NYSDJ January 25

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Managing Immature

Necrotic Teeth

Overcoming the Open Apex Challenge

14

The Open Apex Challenge

Joseph C. Stern, D.D.S.

Managing immature necrotic teeth has always posed challenges because of the unpredictable nature of treating roots with wide open apices that lack an apical stop. Author presents a case series that explores various endodontic techniques and methods for managing an open apex.

22 Pathological Changes in Soft Tissues Associated with Radiographically Normal Impacted Teeth: A Critical Update and Meta-analysis

Adesh S. Manchanda, M.D.S.; Ramandeep S. Narang, M.D.S.; Komaldeep Kaur Sandhu, B.D.S.

A retrospective analysis of histopathological diagnosis of pericoronal tissues associated with impacted teeth was undertaken and correlated with hypothetical classification of pericoronal follicular space, with objective of improving clinical management of treating impacted teeth. Results dictate against complement removal of asymptomatic impacted teeth.

34 Bridging the Dental Care Gap: Addressing Oral Health Disparities in New York State Nursing Homes

Apeksha Phulgirkar, B.D.S., PGCert, M.P.H.; Stacy McIlduff, CFRE

Study undertaken to assess availability of onsite dental care services in New York State nursing homes and role of mobile dental clinics in bridging access gap, especially in rural and underserved areas, revealed significant service gaps and underscored urgent need for targeted interventions.

42 Dental Management of a Talon Cusp on a Permanent Incisor in

Clinical concerns related to a talon cusp include occlusal interferences and increased risk for dental injury, displacement of the affected tooth, caries, tongue irritation and esthetic concerns. Authors present case of 8-year-old girl with occlusal interferences involving permanent maxillary right central incisor due to Type 1 dens evaginatus whose talon cusp was successfully reduced periodically over two months.

A Dream Come True

NYSDJ Editor Stuart Segelnick traces the path that brought him to the helm of his favorite member benefit.

There are many facets of a well-made journal. Producing an exceptional publication such as The NYSDJ takes a lot of time, effort and commitment by its staff: Editor Chester Gary, Managing Editor Mary Stoll, Advertising and Sponsorship Manager Jeanne DeGuire and Art Director Ed Stevens, as well as its contributors and Editorial Review Board members. Dr. Gary has done an amazing job these past eight years at the helm, writing award-winning editorials and working tirelessly to help bring ADA Commons, our indexing platform, to fruition. He has also been an inspiration and trusted advisor to me, as were past editors Dr. Kevin Hanley and the late Dr. Elliott Moskowitz. I am humbled, happy, in fact, ecstatic, to have been chosen by NYSDA to help lead our flagship publication as your new editor.

You may be wondering how I got here? Sometimes I do too. I have to go back to 1992, when I picked up the July issue of The NYSDJ and was delighted to read an editorial about the University at Buffalo School of Dental Medicine celebrating its centennial anniversary. Admittedly, my interest was heightened by the fact that I had graduated just a month earlier from UB, but it was then that I became hooked on what I still consider to be one of

the best benefits of my membership in organized dentistry. Move ahead to the autumn of 2009. A teary-eyed tribute I wrote about a wonderful patient was printed in the Bulletin of the Second District Dental Society called “Hard to Say Goodbye.” This same article received the 2010 Bernard P. Tillis Award, presented by NYSDA for excellence in dental writing, and was reprinted in The NYSDJ. Receiving this prestigious award helped increase my confidence in my writing skills and encouraged me to continue submitting articles to the SDDS Bulletin. In 2015, I was appointed editor of the Bulletin. During these past 10 years, I honed my editorial skills under the guidance and support of the SDDS, especially Executive Director Bernie Hackett, staff member Shayo Farinre and Publishing Committee Chair Dr. Howard Lieb. And I entertained a dream of becoming editor of The NYSDJ. I stayed involved in publishing as a member, then president (2021-2022), of the American Association of Dental Editors and Journalists, which put me in touch with great editors across the country.

Writing is a Learning Experience

At this point, some words about my profes-

sional credentials are in order. I found my first job in a private periodontal practice in the Sheepshead Bay section of Brooklyn in 1994 after receiving a specialty certificate in periodontology from Temple University Dental School. My mentor and boss Dr. J. Herman Beckelman wisely pushed me to join Brookdale University Hospital as an attending periodontist. Hospital dentistry is important in many ways, notably, by helping to treat the health needs of underserved people. New York State has one of the most numerous hospitalbased dental residency programs in the country. To all our members who are involved in hospital-based programs, please, consider sharing your knowledge with our readers by documenting interesting cases you come across and sending them to us for possible publication.

Some years later, while teaching at Wyckoff Heights Medical Center, New York Hospital Queens, and working at my office, I decided to do a little research. With guidance from Dr. Sebastian Ciancio, my former teacher at the University at Buffalo, I surveyed both hospital patients and private-practice patients about their flossing habits and sent my article to the Journal of the American Dental Association (JADA). Months later, I received a letter from theneditor Dr. Marjorie Jeffcoat saying that my article would not be accepted without major, recommended revisions.

My head was spinning. It seemed too huge of an endeavor to satisfy all the requested modifications and, frankly, some were, in my opinion, unwarranted. Looking back, I would advise my younger self and you, my hopeful po-

EDITOR

Stuart L. Segelnick, D.D.S., M.S.

MANAGING EDITOR

Mary Grates Stoll

ADVERTISING/SPONSORSHIP MANAGER

Jeanne DeGuire

ART DIRECTOR

Ed Stevens

EDITORIAL REVIEW BOARD

Frank C. Barnashuk, DDS. Past Clinical Assistant Professor, Department of Restorative Dentistry, University at Buffalo School of Dental Medicine, Buffalo, NY.

David A. Behrman, DMD. Chief, Division Dentistry/OMS, Associate Professor of Surgery, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY.

Michael R. Breault, DDS. Periodontic/Implantology. Private Practice. Schenectady, NY.

David Croglio, DDS. Clinical Assistant Professor, University at Buffalo School of Dental Medicine, Buffalo, NY. Private Practice (retired), Amherst, NY.

Jennifer Frustino, DDS, PhD. Director, Oral Cancer Screening and Diagnostics, Division Oral Oncology and Maxillofacial Prosthetics, Department of Dentistry, Erie County Medical Center, Buffalo, NY.

Michael F. Gengo, DDS. Board-certified Endodontist, Clinical Assistant Professor, Department of Endodontics, University at Buffalo School of Dental Medicine, Buffalo, NY. Private Practice, Hamburg, NY.

G. Kirk Gleason, DDS. General Dental Practice (retired), Clifton Park, NY.

Kevin Hanley, DDS. Orthodontic Private Practice, Buffalo, NY.

Violet Haraszthy, DMD, DDS, MS, PhD. Professor, Chair, Department of Restorative Dentistry, University at Buffalo School of Dental Medicine, Buffalo, NY.

Stanley M. Kerpel, DDS. Diplomate, American Board Oral and Maxillofacial Pathology, Associate Director, Oral Pathology Laboratory, Inc. Attending, Section of Oral Pathology, New York-Presbyterian, Queens, NY.

Robert M. Peskin, DDS. Dental Anesthesiology Private Practice, Garden City, NY.

Joseph Rumfola, DDS. Clinical Assistant Professor, AEGD Program Director, University at Buffalo School of Dental Medicine, Buffalo, NY. Private Practice, Springville, NY.

Jay Skolnick, DMD. Board-certified Pediatric Dentist. Attending dentist, Rochester General Hospital. Private Practice, Webster, NY.

Lisa Marie Yerke, DDS, MS. Diplomate, American Board Peiodontology, Clinical Associate Professor, Director Advanced Education Program in Periodontics, University at Buffalo School of Dental Medicine Department Periodontics & Endodontics, Buffalo, NY. Private Practice, East Amherst, NY.

PRINTER

Fort Orange Press, Albany

NYSDJ (ISSN 0028-7571) appears two times a year in print: January and June/July. The March, April, August/September and November issues are available online only at www.nysdental.org. The Journal is a publication of the New York State Dental Association, 20 Corporate Woods Boulevard, Suite 602, Albany, NY 12211. In February, May, October and December, members have online access to the NYSDA News. Subscription rates for nonmembers: $75 per year or $12 per issue, U.S. and Canada; $135 per year foreign or $22 per issue. Editorial and advertising offices are at Suite 602, 20 Corporate Woods Boulevard, Albany, NY 12211. Telephone (518) 465-0044. Fax (518) 465-3219. Email info@nysdental.org. Website www.nysdental.org. Microform and article copies are available through National Archive Publishing Co., 300 N. Zeebe Rd., Ann Arbor, MI 48106-1346.

tential authors, to provide all the revisions and explain the ones you truly feel need not be revised and resubmit the paper. However, in this instance, I corrected most of what was asked and pivoted, sending my article to The NYSDJ. I’ll never forget how happy I was to receive a letter of acceptance from the editor, Dr. Elliott Moskowitz. The article was published in the May/June 2004 issue as the cover story!

Since then, I have written or coauthored several clinical articles, including the cover story of the July 2024 JADA, which required major revisions and then minor revisions before being accepted for publication. And, yes, I learned my lesson and followed through on the recommended changes.

One more glance at the past, to 1999, when, thanks to Dr. Bob Schoor, who was my instructor at Temple, I started teaching at NYU College of Dentistry, in the postgraduate advanced education periodontal program. Here is where I came to understand the value of collaboration, that writing with a group of people is much more educational and enjoyable. I invite faculty and students from our dental schools to consider collaborating on the writing of interest-

ing case reports and research manuscripts for submission to The Journal. Likewise, I view the many dental meetings occurring within our state, such as the Greater New York Dental Meeting and Northeastern Society of Periodontists, to be fertile ground for Journal submissions. I urge all of these diverse organizations to consider submitting their best posters and case reports to The NYSDJ

Thank You

Without my dental school and hospital affiliations, all the great mentors, colleagues, students and residents I met along the way; without the SDDS, NYSDA and the profound influence of The NYSDJ, I wouldn’t be here today. I thank you all for having a hand in transforming me into your editor. I pledge to continue the legacy of The NYSDJ, but doing so will not be possible without your sustained support.

D.D.S., M.S.

New Laws Aim to Improve Oral Health

Increased access to fluoride varnish and expanded health and wellness campaign expected to improve oral health of children and adults.

