, moving hands and use behavior scales to score the intensity implicit, nondeclarative, unconsciously arms) in the patient’s chart to assist of negative procedural behavior while and automatically accessed memories their teams in preparing for future only 10% utilize pain scales. Thirty- of long-term sensitization and classical procedures. If intensity descriptors five percent of pediatric dentists use fear conditioning are left intact.5,64,65 are also being used (e.g., “a little” no formal measurement scale to score Forty-five percent of the sedation or “thrashing”) or if the qualitative the intensity of procedural behavior. studies in Matharu and Ashley’s (2007) descriptors are only added when Further study is required to determine systematic review of pediatric dental there are big movements, then this the extent of influence that authoritarian sedations used midazolam in at least one could mitigate a failure to assign a pain assessment methodology has on the of their paired drug regimens.61 Therefore, metric to the behavior described. decision process involved in selecting much of the continuance of treatment restraint as an intervention in the during high distress behavior could be Conclusion disruptive behavior of young children due to a misunderstanding regarding Eighty-seven percent of pediatric during procedures involving tissue trauma. sedation pharmacology and not due to dentists believe that when a child is Until an accurate, reliable, clinically a downwardly revising pain assessment exhibiting uncooperative, disruptive, useful, objective measure of pediatric bias. Still, this level of midazolam procedural behavior, the dentist’s procedure pain is found, distress behavior involvement does not fully explain why experience and training permits that occurs coincident with procedural nearly one-third more of study participants them to discriminate between tissue trauma should be accepted as completed treatment regardless of the behavior that is the result of pain the child’s behavioral expression of level of distress that the child exhibited. and behavior that is the result of pain until the child says otherwise. n distress or misbehavior constructs. acknowledgments Consistent Advocates Fifty-two percent of pediatric dentists This research was approved by the Institutional Review Board Only 5% of pediatric dentists hold conflicting pain assessment beliefs. of NorthBay Medical Center, Fairfield, Calif. This work was consistently hold pain assessment beliefs Either they believe that they have the supported by grants UL1TR001855 and UL1TR000130 from the National Center for Advancing Translational Science that are not susceptible to systematic experience and training to discriminate (NCATS) of the U.S. National Institutes of Health. The content is pain underestimation. The other 5% of between pain and non-pain constructs solely the responsibility of the authors and does not necessarily dentists who did not believe they have the during procedures involving tissue trauma represent the official views of the National Institutes of Health.

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Individual differences in the subjective Jun;60(3):169–74. item memory signal that initiates context memory in humans. experience of pain: New insights into mechanisms and models. 17. Pinkham JR. Managing the behavior of the cooperative Curr Biol 2012 Dec 18;22(24):2369–74. doi: 10.1016/j. Headache 2010;50(9):1531–1535. doi: 10.1111/j.1526- preschool child. Dent Clin North Am 1995 Oct;39(4):789– cub.2012.10.055. Epub 2012 Nov 21. 4610.2010.01763.x. 816. 37. Kumaran D, Hassabis D, Spiers HJ, Vann SD, Vargha- 52. Walco GA, Dampier CD, Hartstein G, Djordjevic D, Miller 18. Ripley R. Reader Disappointed in Pediatric Issue. J Calif Khadem F, Maguire EA. Impaired spatial and nonspatial L. The relationship between recurrent clinical pain and pain Dent Assoc 2010 Jan;38(1):6–7. configural learning in patients with hippocampal pathology. threshold in children. In: Tyler DC, Krane EJ, eds. Advances in

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CDA JOURNAL, VOL 47, Nº11

Comparative Evaluation of Fracture Strength of Maxillary Denture Base in Different Arch Shape and Palatal Vault Configuration by Three Different Processing Techniques

Sushil Kar, MDS; Arvind Tripathi, MDS; and Sayida Khan, BDS

abstr ac t Fracture of acrylic resin denture bases, which is characterized in maxillary bases by midline fractures, is a continuing problem in prosthodontics. Therefore, there is a need for improvement especially in terms of fracture strength. The purpose was to investigate and compare the fracture strength of complete maxillary denture base in different arch shape and palatal vault configuration by three different processing techniques — pressure cooker, conventional water bath and microwave.

AUTHORS

Sushil Kar, MDS, is a Sayida Khan, BDS,  olymethyl methacrylate (PMMA) Palatal shapes have been found to have professor in the department is a junior resident is the most frequently used material great influence on the fracture strength of prosthodontics and crown in the department of in denture base fabrication and was of polymerized PMMA resin denture prosthodontics at the and bridge at Subharti first introduced in 1937 by Walter bases.8 Among the different processing Dental College and Hospital Saraswati Dental College in Meerut, India. and Hospital in Lucknow, Wright and Vernon Brothers in techniques, the conventional water bath Conflict of Interest India. PPhiladelphia.1,2 Despite their excellent technique has the major disadvantage Disclosure: None reported. Conflict of Interest properties, there is a need for improvement, of a long processing time.9–11 In 1989, Disclosure: None reported. especially in terms of fracture resistance.3,4 Muley first reported a pressure cooker Arvind Tripathi, MDS,  A recent analysis of denture base fractures polymerization technique that was further is a professor and the 12 head of the department indicated that the ratio of maxillary to investigated by Sidhaye and Undurwade. of prosthodontics at the mandibular fractures was generally 2 to l Kimura et al. conducted various studies Saraswati Dental College based on repairs performed by commercial on microwave polymerized denture base and Hospital in Lucknow, dental laboratories.5,6 Babu MR, Beyli MS resins and concluded that this technique India. and Fraunhofer JA accounted many factors can produce denture bases with comparable Conflict of Interest 25 Disclosure: None reported. for influencing flexural fatigue strength, physical and mechanical properties. Very some of them being frenum notches, surface few studies have reported the influence of irregularities and foreign-body inclusion, different polymerization techniques on the porosities and residual monomer content.7,15 mechanical strength of denture base resins.

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Therefore, the purpose of this study was to investigate and compare the fracture strength of complete maxillary denture base in different arch shape and palatal vault configuration using three different FIGURE 2. Width of the arch was determined at the processing polymerization techniques: posterior end of the tuberosities. conventional water bath, pressure cooker and microwave polymerization techniques. Measurement of U and V Arch Forms Methods and Materials The width of the maxillary The study was carried out on 120 edentulous arch was determined subjects from the outpatient department. between the left and right side of the Ethical clearance was obtained by the edentulous ridge on the posterior end Institutional Human Ethical Committee of the tuberosities (FIGURE 2). To (IHEC) and the Institutional Research determine the arch shape (U or V), and Development Committee (IRDC) of the width at the incisor, premolar Saraswati Dental College, Lucknow, India. FIGURE 1. Depth of the palate was measured by and molar regions was measured. Informed consent from the participants digital Vernier caliper. was obtained and primary impressions of Thickness of the Maxillary maxillary arches were taken. A total of 120 Denture Base specimens were fabricated using four palatal of India, Mumbai, India) that were Modeling wax sheets (Dental vault configurations, out of which 30 subsequently poured with dental stone Products of India) that were specimens each were from deep, moderate, (Kalstone, Kalabhai Karson Pvt Ltd., 2 mm thick were adapted on each shallow and flat palatal vault configuration. Mumbai, India) to obtain the master cast. working cast. Acrylization was Three processing techniques were used in carried out using either conventional the study: pressure cooker, conventional Depth Measurement of Palatal Vault water bath, pressure cooker or water bath and microwave. The specimens Configurations microwave polymerized techniques under each palatal vault configuration A dental surveyor (Ney surveyor, following the standardized protocols were further divided into U arch form and Marathon 103, Saeyang Microtech, (FIGURE 3). Once processed, the V arch form with five specimens each. Daegu, South Korea) was used to denture bases were measured for Mechanical strength of all the specimens determine zero tilt of the casts during thickness using a millimeter gauge was recorded. The specimens were stored measurements. Two lines crossing each at the midline, first premolar region, in water at room temperature for 28 days. other were drawn on the cast; the first right and left second molar region The inclusive criteria were middle- line extended from the middle of the and right and left anterior region and old-aged subjects comprising of incisive papilla to the fovea palatine, and were standardize to 2 mm. equal numbers of males and females while the second line crossed the first with periods of edentulism ranged from at the middle. The crossing point was Evaluation of Mechanical Strength six months to two years. The criteria marked by a lead pencil. The depth of All the specimens were stored in for exclusion were subjects with single the palate at this point was measured distilled water at room temperature tooth and root stumps, TMJ problems, by adjusting a digital depth measuring for 28 days. Subsequently, the patients suffering from systemic diseases, Vernier caliper (any 6 inch/150 mm). specimens were dried and kept denture stomatitis, history of trauma and The data were recorded and categorized with the polished surface on the the presence of cleft or abnormalities in into four categories according to the platform of the Universal Testing the palate. Final impressions were made palate depth: deep (15.5–20.0 mm), Machine (INSTRON UTM, model by selective impression technique using moderate (10.5–15 mm), shallow (5.5–10 3382) (FIGURE 4). The fracture tests zinc oxide-eugenol impression pastes mm) or flat palate (less than 5.5 mm) were carried out on the Universal (DPI impression paste, Dental Products and arch forms U or V (FIGURE 1). Testing Machine at a crosshead

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FIGURE 3. Conventional water bath acrylizer (A), pressure cooker (B) and microwave processing unit (C). FIGURE 4. Specimen was tested on the universal testing machine.

1,400.00 1,400.00

1,200.00 1,200.00

1,000.00 1,000.00

800.00 800.00 Fracture strength Fracture strength Fracture

600.00 600.00

400.00 400.00 Pressure cooker Conv. water bath Microwave Deep Moderate Shallow Flat

FIGURE 5. Mechanical strength differences of specimens processed by different FIGURE 6. Mechanical strength of specimens processed by any of the techniques polymerization techniques. with different palatal vault configuration. speed of 5 mm/min. Force was applied Results Mechanical strength was found to via a specifically designed metal ring be minimum for specimens processed placed on the most prominent part Statistical Tools Employed by pressure cooker with a mean of the palate and the readings were The statistical analysis was done using value of 846.23 ± 187.94 N (range: collected. The data were statistically Statistical Package for Social Sciences 481.62 to 1,225.07 N) followed by analyzed. One-way analyses of variance (SPSS, IBM, Armonl, N.Y.) statistical conventional water bath with 933.89 (ANOVA) were used to test the analysis software, version 15.0. The values ± 181.80 N (range: 627.83 to 1,350.31 differences in mechanical strength were represented in number (%) and N) and maximum for specimens between the selected palatal vault mean ± SD. The ANOVA test was used processed by microwave with 991.37 configurations and arch form groups to compare within the group and between ± 168.63 N (range: 781.01 to 1,378.23 and the highest fracture strength the groups. Post-hoc tests (Tukey-HSD) N). The box plot shows that the between three different polymerization were used for each mean comparison difference in mechanical strength techniques were calculated. and “p” for the level of significance. of specimens processed by different

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CDA JOURNAL, VOL 47, Nº11

TABLE 1 Analysis of Variance and Comparison of Mechanical Strength in Fracture Test (Tukey HSD Test) Sum of squares df Mean square F ‘p’ Between groups 427,379.26 2 213,689.63 6.620 0.002* polymerization techniques was found Within groups 3,776,934.81 117 32,281.49 to be statistically significant with Total 4,204,314.07 119 overlapping of interquartile values Mean difference S.E. ‘p’ of pressure cooker and conventional Pressure cooker versus conventional water bath –87.66 40.18 0.079 water bath and conventional water Pressure cooker versus microwave –145.14 40.18 0.001* bath and microwave (FIGu re 5). Between polymerization techniques, Conventional water bath versus microwave –57.48 40.18 0.329 the difference in mechanical *Statistically significant values. strength was found to be minimum between conventional water bath TABLE 2 and microwave (57.48 ± 40.18 N), Comparison of Mechanical Strength in Fracture Test of the Commonly Used but the difference between pressure Acrylic Denture Base Materials by Pressure Cooker Technique, Conventional cooker and microwave was found to Water Bath and Microwave be statistically significant (TABLE 1). Palatal vault configuration No. of Minimum Maximum Mean SD The mechanical strength of specimens specimens processed by the pressure Deep Pressure cooker technique 10 960.21 1,225.07 1,059.33 74.87 cooker technique was found to be Conventional water bath 10 1,001.29 1,350.31 1,154.74 125.62 maximum for specimens with deep Microwave 10 1,055.43 1,378.23 1,217.39 99.92 palatal vault configuration (1,059.33 Moderate Pressure cooker technique 10 800.05 1,106.12 962.29 88.30 ± 74.87 N; range: 960.21–1,225.07 N) and minimum with flat palatal vault Conventional water bath 10 845.21 1,176.11 1,002.29 90.94 configuration (653.30 ± 86.53 N; Microwave 10 887.47 1,176.87 1,027.03 88.17 range 481.62–799.21 N) (TABLE 2). Shallow Pressure cooker technique 10 609.21 821.07 710.01 69.08 The difference in mechanical Conventional water bath 10 767.21 933.01 845.47 51.81 strength of specimens processed by Microwave 10 827.21 991.45 907.99 50.29 the pressure cooker technique with different palatal vault configuration Flat Pressure cooker technique 10 481.62 799.21 653.30 86.53 was found to be statistically significant Conventional water bath 10 627.83 791.01 733.07 61.23 (p < 0.001) (TABLE 3). The difference Microwave 10 781.01 889.44 813.07 41.44 in mechanical strength was maximum Total Pressure cooker technique 40 481.62 1,225.07 846.23 187.94 between deep and flat palatal vault Conventional water bath 40 627.83 1,350.31 933.89 181.90 configuration (406.03 ± 35.82) and Microwave 40 781.01 1,378.23 991.37 168.63 was found to be statistically significant but no significant difference was found between shallow and flat (56.71 ± 35.82 N) (TABLE 4). Order or mechanical 627.83–791.01 N) (TABLE 2). The found to be maximum for specimens with strength of specimens processed by difference in mechanical strength with deep palatal vault configuration (1,217.39 the pressure cooker technique in different palatal vault configuration ± 99.92 N; range: 1,055.43–1,378.23 N). different palatal vault configuration was found to be statistically significant The mechanical strength was found was deep > moderate > shallow > flat. (p < 0.001) (TABLE 3). The difference to be minimum in specimens with flat The specimens processed by the was found to be maximum between palatal vault configuration (813.07 conventional water bath technique deep and flat (421.67 ± 39.04 N) ± 41.44 N; range 781.01–889.44 N) had a maximum value for deep palatal and minimum between shallow and (TABLE 2). The difference in mechanical vault configuration (1,154.74 ± 125.62 flat (112.40 ± 39.02 N) TABLE( 4). strength of specimens processed by the N; range: 1,001.29–1,350.31 N) The mean mechanical strength of microwave technique with different and minimum with flat palatal vault specimens processed by the microwave palatal vault configuration was statistically configuration (733.07 ± 61.23 N; range technique was 991.37 ± 168.63 N and significant (p < 0.001) TABLE( 3). The

