NYSDJ April 2021

Remote Learning May be Here to Stay the new york state dental journal

Volume87 Number 3

April 2021

Inside:

Assessing the Value of Peer Review

Should Topical Fluoride Varnish Be Offered in Primary Care Medical Settings?

the new york state dental journal

Volume87 Number 3

April 2021 12

Remote Learning May be Here to Stay the new york state dental journal

Volume 87 Number 3

April 2021

Parents’ Acceptance of Topical Fluoride Varnish in a Primary Care Medical Setting Michelle Ferraioli, D.D.S.; Dana Sirota, M.D., M.P.H.; Christie Lumsden, Ph.D.; Richard Yoon, D.D.S.

Inside:

Survey finds little resistance to acceptance of fluoride varnish application in primary care medical setting, bolstering case for adoption of FV application in medical settings as dental caries primary prevention/early intervention strategy.

Assessing the Value of Peer Review

Should Topical Fluoride Varnish Be Offered in Primary Care Medical Settings?

18

Effectiveness of Remote Didactic Learning for Oral and Maxillofacial Surgery Residents Joshua Segal, D.D.S., M.D.; Monika Patel, D.D.S.

Cover: Parents of young children say they would not change homecare habits or dental routines if their children could receive fluoride varnish in physician’s office.

2 Editorial

It’s game on between dentists

and corporations

Positive response to remote learning strategy adopted during pandemic at downstate medical center suggests practice may have a role in delivery of education post-pandemic.

21

Local Anesthesia with or without Vasoconstrictor in Hypertensive and Diabetic Patients João Vitor da Silva Rodrigues; Luciane Dias de Olveira, Ph.D.; Simone Lapena; Leticia de Miguel Nazario; Tais Maria Cardoso de Oliveira; Alessandre Buhler Borges, Ph.D; Regina El Dib, Ph.D.

6 Attorney on Law

The case for peer review

Authors undertake literature review to investigate systemic effects of using local anesthetic with vasoconstrictor versus without in hypertensive patients with controlled blood pressure and/or controlled diabetes during dental extraction and periodontal or routine dental treatments.

10 Association Activities 35 General News 37 Component News 42 Read, Learn, Earn 43 Classifieds 46 Index to Advertisers 48 Addendum

Cloud Advantage

The New York State Dental Journal is a peer reviewed publication. Opinions expressed by the authors of material included in The New York State Dental Journal do not necessarily represent the policies of the New York State Dental Association or The New York State Dental Journal.

32

Tongue Schwannoma Samuel Fleisher, B.A.; Scott M. Peters, D.D.S.; Louis Mandel, D.D.S. Schwannomas are rarely seen in the oral cavity. When they are, they usually involve the tongue, and because they are encapsulated, they can be bluntly dissected from the tongue’s soft-tissue bed. (Case report)

editorial

The Conglomerate/Consumer Transaction v. The Dentist/Patient Relationship Large corporate entities force themselves into the lineup between dentists and patients in a high stakes game for the conscience of oral healthcare delivery.

D

entistry steps up to the plate. As practitioners, we fight off daily deceptive pitches from managed care organizations (MCOs), product manufacturers and non-dentist-owned practice management organizations. Pitches in the form of onerous contracts, misleading marketing and aggressive business tactics intended to defeat the dentist/patient relationship and replace it with a conglomerate/ consumer transaction. These intrusions corrupt the professional norms and legal standards that currently govern the relationship between dentist and patient with marketplace greed. Dentistry must come to bat to defend our ethical and legal commitments to patients in the face of these powerbrokers’ profit-driven assault on the rights and duties inherent in the dentist/patient relationship to protect our professional status and strengthen society’s trust in our oral healthcare leadership.

Managed Care’s Knuckleball in the Dirt MCOs’ game plan seeks to replace dentists as the primary decision-makers in oral healthcare treatment planning. MCOs sell the bogus myth of bargain basement quality dentistry and need dentists on the sidelines when they design their self-serving strategies. Their cost-containment schemes result in limited benefit plans that attract patient populations that either cannot afford or elect not to routinely pursue optimal oral health. Insidiously, MCOs create an implied MCO/patient relationship that portends to protect patients from what MCOs falsely portray

2 APRIL 2021 The New York State Dental Journal ●

as over-treating dentists otherwise incentivized to provide high-cost, complex procedures.

MCOs lead off and broker deals between these prospective patients, their unions and their employers. They wield their newfound power over these patients’ future choice of dentists as leverage against the dentists available to serve these populations.

Under pressure to retain and attract patients in this market, many dentists succumb to one-sided provider agreements with MCOs. These onerous contracts force dentists into the roles of obedient subcontractors who abdicate their authority in the treatment planning process to MCOs. Here, MCOs deliver their knuckleball in the dirt: fee schedules set intentionally below the costs necessary to deliver services within the legal standard of care and ethically. MCOs toss this erratic pitch with no intent for the ultimate treatment to hit the legal and ethical strike zones. They base these arbitrary fee structures upon aggregate cost calculations that bear no relationship to the actual costs necessary to properly treat individual patients, and are set solely to protect the MCOs’ profit margin.

Regretfully, many dentists swing and sign these provider agreements. However, when dentists act as mere subcontractors bound to follow the MCO business plan, they can miss meeting the legal standard of care and their ethical duty to act in their patients’ best interests. In the best case scenario, dentists do not swing and refuse to agree to terms that hinder or preclude them from achieving these standards.

Product Manufacturers’ Curveballs off the Corner of the Plate The manufacturers’ game plan strives to replace dental researchers and practitioners as patients’ primary sources of scientific information. Manufacturers utilize two curveballs to commercialize the dental literature and promote their products. The first curveball, aimed at dentists, initially appears as a legitimate research publication headed into the strike zone when, in fact, this pitch misses the zone of reliability because the manufacturer bought and paid for the results. When the dental profession fails to expose these conflicts of interest and question the veracity of such studies, we facilitate the flow of misinformation to our patients. As a profession, we must keep our eye on this ball, monitor the commercialization of the dental literature and expose manufacturers’ bias and conflicts of interest whenever appropriate.

The second curveball, misleading online marketing aimed directly at patients, exploits patients’ desire for quick cosmetic fixes, and encourages them to demand procedures that utilize manufacturers’ products from their dentist. These pitches create manufacturer/patient relationships in which manufacturers supply biased information directly to patients and dentists act as mere facilitators to give patients what the manufacturers tell patients they should want. Practitioners must drive this hittable pitch for extra bases and maintain collaborative relationships with our patients, correct misconceptions, dispel any myths falsely created in the exploitive advertising and refuse to treat when patients’ demands would lead to substandard care.

Non-Dentist-Owned Management Organizations’ Fastball Down the Middle Non-dentist-owned management organizations’ game plan aims to commodify dental services and reduce long-term dentist/patient relationships into a series of independent transactions. This commercialized environment works synergistically to enable MCOs to supersede dentists as primary decision-makers and manufacturers to replace dentists and dental researchers as the patients’ primary source of scientific information.

The non-dentist management organizations’ fastball moves quickly and deliberately and overpowers every aspect of the process.

Professionally administered oral healthcare delivery involves uniquely qualified doctors rendering services to patients as part of long-term collaborative relationships and making decisions in the best interests of the patient. The fastball transforms the process to fungible providers selling a commodity to consumers in isolated business transactions making decisions in the best interests of the conglomerate.

Dentists swing and miss when they commercialize their services and place the profit margin of the practice entity above their patients’ best interests. We hit home runs when we, as a profession, advocate against non-dentist practice ownership and management of clinical decision-making. As individual practitioners, we must take the time to maintain an ongoing dialogue with patients, understand what serves their best interests and then deliver it.

The New York State Dental Journal APRIL 2021 3 ●

The Business-Profession Squeeze Play These conglomerates implement a squeeze play when they, as business entities, insert themselves into professional relationships but continue to operate under the lower legal standards of the marketplace, devoid of ethical constraints. They squeeze dentists to do the right thing and treat patients ethically and within the standard of care, for less remuneration, in the form of reduced fees in a managed care plan or lose patients for refusing to contract with MCOs in the first place. Although, these business entities legally must, like everyone in the marketplace, including dentists, avoid misrepresentation and fraud in their activities, unlike dentists, they bear no liability for patient injuries that may result from their business decisions.

Furthermore, conglomerates embrace no obligation to act in the best interests of patients or with a conscience that distinguishes right from wrong. In this maneuver, the conglomerates actually use dentists’ elevated standards and principles against dentists.

Conversely, we, as dentists, cannot, without liability, contract away or abdicate, in any form, our legal duty to treat to the standard of care. No contract provision, manufacturers’ marketing claim or non-dentist management groups’ tactic can provide dentists with a defense to malpractice allegations for patient injuries related to dentists’ substandard care. Most importantly,

we damage our own professional status every time we ignore our conscience and its directives to place the best interests of our patients above corporate and self-interest.

Dentistry’s Conscience Grand Slam We have all heard the voice. It sends signals to guide our decisionmaking and distinguish right from wrong. It coaches us on meeting our ethical obligations. Sometimes we listen; other times, we ignore its advice. The voice represents dentistry’s collective conscience. Society bestowed upon dentistry the privilege of self-regulation in return for our ethical commitment to our patients. Society’s trust that dentistry will do the right thing to protect society from conglomerate attacks on our professional commitments stands as our most valuable asset. When we disregard our conscience, we dissipate this trust.

Dentistry steps into the batter’s box late in the game of today’s competitive practice environment with the bases loaded with opportunities to drive home our professional promises. We must listen to our conscience and hit a grand slam or become one of the conglomerates we oppose.

D.D.S., J.D.

ATTORNEY ON LAW

Want to Know if Peer Review Works for Members?

Value of peer review process is borne out in case that played out over two years in downstate New York.

A

Lance Plunkett, J.D., LL.M.

Council on Ethics member recently reported that an Association member was refusing to participate in a peer review case. Naturally, such refusal will lead to a referral on ethics charges and the likely expulsion of the doctor from membership in the tripartite system. The case will undoubtedly end up in court and in the Office of Professional Discipline (OPD). What a great bargain—trading your membership for a lifetime expulsion, a malpractice lawsuit and an OPD action. As an old song says: “Who could ask for anything more?”

Some members see peer review as an imposition or attack rather than the binding arbitration that, win or lose, prevents malpractice litigation, where damages can far exceed the dental fees at issue in peer review—and in a malpractice case, the patient won’t pay any outstanding fees owed either to get into court.

Does peer review really work? A recent court case decided on Dec. 15, 2020, (Klein v. New York County Dental Society) says it works just fine. A summary of the court case and a good explanation of peer review follows, based primarily on the court’s own words.

How the Case Unfolded On Feb. 2, 2020, the plaintiff, proceeding pro se (that is, representing herself), commenced a small claims action for breach of contract and “unpaid business practices.” (Note: This filing was in response to a peer review case that had concluded in 2019.) In this most recent action, the plaintiff was seeking $2,200 in damages from the New York County Dental Society.

6 APRIL 2021 The New York State Dental Journal ●

A virtual trial was held on Dec. 7, 2020. The plaintiff and her witness, an attorney, testified at the trial. Through her testimony and documentary evidence introduced at trial, the plaintiff established that she received treatment from a dentist for temporomandibular joint dysfunction (TMJ), but was unhappy with the results and sought a refund from that dentist in the amount of $11,030. To that end, the plaintiff agreed to resolve her complaint with the dentist through binding arbitration before a panel established by the New York County Dental Society and governed by the rules and procedures of the New York State Dental Association.

In connection with this arbitration proceeding, the plaintiff executed an Agreement to Submit to Peer Review (the Peer Review Agreement). The Peer Review Agreement provided, in relevant part: 1. This is a legally binding contract to enter into binding arbitration as an alternative dispute resolution process for the purpose of finally resolving the stated dispute between the parties.

Each party to this contract specifically agrees that they waive the right to subsequently sue the other party, on the facts or issues that are the subject of this binding arbitration before the Peer Review Committee in any court action or proceeding, including but not limited to any malpractice action or collection action, except to bring an action or proceeding to enforce this binding

arbitration contract and/or the award of the Peer Review Committee.

4. Each party to this contract specifically agrees that the decision and award of the Peer Review Committee shall be binding as a binding arbitration.

8. We agree not to make any claims against any members of the Peer Review Committee for their acts while performing their duties as members of the Peer Review Committee. Peer Review Committee members enjoy immunity from liability as arbitrators.

10. Appeal of the decision of the Peer Review Committee must be made in writing within thirty days of the date of the decision letter. The Council on Peer Review and Quality Assurance of the New York State Dental Association shall decide any such appeal. We agree further that the grounds for appeal of the Peer Review Committee’s decision are limited to significant procedural irregularities or the discovery of significant new evidence not available at the time of the hearing. The original Peer Review decision shall remain in full force and effect until after a new, final decision is made following a rehearing.

The plaintiff testified at trial that she reviewed the Peer Review Agreement with her counsel prior to signing it and fully understood its terms. The Agreement provided that the peer review committee proceedings would be conducted under the rules set forth in the NYSDA Peer Review Manual. As relevant here, the Peer Review Manual provides as follows: 4.2 Peer Review Hearing Arrangements The chairperson of the component society Peer Review committee shall appoint three (3) members of the standing Peer Review committee to hear the case, and one additional member to serve as chairperson. The chairpersons of the Peer Review hearing committees do not vote or enter into the discussion in Peer Review; they act solely as presiding officers to ensure that NYSDA procedures are followed and the rights of all parties are protected.

4.3 Clinical Examinations Each hearing committee’s members shall independently conduct a clinical assessment of the patient and record his/ her findings on the appropriate NYSDA forms. Hearing committee members shall conduct clinical examinations as they would in any doctor-patient treatment situation. At a Peer Review hearing, patients must be treated in accordance with the same standards of professional conduct, including ethical and clinical considerations, as well as the same level of courtesy and consideration; they would be afforded in the dentists’ own offices.

4.4 The Hearing Clinical Examination of Patient The clinical examination should only take place after a patient has completed and signed a health survey form and it has been ascertained that no medical contra­indications to the examination are present. Clinical examinations shall be carried out only by the three (3) members of the hearing committee individually and in a professional manner. The examiners must be objective in their judgment.

How the Case Ended After an arbitration hearing on Oct. 22, 2018, the plaintiff was awarded a refund of $10,450 by the panel of arbitrators. However, the dentist appealed to NYSDA alleging that a procedural irregularity occurred during the proceeding in that the chairperson of the hearing was involved in the clinical examination of the plaintiff, in violation of the Peer Review Manual. After review of the papers submitted by both sides on appeal, NYSDA granted the appeal and vacated the award.

Accordingly, a new arbitration hearing was held on May 30, 2019, and at the conclusion of this hearing, the plaintiff was awarded $8,250. The plaintiff acknowledged that she was paid

8 APRIL 2021 The New York State Dental Journal ●

this amount by her dentist. She subsequently commenced action against the New York County Dental Society seeking $2,200 (i.e., the difference between the amounts awarded in the first and second arbitration hearings). The plaintiff argued that the vacatur of the first arbitration proceeding was due solely to the defendant’s errors in: 1) allowing the chairperson of the first arbitration hearing to participate in the clinical examination of the plaintiff; and 2) permitting the dentist to use this procedural irregularity as grounds for an appeal when the dentist had failed to raise an objection to it during the hearing itself and, therefore, the defendant should pay her the difference between the awards in the first and second arbitration hearings.

After the plaintiff’s case-in-chief, the defendant (New York County Dental Society) moved for a directed verdict, asking the court to rule that the plaintiff had failed to introduce adequate proof to sustain her case without the defendant needing to present its side of the case. The court granted the defendant’s motion and dismissed the proceeding.

The court stated that to the extent the action sought to vacate or modify the arbitration award, it was barred by the plain terms of the Peer Review Agreement, which provided that the determination of the peer review committee shall be binding on

the plaintiff and that the only avenue for disputing the decision of the peer review committee is by a timely appeal to the NYSDA Council on Peer Review and Quality Assurance. The plaintiff made no such appeal and may not seek such relief here, as arbitration clauses, as contractual agreements, must be enforced according to their terms. The court noted that, in any event, the action is barred by paragraph 8 of the Peer Review Agreement and the doctrine of arbitral immunity. Under this doctrine, arbitrators in contractually agreed upon arbitration proceedings are absolutely immune from liability in damages for all acts within the scope of the arbitral process.

The doctrine of arbitral immunity protects arbitrators, and their organizations, from civil liability for all acts performed in their arbitral capacity. The actions of the peer review committee members at both hearings were indisputably performed in their capacity as arbitrators. The court added that, as such, even if these acts were in error, they were protected by arbitral immunity and, accordingly, as the doctrine of arbitral immunity barred the action, it was thereby dismissed with prejudice.

Because of the due process fairness afforded equally to both parties in the peer review procedure, the court had no problem upholding the action of the New York County Dental Society Peer

Review Committee. The court also made clear that the immunity granted the peer review arbitrators personally extended equally to the component dental society that organizes their arbitral functioning. The component was not liable for the additional monies the patient sought in court. But the dentist could not be sued in court for those additional monies because the binding peer review arbitration prevented that option for the patient. Who could ask for anything more? p The material contained in this column is informational only and does not constitute legal advice. For specific questions, dentists should contact their own attorney.

