journa - california dental association · 2019-11-18 · suellan go yao, dmd, and james burke fine,...

Consumption of Cannabis and Effects on Periodontal Oral Health

JournaC A L I F O R N I A D E N T A L A S S O C I A T I O N

Cannabis and Periodontal Health

Oral Lichen Planus and Dairy Allergy

Pre-Eruptive Resorption and DiGeorge Syndrome

September 2017

Changing employment laws and a litigation-conscious public can intimidate the most confident dentists. Especially when practice employees are prepared to take legal action

if they feel an employer breached their rights. With insights from Employment Practice Liability claims

experience and calls to our Risk Management Advice Line, TDIC’s seminar shows how to best handle

employment concerns. Gain the caution and control to navigate past potential violations such as

pregnancy discrimination, termination and sexual harassment.*

Get expert advice while earning C.E. credits and a

5% Professional Liability premium discount for two years.

Even better, take the seminar online at your convenience.

See more ways we reduce your risk at tdicinsurance.com• Confidential guidance through our Risk Management Advice Line

• Publications dedicated to exploring timely dentistry liability issues

• Helpful guides, informed consent forms and sample manuals

• A variety of live and eLearning C.E.-eligible seminars

Protecting dentists. It’s all we do.®

800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783

*Due to the sensitive nature of the issues being addressed and our employer-oriented approach, this course is available to dentists and their spouses only.

TDIC policyholders who complete a seminar or eLearning option will receive a two-year, 5% Professional & Dental Business Liability premium discount effective their next policy renewal. To obtain the two-year, 5% Professional & Dental Business Liability premiumdiscount, California dentists must successfully complete the seminar by April 28, 2018. Any eLearning tests received after the deadline will not be eligible for the discount. Nonpolicyholders who complete a seminaror eLearning option and are accepted for TDIC coverage will also be eligible for this discount.

C DA J O U R N A L , V O L 4 5 , Nº 9

S E P T E M B E R 2 0 1 7 459

Sept. 2017

D E PA R TM E N T S

F E AT U R E S

Consumption of Cannabis and Effects on Periodontal Oral Health

Periodontal disease is only one health condition among many that can be affected by marijuana in terms of incidence, prevalence and manifestation. Further medical study will allow for better policy in regards to marijuana that may affect the population as a whole.Suellan Go Yao, DMD, and James Burke Fine, DMD

Oral Lichen Planus Flares Triggered by Cow’s Milk in a Patient With Elevated IgE Antibodies to Milk

Because dairy elimination is feasible for most patients and the role of laboratory testing is unclear, at this time it is reasonable to try dairy elimination as an early step in management of patients with lichen planus.Nita Chainani-Wu, DMD, MS, PhD; Anuradha Nayudu, BDS; and Daniel Purnell, BA, MPH

Pre-Eruptive Resorption in a Patient With DiGeorge Syndrome

This case report details a patient with concomitant DiGeorge syndrome and pre-eruptive resorption.Tory Silvestrin, DDS, MSD, MSHPE; Nasser Said Al Naief, DDS, MS; Dezhi Wang, MD, HTL, QIHC; and Leif K. Bakland, DDS

475

483

489

The Associate Editor/Baby Teeth Matter

Impressions

Winners of the 2017 Table Clinic Competition

RM Matters/Informed Consent: More Than Just a Form

Regulatory Compliance/What You Need To Know To Conduct a HIPAA Risk Analysis

Tech Trends

461

463

469

495

499

506 463


460 S E P T E M B E R 2 01 7

Volume 45, Number 9September 2017

JournaC A L I F O R N I A D E N T A L A S S O C I A T I O N

CDA classifieds work harder to

bring you results. Selling a practice

or a piece of equipment? Now you

can include photos to help buyers

see the potential.

And if you’re hiring, candidates

anywhere can apply right from

the site. Looking for a job? You can

post that, too. And the best part—

it’s free to all CDA members.

All of these features are designed to

help you get the results you need,

faster than ever. Check it out for

yourself at cda.org/classifieds.

CDA Classifieds. Free postings.Priceless results.

CDA classifieds work harder to

bring you results. Selling a practice

or a piece of equipment? Now you

CDA Offi cersClelan G. Ehrler, DDSPRESIDENT

[email protected]

Natasha A. Lee, DDSPRESIDENT-ELECT

[email protected]

R. Del Brunner, DDS VICE PRESIDENT

[email protected]

Richard J. Nagy, DDS SECRETARY

[email protected]

Kevin M. Keating, DDS, MSTREASURER

[email protected]

Craig S. Yarborough, DDS, MBASPEAKER OF THE HOUSE

[email protected]

Kenneth G. Wallis, DDSIMMEDIATE PAST PRESIDENT

[email protected]

ManagementPeter A. DuBoisEXECUTIVE DIRECTOR

Jennifer GeorgeCHIEF MARKETING OFFICER

Carrie E. GordonCHIEF STRATEGY OFFICER

Alicia MalabyCOMMUNICATIONS

DIRECTOR

EditorialKerry K. Carney, DDS, CDEEDITOR-IN-CHIEF

[email protected]

Ruchi K. Sahota, DDS, CDEASSOCIATE EDITOR

Brian K. Shue, DDS, CDEASSOCIATE EDITOR

Andrea LaMattina, CDEPUBLICATIONS MANAGER

Courtney GrantSENIOR COMMUNICATIONS

SPECIALIST

Kristi Parker JohnsonEDITORIAL SPECIALIST

Blake EllingtonTECH TRENDS EDITOR

Jack F. Conley, DDSEDITOR EMERITUS

Robert E. Horseman, DDSHUMORIST EMERITUS

ProductionVal B. Mina SENIOR GRAPHIC DESIGNER

Randi Taylor SENIOR GRAPHIC DESIGNER

Upcoming Topics October/Biofi lms

November/Student Research

December/Silver Diamine Fluoride

AdvertisingSue Gardner ADVERTISING SALES

[email protected]

Permission and ReprintsAndrea LaMattina, CDEPUBLICATIONS MANAGER

[email protected]

Manuscript Submissionswww.editorialmanager.com/jcaldentassoc

Letters to the Editorwww.editorialmanager.com/jcaldentassoc

SubscriptionsSubscriptions are available only to active members of the Association. The subscription rate is $18 and is included in membership dues. Nonmembers can view the publication online at cda.org/journal.

Manage your subscription online: go to cda.org, log in and update any changes to your mailing information.Email questions or other changes to [email protected].

published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853.

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 CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority 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 that they are contributed solely to the Journal.

Copyright 2017 by the California Dental Association. All rights reserved.

Stay Connected cda.org/journal

Go Digital cda.org/apps

Look for this symbol, noting additional video content in the ePub version of the Journal.


S E P T E M B E R 2 0 1 7 461

Assoc. Editor

What an amazing day! Everyone in the offi ce was smiling molar to molar as our offi ce screened

more than 200 preschoolers. The children and their families lined our parking lot almost an hour before our offi ce opened. Teachers came and joined as well. Parents came and were a part of each patient’s appointment. And almost all of them had smiles too! Of course, the preschoolers mostly high-fi ved and grinned looking down at the goody bags they were awarded at the end of their appointments.

We have been teaming up with the local Fremont Unifi ed School District for more than 25 years to, in many cases, introduce 3-year-olds and their parents to the idea of a dental home. Our offi ce has become a part of the curriculum for these preschool classes. For a few weeks before the visit to our offi ce, the teachers review oral health education with the students. That way the concept of Dr. Nijjar and Dr. Ruchi “counting” their teeth is not foreign to the kids. But often the concept of the children visiting the dentist regularly is foreign to the parent/grandparent/guardian/caregiver who accompanies the children to our offi ce.

Sure enough, the facts personify this as well. Over a third of the children in our state are not going to the dentist. We often estimate various reasons. Could it be because of geographic location? Is the dentist offi ce too far from the family’s house or the child’s school? Could another reason be socioeconomic status? What role does income, education and occupation play in a parent’s decision to take or not to take their child to the dentist? Could another reason be oral health

awareness? Are parents aware that the single reason most children miss school in California is tooth pain? Could insurance coverage be another reason? How many of our children have public or private dental benefi ts?

We checked off the urgent-care-needed (pain, infection, swelling or soft tissue lesions) box on the oral health assessment plan many times today. We asked the parents why these children had not been to the dentist. All of the children knew where a dentist offi ce was located near their home. Many of the parents had taken their children once or twice, just not recently. Most of the children had at least one parent who was working and/or had been to college. Most of the parents admitted that their children had at one time complained about a tooth issue or toothache. And fi nally, all of the children had public and private dental benefi ts. Insurance was not the issue.

Almost all of the parents of the children who needed urgent care had not taken their children to the dentist recently. What was the most common reason? The answer from most of the parents was, “Baby teeth will eventually fall out.” Let us all release a collective … sigh.

It is 2017. Our iPhones can talk to us, listen to us and perform various functions for us. There are self-driving cars. We are growing sheep

from mere cells. Yet, many of our neighbors do not realize that baby teeth are just as important to brush, fl oss and save as adult teeth! I know. Let us all release another collective sigh. I am preaching to the choir.

But there may be hope on the horizon. It is an exciting time. There is a new sheriff in town. Jayanth Kumar, DDS, MPH, is our state’s new dental director. It has been decades since California had a dentist as our state dental director, so in fact it is more accurate to say that we fi nally have a dentist-in-chief who can manage, direct and oversee administration of our state’s dental health. He has committed to help promote healthy habits, increase utilization of dental services, support prevention and early dental treatment, ensure better education for the public, dentists and those who make decisions regarding dentistry in our state, and fi nally survey and measure the progress of these key indicators and the dental health of our state. Dr. Kumar elaborated on these goals at this year’s CDA Leadership Conference and noted the initiatives that dentists are getting involved with throughout California.

One such program is California’s Department of Health Care Services’ Dental Transformation Initiative. The intent is to determine what will help more children to be seen by the

Baby Teeth MatterRuchi K. Sahota, DDS, CDE

What was the most common reason? The answer from most of the parents was, “Baby teeth will eventually fall out.”


462 S E P T E M B E R 2 01 7

S E P T . 2 0 1 7 A S S O C . E D I T O R

dentist. To do this, the federal Center for Medicare and Medicaid Services (CMS) granted $740 million over fi ve years to California to improve its program. More caries assessments are being completed and more data is being collected. Dentists who educate, entice or convince parents to return for continuous recall visits to establish a dental home will receive bonus reimbursements. And fi nally, local pilot projects (i.e., innovative ventures to prevent disease and increase needed care) have been funded to help mend other impediments that could keep children at risk from needing the “urgent care needed” box marked on their oral health assessment form. In fact, my community’s own FQHC’s dental director is eager to start using the allotted funding to help alleviate the barriers that keep patients from utilizing their dental services.

The intent is to drive families to the dental offi ce by focusing on “high-value care, improved access and utilization of performance measures to drive delivery system reform.” The program focuses on “caries assessment, prevention and enticing the critical factor of continuity of care.”

This is exactly what the doctor ordered. Will there be a day when all of our patients understand that going to the dentist is necessary and good for them? Will there be a day that dental health is top of mind for most of the public in California? Will there be a day when parents understand that baby teeth are important and need to be protected?

As CDA dentists, we do our part. Dental societies organize Give Kids a Smile events. CDA Cares brings hundreds of dentists together to help care for the thousands that stand in line for necessary dental care. We

coordinate “tooth talks” in schools. So many travel abroad to carry out dental missions. We CDA dentists give back and do as much as we can to help bring the importance of dental education and care to our communities.

In fact, screening 200 preschoolers was no easy task for the doctors in our offi ce or for our staff colleagues. But everyone agreed it was one of the more fulfi lling days that week. Our team really enjoyed giving back. Contributing to positive change and development of the community can improve staff morale and engagement. As a general note, we know that millennials prefer working for an employer who prioritizes philanthropy — sometimes so much so that they would be willing to earn less if they feel they are working for an offi ce that truly gives back.

But maybe some of us have been involved in some of these outreach efforts at some time. With a dental director at the helm of our state’s dental plan, there will be many more opportunities to become involved. How will we know how to do so? The oral health departments will team up with the local dental societies. So reach out to your dental society. Be there. Be involved. Stay involved. That way, we can raise our hand and do something to help. ■

Ruchi K. Sahota, DDS, CDE, practices family dentistry in Fremont, Calif., and serves as faculty at the University of the Pacifi c, Arthur A. Dugoni School of Dentistry. She is also a certifi ed dental editor, a consumer advisor for the American Dental Association, past president of the Southern Alameda County Dental Society and a fellow of the American College of Dentists, International College of Dentists and the Pierre Fauchard Academy.

The Journal welcomes lettersWe reserve the right to edit all

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


S E P T E M B E R 2 0 1 7 463

The nub:

1. Dentistry and oral health are not the same thing.

2. Opportunity without responsibility is a dangerous position to defend.

3. Larger scope necessitates decreased independence.

David W. Chambers, EdM, MBA, PhD, is a professor of dental education at the University of the Pacifi c, Arthur A. Dugoni School of Dentistry, San Francisco, and editor of the American College of Dentists.

Do We Need a New Defi nition of Dentistry?David W. Chambers, EdM, MBA, PhD

Every Saturday in America thousands of men buy three-eighth-inch drill bits. No one really wants a three-eighth-inch drill bit. Those who can help it avoid buying more than one. What we want is three-eighth-inch holes. The distinction is important. Customers want benefi ts, not features. Patients want oral health, not dentistry.

The American Dental Association recently proposed a defi nition of oral health as “a functional, structural, aesthetic, physiologic and psychosocial state of well-being [which] is essential to an individual’s general health and quality of life.” The FDI World Dental Federation has just developed a defi nition as well: “Oral health is multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confi dence and without pain, discomfort and disease of the craniofacial complex.”

There is much to like in these defi nitions. They focus on the patient; they speak to a richer life for everyone.

The expanded ADA and FDI defi nitions represent both an opportunity and a liability. CBCT images open the prospect for dentists to treat obstructive sleep apnea, but they also place practitioners at legal risk for failing to diagnose oral cancers appearing in these images. Are dentists really responsible for patients’ “total well-being,” including “the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions?” This seems to suggest the need for more training and collaboration with other professions. Wider scope means more responsibility.

But there is also danger in steering too close to the other side of the issue. Certainly dentists would not want to claim exclusivity for the new oral health outcomes being envisioned. Otolaryngologists, plastic surgeons, speech pathologists, psychologists, social workers and therapists of all types all have much to contribute to patients’ total well-being. At the least, involving dentists in “functional, structural, aesthetic, physiologic and psychosocial states” of patients will require collaborative working relationships with a very large number of sister professionals. At the worst, we can expect turf wars.

Further, dentists may not want to assume complete responsibility even for traditional oral health care outcomes. Patients engage in inadequate home care, spotty follow up and damaging habits. Patients refuse optimal treatment plans and insurance companies may not pay for them. How can a dentist be held accountable for less than optimal oral health outcomes under such circumstances?

There is a balance between opportunity and responsibility and between proper action and outcomes. ■

Impressions


464 S E P T E M B E R 2 01 7

S E P T . 2 0 1 7 I M P R E S S I O N S

a researcher who had made similar observations in human LAD. The two decided to become partners in research and published their fi rst joint paper in 2014 in Science Translational Medicine proposing that inhibition of the IL-23/IL-17 pathway could be an effective treatment of LAD.

A recent report in The New England Journal of Medicine, authored by Drs. Moutsopoulos and Hajishengallis, recounts the fruits of this partnership.

The authors describe treating a 19-year-old patient with LAD who had severe periodontitis and a chronic, nonhealing wound. Using a drug that blocks the activity of IL-23 and another signaling molecule, IL-12, the patient’s oral health dramatically improved along with his skin wound, which shared similar features of immune malfunction as his gums.

Learn more about this study at The New England Journal of Medicine (2017); doi:10.1056/NEJMoa1612197.

Research Leads to Treatment for Rare Gum Disease

A partnership between a University of Pennsylvania School of Dental Medicine professor and a scientist at the National Institutes of Health has led to a successful new treatment for leukocyte adhesion defi ciency (LAD), a rare genetic disorder that causes recurrent bacterial infections and terrible gum disease.

“This is really exciting because we see that a treatment performed in mice in our laboratory directly paved the way to a novel clinical treatment for a serious disease that was not responsive to any other treatments,” said George Hajishengallis, DDS, PhD, the Thomas W. Evans Centennial Professor in Penn Dental’s department of microbiology.

Dr. Hajishengallis has spent much of his career studying periodontitis. In the course of his research, he came across a strain of mice that had striking bone loss at a very young age. Upon further investigation, he realized that these animals had the mouse form of LAD.

Noting that the gum disease of LAD mice was likely attributable to very high levels of the signaling molecule IL-17, which leads to damaging infl ammation, researchers used an antibody to block the activity of IL-17 or IL-23, a molecule required for IL-17 production, and inhibited the disease. During a scientifi c conference in 2012, Dr. Hajishengallis met Niki Moutsopoulos, DDS, PhD, of the National Institute of Dental and Craniofacial Research,

Prefabricated Blood Vessels May Revolutionize Root Canals

While root canals are effective in saving a tooth that has become infected or decayed, this age-old procedure may cause teeth to become brittle and susceptible to fracture over time. Now researchers at Oregon Health and Science University in Portland, Oregon, have developed a process by which they can engineer new blood vessels in teeth, creating better long-term outcomes for patients and clinicians. Their findings were published online in June in Scientific Reports.

More than 15 million root canals are conducted annually in the United States. The current procedure involves removing infected dental tissues and replacing them with synthetic biomaterials covered by a protective crown.

Principal investigator Luiz Bertassoni, DDS, PhD, assistant professor of restorative dentistry in the OHSU School of Dentistry and assistant professor of biomedical engineering in the OHSU School of Medicine, and colleagues used a 3-D printing-inspired process, based on their previous work fabricating artificial capillaries, to create blood vessels in the lab. They placed a fiber mold made of sugar molecules across the root canal of extracted human teeth and injected a gel-like material, similar to proteins found in the body, filled with dental pulp cells. The researchers removed the fiber to make a long microchannel in the root canal and inserted endothelial cells isolated from the interior lining of blood vessels. After seven days, dentin-producing cells proliferated near the tooth walls and artificial blood vessels formed inside the tooth.

Read more of this study at Scientific Reports (2017); doi: 10.1038/s41598-017-02532-3.

Credit: OHSU/Kristyna Wentz-Graff


S E P T E M B E R 2 0 1 7 465

Studies Reveal Secrets of Tooth Calcium

Long-Term Breast-Feeding Can Lead to CavitiesChildren who are breast-fed for two years or longer are more likely to have

dental cavities, according to a study published in the July issue of Pediatrics.Researchers analyzed breast-feeding behaviors and sugar consumption for

1,129 children in Pelotas, Brazil. At age 5, the children visited a dentist and were examined for decayed, missing and filled primary tooth surfaces and severe early childhood caries. Severe early childhood caries were defined as six or more decayed, missing and filled primary tooth surfaces.

Among the children in the study, 23.9 percent had severe cavities and 48 percent had at least one tooth surface affected by a cavity. Kids who were breast-fed for two years or longer had a 2.4 times higher risk of having severe cavities, compared to kids who were breast-fed for less than a year.

“There are some reasons to explain such an association,” said Karen Peres, MDS, PhD, lead author of the study and associate professor at the University of Adelaide in Australia. “First, children who are exposed to breast-feeding beyond 24 months are usually those breast-fed on demand and at night. Second, higher frequency of breast-feeding and nocturnal breast-feeding on demand makes it very difficult to clean teeth in this specific period.”