The end of 2024 brought two new laws that specifically affect dentistry. The first such law, Chapter 457 of the Laws of 2024, took effect on Nov. 15. It amended Section 6608 of the New York State Education Law to allow registered dental assistants to apply topical fluoride varnish. Topical fluoride varnish had previously been limited to dentists and dental hygienists. It also amended Section 6902(2) of the Education Law to allow licensed practical nurses (LPNs) to apply topical fluoride varnishes.

Previously, physicians or dentists could only issue an order to a registered professional nurse (RN) to do so (nurse practitioners and physician assistants also could apply topical fluoride varnish). The general purpose of the new law is to improve children’s dental health outcomes by allowing additional healthcare providers to apply fluoride varnish to teeth when there is a prescription and under protocols of an authorized provider.

The justifications for the new law were that applying fluoride varnish to the teeth of young children is proven to reduce dental disease, that too few children in New York are receiving treatments, and that

fluoride varnish application is a standard of care for pediatric offices and for the New York State Medicaid program. Allowing additional types of health providers to perform this service was seen as bringing New York in line with other states and creating more access points at which children and adolescents enrolled in Medicaid could receive this preventive service.

The Legislature reasoned that dental disease in children has been called a “hidden epidemic”—hidden because it is not always apparent until the pain becomes unendurable or until it creates an inability to eat, sleep or concentrate in school. The Legislature also believed that dental disease is hidden by poverty. Most children won’t experience severe dental disease. Instead, the effects are felt primarily by low-income children because it relates to many of the same social and economic factors that drive other health disparities.

In 2021, more than 14% of children in New York reported one or more oral health problems. In 2020, only one in every three New York children enrolled in Medicaid (32.8%) received a preventive dental visit (national median 41.5%), which includes fluoride varnish application. Persistent oral

health disparities remain, with children who are Black and Hispanic/Latino and children experiencing poverty most affected by poor dental health.

Interestingly, the Legislature felt compelled to describe fluoride varnish as a topical solution used to prevent tooth decay that, like fluoridated toothpaste, is applied to the surface of teeth. It helps prevent cavities by making the tooth hard and when cavities are just starting or barely visible. Fluoride varnish is painted onto the front and back, top and bottom of the teeth with a tiny brush, where it hardens as soon as it is touched by saliva in the mouth. It takes less than two minutes to apply and requires no special equipment or extensive training to master the technique. The Legislature seemed determined to demonstrate that it was a “no-brainer” to expand who could perform this simple procedure.

The Legislature also noted that there was highquality evidence that fluoride varnish is effective in preventing tooth decay in children at moderate-tohigh risk and that studies showed that children who received fluoride varnish every three months had fewer cavities than those who got it less often or not at all. The Legislature added that fluoride varnish should be started early, even in infancy, when the first tooth erupts, because it is most effective when applied before tooth decay develops.

New York Medicaid reimburses for up to four applications per child per year. Dental providers can bill Medicaid from birth up to age 21 and medical providers from birth to age 6. The Legislature noted that while providers currently authorized to apply fluoride varnish in New York included dentists, dental hygienists, physicians, nurse practitioners, registered nurses and physician assistants, allowing additional members of care teams to apply the varnish would increase flexibility in offices and provide more opportunities to incorporate the service into visits, and would bring New York in line with many other states that allow a wider variety of health professionals to perform this task.

Oral Health Top of Mind

The second law, Chapter 535 of the Laws of 2024, will take effect on Jan. 21. It amends Section 207 of the New York State Public Health Law to include a new paragraph(s) of subdivision 1 to require that the New York State Department of Health’s Health Care and Wellness Education and Outreach Program include oral health.

NYSDA Directory

OFFICERS

Prabha Krishnan, President 11045 Queens Blvd., Ste 108, Forest Hills, NY 11375

Maurice Edwards, President-Elect 30 East 60th St., #1401, New York, NY 10022

Amarilis Jacobo, Vice President 824 East 181st St., Bronx, NY 10460

Paul Leary, Secretary-Treasurer 80 Maple Ave., Ste 206, Smithtown, NY 11787

William Karp, Speaker of the House 4500 Pewter Ln., Bldg 6, Manlius, NY 13104

BOARD OF TRUSTEES

Anthony M. Cuomo, Immediate Past President 19 Cannon Dr., Newtown, CT 06470

Brendan Dowd, ADA Trustee 1119 Deleware Ave., #6, Buffalo, NY 14209

NY – Lois Jackson 505 Laguardia Pl., Apt L4, New York, NY 10012

2 – John P. Demas 8814 Fort Hamilton Pkwy, Brooklyn, NY 11209

3 – Geoffrey Gamache 24 Eastview Rd., Averill Park, NY 12018

4 – Adrienne L. Korkosz 1309 Union St., Schenectady, NY 12308

5 – Lynn A. Stacy 7504 E State St., Lowville, NY 13367

6 – Louis Giordano 864 Hooper Rd., Endwell, NY 13760

7 – Theresa A. Casper-Klock

33 William St., Ste 1, Auburn, NY 13021

8 – Raymond G. Miller 122 Covington Rd., Buffalo, NY 14216

9 – Gary M. Scharoff 1255 North Ave., Ste A1H, New Rochelle, NY 10804

N – Donald R. Hills 136 Woodbury Rd., Ste L3, Woodbury, NY 11797

Q – Mitchell S. Greenberg 11966 80th Rd., #1A, Kew Gardens, NY 11415

S – Guenter J. Jonke

2500 Nesconset Hwy., Bldg 24A, Stony Brook, NY 11790

B – Jacqueline J. Samuels 120 Alcott Place, Bronx, NY 10475

New Dentist – Kathryn Rothas 920 Lark Dr., Albany, NY 12207

COUNCIL CHAIRPERSONS

Council on Awards Brendan P. Dowd 1119 Delaware Ave., #6, Buffalo, NY 14209

Dental Benefit Programs

Dental Education & Licensure

Dental Health Planning & Hospital Dentistry

Dental Practice

Ethics

Joseph A. Craddock 3325 East Main St., Attica, NY 14011

Robert M. Peskin 601 Frankline Ave., #225, Garden City, NY 11530

Raquel Rozdolski

52 Shingle House Rd., Millwood, NY 10546

Mario Silvestri 501 Plaza Dr., Vestal, NY 13850

Paul W. Teplitsky

1 Hanson Pl., # 705, Brooklyn, NY 11243

Governmental Affairs Radha Sachdeva-Munk 203 Smithtown Blvd., Nesconset, NY 11767

Membership & Communications Kendra J. Zappia 1 Pine West Plaza, #106, Albany, NY 12205

Nominations

Peer Review & Quality Assurance

Professional Liability Insurance

OFFICE

Anthony M. Cuomo 19 Cannon Dr., Newtown, CT 06470

Lawrence J. Lehman 7303 197th St., Fresh Meadows, NY 11366

Roland C. Emmanuele 4 Hinchcliffe Dr., Newburgh, NY 12550

Suite 602, 20 Corporate Woods Blvd., Albany, NY 12211 (518) 465-0044 | (800) 255-2100

Michael J. Herrmann Executive Director

Lance R. Plunkett General Counsel

Mary Grates Stoll Managing Editor

Jenna Bell Director Meeting Planning

Briana McNamee Director Governmental Affairs

Jacquie Donnelly Director Dental Practice Support

Stacy McIlduff Executive Director NYS Dental Foundation

Section 207 allows the Department of Health to conduct education and outreach programs for consumers; patients; educators, including but not limited to elementary and secondary school educators; and healthcare providers. Specifically, the new law calls for a public awareness campaign on the importance of good oral health, including but not limited to, the impact of oral disease, causes of oral disease and its prevention, oral health across the lifespan, the total body connection, the value of early detection, and the availability of oral health services in the community.

The general purpose of the new law is to raise public awareness about the importance of good oral health to good overall health and well-being.

The general purpose of the new law is to raise public awareness about the importance of good oral health to good overall health and well-being.

The justification for the new law was that good oral health is essential for vital functions of life, including eating, breathing and speaking. The Legislature reasoned that dental disease can result in poor nutrition, school absences, missed workdays, and increasing public and private expenditures for dental care.

In addition, the Legislature noted that periodontal disease increases the risk of heart disease, diabetes and premature birth, and that dentists are important frontline healthcare providers in that infectious diseases, cancer, immune disorders and nutritional deficiencies are often reflected in the health of a patient’s teeth and gums. Accordingly, the new law provides for a public awareness campaign to underline the importance of dental care and oral hygiene in promoting overall health and well-being.

Going after the Bad Guys

These new laws are interesting in that there is renewed focus on the connection between oral health and overall health. That is a good thing that has often been missing in public health policy discussions. Also interesting is that the justifications for the new laws mention the high cost of dental services. That is less of a good thing that increasingly has made its way into public health policy discussions. Superficially, increasing awareness and access to dental care and reducing the cost of dental care seem wonderfully complementary public health goals. But, absent serious innovation, the solutions are elusive and often tend toward less involvement of dentists.

One glaring example of a defective and unserious “innovation” is the now-defunct SmileDirectClub. Recently, and somewhat belatedly, the New York State Attorney Gen-

eral recovered 4.8 million dollars for consumers who continued to be charged by SmileDirectClub even after it had gone bankrupt and completely closed its operations.

SmileDirectClub, an alleged telehealth company that offered dental services, filed for bankruptcy in September 2023, but continued to charge consumers for services even after it abruptly halted its business operations. The Attorney General had received complaints from New Yorkers who were still being charged for services they could no longer receive. Finally, the Attorney General managed, in December 2024, to recover the improperly charged monies for affected consumers. But the SmileDirectClub model of easy access, low cost and little involvement from patients’ dentists ended up as a boondoggle that government realized too late was not promoting public oral health but was, instead, promoting the bank accounts of SmileDirectClub.

Members may not know that many years ago (starting in late 2014), NYSDA had met on multiple occasions with both the Attorney General and the New York State Education Department’s Office of Professional Discipline (OPD) with well-founded complaints about the operation of SmileDirectClub at its inception. Government twiddled its thumbs for 10 years, producing only the Education Department’s advice below to consumers:

“Many companies are now offering ‘Do it Your Self’ or ‘DIY’ dental treatments, often at a reduced fee. Examples of these treatments/products include but are not limited to, orthodontic treatment, tooth whitening, grills, mouthguards, at-home tooth replacement, including crowns and veneers, etc. Here are some suggested questions you should ask yourself when considering one of these treatments/products.

1. “Is the DIY treatment/product legal under New York State laws and regulations?

2. Are your teeth healthy enough for the DIY treatment you are considering? What are the potential risks of this treatment/product?

3. Will you ever see a licensed New York State dentist during the course of your DIY treatment? If you have a problem during the course of treatment or while using the product, who will assist you in addressing it?