The New York State Dental Journal

●

APRIL 2021 9

Association Activities NYSDA Hopes New App Will Lead to Healthy Smiles ANYONE who hasn’t done so already, really does need to check out the NYSDA-created app “My HealthySmileNY.” Free to download, and available in both Spanish and English, it’s a platform for all kinds of helpful data, including: • Find a Dentist • Appointment Reminders • Tooth Talk—information on a variety of oral hygiene subjects • A quiz to test the user’s dental IQ There’s even a game to help improve a person’s toothbrushing technique.

The app was designed by NYSDA Director of Health Affairs Betsy Bray. She received help with content formatting from Stephanie Allen, RDH, a certified dental health coordinator, who has been contracted

by NYSDA and is working under a collaborative agreement with Finger Lakes Community Health. Ms. Allen’s role is to increase home utilization, health literacy and decrease no-show rates with caregivers and children enrolled in HeadStart. She is using the app when working one-on-one with families.

NYSDA Joins Multistate Effort to Reduce Opioid-related Deaths NYSDA’S CHEMICAL DEPENDENCY COMMITTEE is participating in a multistate initiative to reduce opioid-related deaths, funded by the National Institutes of Health (NIH) and the Substance Abuse and Mental Health Services Administration. The HEALing (Helping to End Addiction Long-term) Communities Study (HCS) is a four-year initiative that strives to reduce opioid deaths by 40 percent in communities acutely affected by the opioid crisis across four states—New York, Kentucky, Ohio and Massachusetts.

Don Safferstein, the committee’s representative from the Bronx County Dental Society, has been chosen to represent NYSDA on the HCS Community Advisory Board. Membership on the advisory board consists of diverse stakeholders, such as the New York State Department of Health, Office of Substance Abuse Services; New York State Office of Mental Health; and the New York State Assembly.

The collaborative effort is designed to implement evidence-based practices aimed at increasing medication-assisted treatment, expanding naloxone distribution and promoting safer prescribing. Local coalitions receive technical assistance to support planning and implementation of evidence-based practices in their communities to achieve the HCS goals. The project will be implemented in two waves, focused on counties with the highest death rates.

Chemical Dependency Committee members are currently engaged in promoting the initiative in the targeted 16 counties throughout the state.

For more information on the project and the targeted counties, visit: https://heal.nih.gov/research/research-to-practice/healing-communities.

10 APRIL 2021 The New York State Dental Journal ●

NYSDF Unveils Updated Ethics Course AN UPDATED VERSION of the NYSDA ethics course is now available on the New York State Dental Foundation website (www.nysdentalfoundation.org). The course, “Educating the Educated: Ethics & Jurisprudence for the Dental Practitioner,” satisfies the New York State-imposed licensure mandate. Dentists are required to take the course just once in their career.

Course instructors are Dr. Frederick Moore and attorneys Carla Hogan and Lance Plunkett. It is recommended especially for dentists who are moving into New York State who did not fulfill the ethics requirement within their own states or dental residency programs.

Those successfully completing the course earn 3 MCE credits. The cost to take it is $30 for residents, $60 NYSDA members and $120 nonmembers.

Association Activities In Memoriam NEW YORK COUNTY Esther Lim Foreign Dental School 20 West Street, #11J New York, NY 10004 August 1, 2020

SEVENTH DISTRICT Anthony Strazzeri Tufts College ‘54 147 Courtney Drive Fairport, NY 14450 January 18, 2021

FIFTH DISTRICT Robert Callahan St. Louis University ‘55 115 Freedom Boulevard Coatesville, PA 19320 February 15, 2019

Bernard Zeifang University of Pennsylvania ‘59 23 Bromley Road Pittsford, NY 14534 February 18, 2021

Ira Domser Georgetown University ‘47 458 Larchmont Avenue Utica, NY 13502 January 26, 2021

Salvatore Chiappone University at Buffalo ‘44 4872 W. Eddy Drive, Apt. 151 Lewiston, NY 14092 February 22, 2021 Jean Haar University at Buffalo ‘51 1083 Delaware Avenue Buffalo, NY 14209 February 15, 2021 Ronald McMahon

EIGHTH DISTRICT Melvin Block University at Buffalo ‘59 198 Surrey Run Buffalo, NY 14221 September 5, 2020

NINTH DISTRICT James DiCicco Fairleigh Dickinson University ‘60 401 Columbus Avenue, #100 Valhalla, NY 10595 September 29, 2020 NASSAU COUNTY John Cusano Georgetown University ‘55 7 Sherwood Drive Mountain Lakes, NJ 07406 April 6, 2020

University at Buffalo ‘57 1420 Parker Boulevard Buffalo, NY 14223 February 18, 2020

The New York State Dental Journal APRIL 2021 11 ●

Parents’ Acceptance of Topical Fluoride Varnish in a Primary Care Medical Setting Michelle Ferraioli, D.D.S.; Dana Sirota, M.D., M.P.H.; Christie Lumsden, Ph.D.; Richard Yoon, D.D.S.

ABSTRACT Objective: To examine parental knowledge and accep-

allow the primary care physician (PCP) to apply FV,

tance of topical fluoride varnish (FV) use in a primary

98% (n=44) would not stop brushing their child’s

care medical setting for the prevention of dental car-

teeth if FV was applied; and 91% (n=41) would not

ies among high-risk children.

miss routine dental visits if applied in a primary care

Methods: Fifty English-speaking parents of chil-

medical setting.

dren 6 months to 6 years of age presenting for well-

Conclusion: Despite methodological limitations

child visits in the waiting room of a pediatric and

that limit generalization, including small sample size

adolescent community health center in Washington

and recruitment of only English-speaking parents,

Heights, NY, were asked to participate. Following

results suggest that parents of young children are ac-

an explanation of the benefits of FV and application

cepting of FV application in the primary care medi-

method, a 5-minute, 19-item, close-ended question-

cal setting and would not change homecare habits or

naire assessing demographic characteristics, oral

dental routines if FV is applied. These findings sup-

health knowledge and opinions towards FV in a medi-

port the adoption of FV application in primary care

cal setting was completed.

medical settings as a dental caries primary preven-

Results: Out of 50 parents approached, 45 partici-

tion/early intervention strategy.

pated. Sixty percent (n=27) had never heard of FV and, following an explanation of the application method, 67% (n=30) were unconcerned about the temporary discoloration. Ninety-six percent 96% (n=43) would 12 APRIL 2021 The New York State Dental Journal ●

The prevalence of dental caries in low-income U.S. children under the age of 5 is high (34.7%) compared to children from higherincome families (16.5%).[1,2] Further, significantly higher rates are reported for minority groups, particularly Hispanic children.[1,3,4]

As a highly prevalent chronic disease that affects health and wellbeing throughout life, causing pain, infection, and interfering with social and family interactions, caries imposes a significant burden on children and their families.[5] Topical fluoride varnishes (FV) are one of the few evidencebased primary prevention/early intervention treatments available for dental caries in at-risk children, and its use is endorsed by several national health organizations as part of a comprehensive pediatric dental caries prevention education program.[6-8] The efficacy of FV in primary teeth when used at least twice a year has been reported in numerous randomized, controlled trials, which show dental caries reduction rates ranging from 25% to 40%.[9-13] Since parents of very young children see the primary care physician (PCP) earlier (from birth) and more frequently (10 visits by the 18th month of age) than they see the dentist, the primary care medical setting holds potential to effectuate true primary prevention education and anticipatory guidance to combat dental caries.[14,15] Dental caries prevention through PCPs may be a particularly beneficial approach for very high-risk population groups, including low-income, Hispanic and immigrant children, who are disproportionately burdened by dental caries yet often experience numerous barriers to dental care. While, on average, 84% of Medicaid-enrolled children receive a pediatric medical well-child visit, only one-in-three children enrolled in Medicaid visit a dentist at least once a year.[16] Since 2017, Medicaidenrolled PCPs in all states across the U.S. are eligible to receive reimbursement for providing oral health screenings and FV application to young children, further supporting this approach to caries prevention.[17,18,19] The pediatric medical and dental clinics affiliated with Columbia University Medical Center in northern Manhattan serve a very high-risk catchment area, in which preschool children experience dental caries at prevalence rates three-times higher than reported in nationally representative data.[20,21] To inform expansion of dental caries primary prevention efforts by PCPs serving such high-risk populations, the present study sought to evaluate parental oral health knowledge and acceptability of FV application for their children in a primary care medical setting.

Methods This cross-sectional study was conducted at a pediatric and adolescent community health center at the Columbia University Medical Center located in northern Manhattan, in Washington Heights— one of the most economically disadvantaged communities in New York City. This diverse community of approximately 200,000 persons is 71% Latino (the majority from the Dominican Republic), 17% white, 7% black, 3% Asian and 1% other.[22] One-third of the community meets federal poverty guidelines standards.[20-22] A convenience sample of English-speaking parents with children aged 6 months to 6 years who presented to the community

Figure 1. Copy of handout used to explain fluoride varnish application procedure to parents (adapted from Smiles for Life®).23

health center for well-child and sick visits were recruited from the center’s waiting room. After obtaining verbal consent to participate, a single investigator (MF) individually provided participating parents with a verbal explanation of the FV application procedure, including the potential benefit of reduced dental caries and the risk of mild enamel fluorosis, supported by a visual aid (adapted from Smiles for Life®) demonstrating the procedure (Figure 1).[23] Following this two- to three-minute explanation, the parent completed a 19-item, paper-based survey, verbally administered by the investigator, that assessed sociodemographic variables, oral health knowledge and opinions regarding FV application by a PCP.[23] The survey instrument was adapted from a study by Hendaus et al. (2016), who evaluated parental attitudes regarding FV application in a medical setting and its impact on oral health habits.

[24] Sociodemographic questions assessed parent age and child age, number of children under the age of 5 years for whom the parent is the primary caregiver, employment status and high school or GED diploma status. Oral health knowledge questions assessed parental thoughts regarding the influence of diet (content and frequency) on dental health and at-home oral hygiene. Attitudes with respect to FV were determined by assessing parental concerns about FV safety or temporary discoloration, how they felt

The New York State Dental Journal APRIL 2021 13 ●

about allowing PCPs to apply FV, and whether such FV application would affect routine dental visits and oral hygiene behaviors.

Data were collected anonymously, without identifying information, between June 2017 and November 2017. Study procedures, including a waiver of written informed consent, were approved by the Columbia University Medical Center Institutional Review Board (protocol number AAAR2654). Descriptive statistical analyses and Fisher’s Exact tests were completed using SPSS (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY), with statistical significance set at p<0.05.

Results Forty-five parents, out of 50 approached for participation, were enrolled in this study. Just over half of the parents were aged <30 years (56%), with the remainder ranging from 30 to 39 years (35%) and 40 to 50 years (9%). The average age of participating parents was 29 years; children were, on average, 2.8 years of age. The majority of parents reported being the primary caregiver of one child under the age of 5 years (80%, n=36), with few reporting being the caregiver of two or three children under 5 years (18%, n=8 and 2%, n=1, respectively). Over one-quarter of parents (29%, n=13) were unemployed; 33% (n=15) were employed outside the home part time; and 38% (n=17) were employed outside the home full time.

Approximately 80% (n=36) had graduated from high school or received a GED. Findings reveal that 60% (n=27) of parents surveyed had not heard of FV prior to this study. Following an explanation of the FV application procedure, over two-thirds of parents (67%, n=30) were not concerned about the temporary discoloration related to the procedure; 96% (n=43) would allow the PCP to apply FV; 98% (n=44) would not stop brushing their children’s teeth if FV was applied; and 91% (n=41) would not skip routine dental visits if FV was applied in a primary care medical setting (Table 1).

The majority of parents provided accurate responses to knowledge questions with respect to the impact of dietary frequency and content on dental health (Table 1). The majority of

14 APRIL 2021 The New York State Dental Journal ●

parents thought that dental health affects overall health (84%, n=38). Associations between parent education level and questions assessing oral health knowledge (e.g., Do you think snacks such as chips, pretzels, crackers and cereal can affect dental health? Do you think the health of your child’s mouth and dentition affect the rest of the body?) were not statistically significant.

Relationships between parental concerns about safety (i.e., Do you have concerns about the safety of fluoride varnish?) or color of FV (i.e., Would you care about the color of fluoride varnish?) and parent willingness to allow children to receive FV in a primary care medical setting revealed that the majority of parents were not concerned about FV safety (76%, n=34) or temporary discoloration of teeth due to FV application (67%, n=30). Parents who expressed concern about the color or safety of FV were no less likely to allow their PCPs to apply FV for their child than those who had no concerns.

Discussion Though FV application has been shown to be effective in reducing caries incidence (from 25% to 40%),[9-13] most state Medicaid programs reimburse medical providers for its application and oral health screenings in young children[16-17] and national health organizations support the practice—there remains uncertainty among clinicians about the acceptance and impact of FV application by PCPs. There have been anecdotal reports that dentists are concerned that if FV is applied at the pediatrician’s office, parents may think it is a replacement for regular home care or may replace regular dental visits.

While there are several effective approaches to dental caries prevention, available dental services are often underutilized in many high-risk communities.[25] Despite this non-traditional approach, the application of FV in the primary care medical setting holds potential to reduce caries incidence in vulnerable subpopulation groups. The present study sought to address some of these concerns by replicating a study by Hendaus et al. (2016),[24]

the objective of which was to determine parents’ thoughts and attitudes towards FV application in a primary care medical setting

by PCPs, and what impact it might have on oral health habits.

Interestingly, the overwhelming majority (96%) of the parents surveyed in this study within a high-risk population would allow the pediatrician to apply FV. This finding suggests high parental acceptance of this primary prevention and early intervention measure, traditionally dental in nature, being received in a medical setting. These findings are consistent with a study by Adams et al.

(2009), which found a high parental preference for early intervention measures like FV and toothbrushing with a fluoridated dentifrice over other products (e.g., chlorhexidine and xylitol) in a similar population.[25] Adams et al. (2009) studied 211 parents’ preferences for five childhood caries early intervention measures for Hispanic children, concluding that all treatments were highly acceptable, but FV and toothbrushing were preferred over other treatment methods. One reason why parents may be more accepting of topical fluorides could be the familiarity of this early intervention method in the routine and general dental setting.

In the primary care academic medical setting, where interdisciplinary care is foundational, oral health information is often being shared with parents by PCPs, even if the patient has yet

to see the dental provider. Primary care physicians may be emphasizing the importance of seeing a dentist as part of a child’s biannual checkup routine. This may provide some explanation for why nearly all parents in this study reported they would not avoid regular dental visits if FV was applied by the PCP in a primary care medical setting and why no statistically significant associations were found with oral health knowledge variables.

While there have been studies that examined topical FV application in the primary care medical setting, few have focused on parental attitudes and perceptions of FV. Though conducted abroad, the study by Hendaus et al. (2016), on which the present study was based, found similar levels of oral health knowledge and parental acceptability of PCP-applied FV: Greater than 90% of families were aware of dental health as a component of overall health; 70% had never heard of FV but would allow the PCP to apply it; and approximately 80% of parents would not stop brushing their child’s teeth or skip brushing if FV was applied.[24] Similar to the present study, the authors concluded that FV applied in a primary care medical setting was both feasible and acceptable within the community.

Moreover, the study by Adams et al. (2012), which evaluated preferences for early childhood caries intervention methods among 48 parents of young African-American children, also sup-

The New York State Dental Journal APRIL 2021 15 ●

ports high parental acceptability of FV application. Interestingly, while FV and all other treatments assessed were deemed acceptable, toothbrushing was found to be significantly more acceptable to parents than FV and other early intervention measures.[26] These data must be interpreted with caution and may not be widely generalized due to the limitations of the study, including a small sample size and relatively homogeneous population. Further, all aspects of the study were conducted in the English language in a predominantly Hispanic immigrant community where Spanish is commonly spoken. As a result, the conclusions drawn may not accurately reflect parents’ attitudes within the target population.

Despite these limitations, the consistency of responses suggesting parents are supportive of the use of FV for primary prevention has been shown in our study, as well as in studies conducted

by Hendaus et al. (2016),[24] Adams et al. (2009),[25] and Adams et al. (2012).[26] Collectively, these studies represent a much larger sample size of parents from different backgrounds who have similar attitudes regarding the benefits of FV. However, future studies should be conducted with a larger sample size, including both English- and Spanish-speaking participants, to gain a more precise understanding of parental knowledge and opinions regarding topical FV application.

The findings of this study support the use of topical FV as a primary dental caries prevention modality in the primary care medical setting. This approach has the potential to decrease caries incidence, particularly in underserved communities that generally suffer the greatest burden of disease, since children see the PCP significantly more in the first few years of life than they do dental professionals.[14] Understanding parents’ attitudes can help the PCP and the dentist provide better preventive care with an overall goal of reducing the burden of dental disease in high-risk communities. Findings support the use of dental interventions in a medical setting as part of a primary prevention education and anticipatory guidance scheme.

Subsequent evaluation with a larger sample may provide additional insight into ways in which early intervention and medical-dental care programs may be tailored for high-risk communities. p Authors’ research was supported by Health Resources and Services Administration/ DHHS, Postdoctoral Training in General, Pediatric and Public Health Dentistry, D88HP20109. The authors report no conflict of interest in the preparation of this paper. Queries about this article can be sent to Dr. Yoon at rky1@cumc.columbia.edu.

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Dye BA, Mitnik GL, Iafolla TJ, Vargas CM. Trends in dental caries in children and adolescents according to poverty status in the United States from 1999 through 2004 and from 2011 through 2014. J Am Dent Assoc 2017 Aug 1;148(8):550-65.