The study also found that breast-feeding between 12 and 23 months did not bringwith it a higher risk of cavities. About one-quarter of the kids were breast-fed for 24 months or longer.

Learn more about this study at Pediatrics (2017); doi:10.1542/peds.2016-2943.

Two studies on calcium isotopes in teeth have provided new insights into both the extinction of marine reptiles and the weaning age in humans. The fi ndings of these studies, conducted by National Center for Scientifi c Research researchers at Lyon ENS and Université Claude Bernard Lyon and published in Current Biology and PNAS, open new avenues for research in anthropology and paleontology.

A team of geochemists has developed a new high-precision

method for measuring proportions of stable calcium isotopes. This method allows new scientifi c advances in all kinds of domains, such as estimating weaning age in humans from milk teeth or fi nding a new explanation for the extinction of marine reptiles.

There are six stable isotopes of calcium on Earth. These isotopes do not generate natural radioactivity but make it possible to identify chemical reactions through their specifi c signatures, which

are formed by the fractionation of the different calcium isotopes during biological processes and are marked in bones and teeth. The method used by the researchers analyzes the degree of isotopic fractionation in these tissues.

Breast milk is the substance in which calcium isotopes are most fractionated. Thus, by analyzing milk teeth, it is possible to trace someone’s diet in the early years of their life. The more milk in the diet, the more the dental calcium contains light isotopes. By cutting into milk teeth and measuring isotopic ratios using a mass spectrometer, the researchers observed that teeth begin mineralization with very considerable isotopic differences and that these values maintain stable proportions until weaning. By knowing the speed at which tooth enamel is formed, researchers have been able to develop a way to estimate weaning age in our ancestors.

In another fi eld, isotopic analysis of dental calcium allowed researchers to show that on the eve of the extinction of dinosaurs, large marine reptiles were at the top of the marine food chain. The study suggests that this competitive situation could be the reason for their disappearance as a result of the scarcity of their shared source of food.

Learn more about these studies at Current Biology (2017); doi: dx.doi.org/10.1016/j.cub.2017.04.043 and PNAS (2017); doi: 10.1073/pnas.1704412114.

Human canine milk tooth from which the enamel was taken to measure the proportions of calcium isotopes. The enamel is around 500μm thick. Credit: Théo Tacail


466 S E P T E M B E R 2 01 7

and even more worldwide,” Dr. Koo said. “In addition to fl uoride, we desperately need an agent that can target the disease-causing biofi lms and in this case not only the bacterial component but also the Candida.”

Koo and colleagues are now working on novel therapeutic approaches for targeted interventions, which can be potentially developed for clinical use.

To learn more about this study, go to PLOS Pathogens (2017); doi.org/10.1371/journal.ppat.1006407

antimicrobial and might be able to target the enzyme or cell wall of the fungi to disrupt the plaque biofi lm formation.”

The fi ndings point to a new direction for treatment of early childhood caries, according to the study. The current standard of care, beyond the use of fl uoride as a preventive approach, is to target only the bacteria with antimicrobials or to use surgical interventions if the tooth decay has become too severe.

“This disease affects 23 percent of children in the United States

Virtual Beach Improves Dental Patient ExperienceIn a study published in the journal Environment & Behavior, a team of

researchers at the Universities of Plymouth, Exeter and Birmingham in England worked with a dental practice to find out whether virtual reality encounters, such as walking on a beautiful beach, could improve patient experience during routine dental procedures such as fillings and tooth extractions.

Patients who agreed to take part in the study were randomly allocated to one of three conditions: standard care (as in a normal practice); a virtual walk around a beach using a headset and handheld controller; or a walk around an anonymous virtual reality city. Results found that those who “walked” around the beach were less anxious, experienced less pain and had more positive recollections of their treatment a week later than those in the standard-care condition. These benefits were not found for those who walked around the virtual city.

The authors of the research stress that the type of virtual reality environment the patient visits is important. The fact that only patients who visited the beach and not the virtual city had better experiences than standard care is consistent with a growing body of work that shows that natural environments, and marine environments in particular, can help reduce stress and anxiety.

“Our research demonstrates that under the right conditions this technology can be used to help both patients and practitioners,” said Karin Tanja-Dijkstra, PhD, the study’s lead author. Learn more about this research at Environment & Behavior (2017); doi.org/10.1177/ 0013916517710077.

S E P T . 2 0 1 7 I M P R E S S I O N S

Blocking Yeast-Bacteria Interaction May Prevent Biofi lms That Cause Childhood Caries

Though most tooth decay can be blamed on bacteria, such as Streptococcus mutans, the fungus Candida albicans may be a joint culprit in early childhood caries, according to research published recently in the journal PLOS Pathogens.

In earlier research, a team from the University of Pennsylvania School of Dental Medicine found that C. albicans, a type of yeast, took advantage of an enzyme produced by S. mutans to form a particularly intractable biofi lm. In a new study, the researchers have pinpointed the surface molecules on the fungus that interact with the bacterially derived protein. Blocking that interaction impaired the ability of yeast to form a biofi lm with S. mutans on the tooth surface, pointing to a novel therapeutic strategy.

“Instead of just targeting bacteria to treat early childhood caries, we may also want to target the fungi,” said Hyun (Michel) Koo, DDS, PhD, senior author on the study and a professor in the Penn Dental department of orthodontics and divisions of pediatric dentistry and community oral health. “Our data provide hints that you might not need to use a broad-spectrum

Virtual beach in England. Credit: University of Plymouth

Credit: Graham Colm


S E P T E M B E R 2 0 1 7 467

A common periodontal pathogen may delay conception in young women, according to a study carried out at the University of Helsinki and published in the Journal of Oral Microbiology. Previous studies have shown that periodontal diseases may be a risk for general health, but no data on the infl uence of periodontal bacteria on conception or becoming pregnant have been available.

The study population comprised 256 healthy nonpregnant women who

had discontinued contraception in order to become pregnant. Clinical oral and gynecological examinations were performed. Detection of major periodontal pathogens in saliva and analysis of serum and saliva antibodies against major periodontal pathogens as well as a vaginal swab for the diagnosis of bacterial vaginosis at baseline were carried out. Subjects were followed-up to establish whether they did or did not become pregnant during the observation period of 12 months.

Dental Workers Don’t Take All Steps To Control Nitrous Oxide Exposure

Although most dental professionals use a scavenging system to prevent nitrous oxide gas from escaping during a procedure, adherence to other recommended practices is lacking, according to a study of a survey conducted by the National Institute of Occupational Safety and Health (NIOSH). The study was published in the Journal of Occupational and Environmental Hygiene.

NIOSH surveyed 284 dentists, dental hygienists and dental assistants in private practice who had used nitrous oxide in the previous week. More than 93 percent of respondents said they had employed a nasal scavenging mask or local exhaust ventilation around a patient’s mouth when using nitrous oxide. However, 51 percent reported that they did not check for leaks when using the gas on adult patients and 47 percent did not check before using it on pediatric patients.

The survey also found that the flow of nitrous oxide started before the mask was applied to 16 percent of adult patients and 14 percent of pediatric ones, and the flow of nitrous oxide was not halted before turning off the oxygen flow to 10 percent of adult patients and eight percent of pediatric ones. Additionally, 13 percent of dental practices do not have standardized procedures for minimizing nitrous oxide exposure.

Successful management of nitrous oxide should include nasal scavenging masks, supplementary LEV if needed, adequate general ventilation, regular inspection of nitrous oxide delivery and availability of standard procedures to minimize exposure, according to NIOSH.

Learn more at the Journal of Occupational and Environmental Hygiene 14 (6), 409-416 (2017).

Porphyromonas gingivalis, a bacterium associated with periodontal diseases, was signifi cantly more frequently detected in the saliva among women who did not become pregnant during the one-year follow-up period than among those who did. The levels of salivary and serum antibodies against this pathogen were also signifi cantly higher in women who did not become pregnant.

Statistical analysis showed that the fi nding was independent of other risk factors contributing to conception, such as age, current smoking, socioeconomic status, bacterial vaginosis, previous deliveries or clinical periodontal disease.

Women who had P. gingivalis in the saliva and higher saliva or serum antibody concentrations against this bacterium had a threefold hazard for not becoming pregnant compared to their counterparts. Increased hazard was nearly fourfold if more than one of these qualities and clinical signs of periodontitis were present.

“Our study does not answer the question on possible reasons for infertility, but it shows that periodontal bacteria may have a systemic effect even in lower amounts and even before clear clinical signs of gum disease can be seen,” said periodontist and researcher Susanna Paju, DDS, PhD, of the University of Helsinki.

“More studies are needed to explain the mechanisms behind this association.”

Learn more about this study at the Journal of Oral Microbiology (2017); doi.org/10.1080/20002297.2017.1330644.

Periodontal Pathogen May Interfere With Conception

Practice Support

Dental Benefit Plans

While many of your patients rely on dental

benefits to fund their care, your focus should

be on the best care possible. That’s why CDA

Practice Support has experts and tools to help you

navigate the dynamic world of benefit plans. Get

guidance on the unique requirements of provider

agreements, managing and filing dental claims

efficiently and effectively, understanding your

appeal rights and much more.

Call an analyst or explore our library of online

resources, including legal reference guides and

sample letters.

800.232.7645

cda.org/dentalbenefitplans

“Why do I feel so

uncoordinated about

dental benefits?”


S E P T E M B E R 2 0 1 7 469

Dental, dental hygiene and dental assistant students and military/residents from across the state competed in the California Dental Association’s annual Table Clinic Competition at CDA Presents in Anaheim May 4-6. First-place winners from the contests were invited to submit abstracts of their work to appear in the Journal. CDA continues to collaborate with the California Dental Hygienists’ Association for the RDH portion of the competition.

Winners of the 2017Table Clinic Competition

Christina Chi and Minna Chun accept congratulations from Drs. Clelan (Butch) Ehrler and Mark Romanelli on behalf of their team for winning the clinical dental student category. Not pictured are Arfassa Gullo, Darlene Teddy and Emily Hwang.

Effi cacy of Do-It-Yourself Whitening: Color Monitoring with Diff erent Shade Assessment Tools

Christina Chi, Minna Chun, Arfassa Gullo, Darlene Teddy and Emily Hwang, Loma Linda University School of Dentistry

Abstract: The objective of this study was to evaluate the effi cacy of natural whitening products using three shade assessment tools. Extracted human teeth were embedded in typodonts. Four experimental groups were studied: (1) negative control (NC) treated

with grade 3 water; (2) brushing with activated charcoal (COAL); (3) agitating in coconut oil (OIL); and (4) positive control (HP) treated with 20% hydrogen peroxide. Color change was monitored: (1) visually with VITA Bleachedguide 3D-Master; (2) instrumentally with VITA Easyshade Compact Advance 4.0; and (3) imaging with ShadeWave software. Baseline (T1), one day post-whitening (T2) and one month post-whitening (T3) measurements were taken. The Kruskal-Wallis test indicates baseline measurements were not signifi cantly different among the four groups (p > 0.05). At T2 and T3, there was signifi cant difference among the four groups (p < 0.05) due to the HP group. This study confi rms the whitening effi cacy of hydrogen peroxide and provides valuable evidence supporting a new shade assessment method.THE CORRESPONDING AUTHOR, Christina Chi, can be reached at [email protected].

SCIENTIFIC DENTAL STUDENT WINNER

Abstracts


470 S E P T E M B E R 2 01 7

Leveraging Informatics and Web-Based Technologies To Relieve Access to Oral Health Care Barriers in Disadvantaged Communities

Corey D. Stein, MS, Western University of Health Sciences, College of Dental Medicine

Abstract: Nationwide oral health disparities disproportionately hinder access to care for underserved populations. As web-based applications become ubiquitous across U.S. demographics, health policymakers and dental professionals need to explore new technological interventions to enhance health care availability and support clinical practices. The forthcoming manuscript detailed the implementation of a web-based protocol

COMMUNITY/EDUCATION DENTAL STUDENT WINNER

SCIENTIFIC DENTAL STUDENT WINNERS

S E P T . 2 0 1 7 A B S T R A C T S

designed to facilitate meaningful communication between patients and oral health providers. Employing the application permits remote triage of patients’ dental conditions while ascertaining chief complaints prior to direct examination. By utilizing self-reported, qualitative metrics exchanged through a secure network of health care professionals, this protocol is aimed to expedite clinical processes, increase positive patient outcomes and enhance health care utility. We discussed the proposed intervention and its potential to relieve barriers that currently restrict a Southern California community from optimal oral health care.

THE AUTHOR, Corey D. Stein, can be reached at [email protected].

Clinical and Radiographic Presentations in MRONJ After Bisphosphonates vs. Denosumab

Edwin Eshaghzadeh and Chantal Hakim, University of California, Los Angeles, School of Dentistry

Abstract: Not available.

THE CORRESPONDING AUTHOR, Edwin Eshaghzadeh, can be reached at [email protected].

Drs. Clelan (Butch) Ehrler and Mark Romanelli present Corey D. Stein with his award. He won the community/education dental student category with his research on leveraging informatics and web-based technologies to relieve access to oral health care barriers in disadvantaged communities.

Chantal Hakim and Edwin Eshaghzadeh accept their award from Drs. Clelan (Butch) Ehrler and Mark Romanelli for winning the scientific dental student category.


S E P T E M B E R 2 0 1 7 471

RDA STUDENT WINNERS

RDH INFORMATIONAL STUDENT WINNERS (CDA IN COLLABORATION WITH CDHA)

Dental Unit Waterlines: Are Yours Safe?Pamela Cabello, Shawnee Lopez and

Erlinda Benavidez, Citrus CollegeIn 2014, an elderly woman passed away

after contracting Legionnaires disease due to unclean dental waterlines. Two years later, seven children were also hospitalized after contracting Mycobacterium from unclean waterlines during their pulpotomy

Dysphagia: Under-Recognized and Life-Threatening

Tang Blanton and Jose Mendez, West Los Angeles College

Background: Dysphagia is a signifi cant risk factor for aspiration pneumonia. Elderly patients have an elevated risk of dysphagia and aspiration pneumonia due to aging changes in swallowing function and immune status.

procedures. Unclean dental unit water lines may potentially cause patients, especially children, the elderly and those with compromised immune systems, to acquire an infection they otherwise would have not had because of the biofi lm that collects inside the water lines. Our study involved running saliva/food particles through various dental hoses. Each hose was fl ushed using a different type of cleaning agent. We also had one hose that was not fl ushed at all. Based on our results, we decided whether fl ushing waterlines improves the cleanliness of water and which cleaning agent works best. We also tested the water from the air water syringe of two dental offi ces to see if there was any bacterial growth. We predicted that fl ushing and disinfecting waterlines is crucial in keeping waterlines free of debris and as sterile as possible.THE CORRESPONDING AUTHOR, Pamela Cabello, can be reached at [email protected].

Methods: Evaluation of literature regarding benefi ts of early dysphagia detection, existing standardized screening tools and valid physiological markers of dysphagia.

Results: Standardized dysphagia screening improves patient outcomes as demonstrated by reduced hospital stay, reduction of aspiration pneumonia and lower mortality. Reduced tongue strength is strongly correlated with dysphagia. Existing assessment tools and management materials can be adapted for use by dental professionals.

Conclusion: Dental professionals can improve patient outcomes through early dysphagia detection, referral to the dysphagia team and treatment modifi cations for dysphagia. Adoption of hospital protocols may be appropriate for detecting dysphagic patients in dental practices. This table clinic proposed a protocol for dysphagia risk screening and management protocols based on risk categories.THE CORRESPONDING AUTHOR, Tang Blanton, can be reached at [email protected].

Drs. Clelan (Butch) Ehrler and Mark Romanelli congratulate Pamela Cabello, Shawnee Lopez and Erlinda Benavidez, who won the RDA student category with their research on the safety of dental unit waterlines.

Tang Blanton and Jose Mendez receive their award for winning the RDH informational student category. Congratulating the students are Drs. Clelan (Butch) Ehrler and Mark Romanelli and CDHA representatives Brenda Kibbler, Lygia Jolle and Julie Coan.


472 S E P T E M B E R 2 01 7

RDH RESEARCH STUDENT WINNERS (CDA IN COLLABORATION WITH CDHA)

MILITARY/RESIDENT WINNER

Evidence-Based Practice Knowledge, Attitude, Access and Confidence of Students

Victoria Santiago and Melissa Cardenas, Loma Linda University

Background: Two cohorts’ knowledge, attitudes access and confi dence of evidence-based practice evaluated pre- and post-required research design course.

Can’t Breathe When Sleeping Lt. Jabrenta Hubbard, DMDNaval Hospital Camp PendletonAbstract: Imagine a deep sleep when

all of a sudden you stop breathing. The involuntary cessation of breathing is what occurs with sleep apnea. The most common form of sleep apnea,

Methods: IRB exempt status; 35-question survey distributed to students in fi rst course session. Post survey distributed in last session. Data evaluation of knowledge with Fisher’s exact test. Friedman’s test used to evaluate attitude, access and confi dence, all at u = 0.05.

Results: Cohort one n = l 9 (100 percent); cohort two n = 79 (83 percent) completed both surveys. Statistically signifi cant increase in knowledge in both cohorts. Cohort two showed signifi cant improvement in seven out of 10 knowledge questions (p < 0.001). Cohort one showed signifi cant improvement in three out of 10 knowledge questions (p = 0.002). Signifi cant difference in attitude, access and confi dence in cohort one (p < 0.05).

Conclusions: Signifi cant improvement in knowledge for both cohorts; results suggest need to improve knowledge in study design, level of evidence and analyzing results.THE CORRESPONDING AUTHOR, Victoria Santiago, can be reached at [email protected].

obstructive sleep apnea (OSA), results from a closed or restricted upper airway. For OSA to result, an airway closure must exist, breathing cessation must occur during sleep and an anatomical anomaly in the oral pharyngeal region that hinders neurochemical and neuromuscular control of breathing must also be present. Depending on the severity of the sleep apnea, OSA can be treated medically, surgically or with nonsurgical appliances. One particular nonsurgical appliance includes the mandibular advancement device. These devices may be as effective as surgical treatment. Varying fabrications exist for the mandibular advancement devices. The method demonstrated is the oral sleep apnea appliance (OSAP).THE AUTHOR, Lt. Jabrenta Hubbard, can be reached at [email protected].

RDH research winners Victoria Santiago and Melissa Cardenas accept their award for winning the RDH research student category from Drs. Clelan (Butch) Ehrler and Mark Romanelli and CDHA representatives Brenda Kibbler, Lygia Jolle and Julie Coan.

Drs. Clelan (Butch) Ehrler and Mark Romanelli present Lt. Jabrenta Hubbard, DMD, with her award for winning the military/resident category. Her research focused on the treatment of obstructive sleep apnea.

S E P T . 2 0 1 7 A B S T R A C T S


S E P T E M B E R 2 0 1 7 473

to practicingon your terms.Every practice is unique. That’s why CDA created

The Dentists Service Company as a new subsidiary

focused on helping you achieve your vision

of success. Grow your patient base, streamline

operations and boost productivity with TDSC’s

practice management advising services.

Ready to see results? Let’s go.

888.253.1223 tdsc.com

Thank you to the following judges for the annual Table Clinic Competition held at CDA Presents in Anaheim May 4–6.