4. Will initial records, such as X-rays, photographs and impressions/scans be taken prior to the start of your DIY treatment or the use of the product? Will you have access to these records if needed?

5. Are there any hidden fees that may come up during or after your DIY treatment?

6. Is the company you will be working with asking you to sign a release relieving it of any liability? If you have a dispute or are injured during the course of your DIY treatment or during the use of the product, what rights do you have?

7. Are you considering a DIY treatment that involves the orthodontic movement of your teeth? If so, you should be aware that moving teeth incorrectly can potentially damage teeth, the supporting tissue and permanently change your facial appearance.

8. What will happen if the company you are working with goes out of business?

“Additionally, as part of your DIY treatment, will you receive any office visits to see the orthodontist or dentist? If so, will these visits result in added costs to you?

“Should you have any questions or concerns regarding a ‘Direct to the Consumer’ product, please contact the New York State Education Department at conduct@nysed.gov or 1(800) 442-8106.”

Calling a Halt to CTA

Finally, yet another major court decision was issued on Dec. 3. The United States District Court for the Eastern District of Texas struck down as unconstitutional, under the Tenth Amendment of the United States Constitution (ruling that Congress lacked the power to enact the law because it improperly intruded on rights exclusively left to the states), the federal Corporate Transparency Act (CTA), issuing a nationwide injunction stopping its enforcement that was scheduled to begin on Jan. 1 (many dentists have already complied with the law in 2024).

The case is Texas Top Cop Shop, Inc. v. Garland. On Dec. 5, the federal government filed an appeal in the case with the United States Court of Appeals for the Fifth District. They are already appealing a much more limited decision from an Alabama federal court that applied only to the parties in Alabama. The final fate of the CTA must now be awaited on appeals likely to go to the United States Supreme Court, depending on what the next administration decides to do on appeal.

The federal court decision has no effect on the New York State version of this law that commences on Jan. 1, 2026, and applies only to limited liability companies (LLCs and PLLCs). That law was covered in detail in the March 2024 New York State Dental Journal.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.

A Question for Dentists Why Mediation?

Like peer review, carefully structured and executed mediation is a beneficial tool for resolving disputes.

Have you ever felt that the way we try to resolve conflict these days, with each side stuck in its hardened position while viewing the other side as nothing more than a wrongheaded adversary, isn’t the best way for people to go forward?

Our adversarial system of justice surely has its benefits in terms of protecting legal rights, but in too many situations, the system is slow, inefficient and costly—and it almost always results in winners and losers, often unnecessarily creating stress and damaging human relationships, both business and personal, in the process.

Should our first thought to resolve a dispute be protracted litigation? Should our first inclination be that we need a judge to solve a problem for us, that those in conflict cannot find a way to resolve the issue between them?

What if there were another way to approach and resolve conflict? What if there were a way to have two winners or, at the very least, a path where two people could come out of conflict understanding and respecting one another? What if there were a way that empowers those in conflict to fashion their own outcome together? What if this approach were quick, efficient and low-cost?

Well, there is such an approach. It is called mediation. In fact, mediation is already used by the American Dental Association (ADA) as part of its peer review process for resolving fee-based disputes between dentist and patient. But mediation can have a much wider application in the life of a dentist, both professionally and personally, as we will see.

Bound to Peer Review

First, let’s take a look at how mediation is used as part of the peer review process. The process can be initiated ei-

ther by the patient of record or by a providing dentist who maintains an active tripartite membership in the ADA. Once the process is initiated, participation is mandatory for the member dentist. That is, the dentist cannot decline participation, though the patient can. However, once the participants begin the peer review process, both are bound to continue to its conclusion.

Peer review is a two-part process. First, comes the mediation. Once the process is initiated by dentist or patient, a member of the peer review committee will reach out to both and act as a mediator to facilitate a resolution. If the participants can come to their own agreement, that would conclude the peer review process. However, if a resolution is not reached, then a panel of dental arbitrators would decide the fate of a dispute, their decision binding upon the participants.

Mediation can also be a standalone process, where peer review has not been invoked. Let’s look at how mediation on its own works.

Voluntary Process

Mediation is an opportunity for those in conflict to safely say to one another why they have come and what they want. Unlike mediation in the peer review process, standalone mediation is voluntary throughout; participants may withdraw at any time without reaching an agreement. And there is no automatic follow-up process that results in the binding decision by a third party. There is only an agreement if the participants themselves agree on one. Where they do not, the participants are free to choose other avenues to resolve their dispute.

It is foundational to the process that the mediator, always maintaining impartiality, never makes a judgment in favor of one side and at the expense of the other; only the participants themselves are empowered to determine an outcome on their own terms.

Mediation is also a confidential process: what is said in mediation stays there, the mediator and the participants agreeing beforehand to treat the mediation session as a safe space for an honest exchange of views and grievances.

Mediation, then, is a skillful, humane, non-adversarial, cost-effective, time- and stress-saving way for people in dispute to directly address and transform conflict with one another.

Finding Resolution

There are a number of fundamental techniques that the mediator uses to encourage the participants to work together to address their problems.

First, the mediator restates to each participant what they have said. This simple technique has the effect of ensuring that each participant feels heard. It also allows each participant to hear what others have to say from a fresh voice, since very often people in conflict have difficulty listening to one another.

Next, the mediator reframes and summarizes what each participant has said, bringing the focus down to the underlying values, needs and interests that are driving the conflict. For example, in a noise complaint, what does sound mean to each participant? Well, the downstairs neighbor may want quiet enjoyment of their apartment while the upstairs neighbor may want the freedom to express themselves, perhaps by playing music.

Then, once issues are being addressed at this level (quiet vs. freedom, in our example above), the participants are encouraged to brainstorm solutions to their deeply held concerns. In our noise complaint, perhaps the time of day the music is played can be adjusted, or the location in the apartment where it is played can be changed or a carpet can be put down. Or the sound may not be the real issue at all, with something personal coming between the neighbors—and this too may be uncovered and addressed.

These techniques create openness and empathy between the parties so that they may listen past their positions to what lies below, to their values, needs and interests, since this is where resolution of the conflict will take place, with participants crafting their own viable resolution by mutually fashioning win-win responses to participant needs.

Finally, to create security between the participants, a mediated agreement may be written that memorializes the resolution and that may be used as proof of it.

Versatile Tool

Mediation can be used as a tool in virtually any area of conflict. Areas where mediation is employed to great effect include: provision of services in healthcare and other areas; civil claims; partnership; business and contract; workplace and employment; family and divorce; child custody and visitation; surrogate matters; real estate/property/neighbor disputes; and eldercare.

In addition to the fee disputes covered by the peer review process, dentists may have professional disputes revolving around their office settings. One such situation centers around partnership. It is not uncommon for a partner to leave the practice due to illness, relocation or for other reasons. Mediation is well-suited to work through the nuts and bolts of how best to go forward without creating animosity.

Similarly, one can envision everyday situations with dental staff or with the landlord of one’s office property where grievances can be addressed instead of inflamed. Dentists may also be involved in an array of personal matters, such as domestic disputes, civil claims, elder care issues, and many other possible conflicts better handled through the non-adversarial approach of mediation.

Yes, in your business life as dental professionals, in your personal relationships and in your interactions out in the world, as a matter of course, disputes of one kind or another inevitably arise. You may view conflict as an unhealthy impediment to be combated under great duress, or you may see conflict as what naturally happens when people with different values, interests and needs meet and must find ways to get along or, sometimes, to part in a skillful way.

Perhaps, when the time comes, you may choose mediation, beneficial in so many ways, as a skillful response to conflict in your life. p

Shahram (Sean) Shekib, J.D., D.D.S., FAGD, FICD, FAADS, FPFA, FACD, is a certified mediator, co-founder of Attune Mediation, LLC, CEO and founder of Doctors Club Foundation, Inc. He practices in Brooklyn, NY, and is clinical assistant professor, Columbia University College of Dental Medicine, New York, NY.
Martin Applebaum, J.D., M.A., has mediated well over 300 cases in areas involving family issues, contract and business disputes, and other matters. He frequently presents seminars on mediation and mediation techniques.
Mr. Applebaum
Dr. Shekib

New Member Wellness Benefit aims to to Keep Professional and Personal Lives in Balance

NYSDA is excited to announce its collaboration with AllOne Health to provide a new wellness benefit to current active and retired members. NYSDA’s Member Assistance Program (MAP) is a free, confidential benefit that offers wellness resources and services to support mental health, reduce stress and make life easier.

Members and their households will have access to short-term counseling with a licensed mental health clinician and be able to choose from in-person sessions, video or telephonic counseling. Other benefits include life coaching, financial consultation, and work-life resources and referrals. Members will have access to self-help tools, articles, webinars and podcasts.

At NYSDA, we recognize that balancing your professional and personal life can be stressful. We are here to help you navigate these challenges and support your overall well-being. To learn more and get started with your new benefit, visit www. nysdental.org/MAP.

State Board of Dentistry Appointments

RALPH H. EPSTEIN, D.D.S., of Glen Cove, Long Island, and Eugene A. Pantera, D.D.S., M.S., of East Aurora, have been reappointed to the New York State Board of Dentistry. Each received five-year terms as extended members. While they are no longer on the Board, they will serve on licensure disciplinary and/or licensure restoration and moral character panels.

Dr. Epstein is employed by Northwell Health in Manhasset. He received his dental degree from Stony Brook University School of Dental Medicine. Dr. Pantera is retired. He received his dental degree from the University of Detroit and M.S. degree in oral science and certificate in endodontics from the University at Buffalo School of Dental Medicine.

Association Activities

Getting the Message Out

NYSDA was a prominent presence at General Practice Residency Fair staged during Greater New York Dental Meeting in December. There to promote the many benefits of NYSDA membership, Association representatives gave special attention to Committee on Substance Abuse Use Disorder and Well-Being, which provides assistance to those struggling with substance abuse. Doing their part to raise awareness of the Committee and other aspects of membership are, from left: Heather Relation, director of membership outreach and engagement; Dr. Bhagwati Mistry, Ninth District representative to Committee on Substance Abuse and Well-Being; President-Elect Dr. Maurice Edwards.