Benjamin RM. Oral health: the silent epidemic. Public Health Rep 2010;125(2):158-159.

Macek MD, Heller KE, Selwitz RH, Manz MC. Is 75 percent of dental caries really found in 25 percent of the population? J Public Health Dent 2004;64(1):20-25.

Dye BA, Hsu KL, Afful J. Prevalence and measurement of dental caries in young children.

Pediatr Dent 2015;37(3):200-16.

U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. National Institute of Dental and Craniofacial Research, National Institutes of Health, U.S. Department of Health and Human Services: Rockville, MD: 2000.

Available at: https://www.nidcr.nih.go /DataStatistics/SurgeonGeneral/Documents/ hck1ocv.@www.surgeon.fullrpt.pdf. Accessed January 4, 2018.

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American Academy of Pediatric Dentistry. Fluoride Therapy. Pediatr Dent 2017;39(6):242-245.

Weyant RJ, Tracy SL, Anselmo TT, et al. American Dental Association Council on Scientific Affairs Expert Panel on Topical Fluoride Caries Preventive Agents. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc 2013;144(11):1279-91.

Moyer VA. US Preventive Services Task Force. Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.

Pediatrics 2014;133(6):1102-11.

Holm AK. Effect of fluoride varnish (Duraphat) in preschool children. Community Dent Oral Epidemiol 1979;7(5):241-5.

Clark DC, Stamm JW, Robert G, Tessier C. Results of a 32-month fluoride varnish study in Sherbrooke and Lac-Megantic, Canada. J Am Dent Assoc 1985;111(6):949-53.

Autio-Gold JT, Courts F. Assessing the effect of fluoride varnish on early enamel carious lesions in the primary dentition. J Am Dent Assoc 2001;132(9):1247-53.

Weintraub JA, Ramos-Gomez F, Jue B, et al. Fluoride varnish efficacy in preventing early childhood caries. J Dent Res 2006;85(2):172-6.

Bonetti D, Clarkson JE. Fluoride varnish for caries prevention: efficacy and implementation.

Caries Res 2016;50(1):45-49.

Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.

Kolstad C, Zavras A, Yoon RK. Cost-benefit analysis of the age one dental visit for the privately insured. Pediatr Dent 2015;37(4):376-380.

Bouchery E. Utilization of dental services among Medicaid-enrolled children. Medicare & Medicaid Research Review. 2013;3(3):mmrr.003.03.b04. doi:10.5600/mmrr.003.03.b04.

Isong IA, Silk H, Rao SR, Perrin JM, Savageau JA, Donelan K. Provision of fluoride varnish to Medicaid-enrolled children by physicians: the Massachusetts experience. Health Serv Res 2011;46(6 Pt 1):1843-1862.

Kranz AM, Rozier RG, Preisser JS, Stearns SC, Weinberger M, Lee JY. Preventive services by medical and dental providers and treatment outcomes. J Dent Res 2014;93(7):633-638.

Reimbursing physicians for fluoride varnish. Pew Research Center. Accessed July 13, 2018 at http://www.pewtrusts.org/en/research-and-analysis/articles/2011/08/29/reimbursingphysicians-for-fluoride-varnish.

Prevalence of Untreated Dental Caries in Primary Teeth Among Children Aged 2-8 Years, by Age Group and Race/Hispanic Origin—National Health and Nutrition Examination Survey, 2011–2014. MMWR Morb Mortal Wkly Rep. 2017;66:261.

Albert DA, Findley S, Mitchell DA, Park K, McManus JM. Dental caries among disadvantaged 3- to 4-year-old children in northern Manhattan. Pediatr Dent 2002;24(3):229-233.

King L, Hinterland K, Dragan KL, Driver CR, Harris TG, Gwynn RC, Linos N, Barbot O, Bassett MT. Community Health Profiles 2015, Manhattan Community District 12: Washington Heights and Inwood; 2015;12(59):1-16.

Silk H, Douglass A, Clark M, et al. Smiles for Life National Oral Health Curriculum: Module 6. Fluoride Varnish. MedEdPORTAL Publications. 2012.

Hendaus M, Jamha H, Siddiqui F, Elsiddig S, Alhammadi A. Parental preference for fluoride varnish: a new concept in a rapidly developing nation. Patient Prefer Adherence 2016;10:1227-1233.

Adams SH, Hyde S, Gansky SA. Caregiver acceptability and preferences for early childhood caries preventive treatments for Hispanic children. J Public Health Dent 2009;69(4):217-224.

Adams SH, Rowe CR, Gansky SA, Cheng NF, Barker JC, Hyde S. Caregiver acceptability and preferences for preventive dental treatments for young African-American children. J Public Health Dent 2012;72(3):252-260.

Effectiveness of Remote Didactic Learning for Oral and Maxillofacial Surgery Residents Joshua D. Segal, D.D.S., M.D.; Monika Patel, D.D.S.

ABSTRACT The novel coronavirus (SARS-CoV-2) pandemic has had a profound effect upon the clinical and didactic learning of oral and maxillofacial surgery residents.

Restrictions on the assembly of residents for teaching sessions significantly limited the residents’ exposure to interactive didactic material. The Division of Oral and Maxillofacial Surgery at Northwell Health/Long Island Jewish Medical Center responded to this educational deficit by establishing a grassroots cooperative lecture series among over 20 oral and maxillofacial residency programs. Following the lecture series, in order to evaluate the effectiveness of this strategy, an electronic survey was sent to participants. Questions focused on

act, and many specialties have transitioned to telehealth models to accommodate “social distancing” guidelines put in place by the World Health Organization and the United States Centers for Disease Control and Prevention.[1,2]This has inevitably affected our ability to gather as residents for didactic lectures and discussions, and a transition has taken place to a virtual learning model.

Within our oral and maxillofacial surgery community, academic programs and associations have been taking the initiative to develop educational content for trainees and practitioners. The Division of Oral and Maxillofacial Surgery at Northwell Health/ Long Island Jewish Medical Center established a lecture series with almost 400 participants. A survey was subsequently distributed to assess the effectiveness of this learning environment. Previous research has suggested that e-learning can have a positive effect on knowledge acquisition across a wide range of learners related to health professions,[3] and the evaluation of the effectiveness of virtual learning is important for learners and educators alike.

the subjective assessment of learning outcomes, comparing online lectures to those in a traditional setting.

The report presented here summarizes the overall responses (19.3%) received from participants.

The novel coronavirus (SARS-CoV-2) pandemic has dramatically changed the way in which many facets of healthcare institutions function. It has necessitated a paradigm shift in the way we inter-

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Methods An electronic survey, approved by the Institutional Review Board of Northwell Health, was launched between June 2020 and July 2020 among oral and maxillofacial surgery residents and attendings who were present at a weekly virtual lecture series organized by the Northwell Health/Long Island Jewish Medical Center residency program. The survey was performed using the Survey Monkey online platform. A link to the anonymous survey, along with

a general introduction and consent, was sent by email to 399 participants on June 30, 2020. All attendees of the virtual lecture series who provided e-mail addresses were included in the email.

A second round of e-mails was sent 15 days later, in July 2020. Collection of responses was closed on July 15, 2020, three weeks after the initial email. Five general questions were asked in the survey (Figure 1).

All five questions offered multiple choice answers, allowing the responses to reflect if the participant thought lecture engagement and retention of knowledge were more, less or the same to that of a traditional learning setting. It also inquired whether the participant was exposed to a broader curriculum when compared to a traditional setting. For the survey to be submitted, all questions had to be answered.

Results Of the 399 unique participants who were invited to take part in the survey, 77 (19.3%) returned responses. The distribution of respondents is listed in Table 2. It included residents, attend-

The New York State Dental Journal APRIL 2021 19 ●

ings and dental students, with a majority being PGY-4 residents (29.6%) and attending surgeons (24.7%). A majority of participants (86%) heard of the lecture series through their program director.

When asked how virtual learning compared with traditional learning with respect to engagement with the lecture, 60% of respondents felt virtual learning was equally engaging; 19.5% felt it was less engaging; and 18% responded that virtual learning was more engaging than a traditional lecture. A statistically significant number of participants believed the lectures had equal engagement, as shown with ANOVA (p < 0.009), while there was no difference between less engagement and more engagement.

Despite the mixed reaction to the engagement in the lecture, when asked about knowledge retention of virtual lectures, 96% of respondents felt that retention was equal to or greater than that of a traditional setting (p < 0.003). An overwhelming majority 83% (n=72) felt that the virtual lecture series exposed learners to topics not in their traditional curriculum.

Discussion The Northwell Health/Long Island Jewish Medical Center lecture series was initiated on April 2, 2020, and commenced on July

9, 2020. The lectures were presented via Zoom every week, on Thursdays, at 1830h Eastern Standard Time. The lecture topics, listed in Table 1, were determined by the invited speaker based on a specific area of interest or expertise. They were quite variable, which was appropriate given that the lectures were supplements and not replacements for existing curriculum. The virtual lectures were synchronous learning experiences that concluded with an interactive question and answer period.

The responses received from this particular study suggest that the retention of knowledge from remote learning was equal to or better than from traditional lectures, regardless of training level.

The lectures exposed participants to material that they were not exposed to in the past, presumably as a result of exposure to different practices at various institutions in wide geographic regions.

Anecdotally, the lectures provided a sense of community among the programs, as was expressed by many of the participants.

The results of this survey suggest that the virtual learning platform provides a viable infrastructure for training residents that encourages collaboration between programs. Remote learning has the potential to play an effective role in education, even in the post-COVID-19 era. p Queries about this article can be sent to Dr. Segal at jsegal@northwell.edu.

REFERENCES 1.

2.

3.

CDC. Public Health Recommendations after Travel-Associated COVID-19 Exposure. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). https:// www.cdc. gov/coronavirus/2019-ncov/php/risk-assessment.html. Accessed Apr 2 2020.

WHO. Coronavirus Disease (COVID-19) Advice for the Public. World Health Organization. Coronavirus disease 2019. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advic e-for-public. Accessed Apr 2 2020.

Liu Q, Peng W, Zhang F, Hu R, Li Y, Yan W. The effectiveness of blended learning in health professions: systematic review and meta-analysis. J Med Internet Res 2016;18(1):e2

Joshua D. Segal, D.D.S., M.D., FACS, is program director, oral and maxillofacial surgery, Northwell Health/Long Island Jewish Medical Center, New Hyde Park, NY, assistant professor, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, and assistant investigator, Feinstein Institutes for Medical Research, Manhasset, NY. Monika Patel, D.D.S., is chief resident, oral and maxillofacial surgery, Northwell Health/ Long Island Jewish Medical Center, New Hyde Park, NY.

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Local Anesthesia with or without Vasoconstrictor in Hypertensive and Diabetic Patients João Vitor da Silva Rodrigues; Luciane Dias de Oliveira, Ph.D.; Simone Lapena; Letícia de Miguel Nazario; Taís Maria Cardoso de Oliveira; Alessandra Buhler Borges, Ph.D.; Regina El Dib, Ph.D.

ABSTRACT Hypertensive and diabetic patients present a public health issue. Vasoconstrictors have been added to local anesthetics to increase the length of the anesthetic effect during dental procedures. However, there is no consensus showing whether local anesthetic is safer with or without vasoconstrictors in this population.

This paper is a systematic review of the literature, undertaken to investigate the systemic effects resulting from the use of any local anesthetic with either adrenergic or non-adrenergic vasoconstrictor versus local anesthetic without vasoconstrictor in hypertensive patients with controlled blood pressure and/ or controlled diabetes during dental extraction, and periodontal or routine dental treatments.

The number of people with diabetes and hypertension is increasing globally. Despite being preventable, diabetes mellitus (DM) and hypertension fall among the top 10 leading causes of death globally.[1] In 2017, around 425 million people had DM; and this number is expected to rise to 629 million by 2045.[2] This estimate includes people diagnosed with the disease and patients sus-

pected of having DM.[2] The arterial hypertension affects about one billion people worldwide.[3] It is estimated that by 2025, up to 1.56 billion adults worldwide will be hypertensive.[4] Usually, elevated blood pressure is the leading risk factor for mortality and morbidity, accounting for 7% of disability, adjusted life years, and 9.4 million deaths in 2010.[5] About 75% of DM patients will develop hypertension over time. The rate at which hypertension co-exists with diabetes is such that diabetics are 1.5to 2-times more likely to be hypertensive than their non-diabetic counterparts.[6] Some soft-tissue abnormalities associated with oral DM problems were reported. They included xerostomia, cavities and periodontal diseases that require dental care.[7] The oral manifestations reported by hypertensive patients were related to the adverse effects of the antihypertensive drugs, including xerostomia, gingival hyperplasia manifested by pain, gingival bleeding and difficulty chewing.[8] Special care should be given to both DM and hypertensive patients undergoing dental procedures regardless of the reason that led them to treatment.

Local anesthetics are the most commonly used drugs in dentistry, and the usual method for controlling pain in dental practice.[9] Local anesthesia is induced when the propagation of action potentials is avoided, so that the impulse cannot be transmitted from the source of stimulation, such as the tooth or the periodontium, to the brain. Local anesthetics act by blocking the entry of

The New York State Dental Journal APRIL 2021 21 ●

sodium ions into their channels, thus preventing the transient increase in the permeability of the nerve membrane to sodium, which is necessary for an action to occur. Nevertheless, local anesthetics cause vasodilation, which diffuses away from the site of action and results in a very short duration of action intraorally when these drugs are used alone.[10] This diffusion can be reduced by the addition of a vasoconstrictor, usually epinephrine.

For this reason, vasoconstrictors are added in many formulations in order to delay the clearance of the local anesthetic and prolong the anesthesia. This is particularly important because the local anesthetics themselves vary in their capacity to produce vasodilation. For example, when used without vasoconstrictors, lidocaine shortens its duration dilating the local vasculature, while mepivacaine and bupivacaine do not.[11] However, some studies have shown potential side effects that may result in dentists’ uncertainty about the choice of anesthetics.[12-15] A recent study indicated that the vasoconstrictor felypressin, combined with prilocaine, produced similar cardiac effects as epinephrine combined with lidocaine.[16] We, therefore, conducted a systematic review that assessed the systemic effects of any local anesthetic (e.g., prilocaine, mepivacaine, bupivacaine) with either adrenergic (e.g., epinephrine) or non-adrenergic (e.g., felypressin) vasoconstrictor versus local anesthetic without vasoconstrictor among hypertensive patients with controlled blood pressure (BP) and/or controlled diabetes, presenting for dental extraction, periodontal or routine dental treatments, regardless of numbers of anesthetics cartridges or concentration, and type of patient with diabetes.

Methods The Cochrane Handbook for Intervention Reviews[17] guided our choice of methods. Our systematic review results were conducted and reported in accordance with the PRISMA (Preferred Reposting Items for Systematic Reviews and Meta-analysis) statement.[18] This review was registered at PROSPERO, the International Prospective Register of Systematic Reviews (http:// www.crd.york.ac.uk/prospero/index.asp), under the number CRD42018095626.

Eligibility Criteria All randomized (RCTs) and non-randomized clinical trials (nonRCTs) evaluating any local anesthetics (e.g., mepivacaine, bupivacaine, prilocaine) with adrenergic (e.g., epinephrine) or non-adrenergic (e.g., felypressin) vasoconstrictor versus local anesthetic without vasoconstrictor among hypertensive patients and/or patients with controlled diabetes presenting for dental extraction, periodontal or routine dental treatments were considered, regardless of numbers of anesthetics cartridges or concentration, and type of patients with diabetes. Patients under

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antihypertensive treatment and with controlled blood pressure (BP) (i.e., systolic and diastolic BP lower than 140/90 mmHg, respectively) were considered hypertensive patients. Controlled diabetic patients were considered as patients under diet control, on insulin injection, or oral hypoglycaemic medication. Pregnant women and pediatric patients (age 12 or under) were excluded.

Patient-important outcomes were as followed: a) complications, such as arrhythmias, unstable angina; b) hemodynamic parameters, such as systolic and diastolic blood pressure, heart rate, ejection fraction (%), and ventricular function; and c) any other outcome reported by the included studies.

Data Source and Searches The search was performed in the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL, 1, 2018); PubMed (OvidSP, 1966 to 2018); EMBASE (Excerpta Medica database) (OvidSP, 1980 to 2018); LILACS (Literatura Latino-americana e do Caribe em Ciências da Saúde) (1982 to 2018); and the ISI Web of Science. The databases were searched for published studies from inception up to Feb. 21, 2018.

The search was conducted using multiple combinations of the following key words: “hypertension,” “diabetes,” “local anesthetics” and “vasoconstrictors” (Appendix Table 1). No restrictions were placed on language, year of publication or publication status. In addition, a manual search of the reference lists of po-

tential primary studies was conducted, and major conferences for abstracts were hand-searched for additional eligible studies.

Selection of Studies Using standardized screening forms, three teams of two reviewers independently screened all titles and abstracts identified by the literature search, obtained full-text articles of all potentially eligible studies and evaluated these studies for eligibility. Reviewers resolved disagreement through discussion, with third party adjudication if necessary.

Data Extraction and Risk of Bias Assessment Two pairs of reviewers independently extracted the following data using a pre-piloted, standardized data extraction form: characteristics of the study design; participants; interventions; outcomes; and follow-up periods. Authors were contacted for clarification if eligible articles had missing data.