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TABLE 3 Analysis of Variance Sum of squares df Mean square F ‘p’ Pressure cooker Between groups 1,146,587.94 3 382,195.98 59.573 < 0.001 Within groups 230,961.07 36 6,415.59 Total 1,377,549.01 39 statistically significant (p < 0.001) Conventional Between groups 1,015,997.46 3 338,665.82 44.438 < 0.001 (TABLE 5). An overlapping of interquartile values was observed water bath Within groups 274,356.75 36 7,621.02 between shallow and flat palatal vault Total 1,290,354.21 39 configuration F( IG u re 6). The order of Microwave Between groups 910,993.13 3 303,664.38 55.201 < 0.001 mechanical strength of specimens Within groups 198,038.45 36 5,501.07 processed by any of the techniques in Total 1,109,031.59 39 different palatal vault configuration was deep > moderate > shallow > flat. TABLE 4 The difference in mechanical Between Palatal Vault Configuration Comparison of Mechanical Strength in strength of specimens processed Fracture Test (Tukey HSD Test) by any of the techniques with a U arch form (926.55 ± 184.88 N) and Mean difference Standard error ‘p’ V arch form (921.11 ± 192.52 N) Pressure cooker Deep versus moderate 97.04 35.82 0.048 was not found to be statistically technique Deep versus shallow 349.32 35.82 < 0.001 significant (p = 0.875) (TABLE 6). Deep versus flat 406.03 35.82 < 0.001 Discussion Moderate versus shallow 252.28 35.82 < 0.001 The denture base is subjected to load Moderate versus flat 308.99 35.82 < 0.001* during function as well as parafunction. Shallow versus flat 56.71 35.82 0.401 Under the load, the maximum stress Conventional Deep versus moderate 152.45 39.04 0.002* is on the palatal aspect of the denture water bath Deep versus shallow 309.27 39.04 < 0.001* base that enables the initiation and propagation of the cracks thereby Deep versus flat 421.67 39.04 < 0.001* influencing the rate of failure.13 Peyton Moderate versus shallow 156.82 39.04 0.002* and Anthony conducted an experiment Moderate versus flat 269.22 39.04 < 0.001* on the fracture strength of heat-cured Shallow versus flat 112.40 39.04 0.032* and cold-cured denture bases and Microwave Deep versus moderate 190.36 33.17 < 0.001* found that both the heat-cured and Deep versus shallow 309.40 33.17 < 0.001* self-cured dentures resisted an average force of approximately 139 pounds Deep versus flat 404.32 33.17 < 0.001* before the initial break at the midline, Moderate versus shallow 119.04 33.17 0.005* but considerable additional force was Moderate versus flat 213.97 33.17 < 0.001* required to complete the fracture in Shallow versus flat 94.93 33.17 0.034* the front.14 In a survey by Darbar et al., 68% of dentures had broken within *Statistically significant values. three years of their fabrication and difference was found to be maximum palatal vault configuration (997.21 ± midline fracture was found to be the between deep and flat (404.32 ± 33.17 90.19 N; range: 800.05–1,176.87 N). most common problem.15 Of these N) and minimum between shallow and Minimum mechanical strength was midline fractures, 71% were seen in flat (94.93 ± 33.17 N) TABLE( 4). found in specimens with flat palatal maxillary complete dentures and 29% Mechanical strength of specimens vault configuration (733.15 ± 91.77 N; were seen in mandibular dentures. Any processed by any of the techniques was range 481.62–889.44 N). The factor that exacerbates deformation of found to be maximum for specimens difference in mechanical strength of the base or alters its stress distribution with deep palatal vault configuration specimens processed by any of the predisposes the denture to fracture.16 (1,143.82 ± 118.76 N; range: 960.21– techniques with different palatal vault While impact may fracture dentures 1,378.23 N) followed by moderate configuration was found to be when they are dropped, repeated flexing

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CDA JOURNAL, VOL 47, Nº11

TABLE 5 Analysis of Variance and Between Palatal Vault Configuration Comparison of Fracture Strength (Tukey HSD Test; All Three Techniques)

Sum of squares Df Mean square F Sig. Between groups 3,020,422.60 3 1,006,807.53 59.573 < 0.001 from chewing ultimately leads to fatigue Within groups 1,183,891.47 116 10,205.96 17 in many dentures in the mouth. A Total 4,204,314.07 119 study by Lambrecht and Kydd found Mean difference S.E. ‘p’ two types of deformation predominance; the first was extension, a flattening or Deep versus moderate 146.61 26.08 < 0.001* straightening of the base at the midline, Deep versus shallow 322.66 26.08 < 0.001* and the second was compression, an Deep versus flat 410.67 26.08 < 0.001* increase at the curvature of the base at Moderate versus shallow 176.05 26.08 < 0.001* the midline.18 Beyli and von Fraunhofer Moderate versus flat 264.06 26.08 < 0.001* analyzed the causes of fracture of acrylic resin dentures and proposed Shallow versus flat 88.01 26.08 0.005* that the most promising approach to *Statistically significant values. prevent or reduce the incidence was to reinforce the anterior part of the palate of the denture.19 Schneider et al. palatal suture contributes to variation in 30 minutes can lead to more residual compared the tensile bond strengths resistance of the denture bases to fracture monomer than with the conventional of heat- and microwave-polymerized in different palatal vault configurations.20 method.12,24 Mechanical strength of acrylic resins among four types of acrylic Annusavice proposed that in nonuniform specimens processed by the pressure resin denture teeth and suggested objects stresses typically decrease as a cooker technique was found to be that the selection of more compatible function of distance from the area of maximum for specimens with deep combinations of base and resin teeth the applied force or applied pressure.21 palatal vault (1,059.33 ± 74.87 N; may reduce the number of prosthesis Meyer concluded that fracture in the range: 960.21–1,225.07) and minimum fractures and resultant repairs.20 complete denture base occurs due for flat palatal vault configuration The present study tested three to uneven and deflective occlusal (653.30 ± 86.53N; range 481.62–799.21 different depths of the palatal vault with contacts that will deform the denture N). Donovan et al. showed the same an assumption that the depth of the base and create lines of fatigue.22 result in their study.25 The difference palate might have a role in distribution The heating process used to in mechanical strength of specimens of stresses that occur during functional control polymerization is called the processed by the pressure cooker and parafunctional movements of the polymerization cycle or curing cycle, technique with a U arch form (851.69 jaw and concludes that deep palatal vault and any change in properties is more ± 185.26 N) and V arch form (840.78 denture bases have better mechanical likely to result from differences in the ± 195.23 N) was not found to be strength when compared to the other degree of the cure of the interstitial statistically significant (p = 0.857). three. Because stress is force per unit matrix.23 Ease of curing the dentures The water bath heat processing area, there is always a higher tendency in a domestic pressure cooker was technique involves the activation of of fracture of flat palatal vault bases in first suggested by Muley in 1976. In the initiator, i.e., benzoyl peroxide, comparison to deep palatal vault due developing countries where large creating the first free radicals to start to less surface area. Additionally, in numbers of dentists practice outside the polymerization above 60 degrees patients with deep palatal vault, the of metropolitan cities, dentists Celsius (140 degrees Fahrenheit). At height of contour in the anterior part are compelled to process dentures 100.8 degrees Celsius (213.4 degrees of the palate might act as a secondary themselves because of the unavailability Fahrenheit), the methyl methacrylate stress-bearing area that helps in or remoteness of well-equipped boils and creates porosities in the dissipating forces acting on the denture laboratories. When a pressure of 760 resin because the heat liberated due base, whereas in the case of flat palatal mmHg (15 psi) is applied in a 6L to polymerization does not escape vaults, there is no counteracting force pressure cooker by compressor for easily due to the unfavorable thermic dissipation effect by anterior slope of 20 minutes, the boiling water could gradient.26 To control this thermal palate. According to Schneider, the produce steam pressure up to 1,520 gradient, it is necessary to polymerize fulcrum created in a denture at the mid- mmHg. A curing time of less than the denture base resin at a much

734 NOVEMBER 2 01 9 CDA JOURNAL, VOL 47, Nº11

TABLE 6 Comparison of Mechanical Strength in Fracture Test of the Commonly Used Acrylic Denture Base Materials of Different Arch Forms U arch (n = 20) V arch (n = 20) Statistical significance Minimum Maximum Mean SD Minimum Maximum Mean SD ‘t’ ‘p’ Pressure cooker 591.45 1,125.01 851.69 185.26 481.62 1,125.07 840.78 195.23 0.181 0.857 Conventional water bath 653.89 1,350.31 932.33 176.57 627.83 1,320.21 935.46 191.65 –0.054 0.957 Microwave 790.87 1,378.23 995.65 172.29 781.01 1,325.25 987.09 169.25 0.158 0.875 Total 591.45 1,378.23 926.55 184.88 481.62 1,325.25 921.11 192.52 0.158 0.875 Configuration U arch (n = 15) V arch (n = 15) Statistical significance Minimum Maximum Mean Minimum Maximum Mean Minimum Maximum Deep 960.21 1,378.23 1,142.10 Deep 960.21 1,378.23 1,142.10 Deep 960.21 1,378.23 Moderate 899.02 1,108.01 999.40 Moderate 899.02 1,108.01 999.40 Moderate 899.02 1,108.01 Shallow 609.21 9,47.83 824.52 Shallow 609.21 947.83 824.52 Shallow 609.21 947.83 Flat 591.45 889.44 740.19 Flat 591.45 889.44 740.19 Flat 591.45 889.44 Total* 591.45 1,378.23 926.55 Total* 591.45 1,378.23 926.55 Total* 591.45 1,378.23

* Statistically not significant values.

slower rate, approximately eight hours used for this purpose.28 The numerous cured resin are approximately the same for complete polymerization. In the intermolecular collisions that occur as resin cured in a conventional water conventional water bath polymerization cause rapid heating and less than bath.30 The results of the present study technique, mechanical strength of 10 minutes is required for complete are supported by the findings of Gurbuz specimens was found to be maximum polymerization. As the temperature et al. that the heat-curing method for specimens with deep palatal vault increases, the number of monomer of the water bath produces denture configuration (1,154.74 ± 125.62 N; molecules decreases and the residual bases with mechanical strengths lesser range: 1,001.29–1,350.31 N) and monomer content is reduced to a but comparable to the microwave minimum for specimens with flat minimum. The polymerization heat processing technique.31 Kim and Watts palatal vault configuration (733.07 is dissipated more effectively, faster evaluated the effect of woven E-glass ± 61.23 N; range: 627.83–791.01 and with lesser risk of porosity that fiber reinforcement on the impact N). The difference in mechanical results in better dimensional accuracy, strength of complete dentures and strength of specimens processed transverse strength and less residual found that impact strength of maxillary by the conventional water bath monomer content of the denture base.29 dentures was increased by a factor technique with U arch form (932.33 Difference in mechanical strength of greater than twice when reinforced ± 176.57 N) and V arch form (935.46 specimens processed by the microwave with woven E-glass fiber.32 However, ± 191.65 N) was not found to be technique with U arch form (995.65 in a situation where the equipment statistically significant (p = 0.957). ± 172.29 N) and V arch form (987.09 required for microwave and water In 1968, Nishii et al. introduced ± 169.25 N) was not found to be bath were not available, the pressure microwave processing for statistically significant (p = 0.875). cooker technique can be used as a polymerization of denture base resin. In this study, we observed that valid alternative for curing. Another In this technique, microwaves were the denture bases fabricated using observation in this study was that used to generate heat inside the the microwave processing technique the denture bases fabricated on deep resin. Kimura et al. conducted an achieved the maximum mechanical palatal vaults had the highest mean experiment on a microwave flask strength. However, the equipment mechanical strength irrespective of the constructed of glass fiber-reinforced required to process denture bases type of curing employed. Conversely, polyester resin with polycarbonate using the microwave technique is denture bases fabricated on flat palatal bolts, and he processed the denture expensive and not readily available. vaults had the lowest mean mechanical in an LG microwave oven with Levin et al. conducted experiments strength. Differences in mechanical rotating turntable.27 The microwaves on five different resins processed with strength of specimens with a U arch produced are electromagnetic waves. microwaves and conventional water form and a V arch form in none of Domestic microwave ovens that use bath and concluded that the important the palatal vault configuration were a frequency of 2,450 MHz can be physical characteristics of microwave- found to be statistically significant.