The Open Apex Challenge A Case Series

ABSTRACT

Aim: To describe different endodontic techniques for managing immature necrotic teeth. Managing immature necrotic teeth has always posed challenges because of the unpredictable nature of treating roots with wide open apices that lack an apical stop. Traditionally, treatment involved placement of long-term calcium hydroxide, which was often tedious and required multiple visits. Compliance was frequently an issue, especially since many patients in this category are children and as a result, many teeth were lost due to infection or fracture. Recently, with the introduction of more biocompatible materials, a shorter treatment approach has been advocated using calcium silicate materials, such as MTA, which can be placed at the apex to provide a suitable seal. However, this technique remains challenging when encountering a blunderbuss apex, where placing the material without pushing it past the apex can be extremely difficult. More recently, pulp regeneration has emerged as a viable alternative to apexification for managing blunderbuss apices. This case series explores various techniques and methods for managing an open apex.

Apexification is a procedure aimed at inducing an apical hard-tissue barrier in a root with an open apex and promoting the continued apical development of an immature root in teeth with necrotic pulp. In simpler terms, apexification is a root canal treatment for teeth with an open apex, but with several key differences.

Due to the thin root structure and open apex, root canal debridement is primarily achieved through chemical means, with minimal or no mechanical instrumentation. Because there is no defined “apical stop,” using an apex locator to determine working length is often unreliable, making radiographs the most accurate method for measuring working length.

The main challenge in apexification is creating an apical stop that allows for successful obturation. Unlike conventional endodontic treatment, where gutta-percha is typically used as the primary obturating material, it is less effective in teeth with an open apex.

Traditionally, for apexification, long-term calcium hydroxide (CH) was used to induce an apical hard-tissue barrier. After conventional disinfection, CH was placed in the canal as an inter-visit medicament to help stimulate a hard-tissue barrier at the apex. Completion of endodontic therapy was usually delayed until apical barrier formation was achieved. Often, multiple CH dressing changes were needed to allow for an apical bridge to form. Once a barrier formed, which could take more than 12 months, the canal was obturated in a conventional manner with guttapercha and sealer. The disadvantage to this approach was the variability in treatment time and the unpredictability of

the formation of a total and impervious apical seal.[1-2]

More recently, the apical plug technique has been employed, in which a bioceramic (BC) material such as MTA or BC Putty (Brasseler, USA) is placed at the apex to provide an apical seal, rather than waiting for CH to induce the seal. The biggest advantage of this approach is treatment is carried out over a much shorter period, generally over one or two visits. It has also been shown to have a high long-term success rate.

While this approach works well for open apex cases, there remains the challenge of filling an open apex, with a risk of overfilling the canal. With the periapical bone and ligament gone in these open apex cases, there is no physical barrier to help resist an overfill. An extra-radicular apical matrix (barrier) of calcium sulfate (ACE Surgical Supply Co, Inc, Brockton, MA) can be placed to prevent extrusion of the BC material past the apex.[3-17]

Due to the challenges mentioned above, pulp regeneration—or more accurately, pulp revascularization—has gained popularity in recent years. In pulp regeneration, the goal is not to fill or obturate the canal at the apex but, rather, to use a scaffold, such as a blood clot, within the canal to stimulate the formation of new tissue (Case 3). However, a drawback of this approach is the lack of reinforcement in the pericervical area of the tooth, which can increase the risk of microleakage, especially if the tooth fractures.[18-39]

A modified regeneration approach strikes a unique balance by placing a blood clot scaffold at the apical end, minimizing the risk of overfilling the canal. A BC plug is placed on top of the blood clot and the remainder of the canal

is then sealed with a restorative material, which not only strengthens the pericervical region, but also helps prevent microleakage of bacteria should the tooth develop coronal cracks.[40-41]

A major challenge in treating infected immature teeth with a blunderbuss apex (Figure A) is the inability to pre-

both length and width of root. Reestablishment of buccal plate seen in Figures 2G, 2H.

Figure 1A. Preoperative periapical radiograph of tooth #20 showing immature blunderbuss apex with associated periapical radiolucency (PARL). Figure 1BD. CBCT images of tooth #20 showing immature blunderbuss apex with associated PARL. Thin dentin can be visualized in apical third of root. In figures 1C, 1D one can visualize buccal bone fenestration.
Figure 1E. Immediate postop periapical radiograph of tooth #20 after completion of modified regeneration procedure. PARL appears smaller and less radiolucent than preop radiograph. Figure 1F-H. One-year recall CBCT images showing almost complete healing of PARL and increased thickness in
Figure A.

dictably fill the root canal to the apex without risking significant overfilling (Case 2). In recent years, pulp regeneration has gained popularity as a treatment option for these teeth. Instead of attempting to fill the apex with gutta-percha, we draw healthy blood into the canal after disinfection, using it as a scaffold to promote tissue growth and further root development (Case 3).

The blood is drawn into the canal by over-instrumenting the apex with a file. There are generally three goals to the regenerative procedure: eliminate infection; add additional root length; and add additional thickness to the root walls. Classically, continued root growth was thought to be possible only in vital cases (apexogenesis). Recent studies on pulp regeneration have clearly shown that some continuation of root growth is also possible in necrotic infected cases, even when significant periapical pathology is present. The key to achieving this success is thorough disinfection of the root canal and then leaving some space at the apex for continued root growth.

be seen. Figure 2E. Immediate postop after root-end surgery to remove overfilled gutta- percha. Figure 2F. One-year recall showing almost complete healing of PARL.

What differentiates a modified regeneration procedure from a “classic” pulp regeneration procedure is the approach to filling the canal space. In modified regeneration, most of the canal, including the pericervical area, is filled with a restorative material to reinforce the root and provide additional mechanical strength. In contrast, in pulp regeneration, most of the canal is left empty, or more specifically, filled with a blood clot, to allow for continued tissue growth (Case 3).

In modified regeneration, only the apical 3 mm to 5 mm is used as a scaffold for the blood clot. Filling the majority of the canal space with restorative material helps prevent bacterial microleakage, particularly in cases where there is significant loss of coronal tooth structure, as it provides additional protection in the event of a crown fracture. At the interface with the blood clot, or “empty space” in the canal, a bioceramic (BC) material is placed. This material acts as a stimulator to encourage continued tissue growth. The restorative material is then placed on top of the BC material (Figure AC).

Another important factor that supports root growth is hertwig’s epithelial root sheath (HERS), the tissue at the apex responsible for stimulating root development. In the presence of infection, HERS becomes dysfunctional and can only be “reawakened” to play a role in regeneration once the root canal has been thoroughly disinfected. Case 1 demonstrates the modified regeneration procedure, where the root canal was disinfected and filled close to the apex with a combination of BC and restorative materials. No attempt was made to fill the blunderbuss apex to its full length, as doing so would have risked an overfill (Case 2).

Case 1: Modified Regeneration (Figure 1)

A 12-year-old girl presented with her mom with a chief complaint of pain and swelling of the lower left mandibular vestibule. Radiographic imaging revealed a periapical radiolucency (PARL) associated with tooth #20, which had an incompletely formed blunderbuss apex. No caries or restorations were noted, but the tooth was very painful to the touch and did not respond to vitality testing. A diagnosis of pulp necrosis with acute apical access was made.

Figure 2A. Preoperative periapical radiograph of tooth #8 showing immature blunderbuss apex with associated periapical radiolucency (PARL). Figure 2B. Periapical radiograph showing bioceramic (BC) putty in apical third of canal. Figure 2C. Large-sized gutta-percha cone used to condense BC putty close to apex and as master cone to fill remainder of canal. Figure 2D. Periapical radiograph after completion of obturation. Large overfill of gutta-percha past apex can

The likely cause of the necrotic pulp was a worn-down dens evaginatus. The recommended treatment was root canal therapy, more specifically, apexification. After access preparation, bloody and purulent discharge was noted. To obtain working length, a large size 80k-file was placed in the canal to an estimated length and a radiograph taken.

The canal was irrigated with 3 ml of 5.25% sodium hypochlorite. The EndoActivator (Dentsply, Tulsa, OK) was used to sonically agitate the irrigant in the canal to ensure thorough disinfection. Light instrumentation with both rotaries and hand files was completed. The canal was dried with a surgical microsuction tip. CH (Ultracal XS, Ultradent Products Inc, South Jordan, UT) was used as an inter-visit medicament. The tooth was temporarily restored with intermediate restorative material (IRM).

The patient returned after four weeks for completion of treatment. She reported that all symptoms had subsided. Clinical examination revealed that the swelling had resolved. CH was removed from the canal with irrigation and activation with the EndoActivator. The canal was irrigated with a combination of 3 ml of 5.25% sodium hypochlorite and 3 ml of 17% EDTA (ethylene diamine tetra-acetic acid). The canal was dried with a surgical microsuction tip. Red, healthy-looking blood was noted in the apical third of the canal. EndoSequence BC putty (Brasseler USA, Savannah, GA) was used as the material of choice due to its biocompatibility. Care was taken to make sure it was placed 5 mm from the apex. Multiple radiographs were needed to confirm proper placement of the putty.

Once the BC putty was in place for 15 minutes, to allow it to set, the canal was etched, rinsed, dried, and a dual-cure composite placed deep into the canal and allowed to selfcure for about five minutes. The access opening was restored with regular composite (Dentsply Sirona, Charlotte, NC), and the patient was put on a recall schedule to monitor healing.

At the one-year recall visit, the patient was completely asymptomatic, and radiographic examination revealed almost complete healing of the periapical radiolucency. A significant increase in root length and thickness was noted.

Case 2: Apexification (Figure 2)

A 12-year-old boy presented with his dad with a chief complaint of mild discomfort in the upper an-

terior maxilla. The patient reported a history of trauma around three years ago in which teeth #7 and #8 were luxated while playing in the park. For a couple of weeks after the trauma, the teeth were loose but firmed up over time and were generally asymptomatic. Only recently did he report experiencing some minor discomfort in the area.

Clinical exam revealed mild discomfort to percussion on tooth #8, while teeth #7, #9 and #10 tested within normal limits. Teeth #7 and #8 did not respond to vitality testing, while teeth #9 and #10 did. A fistula was present on the buccal aspect, which traced to the apex of tooth #8. Radiograph exam revealed the root of tooth #8 to be immature with a blunderbuss apex and a large periapical radiolucency. The radiolucency extended to the apex of tooth #7. The root canal space of tooth #7 appeared very calcified and did not respond to vitality testing.

As most of the lesion was attached to tooth #8, the plan was to treat #8 and monitor #7. A diagnosis of pulp necrosis with chronic apical abscess was made for tooth #8. Once the tooth was accessed, a necrotic pulp was confirmed. No drainage was noted from the canal. Most of the disinfection was carried out with irrigation rather than instrumentation due to the thin canal walls.