Reviewers independently assessed risk of bias using the riskof-bias approach for Cochrane reviews modified by Busse and Guyatt.[19] Risk of bias was assessed using five separate criteria: adequacy of sequence generation; allocation sequence concealment; blinding (investigators, patients, collectors, statistician, outcome assessors); incomplete outcome data; and selective outcome reporting. For incomplete outcome data, loss to follow-up of less than 10%, and a difference of 5% in missing data between intervention and control groups as low risk of bias were considered.

Certainty of Evidence The reviewers used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate certainty of evidence for each outcome as high, moderate, low or very low.

Detailed GRADE guidance was used to assess overall risk of bias,[20] imprecision,[21] inconsistency,[22] indirectness[23] and publication bias,[24] and results were summarized in an evidence profile.

Data Synthesis and Statistical Analysis We planned to perform meta-analysis; however, this was not possible due to the small number of included studies and lack of data. Risk ratios (RRs) were planned to be calculated for dichotomous outcomes (i.e., one that takes on one of only two possible values when observed or measured, e.g., have arrhythmia or not having it) while mean differences (MD) for continuous variables (i.e., measurement on a numerical scale, e.g., blood pressure mean values), with the associated 95% confidence interval (CI) using a random-effects model with the Mantel-Haenszel statistical method. The variability in results was planned to address across studies by using I2 statistic and the P value obtained from the Cochrane chi square test. Our primary analyses were on eligible patients who had reported outcomes for each study (complete case analysis).

The New York State Dental Journal APRIL 2021 23 ●

Subgroup analyses were planned accordingly to: different local anesthetics (e.g., mepivacaine versus prilocaine); different vasoconstrictors (e.g. adrenergic versus non-adrenergic); different duration of local anesthetics (e.g., ≤ 2 hours vs > 2 hours); different dental procedures (e.g., dental extraction versus implant); different studied population (e.g., hypertensive versus diabetic patients).

Based on guidance from the Cochrane Handbook, we planned to assess publication bias using visual inspection of funnel plots for outcomes with 10 or more studies; however, we were not able to assess it because there was an insufficient number of included studies to allow for this assessment.

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Review Manager (RevMan) (version 5.3; Nordic Cochrane Centre, Cochrane) was used for all analyses.[25] Results Search Results Figure 1 presents the process of identifying eligible studies, including citations identified through search in electronic databases.

Based on title and abstract screening, 57 full texts were assessed.

From these, we included four publications describing two RCTs involving 136 participants [26,27] and two non-RCTs with a total of 104 participants.[28,29]

Characteristics of Included Studies Table 1 describes study characteristics related to study design, setting, number of participants, mean age, gender, inclusion and exclusion criteria, and follow-up. All included studies[26-29] were conducted largely in Brazil. Randomized trials sample size ranged from 6,526 to 7,127, and non-RCTs studies from 5,428 to 5,029.

Table 2 describes study characteristics related to oral procedure, intervention and control groups, and local anesthetic and vasoconstrictors. Two studies were conducted during a dental extraction,[28, 29] one[26] during a routine dental procedure, and the other[27] a periodontal treatment. Of the four studies, one compared prilocaine 3% associated with felypressin 0.03 IU/ml to lidocaine 2% without vasoconstrictor,[26] another to prilocaine 4% without vasoconstrictor to prilocaine 4% associated with felypressin 0.03 IU/ml,[27] and the third compared mepivacaine 2% associated with epinephrine 1:100.000 to mepivacaine 3% without vasoconstrictors.[28] The last compared prilocaine 3% associated with felypressin 0.03 IU/ml versus lidocaine 2% associated with epinephrine 1:100.000.[29] Risk of Bias in Individual Studies Figure 2 and Table 3 describe the risk-of-bias assessment for the included studies. The major issues regarding risk of bias were the

extent of allocation concealment, and blinding of both investigators and outcome assessors in all included studies. Non-RCTs had additional problems of generation of allocation[28, 29] and blinding of participants.[28] Effectiveness of Interventions We found four eligible trials in which three[26, 27, 29] were eligible for representation of meta-analysis. The insufficient number of included studies, lack of data, and difference between dental procedure and local anesthetics used precluded potential meta-analysis.

Mepivacaine with Epinephrine and Mepivacaine Only Results from one non-RCT28 suggest a possible decrease in symptom periprocedural (pain at dental luxation) with mepivacaine plus epinephrine in comparison to mepivacaine only (RR 0.11, 95% CI 0.02, 0.82; p = 0.03; I2=not applicable) (Appendix tables 2,4). However, related to the outcomes ST-segment alteration indicating the occurrence of myocardial ischemia (depression > 1.0mm) and CKMB mass abnormal, there were no statistically significant differences between mepivacaine with epinephrine and mepivacaine only (RR 6.73, 95% CI 0.37 to 123.79; p = 0.20; I2=not applicable; and RR 5.00, 95% CI 0.25 to 99.51; p = 0.29; I2=not applicable; respectively) (Appendix tables 2, 4).

The New York State Dental Journal APRIL 2021 25 ●

Prilocaine with Felypressin versus Lidocaine Only Results from one RCT26 suggest a reduction in the ventricular function 30-50 with the use of prilocaine associated with felypressin versus lidocaine only in patients with coronariopathy (RR 0.22, 95% CI 0.05 to 0.93; p = 0.04; I2=not applicable) (Appendix tables 2,4). There was no statistically significant difference between prilocaine with felypressin versus lidocaine alone related to the other ventricular function’s variables (Appendix tables 2,4).

Lidocaine with Epinephrine versus Prilocaine with Felypressin Results from one non-RCT29 suggest a reduction in both systolic and diastolic blood pressures (MD -9.20, 95% CI -17.24 to -1.16; p = 0.02; I2=not applicable; and MD -9.00, 95% CI -15.48 to -2.52; p = 0.006; I2=not applicable, respectively) with the use of lidocaine with epinephrine compared to prilocaine with felypressin (Appendix tables 3,4).

Discussion Main Findings The use of adrenergic vasoconstrictors in local anesthesia in patients with cardiovascular diseases and/or diabetes is highly questionable in dentistry, since the use of epinephrine over felypressin has benefits, such as hemostasis during surgical procedures, and considering the fact that epinephrine can also be associated with widely used anesthetics in dentistry, such as articaine, lidocaine and mepivacaine. On the other hand, there is the possibility of epinephrine (even in small amounts) altering the patient’s systemic condition, which may increase blood pressure and/or blood glucose levels. The indication for epinephrine has been based on the control of a patient’s systemic disease, blood glucose and blood pressure levels at the time of treatment and according to the dental clinical case (e.g., degree of anesthesia and hemostasis required).

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There is very limited evidence regarding the impact of any local anesthetic (e.g., prilocaine, mepivacaine, bupivacaine) in combination with either adrenergic (e.g., epinephrine) or nonadrenergic (e.g., felypressin) vasoconstrictor among hypertensive patients with controlled blood pressure (BP) and/or controlled diabetes, presenting for dental procedures.

There is little evidence that the use of mepivacaine with epinephrine demonstrated a statistically significant difference in decreasing pain at dental luxation in coronary patients, compared to mepivacaine alone. Furthermore, prilocaine with felypressin proved to be more efficacious than lidocaine alone in reducing ventricular function in patients with Chagas disease or coronaropathy with complex ventricular arrhythmia. Related to the comparison, lidocaine with epinephrine is more effective than prilocaine with felypressin. There was a reduction in both systolic and diastolic blood pressures with the use of the former compared to the latter in hypertensive patients undergoing conventional exodontia. No statistically significant difference was found in chest pain, palpitation, diaphoresis, dyspnea, ST-segment alteration, CKMB activities and Troponin T. Strengths and Limitations Strengths of our review include a comprehensive search; assessment of eligibility, risk of bias and data abstraction independently and in duplicate; assessment of risk of bias; and use of the GRADE approach in rating the certainty of evidence for each outcome.

The primary limitation of our review is the low certainty consequent on study limitations. Only a very small number of RCTs and non-RCTs were identified, with a modest number of participants. We planned to perform meta-analysis; however, this was not possible due to the small number of included studies and lack of data. Moreover, we could not address our hypothesis on diabetic patients due to lack of evidence.

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Another limitation of this review was the insufficient number of included studies to allow the priori analysis. We were not able to assess publication bias because there were fewer than 10 eligible studies addressing the same outcome in a metaanalysis. Subgroup analyses were also planned according to the characteristics of different local anesthetics (e.g., mepivacaine versus prilocaine); vasoconstrictors (e.g., adrenergic versus nonadrenergic); duration of local anesthetics (e.g., ≤ 2 hours vs > 2 hours); and dental procedures (e.g., dental extraction versus implant); different studied population (e.g., hypertensive versus diabetic patients).

However, we were not able to conduct these analyses because there was an insufficient number of studies reporting on these data.

Synopsis of Included Trials Louro et al. (2001),[29] compared the effects of prilocaine 3% associated to felypressin 0.03 IU/mL with 2% lidocaine associated to 1:100,000 epinephrine on blood pressure in hypertensive patients undergoing conventional exodontia. The authors found that 1:100,000 epinephrine and 0.03 IU felypressin can be used safely in hypertensive patients, provided they adhere to their maximum doses. According to the authors, pain control, through adequate anesthesia, and reduction of anxiety, through emotional control of the patient, is very important to avoid cardiovascular complications in the dental office.

Furthermore, Conrado et al. (2007),[28] evaluated the occurrence of variables detecting ischemia during or after dental treatment under anesthesia with vasoconstrictor epinephrine

The New York State Dental Journal APRIL 2021 29 ●

and verified that dental extraction performed under anesthesia with 1:100,000 epinephrine does not imply additional ischemic risks, as long as it is performed with good anesthetic technique and maintenance of the pharmacological treatment prescribed by the cardiologist. These studies are of great importance for dentistry because the use of epinephrine has advantages in local anesthesia and if used in low doses with the correct anesthetic technique, may be recommended in patients with controlled cardiovascular diseases.

According to Malamed (1986)[30] and Bennett (1984),[31] the maximum dose of epinephrine that the patient with controlled cardiovascular disease can receive per treatment session is 0.04 mg, equivalent to 2 epinephrine tubes 1:100,000 or 4 epinephrine tubes 1:200,000. Therefore, according to our findings, epinephrine is not contraindicated in patients with cardiovascular diseases. But its use should be minimized and always associated with a good anesthetic technique, respecting the control of the pain.

Regarding the non-adrenergic vasoconstrictor, Cáceres et al. (2008),[26] evaluated the hemodynamic effects of the use of local anesthetics with a non-adrenergic vasoconstrictor in patients with ventricular arrhythmia, when compared to the use of anesthetic without vasoconstrictor. The results suggested that prilocaine 3% associated with a felypressin 0.03 IU/mL can be safely used in patients with Chagas disease or coronaropathy with complex ventricular arrhythmia. Although this study was wellconducted and with relevant contributions, the comparison was performed with lidocaine without vasoconstrictor, which offers a very short time of pulpal and periodontal anesthesia, not a choice in dental procedures. Thus, in cases where there is contraindication to the use of epinephrine, the choice of prilocaine 3% associated with a felypressin 0.03 IU / mL is the most recommended, since it offers a longer time of anesthesia in relation to lidocaine without associated vasoconstrictor.

In this context, Bronzo et al. (2011),[27] investigated the effect of felypressin on blood pressure in hypertensive patients with controlled blood pressure and verified that felypressin increased the diastolic blood pressure of hypertensive patients with controlled blood pressure. Patients with high trait anxiety exhibited increases in systolic blood pressure during some procedures, suggesting that an increase in blood pressure might also be related to fear or anxiety. Since many patients are afraid of dental procedures, especially of the needle used in the anesthesia, it is common in these anxious patients to experience high endogenous release of adrenaline, which can promote a significant increase of pressure levels, because during a moment of stress, secreted catecholamines reach serum levels much higher than the doses used in dentistry. Thus, control of the patient’s fear and anxiety may be more important than the choice of the vasoconstrictor, since changes in blood pressure or blood glucose are also directly related to emotion, and it is complex to define a specific treatment protocol.

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In conducting this review, we have attempted to answer several clinical questions.

• Is mepivacaine with epinephrine more effective than mepivacaine alone? Does the combination of anesthetic alter the patient’s systemic condition?

• Very low- to low-quality evidence suggests that mepivacaine with epinephrine is more effective than mepivacaine alone in decreasing pain at dental luxation; however, there was no evidence to suggest a difference in chest pain, palpitation, diaphoresis, dyspnea, ST-segment alteration, CKMB activities and Troponin T. • Is prilocaine with felypressin more effective than lidocaine alone? Does the combination of anesthetic alter the patient’s systemic condition?

• Very low- to low-quality evidence suggests that prilocaine with felypressin is more effective than lidocaine alone in reducing ventricular function.

• Is lidocaine with epinephrine more effective than prilocaine with felypressin? Does the combination of anesthetic alter the patient’s systemic condition?

• Low-quality evidence suggests that lidocaine with epinephrine is more effective than prilocaine with felypressin in reducing both systolic and diastolic blood pressures.

Conclusions There is no robust evidence regarding the systemic effects of local anesthesia, with or without vasoconstrictor, in hypertensive and/ or diabetic patients during dental extraction, and periodontal or routine dental treatments. Therefore, in the face of lack of data, dentists should consider patient values and preferences related to the choice of anesthesia and their past experience and own preferences. This review underlines the need to conduct well-designed trials in this field considering diabetic patients. p The authors have no conflicts of interest. Regina El Dib received a Brazilian Research Council (CNPq) scholarship (CNPq 310953/2015-4). Queries about this article can be sent to Dr. El Dib at el.dib@unesp.br.

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Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455): 217–23 doi.org/10.1016/ S0140-6736(05)17741-1.

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Singh P. An emphasis on the wide usage and important role of local anesthesia in dentistry: a strategic review. Dent Res J 2012; 9(2): 127-132.

Subramaniam S, Neelakantan P. Local anesthesia in dentistry—Clinical considerations. Int. J. Drug Dev & Res 2013;5(4):30-36.

Haas DA. An update on local anesthetics in dentistry. J Can Dent Assoc 2002;68:546–51.

Liu W, Yang X, Li C, Mo A. Adverse drug reactions to local anesthetics: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115(3):319-27. doi:10.1016/j. oooo.2012.04.024.

Kaufman E, Goharian S, Katz Y. Adverse reactions triggered by dental local anesthetics: a clinical survey. Anesth Prog 2000;47:134-138.

Karm M-H, Kim M, Park FD, Seo K-S, Kim HJ. Comparative evaluation of the efficacy, safety, and hemostatic effect of 2% lidocaine with various concentrations of epinephrine. J Dent Anesth Pain Med 2018;18(3):143-149. doi:10.17245/jdapm.2018.18.3.143.

Becker DE. Cardiovascular drugs: implications for dental practice Part 1 — cardiotonics, diuretics, and vasodilators. Anesthe Progr 2007;54(4):178-186. doi:10.2344/00033006(2007)54[178:CDIFDP]2.0.CO;2.

Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions 5.1.0. The Cochrane Collaboration: United Kingdom and Australia; 2011.

Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA Group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6(e1000097). doi: 10.1371/journal.pmed.1000097.

Guyatt GH, Busse JW. Modification of Cochrane tool to assess risk of bias in randomized trials. DistillerSR. Available: http://distillercer.com/resources/; 2016.

Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, et al. GRADE guidelines: 4. Rating the quality of evidence—study limitations (risk of bias). J Clin Epidemiol 2011; 64: 407–15. doi: 10.1016/j.jclinepi.2010.07.017.

Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, et al. GRADE guidelines 6. Rating the quality of evidence—imprecision. J Clin Epidemiol 2011; 64:1283–93. doi: 10.1016/j.jclinepi.2011.01.012.

Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, et al. GRADE guidelines: 7. Rating the quality of evidence—inconsistency. J Clin Epidemiol 2011; 64: 1294– 302. doi: 10.1016/j.jclinepi.2011.03.017.

Guyatt GH, Oxman AD, Kunz R, Woodcock J, Brozek J, Helfand M, et al. GRADE guidelines: 8. Rating the quality of evidence—indirectness. J Clin Epidemiol 2011;64:1303–10. doi: 10.1016/j.jclinepi.2011.04.014.

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Rating the quality of evidence—publication bias. J Clin Epidemiol 2011;64:1277–82. doi: 10.1016/j.jclinepi.2011.01.011.

Higgins JPT, Green S, editors. Assessment of study quality. Cochrane reviewers Handbook 4.2.5. Chichester, UK: Section 4[ updated may 2005], 2005.

Cáceres MT 1, Ludovice AC, Brito FS, Darrieux FC, Neves RS, Scanavacca MI et al. Efeito de anestésicos locais com e sem agente vasoconstritor em pacientes com arritmias ventriculares. Arq Bras Cardiol 2008; 91(3): 128-33, 142-7.

Bronzo AL, Cardoso CG Jr, Ortega KC, Mion D Jr. Felypressin increases blood pressure during dental procedures in hypertensive patients. Arq Bras Cardiol 2012; 99(2): 724-31.

Conrado VC, de Andrade J, de Angelis GA, de Andrade AC, de Timerman L, de Andrade MM, et al. Efeitos cardiovasculares da anestesia local com vasoconstritor durante a extração dentária em pacientes coronarianos. Arq Bras Cardiol 2007; 88(5): 507-13.