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Conclusion 8. Arora A, Juneja S, Gupata N. Effect of palatal vault Univ Dent Sch 1983 Dec;23:43–49. The present study therefore suggests depth on flexural strength of three different high impact 28. De Clerck JP. Microwave polymerization of acrylics denture base resins — an in vitro study. Indian J Dent Sci resins used in dental prosthesis. J Prosthet Dent 1987 that denture bases of different palatal vault 2016 Mar;8(1):16–19. May;57(5):650–58. configurations and arch forms processed by 9. Grunewald AH, Paffenbarger GC, Dickson G. The effect 29. Ganzarolli SM, De Mello JA, Shinkai RS, Del Bel Cury using the microwave processing technique of molding processes on some properties of denture base AA. Internal adaptation and some physical properties of resins. J Am Dent Assoc 1952 Mar;44(3):269–82. doi. methacrylate-based denture base resins polymerized by were significantly stronger than denture org/10.1016/S0002-8177(52)43004-4. different techniques. J Biomed Mater Res B Appl Biomater bases processed by conventional water 10. Gharechahi J, Asadzadeh N, Shahabian F, Gharechahi 2007 Jul;82(1):169–73. bath and pressure cooker techniques. M. Flexural strength of acrylic resin denture bases processed 30. Levin B, Sanders JL, Reitz PV. The use of microwave by two different methods. J Dent Res Dent Clin Dent energy for processing acrylic resins. J Prosthetic Dent 1989 However, the equipment required for the Prospect 2014 Summer;8(3):148–52. doi: 10.5681/ Mar;61(3):381–3. microwave polymerization technique is joddd.2014.027. Epub 2014 Sep 17. 31. Gurbuz O, Unalan F, Dikbas I. Comparison of the expensive and not available in the routine 11. Jadhav R, Bhide SV, Prabhudesai PS. Assessment of the transverse strength of six acrylic denture resins. OHDMBSC impact strength of the denture base resin polymerized by 2010; 11(1):21–24. lab, whereas the conventional water bath various processing techniques. Indian J Dent Res 2013 Jan– 32. Sung-Hun Kim and David C Watts. The effect of polymerization technique is the most Feb;24(1):19–25. doi: 10.4103/0970-9290.114926. reinforcement with woven E-glass fibers on the impact commonly used technique worldwide 12. Undurwade JH, Sidhaye AB. Curing cycle resin in a strength of complete dentures fabricated with high-impact domestic pressure cooker: A study of residual monomer acrylic resin. J Prosthet Dent 2004 Mar;91(3):274–280. and the equipment required is readily content. Quintessence Int 1989 Feb;20(2):123–29. available. Deep palatal vault configuration 13. Mathew E, Wain EA. Stresses in denture base. Br Dent J the corresponding author, Sushil Kar, MDS, can be reached denture bases possessed better mechanical 1965; 100:167–171. at [email protected]. 14. Peyton FA, Anthony DH. Evaluation of dentures strength than moderate, shallow and flat processed by different techniques. J Prosthet Dent 1963 vaults. However, the mechanical strength Mar–Apr;13(2):269–282. of denture bases was not influenced by the 15. Darbar UR, Huggett R, Harrison. Denture fracture — a survey. Br Dent J 1994 May 7;176(9):342–5. arch forms (U and V shapes) irrespective 16. Beyli MS, Von Fraunhofer JA. An analysis of causes of the different processing techniques. n of fracture of acrylic resin dentures. J Prosthet Dent 1981 Sep;46(3):238–241. acknowledgment 17. Johnston EP, Nicholls, Smith DE. Flexure fatigue of 10 The authors acknowledge the technical support provided commonly used denture base resins. J Prosthet Dent 1981 by all the faculty members and postgraduate students Nov;46(5):478–83. of the department. The authors also acknowledge the 18. Lambrecht JR, Kydd WL. A functional stress analysis management of the institution for its valuable support. of the maxillary complete denture base. J Prosthet Dent 1962 Sep–Oct;12(5):865–72. doi.org/10.1016/0022- references 3913(62)90039-2. 1. Consani RL, Folli BL, Nogueira MC, Correr AB, Mesquita 19. Schneider RL, Curtis ER, Clancy JM. Tensile bond MF. Effect of polymerization cycles on gloss, roughness, strength of acrylic resin denture teeth to a microwave hardness and impact strength of acrylic resins. Braz Dent or heat-processed denture base. J Prosthet Dent 2002 J 2016 Mar–Apr;27(2):176–80. doi: 10.1590/0103- Aug;88(2):145–5. 6440201600733. 20. Schneider RL. Diagnosing functional complete denture 2. Nandal S, Ghalaut P, Shekhawat H, Gulati MS. New era fractures. J Prosthet Dent 1985 Dec;54(6):809–14. in denture base resins. Dent J Adv Stud 2013 Dec;1:136– 21. Anusavice KJ. Phillip’s Science of Dental Materials. 11th 43. doi: 10.1055/s-0038-1671969. ed. St.Louis: Elsevier; 2004:75. 3. Khalid H. Causes and types of complete denture fracture. 22. Meyer FS. Dentures — causes of failures and remedies. J Zanco J Med Sci 2011; 15(3):1–6. Prosthet Dent 1951;1:672–91. 4. Morris JC, Khan Z, von Fraunhofer JA. Palatal shape and 23. Jagger RG. Effect of curing cycle on some properties the flexural strength of maxillary denture bases. J Prosthet of a polymethylmethacrylate denture base material. J Oral Dent 1985 May;53(5):670–73. Rehabil 1978 Apr;5(2):151–57. 5. Kelly E. Fatigue fracture in denture base polymers. 24. Ming XC, Changi S, Weizhou H. Rapid-processing J Prosthet Dent 1969 Mar;21(3):257–66. doi. procedure for heat polymerization of polymethyl org/10.1016/0022-3913(69)90289-3. methacrylate in a pressure cooker with automatic controls. J 6. Lim SR, Lee JS. Three dimensional deformation of dry- Prosthet Dent 1996 Oct;76(4):445–46. stored complete denture base at room temperature. J Adv 25. Donovan TE, Hurst RG, Campagni WV. Physical Prosthodont 2016 Aug;8(4):296–303. properties of acrylic resin polymerized by four different 7. Babu MR, Rao CS, Ahmed ST, Bharat JSV, Rao NV, techniques. J Prosthet Dent 1985 Oct;54(4):522–24. Vinod V. A comparative evaluation of the dimensional 26. Caul HJ, Wll LA, Acquista N. Determination of monomer accuracy of heat polymerized PMMA denture base cured content of polymethylmethacrylate. J Am Dent Assoc 1956 by different curing cycles and clamped by RS technique and Jul;53(1):56–59. conventional method — an in vitro study. J Int Oral Health 27. Kimura H, Teraoka F, Ohniski H, Saito T, Yato M. 2014 Apr;6(2):68–75. Epub 2014 Apr 26. Applications of microwave for dental techniques. J Osaka

736 NOVEMBER 2 01 9 Call us today at (855) 337-4337 or visit www.integritypracticesales.com

WE ARE DEDICATED TO SELLING YOUR PRACTICE.

Darren Hulstine Linda Salazar, RDA Ken Skeate Brian Flanagan Maricelle Ortiz-Luis, DDS Darren Sharp Kevin Horton Central Coast San Diego Southern California Northern California Southern California Southern California Southern California (805) 878-0633 (619) 933-6225 (805) 338-5850 (707) 898-0842 (858) 722-7461 (714) 928-5822 (805) 791-9661 DRE# 01899816 DRE# 01921421 DRE# 00885612 DRE# 01947466 DRE# 02031988 DRE# 01939069 DRE# 01911548

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San Diego: $1,350,000 | 5 ops Valencia: $600,000 | 5 ops Central Coast Lease: $25/sf/yr NNN | 7 ops Vista + RE: $450,000 | 4 ops Camarillo: $360,000 | 4 ops N. Santa Barbara County: $1,437,000 | 9 ops SOLD! Pacific Beach: $397,000 Ventura Turnkey: $110,000 | 3 ops SOLD! San Luis Obispo: $460,000 Escondido: $180,000 | 2 ops SOLD! Camarillo: $240,000 San Luis Obispo Perio: $640,000 | 4 ops Chula Vista: $430,000 | 5 ops Bakersfield: $275,000 | 3 ops Carmel: $525,000 | 4 ops Palm Desert Area: $210,000 | 5 ops Santa Barbara + RE: $1,050,000 | 4 ops San Jose: $200,000 | 4 ops SOLD! Fullerton: $545,000 Santa Barbara County: $222,702 | 4 ops Watsonville + RE: $491,000 | 5 ops South Bay + RE: $649,000 | 6 ops Santa Barbara: $122,000 | 4 ops San Anselmo: $230,000 | 2 ops Glendora: $425,000 | 4 ops Santa Barbara Wine County: $444,000 | 3 ops SOLD! Sacramento: $850,000 SOLD! Beverly Hills Endo: $399,000 Santa Maria + RE: $360,000 | 4 ops Fresno County: $343,000 | 4 ops Glendale: $650,000 | 4 ops N. San Luis Obispo County: $1,553,000 | 6 ops SOLD! Fresno County: $489,000 Santa Monica: $510,000 | 5 ops Central Coast: $548,000 | 5 ops Davis: $1,700,000 | 6 ops Agoura Hills: $365,000 | 3 ops Central Coast: $390,000 | 3 ops Sacramento: $270,000 | 6 ops Simi Valley: $235,000 | 3 ops Central Coast Endo: $1,000,000 | 5 ops Sacramento Area: $329,900 | 5 ops Newhall: $250,000 | 5 ops SOLD! San Luis Obispo: $1,820,000 Roseville: $360,000 | 5 ops Camarillo: $275,000 | 5 ops San Luis Obispo County: $650,000 | 4 ops Shasta County: $135,000 | 5 ops

DRE #01911548 Broker-Partners: Darren Hulstine and Bill Kimball, DDS Specializing in selling and appraising dental practices for over 40 years!

LOS ANGELES & VENTURA COUNTY ORANGE COUNTY OCEANSIDE— Established in 1990 with 4 eq ops in a one story busy shopping center. PPO CANOGA PARK— 25+ years of goodwill GP w/ ANAHEIM—COMING SOON!! and Cash Only. Grossed approx. $560K in 4 eq ops and 1 plmbd not eq op. Located in a CORONA DEL MAR— Well established GP with 2018. NET $181K. Property ID #5267. single story bldg. Proj. approx. $369K for walking distance to the ocean. Consists of 3 2019. Property ID #5241. eq ops. Grossed $898K in 2018. Net $214K. RIVERSIDE COUNTY Property ID #5285. CENTURY CITY—GP in 11 story prof med bldg. RANCHO MIRAGE— Beautiful Fee for service Has 5 eq in a 1,955 sq ft. Grossed approx. FOUNTAIN VALLEY—COMING SOON!! General / Implant practice located in free $715K. Buyer’s net of $184K. Property ID LADERA RANCH— Beautiful GP in premier standing bldg. Has 4 eq ops. . Grossed $1M in 4509. shopping center. HasSOLD 11 eq ops. Grossed 2018. NET $333K. Property ID #5284. CERRITOS— Located in a busy strip mall, this $1.9M in 2018. NET $400K. Property ID 5262. TEMECULA - Pedo and Ortho Practice! It’s GP has almost 50 yrs of gdwll. Consists of 6 eq LAGUNA NIGUEL— With 16 yrs of goodwill SOLD located in a duplex single story building. ops. Property ID #5286. this GP is located in a single story shopping Grossed $1.7M with a Buyer’ net of $1M. CERRITOS—COMING SOON!! center. Has 4 eq. ops. Property ID #5290. PPO/Cash/Denti-cal. Has 8 eq ops in a 3,500 YORBA LINDA— GP established in 1987 con- CULVER CITY— GP w/ 60 yrs of goodwill to sq ft office. Property ID # 5243. offers is located in 2 story free standing bldg. sists of 4 eq ops in a 1,150 sq ft suite. PPO & Averaging 30 new patient/mo. Grossed $365K Cash Only. Grossed SOLD$658K in 2018. NET TEMECULA—Absentee owner GP with 2 GP SOLD $260K. Property # 5258. in 2018. NET $71K. Property ID #5283. Associates. Has 4SOLD eq ops in busy shopping DUARTE— GP established in1964 located in a WESTMINSTER/FOUNTAIN VALLEY— Estab- center. Grossed $327K in 2018. ID 5259. 2 story mixed bldg. Grossed $404K in 2018. lished in 1978 paperless GP in 2 story free LA QUINTA— Price Reduced!! Well estab- NET $73K. Property ID #5183. standing bldg. Grossed $737K in 2018. Has reasonable rent. Property ID #5291. lished GP with over 8 years of goodwill. This GRANDA HILLS— With 50 yrs of goodwill this modern designed practice has 8 eq ops. On a general practice grossed approx. $328K in the busiest major intersection. Grossed ap- 2018. NET $206K. Property #5276. prox. $1.6M for 2018. NET $568K. Property LONG BEACH —GP w/ 35 yrs goodwill. Has 3 ID #5130. SAN DIEGO COUNTY eq ops in a 1,698 sq ft suite. Grossed $336K in SAN BERNARDINO — General practice located 2018. NET $122K. Property ID #5282. in single story free standing bldg w/ 4 eq ops. Seller owns building. Grossed $401K in 2019. LYNWOOD— GP in single story busy shopping CARLSBAD— This beautiful practice has over 22 Property ID #5289. center. Absentee owner. Grossed $570K in yrs of goodwill. Has 4 eq ops in a 1,800 sq ft 2018. NET $255K. Property ID #5264. suite. Fee for service office. Grossed approx. SAN BERNARDINO—COMING SOON!! $440K for 2018. Property ID # 5256. ROWLAND HEIGHTS— Estab. in 2009, this GP UPLAND—Beautiful general practice located in CARMEL VALLEY — Price Reduced! Turn key is located in a 1 story free standing bldg. practice with 3 eq ops and 1 plumbed not eq on 2 story building with 4 equipped operatories. Grossed $772K in 2018. NET $237K. Property an approx. 1,815 sq ft suite. PPO and Cash only. Grossed $943K in 2018. Buyer’s net of $221K. ID 5278. Grossed approx. $325K in 2018. ID # 5274. Property ID #5237. SIMI VALLEY—COMING SOON! EL CAJON - GP + Real State. Price Reduced !!! Consists of 5 eq ops and equipped with 3D TORRANCE— Located right off the PCH, this Sirona CBCT Digital X-ray. Grossed over $1M in GP is Collecting $43K in monthly revenues. the past 10 years. NET $365K. Property ID # Net of $123K. Property ID #5281. 5265.

VENTURA—COMING SOON!!