To obtain working length, a large size 80k-file was placed in the canal to an estimated length and a radiograph taken. The canal was irrigated with 3 ml of 5.25% sodium hypochlorite. The EndoActivator (Dentsply, Tulsa, OK) was used

Figure 3A. Preoperative periapical radiograph of tooth #20 showing immature blunderbuss apex with associated periapical radiolucency (PARL). Caries can be seen on distal aspect. Figure 3B. Gutta-percha point used to trace fistula to apex of tooth #20. Figure 3C. Periapical radiograph after visit one. Calcium hydroxide (CH) was placed in canal and tooth was temporized with IRM. Figure 3D. Four-month recall. Sinus tract healed, and periapical radiolucency was significantly smaller. Root appeared to have grown in both length and width. CH can still be seen in canal. Figure 3E. Clinical photo showing BC putty in direct contact with blood clot scaffold. Figure 3F. 13-month recall after completion of pulp regeneration. Tooth was restored previously with composite. Almost complete healing of PARL was noted, as well as increased thickness in both length and width of root.

to sonically agitate the irrigant in the canal to achieve thorough disinfection. Light instrumentation with both rotaries and hand files was completed. The canal was dried with a surgical microsuction tip, and CH (Ultracal XS, Ultradent Products Inc, South Jordan, UT) was used as an inter-visit medicament. The tooth was temporarily restored with IRM.

The patient returned after one month for completion of treatment. He reported that all symptoms had subsided. The fistula had healed. CH was removed from the canal with irrigation and activation with the EndoActivator. The canal was irrigated with a combination of 3 ml of 5.25% sodium hypochlorite and 3 ml of 17% EDTA. The canal was dried with a surgical microsuction tip. EndoSequence BC putty (Brasseler USA, Savannah, GA) was used as the material of choice due to its biocompatibility. Care was taken to make sure it was placed as close to the apex as possible. Multiple radiographs were needed to confirm proper placement of the putty.

Split dam

so no clamp is noted on radiograph. Tooth #7 has been obturated with gutta-percha and BC sealer. For tooth #8, BC putty can be seen close to apex but not at apex. Figure 4C. Plugger can be seen condensing BC putty towards apex. Figure 4D. Eightmonth recall periapical radiograph of teeth #7 and #8. For tooth #8, note BC putty at apex and rest of canal filled with dual-cure composite. Significant healing of PARL can be seen.

brane was used. The patient returned for a one-year recall. The radiographic exam revealed almost complete healing of the periapical radiolucency. The lesion that had at one point encompassed both teeth #7 and #8, now had almost completely healed. No further treatment was necessary.

Case 3: Pulp Regeneration (Figure 3)

The BC putty was left in place at the apex for 15 minutes. The plan was to use a size 100 gutta-percha as a master point with a coating of BC sealer (Brasseler, USA), which would be heated and condensed lightly up against the apical BC putty. During the condensing process, the gutta-percha point was pushed past the apex, likely due to the blunderbuss apex with no apical stop. The tooth was temporarily restored with IRM. In retrospect, a modified regeneration approach would have been more appropriate.

When the patient returned for the re-evaluation visit, he was generally asymptomatic but with some slight apical tenderness above tooth #8. The access was restored with composite, and a surgical flap was made to remove the excess guttapercha and smooth out the apex. No bone graft or mem-

A 9-year-old girl presented with her mom for endodontic treatment for tooth #20. The patient was generally asymptomatic but reported a “bubble” on her gums. A gutta-percha point was used to trace the fistula on the buccal aspect to the apex of tooth #20. Radiographically, the apex was blunderbuss with a periapical radiolucency. The likely cause was caries, noted on the distal aspect extending proximal to the pulp.

Clinically, the tooth was negative to percussion, palpation and vitality testing. A diagnosis of pulp necrosis with

Figure 4A. Preoperative periapical radiograph of teeth #7 and #8 showing immature apex for tooth #8 with associated periapical radiolucency (PARL). Apical inflammatory root resorption can be seen on tooth #7. Composite restoration can be seen on tooth #8 extending proximal to pulp. Figure 4B. Mid-treatment periapical radiograph of teeth #7 and #8.
isolation was employed
Figure 4E. Preoperative CBCT sagittal scan slice of tooth #8. Note the open apex and PARL. Figure 4F.  Preoperative CBCT coronal scan slice of tooth 8. Note open apex, PARL and buccal bone fenestration. Figure 4G. Eight-month recall coronal scan slice. Note significant healing of PARL and regeneration of buccal plate.
Figure 4H. Eight-month recall sagittal scan slice. Note significant healing of PARL.

chronic apical abscess was made. Treatment options were discussed with the patient and her parents. The planned treatment was pulp regeneration, in hopes of having further root growth.

Local anesthesia was administered, and the tooth isolated with a rubber dam. The caries was excavated and the pulp chamber accessed. After working length was confirmed radiographically, the canal was irrigated with 3 ml of 5.25% sodium hypochlorite. The EndoActivator (Dentsply, Tulsa, OK) was used to sonically agitate the irrigant in the canal to achieve thorough disinfection. Light instrumentation with both rotaries and hand files was completed. The canal was dried with a surgical microsuction tip, and CH (Ultracal XS, Ultradent Products Inc, South Jordan, UT) was used as an inter-visit medicament. The tooth was temporarily restored with IRM.

The patient missed a couple of appointments in the interim and was seen only after four months. At that time, the sinus tract healed, and the periapical radiolucency was significantly smaller. The root also looked to have grown in both length and width.

At the second visit, CH was removed from the canal with irrigation and activation with the EndoActivator. The canal was irrigated with a combination of 3 ml of 5.25% sodium hypochlorite and 3 ml of 17% EDTA. A size 20k-file was used to over-instrument the canal enough to trigger bleeding. The blood was allowed to reach close to the CEJ. BC putty was lightly condensed against the blood clot using a plugger and then allowed to set for about 15 minutes. A definitive composite restoration was placed.

At the 13-month recall from when the treatment was initiated, radiographic exam showed almost complete healing of the periapical radiolucency and continued root growth. The tooth was healthy and fully functional.

Case 4: Apexification (Figure 4)

A 24-year-old male presented with a chief complaint of pain in the upper anterior maxilla. The patient reported a history of trauma more than 10 years ago in which teeth #7 and #8 were luxated while playing sports. Tooth #8 had a crown fracture and was restored with a composite. The patient reported that after the trauma, he experienced occasional discomfort in the area but not enough for him to present to the dentist for evaluation. More recently, the pain had worsened.

The clinical exam revealed mild discomfort to percussion on teeth #7 and #8. Neither tooth responded to vitality testing, while teeth #6, #9 and #10 did. Radiograph exam revealed the root of tooth #8 to be immature, with an open apex and a large periapical radiolucency. The radiolucency extended to the apex of tooth #7. Apical inflammatory root

resorption was noted on tooth #7. A diagnosis of pulp necrosis with symptomatic apical periodontitis was made for both teeth #7 and #8.

Once the teeth were accessed, necrotic pulps were confirmed. No drainage was noted from the canals. Conventional endodontic treatment was performed for tooth #7. Most of the disinfection for tooth #8 was carried out with irrigation rather than instrumentation due to the thin canal walls and open apex. To obtain working length, a size 35k-file was placed in the canal to an estimated length and a radiograph taken.

The canal was irrigated with 3 ml of 5.25% sodium hypochlorite. The EndoActivator (Dentsply, Tulsa, OK) was used to sonically agitate the irrigant in the canal to ensure thorough disinfection. Light instrumentation with both rotaries and hand files was completed. The canal was dried with a surgical microsuction tip, and CH (Ultracal XS, Ultradent Products Inc, South Jordan, UT) was used as an inter-visit medicament. The tooth was temporarily restored with IRM.

The patient returned after one month for completion of treatment. He reported that all symptoms had subsided. CH was removed from the canals with irrigation and activation with the EndoActivator. The canal was irrigated with a combination of 3 ml of 5.25% sodium hypochlorite and 3 ml of 17% EDTA. The canal was dried with a surgical microsuction tip. EndoSequence BC putty (Brasseler USA, Savannah, GA) was used as the material of choice due to its biocompatibility. Care was taken to make sure it was placed as close to the apex as possible. Multiple radiographs were needed to confirm proper placement of the putty. The putty was slowly condensed to the apex with a plugger. Once it was confirmed that the putty was set at the apex, the remaining canal space and access was restored with a dual-cure composite.

At the eight-month recall, radiographic exam showed significant healing of the periapical radiolucency around both teeth #7 and #8. The teeth were healthy and fully functional.

Conclusion

Treating an immature permanent tooth can be both an endodontic and restorative challenge. In the past, apexification was the treatment of choice for an immature and necrotic tooth.

More recently, pulp regeneration has been discussed as an alternative treatment modality, the advantage being a shorter treatment time and continued root growth. A modified regeneration approach, where the coronal root structure is reinforced with restorative materials, has the benefit of adding strength to an already thin and weakened coronal

root structure while also allowing continued root growth at the apical third.p

Queries about this article can be sent to Dr. Stern at Joseph.stern18@touro.edu.

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41. Desai S, Chandler N. The restoration of permanent immature anterior teeth, root filled using MTA: a review. J Dent 2009;37:652–7.

Joseph C. Stern, D.D.S., is director of endodontics and clinical assistant professor of dental medicine at Touro College of Dental Medicine at New York Medical College, Hawthorne, NY. A diplomate of the American Board of Endodontics, he is in private practice in Clifton, NJ.

Pathological Changes in Soft Tissues Associated with Radiographically Normal Impacted Teeth

A Critical Update and Meta-analysis

ABSTRACT

Aim. The purpose of the study was to conduct a retrospective analysis of histopathological diagnosis of all pericoronal tissues associated with impacted teeth and to correlate it with a hypothetical classification of pericoronal follicular space to improve our clinical management of treating impacted teeth.

Materials and Method. The study was carried out in the Department of Oral and Maxillofacial Pathology at Sri Guru Ram Das Institute of Dental Sciences, Amritsar. Data revealed that during a 12-year period, 1,268 patients reported with a pericoronal follicular space associated with the crown of an unerupted tooth, which was subsequently submitted for histopathological evaluation. Panoramic and periapical radiographs were available in all cases. The study group comprised 593 subjects having a pericoronal radiolucency < 7 mm associated with at least one impacted tooth. In order to establish comparisons, PFs were arbitrarily divided into three groups according to pericoronal space width: Group A ≤ 1.5mm; Group B> 1.5 mm to 4 mm; and Group C> 4 mm to 7 mm. Patients’ ages ranged from 12 to 63

years. A Pubmed, Medline meta-analysis was also searched for previous such work and was tabulated.