Louro RS, Moreira LM, Miranda MS, Medeiros PJ. Comparative study of the use of the prilocaine chloridrate at 3% with felipressin at 0,03UI and the lidocaine chloridrate at 2% with epinephrine at 1:100 000 in the blood pressure of hypertensive patients. [Estudo com-

João Vitor da Silva Rodrigues is an undergraduate student, Department of Biosciences and Oral Diagnosis, Institute of Science and Technology, São Paulo State University - Unesp, São Paulo, São José dos Campos, Brazil.

Luciane Dias de Oliveira, Ph.D., is associate professor, Department of Biosciences and Oral Diagnosis, Institute of Science and Technology, São Paulo State University - Unesp, São Paulo, São José dos Campos, Brazil.

Simone Lapena is a graduate student, Department of Biosciences and Oral Diagnosis, Institute of Science and Technology, São Paulo State University - Unesp, São Paulo, São José dos Campos, Brazil.

Letícia de Miguel Nazario is an undergraduate student, Department of Biosciences and Oral Diagnosis, Institute of Science and Technology, São Paulo State University - Unesp, São Paulo, São José dos Campos, Brazil.

Taís Maria Cardoso de Oliveira is an undergraduate student, Department of Biosciences and Oral Diagnosis, Institute of Science and Technology, São Paulo State University - Unesp, São Paulo, São José dos Campos, Brazil.

Alessandra Buhler Borges, Ph.D., is associate professor, Department of Restorative Dentistry, Institute of Science and Technology, São Paulo State University - Unesp, São Paulo, São José dos Campos, Brazil.

Regina El Dib, Ph.D., is assistant professor, Department of Biosciences and Oral Diagnosis, Institute of Science and Technology, São Paulo State University - Unesp, São Paulo, São José dos Campos, Brazil. Department of Community Health and Epidemiology, Dalhousie University, Faculty of Medicine, Halifax, Canada.

parativo do uso do cloridrato de prilocaína a 3% com felipressina a 0.03UI e do cloridrato de lidocaína a 2% com adrenalida a 1: 100 000 em pacientes hipertensos]. RBO 2001; 58(4): 228-31.

Malamed SF. Handbook of local anesthesia. 2nd ed. St Louis: Mosby-Year Book; 1986.

Bennett CR. Monheim’s local anesthesia and pain control in dental practice. 7th ed. St Louis: Mosby-Year Book; 1984.

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Tongue Schwannoma Case Report Samuel Fleisher, B.A.; Scott M. Peters, D.D.S.; Louis Mandel, D.D.S.

ABSTRACT Schwannomas are uncommon benign neoplasms derived from the nerve sheath’s schwann cells. The rare few seen in the oral cavity usually involve the tongue, and because they are encapsulated, they can be bluntly dissected from the tongue’s soft-tissue bed.

The schwannoma, or neurilemmoma, is an uncommon tumor derived from the myelin-producing schwann cells of the nerve sheath. It is a benign, slow-growing, painless neoplasm that can originate from the sheath of any nerve (cranial, autonomic, peripheral). The optic and olfactory nerves are cranial nerves that are exceptions because of their lack of a schwann cell sheath.[1] Schwannomas develop equally in both sexes.[2-4] The age range of 30 to 50 years is considered the most likely period for this unusual tumor’s occurrence.[5,7] The schwannoma is a solitary, well-circumscribed growth that tends to push adjacent structures aside as it proliferates. Reportedly, 25% to 45% of these tumors involve the head and neck region,[1,7-9] with as few as 1% of them occurring intraorally.[2,3,5,6] The tongue represents the most common intraoral location, followed by the palate, buccal mucosa and mouth floor.[5,6,10,11] Besides these soft-tissue locations, the tumor can occur intraosseously, usually in the posterior mandible.[7,9] The oral as-

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pect of the tongue is more frequently involved than the tongue base. The mean size for a schwannoma in the anterior tongue is approximately 2 cm,[2,4,8] while those posteriorly located tend to be larger. Although schwannomas in the anterior tongue cause no symptoms, dysphagia, dyspnea and dysphonia can occur with those larger schwannomas that are located in the tongue base.[1] Tongue schwannomas probably arise from the sheath around the hypoglossal nerve.[3] However, because of this nerve’s close proximity to the glossopharyngeal and lingual nerves, the exact nerve of origin is difficult to ascertain.[8] When establishing a clinical differential diagnosis for a submucosal tongue nodule, one must consider benign tumors, such as the granular cell tumor (GCT), the neurofibroma (NF) and the schwannoma. All three entities are categorized as benign neural tumors, with the NF representing the most common peripheral nerve tumor. Because solitary lesions are clinically indistinguishable, a biopsy is required for the definitive diagnosis. Of importance, the presence of multiple NFs may be seen in patients with NF1 (von Recklinghausen disease of the skin).[3,5,11] Schwannomas are usually absent from NF1, but may be a component of other syndromes, such as neurofibromatosis II (NF2) and schwannomatosis.

Patients with NF1 are at increased risk for development of a malignant peripheral nerve sheath tumor following a malignant transformation of a NF. This malignant transformation is rarely, if ever, seen in cases of isolated (non-syndromic) NFs. With re-

A 36-year-old female, in excellent health, was seen in the Columbia University College of Dental Medicine because of a slowly growing, painless nodule involving the tongue (Figure 2A). The patient said the nodule had been present for at least

Case Report A 36-year-old female, in excellent health, was seen in the Columbia University College of Dental Medicine because of a slowly growing, painless nodule involving the tongue (Figure 2A). The patient said the nodule had been present for at least two years.

Because it has been getting larger, she had decided to seek care.

The intraoral examination revealed that the nodule involved the right lateral border of the middle third of the tongue. The growth measured 1.4 cm in all dimensions, and its overlying mucosa was not inflamed. No other oral lesion was noted. Palpation indicated that the nodule was firm and painless. It was well-circumscribed and not fixed in position.

two years. Because it has been getting larger, she had decided to seek care.

spect to schwannomas, neither solitary nor syndromic cases are associated with malignant degeneration. The GCT, although not associated with any specific syndrome, has a strong predilection for the dorsal tongue. In fact, the tongue represents the single most common site for diagnosis of this entity, with approximately one-half of cases reported at this site.

Histologically, the schwannoma has distinctive Antoni A and Antoni B zones (Figure 1). Microscopically, the Antoni A area is recognized by the presence of rows of palisaded schwann cell nuclei, separated by bands of amorphous Verocay bodies.

Antoni type B areas are composed of loosely arranged schwann cells in a meshwork of collagen fibers.[9] This microscopic appearance helps distinguish schwannoma from a solitary circumscribed neuroma, a benign neural entity that clinically resembles a schwannoma but lacks the classic Antoni A pattern histologically and also contains multiple axons microscopically, which are not seen in schwannomas. Similarly, the microscopic appearance of the GCT is distinct from that of a schwannoma and a NF. As its name suggests, the GCT contains large cells filled with cytoplasmic granules.

Immunohistochemistry has proven to be helpful in the diagnosis of schwannomas. The presence of the unique protein markers S-100 and Leu[7] identify the existence of schwann cells. These proteins are seen in cells derived from the embryologic neural crest[1,7,9,12] and serve to clinch, in association with the tissue’s histologic pattern, a diagnosis of schwannoma. Differentiation from a NF is possible because, although the NF will demonstrate these markers, it will also be positive for factor Xllla, whereas the schwannoma does not stain for factor Xllla.[12] While solitary circumscribed neuromas will also express positivity for S100, they will lack staining with GFP, which helps distinguish them from schwannomas.

Figure 1. Schwannoma demonstrates classic Antoni A and Antoni B patterns (H&E stain, magnification x100).

Figure 2A. Clinical view schwannoma of tongue.

The New York State Dental Journal APRIL 2021 33 ●

Based on the clinical appearance of the lesion, a benign neoplastic process was favored. Because of its accessibility and clinical features, surgical excision via blunt dissection was performed in an out-patient setting utilizing local anesthesia (Figures 2B, 2C). The excised specimen was reported by the pathologist to be a schwannoma type A. Discussion The clinical picture presented by our patient pointed to an accessible circumscribed lesion that would lend itself to a localized surgical soft-tissue dissection. Such was the case, and the encapsulated lesion was readily enucleated from its soft-tissue surroundings. Because it was removed in toto, a recurrence is not anticipated. Schwannomas that recur probably result from incomplete surgical removal.

The reported lesion was visually and clinically localized, accessible and not related to any vital structures. Therefore, imaging

was not deemed necessary. However, MRI is advocated for those schwannomas located in areas where they might impinge upon vital structures.[1,5,13] The MRI has the advantage of avoiding imaging artifacts caused by metallic dental fillings and prostheses.

Additionally, it avoids the radiation associated with computerized tomography, and it clearly depicts the lesion’s anatomic location and its relation to other structures.

Conclusion Schwannomas are benign, solitary, circumscribed neoplasms derived from the schwann cells in a nerve’s myelin sheath. Because they are encapsulated, the oral soft-tissue schwannoma can readily be dissected free from its surroundings. Definitive diagnosis awaits the pathologist’s report. p Queries about this article can be sent to Dr. Mandel at lm7@columbia.edu.

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Figure 2B. Surgical removal (blunt dissection) of schwannoma.

Figure 2C. Schwannoma of tongue. Immediate postoperative view with sutures in place.

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13.

Cohen M, Wang MB. Schwannoma of the tongue: Two case reports and review of the literature. Eur Arch Otorhinolaryngol 2009; 266:1823-9.

Lira RB, Goncalves Filho J, Carravalho GB, Pinto CA, Kowalski LP. Lingual schwannona: case report and review of the literature. Acta Otorhinolaryngol Ital 2013; 33:137-40.

Moreno-Garcia C, Asuncion Pons-Garcia M, Gonzalez-Garcia R, Monje-Gil F. Schwannoma of the tongue. J Maxillofac Oral Surg 2014;13:217-21.

Lee E-Y, Kim J-J, Seok H, Lee J-Y. Schwannoma of the tongue: a case report with review of literature. Maxillofac Plast Reconstr Surg 2017;39:17-29.

Luksic I, Muller D, Virag M, Manojlovic S, Otovic KT. Schwannoma of the tongue in a child.

J Craniomaxillofac Surg 2011;39:441-4.

Catalfamo L, Lombardo G, Nava C, et al. Tongue schwannoma: clinicopathological findings. J Craniofac Surg 2011;22:1158-61.

Lambade PN, Palve D, Lambade D. Schwannoma of the cheek: clinical case and literature review. J Maxillofac Oral Surg 2015;14:327-31.

Bhola N, Jadhav A, Borle R, Khemka G, Bhutekar U, Kumar S. Schwannoma of the tongue in a paediatric patient: a case report and 20-year review. Case Rep Dent 2014;2014:1-5.

Aswath N, Manigandan T, Sankari SL, Yogesh L. A rare case of palatal schwannoma with literature review. J Oral Maxillofac Pathol 2019;23 (Suppl 1):36-9.

Isildak H, Yilmaz M, Ibrahimov M, Aslan M, Karaman E, Enver O. Schwannoma of the hard palate. J Craniofac Surg 2010; 21:276-8.

Nisa L, van Buren T, Tiab A, Giger T. Giant plexiform schwannoma of the tongue: Case report. Case Rep Otolaryngol 2011;2011:1-3.

Kurup S, Thankappan K, Krishnan N, Nair PP. Intraoral schwannoma—a report of two cases. BMJ Case Rep 2012; 2011:1-5.

Abreu I, Roriz D, Rodrigues P, Moreira A, Marques C, Alves FC. Schwannoma of the tongue —a common tumour in a rare location: A case report. Eur J Radiol Open 2017; 4:1-3.

NEWS General

NYU Receives Grant to Investigate Oral Cancer Pain Treatment

NYU COLLEGE OF DENTISTRY clinician-scientists Seiichi Yamano and Brian Schmidt have set out to develop a new class of medicines using gene therapy to effectively and safely treat oral cancer pain. The National Institute of Dental and Craniofacial Research (NIDCR), part of the National Institutes of Health (NIH), has awarded the researchers a five-year, $2.9-million grant to test whether nonviral co-delivery of DNA and RNA will safely alleviate oral cancer pain.

Patients with oral cancer often suffer from severe pain. These patients may find it difficult to eat, drink, or even talk. The opioid medications used to treat oral cancer pain become less effective as patients develop drug tolerance, and cause numerous debilitating side effects.

Gene therapy offers an alternative to opioids for the treatment of cancer pain by reversing cancer-induced epigenetic changes. This approach selectively disrupts pain signaling without the side effects of opioids.

“Complete elimination of cancer pain in a patient is exceptionally challenging because there are multiple and redundant pain-signaling mechanisms and pathways,” explained Dr. Schmidt, who is a professor in the Department of Oral and Maxillofacial Surgery at the College of Dentistry, as well as director of NYU’s Bluestone Center for Clinical Research and the NYU Oral Cancer Center.

As a strategy to obstruct these multiple and varied pathways, Dr. Yamano and Dr. Schmidt created two nonviral vectors that can efficiently deliver DNA and RNA to cells (transfection) with no toxicity: a cell-permeable peptide combined with a cationic lipid

for DNA, and a lipopolymer for RNA. They hypothesize that the combination of OPRM1 (mu opioid receptor gene) re-expression and F2RL1 (gene for protease-activated receptor-2, or PAR2) downregulation in the cancer could Seiichi Yamano Brian Schmidt eliminate cancer pain.

In preliminary studies, the researchers demonstrated that nonviral transfection with OPRM1 DNA led to re-expression of the mu opioid receptor and partial reduction of pain in preclinical cancer models. PAR was found to be elevated in certain neurons that supply the cancer with nerves and drive pain. Knockdown of the F2RL1 gene partially attenuated pain.

In their newly funded NIH grant, the researchers will test whether the combination of OPRM1 re-expression and F2RL1 downregulation in the cancer can go beyond reducing cancer pain to eliminate it.

“Our approach is innovative because delivering DNA and RNA into a cancer with nonviral vectors for the management of pain has not been done before,” said Dr. Yamano, an associate professor of prosthodontics at the College of Dentistry. “If we are successful, the knowledge generated through this research could set the stage for a clinical trial and, ultimately, lead to the development of novel non-opioid medicines for cancer pain.”

New York Dental Students Chosen for ASDA Posts TWO MEMBERS OF THE Columbia University College of Dental Medicine Class of 2022 have been elected to offices with the American Student Dental Association. They are Michelle Skelton, named an ASDA vice president, and Sebastian Celis Cifuentes, elected speaker of the house. The elections were held during a virtual Annual Session in February.

Ms. Skelton recently served as ASDA District 2 Trustee and is a board liaison to the ASDA Council on Membership and ASDA consultant to the ADA Council on Scientific Affairs. Mr. Celis Cifuentes previously served as chair of the ASDA Council on Advocacy and president of the Columbia ASDA chapter. He is involved as well with the Hispanic Student Dental Association.

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Anticipated to begin operation in early 2022, second mobile dental clinic is expected to expand school’s outreach by more than 1,000 patients annually.

UB Receives $780,000 Grant for New 40-foot Mobile Dental Clinic THE UNIVERSITY AT BUFFALO SCHOOL OF DENTAL MEDICINE has received a $780,000 grant from the Mother Cabrini Health Foundation to expand its successful S-Miles to Go dental program through the addition of a second drivable mobile dental clinic.

The new mobile dental van—a 40-foot-long, two-chair clinic outfitted with a state-of-the-art panoramic X-ray unit, digital radiography, a sterilization center, wheelchair lift and electronic health record system—will meet the oral healthcare needs of Erie County’s underserved populations, including older adults and people with disabilities.

Anticipated to begin operation in early 2022, the second mobile dental clinic is expected to expand the school’s outreach by more than 1,000 patients annually. The new dental unit will also be staffed by UB dental faculty, staff and students, and provide students with experiential learning opportunities caring for the most vulnerable populations in the region.

The funding will also support the operations of the School of Dental Medicine’s existing mobile dental van, which provides access to oral healthcare for veterans and underserved children and families, primarily in Chautauqua County.

The grant marks the second award provided to the UB S-Miles to Go program by the Mother Cabrini Health Foundation, an organization that provides funding to enhance access to affordable, quality healthcare and to address the unmet healthcare needs of communities across New York State. In 2020, the foundation provided UB with a $200,000 grant to expand mobile dental services in underserved rural areas.

S-Miles to Go offers a full range of educational and oral healthcare services, including exams, cleanings, fillings, sealants, fluoride treatments and extractions. The program has served Western New York communities for over 20 years, providing more than 45,000 patient visits.

State Board Appointments Announced KERRY M. MCENTEE, D.M.D., of Bronxville has received a five-year appointment to the State Board for Dentistry. Dr. McEntee specializes in general dentistry, oral and maxillofacial surgery and oral surgery. In addition to her private practice, she holds an appointment with Jacobi Medical Center, Bronx. She is a graduate of the University of Wisconsin, Madison, University of Pennsylvania School of Dental Medicine and Stony Brook University Medical Center.

Also receiving five-year appointments to the Board of Dentistry were hygienists Tera Bell, R.D.H., Irondequoit, and Karen Palleschi, R.D.H., of Mechanicville.

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at this time, plans are being made for several regular summer activities, particularly the William Knauf Memorial Golf Tournament, tentatively set for June 14. And the UB Dental Alumni Association is planning for an in-person Buffalo Niagara Dental Meeting Nov. 3-5. It is hoped that with vaccinations proceeding, all restrictions will be removed by November.