RDA CompetitionPatricia Alvarez, RDAIzabella Ambartsumyan, RDAShari Becker, RDALisa Bocanegra, RDAMaleah Brooks, RDAMelrose Nabua, RDAMaria Christina Ochoa, RDAKaren Schroeder, RDAManolita Teh, RDATobi Trotta, RDAGeorgina Vargas-Burket, RDA

RDH CompetitionAlan Budenz, DDSHoward Richmond, DDSJudith Strutz, DDS

Dental Student CompetitionsKai Chiao Chang, DDSJaymie Coria, DDSMarileth Coria, DDSSamuel Demirdji, DDSRamesh Gowda, DDSJames Lau, DDSMei Lu, DDSPradip Patel, DDSLeonard Raimondo, DDSClaudia Ritholz, RDAR. Jerry Smith, DDSAnn Steiner, DDSZaw Thu, DDS

Military/Resident CompetitionMonica Bruce, DDSKai Chiao Chang, DDSWyeth Hoopes, DDSHemant Joshi, DDSMadhavi Joshi, DDSAnn Steiner, DDSJames Strother, DDSKen Yaros, DDS


S E P T E M B E R 2 0 1 7 475

c a n n a b i s

AUTHORS

Suellan Go Yao, DMD, is a clinical instructor at Columbia University College of Dental Medicine, Department of Periodontics in New York. She also maintains a private practice in New York.Confl ict of Interest Disclosure: None reported.

Consumption of Cannabis and Eff ects on Periodontal Oral HealthSuellan Go Yao, DMD, and James Burke Fine, DMD

A B S T R AC T Cannabis plays a role in the legal, medical and dental fi elds. With more states passing medical marijuana laws, policymakers are concerned about possible cannabis use among nonpatients. Oral health effects include periodontitis, bone loss and gingival enlargement. Its Schedule I classifi cation makes it diffi cult to run randomized controlled studies on its effects. However, further medical study will allow for better policy concerning marijuana that may affect the population as a whole.

Cannabis, which is more commonly known as marijuana, is derived from the plant Cannabis sativa. “Cannabinoids”

are a group of molecules that act on the cellular cannabinoid receptors. They are divided into three groups: endogenous (endocannabinoids), synthetic and phytocannabinoids (plant derived). Delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are in the third group.1 THC is considered the plant’s main constituent and is the most psychoactive component, while CBD is nonpsychoactive. There are three forms of cannabis: marijuana, which consists of dried leaves and flowers, hashish, which is resin from the flower heads compressed to small blocks, and hash oil, which is a thick liquid extracted from hashish. Marijuana has the least concentrated form of THC.2

Administration and FunctionThere are three main routes of

administration: inhalation to the lungs by smoking the vaporized plant, ingestion to the gut of lipophilic, alcoholic or supercritical fl uidic extracts of the plant and topical application to the skin of the plant extract.3 Smoking marijuana is the most common route because of its ease of use and rapid effects. Hashish can be baked and eaten in foods or mixed with tobacco. Hash oil is commonly spread on the tip of a cigarette and smoked.2

Other routes are oromuscosal, rectal, intravenous and cannabidiol adsorption.4

The endocannabinoid system consists of receptors, their ligands and ancillary proteins. The endogenous receptors are CB1 and CB2. The CB1 receptors are found in the cerebral cortex, limbic areas, basal ganglia, cerebellum and thalamic areas, whereas the CB2 receptors are found in the cells in the immune system, mostly the macrophages.2 These areas in the brain

James Burke Fine, DMD, is senior associate dean for academic aff airs and professor of clinical dentistry at Columbia University College of Dental Medicine in New York. He is an attending dental surgeon at Presbyterian Hospital Dental Service in New York. Dr. Fine has a private practice limited to periodontics in Hoboken, New Jersey, and is in the faculty practice at Columbia University.Confl ict of Interest Disclosure: None reported.


476 S E P T E M B E R 2 01 7

where the CB1 receptors are found are involved in cognition, memory, reward, pain perception and motor coordination.5 The CB1 receptor is 10 times more prevalent in the central nervous system than the other studied receptor involved in pain, the μ-opioid receptor.3

Adverse Eff ectsAcute adverse effects can include

anxiety, panic reactions and psychotic symptoms, which are most commonly reported by beginner users.5 However, because there is a low expression of the receptor in the brainstem, cannabinoids have minimal toxicity and have an absence of fatal overdose or respiratory depression. Withdrawal symptoms can include restlessness, irritability, mild agitation, insomnia, nausea and cramping. There have been reviews and studies of the adverse effects3,8,9,10 (TABLE 1).

Tobacco smoking has been considered a cause of lung cancer. Cannabis smoke contains many of the same carcinogens as tobacco smoke.6 The International Lung Cancer Consortium (ILCCO) is a group of lung cancer researchers established in 2004 who share compatible data of ongoing and completed lung cancer case control and cohort studies from different geographical areas and ethnicities. One of its key goals is to evaluate potential lung cancer risk factors that are diffi cult to evaluate in individual studies. Zhang et al.7 did a pooled analysis based on the individual level data from the participating ILCCO studies. They found little or no association between the intensity,

duration, cumulative consumption or age of start of cannabis smoke and the risk of lung cancer in never smokers. However, there was a suggestive association between high intensity and cumulative cannabis smoking on adenocarcinoma lung cancer.

Medical Use OriginThe use of cannabis as a medicine

dates back to approximately 2737 BC in China, where it was used for rheumatic pain, intestinal constipation, disorders of the female reproductive system and malaria.11,12,13 In the 20th century, the medical indications of cannabis were summarized in Sajou’s Analytic Cyclopedia of Practical Medicine (1924) in three areas: sedative or hypnotic, analgesic and other uses. But in the early 1900s, the medical use of cannabis started to decline because of increasing availability of synthetic pharmaceuticals, potency variability and unreliable supply sources that made it diffi cult to get replicable effects. And lastly, also because of legal restrictions. In 1937, the Marijuana Tax Act imposed a tax on use of the plant. Then in 1941, cannabis was removed from the U.S. pharmacopeia. The 1960s saw a boom in the recreational use of cannabis in the younger population in the Western world, and this boost of consumption along with better scientifi c knowledge about the plant contributed to an increased scientifi c interest in cannabis. This interest was renewed in the 1990s when the receptors and the endogenous cannabinoid system in the brains were described. This interest has been increasing since.11

Legal StatusCannabis is classifi ed as a Schedule

I substance by the U.S. Food and Drug Administration (FDA). Schedule I drugs, substances or chemicals are defi ned as drugs with no currently accepted medical use and a high potential for abuse. Schedule I drugs are the most dangerous drugs of all the drug schedules with potentially severe psychological or physical dependence.14 Two categories of cannabinoid medicines are currently used in North America. The fi rst is cannabis-derived pharmaceuticals, which include dronabinol, nabilone and nabiximols. Dronabinol is a schedule II drug and nabilone is a schedule III drug. Both were approved in 1985 for the treatment of nausea and vomiting associated with cancer chemotherapy in patients who have not responded to other conventional antiemetic therapy. Dronabinol was also approved for the treatment of anorexia-associated weight loss in AIDS patients in 1992.15 The second category is phytocannabinoid-dense botanicals or medical cannabis. On Nov. 5, 1996, California became the fi rst state to legalize medical cannabis.16 Twenty-fi ve states and the District of Columbia have legalized medical use of cannabis (TABLE 2). In November 2012, Colorado and Washington also passed legislation for the legal production, sale and use of recreational cannabis. In Alaska, Oregon and the District of Columbia, marijuana is legalized also for recreational use. After the November 2016 election, medical marijuana laws recently passed in Arkansas, Florida and North Dakota but still have yet

c a n n a b i s

TABLE 1

Summary of Adverse Effects

Study Summary

Wang et al., 20088 The most common nonserious adverse eff ects were dizziness, somnolence events, muscle spasm events, other gastrointestinal tract disorder, pain events, dry mouth events and bladder disorder. The rate of these nonserious events was almost two times higher in the cannabinoids group than the control.

Lynch and Campbell, 20119

Aggarwal, 20133

No serious adverse events were found, but the most frequent nonserious adverse events reported were sedation, dizziness, dry mouth, nausea and disturbance in concentration.

Tan et al., 200910

Aggarwal, 20133

Smoking both tobacco and cannabis synergistically increase the risk of respiratory symptoms and chronic obstructive pulmonary disease, but smoking only cannabis was not associated with this increased risk.


S E P T E M B E R 2 0 1 7 477

to be effective. California, Massachusetts and Nevada all passed measures for legalizing recreational use of marijuana. Laws for recreational use in Massachusetts and Nevada have not yet been implemented.17 Louisiana has changed its law concerning medical marijuana from “prescribed to recommended.”18 In January 2014 in New York, the governor issued a directive that allowed 20 hospitals to dispense medical cannabis to patients who have been certifi ed by a doctor to have certain conditions, such as cancer. It also created a limited research program for New York’s health department to establish guidelines and make decisions as to which hospitals can participate in the program. These hospitals would decide which patients would qualify for the medical cannabis use and receive the cannabis from the federal government.19

Pain Management and PrescribingIn 1999, the Institute of Medicine

released its fi rst report indicating that cannabinoids may have a role in the treatment of pain, movement and memory, but that there are risks associated with the use. It made six major recommendations to the medical community to better establish the safety and effi cacy of

cannabis. These include the evaluation of the physiologic and psychological effects, individual health risks, various delivery systems and short-term clinical trials to determine effectiveness for targeted medical conditions.15

Pain is the No. 1 reason that cannabis is prescribed to patients. In reference to pain, cannabis has been best researched clinically for its role in the management of neuropathic pain and malignant pain. Other chronic pain syndromes, especially those that involve hyperalgesia and allodynia and acute pain, have also been described. A 2011 systematic review of cannabinoids for treatment of chronic noncancer pain looked at studies of neuropathic pain, fi bromyalgia, rheumatoid arthritis and mixed chronic pain syndromes. It concluded that “overall there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of effi cacy in fi bromyalgia and rheumatoid arthritis.” It also mentioned that smoked cannabinoid botanicals demonstrated a signifi cant analgesic effect in HIV neuropathy.3,9

In February 2013, the clinical decisions interactive at nejm.org presented a case vignette concerning a cancer patient asking her doctor for the possibility of using marijuana to alleviate the pain, nausea and fatigue. It posed two recommendations: recommending or not recommending medicinal use of marijuana with a defense for both options by experts (J. Michael Bostwick, MD, Gary M. Reisfi eld, MD and Robert L. DuPont, MD) in the fi eld.20 The polling results showed 76 percent of all votes in favor of the use of marijuana for medicinal purposes. Most of the votes came from the U.S., Canada and Mexico. In North America, 76 percent of votes supported medical marijuana; outside North America, 78 percent of

votes supported medical marijuana. It is often debated whether the answer of the question belongs to the physician or to the patient (if legalized). While a majority of clinicians recommend the use of medical marijuana in certain situations, many from both sides believe in the need for more research for a stronger basis of evidence.21

Nonlegal, Nonmedical UseAs more states pass medical marijuana

laws, policymakers are concerned with the possible increase of cannabis use among nonpatients. Looking at marijuana possession arrests in cities from 1988 to 2008, Chu16 found that these laws increase marijuana arrests among adult males by approximately 15–20 percent. Based on data on treatment admissions to rehabilitation facilities, he found that marijuana treatments among adult males increased by 10–20 percent after the passage of these laws. This suggests a positive legalization effect on illegal marijuana use. Limitations of the study are that bias may be introduced by the potential endogenous responses of police, rehabilitation facilities and treatment patients; the arrest and treatment data do not answer whether these medical marijuana laws increase initiation rates among general populations and the study assumes homogeneity in medical marijuana laws across the states. However, Chu concludes that the study presents evidence that some indicators of heavy marijuana use do respond to these medical marijuana laws.

Pacula et al.22 also examined the impact of medical marijuana laws on marijuana use in the general population and among youth. They found that while simple dichotomous indicators of medical marijuana laws are not positively associated with marijuana use or abuse, such measures hide the positive infl uence legal dispensaries have on adult and youth

TABLE 2

States With Legalized Medical Use of Cannabis

Source: medicalmarijuana.procon.org

Alaska Minnesota

Arizona Montana

California Nevada

Colorado New Hampshire

Connecticut New Jersey

District of Columbia New Mexico

Delaware New York

Hawaii Ohio

Illinois Oregon

Maine Pennsylvania

Maryland Rhode Island

Massachusetts Vermont

Michigan Washington


478 S E P T E M B E R 2 01 7

use, particularly heavy use. It is clear that not all the laws are equal. They found that in general medical marijuana law polices have no impact on recreational marijuana use or are associated with reduced marijuana consumption depending on the population and behavior assessed. However, because of the heterogeneous effects of specifi c underlying policy dimensions, they infl uence users differently based on the user’s age and use. They found that states that allow dispensaries face a greater risk of increased recreational use and related negative consequences relative to other medical marijuana law policy frameworks. With the changing of medical marijuana laws, it is important to understand the possible heterogeneous effects of these policies.

There is also fear that marijuana will follow the path of tobacco, in terms of advertising, addictiveness and use. The tobacco industry increased due to product development, marketing and lobbying. The marijuana industry can become similar and deny addiction

potential, downplay the adverse health effects, create a large market as quickly as possible and protect this market via lobbying, campaign contributions and advocacy efforts. As seen with tobacco, this private industry of marijuana may not safeguard the public health.23

Oral Health Eff ectsSmoking tobacco is a recognized

behavioral risk factor for periodontal disease. However, smoking cannabis may also contribute to the etiology of periodontal disease. Studies have found that some oral effects can include periodontitis at an earlier age, gingival enlargement similar to Dilantin-induced enlargement in long-term chronic cases and bone loss. Several studies used the Dunedin Multidisciplinary Health and Development study (DMHDS). It is a longitudinal study of a complete birth cohort at the Queen Mary Hospital in Dunedin, New Zealand, from April 1, 1972 to March 31, 1973. Perinatal data was obtained and the cohort was assessed

within a month of their third birthdays and then every two years starting at ages 5 to 15 and then at ages 18, 21, 26, 32 and 38. More than 90 percent of the cohort self-identify as European24,25,26,27 (TABLE 3).

Thomson et al.24 looked at the independent contributions of cannabis and tobacco smoking to periodontal disease using the DMHDS. They found that regular exposure to cannabis smoke was strongly associated with the prevalence and incidence of periodontal attachment loss by age 32. Limitations of the study were the self-reported smoking exposure data and that periodontal attachment loss was measured at three sites as opposed to six sites. However, strengths included the high follow-up rates, prospective determination of smoking exposure and use of data on periodontal incidence and prevalence. Cannabis use in New Zealand does not typically involve mixing with tobacco. Periodontal epidemiological research should determine if the association exists in other populations. David Balayssac,

c a n n a b i s

TABLE 3

Summary of Oral Health References

Study Summary

Thomson et al., 200824 Cannabis smoking may be a risk factor for periodontal disease independent of tobacco use.

Balayssac and Zangarelli, 200828 Thomson et al. study should have included other drugs such as methylenedioxymethamphetamine (MDMA, ecstasy), cocaine and alcohol.

Hujoel, 200829 Thomson et al. study contributed to other evidence that destructive periodontal disease occurs at a younger age that previously believed and it gives the dental professional the ability to detect possible unhealthy lifestyles.

Lopez and Baelum, 200930 No evidence to suggest use of cannabis is positively associated with periodontal disease in population of Chilean high school students.

Nogueira- Filho et al., 20111 Cannabis smoke may impact alveolar bone by increasing bone loss resulting from ligature-induced periodontitis.

Rawal et al., 201232

Baddour HM, 198434

Layman FD, 197833

Chronic marijuana use may result in gingival enlargement similar to phenytoin-induced enlargement.

Thomson et al., 201325 Periodontitis commences relatively early in adulthood and its progression accelerates with age, particularly among smokers (tobacco or cannabis).

Kayal et al., 201435 Illicit drug use is associated with more severe forms of periodontitis.

Zeng et al., 201426 The study fi ndings confi rm the importance of chronic smoking (tobacco or cannabis) as a risk factor for periodontal attachment loss.

Meier et al., 201627 Cannabis use for up to 20 years is associated with periodontal disease, but unrelated to health problems in early midlife. Periodontal health showed a robust adverse association in analyses of persistent dependence and joint-years.


S E P T E M B E R 2 0 1 7 479

PhD, PharmD, and Aude Zangarelli, PhD, PharmD,28 commented to this study, stating that it did not provide data on the use of other illicit drugs in this population and that the association should take into account potential confounding by other substances that can affect oral health. As a reply back to this comment, the authors stated that they demonstrated that the effects of cannabis were independent of tobacco use and that the role of other drugs in the etiology of periodontal disease should be studied. Hujoel29 thinks that this study contributes to the evidence that destructive periodontal disease occurs at a younger age than previously believed. He thinks that primary prevention of destructive periodontal disease should include smoking prevention and that the dental profession has this opportunity to detect early signs of unhealthy lifestyles with the high prevalence of dental care in the young population in the U.S.

In support of periodontal disease at an earlier age, Lopez and Baelum30 did a study to investigate the association between cannabis use and destructive periodontal disease among adolescents. They used clinical attachment loss and necrotizing ulcerative gingival lesions (NUG) as outcomes for destructive periodontal disease and used data from a screening study for signs of periodontitis among high school students from Santiago, Chile. The cannabis exposure groups were either “ever use of cannabis” or “regular use of cannabis.” Their fi ndings did not corroborate with Thomson et al.24 Only one statistically signifi cant association was observed between the use of cannabis and the periodontal outcomes (“ever use of cannabis” and presence of NUG) and this association was not consistent with a deleterious effect of cannabis use. However, there was a temporal difference between how the two studies were conducted and the age groups studied were different. The group

in the Thomson et al.24 study were older and so their duration of exposure was most likely longer. Also, in this study, there may have been some residual effect of tobacco smoke, because they think that cannabis is usually mixed with tobacco in hand-rolled cigarettes. Even though this study did not confi rm a positive association between cannabis use and signs of periodontitis, its results may suggest that the periodontal effects may differ between a short-term and long-term exposure to cannabis that it is also diffi cult to control confounding and that further studies are still needed.

Nogueira-Filho et al.1 conducted a study that evaluated the possible effect of marijuana smoke inhalation on bone loss during the induction of periodontitis in rats. They found that marijuana smoke inhalation increased bone loss in the furcation area with induced periodontitis rats but there was no effect in periodontally healthy sites. A limitation of the study was that some animals may have died from respiratory diffi culties and may not be comparable to doses inhaled by human marijuana users. The results of this study may differ from another study by Napimoga et al.31 who demonstrated that the administration of cannabidiol from marijuana signifi cantly inhibited bone loss in experimental periodontitis in rats. However, that study looked at one

compound of marijuana smoke, which was administered via intraperitoneal injections, while this study evaluated the marijuana smoke as a whole, which was inhaled. The current study results demonstrate that cannabis smoke might alter bone pathophysiologic patterns and might be related to impaired immune function during the process of bone loss or activation of specifi c receptors that might increase bone loss because the results were found in the ligated sites. However, more studies are needed to determine if marijuana smoke is a threat to periodontal outcome for periodontal treatment.

Rawal et al.32 presented two cases of marijuana-associated gingival enlargement. The association between chronic cannabis use and gingival enlargement was reported by Layman33 and then Baddour et al.34 The cases presented in this paper showed gingival enlargement that can be compared to gingival enlargement occurring with phenytoin use. Due to the similarities, there may be common pathogenic mechanisms that need to be further explored.