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Before Recording, Protect Private Patient Information

TDIC Risk Management Staff

n our digital world, it seems as Most important, dental practice owners though we are inundated with video should consider HIPAA and privacy rules recordings at every turn. Our every when installing cameras. Ensure that move is being observed, whether via Only record video, cameras are not able to capture a computer our smartphones, our doorbells or even not audio. Many states, screen with a patient’s private information. Isatellites miles above the earth. But what including California, Patients can often feel uncomfortable does this mean for the dental office? being recorded, so be prepared to turn off Surveillance cameras in dental have strict laws the camera if requested to do so. Be sure offices are becoming more and more against eavesdropping. to document this in the patient’s chart. common. The driving force behind If using cameras, it is also crucial them is typically security, as cameras for practice owners to consider who can aid in loss control, deter theft and has access to the recordings. This discourage other criminal activity. But cameras are not without their drawbacks. Prior to hitting the record button, practice owners should be aware of the laws and regulations surrounding their use. While laws vary from state to state, some basic guidelines include the following: ■■ Only record video, not audio. Many states, including California, have strict laws against eavesdropping. ■■ Do not place cameras in areas answers where there is a reasonable expectation of privacy, such as restrooms or changing rooms. ■■ Inform all employees, in writing, that cameras are in use. You do not need their permission, but you do need a signed acknowledgment, which should From one-on-one risk management advice by phone be kept in their employee file. to informed consent forms to expert-led seminars, ■■ Inform patients that cameras are in use. If used in the we’re here to help you practice with confidence. reception area, this can be We are The Dentists Insurance Company. done with a simple sign. If used in operatories, have patients Learn more at tdicinsurance.com/rm sign an acknowledgment

and release form. ® Protecting dentists. It’s all we do. ■■ Have a consistent policy in place on how recordings may be used 800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783 and how long to keep them.

NOVEMBER 2 0 1 9 739 NOV. 2019 RM MATTERS

CDA JOURNAL, VOL 47, Nº11

is true for recordings taken both In another case reported to the record treatment. TDIC advises inside and outside of the practice. Advice Line, an 8-year-old patient against allowing patients to record If an exterior camera captures a with autism was seen for fillings. treatment as other patients or patient entering the office, that The dentist used a protective employees could inadvertently alone is considered private health stabilization board to stabilize the be recorded without consent. information and must be protected. child. The child’s mother was not “A video of a patient undergoing In one case reported to The Dentists in the operatory during treatment. an exam or treatment is considered Insurance Company’s Risk Management The patient became uncooperative protected health information under Advice Line, a patient backed into and the assistant began to tap HIPAA, and under the law it must a parked car in the parking lot after the patient’s head, a successful be treated as such,” Cervantes said. leaving her appointment. She drove technique they had used in the past Video surveillance can be a off without leaving a note, as required to calm patients with autism. proactive way for practice owners to in California, which is a misdemeanor The dentist was able to complete protect their patients and themselves. hit-and-run. Because the dental office’s the treatment. Upon dismissing the They can also pose unexpected risks windows faced the parking lot, the car’s patient to his mother, she explained if used without caution. By following owner came into the office and inquired to her that though the child was a few basic guidelines, it is possible if they witnessed who had hit his car. uncooperative, they were able to to benefit from video cameras while Upon reviewing the surveillance complete the scheduled treatment. at the same time keeping the private footage, the dentist saw that the A few hours later, the patient’s health information of patients and incident occurred and confirmed father showed up to the office with employees just that — private. n that it involved one of his patients. pictures of his child on his cellphone, The owner of the damaged vehicle furious because the child had a bruise TDIC’s Risk Management Advice Line requested to view the footage and under his eye. He noticed that the is a benefit of CDA membership. If you asked for the patient’s contact office had a surveillance camera. need to schedule a no-cost consultation number. The dentist called the The father demanded to see the with an experienced risk management Advice Line seeking guidance on footage. The dentist allowed him to analyst, visit tdicinsurance.com/RMconsult how to handle the situation. view it. He became even more upset or call 800.733.0633. The Risk Management analyst when he saw that the assistant was reminded the dentist of his obligation tapping his child’s head and felt that to report the incident to law this may have contributed to the enforcement. She also advised that child’s anxiety levels increasing. He he should reach out to the patient, expressed that the office should be inform her of the footage and suggest familiar with and have the skills to that she contact the damaged appropriately manage patients with vehicle’s owner. Additionally, he autism. He told the dentist that she was advised to let the patient know would be hearing from his attorney that should law enforcement ask to and stormed out of the office. view the footage, he must comply. The dentist called the Advice Line “In an effort to protect privacy, it to ask whether she was required to is not a good idea to universally allow turn over the footage to the patient’s someone to view footage when asked. father. The analyst advised the dentist There are precautions to consider, that the video is part of the patient such as other patients who may be record; therefore, she must ensure visible in the footage or staff who may that it does not include information not have consented to release footage pertaining to other patients or staff. containing their images,” said Risk Similarly, there are situations Management analyst Trina Cervantes. in which patients may request to

740 NOVEMBER 2 01 9 CARROLL “Matching the Right Dentist to the Right Practice” V & C O M P A N Y

4359 SANTA CRUZ GP offering 30+ years of goodwill within 4355 SAN FRANCISCO ENDO Endodontic practice in signature walking distance to the beach! Located in a well-established, building with wealth of referral sources. State-of-the-Art, modern, attractive, single story professional building complex w/ample 1,027 square foot office with 2 fully equipped ops. Well established, parking, good visibility and easy access. 2 doctor days/week, 2 seller with sterling reputation willing to help for smooth transition. hygiene days/week, 380 active patients with approx. 10 new patients/mo. 3 fully equipped ops in 850 sq. ft. Average GR $250K 4331 SAN FRANCISCO GP Downtown SF practice in gorgeous, with Average adj net of $135K. Asking price $150K. remodeled 1,300 office with panoramic views. Suite includes 4 fully equipped ops, reception area, business office, private office, staff 4351 SEBASTOPOL AREA GP & BLDG. Charming practice lounge, lab area, and sterilization area. Beautiful, modern cabinetry situated amidst rolling hills, soaring redwood trees and lush and equipment. 1,600 acStivOeLpDatients with 15-20 new patients/mo. vineyards. Where coffee shops roast their own beans, dining Owner/doctor works 3 days/wk with 5 hygiene days/wk. Average options vary from down-home to gourmet, and people are friendly. gross receipts $738K with average adj. net of $305K. Asking Offering 70+ years of goodwill. Beautiful, modern facility with 3 fully- $495K. equipped ops (room for a 4th op) and digital x-ray. Equipment in pristine condition, most purchased 2016-2018. Dental suite has lots 4358 SAN MATEO GP Unique opportunity to own a downtown of natural light with views looking into a courtyard and garden. 2019 San Mateo GP surrounded by a variety of retail, restaurant, service GR annualized at $679K+ with adj. net of $210K. Average 3.5 and specialty shops generating significant foot traffic and daily doctor days/week and 4 hygiene days/week. 800 active patients, all business draw. 1,498 square foot facility with 4 ops, reception area, fee-for-service. Seller owns the building, it is available for purchase. business office, privaPteEoNfficDeI,NstGaff lounge, lab area, sterilization area, Asking $305K for practice, $425K for building. Owner/doctor willing bathroom, storage & dedicated parking spaces. Family oriented to help for smooth transition. practice with an emphasis on Restorative care. Average annual Gross Receipts $400K+. 4338 PENINSULA PROSTHODONTIC PRACTICE Preeminent 45 year Prosthodontic practice located in mid peninsula 4362 MARIN COUNTY GP Seller owned 1,550 square foot facility neighborhood. State-of-the-art 1,242 square foot facility with 5 with 5 fully-equipped ops. Owner/Doctor transitioning into retirement operatories. Seller willing to help in the transition. Outstanding and offering 36 years of goodwill in desirable area. Located on a well referral sources. AveragPe EGNroDssINReGceipts $1.3M with 4 doctor-days traveled road in a charming town with temperate weather, easy, per week. Asking $884K. outdoor living and natural beauty. Enjoy California living at its best. No Delta Premier patients. Excellent reputation and word-of-mouth 4256 SANTA CRUZ COUNTY GP Seller moving out-of-state and referrals. Seller will help for smooth transition. Average Gross offering 33 years of goodwill. Wonderful location on major Receipts last 2 yrs is $450K. Asking $248K for the practice. Bldg thoroughfare in a charming beach community close to wineries and condo is available for purchase. the water. Tranquil and modern, beautifully appointed, 5 op facility. Approx. 1,300 active patieSntOs (LaDll fee-for-service). Seller will help for 4216 SIERRA NEVADA FOOTHILLS 23 year practice located in smooth transition. Asking $180K. the heart of the Sierra Nevada foothills in modern building close to downtown area. 1,024 square foot office with 4 fully- equipped ops., 4343 CAPITOLA GP Gorgeous, state-of-the-art practice offering upgraded major equSipOmLeDnt and digital radiography. Average Gross 33+ years of goodwill. Beautifully appointed office environment and Receipts $890K+ with 56% average overhead. Asking price for building, located within minutes of charming downtown Capitola, practice $604K. known for its colorful, seaside shops and restaurants tucked into a hillside along Soquel Creek. Must see this office to appreciate its COMING SOON: splendor. EZ freeway access. 5 fully equipped ops. 850-900 Napa County GP, Santa Clara GP, Monterey County GP, active patients (all fee-for-service). 4 doctor days/4 hygiene days Alameda County Pediatric Dentistry, Santa Cruz County GP, per week. 2018 GR $928K with adj. net of $328K. Seasoned staff & Mid-Peninsula GP willing to stay on and Owner/Doctor willing to help for smooth transition. Asking $643K for practice. Seller owns building, it is Carroll & Company available for purchase, or to lease. 2055 Woodside Road, Suite 160 Redwood City, CA 94061 4261 CAPITOLA GP Retiring doctor offering an established DRE #00777682 practice in professional office complex built around a garden setting. Average gross $743K+ withS3OdLoDctor days and 6 hygiene days per week. Asking $562K. Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll

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

Dr. Thomas Dr. Russell Dr. Rishi Jim Jay Kerri Gina Steve Jaci Kim Thinh Wagner Okihara Salwan Engel Harter McCullough Miller Caudill Hardison Ta Tran LIC #01418359 LIC #01886221 LIC #02085289 LIC #01898522 LIC #01008086 LIC #01382259 LIC #02015193 LIC #00411157 LIC #01927713 LIC #02085576 LIC #01863784 (916) 812-3255 (619) 694-7077 (909) 239-2800 (925) 330-2207 (916) 812-0500 (949) 300-0312 (707) 391-7048 (951) 314-5542 (949) 675-5578 (408) 687-5001 (949) 675-5578 45 Years in Business 38 Years in Business 10 Years in Business 46 Years in Business 36 Years in Business 35 Years in Business 30 Years in Business 30 Years in Business 26 Years in Business 16 Years in Business 11 Years in Business PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS NORTHERN CALIFORNIA SACRAMENTO AREA: Price reduced by TRACY: New Listing! 55+ yrs Goodwill. Central SIMI VALLEY: New Listing! 3 Ops, 30 yrs. $100K! GP/Specialty HMO/some PPO Practice. 9 location. 1,700 sf. w/ 4 Ops, Digital X-ray, Digital Goodwill. Strip mall location. 2018 GR $263K CONCORD: East Bay, Digital, 3 Ops, modern/ w/ $77K Adj. Net. #CA626 attractive bldg and space, PPO, 1,200 sf, Dentrix. Ops, Digital Sensors & Pano, Imaging System, I/ Pano, CAD/CAM. 2018 GR $732K. #CA630 2018 GR $1M+ on 34 avg. Dr. hrs/wk. #CA595 O Cam. 2017 GR $1.1M, 2018 Quickbooks (to be VISALIA: New Listing! Practice and bldg. for SIMI VALLEY: New Listing! 6 Ops, 5 Equip. verified) GR $680K. 5,000 sf bldg. avail. #CA567 sale, 5 Ops, 2,000 sf. Street frontage. 2018 GR Great location w/ low rent, 45 yrs. Goodwill. CONTRA COSTA COUNTY: Goodwill/ 2018 GR $297K w/ $89K Adj. Net. #CA637 Records for only the Pedo and/or Ortho portion SACRAMENTO AREA: New Listing! 4 Ops w/ $334K. Great deal for quick sale, Refers out most of Practice. 11+ yrs Goodwill. Buyer must be 1 add'l avail. 45+ yrs. Goodwill in well-estab Specialty procedures. #CA628 SIMI VALLEY: 6 Ops, 39 yrs. Goodwill. location. 1,403 sf office condo avail. for purchase. within 15 miles of Contra Costa County. Asking SOUTHERN CALIFORNIA Strong hyg. program. Prof. bldg. in great location. Price is below appraised value. #CA576 2018 GR $574K. #CA603 EagleSoft, Digital, Pano. 2018 GR $783K. New Listing! 2018 GR #CA617 FREMONT: 4 Ops in approx. 1,800 sf. suite. SAN FRANCISCO: BAKERSFIELD AREA: New Listing! 6 Ops, 39 Dentrix PMS, Digital X-ray, Diode Laser, I/O $561K on reduced schedule. 4 Ops in modern yrs. Goodwill, Dentrix, I/O Cam. 2018 GR $475K SOUTH BAY/TORRANCE AREA: New Camera. 2017 GR $446K on 3 day/wk. #CA547 1,130 sf. 41 yrs. goodwill, 18 in current 450 Sutter w/ $165K Adj. Net. Unique opportunity to merge Listing! 6 Ops in prof. bldg. 44 yrs. Goodwill. location. #CA618 two practices to one large one. #CA622 SoftDent, Digital X-rays, I/O cam, and Laser. FREMONT: New Listing! Priced to sell! 40+ yrs SANTA CRUZ COUNTY: Well-estab. Growing BAKERSFIELD AREA: New Listing! Practice Visiting specialists keeps procedures in-house. Goodwill in Fremont. 2,900 sf, 9 equipped Ops Strong hyg. program. 2018 GR $1M+. #CA624 in stand-alone bldg. 2018 GR $631K. #CA607 community. 1,410 sf, 4 Ops, Carestream PMS, +RE+Merger w/ #CA622. 5 Ops, 4 hyg. days/wk. Dexis sensors, 6½ hyg days/wk. 2018 GR $1.1M Most specialty procedures referred out - room to VENTURA: 4 Ops, Modern Design, Dentrix, GREATER AUBURN:1,330 sf. office w/ 3 Ops +. Owner retiring. #CA609 grow! 2018 GR $375K.#CA623 Digital, Pano and CEREC. 2018 GR $725K w/ and 4th plumbed. Rent: $1,550/mo. Carestream $343K Adj. Net. #CA586 software. 2018 GR $474K on less than 3 days/ SONOMA COUNTY: 2018 GR $906K. 1,000 sf. BAKERSFIELD PEDO: Partnership opportunity wk. Retiring seller refers out all Endo, Perio, 3 Ops w/ opportunity to expand. Paperless, at successful 30+ yr. Pedo practice w/ Ortho and WESTERN SAN FERNANDO VALLEY: Ortho and surgery. #CA570 Dentrix PM, XDR Digital sensors, and I/O cam. OS services. Over 4K active patients, avg. 40 NP 5 Ops, 4 Equip, EagleSoft, Digital, Laser, I/O Selling both Practice and portion of dental bldg. per month. GR $2.5M+ for the past 3 yrs. #CA599 Cam. 12+ yrs. Goodwill, Prof. bldg. near GREATER EL DORADO HILLS: Multi- ownership. #CA594 COVINA: New Listing! GP w/ great visibility, hospital. Accepts PPO and 3 HMO plans. 2018 doctor practice, 3,000 sf. Possible 8 Ops, 7 equip. GR $484K w/ $218K Adj. Net. #CA614 I/O Cam, Digital X-rays, Digital Pan. Sellers will SONOMA COUNTY: Modern GP offering a 4 Ops, digital X-rays. Most Specialty referred out consider working P/T. #CA578 broad range of service. 6 Ops in 2,200 sf. space. so there is room to grow. Bright, cheery space, WESTERN SAN FERNANDO VALLEY Seller owned facility. 2018 GR of $802K with 4 word-of-mouth referrals. #CA634 PEDO PRACTICE: VERY MOTIVATED GREATER SACRAMENTO: 3 Op, PPO hyg. days/wk. Dexis Digital X-ray, Dentrix PM, SELLER! Great opportunity to purchase a Pedo practice in approx. 1,399 sf. High-end TI's and GLENDALE: 4 Ops, 3 Equipped, EagleSoft, I/O Camera, Laser. MOVE-IN READY, this will Digital, I/O Camera, newer equip. Prof. bldg. 2018 practice in the SF Valley. In an upscale location, neighborhood, SoftDent, Carestream sensors, I/O not last! #CA564 4 Ops, EagleSoft, I/O Camera. 10+ yrs. Goodwill. Cam. 2017 GR $506K on 4.25 day/wk. #CA543 GR $508K w/ $249K Adj. Net. #CA575 SONOMA COUNTY: GP 1,890 sf. office, 4 Ops 2017 GR $266K on 3 day/wk. #CA399 GREATER SACRAMENTO: Price Reduced! GLENDALE: 4 Ops, prof. bldg. Seller retiring, 2017 GR $529K on 3 Dr. days/wk. and 3.5 days/ 14 yrs. Goodwill, A-dec equip, CEREC, Digital North Area: Modern 4 Op w/5th Open, PPO hyg. Dexis, Dentrix, I/O Cam, laser. Real Estate SAN DIEGO practice, 1,664 sf. Higher-end TI's and X-rays, 35+ hrs hyg/wk. 2018 GR $499K. available for purchase. Doctor retiring. #CA563 #CA573 ENCINITAS: 4 Ops. Busy retail center. neighborhood, Gendex sensor, I/O Cam, Nomad, Remodeled 5 yrs. ago with new equipment. Pano and Laser. 2018 GR $786K. #CA550 SONOMA COUNTY: Large GP. 2018 GR HUNTINGTON BEACH: 4 Ops. Been open in above $2.8M. Stand-alone 3,000 sf. Prime Real HB for 50+ yrs. EagleSoft, 2 hyg. days/wk. Huge Dentrix, Digital, Pano, and Laser. 4 hyg. days/ GREATER SACRAMENTO: 6 Ops, Digital Estate, 72 NP/mo. & 10 days of hyg/wk. 6 Ops, wk. 2018 GR $813K. #CA574 X-rays, Pano, Lasers, Dentrix software. 2018 GR upside potential as most specialty services referred Pano X-ray, Dexis, Cameras, Laser, Dentrix. Both out. 2018 GR $356K w/ $141K Adj. Net. #CA613 MISSION VALLEY: New Listing! GP/Multi- $1.3M+. 7-8 hyg. days/wk. Dr. Retiring. #CA584 Business & Real Estate for sale or Lease. Doctor LAKE ARROWHEAD/SAN BERNARDINO Specialty, 24 Ops, 18 equip, Digital, Seller GREATER SACRAMENTO: Price Reduced Retiring. #CA544 motivated for quick sale. #CA638 by $50K! PPO Practice, 4 Ops, Digital Sensors, MTNS: PRICE REDUCED! PPO/FFS. 6 Ops, SONOMA COUNTY: 2018 GR $2M+. 8 Ops, SoftDent, Dexis Digital X-rays, I/O Cam, Pano, NORTH COUNTY PERIO: 4 Ops, 3 Equip. Imaging System, I/O Cam. 33 yrs. Goodwill. 4,600 sf. 13 hyg. days on 4.5 day/wk. 42 yrs. Newer equipment including a CT Scanner, 2017 GR $652K. Office Condo available for and laser. 2018 GR $1.08M w/ $300K+ Adj. Net. Goodwill. Doctor retiring and will work back. Bldg. also for sale. #CA517 Digital and Dentrix. Excellent location in a well- purchase with this Practice. #CA561 Paperless, Digital, high-tech, modern. #CA601 maintained complex. Priced to sell quickly. 2018 GREATER STOCKTON AREA: Established LOS ANGELES: New Listing! 5 Ops plus 3 chair WESTERN CONTRA COSTA CO.: 1,625 sf. ortho bay. Visiting Perio and 2 hyg/days. EZ GR $269K. #CA605 "All-Pedo" Limited GP Practice with 3 Ops. 4 Ops, 1 plumbed. Fully digital, paperless charts, 1,169 sf, attractive children-designed setting, 2 Dental, Digital, 3DCBCT, Digital Ceph. 2018 GR SAN DIEGO COUNTY ORTHO: Digital Pan, Digital X-ray, Eaglesoft PMS. 2018 over $1.7M. #CA619 Seller works out of 2 sites over 4 day/wk. Digital Sensors, Nitrous, 3 Cavitron units. 2017 GR $764K, 5 days/hyg. Avg. 65 NP/mo. #CA569 Upgrades to computer hardware. Paperless. GR $273K on avg. 3 Dr. days/wk. #CA555 LOS ANGELES: 7 Ops. Prof. bldg. in great YUBA CITY AREA: 46 yrs. Goodwill, 3 Ops w/ Over 26 yrs. Goodwill. Rare and excellent LAKE TAHOE AREA ENDO PRACTICE: location of LA. Strong hyg. program w/ 5+ hyg. 4th Open in 1,400 sf. Priced below professional days/wk and 37 yrs. Goodwill. 2018 GR $983K opportunity that will sell quickly. #CA615 New Listing! 3 Ops, Digital Sensors, Cone beam. Valuation. 2018 GR $271K. #CA580 New Listing! 1,100 sf. 2017 GR $523K on 32 Dr. hrs/wk, w/ $277K Adj. Net. #CA606 SAN DIEGO EAST COUNTY: CENTRAL CALIFORNIA NORTH ORANGE COUNTY: This 5 Op Spring Valley, 3 Ops, strip mall location. PPO, similar 2018 & 2019 GR. #CA602 Digital, EZ Dental, Excellent area. #CA636 New Listing! 5 Ops w/ practice has been open since 1965. Dentrix, digital LAKE TAHOE AREA: CENTRAL COAST ENDO PRACTICE: 3 SAN DIEGO PERIO: 5 Ops, 4 equipped, in 6th Open, Operatory views of Lake Tahoe, only Ops, Digital X-rays, Paperless, Cone Beam CT, Pano. Retiring seller will assist w/ a smooth transition. One-story prof. bldg. 2018 GR $231K. an excellent, bright location. Digital X-rays and 34 Delta Premier patients, 2,100 sf, 2018 GR and PBS Endo Software. 2018 GR $1.1M+ w/ Dentrix. Seller is retiring. 2017 GR $379K. $711K on 22 avg. Dr. hrs/wk. #CA608 $635K Adj. Net. #CA489 Room to grow as most specialty procedures are referred out. #CA558 Room to grow! #CA559 MONTEREY PENINSULA: New Listing! FRESNO PERIO/IMPLANT PRACTICE: 6 Beautiful 1,130 sf. office w/ 3 Ops. 70 yrs Ops, large conference room for teaching/meetings, ORANGE COUNTY ENDO PRACTICE: Built OUT OF CALIFORNIA Goodwill, 32 with present owner. Dentrix PMS, 20 yrs Goodwill. 2017 GR $649K & 2018 GR in 2018, 6 Ops, 5 equipped, 3 Scopes, Cone Beam Dexis Digital X-ray, I/O Camera, Diode Laser. $408K. 2 day/wk. Cash only office. #CA518 CT, fully digitized and paperless. GR for the past CENTRAL OAHU, HAWAII: Family- 2018 GR $528K on 4 days/wk. #CA625 3 yrs. at $1.3M+. Very low overhead. Excellent oriented GP located in a busy shopping area. FRESNO AREA: GP/Prosthodontic. Prime for a opportunity. Seller retiring. #CA593 Newly refurbished, 3 Ops w/ new equip. Digital NEVADA CITY/GRASS VALLEY AREA: GP to purchase. 4 Ops, 1,500 sf. Digital Sensors, X-Rays, Upgradeable 2D Panorex, Dentrix. 3 Ops, 55% of patients are "100% Out of Pano (film), DentalMate Software, attractive office PALM SPRINGS AREA: 6 Ops, 5 equip, utilizes MacPractice, Digital X-rays, and Excellent opportunity. Seller is relocating. Pocket". 1,700 sf, SoftDent, Film-based Pano. bldg. and space. 2018 GR $386K. #CA588 #HI112 2018 GR $270K on 24 Dr. hrs/wk. #CA611 Microscope. 6 days hyg./wk. Most specialty work MADERA: Centrally located, high visibility. referred out. Big upside potential. No PPO or HONOLULU, HAWAII OMFS PRACTICE: PALO ALTO: 3 Ops, 700 sf. Downtown leased 3,141 sf. 7 Ops, Dexis Digital X-rays, Invisalign, HMO. 2018 GR $705K. $210K Adj. Net #CA612 4 Ops. Consistent GR of $1M+ for past 3 yrs. office. Curve Hero PMS, Dexis, paperless. 2018 Delta PPO. $968K GR w/ low overhead. #CA566 Convenient location with ample free parking. GR $459K. #CA592 PALM SPRINGS AREA MULTI- MADERA: Modern 4 Op (room for 5th PPO and SPECIALTY: 5 Ops, 1 plumbed. 2,500 sf. 27 yrs. PPO with no hospital affiliations. Dentrix, SACRAMENTO: Downtown/Midtown: Hi- Denti-Cal practice with newer equipment, 1,800 sf. Goodwill. Hi-end patient base. Rent $3,600/mo! Digital Pano. Seller retiring. #HI113 traffic, 4 Ops, under 5% Delta Premier patients. 2017 GR $233K on 2 Dr. days/wk. Bldg facility Dentrix, Digital, CT Scan and Gemini Dual Wave NORTH COAST, OREGON: New Listing! 2018 GR $607K on 30 Dr. hrs./wk. #CA590 also available for purchase. #CA542 Laser. History of collecting $1.2M+/yr. #CA604 Nestled on a lake inlet minutes to the ocean. Dr SACRAMENTO: 3 Ops, Shopping ctr. location, MODESTO AREA PERIO PRACTICE: New POMONA: Great potential! Low rent. 4 Op works 3 days/wk, 2 days hyg/wk. 2018 GR Digital X-ray, move in ready. 2017 GR $572K, Listing! Specialty w/ 4 Ops and 5th Open in 1,600 practice. Only open 2 days/wk. Seller is retiring. $366K. Dr. retiring. #OR112 30 hrs./wk., 29 yrs Goodwill. #CA527 sf. LANAP Laser and Digital Sensor. 2018 GR 2018 GR $279K. Priced to sell. #CA610 SOUTH COAST, OREGON: New Listing! $494K on 4 days/wk. Dental bldg. avail. #CA598 SACRAMENTO AREA: Price reduced by SAN GABRIEL VALLEY: 4 Ops, Digital Turnkey, 3,200 sf. 6 ops, Eaglesoft, Dexis, Pano. $100K! GP/Specialty HMO/some PPO. 9 Ops, MODESTO AREA: New Listing! 60 yrs. X-rays, 65 yrs. Goodwill. Most specialty work 2018 GR $740K. Bldg. avail. #OR113 Digital Sensors & Pano, Imaging System, I/O Goodwill. 5 Ops, approx. 1,450 sf. 2018 GR $1.1M referred out, most PPO plans are accepted. Busy Cam. 2017 GR $1.1M, 2018 Quickbooks(to be on 3 day/wk. Dental Condo also available for road with great visibility, open 4 days/wk. Nicely verified) GR $680K. 5,000 sf bldg. avail #CA567 purchase or lease. #CA638 appointed; excellent opportunity. #CA596

Northern California Office www.henryscheinppt.com Southern California Office 1.800.519.3458 1.888.685.8100 Henry Schein Corporate Broker #01230466 Regulatory Compliance CDA JOURNAL, VOL 47, Nº11