Results. In the present study, 56.49% of the specimens, that is 335 out of 593 follicular samples, with radiolucency <7mm had undergone various pathological changes. Histologic diagnosis of the pathological changes associated with the impacted teeth showed a strong distribution of dentigerous cyst (n=287), followed by odontogenic keratocyst (n=27) and ameloblastoma (n=15), respectively. Lesions such as odontogenic myxoma, odontogenic fibroma and calcifying odontogenic cyst were also sparsely documented. Dentigerous cyst was frequently diagnosed in the 18- 30-year age group, with the mean age of 23.1 years. Other cysts and tumors diagnosed had a mean age of 30.6 years.

Conclusion. Cystic changes may develop in both clinically and radiographically asymptomatic impacted teeth. The data from this study cannot justify the complement removal of all asymptomatic impacted teeth but suggests that there is a risk of pathologic changes, particularly in the second to third decade of life.

The primitive dental sac/dental follicle (DF) and dental papilla derived from neural crest cells are the immature tissues that compose the ectomesenchymal portion of the tooth germ.[1] These develop into periodontal ligament and attachments, and dentin and pulp tissue, respectively.[1-3] Once the tooth has fully developed inside the jaw, the coronal part of the follicle is termed pericoronal sac or follicle (PF) and occasionally persists adjacent to the crown of unerupted or impacted teeth.[1,2] It is composed of fibrous connective tissue with variable amount of lining epithelium, including enamel (columnar), cuboidal, squamous and, rarely, respiratory epithelium, and frequently contains epithelial residues of odontogenesis, which could be the starting point of pathology.[2,4-7]

Radiographically, dental follicles are normal developmental structures that characteristically appear as thin, semicircular radiolucencies around unerupted or impacted teeth.[3] Such pericoronal radiolucencies, which represent a normal or enlarged dental follicle, require no intervention; alternatively, they may represent a pathological entity that requires appropriate management and histopathological interpretation.[8]

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These PF, radiographically, appear as a thin pericoronal radiolucency, considered normal by some authors when it is less than 3 mm thick[3,9] and by others when it is no thicker than 2.5 mm.[10] However, scientific evidence supporting this assumption is limited, and there is no internationally accepted consensus on the clinical criteria to differentiate between normal and pathological conditions based on radiographic features.[11] Recent studies have reported pathological changes in PF of up to 2.5 mm,[4,7,12-15] with frequency varying from 23%[13] to 58.5%,[15] particularly associated with the third lower molar.

Many reports in literature have discussed the prevalence of cyst and tumor development associated with impacted teeth, with dentigerous cyst (DC) being the most common one.[16] The overall consensus seems to be that pericoronal cyst and tumor development is rare.[5,17] Some reviews have used this information to support the rationale for no treatment of asymptomatic impacted teeth. The fact that not all pericoronal cysts and tumors are symptomatic or that radiographic evidence of their presence may be subtle or nonexistent masquerades the actual statistical presence of cysts and tumors.

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Radiological and histopathological criteria for distinguishing between a normal or slightly enlarged DF and a DC are controversial. Radiographical signs of DC include a pericoronal width of at least 3 mm to 4 mm and an asymmetric appearance of the radiolucency.[3,18] Histopathological diagnosis of DC is mainly based on the presence of a continuous lining of stratified squamous epithelium or cuboidal cells, which may exhibit occasional mucous cells, ciliated cells and, rarely, sebaceous cells.[16]

According to Saravana,[14] the presence of squamous epithelium in the lining of a tissue sac that invests the crown of an unerupted or impacted tooth defines progression from DF to DC. These lesions may enlarge considerably if allowed to develop unchecked and have the potential for pathological transformation into tumors and malignancies. Because surgical therapy for such pathologies is usually more extensive than that required for removal of asymptomatic unerupted teeth and their associated follicles and papillas, their prophylactic removal is debatable but worth considering.[19] The resolution of this perplexity among dental professionals in dealing with asymptomatic and radiographically normal impacted teeth can help formulate evidence-based policies in management of impactions to deliver long-term benefit to the patients and improve our knowledge about the epidemiology of associated diseases.

The purpose of the study presented here was to conduct a retrospective analysis of histopathological diagnosis of all pericoronal tissues associated with impacted teeth and to correlate it with a hypothetical classification of pericoronal follicular space to improve our clinical management of treating impacted teeth.

Materials and Methods

The study was carried out in the Department of Oral and Maxillofacial Pathology at Sri Guru Ram Das Institute of Dental Sciences, Amritsar, Punjab, India, after obtaining institutional ethical clearance. All specimens described by the contributor as being pericoronal tissues associated with the crowns of unerupted tooth were retrieved from the archives. Data revealed that during a 12-year period, 1,268 patients reported with a pericoronal follicular space associated with

the crown of an unerupted tooth; these were subsequently submitted for histopathological evaluation. Panoramic and periapical radiographs were available in all cases and were used to measure the width of the pericoronal space, which was determined from half of the mesial, distal and occlusal surfaces; the widest region was selected.[20]

Patients whose history sheet showed a pericoronal radiolucency >7mm were excluded from the current study. Hence, the study group comprised 593 subjects having a pericoronal radiolucency <7 mm associated with at least one impacted tooth, including 471 third molars, 72 canines, 43 premolars and 7 supernumerary teeth.

In order to establish comparisons, PFs were arbitrarily divided into three groups according to pericoronal space width: Group A ≤ 1.5mm; Group B > 1.5 mm to 4 mm; and Group C > 4 mm to 7 mm. The tooth and follicle were removed carefully, and the follicular tissue was submitted for histopathological evaluation. A consensual definition of “dentigerous cyst” has been agreed upon which states that any soft-tissue specimen with squamous or cuboidal epithelium spreading along the surface of the follicle would be deemed cystic. Other pathological findings were reported according to accepted diagnostic criteria.

Dental follicles were diagnosed when pericoronal-reduced enamel epithelium was found on strips of connective tissue removed from the crown of unerupted or impacted teeth. As per institutional protocol, a diagnosis was registered only when the participating pathologists’ results were in concordance with that of the surgeons’ finding during surgical exploration. In cases with inconsistent outcomes, a consensual diagnosis was arrived at after a joint review. Observations were tabulated and percentage was obtained. Associations between the attributes were tested using SPSS version 10 and Epi-Info 6.04 d software.

Results

The soft-tissue specimens and radiographs of 335 males and 258 female patients were enrolled in the study. Patient ages ranged from 12 to 63 years (mean=23.6 years). Among the total of 593 patients, 471(79.4%) had an impacted third molar; 72 (12.4%) had an impacted canine; 43 (7.2%) an

impacted premolar; and 7 (1%) had an impacted supernumerary tooth. Of the 471 impacted molars, 43 (9.12%) had a follicular space of ≤ 1.5 mm; 166 (35.24%) had a follicular space >1.5-4 mm; and 262(55.62%) had a follicular space of > 4 mm -7 mm.

In the 72 impacted canines, 5 (6.94%) had a follicular space of ≤1.5 mm; 18 (25%) had a follicular space >1.5-4 mm; and 49 (68.05%) had a follicular space of > 4 mm to 7 mm. Of the 43 impacted premolars, 2 (4.65%) had a follicular space of ≤1.5 mm; 5(11.62%) had a follicular space >1.5-4 mm; and 36(83.72%) had a follicular space > 4 mm -7 mm. In the 7 supernumerary teeth, 1 (14.28%) had a follicular space >1.54 mm, and 6(85.71%) had a follicular space > 4 mm -7 mm (Table 1).

Surprisingly, we found that 56.49% of the specimens, that is 335 out of 593 follicular samples with radiolucency, <7 mm had undergone various pathological changes. In group A(FS≤1.5 mm), 13/50(26%) samples showed pathological changes. In group B (FS >1.5 mm-4 mm); and group C (FS>4 mm-7 mm) 66/190(34.7%) and 256/353(72.5%) samples showed pathological changes, respectively (Table 2). Non- pathologic dental follicles comprised 43.51% (258/593) of the total number of submissions.

Histologic diagnosis of the pathological changes associated with the impacted teeth showed a strong distribution of dentigerous cyst (n=287), followed by odontogenic keratocyst (n=27) and ameloblastoma (n=15), respectively. Lesions such as odontogenic myxoma, odontogenic fibroma and calcifying odontogenic cyst were also sparsely documented (Table 3). Dentigerous cyst was frequently diagnosed in the 18- to 30-year age group, with the mean age of 23.1 years. Other cyst and tumors diagnosed had a mean age of 30.6 years (Figure 1). Although we found a statistically significant increase in the rate of pathosis with increasing age, the correlation was stronger in the 20- to -30-year age group (p<0.05).

Analysis regarding site revealed a greater incidence of impacted teeth in the mandible (348/593; 58.6%) than the maxilla (245/593; 41.3%). No significant difference was seen in relation to right side vs. left side. In the

present study, the mandibular third molar was the most frequently associated impacted tooth, followed by maxillary third molar and maxillary cuspid. Two supernumerary teeth were found to be impacted in the midline. Regarding the frequency of pathosis, the mandibular third molar left side followed by mandibular third molar right side, maxillary third molar right and left side was observed (Table 4).

Discussion

Impacted tooth is among the most common complaints of patients presenting to the dental surgeon for treatment. The decision to remove an impacted tooth is less challenging when signs and symptoms of pathosis are present, but it is made more demanding when the patient is asymptomatic. A National Institutes of Health Consensus Development Conference on Removal of Third Molars in 1979 developed criteria for the treatment of impacted teeth showing evidence of irreversible pathologic change. One conclusion of the conference was that well-designed prospective studies were needed to determine what to do about asymptomatic teeth.[21]

Data on the incidence and progression of pathological conditions in and around impacted teeth are important factors to take into account when decisions are made whether or not to remove the teeth, particularly those that are asymptomatic and that show no signs of pathology. These factors, as well as the prevalence of impacted teeth, should

be considered when planning radiographic examinations, primary as well as follow-ups, in cases where impacted teeth are not removed.[22]

Radiographic examination is important in identifying an enlarged pericoronal space that is suggestive of pathologic process. The critical width of the follicle as seen radiographically has been estimated to be between 2 mm and 5 mm.[15,16] It is often assumed, however, that the absence of pericoronal radiolucency reflects absence of pathosis.