NASSAU COUNTY Headed in the Right Direction

Successful Restorations

GLIDM, Women’s Conference Makes Come Back

We’re well into 2021, and things are progressing nicely. While masks, social distancing and virtual meetings are still the norm, we’ve learned that there should be enough vaccine to distribute to all Americans by the end of May. In anticipation, we are beginning to get back to scheduling “inperson” meetings and courses for the fall.

Our May General Membership Meeting will still be virtual, and it will be a special one! It’s a COVID-19 update panel, featuring Aaron Glatt, M.D., chief of infectious disease at Mt. Sinai/South Nassau Hospital, who will provide the current medical perspective of COVID; Nassau County Executive Laura Curran, with the local government perspective; and Paul Leary, Second District ADA Trustee, with the ADA/ NYSDA perspective.

For the fall season, we have planned two in-person events, jointly sponsored by the Suffolk County Dental Society. First, after an 18-month hiatus due to COVID, our Greater Long Island Dental Meeting (GLIDM) will return. And it promises to be “Better Than Ever!’ Redesigned from the ground up, it will be a one-day, fun-filled and informative event at the Huntington Hilton, complete with vendors and their meeting specials.

The next event is our 12th annual “Scrubs & Stilettos” Women’s Dental Conference. Designed around the interests and needs of women dentists, it will take place on Friday, Nov. 12, from 8 a.m. to 1 p.m., at a new bigger venue, The Heritage Club at Bethpage. Watch your email for more information and registration details. Plan to attend this unique and award-winning conference.

BBQ and Recruitment

Financial Assist

Another special event we are planning, for the evening of Aug. 25, is an in-person membership recruitment night for residents and senior dental students called “Burgers, BBQ and Belonging—Why ADA Membership Matters.” It will be held at the Crest Hollow Country Club, outside, in the club’s Coral Beach area. We expect it will be a pleasant social gathering, with food, drink and mentorship, and jam packed with useful information about the tripartite that attendees will be able to take home pre-loaded onto a thumb drive for future reference. We are also going to invite nonmember dentists practicing in Nassau County.

Finally, now that 501c6 organizations are eligible, the Nassau County Dental Society was successful in obtaining over $33,000 from the second round of the federal PPP loan program.

So, all things considered, 2021 appears to be heading in the right direction here on Long Island!

EIGHTH DISTRICT

Slowly Reopening Kevin J. Hanley, D.D.S. As things begin to open up in Western New York, the Eighth District is looking forward to having some in-person functions. While all society matters are being held virtually

The Erie County Dental Society held a virtual meeting on March 25 in conjunction with Ivoclar Vivadent. Titled “Esthetic Restoration: Materials Selection and Bonding Protocols,” the CE program was presented

by Shashikant Singhai, B.D.S., M.S., director of education and professional services, Ivoclar Vivadent, and Thomas Hill, manager of scientific services, Ivoclar Vivadent.

The duo discussed the classification and comparison of contemporary ceramic materials, and the differences in restorative materials options. They provided tips for clinical selection, incorporating evidencebased decision making into treatment planning and diagnosis for more predictable clinical outcomes, and an overview of bonding protocols. Attendees earned 1.5 hours of MCE credit.

Ortho Cases Presented for Review The Greater Buffalo Association of Orthodontists held a virtual meeting on April 14, at which members reviewed cases treated by senior orthodontic residents at the University at Buffalo School of Dental Medicine, Department of Orthodontics. These treatment plans and outcomes were presented in a PowerPoint format via Zoom. Attendees then evaluated and discussed the treatments, the techniques used, the quality of the finished cases, and graded the presentations and cases using a standardized grading system provided by the Orthodontic Department.

It was an enlightening evening presentation, during which future colleagues met with established orthodontists. Both sides benefited from the experience. And the orthodontists received 2 MCE credits for their participation.

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Successful Implants Through 3D Printing On April 22, the Erie County Dental Society held another virtual meeting on the topic “Benefits of 3D Printing in the Office/ When Implants Fail: How, Why and What to Do.” Local periodontists Roger Anderson and Tim Violante discussed the benefits of 3D printing in the office, the range of products available, implant surgical applications and the benefits of communication, surgical precision and improved outcomes. Other topics included what to do at the outset to achieve long-term implant success, the leading causes of short- and long-term implant failure and how to reduce such risks, and early and late signs of implant failure, as well as the role of CBCT in diagnosing and treatment planning. Those attending received 2 hours of MCE credits.

QUEENS COUNTY

VP Nod Goes to Prabha Krishnan Arelys Santana, D.D.S. At their meeting March 16, the Board of Trustees of the Queens County Dental Society elected long-time member Prabha Krish-

nan as the nominee from QCDS for the position of vice president of the New York State Dental Association, to serve in 2022.

Her nomination was recognition of the many years of service, hard work and dedication Dr. Krishnan has given to our society.

Dr. Krishnan is no stranger to organized dentistry. She has served QCDS, NYSDA and ADA in a variety of positions. When she was president of Queens County in 2009, she hosted the Women’s Dentist Conference.

This event received the prestigious Golden Apple Award from the ADA. From 2015 to 2019, she was a NYSDA Trustee, and she currently serves as a member of the ADA Council on Communications.

We are excited to know we will continue to benefit from Dr. Krishnan’s leadership, as we are confident she will represent all of us well, doing what is best for our profession and for the public.

SECOND DISTRICT

SDDS Gears up for NYSDA HOD Alyson Buchalter, D.M.D. As we are by now all aware, this year’s NYSDA House of Delegates meeting has been rescheduled from June to August 13-15. As the host component, the Second District Dental Society is very excited and is moving forward with plans for a fun and productive event in Jersey City.

The HOD will take place at the Westin Hotel in downtown Jersey City, which

38 APRIL 2021 The New York State Dental Journal ●

puts us one mile from Liberty State Park, a little more than a mile and a half from the Hoboken Waterfront and a four-minute walk to the Newport Center Mall.

In addition to hosting NYSDA’s first in-person HOD meeting since the onset of the COVID pandemic, we are planning boat rides, a cocktail party and a golf outing— all while observing COVID-safe protocols.

Aided by what appears to be a successful vaccination program, our committee members are working hard to ensure all attendees have a good time within the bounds of up-to-the-minute CDC and New York State safety guidelines.

This year’s golf outing will take place at the Richmond County Country Club, locally renowned for its unique and challenging course. Designed by the first president of the PGA, Robert White, it presents a spectacular view of the Atlantic Ocean and New Jersey highlands. Those who elect to come early for the outing are in for a treat.

In lieu of the traditional indoor Saturday night dinner dance, on Friday night, NYSDA will host a banquet and dancing on a chartered luxury yacht. With the added benefit of outdoor space, for COVID safety, we will be treated to amazing views of lower Manhattan and New York City skyline. With pride in his accomplishments, we are looking forward to honoring our own Craig Ratner as he completes his term as NYSDA President.

On Saturday night, the SDDS will invite all attendees to a special roof-top cocktail party. The views of the Manhattan skyline,

dentist from Arizona. Dr. MacLean’s lecture covered silver diamide fluoride, glass ionomer, the Hall technique and minimally invasive cosmetic options for enamel defects.

Present for the lecture were 53 dentists and 11 dental hygienists. Christina Cocozzo from the Fourth District and Anthony Ficara from the Third District were cohosts.

The second virtual CE program took place April 30. It consisted of a morning lecture on geriatric dentistry and an afternoon session entitled “Diagnostic Driven Dentistry.” The presenter was internationally recognized lecturer Lou Graham.

Hudson River, Statue of Liberty, Staten Island and beyond will be, without exaggeration, breathtaking. FUN, FUN, FUN! Thank you to the hard-working members of the planning committee who, due to the ever-changing COVID environment, have had to pivot multiple times. They are Paul Albicocco, Mitch Mindlin, John Halikias, Phyllis Merlino, Tricia Quartey, Michael D’Anna, Marc Meiselman, Bryan Pieroni, Michael Costa and Executive Director Bernard Hackett.

The SDDS is very excited to see you, in person, at this extra special HOD event!

SUFFOLK COUNTY

New Dentist Events Howard Schneider, D.D.S. Our New Dentist Committee has been very busy before, during and after the transitioning of its chair, from Alexander Sanchez to Lauren Heisinger. The committee has added several informative and engaging events, and even more are being planned. Here is the near-term line-up of new dentist events (all virtual except as noted): • April 28: “Navigating Dental Associate Agreements” • May 12: “Professional Liability and Defensive Dentistry” • May 20: Bank of America Presents “Purchasing a Practice” • July 21: New Dentist Summer Social, an in-person event at Insignia Steakhouse in Smithtown.

All virtual events are offered at no charge to residents, SCDS members and dental students. Other ADA members are asked to pay $10. The charge to non-ADA members is $25. You can find more details on these and other events at http://suffolkdental. org/calendar-of-events.html

Virtual Infection Control Course David Scharf will present our popular New York State infection control course virtually on May 17. The fee for participating is $150 for ADA members, $100 for dental staff and $250 for non-ADA member dentists.

Visit the SCDS website, Suffolkdental.org/ calendar-of-events for details.

Shredding Event On May 22, from 9 a.m. to noon, we will hold our annual MLMIC-sponsored shredding event. It will be held outside, rain or shine, in the rear parking lot of 150 Motor Parkway, Hauppauge.

This service is being offered free to all SCDS members. All others are being charged $10 (cash only) per banker’s box of material. Again, please see our website for complete details.

Stony Brook Dental School Graduation Congratulations to SCDS past president Scott Firestone on being selected as a marshal for the Stony Brook Dental School Class of 2021 graduation ceremony on May 19.

Don’t Miss a Thing Like/follow us on social media. We continue to make a significant push to better communicate and connect with our members in methods that more easily integrate with their lifestyle. You can find us on Facebook, Twitter, Instagram, LinkedIn and, even, Spotify, in addition to our traditional www.

SuffolkDental.Org presence.

FOURTH DISTRICT CE is Virtual

Rachel Hargraves, D.D.S. The Fourth District Dental Society joined with the Third District Dental Society March 19 to sponsor the first of two virtual continuing education events. The guest lecturer was Jeannette MacLean, a pediatric

NINTH DISTRICT Almost There

Olga Lombo-Sguerra, D.D.S. Having recently passed the one-year mark of the global pandemic that has changed our lives, we finally see the proverbial light at the end of the tunnel. We urge you to stay vigilant and safe until we reach it. And to keep in mind, this small bit of wisdom: “If you focus on the hurt, you will continue to suffer. If you focus on the lesson, you will continue to grow!”

The Ninth District has grown through the lessons of this past year. We have become proficient with the Zoom platform, enabling us to, once again, provide our members with a full-course selection this spring. Ninth District members and leaders want to thank all of the presenters for their willingness to forego an honorarium, so that we can provide these courses at no charge to our members during this difficult time.

Our March 10th General Meeting was a huge success. Larry Lieberman’s presentation of ”Soft- & Hard-Tissue Dental Lasers with Aesthetic Capabilities” was well-received by attendees, many of whom declared it was both interesting and extremely informative.

There appears to be great anticipation for the May 12th General Meeting, at which Queens County Executive Director and past ADA President Chad Gehani will provide an overview of “Organized Dentistry” and answer questions as to why it’s more important today than ever. This will

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be followed by a discussion of “Management of Periapical Pathosis.” After a break, Rekha Gehani will present on the topic “Orthodontics: An Integral Part of Cosmetic Dentistry.” Members will receive six MCE credits, for which they are not being charged. Members of other components are invited to attend. They are asked to register on the Ninth’s website: www.ninthdistrict. org; or call headquarters ( 914) 747-1199.

Keeping Informed Our thanks to the ADA, NYSDA and our executives and delegates for continuing to update us on COVID vaccinations and ever-changing protocols. We hope by now most of our members and their staffs have been vaccinated and are providing support to other members and their patients regarding this important healthcare effort.

Our May Bulletin, which is nearing completion, will be an online issue. Keep an eye on your inbox for notification of its availability. Once again, we are grateful to our advertisers and sponsors for their continuing support and welcome any comments and ideas for upcoming issues.

We continue to be vigilant about the pandemic and stopping its spread as we look forward to once again getting together in person. Until then, we encourage members and their staffs to get vaccinated as soon as possible and to reach out to headquarters with any issues, questions or concerns they have.

counted several “wins” for NYSDA, including getting teledentistry reforms adopted in New York State and leading the successful nationwide response to do-it-yourself dentistry. Dr. Henner also reviewed the extensive efforts NYSDA took during the height of the pandemic to advocate on behalf of dentists with state leaders and to communicate daily with members. He said the Association has undertaken an evaluation of its response to the pandemic and that based on findings, will establish new protocols for handling any future issues.

He noted that the NYSDA House of Delegates meeting will take place in-person in August.

Our guest speaker, Robert Elliott, a pediatric dentist in Cary, NC, shared strategies and systems he has implemented to keep staff morale high, particularly during the stress of the pandemic. The focus of his presentation was “Maintaining Team Loy-

NEW YORK COUNTY

First General Membership Meeting of 2021 Mina C. Kim, D.M.D. NYCDS was pleased to have NYSDA President-Elect Kevin Henner address members at our April 5th meeting. Dr. Henner re-

40 APRIL 2021 The New York State Dental Journal ●

alty and Support in the Middle of a Pandemic.” Dr. Elliott said he considers strong team morale essential, not a luxury. His guiding motto is “take care of your employees and they will take care of you.” He demonstrated a variety of ways to make sure your team feels heard and valued.

Finding Balance During the Pandemic NYCDS continues to offer webinars on topics that impact members on a personal level.

On April 13, psychotherapist Lila Margulies led a one-hour program on “The Impact of Pandemic Life on Working Women and the Move Toward Finding Balance.” Lila provided an honest assessment of the myriad reasons people, and in particular, working mothers, are overwhelmed during the pandemic. She went on to discuss concrete ways to reduce anxiety, develop new positive routines, and the importance of self-care and self-forgiveness. Attendees related to the topic and expressed their appreciation for the program.

New Dentist Event Paul Goodman led an energetic and engaging webinar for new dentists on March 24 on “Developing Your Dentisting Core.” Dr. Goodman is a practicing general dentist, managing partner of a group practice with two locations, and head of the professional development company Dental Nachos.

The focus of his presentation was the importance of developing the core skills necessary for success. These include clinical, business, leadership and communication, which need to be worked on regularly in order to achieve consistent improvement.

He talked in particular about strengthening communication skills to improve patient service and practice revenue. Dr. Goodman emphasized the impact words can have and inspired attendees to think differently about how they will communicate with patients and others in the future.

Continuing Education We plan to continue offering daytime and early evening webinars to fit your schedule through summer 2021. And we are planning an in-person continuing education program to start after Labor Day. Upcoming webinars, which are free to ADA members, include: • May 5: Women in Dentistry Seminar Series: “Get F.I.T. in 2021!” led by Bank of America.

• May 19: ACD Mentoring Lecture Program: “Peer Review,” led by Egidio Farone.

Visit www.nycdentalsociety.org for the latest course and registration information.

The New York State Dental Journal APRIL 2021 41 ●

continuing education

Read, Learn and Earn Readers of The New York State Dental Journal are invited to earn two (2) home study credits, approved by the New York State Dental Foundation, by properly answering 20 True or False questions, all of which are based on articles that appear in this issue.

To complete the questionnaire, log onto the site provided below. All of those who achieve a passing grade of at least 70% will receive verification of completion. Credits will automatically be added to the CE Registry for NYSDA members.

For a complete listing of online lectures and home study CE courses sponsored by the New York State Dental Foundation, visit www.nysdentalfoundation.org/course-catalog.html.

Click below

ONLINE CE QUIZ

42 APRIL 2021 The New York State Dental Journal ●

Parents’ Acceptance of Topical Fluoride Varnish in a Primary Care Medical Setting—Page 12-16 1. The study concluded that the application of topical fluoride varnish (FV) in the study group would not change homecare habits or dental routines.

❑ T or ❑ F 2. The prevalence of caries in low-income US children under the age of 5 is comparable to children from higher-income families.

❑ T or ❑ F

Visit our online portal for more....

Tongue Schwannoma—Page 32-34 1. Schwannomas are common benign neoplasms.

❑ T or ❑ F 2. Schwannomas are not encapsulated.

❑ T or ❑ F

Visit our online portal for more....

CLASSIFIED INFORMATION

RATES: $60 for 45 words or less; 75 cents each additional word; Includes 30-day posting on

FOR SALE MIDTOWN MANHATTAN: Long-established FFS practice for sale. Owner dentist losing lease and wishes to remain in practice 6 months at suitable Midtown location as buyer’s subtenant, leading to transfer of patients. Will need at least 2 ops FT from July 1 and closing on or around November 30. For more information, please call (917) 526-0721; or email: madisonddsgroup@aol.com.

CAPITAL DISTRICT: Suburban general dentistry practice for sale. Grossing $600K on 3.5 days/ week. Four modern ops; new equipment, fully computerized with Dentrix software. Large FFS base with minimal insurance participation. Good new patient flow and referral base with patients seeking esthetic and implant dentistry. Ample off-street parking available. Seller retiring but will stay to introduce. Email: jgrossman@ggcpallp.com.