Sales and Use Tax

CDA Practice Support

hinking of selling items at that are used in the performance your dental practice? Do you of their services. The primary purchase items from out-of- Dentists generally are method of collection is for a dentist

state vendors? Do you know considered consumers and to pay sales tax to the supplier what items are exempt from pay sales and use tax on upon the purchase of product. Ttax? If so, then you should know Services generally are not taxable. California’s sales and use tax rules. materials, supplies, dental A tangible item that is incidentally Sales tax is collected by sellers laboratory products … that included as part of a service is not on items sold within California. Use are used in the performance subject to sales tax. For example, tax is similar to sales tax, except a tray fabricated for the purpose of that purchasers pay it to the state of their services. providing in-office teeth whitening for items used within California is not taxed even if given to the that were purchased from out-of- patient after the treatment. state vendors who do not collect “Medicines” as defined by California sales tax. The tax rate for price. In this scenario, the dental Regulation 1591 and with some both sales and use tax are the same practice is responsible for collecting exclusions are not subject to sales but the rates can vary by location. and reporting sales tax on the and use tax. Medicines include “any A dentist or dental practice difference between the purchase cost product fully implanted or injected that receives at least $100,000 and the sale price. For example, the in the human body, or any drug or in gross receipts annually and is dental practice pays a distributor any biologic, when such are approved not otherwise registered with the for electric toothbrushes at $25 by the United States Food and California Department of Tax and each plus sales tax. The practice Drug Administration to diagnose, Fee Administration (CDTFA) must then sells each toothbrush for $30 cure, mitigate, treat or prevent any register as a “qualified purchaser” and each plus sales tax. The practice disease, illness or medical condition report and pay use tax. A business collects the sales tax for each $30 regardless of ultimate use, or … any with a California seller’s permit or a sale and reports and forwards the substance or preparation intended consumer use tax account can report sales tax on the $5 price difference. for use by external or internal and pay use tax through those accounts. Purchase product, pay sales tax application to the human body in the A seller’s permit is required if selling to distributor and sell it at cost. A diagnosis, cure, mitigation, treatment items subject to sales tax. Following are dental practice that does this can or prevention of disease and which is three methods of product acquisition inquire with the CDTFA as to the commonly recognized as a substance and sales and their associated necessity of a seller’s permit. Whether or preparation intended for that sales tax collection obligation. or not a permit is obtained, the use.” The regulatory definition of Purchase product without paying sales dental practice should maintain medicines includes permanently tax to distributor and then sell product. records to document that it was implanted articles such as dental A dental practice must provide a not necessary to collect sales tax. implant systems, including dental California Resale Certificate to the bone screws and abutments.1 distributor in order to not pay sales What Is Taxable? Orthodontic appliances are tax to the distributor. The dental Dentists generally are considered specifically excluded from the practice then must collect sales tax consumers and pay sales and use definition of “medicines” as are based on the price it sells the product. tax on materials, supplies, dental dental prosthetic devices and Purchase product, pay sales tax to laboratory products such as crowns materials such as dentures, removable distributor and sell product for higher and other “tangible personal property” or fixed bridges, crowns, caps,

NOVEMBER 2 0 1 9 743 NOV. 2019 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 47, Nº11

inlays and artificial teeth. These are items for which dental practices should pay sales or use tax when purchased. The tax may not be passed on to patients as a separate tax. Dental laboratories are the retailers of the plates, inlays and other products that they manufacture for dentists or other consumers. Tax applies to their entire charges for such products regardless of whether a separate charge or billing is made for materials and manufacturing services.2 n

references 1. Regulation 1591. Medicines and Medical Devices. www. cdtfa.ca.gov/lawguides/vol1/sutr/1591.html. 2. Regulation 1506. Miscellaneous Service Enterprises. www.cdtfa.ca.gov/lawguides/vol1/sutr/1506.html.

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 benefits plans and regulatory compliance.

744 NOVEMBER 2 01 9 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 Offices: all of Southern California. CA DRE #00863149 805.777.7707 818.991.6552 Your calls are invited. Put our thirty years of experience to work for you! Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461 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!

NORTHERN 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

6169 VACAVILLE Long established Delta PPO practice. 5-days of 4003 PEDO CHINESE / HISPANIC 3,000+ Charts. Move to your office. hygiene. 2019 trending $740,000 with Available Profits of $280,000. Great Full Price $150,000. north/side location. Full Price $300,000. 4006 ALTA LOMA High identity Center. Absentee owned and Grossing 6168 SACRAMENTO’S CAMPUS COMMONS “Bread & butter” Delta $700,000. 5 ops, 3 equipped. PPO practice averages $480,000 in collections per year. Well liked Dentist. 4009 IRVINE Lady DDS Grossing $1 Million. 5 Ops. Partnership. 10+ weeks off a year. 4-days of Hygiene. 3-D Cone Beam. Great implant 4011 DIAMOND BAR This is a dream Million Dollar location to be. 5 ops upside as retirees in area require this service. Full Price $200,000. Several Restaurants bring in droves of customers on a daily basis. FP $150,000. 6167 NORTH SANTA CLARA COUNTY - “OUT-OF-NETWORK” 4013 ORANGE COUNTY BEACH CITY Grossed $70,000 last month. Perfect for Skilled Dentist who seeks strong patient relationships and wants 4 ops with room for more. Full Price $800,000. to be insurance independent! 2019 trending $840,000+ on Owner’s 3-day 4015 HEMET Easy way to Gross $500,000. Grossing $240,000 on one week. Office has been upgraded and charting is paperless. day week. Full Price $110,000. 6166 TRI-VALLEY’S PLEASANTON 2019 trending $850,000+ in 4019 ONE MILLION DOLLAR NET PROFITS Opportunity of a lifetime. collections and Averages 20 new patients Available Profits of $450,000+. APPLE VALLEY Grosses $500,000 to $600,000. 3 ops. Low overhead. per month. Attractive 4-op office, Digital Pan and Fabrication Center. BAKERSFIELD AREA Grossing $40,000 per month on 2 day week. 6165 ROSEVILLE ORTHO – “OUT-OF-NETWORK” Stanford DIAMOND BAR 5 ops with digital Pan. Very busy future here. FP $150,000. Ranch. Great satellite office. $455,000 invested in build-out, furnishings, IRVINE Lady DDS grossing $1 Million. Will share office. computers and equipment. 3-chair Bay. Digital Pan with Ceph. 51 active LA HABRA Huge Shopping Center. Well maintained. PT Seller will stay. patients and averages 3 New Patients per month. Full Price $150,000. 6164 SAN FRANCISCO BAY AREA - “OUT-OF-NETWORK” LADERA RANCH 4 ops. Grossing $500,000. High Growth area. Highly regarded as evidenced by 25+ new patients per month. Collections LAGUNA WOODS Grossed $800,000 during Renovation. Renovation done. have topped $2 Million in each of the last 3-years with Profits averaging $1 Should now gross $1 Million. Million. Paperless. 3D Cone Beam. Great location. Seller shall work-back LOS ALAMITOS Established 4 ops with real estate. to affect orderly transition. Rare opportunity for Dentist seeking Superior MIRACLE MILE NEAR FAIRFAX Beautiful corner suite with Wilshire Platform to practice their craft at highest level. view. 3 ops recently remodeled. 6163 LAKEPORT Attractive option to practicing in ultra-competitive ORANGE Grossing $1.2 Million. State-of-art beautiful settings in expensive housing markets. Appeal of practicing here is ability ORANGE COUNTY High profile shopping center. Grossing $1.5 Million. live a less hectic life. Decompress, have more time for yourself. Beautiful 6- ORANGE COUNTY Near Chapman / Tustin Streets. Grossing $400,000. op facility with high-end technology and completely networked. 2018 Merge or grow. collected $956,000 with Profits of $360,000. 2019 trending $1.1+ Million ORANGE COUNTY BEACH 5 ops. Gross $1.2 Million first year. Area growing. in collections. Building optional purchase. Full Price $240,000. ORANGE COUNTY BEACH CITY Absentee owned. Grossing $900,000+. 6162 REDDING Great alternative to practicing in uber-competitive markets 4 ops with room for 5th. Hands-on Owner will do $1 Million first year. in ultra-expensive housing communities. Strong foundation evidenced by ORANGE COUNTY BEACH CITY Grossing $800,000 part-time. Valuable 1,500+ patients and 8-days of Hygiene. Charges totaled $709,800 in 2018 - Real Estate may be available. down from 2017 which realized $779,000. Owner chooses to work less and PALM SPRINGS AREA Grossing $1.5 Million. 8-ops. takes 9-weeks off. "Bread & butter” practice. All specialty work referred. REDLANDS 5 ops. Grossing $500,000. Low overhead. Part-time Seller. Roll-up sleeves and do $1+ Million. Patients are here. Seller previously Full Price $450,000. owned very busy Group Practice in Orange County beach community. RIVERSIDE Lady DDS grossing $300,000. 3 ops. Full Price $250,000. Comparing both, he prefers his Redding practice. Full Price $175,000. SAN JUAN CAPISTRANO BEACH Grossing $200,000 on 16 hour week. 6158 FORTUNA Relaxed lifestyle in Humboldt County’s Banana Belt. SANTA CLARITA 70,000 utos pass daily. Tremendous upside. Adjacent to Ferndale. Perfect for Dentist seeking small town living. 2018 a this location Collected $395,000 with $156,000 in Profits. 2019 trending $400,000+. 6- Full Price $250,000. weeks off. Lots of work referred. Full Price $75,000. SOUTH ORANGE COUNTY Crown Valley Shopping Center. 4 ops. 6157 SACRAMENTO’S ELK GROVE AREA - “SOLD” 2018 Grossing near $800,000. Lots of new home development. collected $909,000 on Owner’s 3-day week. Successor can increase to UNION PRACTICE - INLAND EMPIRE Grossing $650,000 on 2.5 day 4-days as practice is rich in patients. 25+ new patients per month. 5-ops, week. Nets close to $400,000. digital Pan, strong Recall, great staff. UPLAND 3 ops, low overhead. Seller will transition. Full Price $360,000. 6152 SAN RAFAEL - “SOLD” 2018 collected $520,000. Stand-alone WANTED: IRVINE - NEWPORT BEACH - COSTA MESA - TUSTIN building optional purchase. Nearby DDS who desires their own building Nearby High "Fee-for-Service” Senior Dentist lost lease. Seller would like to should relocate their practice and have instant $1+ Million practice in merge his 40-year practice doing $800,000 with yours. Seller's intent is to retire superior location. in the near future. 6147 SAN FRANCISCO BAY AREA - “OUT-OF-NETWORK” - WEST LOS ANGELES Prestigious Medical Building. Grossing $800,000. “SOLD” 2018 collected $2.2 Million. Hygiene produced $1+ Million. WESTMINISTER Starter in busy strip center. One side Hispanic, other side $700,000+ in profits. Seller available for long transition. Vietnamese. Full Price $85,000. Ethics CDA JOURNAL, VOL 47, Nº11

Ethically Reporting Substandard Treatment

Robert Reed, DDS

he following is a true story of So, the question is what actions could obligation to report substandard care, an ethical dilemma that would have been taken early on to possibly but we do have an ethical obligation to challenge any of us. I was asked to prevent this unfortunate outcome? do so in instances of gross or continual lunch by a friend who wanted to ■■ The dentists Dr. B was working faulty treatment (CDA Code of Ethics, know how to handle a situation; for could have called CDA Section 1F1). All of this could possibly Twhat was the right thing for him to do? and sought advice on how to have been avoided if Dr. B’s colleagues My friend, Dr. A, was asked if he would best handle the situation. had intervened in a timely manner. n cover emergencies for Dr. B while Dr. B ■■ They could have met with was out of the office for three months. Dr. B and discussed their Robert Reed, DDS, recently retired from Dr. A readily agreed. Before Dr. B opened his observations that the quality of 50 years of practice in Bakersfield, Calif. own practice, he had worked for a few other his work was deteriorating. He serves as a member of the CDA Judicial dentists locally, and during that time Drs. ■■ If Dr. B had colleagues who were Council and the CDA Foundation Board A and B got together socially and became close friends, the dentists could of Directors. If you have an ethical concern friends. You can imagine Dr. A’s surprise have sought their advice. you’d like to have the judicial council address, when he saw the first of Dr. B’s emergencies There is a profound ethical issue please email Lori Alvi at [email protected]. and it appeared to him that the treatment here. As dentists, we do not have a legal was well below an accepted standard of care. The patient complained of spending all her money for treatment that wasn’t satisfactory. It seemed to Dr. A that the case could not be finished without starting over and that is when he called me to discuss the situation. After gaining the patient’s permission, we looked at the films and read over the clinical notes. I was in total agreement with him; it was time to start over with bone grafting and new implants. When I asked Dr. A what he thought he should do, he replied that he didn’t know and was seeking my input. His feeling was the glaringly substandard treatment was beyond peer review and that he should contact the dental board to investigate. He wanted to know if I agreed or had any other suggestions for him. I told him his choice to call the dental board was, in my opinion, the correct action to take. Dr. A called the board, it investigated and an administrative hearing was held. Based on cumulative information from multiple patients, Dr. B’s license was revoked. Dr. A received a few calls from other dentists in the community supporting his report to the board, saying they had also observed substandard treatment by Dr. B. Dr. A asked the dentists why they hadn’t taken action. The question was met by silence.