Previous medical literature suggests that the pericoronal radiolucency of < 2.5 mm in width is non-pathologic. [10,23] Scientific documentation of the validity of this assumption, however, is limited.[23,24] Shear suggests that some unerupted teeth have a slightly dilated follicle in the pre-eruptive phase. This does not signify a cyst or even necessarily a potential cyst unless the pericoronal width is at least 3 mm to 4 mm.[25] Stanley[17] proposed that a cystlike lesion has a pericoronal space of at least 5 mm and exhibits a well-defined circumscribed border. Glosser and Campbell[4] suggested pericoronal radiolucency of 2.5 mm or more as evidence of radiographic pathology. Radiographic interpretation of a pericoronal space as normal or pathologic is difficult. Thus, several researchers have concluded that radiographs alone are insufficient to diagnose pathological changes, making histological diagnosis necessary.[15,26]

A bibliographic search in PubMed, Scopus, Web of Science and Embase with keywords “asymptomatic,” “impacted,” “histopathological changes,” “radiographically normal” and “follicular space” was done, and a meta-analysis was conducted and tabulated (Table 5). All searches showed a two-grade division of follicular space of impacted teeth with associated pathological changes, while ours is the first study that divided the follicular space in a three-

point scale, revisiting the dilemma of what can be defined as a normal follicular space.

In the current study, a retrospective analysis of histopathological diagnosis of pericoronal tissues associated with asymptomatic impacted teeth was correlated with the pericoronal follicular space width, which was divided into three groups. Prevalence of impacted molars, followed by canines, premolars and supernumerary teeth, was seen, respectively. Pericoronal follicular space of soft tissues associated with these impacted teeth revealed 56.49% (335/593) of the specimens in the current study undergoing various pathological changes. The majority of the pathologic changes, i.e., 256/335 (76.4%) were seen when the FS was >4 mm to 7 mm (Group C), followed by Group B and A, respectively, suggesting that as the FS increases, the incidence of pathosis increases.

Of the 56.49% of follicles that showed pathosis, 287 (86%) were diagnosed as dentigerous cyst; 27 (8%) were diagnosed as OKC; 15 (4.4%) exhibited ameloblastomalike proliferation; and the rest showed equal distribution

Figure 1: Comparative Distributive Graph of Dentigerous Cyst and other Pathosis (other cyst and tumors) with Age

(0.59% each) of odontogenic myxoma, odontogenic fibroma and calcifying odontogenic cyst. Rakprasitkul,[7] in his study on asymptomatic pericoronal tissue of 104 impacted third molars, found an incidence of pathological tissue of 58.65% (dentigerous cyst, 50.96%; chronic nonspecific inflammatory tissue, 4.81%; odontogenic keratocyst, 1.92%; and ameloblastoma, 0.96%).

A similar study by Ali Hossein[19] on 171 ITM, reported 53% pericoronal tissues showing a pathological change, of which the presence of dentigerous cyst was seen in 38% of the cases, ameloblastoma in 5.8%, followed by sulfur granules (4%), foreign-body granulomas and stratified squamous epithelium (3%). Similarly, Curran et al.[5] studied histologic changes in the nonpathologic follicular tissue and diagnosed 32.9% pathologically significant lesions. Dentigerous cyst (77.5%) had the highest incidence, followed by OKC (9.1%), odontoma (8.2%), ameloblastoma (1.5%), CEOC (0.7%), carcinoma (0.7%) and myxoma (0.1%).

Glosser and Campbell[4] found pathological changes in 32% of the impacted third molar follicles; Aldelsperger et al.[23] detected pathosis in 34%; Yildirim et al.[13] detected pathological changes in 23% of asymptomatic follicles; and Baykul et al.[12] have described cystic changes in 50% of asymptomatic follicles. A similar study by Kotrashetti et al.[15] reported 58.5% of asymptomatic cases with definite pathological changes. Of the 41 tissue samples they evaluated, 18 were suggestive of dentigerous cyst.

The results of our study compare favorably with those of others, in that dentigerous cyst is the most frequent pathological entity detected in clinically normal dental follicles of impacted teeth. The proportion of dentigerous cyst relative to all pathological changes seen in impacted teeth follicular tissues vary from 86% in our study and 100% in many studies.[4,12]

Some investigators[4] believe that panoramic and periapical radiographs are insufficient for a definitive diagnosis of dentigerous cyst, which is also the finding of the present study. Not uncommonly, dental follicles exhibit significant thickening of their walls that can create detectable pericoronal radiolucencies without cyst formation. On the other hand, significant pericoronal pathosis, such as odontogenic keratocyst and calcifying odontogenic cyst, have been discovered on histopathologic examination of follicular tissue that was not associated with detectable radiographic enlargement.[5]

In the present study, we discovered a strong correlation between the incidence of cystic change in follicular tissues and age. Notably, this appeared to be true as patients advanced from the second to third decade of life. Previous

authors have also reported an increasing incidence of dentigerous cyst formation as age increases.[4,19,23,25] The mean age distribution of DC was 23.1 years, while of the other reported cyst and tumors, it was 30.6 years in the current study. Mourshed[27] found a 1.44% incidence of dentigerous cysts in a radiographic examination of unerupted teeth. Shear and Bernick[25,28] have reported the peak incidence of dentigerous cyst in the second decade. Knight et al.,[29] in a microscopic study, found dentigerous cysts in 44.70% of the impacted teeth.

Consolaro[30] showed that with aging, there is a tendency of transformation of reduced enamel epithelium into stratified squamous epithelium. Baykul et al.[12] reported cystic changes associated with impacted third molars in 56% of the patients 20 years old. In the study done by Yildirimet al.,[13] 89% of the patients whose follicles showed cystic changes were ≥ 20 years old.

According to our results, which are in concordance with other studies, we support the removal of impacted teeth under prophylactic indication as far as possible at a younger age even if the teeth are asymptomatic. However, a small pericoronal radiolucency may represent either a large dental follicle or a small dentigerous cyst. Microscopic examination alone may be insufficient for a definitive diagnosis because a lining of non-keratinized stratified squamous also occurs in some normal follicles. So, the only reliable way to differentiate between the two is by surgical exploration. A true cyst will exhibit a fluid-filled cavity that allows the surgeon to easily separate the DC from at least a portion of the enamel surface of the impacted tooth.[16]

Also, there are many anecdotal reports of complications associated with retained impacted teeth. Even surgeons are sometimes perplexed by the lack of data supporting what has become, for many, one of the most common procedures in oral and maxillofacial surgery.[4] On the other hand, it is also possible that at least some of these cystic areas involute or do not progress to become larger destructive lesions. Hence, a clinical radiographic and histopathological correlation, along with the surgeon’s input at the time of exploration of the FS, is needed for such dilemmas.

In the present study, a greater incidence of impacted teeth was found in the mandible (58.6%) than the maxilla (41.3%), while no significant difference was seen in relation to right side vs. left side. Regarding follicular tissue pathosis, more pathological changes were seen in the lower jaw than in the upper, particularly in the mandibular left (n=110) and right (n=77) impacted third molars, followed by maxillary right (n=45) and left (n=28) impacted third molars.

Adelsperger et al.,[23] in their study, found no statistical difference with regard to the left vs. right side, upper vs. lower dental arch or specific tooth location. Glosser et al.[4] in their study on normal third-molar impactions concluded that more cysts occurred in the lower jaw than the upper, which had no explanation but could be a reflection of radiology-based rather than histology-based interpretation of the study. A significant incidence of pathosis in the lower jaw (vs. upper) was also seen in the study by Mesgarzadeh et al.,[19] which were consistent with findings of Glosser et al.,[14] Raprasitkul,[7] Daley et al.[16] and Kim et al.[3] but not with Adelsperger et al.[23]

Saravana et al.,[14] in their study on ILTM, revealed more follicular changes on the right side than on the left side of the mandible. Significant pathological changes have also been reported by Mesgarzadeh et al.[19] in the mandibular right and mandibular left impacted third molars vs. other sites.

Conclusion

According to the present results, cystic changes may develop in both clinically and radiographically asymptomatic impacted teeth. The data from this study cannot justify the complement removal of all asymptomatic impacted teeth but suggests that there is a risk of pathologic changes, particularly in the second to third decade of life.

If we consider the severity of pathologic conditions associated with impacted teeth, the progression rate of untreated

pathologic complication conditions, patient discomfort, agespecific severity of surgical and postsurgical complication, and economic consequences of removal at a stage when pathology has developed, removing asymptomatic impacted teeth is better than observation and periodic follow-up.

Future scope of the study is to include more dental follicles; use of a three-dimensional, computerized tomography scan to measure the accurate width of the follicle; and comparison with histological findings and proliferative markers so that the critical width of the follicular space can be standardized and such lesions dealt with cautiously. p

Queries about this article can be sent to Dr. Manchanda at adesh_manchanda@ yahoo.com.

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1. Nanci A. Ten Cate’s Oral Histology. Development, Structure and Function, Mosby Elsevier: St Louis, Mo, USA, 7th edition, 2008.

2. Villalba L, Stolbizer F, Blasco F, Maurino NR, Piloni MJ, Keszler A. Pericoronal follicles of asymptomatic impacted teeth: a radiographic, histomorphologic, and immunohistochemical study. Int J Dent 2012; 2012: 935310.

3. Kim J, Ellis GL, Eisenberg E. Dental follicular tissue: misinterpretation as odontogenic tumor. J Oral Maxillofac Surg 1993; 51(7): 762–767.

4. Glosser JW, Campbell JH. Pathologic change in soft tissues associated with radiographically “normal” third molar impactions. Br J of Oral and MaxillofacSurg1999; 37(4): 259–260.

5. Curran AE, Damm DD, Drummond JF. Pathologically significant pericoronal lesions in adults: Histopathologic evaluation. J Oral Maxillofac Surg 2002; 60: 613-617.

6. Meleti M, Waal ISD. Clinicopathological evaluation of 164 dental follicles and dentigerous cysts with emphasis on the presence of odontogenic epithelium in the connective tissue. The hypothesis of “focal ameloblastoma.” Med Oral Patol Oral Cir Bucal 2013Jan 1; 18(1): 60-4.

7. Rakprasitkul S. Pathologic changes in the pericoronal tissues of unerupted third molars. Quintessence International 2001; 32(8): 633–638.

8. Farah CS, Savage NW. Pericoronal radiolucencies and the significance of early detection. Australian Dental Journal 2002; 47(3): 262-265.

9. Edamatsu M, KumamotoH, Ooya K, Echigo S. Apoptosis-related factors in the epithelial components of dental follicles and dentigerous cysts associated with impacted third molars of the mandible. Oral Surg, Oral Med, Oral Pathol, Oral Radiol, and Endo 2005; 99(1):17–23.