Thomson et al.25 conducted another study using the DMHDS to describe changes in the occurrence of periodontal attachment loss and evaluate risk factors for unfavorable attachment loss progression through ages 26, 32 and 38. They found that the prevalence and extent of attachment loss increased with age with greater changes between the ages of 32 and 38 as compared to the ages 26 and 32 and more new attachment loss than progression. There was a doubling of proportion of sites showing attachment loss, especially among the anterior teeth in the mid to late 30s. Those who were longer-term smokers and those of low socioeconomic status (SES)

Those who were longer-term smokers and those of low socioeconomic status (SES) were more likely to be in the groups with the least favorable trajectory of periodontitis experience.


480 S E P T E M B E R 2 01 7

were more likely to be in the groups with the least favorable trajectory of periodontitis experience. Limitations of the study were that there were some SES differences in those who were periodontally examined, the use of partial recording protocols for the periodontal exams and the inability to determine whether any participant had periodontal surgery by age 38. This study implies that the eradication of smoking can result in the greatest population gains in periodontal health.

With the use of illicit drugs as a problem worldwide and the lack of epidemiological research regarding periodontal health of people addicted to drugs, Kayal et al.35 conducted a study to determine the periodontal health status and oral hygiene in people addicted to drugs in Jeddah, Kingdom of Saudi Arabia. It was a cross-sectional study conducted at Al-Amal Hospital, a drug rehabilitation center, from October to December 2012 with 57 male inpatients who were recovering from drug addiction. Cannabis was the drug of choice of most participants. This study population was of low education level and socioeconomic status. They found that illicit drug use, especially heroin and cocaine, was associated with more severe forms of periodontal disease.

Zeng et al.26 also used the DMHDS to reexamine the periodontal effects of smoking and the impact of other putative risk factors through early to middle adulthood cross-sectionally using a more informative approach. A generalized linear mixed model with a quasi-binomial approached was used as an extension of the traditional multilevel modeling method for data analysis. Cannabis smoking was determined at ages 18, 21, 26, 32 and 38 by asking the participants how many times they had used cannabis in the previous year. This study confi rmed

the importance of chronic smoking (tobacco or cannabis) as a risk factor for periodontal attachment loss. At age 32, smoking cannabis weekly or daily was associated with higher attachment loss. The impacts of all covariates continued to increase with age. A commentary by Brett Duane, BDS, MPH, PHD, in Evidence-Based Dentistry36 reviewed the study.

Another study using DMHDS was by Meier et al.27 to test whether cannabis use from ages 18 to 38 was associated with health at age 38 and whether cannabis use at those ages was associated

with individual health decline using the same measure of health at both ages. As comparison, they also tested associations between tobacco use and physical health. Their fi ndings showed that cannabis use over 20 years was unrelated to health problems in early midlife. However, the sole exception was that cannabis use was associated with periodontal disease. Cannabis use for up to 20 years was not associated with net metabolic benefi ts. Their results should be interpreted in the context of prior research showing that cannabis use is associated with other health problems. Limitations of this study were that cannabis joint years were based on self-reports, it was diffi cult to separate cannabis and tobacco use, fi ndings were based on a single New Zealand cohort, the conclusions were limited to a specifi c

set of health problems assessed in early midlife, fi ndings for cannabis were compared against fi ndings for tobacco, and the study could not comment on the health effects of cannabis use in older adults or the safety of medical marijuana use in patients who were already unwell.

A recent study by Shariff et al.37 examined the relationship between frequent recreational cannabis use and periodontitis prevalence in the U.S. They analyzed data from the National Health and Nutrition Examination Survey (NHANES 2011–12) and found that frequent recreational cannabis use was associated with deeper probing depths, more clinical attachment loss and higher odds of having severe periodontitis. Their data are in agreement with other existing studies. Limitations of the study are a possible selection bias due to the exclusions of individuals with incomplete cannabis use or other covariates and because the cross-sectional nature of the study precludes any inferences on a causal relationship between cannabis use and periodontitis. This study supports the idea that dental professionals should be aware of cannabis use as a possible risk factor for periodontitis.

ConclusionMarijuana has a long history in

medicine. Its Schedule I classifi cation makes it diffi cult to run randomized controlled studies on its effects. The need for more study of its effect as a medicine is clearly recognized as well as the need for the evolving policies concerning marijuana use. Periodontal disease is only one health condition among many that can be affected by marijuana in terms of incidence, prevalence and manifestation. Further medical study will allow for better policy in regards to marijuana that may affect the population as a whole. ■

c a n n a b i s

This study confi rmed the importance of chronic smoking (tobacco or cannabis) as a risk factor for periodontal attachment loss.


S E P T E M B E R 2 0 1 7 481

REFERENCES

1. Nogueira-Filho GR, Todescan S, Shah A, Rosa BT, Tunes Uda R, Cesar Neto JB. Impact of Cannabis sativa (marijuana) smoke on alveolar bone loss: A histometric study in rats. J Periodontol 2011 Nov;82(11)1602–7. doi: 10.1902/jop.2011.100362. Epub 2011 Mar 29.2. Cho CM, Hirsch R, Johnstone S. General and oral health implications of cannabis use. Aust Dent J 2005 Jun;50(2):70–4.3. Aggarwal SK. Cannabinergic pain medicine. A concise clinical primer and survey of randomized-controlled trial results. Clin J Pain 2013 Feb;29(2):162–71. doi: 10.1097/AJP.0b013e31824c5e4c.4. Huestis MA. Human Cannabinoid Pharmacokinetics. Chem Biodivers 2007 Aug;4(8):1770–1804.5. Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet 2009 Oct 17;374(9698):1383–91. doi: 10.1016/S0140-6736(09)61037-0.6. Moir, D, Rickert WS, Levasseur G, Larouse Y, Maertens R, White P, Desjardins S. A comparison of mainstream and sidestream marijuana and tobacco cigarette smoke produced under two machine smoking conditions. Chem Res Toxicol 2008 Feb;21(2):494–502. Epub 2007 Dec 77. Zhang LR, Morgenstern H, Greenland S, Chang SC, Lazarus P, Dawn Teare M, Woll PJ, Orlow I, Cox B on behalf of the Cannabis and Respiratory Disease Research Group of New Zealand, Brhane Y, Liu G, Hung RJ. Cannabis smoking and lung cancer risk: Pooled analysis in the International Lung Cancer Consortium. Int J Cancer 2015 Feb;136(4):894–903. doi: 10.1002/ijc.29036. Epub 2014 Jun 30.8. Wang T, Collet J, Shapiro S, Ware MA. Adverse effects of medical cannabinoids: A systematic review. Can Med Assoc J 2008 Jun;178(13):1669–78.9. Lynch ME, Campbell F. Cannabinoids for treatment of chronic noncancer pain; a systematic review of randomized trials. Br J Clin Pharmacol 2011 Nov;72(5):735–44. doi: 10.1111/j.1365-2125.2011.03970.x.10. Tan WC, Lo C, Jong A, Xing L, Fitzgerald MJ, Vollmer WM, Buist SA, Sin DD. Marijuana and chronic obstructive lung disease: A population-based study. CMAJ 2009 Apr;180(8):814–20.11. Zuardi AW. History of cannabis as a medicine: A review. Rev Bras Psiquiatr 2006 Jun;28(2):153–7. Epub 2006 Jun 26.12. Li HL, Lin H. An archaeological and historical account of cannabis in China. Econ Bot 1974;28(4);437–47.13. Touwn M. The religious and medicinal uses of Cannabis in China, India and Tibet. J Psychoactive Drugs 1981 Jan–Mar;13(1);23–34.14. Drug schedules. www.dea.gov/druginfo/ds.shtml.15. Borgelt LM, Franson KL, Nussbaum AM, Wang GS. The pharmacologic and clinical effects of medical cannabis. Pharmacotherapy. 2013 Feb;33(2):195–209. doi:10.1002/phar.1187.16. Chu YWL. The effects of medical marijuana laws on illegal marijuana use. J Health Econ 2014 Dec;38:43–61.17. State Marijuana Laws in 2017 Map. www.governing.com. Accessed Nov. 9, 2016.18. Louisiana SB 217. medicalmarijuana.procon.org/sourcefiles/louisiana-sb271-enacted.pdf.

19. Milhofer J. Medical marijuana — Coming soon to a medicine cabinet near you? Minn Med 2014; Apr;97(4):44–46.20. Adler JN, Colbert JA. Medicinal use of marijuana. N Engl J Med 2013;368:866–8.21. Adler JN, Colbert JA. Medicinal use of marijuana — Polling results. N Engl J Med 2013;368(22):e20(1).22. Pascula RL, Powell D, Heaton P and Sevigny EL. Assessing the effects of medical marijuana laws on marijuana use: The devil is in the details. J Policy Anal Manag 2015 Winter;34(1):7–31.23. Richter KP, Levy S. Big marijuana — Lessons from big tobacco. N Engl J Med 2014 Jul;371(5):399–401. doi: 10.1056/NEJMp1406074. Epub 2014 Jun 11.24. Thomson WM, Poulton R, Broadbent JM, Moffitt TE, Caspi A, Beck JD, Welch D, Hancox RJ. Cannabis smoking and periodontal disease among young. JAMA 2008 Feb 6;299(5):525–31.25. Thomson WM, Shearer DM, Broadbent JM, Foster Page LA, Poulton R. The natural history of periodontal attachment loss during the third and fourth decades of life. J Clin Periodontol 2013 Jul;40(7):672–80. doi: 10.1111/jcpe.12108. Epub 2013 May 9.26. Zeng J, Williams SM, Fletcher DJ, Cameron CM, Broadbent JM, Shearer DM, Thomson WM. Reexamining the association between smoking and periodontitis in the Dunedin study with an enhanced analytical approach. J Periodontol 2014 Oct;85(10):1390–7. doi: 10.1902/jop.2014.130577. Epub 2014 Feb 20.27. Meier MH, Caspi A, Cerda M, Hancox RJ, Harrington HL, Houts R, Poulton R, Ramrakha S, Thomson WM, Moffitt TE. Associations between cannabis use and physical health problems in early midlife: A longitudinal comparison of persistent cannabis vs. tobacco users. JAMA Psychiatry 2016 Jul 1;73(7):731–40. doi: 10.1001/jamapsychiatry.2016.0637.28. Balayssac D, Zangarelli A. Association of cannabis smoking and periodontal disease. JAMA 2008 May 21;299(19):2273; author reply 2273-4. doi: 10.1001/jama.299.19.2273-a.29. Hujoel PP. Destructive periodontal disease and tobacco and cannabis smoking. JAMA 2008 Feb 6;299(5):574–5. doi: 10.1001/jama.299.5.574.30. Lopez R, Baelum V. Cannabis use and destructive periodontal diseases among adolescents. J Clin Periodontol 2009 Mar;36(3):185–9. doi: 10.1111/j.1600-051X.2008.01364.x.31. Napimoga MH, Benatti BB, Lima FO, Alves PM, Campos AC, Pena-Dos-Santos DR, Severino FP, Cunha FQ, Guimarães FS. Cannabidiol decreases bone resorption by inhibiting RANK/RANKL expression and pro-inflammatory cytokines during experimental periodontitis in rats. Int Immunopharmacol 2009 Feb;9(2):216–22. doi: 10.1016/j.intimp.2008.11.010. Epub 2008 Dec 12.32. Rawal SY, Tatakis DN, Tipton DA. Periodontal and oral manifestations of marijuana use. J Tenn Dent Assoc 2012 Fall–Winter;92(2):26–31.33. Layman FD. Marijuana: Harmful or not? Tex Dent J 1978 Jun;96(6):6–8.34. Baddour HM, Audemorte TB, Layman FD. The occurrence of diffuse gingival hyperplasia in a patient using marijuana. J Tenn Dent Assoc 1984 Apr;64(2):39–43.

35. Kayal RA, Elias WY, Albarthi KJ, Demyati AK, Mandurah JM. Illicit drug abuse affects periodontal health status. Saudi Med J 2014;35(7):724–8.36. Duane B. Further evidence that periodontal bone loss increases with smoking and age. Evid Based Dent 2014 Sep;15(3):72–3. doi: 10.1038/sj.ebd.6401038.37. Shariff JA, Ahluwalia KP, Papapanou PN. Relationship between frequent recreational cannabis (marijuana and hashish) use and periodontitis in adults in the United States: NHANES 2011–12. J Periodontol 2017 Mar;88(3):273–80. doi: 10.1902/jop.2016.160370. Epub 2016 Oct 8.

THE CORRESPONDING AUTHOR, James Burke Fine, DMD, can be reached at [email protected].

®

Connect to the best and brightest in dentistry.

cda.org/member

More than 27,000 members working together means that CDA

is growing stronger than ever. With an easier online application,

valuable special offers and rewards for referring new members,

there’s no better time to share our support, advocacy, education

and protection. See how membership helps build professional

connections and creates pathways for success.


S E P T E M B E R 2 0 1 7 483

o r a l l i c h e n p l a n u s

AUTHORS

Nita Chainani-Wu, DMD, MS, PhD, completed her doctor of medicine in dentistry at the University of Pennsylvania, her oral medicine clinical training and master’s degree at the University of California, San Francisco, and a master of public health and doctorate of epidemiology at the University of California, Berkeley. Her clinical expertise includes lesions aff ecting the soft tissues of the mouth, including oral premalignant conditions, and she has a private clinical practice in oral medicine.Confl ict of Interest Disclosure: None reported.

Anuradha Nayudu, BDS, completed her bachelor of dental surgery at the University of Nasik, India, and is currently a second-

Oral Lichen Planus Flares Triggered by Cow’s Milk in a Patient With Elevated IgE Antibodies to MilkNita Chainani-Wu, DMD, MS, PhD; Anuradha Nayudu, BDS; and Daniel Purnell, BA, MPH

A B S T R AC T A female patient with painful oral lichen planus that required daily topical corticosteroids completely eliminated cow’s milk/milk products (CMP) from her diet. Her oral discomfort improved about two months later and had mostly resolved by eight months. Blood tests showed an elevation of total immunoglobulin E (IgE) and CMP-specifi c IgE antibody titers. Over the next seven years, she was largely asymptomatic when continuing to avoid CMP, with the occasional inadvertent ingestion that resulted in fl ares.

Hepatitis C virus has been associated with oral lichen planus in some studies, although the causal relationship of HCV with OLP is uncertain.6

Symptoms of lichen planus can range from none in the milder cases to severe discomfort particularly in patients with erosive changes.2,7,8

These symptoms can have significant effects on oral and general health as they may interfere with oral hygiene9 as well as with chewing and therefore prevent intake of a healthy diet in patients with severe OLP.10

Sensitivity to acidic and spicy foods is often a complaint, and sometimes these foods are erroneously identified by the patient as the cause of their OLP or the cause of flare-ups of the OLP. However, it is likely by the nature of these foods that they may simply induce irritation of preexisting lesions rather than be a true causative

year master of public health student with an emphasis in epidemiology at the University of California, Irvine. She is a graduate research assistant at the Beckman Laser Institute in Irvine.Confl ict of Interest Disclosure: None reported.

Daniel Prunell, BA, MPH, has a bachelor’s degree in psychology from the University of California, Berkeley, and a master of public health law in bioethics and human rights from Boston University. He is a consultant and technical writer at Coherent Logix Inc. in San Jose, Calif.Confl ict of Interest Disclosure: None reported.

Oral lichen planus (OLP) is a chronic, immunologically mediated, mucocutaneous disease.1 The clinical

presentation includes white reticular striations on the oral mucosa that may be accompanied by erythema and erosions.2,3

In most patients with lichen planus, a cause is never identifi ed.1 Some medications such as ACE-inhibitors or NSAIDS can trigger lichenoid drug reactions, which may have similar clinical features as lichen planus. These reactions usually occur soon after these medications are started, although in some cases they can occur after the patient has been on the medication for months or years. Confi rmation of a lichenoid reaction to a given medication is done clinically and in retrospect, if discontinuation of the medication results in resolution of clinical signs and symptoms.4,5


484 S E P T E M B E R 2 01 7

factor. Conversely, foods that are soft and bland such as dairy products may be identified by patients as noncontributory to the disease flares and even soothing and helpful.10

In a literature search, we were unable to identify any published reports of a given food as a potential causative factor in a case of oral lichen planus. This is the first report to our knowledge of a patient with oral lichen planus, where ingestion of cow’s milk was identified as a trigger for her oral flares and elimination of cow’s milk intake and any foods containing cow’s milk/milk products (CMP) was followed by significant and sustained resolution of the clinical signs and symptoms of lichen planus. Furthermore, IgE testing showed an elevation in total IgE antibody levels and cow’s milk specific IgE antibody levels, and occasional ingestion of cow’s milk containing products (oral challenges) resulted in recurrence of symptoms.

Case ReportA 49-year-old female with a chief

complaint of “sensitivity in the mouth” was initially seen in November 2006. She reported oral sensitivity of three weeks’ duration. At onset, this was only when brushing; however, the sensitivity had worsened over the past week, especially when eating spicy or high-temperature foods. She reported that she had not started any new medications or toothpaste recently

and stopped using mouth rinse when the symptoms started. She did not eat hard candy or chew gum. She did not have any skin or vaginal symptoms.

She reported a history of asthma and hypothyroidism. Her only medications were daily Levoxyl and albuterol inhaler as needed. She was also on calcium supplements and a multivitamin. She reported no known drug allergies. She reported no history of tobacco use and alcohol consumption consisted of one to two glasses of wine per week.

On examination, white reticular lesions on the right and left buccal mucosa as well as white reticular lesions and associated erythema on the upper and lower facial gingiva were seen (F IGURES 1A–1C). The clinical impression was oral lichen planus. A biopsy of the right buccal mucosa confi rmed the clinical diagnosis of OLP. A board-certifi ed oral pathologist read the biopsy and it was consistent with OLP.

Initial management included a swish-and-spit mouth rinse of an elixir of dexamethasone (twice per day) and application of a topical 0.025% fl uocinonide paste (0.05% fl uocinonide ointment mixed with equal parts Orabase-B) three times per day. At the one-month follow-up, she reported some improvement in symptoms and no adverse effects from the medication. She was continuing to refrain from spicy food.

However, over the next few months worsening of oral discomfort along

with increased erythema of the oral mucosa occurred. Soft acrylic trays were fabricated in June 2007 for use with the previously prescribed topical 0.025% fl uocinonide paste in order to increase contact time of the topical medication with the oral mucosa while decreasing the amount ingested. Periodic worsening of symptoms, or fl are-ups, were well controlled using the topical corticosteroids in the soft acrylic trays over the next several months of follow-up, however she continued to have a chronically present low level of oral discomfort.

In November 2007 in an attempt to identify a food-based trigger for the flares, a dairy elimination diet was discussed with the patient. She was advised to refrain from cow’s milk and all milk products and foods containing milk. After two months of avoiding cow’s milk and milk products, she reported only slight improvement in oral symptoms. However, at her six-month follow-up she reported significant symptom improvement after continued avoidance of foods and beverages containing cow’s milk. Notably, this improvement occurred in spite of the patient being under significant life stress, a factor that she had previously identified as a trigger for her lichen planus flares.

In October 2008, a blood test to measure total immunoglobulin E (IgE) levels as well as IgE levels to foods included in a standard food panel was obtained. Two weeks


FIGURES 1. Images from November 2006. Presence of white reticular lesions on buccal mucosa and gingiva. Erythema is seen on facial gingiva. Histopathology was “consistent with lichen planus.”