NOVEMBER 2 0 1 9 747

LDM_CDA_Journal_1.3_Square_LindaBrown_05_23_17.indd 1 5/24/2017 9:21:40 PM Timothy Giroux, DDS John M. Cahill, MBA Edmond P. Cahill, JD Your Life’s Work Jon B. Noble, MBA Mona Chang, DDS Comes Down To BAY AREA BAY AREA CONTINUED BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED

This Decision AC-989 SAN FRANCISCO (Facility): Busy Retail Shopping CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 ops DN-1032 PLEASANTON Facility: The perfect place to live, practice & raise a HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neighborhood! Plaza w/ major anchor tenants! 3 ops Price Reduced 640 sf Collections $433k in 2017 $275k family! 1400sf w/4ops. Includes CTScan! $185k ~1250 sf w/ 3 ops. Reduced Price $195k/Real Estate Available What separates us from $125k CC-927 SAN RAFAEL: Build the practice of your dreams DN-1041 SAN JOSE: This stunning practice is an excellent opportunity for new HG-987 LAKE TAHOE AREA: State-of-the-Art Practice located in picturesque AC-1059 DALY CITY: Amazing practice w/ seasoned staff by increasing this 2-day work week! 800 sf w/ 3 ops grads! 1207sf w 2ops + 1 add’l. $195k mountain setting! ~ 3,400 sf w/ 6 Ops CALL FOR DETAILS other brokerage firms? in highly desirable neighborhood. 1500 sf w/ 4 ops $175k DN-1003 PLEASANTON Facility: This is an excellent opportunity for a graduate or HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by in-

$345k CC-960 SONOMA: Great location in one-of-a-kind set- a dentist seeking a Satellite location. 1000sf w/ 3ops. $68k creasing office hours! 750 sf w/ 2 ops $65k Western Practice Sales is locally AG-871 SAN FRANCISCO: Seller Motivated! ~600 sf w/ 2 ting! 950 sf w/ 3 ops. $385k/ Real Estate Available DN-1046 SANTA CRUZ AREA: Opportunities like this does not come along, HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 ops owned by dentists and has been ops Price Reduced $65k $350k except once in a lifetime! Office 2050 sf w/ 5 ops. Total sq ft 3880. $595k / Reduced Price: $265k AG-944 SAN FRANCISCO: An opportunity like this does CC-979 NOVATO: Seller Retiring. 803 sf w/ 3 ops near Real Estate: $1.1mil HG-934 GRASS VALLEY: Underworked PT base should support larger production proudly serving dentists in not come along very often! ~980 sf w/ 3 ops Reduced downtown and Old Town Novato. $195K (Real Es- NORTHERN CALIFORNIA numbers! ~1200 sf w/ 3 Ops Reduced $168,750/Real Estate Available California for over 45 years. Our $575k tate $215k) HN-999 CALAVERAS Co. (Facility/Real Estate): 1,500 sf w/ 2 equipped Ops + 1 personal attention to our sellers AG-945 SOUTH SAN FRANCISCO: Be a part of this vi- CC-1020 SANTA ROSA: Cash Flow of over $270k. EC-1018 WEST SACRAMENTO: All new leaseholds & top of the line PC EQ in 5 fully plumbed & 3 partially plumbed.$ 500k brant, diverse population. ~1800 sf w/ 4 ops $495k Unique FFS Practice. 1320 sf w/ 4 ops. $450k ops! 6 ops currently in use. 10 ops total available! $795k HN-991 PLACERVILLE: Quality, conservative and compassionate practice! Will and reputation of integrity and AG-990 SAN FRANCISCO: Build the practice of your CC-1030 SANTA ROSA: Condo office in modern bldg EG-910 MIDTOWN SACRAMENTO: A thriving practice does not come along consider work back. 1,654 + 473 sf w 5 ops. $675k honesty has made us Northern dreams! ~850 sf w/ 3 ops $228k w/ ample parking & adjoining Ortho practice! 1683 sf very often! ~1107 sf w/ 2 + 1 add’l. Reduced $210k California’s Preferred Dental AG-993 WEST PORTAL AREA: Desirable area w/ easy w 5 ops $325k EG-968 SACRAMENTO: Desirable, mid-town neighborhood, w/ ample parking CENTRAL VALLEY & SOUTHERN CALIFORNIA Practice Broker. commute to downtown San Francisco. ~1000sf w/ 3 CC-1049 SANTA ROSA: Fully Remodeled, Amazing in garage! ~1527 sf w/ 5 Ops. Reduced $480k ops Reduced Price: $410k Location. 2000 sf w/ 5 ops $685k Real Estate Also EG-972 ELK GROVE: Prime location! Real Estate available to purchase in the IC-975 MODESTO: Established 33 years. 1,100 sf w/ 3 ops $225k

AG-994 SAN FRANCISCO: Highly profitable with net Available future! ~ 3500 sf w/ 8 ops+. Reduced $495k IG-881 TURLOCK: Long established has unsurpassed quality care. ~3500 sf w/ 10

Our extensive buyer profit over $400k! ~850 sf w/ 3 Ops $825K CG-616 NAPA COUNTY: State-of-the-Art office! ~850 EG-1012 EAST SACRAMENTO: A practice like this one does not come available Ops (shared). Reduced: $295k BC-741 DANVILLE (FACILITY): Move in Ready! ~ 1600 sf w/ 2 Ops. Price Reduced – Seller Motivated $250k very often! ~ 2900 sf w/ 8 ops. $2.5M IG-1007 GREATER MODESTO AREA: Combines a quality learning environment database sf w/ 3 ops. PRICED TO SELL! $10k CG-995 VALLEJO: Live, play and practice here where EG-1016 LINCOLN: Look no further than this growing community to spring- with relaxed rural living. ~3000sf w/ 6 ops. $645k allows us to offer you… BC-926 ANTIOCH: Long established, well respected your lifestyle can’t be beat! ~2035 sf w/ 7 ops board into your success! ~1800 sf w/ 4 Ops Reduced $570k IG-1009 TRACY: This opportunity is waiting for you to sink your roots down and office. 1866 sf w/ 5 ops $495k $1.175M EG-1039 EL DORADO HILLS VICINITY: The ideal opportunity to practice in this invest your future here! ~1200sf w/ 4 ops. $745k Better Exposure BC-949 ALBANY: Desirable commercial/residential CG-1048 SONOMA: This highly successful family- community! ~1100 sf w/ 4 Ops. $350k IN-917 MERCED AREA: Well established practice with a stable, loyal patient area. Medical Prof Bldg w/ good frontage. 3200sf w/ oriented practice has it ALL! ~1500 sf w/ 4 ops $650k EG-1061 SOUTH AUBURN VICINITY: Come live, play and practice in the heart of base! 1300 sf w/ 3 Ops. Reduced! $295k Better Fit 4 ops $695k Real Estate: $1.8 CN-911 SANTA ROSA: “Quality Care & Patient well- this pristine town! ~1100 sf w/ 4 Ops. $350k JC-811 FRESNO COUNTY: Seller willing to consider Associateship for qualified DDS BC-1010 ANTIOCH: Amazing Opportunity in Health being FIRST”. 2250 sf w/4 ops + 1add’l. Seller Ready to EN-1051 SACRAMENTO: Location, Accessibility and Quality Relationships! w. intention to Buy In! Considerable Goodwill in Community! 3,000 sf w/ 6 ops Better Price! Prof. Complex 2118 sf w/ 2 equipped ops + 3 add’l Retire $499k 1,671sf w/ 5ops. $395k $350k $250k DG-862 MID-PENINSULA: Rare gem with up to 7 opera- EN-1052 EAST SACRAMENTO: Remarkable, long-established opportunity, loaded JC-823 LOS BANOS: Heavy emphasis on hygiene. 1000 sf w/ 3 ops $80k BC-1022 OAKLAND: “Pill Hill” Area adjacent to hospi- tories in the Bay Area! ~2274 sf w/ 6ops + 1 add’l. w/ goodwill! 1100 sf w/ 4 ops. $950k JC-1054 VISALIA: Practice AND REAL ESTATE! Prof Bldg on major thoroughfare. tal! 1064 sf & 2 ops. Plumbed for 1 add’l $150k $475k EN-1055 ROCKLIN Facility: Build your own success here in this family-oriented 2,260 sf w/ 6 ops $275k/ Real Estate $517k BC-1056 SAN RAMON (Facility): Move-in ready facili- DG-986 CAMPBELL: The ideal opportunity to practice community! 1650 sf w/ 4 ops +1 add’l. $95k KL-909 SAN DIEGO: Remarkable Opportunity. Long established in vibrant ty in well maintained professional complex. 1698 sf in this community! ~988 sf w/ 3 ops Seller Motivated EN-1062 ROSEVILLE Facility: Enjoy your success in the busy swirl of activity and North Park. 2400 sf w/ 5 ops & 2 Pedo chairs $810k w/ 4 ops $100k $288k growth! 1026 sf W/ 2 ops. $65k KG-921 SANTA MARIA: Live and practice in this desirable collegiate coastal com- BG-981 BERKELEY: Long established, family-oriented DG-1006 MONTEREY AREA: This practice is one which FC-650 FORT BRAGG: Family-oriented practice. 5 ops in 2000 sf $350k for the munity! ~930 sf w/ 3 ops Seller Motivated $285k practice. ~1100 sf w/ 3 Ops $345k/ Real Estate Avail- every dentist aspires to! ~3400 sf w/ 8 ops Reduced Practice & $400k for the Real Estate able $499k $1.325M FG-841 ARCATA: Great demographics w/ very little competition! ~1114 sf w/3 SPECIALTY PRACTICES BG-1025 WALNUT CREEK: You won’t find a more out- DG-1009 CARMEL: Amazing fee-for-service practice w/ ops Reduced Price: $200k/ Real Estate Available standing opportunity than this extraordinary practice! no contracts! ~1150 sf w/ 4 ops $625K FN-961 EUREKA: Where the quality of life can’t be beat! 1400sf w. 4 ops. BC-784 CENTRAL CONTRA COSTA CO Perio: Seasoned Staff. Office runs like well- ~2138 sf w/ 6 ops. $750k Real Estate: $995k DG-1014 MONTEREY: Don’t miss your opportunity to Practice Reduced: $395k/ Real Estate Available $395k! oiled machine! 3 ops $295k BN-952 BERKELEY: Don’t hesitate on this incredible live and practice in beautiful Monterey! ~1125 sf w/ FN-855 NO. HUMBOLDT: Seller relocating! Long-established, 100% FFS practice! BG-843 WALNUT CREEK Perio: Priced at 50% of collections! 4 ops $390k opportunity! ~835 sf w/ 3 Ops. Seller Motivated $200k 4 Ops. $875k 1600 sf w/ 3ops + 1 add’l. $190k/ Real Estate Available BG-1024 WALNUT CREEK Prosth: Stellar reputation for providing the highest level BN-1023 RICHMOND: This is a rich opportunity for the DG-1034 BELMONT: Med Prof Bldg on bustling com- GN-953 CHICO: Established for 34 years and the seller is passing their goodwill of treatment! ~2138 sf w/ 6 ops. $750k Real Estate: $995k astute dentist! 1450sf w/2 ops + 2 add’l. $50k/ Real mercial corridor. ~2000 sf w/ 5 ops $425k on to you! 1067sf w/ 3ops. Now Only $220k! BN-998 WALNUT CREEK/SAN RAMON AREA Ortho: Looking for your dream Estate $750k DG-1035 LOS GATOS: Over 40 years Goodwill in this GN-924 TEHAMA COUNTY: Don’t miss this ideal opportunity! 3000 sf w/ 6 ops. Orthodontic practice! 1450 sf w/ 5 Open bays/Chairs.$ 1.150M BN-1038 BERKELEY: A perfect opportunity to own a charming community! ~1010 sf w/ 4 ops. $790k Practice $495k / Real Estate $455k DC-835 TRI-VALLEY Perio: Collections over $1.2M. 2,100 sf $800k practice in one the Bay Area’s most popular cities! DG-1042 MOUNTAIN VIEW: Amazing opportunity GN-988 YUBA CITY: Excellent Merger Opportunity! Location and Lifestyle! 1,600 sf DN-1044 FOSTER CITY Pedo: Shared Space Situation. Conveniently located Call or email today for a free 1000sf w/ 3ops. $385k providing quality, high-end dentistry! ~ 890 sf w/ 3 w/ 3 ops. $100k within walking distance of major corporations. 830sf w/ 3 ops. $195k copy of Dr Giroux’s book BN-1060 LAYAFETTE: Imagine being able to live, Ops $895K HG-1053 GRASS VALLEY: Well-established practice of 40+ years, known for its GG-940 NORTH OF SACRAMENTO Pedo: Practice is on track to collect more than practice & raise your family here in this community! DN-1031 CUPERTINO: This remarkable practice awaits quality dentistry! ~1200 sf w/ 3 ops $420K $1,000,000 in revenues this year! ~4300 sf w/ 5 ops. Reduced $555k 1400sf w/ 3op $225k only your talent and skill! 1500sf w 3 ops + 1 add’l. HG-815 TRUCKEE AREA: Amazingly priced at 50% of Collections! ~1000 sf w/ 3 JG-757 VISALIA Perio: Incredible Giveaway at this price! Collections over Top Ten Issues for $1.25M ops $165k/ Real Estate Available $800k! ~2000 sf w/ 5 ops Steal at $150k Dentists Contemplating Retirement in Ten Years or Less 800.641.4179 [email protected] “ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM Timothy Giroux, DDS John M. Cahill, MBA Edmond P. Cahill, JD Your Life’s Work Jon B. Noble, MBA Mona Chang, DDS Comes Down To BAY AREA BAY AREA CONTINUED BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED

This Decision AC-989 SAN FRANCISCO (Facility): Busy Retail Shopping CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 ops DN-1032 PLEASANTON Facility: The perfect place to live, practice & raise a HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neighborhood! Plaza w/ major anchor tenants! 3 ops Price Reduced 640 sf Collections $433k in 2017 $275k family! 1400sf w/4ops. Includes CTScan! $185k ~1250 sf w/ 3 ops. Reduced Price $195k/Real Estate Available What separates us from $125k CC-927 SAN RAFAEL: Build the practice of your dreams DN-1041 SAN JOSE: This stunning practice is an excellent opportunity for new HG-987 LAKE TAHOE AREA: State-of-the-Art Practice located in picturesque AC-1059 DALY CITY: Amazing practice w/ seasoned staff by increasing this 2-day work week! 800 sf w/ 3 ops grads! 1207sf w 2ops + 1 add’l. $195k mountain setting! ~ 3,400 sf w/ 6 Ops CALL FOR DETAILS other brokerage firms? in highly desirable neighborhood. 1500 sf w/ 4 ops $175k DN-1003 PLEASANTON Facility: This is an excellent opportunity for a graduate or HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by in-