GREATER ALBANY: Practice for sale. Considering an Eastern NY practice? This is it. Current doctor highly regarded in community and practicing for 40 years. Dental office located in charming, free-standing building with 2,800 square feet. Real estate also for sale. 6 fully equipped ops. Collections $1.02M and EBITDA over $250K. 4,000 active patients. Contact Kaile Vierstra with Professional Transition Strategies via email: kaile@professionaltransition.com; or call: (719) 694-8320.

WESTCHESTER: Full buyout of Tri-State periodontal practice. Thriving practice for sale and sure to go quickly. Currently sees over 40 new patients/month, with 7,500 active patients. Gorgeous practice located in one of most desirable and attractive communities north of Manhattan. 8 fully equipped operatories.

Collections of $1.7M and EBITDA of $29K. To learn more, email Kaile with Professional Transition Strategies at: kaile@professionaltransition.com. We look forward to speaking with you! View online at: https://professionaltransition.com/properties-list/westchester-nyperiodontal-practice-for-sale.

number. Web only, $40 for 30 days. Box display: 1 column wide by 1 inch deep (min.), $100; each additional 1/2 inch $40. Payment must accompany all ads. Copy due 1st of month, one month prior to date of publication. All ads are subject to editing by The Journal. Box replies to: NYS Dental Journal, 20 Corporate Woods Boulevard, Suite 602, Albany, NY 12211. Please use complete box number with replies.

CENTRAL NY: Prosthodontic practice for sale. New to market. Well-established prosthodontic practice just outside downtown of one of region’s most desirable communities.

Located in gorgeous free-standing building, real estate also for sale. Current doctor interested in buy-out or partnership.

3 fully equipped operatories. Collections nearly $900K and SDE $330K. 2,350 active patients and 10 new patients/ month. To learn more, please email Kaile with Professional Transition Strategies at: kaile@professionaltransition.com.

We look forward to speaking with you! View online at: https://professionaltransition.com/properties-list/syracuse-ny-prosthodontic-practice-for-sale.

BRONX: Co-op City. Beautiful architecturally designed practice for sale. Newly renovated; well running practice for over 30 years. 3 ops, lab, storage room, N20 in 1,000 square feet. Only good insurance. No Medicaid, no HMO, no DMO. Owner retiring due to serious medical condition. Please call and leave message. Contact: (718) 862-9232.

WESTCHESTER: Periodontal practice for sale. 8 fully equipped ops. Collections $1.7M and EBITDA $290K. Well-established practice with excellent referral base.

7,500 active patients and 40 new patients per month.

Contact Kaile Vierstra with Professional Transition Strategies via email: kaile@professionaltransition.com; call: (719) 694-8320.

MIDTOWN MANHATTAN: Esthetic/Restorative FFS-only practice for sale. Low to mid 7-figure gross for past 5 years. 32-hour week. 1,850 square feet. 5 ops, 2 POs, lab. Can extend lease or willing to move.

Paperless, Itero scanner, Dentrix. Contact for details: midtowndmd2@gmail.com.

BRONX: Newly renovated, 31-year-old practice in Bronx. Running well; owner retiring. Three ops, digital X-rays, lab, sterilization room, Nitrous oxide. Very good set up. Must see. No Medicaid, no HMO, no DMO. Only good insurance and private pay. Call for details: (718) 862-9232.

OSWEGO: 6 ops in north central part of NYS. Town is located on beautiful lake housing popular state college.

Revenue $868K; sale price $550K. All digital; quality equipment. 3,000-square-foot office space in professional, standalone building. Includes rental space earning $25K/year also for sale. Loyal staff; large patient base of PPO patients. Accepting all insurances; no Medicaid.

Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick at (315) 430-0643; email: donna.bambrick@henryschein.com. #NY1751.

BRONX: Great family neighborhood in highly desirable area. Strong PPO/FFS private practice features 3 ops in 900-square-foot condo. Real estate also available. Seller refers Endo, Pedo, Oral Surgery, Perio and implant placement. Room to grow, adding days and procedures. Strong hygiene program. Contact Henry Schein Professional Practice Transition Sales Consultant Michael Apalucci at (718) 213-9386; email: michael.apalucci@henr yschein.com. #NY1874.

WATERTOWN: Class act office in best location, near Fort Drum, off main highway, with high visibility in active small strip mall. Doctor moving out of state. Gross revenue $445K working 3.5 days.

Three ops, Eaglesoft, Planmeca digital pan, all A-Dec chairs and cabinetry, including sterilization center.

Only 9 years old. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick by email: donna.bambrick@henryschein.com; or call (315) 430-0643. #NY2484.

CICERO: Well-established general practice in community’s fastest growing suburb. Located in busy plaza with 1,460 square feet. Walking distance to area’s largest high school, creating potential for significant growth. Four (4) A-dec ops, sterilization center, new digital Pan, Dentrix software and Dexis sensors. Doctor refers out most specialty procedures.

Healthy new patient flow and patient base; accepting mix of insurances, plus FFS. Gross just under $700K. Contact Transition Sales Consultant Donna Bambrick by email: donna.bambrick@henryschein.com; or call (315) 430-0643. #NY1677.

LONG ISLAND: North Shore. Ready for terrific opportunity in highly desirable area? Step right up.

PPO and FFS private practice with updated equipment features 3 ops in 900 square feet utilizing Dentrix, digital X-rays, Dexis and laser. Clinical procedures referred. 41 patient hours per week and strong supporting staff. Met all post-COVID challenges and now uses Electrostatic Disinfection. Seller available to stay as needed. Contact Henry Schein Professional Practice Transition Sales Consultant Mike Apalucci at (718) 213-9386; or email: michael.apalucci@henryschein.com. #NY2403.

The New York State Dental Journal APRIL 2021 43 ●

CLASSIFIEDS

CATTARAUGUS COUNTY: Dream practice with great profit. Collecting over $1.8M/year and growing year over year at healthy pace. Pre-tax cash flow of about $430K for buyer; cash flow with seller staying on to work as associate two days/week. New, state-of-the-art office; fully computerized and digital.

7-operatory facility with CEREC, CBCT, 2 full-time and 1 part-time hygienists. Over 2,800 active patients and average of 30 new patients/month from NY and PA. Practice offers implant placement and restoration and other specialty services. Contact consultant Berdj Feredjian, DDS, for more information about this great practice opportunity by phone: (973) 476-8660; or email: berdj@paragon.us.com.

NYSDA website. $10 additional for Journal box

CLASSIFIEDS

WOLCOTT: Great rural lifestyle with fully modernized, up-to-date, high-tech general practice.

Revenue $850K on 3 days/week. One hour from Rochester and Syracuse. Stand-alone, converted, 2,500-square-foot residence has real estate for sale. Two full-time hygienists; four (4) ops, mostly all A-dec, New Sirona CBCT, Eaglesoft, Schick sensors, CEREC scanner and milling machine. 50% FFS and 50% indemnity plans, with 8-10 new patients per month. Consideration for Associate with buyin agreement. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick by email: donna.bambrick@henryschein.com; or call: (315) 430-0643. #NY2692.

SOUTH BUFFALO: Very reasonably priced practice for sale. Excellent option especially if considering expansion of current practice or recent graduate not desiring to incur sizeable debt. 2 large, bright ops with great Pelton Crane chairs/delivery units. Utilizes Sirona Orthophos XG5 pan with bitewing feature. Clinical production highly focused on quality restorative, with most specialty services referred to local specialists. In-network with larger insurance providers. No Medicaid. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick at (315) 430-0643; email: donna.bambrick@henryschein.com. #NY273.

STATEN ISLAND: Wonderful family practice in well-designed, 2-op office with third plumbed op.

Digital X-rays, intraoral camera and Dentrix. Beautiful 3,700-square-foot property for sale with two-story, 1,800-square-foot office and patient-friendly, open-air area. High visibility neighborhood, with easy access off main highway. Mix of FFS/PPO grossing $287K on 28 hours/week. Great potential for more days with additional procedures kept in-house. Contact Henry Schein Professional Practice Transition Sales Consultant Mike Apalucci at (718) 213-9386; or email: michael.apalucci@henryschein.com. #NY311.

NASSAU COUNTY: North Shore. Productive, wellestablished practice located in very desirable community. 5 operatories, plus 1 additional not equipped in 1,700 square feet, utilizing Eaglesoft, Schick, Biolase, Sirona CBCT and Itero. 60% PPO; 20% FFS; 20% Delta Premier. Seller willing to work post-sale for agreed timeframe. Great opportunity to acquire strong solid practice running at 39 hours/week with unlimited growth potential. Location, location, location. Contact Henry Schein Professional Practice Transition Sales Consultant Linda Zalkin at (631) 357-1003; or email: linda.zalkin@henryschein.com. #NY313.

WATERTOWN AREA: General practice with $500K revenue. Digital. Walk-in ready with nice equipment. Located in stand-alone building, which is for sale with two (2) apartments with private entry. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick by email: donna.bambrick@henryschein.com; or call (315) 430-0643. #NY1421.

44 APRIL 2021 The New York State Dental Journal ●

SYRACUSE: Immaculate general practice. Fully equipped with latest technology: Dentrix, Dexis, Waterlase, CAD/CAM, digital Pan. Three ops; 2,300 active patients. Strong FFS and some PPO. Revenue $481K. Refers out specialties. Stand-alone, converted residence with income apartment featuring 3 bedrooms, 1.2 baths. Building for sale; near hospital and college. Contact HSPPT Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY317.

NASSAU COUNTY: Exciting opportunity to purchase extraordinarily profitable GP dental practice on Long Island’s North Shore. In this location for 35 years in terrific community. 4 operatories, large lab, administrative space and ample reception room.

Wireless intraoral camera, Dexis digital X-ray and Tru-Def Intraoral Scanner included in fully computerized office with 8 workstations and server. Seller willing to stay for period to assure strong and effective transition. 3-year average annual gross: $987K. Contact Henry Schein Professional Practice Transition Consultant Mike Apalucci at (718) 213-9386; or email: michael.apalucci@henryschein.com. #NY1296.

SUFFOLK COUNTY: South Shore. Begin practicing immediately in beautifully treated facility located in growing and popular community. 1,500 square feet. 3 ops, plus additional room for expansion. Digital X-rays, intraoral camera with Dexis and Dentrix software.

Insurance and FFS driving $528K in gross receipts, with strong profit margins. Seller owns condo available for lease or purchase. Strong hygiene program; all specialties referred out. 22- to 24-hour workweek.

Lovely office; amazing upside for continued growth.

Contact Mike Apalucci at (718) 213-9386; or email: michael.apalucci@henryschein.com. #NY1587.

AMHERST: General/Prosthodontic practice situated in growing community. 4 fully equipped operatories and one unequipped for expansion. 1,875 square feet of leased space in handicap-accessible beautiful office park. Dentrix, Digidoc cameras, Gendex sensors, Planscan with milling unit and glazing machine, Sarona Pan digital X-rays and Ivoclar laser. Great staff. All endo and oral surgery referred out; no state insurance. Doctor willing to stay for transition. Gross revenue $439K. Contact Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY1594.

ERIE COUNTY: Well-established general practice in heart of south Buffalo. Highly visible practice, located on busy street with on-street and off-street parking. 5 ops with excellent workflow. Dentrix, digital pan and sensors. Mix of FFS and PPO, with some Medicaid. Real estate for sale, with apartment for rental or to live. Great opportunity to acquire strong net income practice and grow. Gross revenue $410K. Contact Brian Whalen at (716) 913-2632; or email: brian.whalen@henryschein.com. #NY1796.

NASSAU COUNTY: General practice with 3 equipped ops. Digital; high tech. Updated using EagleSoft. Located in desirable, diverse financial community. Gross $387K. Contact Henry Schein Professional Practice Transition Sales Consultant Mike Apalucci at (718) 213-9386; or email: michael.apalucci@henryschein.com. #NY316.

ERIE COUNTY: Located on busy road, surrounded by established residential population and beautiful town.

3-op digital practice; well-positioned for future growth. $307K gross revenue. Crown and bridge, restorative and preventative focus. Some specialties referred out.

Strong patient base and mixed PPO. Real estate next to practice owned by seller and for sale with practice.

Contact Brian Whalen at (716) 913-2632; or email: brian.whalen@henryschein.com. #NY1648.

SUFFOLK COUNTY: Seller ready to retire from 40 years of practicing in small professional building in lovely community. 1,350 square feet. 4 ops plus 1. Nicely appointed; extremely neat, with welcoming, warm feel.

2019 gross receipts $330,951; 2018 gross receipts $373,230. Specialties referred out. 70% PPO and 30% FFS. 1,250 active patients. Rent: $2,705, including water. Functional office needs updating. Seller highly motivated. Contact Henry Schein Professional Practice Transition Consultant Linda Zalkin at (631) 357-1003; or email: linda.zalkin@henryschein.com. #NY1704.

NASSAU COUNTY: North Shore. Well-established practice in desirable community with 4 ops, digital X-ray and Easy Dental in 1,200 square feet. Open 39 hours/ week; referring out most specialty procedures. 85% PPO and 15% FFS. Well-trained, experienced staff of 6 available for transition. Fourteen new patients per month with no outside marketing and 1,800 loyal patients.

2020 showed nice post-Covid production rebound.

Seller will remain available for smooth transition.

Contact Linda Zalkin at (631) 357-1003; or email: linda.zalkin@henryschein.com. #NY1854.

DUTCHESS COUNTY: Well-established GP in desirable growth community. Established 47 years, practice has loyal patient base and is located in professional building with ample free parking and main street visibility. 1,000-square-foot office. Seller owns real estate and willing to continue long-term lease.

Four treatment rooms. Digital X-ray, intraoral cameras, laser unit and Eaglesoft. Most specialty procedures referred. $613K revenue can quickly grow by adding days and procedures. Contact Henry Schein Professional Practice Transition Sales Consultant Mike Apalucci at (718) 213-9386; or email: michael.apalucci@henryschein.com. #NY2390.

LIVERPOOL: North Syracuse. Six (6) ops with Pelton Crane and X-ray room with pan, Dexis and ScanX. Insurance practice. Professional building with parking; working 4 days/week. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY250.

QUEENSBURY: North of Albany. General practice with revenue of $520K. Selling practice and building for $400K. Practice alone valued at $367K. Stand-alone building in professional office park with large parking lot. Six miles from Lake George; near 4-year college, ski areas and 20 minutes from Saratoga Springs. Four bright ops. Practice Works practice management program, Kodak intraoral cameras and pan. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick by email: donna.bambrick@henryschein.com; or call (315) 430-0643. #NY1735.

SARATOGA COUNTY: Dentist looking to sell thriving private practice. Building included. Collections average $500-$600K. Doctor seeks to retire. Highly motivated seller. Inquiries to: practiceforsale601@gmail.com.

KINGSTON: Biological/Holistic, high-producing FFS practice that is mercury safe. About 2 hours from NYC and minutes from Woodstock. Revenue of $1.5M. Five ops. Stand-alone building also for sale.

Great systems keep A/R low. Open 5 days/week.

Equipment 6 years old, includes Ozone Generators, lQ air operatory filtration, Dentrix and Dexis. Paperless office. 1,600 patients. Perio associate one day/week.

Doctor will stay if needed. 15 new patients/month, dedicated staff. Contact Transition Sales Consultant Donna Bambrick at (315) 430-0643; or email: Donna.bambrick@henryschein.com. #NY2560.

SUFFOLK COUNTY: Orthodontic practice on North Shore.

1,280-square-foot, 4-chair condominium office. Modern decor and equipment, management software, digital pan/ cep unit and model scanner. PPS and FFS. Contact Dr. Scott Firestone by email: Scott.Firestone@henryschein.com; or call (516) 459-9258.

GLENS FALLS: General dental practice for sale.

Outstanding, long-time, quality family practice. Fully digital with CEREC. Owner will train during transition.

Sale includes building with office, equipment and apartment. Self-sufficient. Three ops and room for fourth. Excellent reputation and ever-expanding patient base and loyal staff. Golden, walk-in opportunity for right person. $550K on 4.5-day week. For details call: (518) 791-7457.

ITHACA: Affordable Finger Lakes area. Turnkey general practice. Eager to retire. Valuation $291K; asking

of 8-12 patients. Staff includes two dental assistants, one front desk and one office manager. Seller looking to retire but willing to work for short period to help transition. Great opportunity for someone looking to grow established practice with little competition.

Contact catriona@nationaldentalplacements.com for more information.

NORTH SHORE, SUFFOLK COUNTY: Great opportunity. Owner retiring. Professional building and lucrative practice for sale. Busy location with designated parking spaces and handicap access. Dental practice: 4 ops, lab, private office, waiting and reception room, staff kitchen and storage. Second floor: renovated apartment in desirable downtown location. For details, contact Katy Anastasio, Licensed RE Broker at (631) 549-5800; or email: aarealtors@gmail.com.

NORTHERN WESTCHESTER: Highly respected, long-established integrative dental practice in prime professional building. 4 ops, fully computerized, digital X-rays, cone beam and laser. Over $1.9M revenue in 2019; on track to do $2M+ in 2020. Close to 1,000 FFS patients, with over 20 new patients/month. Rare opportunity to own 5-star practice in beautiful suburb 45 minutes from NYC. NYERIRLE.

BROOME COUNTY: Beautiful, busy, well-established practice with very limited competition available for immediate purchase. Six well-equipped operatories, digital X-ray and pan, updated computer system, turnkey. Easy transition to new owner. Gross revenue $585K/net $285K on 4-day work week. Practice alone appraised at $411K. Will sell practice and building for $399K. Contact cncnl@aol.com; or text to: (607) 768-3810.