FIGURE 1A . FIGURE 1B . FIGURE 1C .


S E P T E M B E R 2 0 1 7 485

prior to the test, she was advised to consume milk and milk products. However, she reported that she was unable to ingest much milk or milk products during this time, as her OLP fl ared when she started to do so.

The blood draw and testing was done at Quest Diagnostics laboratory in Northern California. The total immunoglobulin E level was elevated at 795 kU/L, (normal range: < 114 kU/L). Food-specifi c IgE antibodies to the following common food allergens were included in the standard food panel: clams, egg whites, codfi sh, corn, milk, peanuts, scallops, shrimp, soybeans, walnuts, wheat and sesame seeds. The levels for all but milk and egg whites were within normal limits. Specifi c IgE levels to milk were elevated at 1.4 kUA/L. This is in the Class 2 range (0.7 to 3.49, moderately elevated level indicating that this food is a probable contributing factor to total allergic load-per ImmunoCAP interpretive guidelines). Specifi c IgE levels to egg whites were also elevated at 0.9 kUA/L, within Class 2 range.

At her follow-up examinations in 2009, she reported that she had been avoiding cow’s milk and milk products completely but had continued eating eggs. She reported signifi cant improvement in OLP symptoms, which she attributed to this dietary change. She had also noted that on several occasions she experienced fl are-ups with worsening oral symptoms when she had inadvertently consumed food

containing cow’s milk. Overall, her symptoms were reduced to the point where she could eat spicy foods with-out pain or discomfort. Oral mucosal examination revealed signifi cant reduction of gingival erythema and a regression of the white reticular lesions on her buccal mucosa(F IGURES 2A–2C). She was advised to continue using topical fl uocinonide paste on an as-needed basis for fl ares.

As of her follow-up in October 2015, the patient’s symptoms remain under good control. She continues to refrain from consuming cow’s milk or milk products. She uses fl uocinonide in case of fl ares. Her lichen planus lesions remain limited and stable and are confi ned to the gingiva with the presence of minimal erythema.

DiscussionManagement of symptomatic

oral lichen planus involves the use of anti-infl ammatory medications to reduce discomfort and accelerate healing of ulcerations. These medications may include topical and systemic corticosteroids2,11 that are commonly used to control OLP symptoms. Systemic corticosteroids have signifi cant side effects when used long term, therefore their use is limited to control of severe disease or for short-term use for control of acute fl ares. A common side effect of topical steroid use is oral candidiasis; therefore, compounded oral pastes containing topical corticosteroids

along with antifungals such as nystatin can be used in patients with this complication who need continued use of topical corticosteroids. Other medication options include topical formulations of immunosuppressants like cyclosporine12 and tacrolimus.13 High-dose oral curcuminoids extracted from turmeric (Curcuma longa) have demonstrated effi cacy in control of OLP and have a good safety profi le.14 In some instances where symptoms are severe and chronic, adjunctive steroid-sparing agents such as mycophenolate Mofetil or azathioprine are used in combination with corticosteroids15 And more recently biologics such as etanercept have been used.16 Some of these medications can have signifi cant toxicity and side effects especially when used long term.17

If an environmental trigger for OLP was identifi ed for a given patient, such that avoidance of the trigger could result in control of symptoms, this would positively affect the health of the patient by alleviation of oral discomfort, the resultant improvement of oral hygiene and nutrition and by eliminating the need for potentially toxic medications.

Identifi cation of food triggers in oral lichen planus can be challenging, as it is an immunologically mediated condition likely involving cell mediated delayed hypersensitivity mechanisms2 and there may be a time lag between ingestion of the food and exacerbation of symptoms and signs.

FIGURES 2. Images from August 2012. Signifi cant and sustained regression of clinical signs and symptoms of oral lichen planus.

FIGURE 2A . FIGURE 2B . FIGURE 2C .


486 S E P T E M B E R 2 01 7

Cow’s milk is a common food allergen18 and has been identified as a possible trigger for autoimmune or immunologically mediated conditions such as rheumatoid arthritis,19,20 atopic dermatitis,21 recurrent aphthous stomatitis,22 insulin dependent Type 1 diabetes,23 systemic lupus erythematosus,24 asthma25 and eczema.26 Cow’s milk consumption may also influence the severity of an immunologic condition as seen in atopic dermatitis where higher severity of atopic dermatitis was seen in children subsequently diagnosed with cow’s milk allergy.21

While dietary elimination trials focusing on multiple foods pose practical difficulties,27 dietary elimination targeting a single food such as dairy elimination trials are more feasible.

Laboratory testing for delayed hypersensitivity reactions to foods either by skin testing or serum IgE levels have uncertain accuracy.26 Studies evaluating the accuracy of these tests in determining triggers for lichen planus to our knowledge have not been published. Furthermore, it has been seen in a number of common dermatologic disorders that elevated serum IgE is a secondary phenomenon rather than a causative factor.28

In our patient, there was a several-weeks delay after dairy elimination before noticeable improvement was evident. However, within six to eight months of dairy elimination the patient’s symptoms had almost resolved and she had significantly decreased topical steroid use. In addition, occasional oral challenges with dairy that occurred when the patient ingested foods containing dairy products over the last seven

years have consistently resulted in exacerbations of symptoms of oral lichen planus. Therefore, there was clinical evidence for the role of dairy prior to blood testing for total and food-specific IgE levels, and the history continues to indicate an ongoing role of dairy in triggering flare-ups.

Furthermore, while significant reduction in clinical manifestations occurred after avoidance of cow’s milk in this patient, mild erythematous lesions on the gingiva chronically persisted over the years. Therefore, this case doesn’t fit the criteria of a lichenoid reaction where we can expect complete resolution of clinical signs and symptoms after discontinuation of the etiologic agent and after allowing sufficient time for the healing process. Rather, cow’s milk seems to exacerbate her otherwise mild, chronic OLP.

The proportion of patients with OLP where flares are triggered by cow’s milk intake is not known at this time. In addition, the accuracy of IgE testing or skin testing to determine if cow’s milk plays an etiologic role in a given patient with OLP is unclear. Future clinical studies evaluating the role of cow’s milk as an etiologic factor in OLP, and those evaluating accuracy of laboratory testing in this scenario, would be valuable both in adding to our understanding of the pathogenesis of OLP and in management of patients with OLP.

Because dairy elimination is feasible for most patients and the role of laboratory testing is unclear, at this time it is reasonable to try dairy elimination as an early step in management of patients with lichen planus, particularly those with symptoms severe enough to require medications. ■

REFERENCES

1. Sugerman PB, Savage NW. Oral lichen planus: Causes, diagnosis and management. Aust Dent J 2002 Dec;47(4):290–7. PMID: 12587763.2. Chainani-Wu N, Silverman S Jr., Lozada-Nur F, Mayer P, Watson JJ. Oral lichen planus: Patient profile, disease progression and treatment responses. J Am Dent Assoc 2001 Jul;132(7):901–9. PMID: 11480643.3. Canto AM, Müller H, Freitas RR, Santos PS. Oral lichen planus (OLP): Clinical and complementary diagnosis. An Bras Dermatol 2010 Sep–Oct;85(5):669–75. PMID: 21152791.4. Wright J. Diagnosis and management of oral lichenoid reactions. J Calif Dent Assoc 2007 Jun;35(6):412–6. PMID: 17849968.5. Rice PJ, Hamburger J. Oral lichenoid drug eruptions: Their recognition and management. Dent Update 2002 Nov;29(9):442–7. PMID: 12494560.6. Chainani-Wu N, Lozada-Nur F, Terrault N. Hepatitis C virus and lichen planus: A review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004 Aug;98(2):171–83. PMID: 15316544.7. Chainani-Wu N, Silverman S Jr., Reingold A, Bostrom A, Lozada-Nur F, Weintraub J. Validation of instruments to measure the symptoms and signs of oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008 Jan;105(1):51–8. PMID: 18155609.8. Edwards PC, Kelsch R. Oral lichen planus: Clinical presentation and management. J Can Dent Assoc 2002 Sep;68(8):494–9. PMID: 12323106.9. Scattarella A, Petruzzi M, Ballini A, Grassi F, Nardi G. Oral lichen planus and dental hygiene: A case report. Int J Dent Hyg 2011 May;9(2):163–6. PMID: 21356010.10. Czerninski R, Zadik Y, Kartin-Gabbay T, Zini A, Touger-Decker R. Dietary alterations in patients with oral vesiculoulcerative diseases. Oral Surg Oral Med Oral Pathol Oral Radiol 2014 Mar;117(3):319–23. PMID: 24144994.11. Thongprasom K, Carrozzo M, Furness S, Lodi G. Interventions for treating oral lichen planus. Cochrane Database Syst Rev 2011 Jul 6;(7):CD001168. PMID: 21735381.12. Bagan J, Compilato D, Paderni C, Campisi G, Panzarella V, Picciotti M, Lorenzini G, Di Fede O. Topical therapies for oral lichen planus management and their efficacy: A narrative review. Curr Pharm Des 2012;18(34):5470–80. PMID: 22632394.13. Hodgson TA, Sahni N, Kaliakatsou F, Buchanan JA, Porter SR. Long-term efficacy and safety of topical tacrolimus in the management of ulcerative/erosive oral lichen planus. Eur J Dermatol 2003 Sep–Oct;13(5):466–70. PMID: 14693491.14. Chainani-Wu N, Collins K, Silverman S Jr. Use of curcuminoids in a cohort of patients with oral lichen planus, an autoimmune disease. Phytomedicine 2012 Mar 15;19(5):418–23. PMID: 22305276.15. Verma KK, Mittal R, Manchanda Y. Azathioprine for the treatment of severe erosive oral and generalized lichen planus. Acta Derm Venereol 2001 Oct–Nov;81(5):378–9. PMID: 11800155.16. Yarom N. Etanercept for the management of oral



S E P T E M B E R 2 0 1 7 487

lichen planus. Am J Clin Dermatol 2007;8(2):121. PMID: 17428119.17. Chainani-Wu N,Wu TC. Immunosuppressants. J Calif Dent Assoc 2008 Oct;36(10):775–9. PMID: 19044098.18. Sackesen C, Assa’ad A, Baena-Cagnani C, Ebisawa M, Fiocchi A, Heine RG, VonBerg A, Kalayci O. Cow’s milk allergy as a global challenge. Curr Opin Allergy Clin Immunol 2011 Jun;11(3):243–8. PMID: 21522064.19. Parke AL, Hughes GR. Rheumatoid arthritis and food: A case study. Br Med J (Clin Res Ed) 1981 Jun 20;282(6281):2027–9. PMID: 6788180.20. Panush RS, Stroud RM, Webster EM. Food-induced (allergic) arthritis. Inflammatory arthritis exacerbated by milk. Arthritis Rheum 1986 Feb;29(2):220–6. PMID: 3513771.21. Pourpak Z, Farhoudi A, Mahmoudi M, Movahedi M, Ghargozlou M, Kazemnejad A, Eslamnoor B. The role of cow milk allergy in increasing the severity of atopic dermatitis. Immunol Invest 2004 Feb;33(1):69–79. PMID: 15015834.22. Besu I, Jankovic L, Konic-Ristic A, Raskovic S, Besu V, Djuric M, Cakic S,Magdu IU, Juranic Z. The role of specific cow’s milk proteins in the etiology of recurrent aphthous ulcers. J Oral Pathol Med 2013 Jan;42(1):82–8 PMID: 22924810.23. Cavallo MG, Fava D, Monetini L, Barone F, Pozzilli P. Cell-mediated immune response to beta casein in recent-onset insulin-dependent diabetes: Implications for disease pathogenesis. Lancet 1996 Oct 5;348(9032):926–8. PMID: 8843812.24. Carr R, Forsyth S, Sadi D. Abnormal responses to ingested substances in murine systemic lupus erythematosus: Apparent effect of a casein-free diet on the development of systemic lupus erythematosus in NZB/W mice. J Rheumatol Suppl 1987 Jun;14 Suppl 13:158–65. PMID: 3497268.25. Yusoff NA, Hampton SM, Dickerson JW, Morgan JB. The effects of exclusion of dietary egg and milk in the management of asthmatic children: A pilot study. J R Soc Promot Health 2004 Mar;124(2):74–80. PMID: 15067979.26. du Toit G, Meyer R, Shah N, Heine RG, Thomson MA, Lack G, Fox AT. Identifying and managing cow’s milk protein allergy. Arch Dis Child Educ Pract Ed 2010 Oct;95(5):134–44. PMID: 20688848.27. David TJ, Waddington E, Stanton RH. Nutritional hazards of elimination diets in children with atopic eczema. Arch Dis Child 1984 Apr;59(4):323-5. PMID: 6721557.28. O‘Loughlin S, Diaz-Perez JL, Gleich GJ, Winkelmann RK. Serum IgE in dermatitis and dermatosis: An analysis of 497 cases. Arch Dermatol 1977 Mar;113(3):309-15. PMID: 139128.

THE CORRESPONDING AUTHOR, Nita Chainani-Wu, DMD, MS, PhD, can be reached at [email protected].

Free eDelivery.

Available for iPad, iPhone, Android or Kindle Fire.Check it out at cda.org/apps.

to savings.Big discounts. 25,000+ products. One single site.

Exclusive to CDA member dentists, The Dentists

Service Company leverages the buying power

of the association’s membership and shares the

exceptional savings with your practice.

How do we do it? Through the Marketplace, an

easy-to-use online shopping experience that offers

the supplies you use every day at discounts you

can’t get on your own.

Start shopping today and see the

TDSC difference for yourself.

888.253.1223 tdsc.com


S E P T E M B E R 2 0 1 7 489

d i g e o r g e s y n d r o m e

AUTHORS

Tory Silvestrin, DDS, MSD, MSHPE, is an assistant professor of endodontics at the Loma Linda University School of Dentistry. He holds a dental degree, endodontic certifi cate, a master of science in dentistry and a master’s degree in health professions education.Confl ict of Interest Disclosure: None reported.

Nasser Said Al Naief, DDS, MS, is chair of the department of pathology and radiology at the Oregon Health Sciences School of Dentistry and the director of the oral and maxillofacial pathology laboratory.Confl ict of Interest Disclosure: None reported.

Pre-Eruptive Resorption in a Patient With DiGeorge SyndromeTory Silvestrin, DDS, MSD, MSHPE; Nasser Said Al Naief, DDS, MS; Dezhi Wang, MD, HTL, QIHC; and Leif K. Bakland, DDS

A B S T R AC T DiGeorge syndrome (DGS) is associated with defects of the palate, truncus arteriosus and tetralogy of Fallot, as well as cognitive defects and neuromuscular problems. Pre-eruptive resorption (PER) is a rare resorptive entity found within the dentin in the occlusal aspect of an unerupted tooth. A literature search could not identify any previous report on a patient diagnosed with both DGS and PER. This case report details a patient with concomitant DGS and PER.

Early diagnosis and treatment of pre-eruptive resorption (PER) is important for dentists in order to prevent progression of this entity to a degree that could

render a tooth unrestorable. Many general dentists acquire panoramic radiographs on growing patients, and this is the ideal medium for initial recognition of PER. This case report discusses the occurrence of PER in a patient with concurrent DiGeorge syndrome (DGS). To our knowledge, this is the fi rst report of a patient with concomitant DGS and PER. The importance of this study is to provide a case report showing a possible association with DGS and dental anomalies — specifi cally PER. Additionally, this manuscript provides a literature review of the prevalence, management and proposed etiologies of PER.

The patient in this report had the notable dental fi nding of PER along with a systemic disorder of DGS. An extensive review of the literature did not yield any reports of a similar combination of conditions. While a connection between the two conditions appears to be unlikely, the combination is unique and apparently not previously reported.

Case ReportA 12-year-old girl in mixed

dentition stage was found during routine radiographic examination to have a pre-eruptive occlusal radiolucency in the mandibular left second molar (tooth No. 18). She was in orthodontic treatment to correct a bilateral mandibular crossbite and her complaint was of intermittent, spontaneous, dull throbbing pain in her teeth after sugary drinks. Her dentist restored several teeth with

Dezhi Wang, MD, HTL, QIHC, graduated medical school at Shanghai Jiao Tong University and is a laboratory manager in the department of pathology at the University of Alabama at Birmingham.Confl ict of Interest Disclosure: None reported.

Leif K. Bakland, DDS, is a professor emeritus of endodontics at the Loma Linda University School of Dentistry. He is a former dean and department chair. He has also authored many texts and articles.Confl ict of Interest Disclosure: None reported.


490 S E P T E M B E R 2 01 7

carious lesions and her pain subsided. A subsequent panoramic radiograph showed the presence of a pre-eruptive coronal radiolucency in tooth No. 18 (F IGURE 1). A layer of bone was observed above the unerupted tooth.

The quality, coloration and hardness of the enamel on the affected tooth was clinically indistinguishable from the other teeth in the patient’s dentition. This was a contributing factor for the referral for evaluation of the patient, as no one tooth in particular clinically appeared different than any other (i.e., no pathosis or developmental disturbance was noted). The deciduous teeth presented no caries and the enamel quality was indistinguishable from a patient with otherwise intact dentition and within normal limits on all teeth.

Two options for managing the condition were presented to the patient and her guardian. One would be to surgically expose the unerupted tooth and remove the resorptive lesion. The second option would be to wait for the tooth to erupt before removing the lesion. They chose the latter option and returned one year later when the tooth had partially erupted. The crown was then further exposed surgically, but the patient delayed the return visit to have the resorptive lesion removed.

Six months after the surgical exposure of the tooth, the patient returned and was referred for endodontic consultation. An extensive medical history was obtained that included a diagnosis of DGS, which was made when she was 5 years old. DGS is an autosomal dominant syndrome and is associated with the deletion of part of chromosome 22.1 A feature of DGS is tetralogy of Fallot, a condition characterized by congenital cyanotic cardiovascular malformations,1 for which her physician had recommended premedication with amoxicillin (2 g) one hour before any dental procedure. She had also been diagnosed with asthma and had H1N1 fl u three years earlier. Two years earlier, she had cardiac surgery to manage her tetralogy of Fallot. Her list of medications included furosemide (Lasix), an antihistamine (loratadine), spironolactone (Aldactone), montelukast (Singulair) and fl uticasone propionate (Advair Diskus). Based on the clinical and radiographic evaluations, a treatment plan was presented and accepted for the management of the PER: Removal of the resorptive lesion to evaluate the possibility for restoring the tooth. Absent suffi cient coronal tooth structure, the tooth would be extracted.

One hour prior to the dental procedure, the patient took 2 g amoxicillin as prescribed. Under nitrous oxide sedation, she received local anesthesia of 3.4 mL, 2% lidocaine with 1:100,000 epinephrine by left inferior alveolar nerve block and lingual and buccal infi ltration. Tooth No. 18 was isolated with a dental dam and the overlying enamel was removed with a diamond bur under copious water spray, exposing reddish, granular resorptive tissue underneath. After unroofi ng the entire lesion, it was removed using spoon excavators. Along with the lesion, some of the underlying demineralized dentin was also removed resulting in exposure of the dental pulp in the mesiolingual area of the pulp chamber. The extensive resorptive defect left insuffi cient tooth structure for restoration, and the tooth was extracted using a Molt No. 9 periosteal elevator and a No. 151 extraction forceps. The socket was irrigated with saline and covered with sterile gauze. Hemostasis was confi rmed before the patient was dismissed and postoperative instructions were provided to the patient and her guardian. Postoperative


FIGURE 1. Panoramic radiograph showing an intracoronal radiolucent lesion in the unerupted mandibular left second molar (tooth No. 18).