$345k CC-960 SONOMA: Great location in one-of-a-kind set- a dentist seeking a Satellite location. 1000sf w/ 3ops. $68k creasing office hours! 750 sf w/ 2 ops $65k Western Practice Sales is locally AG-871 SAN FRANCISCO: Seller Motivated! ~600 sf w/ 2 ting! 950 sf w/ 3 ops. $385k/ Real Estate Available DN-1046 SANTA CRUZ AREA: Opportunities like this does not come along, HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 ops owned by dentists and has been ops Price Reduced $65k $350k except once in a lifetime! Office 2050 sf w/ 5 ops. Total sq ft 3880. $595k / Reduced Price: $265k AG-944 SAN FRANCISCO: An opportunity like this does CC-979 NOVATO: Seller Retiring. 803 sf w/ 3 ops near Real Estate: $1.1mil HG-934 GRASS VALLEY: Underworked PT base should support larger production proudly serving dentists in not come along very often! ~980 sf w/ 3 ops Reduced downtown and Old Town Novato. $195K (Real Es- NORTHERN CALIFORNIA numbers! ~1200 sf w/ 3 Ops Reduced $168,750/Real Estate Available California for over 45 years. Our $575k tate $215k) HN-999 CALAVERAS Co. (Facility/Real Estate): 1,500 sf w/ 2 equipped Ops + 1 personal attention to our sellers AG-945 SOUTH SAN FRANCISCO: Be a part of this vi- CC-1020 SANTA ROSA: Cash Flow of over $270k. EC-1018 WEST SACRAMENTO: All new leaseholds & top of the line PC EQ in 5 fully plumbed & 3 partially plumbed.$ 500k brant, diverse population. ~1800 sf w/ 4 ops $495k Unique FFS Practice. 1320 sf w/ 4 ops. $450k ops! 6 ops currently in use. 10 ops total available! $795k HN-991 PLACERVILLE: Quality, conservative and compassionate practice! Will and reputation of integrity and AG-990 SAN FRANCISCO: Build the practice of your CC-1030 SANTA ROSA: Condo office in modern bldg EG-910 MIDTOWN SACRAMENTO: A thriving practice does not come along consider work back. 1,654 + 473 sf w 5 ops. $675k honesty has made us Northern dreams! ~850 sf w/ 3 ops $228k w/ ample parking & adjoining Ortho practice! 1683 sf very often! ~1107 sf w/ 2 + 1 add’l. Reduced $210k California’s Preferred Dental AG-993 WEST PORTAL AREA: Desirable area w/ easy w 5 ops $325k EG-968 SACRAMENTO: Desirable, mid-town neighborhood, w/ ample parking CENTRAL VALLEY & SOUTHERN CALIFORNIA Practice Broker. commute to downtown San Francisco. ~1000sf w/ 3 CC-1049 SANTA ROSA: Fully Remodeled, Amazing in garage! ~1527 sf w/ 5 Ops. Reduced $480k ops Reduced Price: $410k Location. 2000 sf w/ 5 ops $685k Real Estate Also EG-972 ELK GROVE: Prime location! Real Estate available to purchase in the IC-975 MODESTO: Established 33 years. 1,100 sf w/ 3 ops $225k

AG-994 SAN FRANCISCO: Highly profitable with net Available future! ~ 3500 sf w/ 8 ops+. Reduced $495k IG-881 TURLOCK: Long established has unsurpassed quality care. ~3500 sf w/ 10

Our extensive buyer profit over $400k! ~850 sf w/ 3 Ops $825K CG-616 NAPA COUNTY: State-of-the-Art office! ~850 EG-1012 EAST SACRAMENTO: A practice like this one does not come available Ops (shared). Reduced: $295k BC-741 DANVILLE (FACILITY): Move in Ready! ~ 1600 sf w/ 2 Ops. Price Reduced – Seller Motivated $250k very often! ~ 2900 sf w/ 8 ops. $2.5M IG-1007 GREATER MODESTO AREA: Combines a quality learning environment database sf w/ 3 ops. PRICED TO SELL! $10k CG-995 VALLEJO: Live, play and practice here where EG-1016 LINCOLN: Look no further than this growing community to spring- with relaxed rural living. ~3000sf w/ 6 ops. $645k allows us to offer you… BC-926 ANTIOCH: Long established, well respected your lifestyle can’t be beat! ~2035 sf w/ 7 ops board into your success! ~1800 sf w/ 4 Ops Reduced $570k IG-1009 TRACY: This opportunity is waiting for you to sink your roots down and office. 1866 sf w/ 5 ops $495k $1.175M EG-1039 EL DORADO HILLS VICINITY: The ideal opportunity to practice in this invest your future here! ~1200sf w/ 4 ops. $745k Better Exposure BC-949 ALBANY: Desirable commercial/residential CG-1048 SONOMA: This highly successful family- community! ~1100 sf w/ 4 Ops. $350k IN-917 MERCED AREA: Well established practice with a stable, loyal patient area. Medical Prof Bldg w/ good frontage. 3200sf w/ oriented practice has it ALL! ~1500 sf w/ 4 ops $650k EG-1061 SOUTH AUBURN VICINITY: Come live, play and practice in the heart of base! 1300 sf w/ 3 Ops. Reduced! $295k Better Fit 4 ops $695k Real Estate: $1.8 CN-911 SANTA ROSA: “Quality Care & Patient well- this pristine town! ~1100 sf w/ 4 Ops. $350k JC-811 FRESNO COUNTY: Seller willing to consider Associateship for qualified DDS BC-1010 ANTIOCH: Amazing Opportunity in Health being FIRST”. 2250 sf w/4 ops + 1add’l. Seller Ready to EN-1051 SACRAMENTO: Location, Accessibility and Quality Relationships! w. intention to Buy In! Considerable Goodwill in Community! 3,000 sf w/ 6 ops Better Price! Prof. Complex 2118 sf w/ 2 equipped ops + 3 add’l Retire $499k 1,671sf w/ 5ops. $395k $350k $250k DG-862 MID-PENINSULA: Rare gem with up to 7 opera- EN-1052 EAST SACRAMENTO: Remarkable, long-established opportunity, loaded JC-823 LOS BANOS: Heavy emphasis on hygiene. 1000 sf w/ 3 ops $80k BC-1022 OAKLAND: “Pill Hill” Area adjacent to hospi- tories in the Bay Area! ~2274 sf w/ 6ops + 1 add’l. w/ goodwill! 1100 sf w/ 4 ops. $950k JC-1054 VISALIA: Practice AND REAL ESTATE! Prof Bldg on major thoroughfare. tal! 1064 sf & 2 ops. Plumbed for 1 add’l $150k $475k EN-1055 ROCKLIN Facility: Build your own success here in this family-oriented 2,260 sf w/ 6 ops $275k/ Real Estate $517k BC-1056 SAN RAMON (Facility): Move-in ready facili- DG-986 CAMPBELL: The ideal opportunity to practice community! 1650 sf w/ 4 ops +1 add’l. $95k KL-909 SAN DIEGO: Remarkable Opportunity. Long established in vibrant ty in well maintained professional complex. 1698 sf in this community! ~988 sf w/ 3 ops Seller Motivated EN-1062 ROSEVILLE Facility: Enjoy your success in the busy swirl of activity and North Park. 2400 sf w/ 5 ops & 2 Pedo chairs $810k w/ 4 ops $100k $288k growth! 1026 sf W/ 2 ops. $65k KG-921 SANTA MARIA: Live and practice in this desirable collegiate coastal com- BG-981 BERKELEY: Long established, family-oriented DG-1006 MONTEREY AREA: This practice is one which FC-650 FORT BRAGG: Family-oriented practice. 5 ops in 2000 sf $350k for the munity! ~930 sf w/ 3 ops Seller Motivated $285k practice. ~1100 sf w/ 3 Ops $345k/ Real Estate Avail- every dentist aspires to! ~3400 sf w/ 8 ops Reduced Practice & $400k for the Real Estate able $499k $1.325M FG-841 ARCATA: Great demographics w/ very little competition! ~1114 sf w/3 SPECIALTY PRACTICES BG-1025 WALNUT CREEK: You won’t find a more out- DG-1009 CARMEL: Amazing fee-for-service practice w/ ops Reduced Price: $200k/ Real Estate Available standing opportunity than this extraordinary practice! no contracts! ~1150 sf w/ 4 ops $625K FN-961 EUREKA: Where the quality of life can’t be beat! 1400sf w. 4 ops. BC-784 CENTRAL CONTRA COSTA CO Perio: Seasoned Staff. Office runs like well- ~2138 sf w/ 6 ops. $750k Real Estate: $995k DG-1014 MONTEREY: Don’t miss your opportunity to Practice Reduced: $395k/ Real Estate Available $395k! oiled machine! 3 ops $295k BN-952 BERKELEY: Don’t hesitate on this incredible live and practice in beautiful Monterey! ~1125 sf w/ FN-855 NO. HUMBOLDT: Seller relocating! Long-established, 100% FFS practice! BG-843 WALNUT CREEK Perio: Priced at 50% of collections! 4 ops $390k opportunity! ~835 sf w/ 3 Ops. Seller Motivated $200k 4 Ops. $875k 1600 sf w/ 3ops + 1 add’l. $190k/ Real Estate Available BG-1024 WALNUT CREEK Prosth: Stellar reputation for providing the highest level BN-1023 RICHMOND: This is a rich opportunity for the DG-1034 BELMONT: Med Prof Bldg on bustling com- GN-953 CHICO: Established for 34 years and the seller is passing their goodwill of treatment! ~2138 sf w/ 6 ops. $750k Real Estate: $995k astute dentist! 1450sf w/2 ops + 2 add’l. $50k/ Real mercial corridor. ~2000 sf w/ 5 ops $425k on to you! 1067sf w/ 3ops. Now Only $220k! BN-998 WALNUT CREEK/SAN RAMON AREA Ortho: Looking for your dream Estate $750k DG-1035 LOS GATOS: Over 40 years Goodwill in this GN-924 TEHAMA COUNTY: Don’t miss this ideal opportunity! 3000 sf w/ 6 ops. Orthodontic practice! 1450 sf w/ 5 Open bays/Chairs.$ 1.150M BN-1038 BERKELEY: A perfect opportunity to own a charming community! ~1010 sf w/ 4 ops. $790k Practice $495k / Real Estate $455k DC-835 TRI-VALLEY Perio: Collections over $1.2M. 2,100 sf $800k practice in one the Bay Area’s most popular cities! DG-1042 MOUNTAIN VIEW: Amazing opportunity GN-988 YUBA CITY: Excellent Merger Opportunity! Location and Lifestyle! 1,600 sf DN-1044 FOSTER CITY Pedo: Shared Space Situation. Conveniently located Call or email today for a free 1000sf w/ 3ops. $385k providing quality, high-end dentistry! ~ 890 sf w/ 3 w/ 3 ops. $100k within walking distance of major corporations. 830sf w/ 3 ops. $195k copy of Dr Giroux’s book BN-1060 LAYAFETTE: Imagine being able to live, Ops $895K HG-1053 GRASS VALLEY: Well-established practice of 40+ years, known for its GG-940 NORTH OF SACRAMENTO Pedo: Practice is on track to collect more than practice & raise your family here in this community! DN-1031 CUPERTINO: This remarkable practice awaits quality dentistry! ~1200 sf w/ 3 ops $420K $1,000,000 in revenues this year! ~4300 sf w/ 5 ops. Reduced $555k 1400sf w/ 3op $225k only your talent and skill! 1500sf w 3 ops + 1 add’l. HG-815 TRUCKEE AREA: Amazingly priced at 50% of Collections! ~1000 sf w/ 3 JG-757 VISALIA Perio: Incredible Giveaway at this price! Collections over Top Ten Issues for $1.25M ops $165k/ Real Estate Available $800k! ~2000 sf w/ 5 ops Steal at $150k Dentists Contemplating Retirement in Ten Years or Less 800.641.4179 [email protected] “ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 47, Nº11

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

Overcast (Free; optional $10 per year to hide ads, Amazon Echo Auto ($24.99, by invitation only, Amazon) Overcast Radio LLC) Given the presence of Apple (via AirPlay) and Google (via Android Searching and sorting through all of the available podcasts for Auto) in the automotive industry, it is not surprising that Amazon desired content can be an overwhelming challenge. Overcast is a has made Alexa available for cars. Unlike Apple and Google, mobile app that streamlines this process and enhances the listening which have chosen to partner with manufacturers to integrate their experience so that users can enjoy finding and listening to their products into a car’s onboard systems, Amazon has created the favorite podcasts. ultra-affordable, standalone Echo Auto, which is half the size of a modern cellphone and powered by micro-USB. For cars with Overcast is a free, ad-supported mobile podcast player app available Bluetooth, the Echo Auto leverages the cellphone’s Bluetooth for iPhone, iPad and Apple Watch devices. While it requires an connection to project audio to the speaker system; for cars without account to be created in order to use the app, an email address Bluetooth, it can use a wired 3.5 mm or USB connection to do the and password are not required unless users want to have the same same task. This review utilized a car with Bluetooth and an iPhone X podcasts available over multiple devices. Once users are logged in, with the latest Alexa app. they can search for podcasts and episodes by name or add them from a directory of popular categories. When a podcast is found, users Setting up the Echo Auto is easy, but not straightforward. The written can tap the subscribe button to have its latest episode downloaded directions are not clear and how the device works is not articulated and available on-demand, or they can choose to listen to a single on Amazon. Your phone needs to be connected via Bluetooth to episode or download it for later. Any podcasts not available through your car to begin, then opening the Alexa app allows the Echo the search function or the directory can also be added manually Auto to begin functioning. By itself, the Echo Auto provides excellent through a URL. Once a library of subscribed and downloaded voice recognition and limited Alexa integration, but therein lies the podcasts has been made, users can make their own custom playlists problem: Opening the Alexa app on a modern cellphone that is or smart playlists based on their preferences. Siri Shortcuts and paired by Bluetooth to a car offers the same features. Crucially, syncing recent podcasts to Apple Watch are supported. Unique to Alexa’s map feature is primitive, with its destination search ability this app is the ability to enable Smart Speed, which shortens periods limited, current location detection poor and a frustrating process to of silence in podcasts, and Voice Boost, which normalizes the volume change routes. Despite having multiple Alexa-enabled home devices of podcasts so that voices are smooth and clear. Podcasts can be (and therefore expecting some kind of enhanced experience), I played at up to three-times speed and the unique features previously found myself using my cellphone as the Echo Auto either could mentioned can be custom enabled for each podcast. Users have the not properly recognize my voice commands or did not have the option to purchase an in-app subscription to Overcast Premium for capacity to find or convey the information I needed. The Echo Auto $10 per year for an ad-free experience. is an affordable Amazon device, which unnecessarily duplicates and complicates auto travel applications. After one week with it, I Podcasts have become a popular source for rich media content utilized the Echo Auto in the most satisfying way: I asked Alexa to around the world. Navigating through this endless sea of audio and return the Echo Auto to Amazon. video episodes to find what engages users is complicated. With Overcast, users can easily find the podcasts they like and listen to — Alexander Lee, DMD them with an adaptive, immersive and enjoyable experience. — Hubert Chan, DDS Would you like to write about technology? Dentists interested in contributing to this section should contact Andrea LaMattina, CDE, at [email protected].

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