ROCKLAND COUNTY: Suffern. Dental practice for sale. Office for rent. Be the exclusive dentist in beautiful, middle class, 1,500-family residential garden apartment complex. Immediate income. Fully furnished and equipped. Retiring dentist will introduce. Contact: (845) 642-2463.

MARTHA’S VINEYARD: Practice and real estate for sale. Practice established 45 years ago. Current owner for 34 years. 4 days/week; 46 weeks/year. Pre-COVID annual gross $1M+. Perfect community in which to live and work. Fully digital. Six days hygiene per week and 2 days perio/surgery per month. Pedo practice currently vacant. Endless possibilities and opportunities.

No brokers. Inquiries to: mvdentalsociety@gmail.com.

ALBANY AREA: Reputable OMS practice for sale outside Albany. FFS/PPO mix with very small Medicaid component of roughly 5%. Clinically, practice 80% oral surgery, 10% implants, and 10% TMJ. Computerized but not fully digital. With no current marketing practice production over $1M; collections average $765K. Overhead less than 30%. 1,700-square-foot office located in freestanding building with three operatories. Seller works four hours/day and sees average

PARAGON Practice Transitions “We Put the SUCCESS in SUCCESSion” SOUTHERN WESTCHESTER: Long-established general practice with specialists coming in. State-ofthe-art office in most desirable location. Over $1.5M in collections on FFS patients. Fully computerized, digital X-rays, panoramic. Own practice of your dreams.

NYNEIRGR.

ORANGE COUNTY: Well-respected endodontic practice within 1 hour of NYC. Approximately $650k revenue; combination of better PPO and FFS. Seller willing to stay to introduce and assist transfer of practice. Modern facility; computerized with digital X-ray.

NYERIRPU. ULSTER COUNTY: Fabulous, long-established, FFS practice. Gross revenue nearly $900K, with over $200K in passive income. Over 800 FFS patients. Five ops; fully computerized, with digital X-rays, panoramic and soft-tissue laser. Practice in “New Hamptons” in relaxed atmosphere and make over $400K net income.

NYIAIRLE. NORTHERN SUFFOLK COUNTY: Longestablished, highly respected FFS general practice for merger into your location. Approximately $500k in collections. Doctor willing to stay on for one year to assure transfer of patient population. A rare gem that will not be on the market long. NYERIRPA. For more information, please contact: Ira@paragon.us.com; or call (516)318-3900.

Find us online at: www.paragon.us.com.

BUFFALO SUBURB: General dentistry practice in Buffalo suburb for sale. Second owner of practice established for 61 years. Good gross and net on parttime hours. Practice strictly hygiene and restorative.

All endo, perio, implants and oral surgery referred out.

Great opportunity for growth. Owner looking to retire later this year. Real estate available if desired. Very favorable terms. Preferably looking to sell or merge.

Replies to: khc6591@aol.com.

The New York State Dental Journal APRIL 2021 45 ●

CLASSIFIEDS

NORTHEAST BRONX: Established since 1980, private and insurance-based GP located in busy, desirable Bronx community. Loyal patient base, with many new patients per month. Street corner street-front location with bus stop right at office and directly across from Montefiore Medical Center. Selling practice and real estate together. 1,700-square-foot office. 3 equipped treatment rooms, with 2 additional plumbed. Seller willing to stay as needed. Contact Henry Schein Professional Practice Transition Sales Consultant Mike Apalucci at (718) 213-9386; or email: michael.apalucci@henryschein.com. #NY2404.

$225K. 1,574 active patients are 99% FFS. 2019 annual collections $481K with relaxed pace of 4-day week. Excellent income growth potential. Referrals include implant placement, ortho, endo and oral surgery. Three bright, spacious, fully equipped operatories. Updated technology includes digital X-rays and Eaglesoft. HEPA-filtered/UV- treated air (>12 changes/ hour) and chairside extraoral HEPA filtration units. Highly visible, well-maintained, handicap-accessible, free-standing building with off-street parking. Building for sale ($275K) or lease. Includes second-floor apartment for use or rental income. Sale of building and equipment to specialty practice or use as satellite office considered.

Region has natural beauty, excellent schools, recreational and cultural activities. Inquiries confidential. Contact Dr. Bernie Kowalski by phone: (267) 337-3215; or email: b.kowalski@choicetransitions.com.

BUFFALO: Periodontal practice. Ownership opportunity. Busy periodontal practice; two locations; over 2,100 active patients. Current doctor seeking 50/50 partner.

9 operatories and collections of $2.25M. Adjusted EBITDA $480K. 40-50 new patients per month. To learn more, please contact Kaile Vierstra with Professional Transition Strategies: kaile@professionaltransition.com.

MANHATTAN: Murray Hill. Space available in established, friendly dental practice off Park Avenue. One op with shared reception area, WiFi and utilities. First floor of luxury doorman building in desirable location at 35 East 35th Street. Call (212) 532- 0690; or email: parkavedentistny@gmail.com.

tal ops with Pelton Crane equipment, massage chairs and two TVs at 12 o’clock and overhead. Pano/CT/ Ceph available. Shared front desk space and private office. Will consider sharing staff if needed. Located at 53rd Street and Madison Ave. Please inquire at: nycmidtownoffice@gmail.com.

MIDTOWN MANHATTAN: 2-3 operatories for rent with shared front desk space. For more information, please email: veronica@madisonavenuesmiles.com.

FOR RENT

MIDTOWN MANHATTAN: Beautiful, new, largewindowed dental operatories for rent. Pelton Crane equipment, massage chairs, private office and front desk space. Doorman; warm environment. Best location – 46th Street and Madison Avenue. Please call (212) 371-1999; or email: karenjtj@aol.com.

MANHATTAN: Fifth Avenue; Upper East Side. 3 ops for rent full or part time. Have your own business office.

Full lab plus kitchen and private office. Great location and beautiful office. Contact: lloydxray@gmail.com.

NASSAU COUNTY: Excellent opportunity for specialists seeking space sharing at new, modern digital office. Easy access to highway. Please contact to discuss options. Phone: (516) 592-1555; or email: parul-dua@yahoo.com.

CLASSIFIEDS

INDEX TO ADVERTISERS Accounting Dentistry . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 & 15

Choice Transitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cover II

Epstein Practice Brokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

First Republic Bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Jacobson Goldberg & Kulb . . . . . . . . . . . . . . . . . . . . . . . . . . 20

MLMIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cover IV

NYSDA Support Services . . . . . . . . . . . . . . . . . . . . . . . . . . 4 & 9

NYSDA Member Renewal . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

NYSSOMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cover III

UB Continuing Ed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

46 APRIL 2021 The New York State Dental Journal ●

MANHATTAN: Murray Hill. 4-op office available for rent 1-3 days/week. Accessible all weekends and holidays. Established dental practice in luxury doorman building. Convenient to public transportation. Perfect for start-up or established general practice that needs room to grow or maintain existing practice. Owner reducing days. Opportunity to transition into buy out. Contact: murrayhilldentist@gmail.com.

MANHATTAN: Upper East Side office for rent. Fully equipped office with 5 chairs available 2 days/week for part-time rental. Perfect for specialist or GP. Close to Mt. Sinai Hospital and convenient to transportation.

Potential for office purchase and ideal for transition of practice or temporary space while ongoing office renovations. Please call (917) 319-2343; or email: shmadg@aol.com.

WHITE PLAINS: Modern, state-of-the-art operatories available in large office with reception. Available FT/PT; turnkey. Rent includes digital radiology with Panorex, equipment, Nitrous, all disposables. Start-up or phase down. Need a satellite or more space? Upgrade or downsize. Please call (914) 290-6545; or email: broadwayda@gmail.com.

MIDTOWN MANHATTAN: Facing Central Park South. Fully digital dental office, including i-Cat, for lease. Great opportunity; be on your own.

State-of-the-art décor, newly renovated, modern office and equipment, handicap access. Near all public transportation. Available immediately, full time or part time. To schedule appointment, please email: perioimplantbythepark@gmail.com; or call: (917) 679-6013.

MIDTOWN EAST: Grand Central area. 2 operatories and office available for rent full or part time. Operatories are recently renovated with modern equipment.

Bathroom within office suite. Shared front desk space available. Full access to sterilization. Please email: tyoung89@gmail.com.

MIDTOWN MANHATTAN: Dental ops for rent on Madison Avenue. FFS practice has 1-2 ops available full time or part time. Beautiful, new, large-windowed den-

MANHATTAN: Tribeca area dental office for rent.

Brand new, modern dental office has 2 operatories available. 100+ square feet (9’x 12’) of illuminated space; 10-foot ceilings. New state-of-the-art Italian dental chairs with Cavitron, curing light, camera, monitor, all directly connected to chair functionality. X-ray machine, wall-mounted TV, 2 sinks, base and upper cabinets spanning total of 14’ along two separate walls.

Dentists will also have access to brand new reception desk, central AC, 17’-long lab area. Please contact for information. Phone: (917) 392-0506; or email: Patmoez@gmail.com.

SERVICES TAXES: Your office, business or personal. Specialty dentists. Personable CPA. Call Stuart A. Sinclair, CPA, at (516) 935-2086. Visit our website: www.dentaxsolutions.com. Offices located at 1120 Old Country Rd., Plainview, NY 11803.

OPPORTUNITIES AVAILABLE ROCKLAND AND DUTCHESS COUNTIES: Superstar or rising star dentist needed for private practice. Seeking General Dentist or Prosthodontist confident in their ability to succeed and sees unlimited opportunities available through commitment, communication, continuing education and effort. Amazing opportunity for experienced practitioner to join expanding, qualityoriented, full-service cosmetic/restorative/implantfocused family practices established over 30 years.

Focus on comprehensive care and providing all aspects of dentistry, including pediatrics, endodontics, cosmetic, restorative, periodontics, implantology (surgical and prosthetics), full-mouth reconstruction, sleep medicine and Botox. State-of-the-art facilities with technology necessary to provide five-star treatment planning and care. We pride ourselves on our doctors’ and team’s commitment to constant learning through continuing education and mentoring. Excellent compensation, benefits and equity opportunities. Please send resume by email: dr.caronson@gmail.com.

INDIANA: Associateship available. Full-time associate wanted for very busy practice located in Plymouth, Indiana. Plymouth is growing community in North Central Indiana. Low taxes, low crime, low reported cases of COVID-19. Easy access to South Bend, Fort Wayne, Chicago and numerous recreational lakes. Must be proficient in all aspects of dentistry. Pay based on 35% production. Buy-in possible after 1 year. Send resume to: drbrucefbecker@yahoo.com.

SARATOGA COUNTY: Fantastic and rare opportunity to join high-quality and rapidly growing dental group. Modern, state-of-the-art facilities with new equipment, digital X-rays and paperless charting. Seeking the right dentists to join our team as we expand and grow. First- and second-year salary minimum guaranteed with opportunity for earnings well above average.

Flexible terms can be tailored to fit individual desires if determined to be right fit. Very competitive compensation methodology. Training available for precision-guided dental implant surgery. Very strong mentorship program for new and recent graduates. Contact John O’Brien, DDS, by email: jobrien1218@gmail.com; or call (518) 703-5321.

POTSDAM: Full-time associate wanted for partnership. Busy FFS general practice supports 2 FT and 1 PT dentist and 5 FT hygienists. Senior dentist retiring.

New 4,500-square-foot building and 9 operatories of new equipment, including digital X-rays, paperless charting, iTero scan. Services include restorative, periodontal, endodontics, orthodontics and hybrid dentures.

Potsdam is located in Adirondack foothills in center of St. Lawrence County. Outdoor enthusiasts will enjoy St. Lawrence River and ADK mountains in backyard.

Ottowa, Lake Placid and Thousand Islands all within 90 minutes. Tight-knit community considered cultural and educational center rich in education and technology hosting State University of Potsdam and Clarkson University, with St. Lawrence University and SUNY

BINGHAMTON: Longstanding group practice in Southern Tier producing high-quality work with attention to detail. Looking for full-time associate leading to possibility of partnership buy-in for right candidate. Ideal candidate will possess great attention to detail, strong communication skills, as well as strong work ethic. FFS practice with some insurance plans. We pride ourselves on practicing dentistry the way it was meant to be practiced. Benefits include health insurance, 401K, malpractice and more. For details, contact davidsalomons@hotmail.com; or call: (607) 760-9064.

CAPITAL DISTRICT: Associate dentist. Wellestablished, multi-doctor practice seeks FT associate to join our progressive practice. Work in state-of-the-art facility where team is focused and diligent. Candidate should be positive, outgoing and dedicated to patient care and education. Please forward CV and cover letter to: eastviewjo@gmail.com.

CLASSIFIEDS

FACULTY POSITIONS: Midwestern University.

Faculty Position: Assistant Professor Midwestern University College of Dental Medicine-Illinois Midwestern University, Downers Grove, IL. Seeking full‐time faculty member responsible for teaching in one‐to‐one, small group and plenary settings; demonstration and facilitation related to clinical situations; and the use of electronic media as needed. Candidates must possess DDS/DMD degree and be eligible for licensure in Illinois. Successful candidate will possess an enthusiasm for dentistry; excellent clinical, communication and interpersonal skills, and ability to embrace new technology. Previous teaching experience not required but candidate must have history of clinical experience. Also hiring for Clinical Assistant Professor, Pediatric Dentist. http://midwestern.edu/faculty-andstaff/employment.xml. Midwestern University is Equal Opportunity/Affirmative Action employer that does not discriminate against an employee or applicant based upon race, color, religion, gender, national origin, disability, or veterans status, in accord with 41 C.F.R. 60-1.4(a), 250.5(a), 300.5(a) and 741.5(a).

Canton 15 minutes away. Potsdam boasts one of NY’s finest public school systems and progressive medical facility, St. Lawrence Health System. Other nearby employers include ALCOA Aluminum, Corning Glass, NYS Power Authority and NYS Dept of Corrections. To learn more, visit: www.sandstonedentistry.com.

DANBURY, CT: Premier Dental, a DCA-affiliated practice, seeks FT general dentist. 2+ years experience required. Must be able to work 2 Saturdays/month.

Outstanding earnings and full benefit package. Email resume to: bames@dentalcarealliance.com. Visit us online at: www.dentalcarealliance.com.

BINGHAMTON: Third-generation family practice seeks capable associate to build long career. We recently merged with another practice and have plenty of treatment for eager doctor. 100% FFS and offering advanced technology, such as CBCT and intraoral scanning. Also open to considering candidates who have open time while building their own practices or senior doctors looking to continue part time. Please contact Michael C. Perna, DDS, at Perna Dental, 55 Oak Street, Binghamton by phone: (607) 722-0832; or email: drmike@drperna.com.

SYRACUSE: Private, family-oriented, fast growing, long-standing practice seeks Associate to provide genuine and compassionate patient care. Must have great attitude, passion for patient care and strong clinical background. Should be diligent and proficient about profession as long-term career opportunity. Associate dentist will enjoy being part of busy and thriving practice. We offer full range of general dentistry and specialty care. Well-trained and motivated team provides excellent patient care. Modern, state of the art the practice is fully digital, paperless with up to date equipment. Qualifications: valid dental license for NY State; current malpractice insurance and leadership skills. Great pay and benefits provided. Reply to: atwaldental@gmail.com

The New York State Dental Journal APRIL 2021 47 ●

Communicate Conveniently and Compliantly in the Cloud Increased speed, profits and protection are your rewards.

Robert McDermott

There are tangible benefits to choosing a cloud-based, fully HIPAA-compliant email service. In addition to greater protection from cybercrime, HIPAA-compliant cloud services can integrate seamlessly into your workflow. This means less jumping between tabs (speed), greater connectivity with other providers (profit) and the highest levels of security (protection). And, it can all be done from anywhere.

Speed It gets your work done faster. Cloud-based, compliant email can streamline your workflow with one interface for both your compliant and regular email messages. One interface means one login to send and receive protected health information (PHI) and check your Gmail, Hotmail, Yahoo! etc., no longer forcing you to log in and out of different windows.

The cloud gives you freedom to send and receive compliant email no matter where you are. Often, patient care doesn’t begin and end at the time of the appointment. If records need to be transferred to a specialist or information is requested, you can send quickly and easily from any device and any location.

Profit Your compliant, cloud-based email can save you time and resources with a built-in referral network. Search by zip code or

48 APRIL 2021 The New York State Dental Journal ●

specialty to make sure your patients get care from verified providers no matter where they are in the city, state or country. And it works both ways. Doctors can find you with ease to send patients your way for care.

Protection The cloud means all of your data is backed up with every keystroke and stored in extremely secure data centers, not on a vulnerable server in your office. When you are sending PHI through the cloud, the data is often stored in a secure, private data center.

These centers provide stringent access controls and 24/7 monitoring to prevent hacking or other attacks on PHI. Storing your patient and practice information on a server in your office or through common cloud services hosted on the public internet is far less secure.

Now is an excellent time to look at your business services with fresh eyes. Protect your practice by keeping patient data safe from cybercriminals, and work smarter and faster through the cloud.

Robert McDermott is president and CEO of icoreConnect, iCoreExchange, a cloud-based, HIPAAcompliant email. icoreConnect, a NYSDA-endorsed vendor, has no file size limits on attachments.

Visit iCoreConnect.com/NYSDA, or call (888) 810-7706 for special pricing and a free iCoreExchange demo.