FIGURE 2. Radiographic image of extracted tooth No. 18 prior to decalcifi cation. The extent of tooth resorption can be seen as well as the presence of osteodentin within the resorptive area (arrow). Undiff erentiated pulp mesenchymal cells within the cell-rich zone terminally diff erentiate into odontoblast-like cells to deposit this osteodentin, which is composed of odontoblasts becoming trapped in a newly formed matrix and the tubular pattern becoming obscured and distorted causing the abnormal radiolucent appearance of this entity.


S E P T E M B E R 2 0 1 7 491

evaluation 14 days later showed good healing. Because of her young age, tooth No. 17 was expected to erupt into the vacated No. 18 position.

The extracted tooth was preserved with the guardian’s permission to be processed for histological evaluation. A radiograph taken of the extracted tooth shows the extensive resorption of the crown (FIGURE 2).

Histological EvaluationThe tooth was placed in a 15 ml

Eppendorf tube with 70% ethanol and subsequently bisected using a diamond coated blade. One of the halves was decalcifi ed using 4.3% ethylenediaminetetraacetic acid, as described by Cho et al.2 and subsequently embedded in paraffi n, and then two 4μm-thick sections were obtained, one of which was stained with hematoxylin and eosin stain and the other was stained with Giemsa stain.3

Both stains delineated the presence of a prominent resorptive area in the tooth crown and also the deposition of abnormal dentin and osteodentin (F IGURE 3). The other specimen half was sectioned and grinded into an about 30μm-thick section by using an EXAKT Cutting and Grinding system (EXAKT Technologies, Norderstedt, Germany) and stained with methylene blue and basic fusion stain, demonstrating the deposition of globular dentin/osteodentin within the resorptive area (F IGURE 4).4,5

DiscussionDGS is a very rare embryologic

disorder, characterized by defects in tissues derived from the third and fourth branchial arches and pouches and accompanied by cellular immune defi ciency, hypocalcemia as a result of thymic aplasia (hypoplasia) and agenesis

of the parathyroid gland, respectively.1

Cardiovascular abnormalities are also characteristically present.1,6–7

Aside from several systemic and developmental abnormalities associated with this condition, patients also present with characteristic craniofacial features, including hypertelorism, lower than usual ear lobes, downward eye slanting, micrognathia, cleft palate and a broad nose.1 Additional craniofacial conditions of DGS include delayed tooth development and eruption of permanent teeth as well as enamel hypoplasia. Further, histomorphological examinations of patients’ dentitions often display increased calcifi cation of the dentin and deposition of osteodentin within the pulp.8

PER appears as a radiographic lesion adjacent to the dentinoenamel junction in the occlusal aspects of the crown and is often an incidental fi nding on radiographs of unerupted teeth.9 The radiographic appearance usually shows teeth with thin occlusal enamel and radiolucent areas toward the mesial aspects of the crowns,10 which was not the case in this report. The resorptive lesions appear to be progressive, but

the progression may slow down before the tooth erupts.9 The unpredictable nature of PER is illustrated in a report by Holan et al.11 who found resorption involving the pulp before the tooth erupted, suggesting that the progression of the resorptive action may increase at the time of eruption. In most cases, however, the lesions extend no further than two-thirds of the dentin thickness.12

After teeth with PER are fully erupted, it is diffi cult to differentiate PER from occlusal caries.13 In the absence of bacteria, however, occlusal carious does not occur prior to eruption.14 It can also be diffi cult to differentiate PER from external resorption. McNamara15 reported on a case of a molar with apparent intracoronal resorption that upon histological examination after extraction appeared to have an occlusal developmental pit communicating with the resorptive defect in the underlying dentin. Another possible differential diagnosis has been Turner’s hypoplasia, but many of the patients diagnosed with PER lesions have no history of previous infection of primary molars.9

FIGURE 3 . Sections of the tooth stained with Giemsa stain (left) and hematoxylin and eosin (right). Osteodentin and abnormal dentin is indicated by the arrows. Osteodentin is formed after injury to the pulp or irregular displacement of odontoblasts and can be a response to disrupted growth/eruption of teeth with altered biomechanical and developmental stresses. This osteodentin has a sparse and irregular tubular pattern with some cellular inclusions.

FIGURE 4 . Ground section stained with methylene blue basic fusion special demonstrates globular dentin and osteodentin deposition (arrow) within the resorptive region.


492 S E P T E M B E R 2 01 7

Clinically, the enamel in teeth with PER appears thin, and radiographically the undermined dentin and enamel have a shell-like appearance. Below the occlusal enamel, the lesion appears as soft red tissue with a different texture and appearance than carious dentin. Histologically, the resorptive lesion is composed of loose fi bromyxoid tissue containing islands and strands of odontogenic epithelium as well as infl ammatory cells (including multinucleated giant cells, osteoclasts and other chronic infl ammatory cells) and resorption

lacunae but with no evidence of caries or microbiota.14 Clinical symptoms are most often absent even if the pulp has become involved.10 However, Brunet-Llobet et al.16 presented a case of severe pain attributed to PER.

The etiology of PER has not been fi rmly established. One suggestion has been that damage to the reduced enamel epithelium of the developing tooth may allow invasion of cells from the periodontium leading to PER.13 That possibility has been questioned because of absence of observed developmental defects.17 Another

suggestion has been that PER could be due to abnormal development of the crown follicle, though no data is available to support that.18 It has also been thought that the pathogenesis of this lesion is due to local pressure from eruption causing the resorptive entity,18 and possibly that invasion of resorptive cells through minor defects in enamel can lead to the pre-eruptive resorption.15,17,19–20

There have been many case reports on PER in permanent teeth.11,14,20,21–27 The most frequently affected tooth is the permanent mandibular second molar.24 A recent case series showed a 5:1 ratio of the mandible versus the maxilla.17 Permanent maxillary second premolars are the second most frequent teeth and anterior teeth are the least frequent ones.10 PER predominantly involves single teeth,28,29 but a case of multiple involved teeth has been reported.30 The prevalence of PER has been reported to be 0.5–6 percent, but this percentage is greater when third molars are included.9,13,14 The presence of PER is not related to the sex or race of patients,13 nor to their medical status, but a recent case report of a patient with amelogenesis imperfecta and multiple PER lesions suggests that there may be a link between this systemic condition and the fi nding of PER in multiple teeth.31

The management of teeth with PER includes observation (prior to eruption), restoration of the crowns following eruption of the teeth, surgical exposure of the crowns prior to eruption to allow restoration of the crowns and lastly to extraction of unrestorable teeth. If the crown can be restored, pulpal considerations would include pulp capping or pulpotomy. Davidovich et al.32 presented a successful case of


Compounding Pharmacy for Dentists

Topical Anesthetic Formulations Include:

TAC 20 Alternate

Profound Gel

The Baddest Topical in Town™

Other Popular Products:Dyclonine 1% Rinse Minocycline 2% Gel (Alternate to Arestin®) Fusion Bone Binder

(855) 876-3060 www.WoodlandHillsPharmacy.com

Mention that you saw our ad in CDA Journal and get 10% off your first order. Valid until 9/30/17

Compound Topical Anesthetics

Multiple flavors

Extra-thick gel or plasticized ointment base

Why choose a compounding pharmacy?

Through our pharmacy you can obtain:

Powerful topical anesthetics with higher strengths

Combinations of effective ingredients in customized formulations

Dental products that are not commercially available


S E P T E M B E R 2 0 1 7 493

pre-eruptive resorption treated with surgical exposure of the unerupted tooth, removal of the resorptive tissue, pulpotomy and restoration with glass ionomer and amalgam. Others have suggested simply placing a sealant on the occlusal surface of the affected tooth and monitoring the site for progression of the lesion and have reported success over a period of fi ve or more years.18,23,33 Extraction creates associated problems in a growing child that need both short- and long-term attention.

Patients with DGS have early childhood hypocalcemia, which is often associated with autism-related behaviors and may contribute to hypocalcemia of developing teeth.34 If developing teeth lack the requisite hard tissue to form correctly during odontogenesis, then potentially this could explain the concomitant fi nding of DGS and PER in the patient.

Dentin dysplasia is an unlikely diagnosis given that the pathosis appears to be isolated to a single tooth, rather than the most common presentation of dentin dysplasia manifesting in all teeth due to its autosomal dominant inheritance pattern.35 Given that this case presents an isolated tooth with PER in a patient with DGS, it is much more plausibly related to the patient’s existing syndrome rather than attributed to dentin dysplasia.

This report of a patient with PER concomitant with a diagnosis of DGS appears to be the fi rst such report in the literature. Abnormalities in the dentin that have been reported in patients with DGS previously were also seen in this patient with PER. Thus, a possible link between the systemic condition of DGS and PER warrants further investigation.8 ■

REFERENCES

1. Conley ME, Beckwith JB, Mancer JF, Tenckhoff L. The spectrum of the DiGeorge syndrome. J Pediatr 1979;94:883–90.2. Cho A, Suzuki S, Hatakeyama J, Haruyama N, Kulkarni AB. A method for rapid demineralization of teeth and bones. Open Dent J 2010;4:223–9.3. Molina DM, Oporto JA. Comparative study of dentine staining techniques to estimate age in the Chilean dolphin, Cephalorhynchus eutropia (Gray, 1846). Aquatic Mammals 1993;19:45–8.4. Luque PL, et al. Comparison of two histological techniques for age determination in small cetaceans. Mar Mammal Sci 2009;25:902–19.5. Kvaal SI, Solheim T, Bjerketvedt D. Evaluation of preparation, staining and microscopic techniques for counting incremental lines in cementum of human teeth. Biotech Histochem 1996;71:165–72.6. Fukui N, Amano A, Akiyama S, Daikoku H, Wakisaka S, Morisaki I. Oral fi ndings in DiGeorge syndrome: Clinical features and histologic study of primary teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:208–15.7. Bockman DE, Kirby ML. Dependence of thymus development on derivatives of the neural crest. Science 1984;223:498–500.8. Soejima Y IM, Shinji H, Tsukamoto S, Motokawa W. Dental fi ndings of DiGeorge syndrome: Report of a case. Jpn J Pediatr Dent 1995;33:1109–16.9. Ari T. Management of “hidden caries:” A case of severe pre-eruptive intracoronal resorption. J Can Dent Assoc 2014;80:e59.10. Hata H, Abe M, Mayanagi H. Multiple lesions of intracoronal resorption of permanent teeth in the developing dentition: A case report. Pediatr Dent 2007;29:420–5.11. Holan G, Eidelman E, Mass E. Pre-eruptive coronal resorption of permanent teeth: Report of three cases and their treatments. Pediatr Dent 1994;16:373–7.12. Brooks JK. An unusual case of idiopathic internal root resorption beginning in an unerupted permanent tooth. J Endod 1986;12:309–10.13. Seow WK. Pre-eruptive intracoronal resorption as an entity of occult caries. Pediatr Dent 2000;22:370–6.14. Spierer WA, Fuks AB. Pre-eruptive intracoronal resorption: Controversies and treatment options. J Clin Pediatr Dent 2014;38:326–8.15. McNamara CM, Foley T, O’Sullivan VR, Crowley N, McConnell RJ. External resorption presenting as an intracoronal radiolucent lesion in a pre-eruptive tooth. Oral Dis 1997;3:199–201.16. Brunet-Llobet L, Lahor-Soler E, Miranda-Rius J. Oral pain due to severe pre-eruptive intracoronal resorption in permanent tooth. Eur J Paediatr Dent 2014;15:332–4.17. Kjaer I, Steiniche K, Kortegaard U, Pallisgaard C, Bille ML, Seirup T, et al. Pre-eruptive intracoronal resorption observed in 13 patients. Am J Orthod Dentofacial Orthop 2012;142:129–32.18. Moskovitz M, Holan G. Pre-eruptive intracoronal radiolucent defect: A case of a nonprogressive lesion. J Dent Child 2004;71:175–8.19. Blackwood HJ. Resorption of enamel and dentine in the unerupted tooth. Oral Surg Oral Med Oral Pathol 1958;11:79–85.20. Klambani M, Lussi A, Ruf S. Radiolucent lesion of an

unerupted mandibular molar. Am J Orthod Dentofacial Orthop 2005;127:67–71.21. Yaqoob O, DiBiase AT, Kane R, Fleming PS. Pre-eruptive coronal resorption of a maxillary canine: A case report. Orthodontics 2011;12:148–51.22. Manan NM, Mallineni SK, King NM. Case report: Idiopathic pre-eruptive coronal resorption of a maxillary permanent canine. Eur Arch Paediatr Dent 2012;13:98–101.23. Counihan KP, O’Connell AC. Case report: Pre-eruptive intracoronal radiolucencies revisited. Eur Arch Paediatr Dent 2012;13:221–6.24. Johnson M, Harkness M. Pre-eruptive coronal radiolucency in a mandibular premolar: A case report and literature review. N Z Dent J 1997;93:84–6.25. Dowling PA, Fleming P, Corcoran F. A case report of pre-eruptive coronal resorption in a mandibular canine. Dent Update 1999;26:444–5.26. Keetley DA. A case report of pre-eruptive coronal resorption in a mandibular canine. Dent Update 2000;27:100.27. McEntire JF, Hermesch CB, Wall BS, Leonard DL. Case report: Pre-eruptive intracoronal resorption. Oper Dent 2005;30:553–6.28. Nik NN, Abul Rahman R. Pre-eruptive intracoronal dentin defects of permanent teeth. J Clin Pediatr Dent 2003;27:371–5.29. Seow WK, Wan A, McAllan LH. The prevalence of pre-eruptive dentin radiolucencies in the permanent dentition. Pediatr Dent 1999;21:26–33.30. Seow WK. Multiple pre-eruptive intracoronal radiolucent lesions in the permanent dentition: Case report. Pediatr Dent 1998;20:195–8.31. Miloglu O, Karaalioglu OF, Caglayan F, Yesil ZD. Pre-eruptive coronal resorption and congenitally missing teeth in a patient with amelogenesis imperfecta: A case report. Eur J Dent 2009;3:140–4.32. Davidovich E, Kreiner B, Peretz B. Treatment of severe pre-eruptive intracoronal resorption of a permanent second molar. Pediatr Dent 2005;27:74–7.33. Czarnecki G, Morrow M, Peters M, Hu J. Pre-eruptive intracoronal resorption of a permanent fi rst molar. J Dent Child 2015;81:151–5.34. Muldoon M, Ousley OY, Kobrynski LJ, Patel S, Oster ME,Fernandez-Carriba, et al. The eff ect of hypocalcemia in early childhood on autism-related social and communication skills in patients with 22q11 deletion syndrome. Eur Arch Psychiatry Clin Neurosci 2015;265(6):519–24.35. Li F, Liu Y, Liu H, Yang J, Zhang F, Feng H. Phenotype and genotype analyses in seven families with dentinogenesis imperfecta or dentin dysplasia. Oral Dis 2016;doi10.1111/odi/12621 [Epub ahead of print].

THE CORRESPONDING AUTHOR, Tory Silvestrin, DDS, MSD, MSHPE, can be reached at [email protected].


S E P T E M B E R 2 0 1 7 495

RM Matters

A common allegation in many professional liability claims is the lack of informed consent. Patients argue that had they known about the possibility

of complications, they would have made a different decision regarding their dental treatment. One of the best ways dentists can protect themselves in these cases is by ensuring patients are armed with the facts needed to make informed decisions.

Informed consent requires a dentist to explain the likelihood of success of a given procedure and its risks, benefi ts and alternatives. A dentist, not a staff member, must lead this conversation. The amount of time spent discussing options and answering a patient’s questions depends on the level of risk. Higher risk levels and more invasive treatments are two indicators that more time and detail should be spent informing the patient about the risks, benefi ts and alternatives to treatment, including no treatment at all.

“Informed consent is not a form. It is a conversation,” said John Sillis, an attorney at Zaro & Sillis in Sacramento, Calif. “Whether you use consent forms for each procedure or write the information in the patient’s chart, you as the doctor must have some measure of a conversation with the patient about the risks, benefi ts and alternatives of the proposed treatment.”

Sillis says the discussion of risks, benefi ts and alternatives, or RBA, should be documented in the chart as “RBA discussed and questions answered” or “RBAQA.” To prove the discussion occurred, dentists are advised to establish a custom and a practice; that is, a habit in the way they practice. While a dentist may have trouble recalling the details of a specifi c case, they can convey the typical protocol that they would customarily employ for the procedure, even years later, Sillis added.

Informed Consent: More Than Just a FormTDIC Risk Management Staff

You are not a sales goal.

You are a dentist deserving of an insurance company relentless

in its pursuit to keep you protected. At least that’s how we see

it at The Dentists Insurance Company, TDIC. Take our Risk

Management program. Be it seminars, online resources or our

Advice Line, we’re in your corner every day. With TDIC,

you are not a sales goal or a statistic. You are a dentist.

Protecting dentists. It’s all we do.®

800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783

The Dentists Insurance Company reminds dentists that while informed consent discussions vary from treatment to treatment, information should always include the following:

■ The nature of the recommended treatment.

■ The risks, complications and benefi ts of the recommended treatment, including the likelihood of success.

■ The alternatives to that treatment, including doing no treatment.

■ An explanation of the treatment plan’s expected sequence of events.

Sillis recounts a case in which a dentist was sued for causing injury to the inferior alveolar nerve from a third molar extraction. The dentist had used a standard informed consent form that included nerve damage as a potential risk; however, the form did not include the potential for permanent injury to the nerve.

“Simply adding that term on the form would have successfully defended against that claim,” Sillis said.

In another case, a patient claimed the dentist performed root canal therapy


496 S E P T E M B E R 2 01 7

unnecessarily. The teeth in question had received several restorations for recurrent caries. Though the risk of pulpal involvement was possible due to the extent of the old restorations, the dentist did not use a consent form nor did he document that he had discussed this possibility with the patient. The teeth remained symptomatic and required root canal therapy and the patient fi led suit.

“The dentist could have avoided the suit by either having used a prepared consent form that included language that the treatment may not resolve the symptoms and may require

additional treatment up to and including extraction or simply had the discussion orally with the patient, including that information and then noted it in the chart, ‘RBA discussed,’” Sillis said.

According to TDIC, informed consent discussions are often complicated by language barriers. If a patient is hearing impaired, the dentist is obligated to provide a sign language interpreter. If the patient speaks a language not spoken by the dentist, insurance providers are required to provide a translator. The practice of allowing minor children to translate for the

parents can be problematic so proceed with caution. It should also be noted that dentists cannot charge patients for a sign language interpreter and dentists who are subject to ACA 1557 must provide for language translation.

TDIC also reminds dentists that only a legal guardian can provide consent for minor patients. For divorced parents, this means only the parent with legal custody. If in doubt, TDIC recommends requesting legal documentation of custody. Emancipated minors can provide their own informed consent.

Although patients ultimately decide which treatment avenues to take, their signed forms aren’t always enough to protect a dentist from liability. Patients cannot consent to substandard care, whether or not they sign forms, nor should a dentist practice below the standard of care at patients’ requests. Conversely, a dentist should not continue to treat patients who continue to refuse recommended treatment and should consider dismissing them from care following a formal dismissal protocol.

Procedure-specifi c informed consent forms in multiple languages are available to TDIC policyholders. To download, visit tdicinsurance.com/risk-management/informed-consent.

Making an informed decision is the right of every patient, but it is the responsibility of dentists to ensure patients have the comprehensive information needed to exercise that right. Patients have numerous options when it comes to their oral health and only with thorough considerations of the risks, benefi ts and alternatives can they truly provide informed consent. ■

TDIC’s Risk Management Advice Line at 800.733.0633 is staffed with trained analysts who can answer informed consent and other questions related to a dental practice.

S E P T . 2 0 1 7 R M M A T T E R S

“Matching the Right Dentist tothe Right Practice”

4150 SANTA CRUZ COUNTY GPSeller retiring from successful 33 year general practice. Fee-for-service only practice. Fully-equipped 4 op facility inbeautiful, remodeled Seller owned building. Buliding also forsale.

4162 PETALUMA GPRetiring Seller looking to transition a stable and loyal patientbase. Averaging 10-15 new patients per month with 2dedicated days of hygiene and approx. 3 doctor days perweek. 2016 Gross Receipts $304K+. Asking $150K forpractice. 7 ops (5 fully equipped) in 2,400 sq. ft. Singlestory, stand alone dental building available to purchase, orSeller will supply long-term lease with a Right of FirstRefusal to buy the building.

4145 ROSEVILLE GPWell-established GP offering 27+ years of goodwill. Ownerrelocating out of the area. General & Cosmetic Practicewith 6 fully equipped ops. Lots of upgraded/newerequipment. Opportunity to purchase single story 2,700 sq.ft. stand-alone professional bldg. Asking price for thePractice $520K.

4129 PETALUMA GPGP located in stunning 1,856 sq. ft. seller owned facility.State-of-the-art office includes 6 ops, staff lounge,reception area, private office, business office, lab area,sterilization area, consult room, separate storage area,bathroom plus private bathroom. Asking $525K.

4169 NAPA GPGeneral practice in seller owned building in a prime location.Remodeled, state-of-the-art, 2,000 square foot, beautifuloffice with 7 ops. Over 2,000 loyal patients. Asking $817K.

4177 SAN JOSE PROSTHOImplant, cosmetic and prosthodontic practice, established25+ yrs in desirable West San Jose area close to severalamenities and referral sources. Ideal for the restorativegeneral dentist inspired by cosmetic and implant dentistry,or a prosthodontist. 3 fully equipped ops in 1,600 squareft. Bright and modern treatment rooms in well establishedprofessional medical building. Lots of on-site parking, EZfreeway access. 3 yr. average GR $1.2M+ with adjustedaverage net of $500K+ Asking $813K.

4133 NAPA GPNapa County GP in newly furnished, fully equipped 2 opfacility with digital x-ray. 4 doctor day/week with 3 hygienedays. Monthly average revenue of $36K. Seller willing tohelp for a smooth transition. Asking $331K.

4185 SILCON VALLEY ORTHOCompact, well-run practice available due to relocation.Established 23 years in convenient, high traffic location nearmajor routes. 1,100 sq. ft. leasehold with reception, waitingroom, 3 chairs, exam room, lab/sterilization area, storagearea, private office + bathroom, patient bathroom. 2.5-daydoctor week offers ample opportunity to expand. Asking$186k.

4171 PLEASANTON GPPut the "pleasant" in Pleasanton. Well-established, 25 yearfamily practice in a rapidly growing community with smalltown flavor. Beautifully remodeled office with 5 ops.,reception area, business office, private office, staff loungeand dedicated parking. Seller transitioning to retirement,working 4 doctor days per week. 5 year average GR $509K+. Seller owned 1,700 square foot condominiumized suitefor sale with practice. Asking price for practice $313K.

4127 MENLO PARK GPGP offering 35+ yrs of goodwill, this gem on the Peninsulais truly a find. 4 ops in 950 sq. ft. 2016-2014 average GR$567K with average adj. net of $156K. 750+ activepatients. 4 hygiene days a week generate 40-45% of therevenue. Asking $417K.

4108 HUMBOLDT COUNTY GPWell-established, high performing general practice boasts 6fully equipped ops. in 2,900 sq. ft. free standing office w/Digital X- ray, 2 platinum Dexis sensors, & Cerec Omnicam& MCXL units. Perfect for a dentist who wants to escapethe grind and live along the coastline. 2016 GR $1.5M+.Asking $995K.

UPCOMING:Mid-Peninsula Endo, San Mateo GP, Sonoma CountyPerio & San Bruno GP

Carroll & Company2055 Woodside Road, Suite 160Redwood City, CA 94061BRE #00777682

Mike Carroll Pamela Carroll-Gardiner

CARROLL& C O M P A N YC

PENDING

PENDING

PENDING

Mary McEvoy Carroll

SOLD

carroll.company [email protected] (650) 362-7004 (650) 362-7007

NORTHERN CALIFORNIA

CONTRA COSTA COUNTY:

EL DORADO COUNTY:

OAKLAND:

SACRAMENTO:

SAN FRANCISCO:

SAN FRANCISCO:

SAN RAMON-FACILITY:

STOCKTON:

BURBANK:

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

Making your transition a reality.

www.henryscheinppt.com 1.888.685.81001.800.519.3458

:

PALM SPRINGS:

:

:

:

:

:

: :

: New Listing!

:

: New Listing!

:

:

:

:

CENTRAL CALIFORNIA

MODESTO:

DENTAL PRACTICE BROKERAGE

: New Listing!

: !

: New Listing!

: New Listing!

New Listing!

: New Listing!

SOUTHERN CALIFORNIA

New Listing!

: New Listing!

: New Listing!

: New Listing!

:

: New Listing!

: New Listing!

: New Listing!

:

UT OF CALIFORNIA

CENTRAL OAHU, HAWAII:

: New Listing!

: New Listing!

: New Listing!

: New Listing!

: New Listing!

: New Listing!

: New Listing!

: New Listing!

:

: New Listing!

:

: New Listing!

: New Listing!

: New Listing!

: New Listing!


S E P T E M B E R 2 0 1 7 499

A risk analysis of a dental practice’s electronic information systems combined with a risk management plan are

signifi cant and necessary elements for HIPAA compliance. What is a HIPAA risk analysis? It is a process with which a covered entity evaluates risks to the confi dentiality, integrity and availability of electronic patient information (ePHI). Although it is required, a risk analysis is missing or incomplete from many covered entities’ compliance programs. A review of enforcement actions taken by the U.S. Department of Health and Human Services Offi ce of Civil Rights (OCR) indicates many covered entities fail “to conduct an accurate and thorough risk analysis to assess the potential risks and vulnerabilities to the confi dentiality, integrity and availability of ePHI and failed to plan for and implement security measures suffi cient to reduce those risks and vulnerabilities.”

This article describes the steps a dental practice should take to complete the assessment. Next month, this column will review what needs to be included in a security risk management plan. The dental practice’s designated HIPAA security offi cer should complete both analysis and plan and may use the services of an external information technology (IT) advisor if needed. A thorough discussion of the risk analysis process can be found on the Security Rule Guidance Material page of the hhs.gov website, www.hhs.gov/hipaa/for-professionals/security/guidance/index.html.

What You Need To Know To Conduct a HIPAA Risk Analysis CDA Practice Support Staff

Regulatory Compliance

Are you thinking of buying a dental practice, merging, or selling your practice? The future you want is closer than you think. Our guidance makes all the difference.

Your local PARAGON dental transition consultantTrish Farrell

Approved PACE Program ProviderFAGD/MAGD CreditApproval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement4/1/2016 to 3/31/2020Provider ID# 302387.

866.898.1867 [email protected] paragon.us.com

You have goals. PARAGON can help you reach them.

Inventory Information AssetsBegin the process by identifying

and listing where and who holds the dental practice’s ePHI. Examples of where ePHI can be held include server, workstations, off-site back-ups, portable drives, laptop computers, smartphones, photocopiers, email service provider, claims clearinghouse, appointment reminders service providers and off-site bookkeepers.

The dental practice’s designated HIPAA security offi cer should complete both analysis and plan.


500 S E P T E M B E R 2 01 7

Identify and list by role (for example, hygienist, bookkeeper, software tech) who has access to ePHI and the respective level of access. Identify and list the entities with whom the practice needs to have a HIPAA business associate agreement and whether one is in place. It is a good idea to include on the list contact information and effective and termination dates or respective agreements.

List the hardware and software that store or use ePHI. Make note of the software version and the date when security patches were applied.

Identify and Assess Threats and Vulnerabilities

A “threat” to an information system can be a person or thing that, intentionally or not, uses a system vulnerability to compromise ePHI. A “vulnerability” is a weakness in system security procedures, design, implementation or internal controls, for example, an unsecured wireless network or unknown backdoor to the practice database. It is diffi cult to know every vulnerability in an information system

and new vulnerabilities are discovered over time, so a covered entity is not expected to fi x each and every one. A covered entity is expected to do the best it can with the resources at hand and is not required to take extraordinary measures to address a vulnerability.

Make a list of natural, human and environmental threats to information systems under the control of the dental practice. Examples are numerous and include fi re, earthquake, water damage, power outage, disgruntled employee, employee error, hacker and theft (TA B L E 1). Assess each threat for the likelihood of occurrence and the impact on the practice. For example, consider the likelihood of an employee mistakenly clicking on a phishing email that downloads ransomware

and the impact it would have on the practice. Is the threat occurrence risk low because employees are trained to beware of phishing emails or is it a medium risk? If a practice is hit by ransomware, will the impact be low, medium or high? A dental practice’s ability to quickly restore its data and remove the malware, as opposed to stopping ransomware, makes the impact to the practice low.

This process forces the consideration of consequences and whether the practice has appropriate safeguards in place to mitigate impact. Safeguards include physical items (a lock or offi ce wall, for example), technical solutions (encryption) and administrative policies and procedures (no sharing

TABLE 1

Items to Document/Assess

Information Assets Threats Vulnerabilities

Server Theft/burglary Security patches not applied

Desktop computers, on-site Loss of power or electrical issue Inadequate anti-malware protection

Back-up, on-site Flooding Unsecure network confi guration

Back-ups, off -site/cloud Water damage from pipe leak Unsecure wireless router

Laptop computers Earthquake Lack of administrative policies, e.g.:■ ePHI disposal■ Equipment repair■ Unique user ID■ Device removal

Tablets Fire

Smartphones Computer virus, malware

Photocopier Ransomware

Third-party service providers ■ Software■ Appointment reminders■ Patient portal■ Billing■ Collections■ Claims clearinghouse

Network connectivity issue

Employee, accidental or intentional acts

Hacker

TABLE 2

Threat Occurrence/Impact on Practice

1 Low impact 2 Medium impact 3 High impact

1 Low risk 2 3 4

2 Medium risk 3 4 5

3 High risk 4 5 6

SEPT. 2017 REGUL ATORY COMPL IANCE

C O N T I N U E S O N 5 0 2

6130 MARIPOSA Relaxed lifestyle in Sierra Foothill community. 2016 collected $1 Million. Extremely strong Hygiene Department. Seller can work-back if Buyer desires. 6129 PRACTICE – SAN MATEO 2016 collected $775,000 on 3.5 day week. Beautiful 5-op office. Excellent candidate for acquisition by nearby practice. Seller shall work back to assist in orderly transition. Acquire here or move into nearby practice. Choice is yours.6128 LOS GATOS AREA Capitation & PPO. 3-Adec equipped ops, Pano, Digital charting. Collects $420,000+ year. Available Profits of $190,000 in 2016.6127 SAN RAFAEL’S NORTHGATE Collected $210,000 in 2016 on part-time schedule. Available Profits of $106,000.6126 FRESNO Located at busy intersection. Collected $616,000 with profits of $364,000. 4-Ops.6125 OAKLAND AREA Collections average $735,000 per year. High income zip code with well employed Millennials next door. 10+ new patients per month. Digital and paperless.6124 SAN RAMON 100% Out-of-Network. 5-Ops. 6-days of Hygiene. $700,000 per year performer. 6122 SANTA CLARA - STARBUCKS "LIKE" LOCATION! Best exposure in beautiful strip center. Office just remodeled. 5-Ops. 2017 trending $1 Million in Collections on 4-days. Perfect platform to operate 6-days a week. Wants to do $1.5-to-$2 Million. 6121 NAPA VALLEY FAMILY PRACTICE Highly respected community asset. Collections last 5-years have averaged $1.28 Million per year. Beautiful facility. Condo optional purchase. 6120 OAKLAND’S PIEDMONT AREA Highly coveted area. Right off Highway 13. 3-days of Hygiene. 4-Ops with 5th available. 2016 collected $650,000+.6119 NORTH BAY ORTHO Desirable family community. Best technology, cone beam and paperless. Owner works part-time. Revenue streams averaged $775,000/year in past. Strong profits. Does no marketing to local Dental Community.6118 SAN FRANCISCO’S EAST BAY Forty percent partnership in well positioned and branded practice. 2016 collected $2.53 Million. 2017 trending $3.2+ Million in collections. Full complement of specialties. 6-month Trial Association wherein interested Candidate shall see ability to make $350,000+ per year. 6107 EUREKA 100% Out-of-Network with insurance industry. 2016 collected $930,000+ on Doctor’s 20-hour week. Doctor's schedule booked 3-months out. 7+ days of Hygiene. Highly respected. Full Price $250,000. Condo is optional purchase.6098 WEST PETALUMA The business center of the North Bay! Business parks are growing and young families are drawn to this great family community per unique amenities of this historic river city. Collected $468,000 with Profits of $212,500. 4-days of Hygiene.6089 MOUNT SHASTA Small town living renowned for outdoor lifestyle. 3-day week collected $950,000. Very strong bottom line. Digital including Pano.

RIPOSA Relaxed lifestyle in Sierra Foothill comm

NORTHERN CALIFORNIA(415) 899-8580 – (800) 422-2818

Raymond and Edna [email protected]

California DRE License 1422122

SOUTHERN CALIFORNIA(714) 832-0230 – (800) 695-2732Thomas Fitterer and Dean George

[email protected]

California DRE License 324962

ANAHEIM – NEAR DISNEYLAND 4-ops. Grosses $40,000+/mth. Includes building. Full Price $650,000. ANTELOPE VALLEY Prior DDS grossed $1.8 Million. 60,000 autos pass intersection daily. $80 Billion in government contracts will make this highest growth area in SoCal next 10-years. New DDS overwhelmed. Will work back for MSO or Specialist. Renovated 8 op office. Working Owner will net $500,000 at $1.5 Million, and $800,000 when grossing $2 Million. Full Price $250,000. ANTELOPE VALLEY Established 50 years. Absentee Owner. Grossing $1 Million. 6 ops. Rent $2,000/month. Full Price $800,000.BAKERSFIELD 50 year old practice and renovated building. 10,000 sq.ft. lot. 5 ops. Grosses $400,000-to-$600,000. Seller will let you work before buying. Practice and RE $685,000 includes AR.BURBANK / GLENDALE Absentee Seller. Grosses $1-to-$1.2 Million. 6 ops. Gorgeous high identity corner building. Refers Endo, OS, Implants. $300,000 in recent renovations. Full Price 85% of Gross. CERRITOS – EMERGENCY SALE Grossing $450,000. 3 Hygiene days. Digital with Pano. Well equipped for Implants. Full Price $350,000.DIAMOND BAR 5-Ops. Grosses $500,000.INLAND EMPIRE - EMERGENCY SALE Shopping Center. Operated by part-time Associate. Fantastic staff. Grossing $350,000. Owner-Operator will do $500,000+. 5-Ops plumbed, 3 equipped. Gorgeous office. Full Price $350,000.INLAND EMPIRE - EMERGENCY SALE High identity Target Center. Grosses $1 Million. No marketing. 5-days Hygiene. 200,000 autos pass daily. Recently renovated at cost of $300,000. Bargain.IRVINE / SANTA ANA Vons Shopping Center. 10-years old. Grosses $50-to-$60,000/month. Seller will work back 2 days. Near South Coast Plaza. Lots of new patients. Success assured. LAKE ELSINORE - HMO Established 40 years. Popular Seller wants to work back 2 days. Grossing $550,000. Lots of room to go to $800,000 first year. 6 Ops. Low rent. LOS ANGELES BEACH CITY Grossing $2.4 Million. Private & PPO. Building available. Seller requires work back contract. Take home Net of $1 million. Full Price $2.4 Million. Bank approved Financing. LOS ANGELES - HMO Grossing $1.5 Million.NEWPORT BEACH’S FASHION ISLAND - “Coming Up!” Contact Tom Fitterer and register interest. ORANGE COUNTY BEACH CITY - HMO Grossing $1.5 Million. Full Price $1.3 Million. Hands-on Owner will do $2 Million. PEDO - PASADENA AREA Refers 30-to-40 ortho patients per month. Grossing $450,000. Low overhead. Fantastic for GP Group. Full Price $390,000. Building available.SAN FERNANDO VALLEY Established 40-years. Recently renovated with best. Absentee Owner. Previously did $1 Million. 6 ops. Grossing $550,000. TORRANCE Strip center on Hawthorne. 3 ops. Grosses $300,000. Refers Endo, OS, Implants, Perio and Ortho. Close to Palos Verdes. Full Price $295,000.

MORE OPPORTUNITIES AVAILABLE Bellflower, Corona, Dana Point, East LA, Ladera Ranch, Norco. San Juan Capistrano established 40 years, Lawndale Galleria, Anaheim, Irvine, Orange/Tustin.

PracticesWanted

NORT

Specialists in the Sale and Appraisal of Dental PracticesServing California Dentists since 1966

How much is your practice worth??Selling or Buying, Call PPS today!

SOLD

SOLD

SOLD

SOLD

SOLD

SOLD


502 S E P T E M B E R 2 01 7

SEPT. 2017 REGUL ATORY COMPL IANCE

passwords). As each threat situation is considered, identify and list the safeguards already in place. This process prioritizes the security issues that should be addressed (TA BLE 2).

Risk Assessment ToolsA dental practice may fi nd a risk

assessment tool useful for its initial risk analysis. A free security risk assessment tool is available from the government at HealthIT.gov. It was developed in collaboration with OCR and includes video tutorials. The FIGURE shows a sample question from the tool. The ADA Complete HIPAA Compliance Kit, sold by the American Dental Association, also includes a tool similar to the one from HealthIT.gov. Vendors such as IT consultants may offer an assessment tool or may simply perform the assessment for the practice.

Next StepsA risk management plan must be

developed. Considerations for the plan will be reviewed in next month’s column. Keep in mind that the risk analysis and risk management plan are ongoing processes. Once a risk analysis is completed, a covered entity should review it on a regular basis and update its plan as needed. “Regular basis” is not defi ned in the HIPAA regulations, but an annual review is typically recommended by information security consultants. More frequent reviews may be necessary if a covered entity implements a series of new technology. ■

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

FIGURE. Sample HealthIT.gov risk assessment question.

T20 - §164.312(a)(2)(iv) Addressable Does your practice have policies and procedures for implementing mechanisms that can encrypt and decrypt ePHI?

❍ Yes❍ No

If no, please select from the following:❍ Cost❍ Practice Size❍ Complexity❍ Alternate Solution

Please detail your current activities:

Please include any additional notes:

Please detail your remediation plan:

Please rate the likelihood of a threat/vulnerability aff ecting your ePHI:❍ Low❍ Medium❍ High

Please rate the impact of a threat/vulnerability aff ecting your ePHI:❍ Low❍ Medium❍ High

Overall Security Risk:❍ Low❍ Medium❍ High

Related Information:

C O N T I N U E D F RO M 5 0 0

800.752.7461

With scores of Buyers, profiles of their practice interests and financial ability,

is able to find the right buyer for your practice.

Experience the difference. Call Lee Skarin and Associates for responses to all of your questions - No obligation!

Visit our website for current listings: www.LeeSkarinandAssociates.comDental Practice Brokers CA DRE #00863149

Lee Skarin and Associates has been serving the dental profession since 1959. Kurt Skarin has over 30 years experience in dental practice sales. We have sold more practices than any broker in the state within

the last 12 months. Our experienced practice appraisals are backed with

credentials unequaled among dental practice brokers. We provide in-house legal counsel to advise you in all

aspects of the sale and purchase, including the tax consequences of the sale.

Excellent financing is available, in most cases for 100% of the purchase price.

With a reputation for experienced, concientious, and ethical performance, we give our clients personal attention in all aspects of the purchase.

Largest Broker in Northern California

Extensive Buyer

Database & Unsurpassed

Exposure allows us to offer you

BAY AREA CONTINUED BN-504 RICHMOND: Established Practice & Real Estate! 1450sf w/ 2 ops + 2 add’l $$100k / RE $700k BN-736 BERKELEY: Step into this quality prac-

ce and you’ll know you belong here! 906sf w/3 ops. $$495k BG-734 ANTIOCH: Chance to own your own condo unit with this one! 1,323 sf w/ 4 ops. $315 / RE: TBD CC-632 SAN RAFAEL: Small town life in vibrant, growing city. 3 ops in 800sf office. Beautiful bldg $145k CC-661 SAN RAFAEL: Starter practice in beautiful location w/ like-new equipment. 3 ops, 900sf $190k CC-719 SAN RAFAEL: Panoramic views of Mt. Tamalpias from each operatory window, 4 ops, 1,550sf $$260k CC-720 SONOMA COUNTY: Well-established practice w/stable pts base. Excellent signage, 3 ops, 940sf w/ newer high-end Equip $$375k CG-616 NAPA: State-of-the-Art practice. Seller moving out of state! $$425k CG-735 ROHNERT PARK: Collections over $600k, Net Profit over $230k and expertly located near major anchor tenants! $$370k DC-480 SILICON VALLEY: Multi-Specialty prac-tice. 14+ ops in 7500sf. Owner financing availa-ble $$1.075M DC-671 SAN JOSE: Starter prac ce. Desirable area. 6 npts/mo, 3 ops in 900sf $$150k DC-692 DUBLIN Facility: Modern digital office. 5 ops 1800sf $$210k w/ Cone Beam Unit or $165k without DG-635 CASTRO VALLEY: Excellent loca on & stellar reputa on! Solo Group Prac ce $$650k DG-726 SAN JOSE: Busy, Vibrant Prac ce. Col-lec ons over $1.1M on a relaxed 4 day work week. ~2850sf w/7 ops $$885k DN-665 SANTA CRUZ AREA: Loyal, stable, mul -genera onal pa ent base. FFS. 1460sf w/ 4 ops $540k DN-688 MONTEREY: State-of-the-art equip-ment & latest technology! 1900 w/ 5 ops $1.4mil/RE $795k

BAY AREA AC-566 SAN FRANCISCO: Views of Washington Square. 3 ops +2 add’l, 1400sf $$200k AC-624 SAN FRANCISCO: Wonderful patients, solid income in great stand-alone bldg $$475k AC-640 SAN FRANCISCO: On 23rd Floor of pres-tigious bldg, 2 ops in 700sf. Seasoned Staff. Seller Retiring $$175k AC-649 SAN FRANCISCO Facility: Richmond District, 3 ops+1 add’l, Equipment less than 5yrs old $$120k AG-645 SAN FRANCISCO: Low Overhead, com-pact practice ready for expansion or relocation. Retail/Commercial area. 2nd Floor $$99k AG-669 SAN FRANCISCO: RARE opportunity in the heart of the city! 2 ops LOW OVERHEAD! $88k AN-513 REDWOOD CITY: Prac ce of your dreams! 900sf w/ 4 ops + 2 add’l $$350k AN-686 SAN FRANCISCO: Office designed w/ pa ent flow & maximum office efficiency. 1000sf w/ 4 ops $$825k AN-712 SAN FRANCISCO: Easy accessibility, ex-cep onal visibility, free parking & eextremely low rent! 1000sf w/ 2 ops + 2 add’l $$89.5k BC-662 HAYWARD: Starter practice in the “Heart of the Bay” near hospital, 3 ops in 1056sf $75k BC-663 DANVILLE: Seller retiring from this family-oriented practice. 4 ops in 1262sf $240K BC-681 WALNUT CREEK: Remodeled office. Semi-rural community, 1000sf w/ 4 ops $$432k BC-682 CONCORD: Located in desirable, bus-tling community w/ seasoned, caring staff. 836sf w/ 3 ops $$224k BC-710 WALNUT CREEK: Desirable location in stand-alone, single-story bldg. 1313sf w/ 3 ops $150k / RE $850k BG-724 RICHMOND: Spacious office w/ enor-mous growth potential! 2000sf w/ 4 ops PPrac-tice $138k / Real Estate $700k BG-731 LAFAYETTE: Well-educated, health con-scious pa ent base. 1,000 sf w/ 3 ops 35+ years goodwill $$265k

BAY AREA CONTINUED DN-693 SAN JOSE Facility:

$150k DN-713 CASTRO VALLEY Lease:

Call for details! DG-723 SAN JOSE:

$850k

NORTHERN CALIFORNIA EC-531 GREATER SACRAMENTO:

$800k for Prac ce & Real Estate EG-685 LINCOLN/ROCKLIN:

$570kEG-716 ELK GROVE:

$270k EG-722 ROSEVILLE:

$1.15MEG-727 SACRAMENTO:

$275kEN-625 SACRAMENTO:

$450k EN-626 CARMICHAEL:

$300k EN-627 CARMICHAEL:

$268k EN-628 ORANGEVALE:

375k EN-654 CITRUS HEIGHTS:

$150k EN-660 ROSEVILLE:

$995k EN-664 SACRAMENTO Facility:

$55k EN-689 MIDTOWN SACRAMENTO Facility:

$99k EN-702 SACRAMENTO:

$495k EN-708 SACRAMENTO:

$150k FC-650 FORT BRAGG:

$350k for the Prac ce & $400k for the Real EstateFC-677 FORT BRAGG:

$500k

NORTHERN CALIFORNIA CONTINUED GC-472 ORLAND:

$160k GG-453 CHICO: $200kGG-454 PARADISE:

$525kGN-606 BUTTE COUNTY:

$125k GN-656 NO. TEHAMA CO: Great Loca on!

$275k GN-667 OROVILLE: Great place to work & play!

$295k GN-668 BUTTE COUNTY:

$95k GN-717 YUBA CITY: Building available for purchase! $475k HN-213 ALTURAS: Collected ~$760 in 2016! $195k HN-280 NORTHEAST CA: $60k HN-618 SIERRA FOOTHILLS:

$95k

CENTRAL VALLEY IC-468 SAN JOAQUIN VALLEY

$425k IC-715 TRACY

$435k IG-687 TURLOCK:

$298k JN-690 LINDSAY

Prac ce $150k/ Real Estate $150k

SOUTHERN CALIFORNIA

KC-678 LOMPOC & SANTA MARIA: $240k

SPECIALTY PRACTICES BC-709 HAYWARD Ortho:

$215k IC-543 CENTRAL VALLEY Ortho:

$125k

800.641.4179 [email protected]

Largest Broker in Northern California

Extensive Buyer

Database & Unsurpassed

Exposure allows us to offer you

“ASK THE BROKER” CAN NOW BE FOUND AT WWW.WESTERNPRACTICESALES.COM

BAY AREA CONTINUED BN-504 RICHMOND:

$100k / RE $700k BN-736 BERKELEY:

$495k BG-734 ANTIOCH:

$315 / RE: TBD CC-632 SAN RAFAEL:

$145k CC-661 SAN RAFAEL:

$190k CC-719 SAN RAFAEL:

$260k CC-720 SONOMA COUNTY:

$375k CG-616 NAPA:

$425kCG-735 ROHNERT PARK:

$370kDC-480 SILICON VALLEY:

$1.075M DC-671 SAN JOSE:

$150k DC-692 DUBLIN Facility:

$210k w/ Cone Beam Unit or $165k without DG-635 CASTRO VALLEY:

$650kDG-726 SAN JOSE:

$885kDN-665 SANTA CRUZ AREA:

$540k DN-688 MONTEREY:

$1.4mil/RE $795k

BAY AREA AC-566 SAN FRANCISCO:

$200k AC-624 SAN FRANCISCO:

$475k AC-640 SAN FRANCISCO:

$175k AC-649 SAN FRANCISCO Facility:

$120k AG-645 SAN FRANCISCO:

$99kAG-669 SAN FRANCISCO:

$88kAN-513 REDWOOD CITY:

$350k AN-686 SAN FRANCISCO:

$825k AN-712 SAN FRANCISCO:

extremely low rent $89.5kBC-662 HAYWARD:

$75kBC-663 DANVILLE:

$240KBC-681 WALNUT CREEK:

$432k BC-682 CONCORD:

$224k BC-710 WALNUT CREEK:

$150k / RE $850kBG-724 RICHMOND:

Prac-tice $138k / Real Estate $700kBG-731 LAFAYETTE:

$265k

Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA

BAY AREA CONTINUED DN-693 SAN JOSE Facility: A rac ve & spacious! Faces one of the city’s major thoroughfares. 1080sf w/4 ops $$150k DN-713 CASTRO VALLEY Lease: Well maintained, attractive, “Move-In Ready” dental office. 1500sf w/ 5ops CCall for details! DG-723 SAN JOSE: The prac ce exceeds $1.2mil in collec ons annu-ally! 1,450 sf w/ 5ops. $$850k

NORTHERN CALIFORNIA EC-531 GREATER SACRAMENTO: Beau ful! 1750sf w/ 4 ops + 1 add’l office $$800k for Prac ce & Real Estate EG-685 LINCOLN/ROCKLIN: Perfect loca on in amazing community! Retail Shopping Center w/ 4 ops $$570k EG-716 ELK GROVE: Remarkable poten al for growth w/ a en on to marke ng & increased office hours! 1200sf w/3 ops $$270k EG-722 ROSEVILLE: This WILL sell quickly! PRIME LOCATION in most desirable retail center in town! 1919sf w/ 4 ops $$1.15M EG-727 SACRAMENTO: Steady Income from HMO. Increase office hours & begin adver sing to watch the collec ons skyrocket! 1100sf w/3 ops $$275k EN-625 SACRAMENTO: Looking for an HMO prac ce in a great Loca-

on? 2500sf w/5 ops $$450k EN-626 CARMICHAEL: Lifestyle you just can’t be beat! HMO 1250sf w/ 3 ops $$300k EN-627 CARMICHAEL: Remarkable HMO opp. awaits your talent & skill! 1200sf w/3 ops + 1 add’l $$268k EN-628 ORANGEVALE: Great place to work, play & live. HMO 1310sf w/ 4 ops + 1 add’l $3375k EN-654 CITRUS HEIGHTS: Well established & loaded with 30+ years of goodwill! 1300sf, 3 ops + 2 add’l. $$150k EN-660 ROSEVILLE: Highly-esteemed, well-respected, fee-for-service prac ce w/ loyal pa ent base. 2950sf w/ 5 ops $$995k EN-664 SACRAMENTO Facility: Great corner loca on, excellent visibil-ity & easy access! 2300sf w/ 4 ops $$55k EN-689 MIDTOWN SACRAMENTO Facility: Bring your talent, hang your sign & make it your own! 2000sf w/ 4 ops $$99k EN-702 SACRAMENTO: Long-established prac ce w/ emphasis on pre-venta ve vs reac ve den stry! 1600sf w 4 ops + 1add’l. $$495k EN-708 SACRAMENTO: Family-oriented prac ce with apprecia ve & loyal pa ent base. 1600sf w 4 ops + 1add’l. $$150k FC-650 FORT BRAGG: Family-oriented prac ce. 5 ops in 2000sf, 6 npts/mo $$350k for the Prac ce & $400k for the Real Estate FC-677 FORT BRAGG: Beau ful, FFS Prac ce, 4 ops +1 add’l, in 2375sf, Gross $1M+/yr $$500k

NORTHERN CALIFORNIA CONTINUED GC-472 ORLAND: Live & practice in charming small town community. 1000sf w/ 2 ops. Seller Retiring $$160k GG-453 CHICO: 5000sf w/ 7 ops. Perfect for 1 or more dentists! $$200k GG-454 PARADISE: 2550sf w/ 9 ops. 40 yrs goodwill! Amazing Oppor-tunity! $$525k GN-606 BUTTE COUNTY: Hesitate & you’ll miss out on this one-of-a-kind opportunity! 1700sf w/ 4 ops $$125k GN-656 NO. TEHAMA CO: Great Loca on! Ideal place to work, live & raise a family! 2468sf w/ 5 ops $275k GN-667 OROVILLE: Great place to work & play! Constant growth a rac ng an influx of residents! 1000sf w/ 3 ops $$295k GN-668 BUTTE COUNTY: Remodeled in 2010! Well-maintained, long-established professional complex. 1200sf w/ 2 ops $$95k GN-717 YUBA CITY: Seller Re ring. All reasonable offers considered. Building available for purchase! 2400sf w/ 5 ops $$475k HN-213 ALTURAS: Well managed w/consistent revenues! CCollected ~$760 in 2016! 2200sf w/ 3 ops + 1 add’l. $$195k HN-280 NORTHEAST CA: Only Practice in Town! 900sf w/ 2 ops $60k HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by increasing office hours! 750sf w/ 2 ops $$95k

CENTRAL VALLEY

IC-468 SAN JOAQUIN VALLEY: High-end restora ve prac ce! 6 ops in 2500+sf office. Call for Details! $$425k IC-715 TRACY: 30+npts/mo. 1600sf, 5 ops +1 add’l. Seller star ng new career $$435k IG-687 TURLOCK: Established quality prac ce - remarkable opportuni-ty! 2000sf w/ 5 ops $$298k JN-690 LINDSAY: Stable, mul -genera onal, loyal & apprecia ve pa-

ent base. 1700sf w/ 3 ops PPrac ce $150k/ Real Estate $150k

SOUTHERN CALIFORNIA

KC-678 LOMPOC & SANTA MARIA: Live & practice along the central coast. Plenty of room for growth, Call for Details! $$240k

SPECIALTY PRACTICES BC-709 HAYWARD Ortho: Provide personalized care to wonderful patient base. 5-8 npt exams/mo, 4 chairs/bay, 1948sf $$215k IC-543 CENTRAL VALLEY Ortho: 1650sf w/ 5 chairs in open bay & plumbed for 2 add’l. Strong referrals and PT base $$125k

Edmond P. Cahill, JD Timothy Giroux, DDS


506 S E P T E M B E R 2 01 7

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

Seeing AI: Talking Camera for the Blind (Free, Microsoft Corp.)

Technology continually evolves to enhance the lives of those with sensory impairment. Powerful mobile devices coupled with the vast array of data from the internet has fueled this evolution to create even more useful applications than ever before. Seeing AI for iOS is one of these applications that gives people with low vision an ability to see things from another perspective. It combines the use of the camera and speakers on mobile devices to translate sight to sound with immediate feedback.

Seeing AI has several modes specifi cally designed to assist the visually impaired with common tasks while using the camera in the background. In Short Text mode, the user simply points the mobile device camera to any text and the app will read aloud any words or sentences that it can detect continuously. With Document mode, the app will search for the borders of a document, snap a picture automatically when it fi nds one and immediately process the photo for words that the user can then subsequently use VoiceOver to read aloud. Product mode scans for barcodes and identifi es products for the user with audio feedback. Person mode allows the user to snap a picture of a person and receive back an audio description of that individual, which includes gender, age and the type of emotion displayed. Users can train the app with a few pictures to recognize specifi c people so that Person Mode can report back actual names of individuals. In Scene mode, users can snap a picture of what is around them and receive back an audio description of their surroundings along with any objects that it recognizes. Audio feedback is built-in for every feature in the app. In low-light conditions, the app automatically utilizes the camera fl ash to increase visibility. All modes are accessible with a swipe and tap at the bottom of the screen. While the app does its best to be accurate, complex typography and nonstandard word alignment have diffi culty being recognized. Additional modes are under development and will be made available with app updates.

Leveraging the power of mobile technologies and the internet, Seeing AI is a welcome assistant to those with low vision. Although not entirely accurate, it off ers a wide array of amazing features that help augment the other dominant senses in a simple and consistent manner. Seeing from another perspective has now become clearer.

— Hubert Chan, DDS

Study Says Facebook Connects the World More Than Any Other Internet ResourceWhen it comes to social media and the internet, many resources are largely used to connect people around the world. A new study by System1 Research has discovered that Facebook is the best at doing that. The consumers surveyed for the study mentioned Facebook two times more than they mentioned Google and 10 times more than Twitter. Internet usage is also ruled by Facebook, according to the study. Around 81 percent of those surveyed said they used Facebook regularly, compared to 79 percent for Google.

— Blake Ellington, Tech Trends editor

Generation Z Purchasing Habits Reveal Diff erences From MillennialsMove over millennials, there is a new generation beginning to enter the marketplace. Generation Z is the generation born after 1995, and a new study says social media is an even bigger infl uence on their purchasing habits. The study, conducted by Kantar Millward Brown, found that Snapchat impacts the purchase decisions of 21 percent of Generation Z, which is double the percentage of millennials. As a whole, social media sways 80 percent of Generation Z when it comes to purchases, compared to 74 percent of millennials. Instagram is also a big infl uencer of Generation Z at 44 percent.

— Blake Ellington, Tech Trends editor

Would you like to write about technology?Dentists interested in contributing to this section should contact Andrea LaMattina, CDE, at [email protected].

Tech Trends

The Artand Scienceof Dentistry

Discover ongoing opportunities to learn, connect and grow:

• See and share the best moments from the convention in our Social Hub

• Catch up on classes you missed online through our on-demand library

• Check with our exhibitors for continuing deals on dental innovations

• Mark your team’s calendar for the convention dates next year

Experience the nation’s leading dental convention.

See what’s next at cdapresents.com.

Keep the CDA Presents energy alive.

Anaheim, CA San Francisco, CA May 17–19, 2018 Sept. 6–8, 2018

Available exclusively from:

This system isn’t only useful for anterior restorations. The Uveneer

template system can also be used for shade selection and to create

mock-ups and temporaries during porcelain veneer fabrication.

IImamagesgesess cococococourttesy ofofofofof DrDDD . SSigagaaig l Jl JJaacocobsobsooonnnnn

Imamagesgesesesesess coc urttttesesesyesyes of DrDr.. Ianan ShuhuS mamann

ImamaaI gessg ccourttesesy ofof DrDrrrrrr. BB. BB. B. B. B. BBob ooooooo Loowwee

With the Uveneer direct composite template system, you can quickly and easily create natural-looking direct composite veneers in one visit.

800.552.5512 | ultradent.com© 2017 Ultradent Products, Inc. All Rights Reserved.

SIMPLE AND VERSATILE

BEFORE

BEFORE

BEFORE

AFTER

AFTER

AFTER

journa - california dental association · 2019-11-18 · suellan go yao, dmd, and james burke fine,...

Documents