10. Eliasson S, Heimdahl A, Nordenram A. Pathological changes related to long-term impaction of third molars: a radiographic study. Int J Surg 1989; 18: 210-212.

11. Chu FC, Li TK, Lui VK, Newsome PR, Chow RL, Cheung LK. Prevalence of impacted teeth and associated pathologies—a radiographic study of the Hong Kong Chinese population, Hong Kong Medical Journal 2003; 9(3): 153-163.

12. Baykul T, Saglam AA, Aydin U, Basak K. Incidence of cystic changes in radiographically normal impacted lower third molar follicles. Oral Surg Oral Med Oral Pathol Oral Radiol Endo 2005; 99(5): 542– 545.

13. Yildirim G, Ataoglu H, Mihmanli A, Kizilo D, Avunduk MC. Pathologic changes in soft tissues associated with asymptomatic impacted third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endo 2008; 106(1): 838–842.

14. Saravana GHL, Subhashraj K. Cystic changes in dental follicle associated with radiographically normal impacted mandibular third molar. Br J Oral Maxillofac Surg 2008; 46(7): 552–553.

15. Kotrashetti VS, Kale AD, Bhalaerao SS, Hallikeremath SR. Histopathologic changes in soft tissue associated with radiographically normal impacted third molars. Indian J Dent Res 2010; 21(3):385–390.

16. Daley TD, Wysocki GP. The small dentigerous cyst: a diagnostic dilemma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:77-81.

17. Stanley HR, Allatar M, Collett WK, Stringefellow HR, Spiegel EH. Pathological sequale of neglected impacted third molars. J Oral Pathol 1988; 17: 113-117.

18. Narang RS, Manchanda AS, Arora P, Randhawa K. Dentigerous cyst of inflammatory origin: a diagnostic dilemma. Ann Diagn Pathol 2012; 16: 119-23.

19. Mesgarzadeh AH, Esmailzadeh H, Abdolrahimi M, Shahamfar M. Pathosis associated with radiographically normal follicular tissues in third molar impactions: a clinicopathological study. Indian J of Dent Research 2008;19(3):208–212.

20. Oliveira DM, Andrade ESDS, Silveira MM, Camargo IB. Correlation of the radiographic and morphological features of the dental follicle of third molars with incomplete root formation. Int J Med Sci 2008; 5(1): 36–40.

21. NIH Consensus Development Conference for Removal of Third Molars. J Oral Surg 1980; 38: 235–236.

22. Ahlqwist M, Grondahl HG. Prevalence of impacted teeth and associated pathology in middle-aged and older Swedish women. Community Dent Oral Epidemiol 1999; 19: 116-9.

23. Aldelsperger J, Campbell JH, Coates DB, Summerlin DJ, Tomich CE. Early soft-tissue pathosis associated with impacted third molars without periocoronal radiolucency. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 89(4): 402-406.

24. Moreira Diaz E, del Valle Ruiz M, Rodriguez Alonso LR. Estudio de la correlación entre la imagen radiográfica y elaspectohístico del sacopericoronario de lostercerosmolaresretenidos. Rev Cub Est 1977; 14: 137-44.

25. Shear M. Dentigerous cyst. 3rd ed. Cyst of Oral Regions. Butter Worth Aeinemann Limited 1992:81.

26. Damante JH, Fleury RN. A contribution of the diagnosis of the small dentigerous cyst or the paradental cyst. Pesqui Odontol Bras 2001; 15:238-46.

27. Mourshed F. A roentgenographic study of dentigerous cysts. I. Incidence in a population sample. Oral Surg Oral Med Oral Pathol 1964;18:47-53.

28. Bernick S. Dentigerous cysts of the jaw. Oral Surg Oral Med Oral Pathol 1949; 2: 914-21.

29. Knights EM, Brokaw WC, Kessler HP. The incidence of dentigerous cysts associated with a random sampling of unerupted third molars. Gen Dent 1991; 39: 96-98.

30. Consolaro A. caracterizaçãomicroscópica de folículospericoronários de dentesnão-irrompidos e parcialmenteirrompidos—suarelação com aidade. Bauru, 1987. Tese - Faculdade de Odontologia de Bauru, Universidade de São Paulo.

31. Cabbar F, Guler N, Comunoglu N, Sencift K, Cologlu S. Determination of potential cellular proliferation in the odontogenic epithelia of the dental follicle of the asymptomatic impacted third molars. J of Oral and Maxillofac Surg 2008; 66: (10): 2004–2011.

32. Khorasani M, Samiezadeh F. Histopathologic evaluation of follicular tissues associated with impacted third molars. J of Dentistry 2008; 5(2): 65-70.

33. Urs AB , Shetty DC, Ahuja P, Bablani D, Manchanda AS. Asymptomatic third molar removal – A clinical and pathological insight. J of Orofac Sciences 2010; 2(1): 23-26.

34. Adaki SR, Yashodadevi BK, Sujatha S, Santana S, Rakesh N, Adaki R. Incidence of cystic changes in impacted lower third molar. Indian J of Dent Res 2013; 24(2): 183-187.

35. Choudhary A, Kesarwani Pathological changes in radiographically normal dental follicle. Indian J of Contemporary Medical Research 2019; 6(5): E4-7.

Manchanda Dr. Narang Dr. Sandhu

Adesh S. Manchanda, M.D.S., is a reader, Department of Oral & Maxillofacial Pathology, Sri Guru Ram Das Institute of Dental Sciences & Research, Amritsar, Punjab, India.

Ramandeep S. Narang, M.D.S., is professor and head, Department Oral & Maxillofacial Pathology, Sri Guru Ram Das Institute of Dental Sciences & Research, Amritsar, Punjab, India.

Komaldeep Kaur Sandhu, B.D.S., is affiliated with Sri Guru Ram Das Institute of Dental Sciences & Research, Amritsar, Punjab, India.

Dr.

Bridging the Dental Care Gap

Addressing Oral Health Disparities in New York State Nursing Homes

ABSTRACT

Oral health is a critical component of overall wellbeing, yet disparities in access to dental care disproportionately affect vulnerable populations, particularly elderly residents in nursing homes. Poor oral hygiene is linked to systemic health conditions, such as cardiovascular disease, diabetes and cognitive decline. Despite federal regulations mandating oral health assessments in nursing homes, many facilities lack adequate resources, and care often falls to undertrained staff.

This study assesses the availability of onsite dental care services in New York State’s nursing homes and the role of mobile dental clinics in bridging the access gap, especially in rural and underserved areas. A mixed-methods approach combining geospatial analysis and a review of publicly available datasets was employed. The study analyzed dental care resources in 603 licensed nursing homes, focusing on facilities in dental health professional shortage areas (HPSAs).

Results revealed that only 198 of New York’s nursing homes provide onsite dental services, with significant service gaps in HPSA-designated counties. Additionally, only 17 organizations offer mobile dental services across the state, further limiting access to care for nursing home residents

in underserved regions. The findings underscore the urgent need for targeted interventions, including expanding mobile dental clinics and improving onsite dental care services.

A phased implementation of mobile dental units, prioritizing nursing homes in full shortage areas, is proposed as a cost-effective solution to address these disparities. By focusing on collaborative community partnerships, this approach could significantly improve oral health outcomes and serve as a model for addressing healthcare disparities in other underserved populations.

Oral health is an essential component of overall well-being, influencing physical, psychological and social health. Poor oral health can cause pain, impair functionality and significantly diminish quality of life. Emerging evidence suggests strong associations between oral diseases and systemic health conditions. For instance, chronic periodontitis has been linked to an increased risk of atherosclerotic vascular disease, while dental diseases have been found to exacerbate pulmonary conditions, such as chronic obstructive pulmonary disease (COPD) and pneumonia.

In some cases, orofacial pain has been identified as the sole presenting symptom of stroke, highlighting the pivotal role of oral health in the early detection of broader systemic health problems.[1] A growing body of research emphasizes connections between periodontal disease, tooth loss, oral

cancer and diabetes. Although periodontal treatments may offer only short-term benefits for metabolic control, the association between oral health and chronic conditions, particularly diabetes, remains clinically significant.

Additionally, poor oral hygiene has been associated with cognitive decline, as conditions such as gingivitis, dental caries and tooth loss have been shown to increase the risk of dementia and cognitive impairment.[1] These findings underscore the necessity of maintaining good oral health to support overall well-being, particularly among vulnerable populations.

Dental Care Provider Shortage Areas and Nursing Homes in New York State

Despite advancements in dental care, significant barriers to access persist, disproportionately affecting low-income, rural and underserved communities. In the United States, approximately 68.5 million adults either lack dental insurance or face limited access to essential oral health services.[2] Data show that 2.8 million New Yorkers live in dental health professional shortage areas,[3] and 21.55% of the population resides in rural areas,[4] where dental care access is particularly limited.

According to a 2024 report from the Health Resources and Services Administration (HRSA) on health professional shortage areas (HPSA), only 16.15% of New York’s dental needs are currently being met, with an estimated shortfall of 588 dental practitioners.[5] These disparities are most acute among underserved populations, including nursing home residents, individuals with disabilities and those living in rural areas.[6,7] Among these vulnerable groups, elderly residents in nursing homes face particularly significant challenges in accessing dental care.

Nationwide, approximately 1.4 million individuals reside in nursing homes,[1] with New York State alone housing 96,866[8] residents across 603 licensed facilities.[9] Many of these residents suffer from conditions such as dementia and Alzheimer’s disease, which complicates their ability to perform routine oral hygiene practices. As cognitive conditions progress, residents may forget or be unable to comprehend the importance of maintaining oral hygiene, leading to severe deterioration in oral health.[10,11]

Research demonstrates that oral care in nursing homes is often inadequate. A 2006 study conducted in upstate New York found that only 16% of nursing home residents received any form of oral care, and when provided, care often lasted as little as 16.2 seconds.[12]

Similarly, a study in North Carolina revealed that over onethird of tooth surfaces and more than half of denture surfaces were covered in plaque. A 2018 study in Japan further highlighted that caregivers in nursing homes often lack formal dental hygiene training, leading to inconsistent and substandard care—a problem exacerbated in rural areas with limited access to dental professionals.[1]

The delivery of dental care in nursing homes is often restricted by the facility’s ability to provide such services.[13] Daily oral care responsibilities typically fall to registered nurses (RNs), licensed practical nurses (LPNs) and certified nursing assistants (CNAs), many of whom lack adequate training in oral health.[14] High staff turnover, with 38% of nursing home employees expected to leave their positions within two years, further complicates the provision of consistent care.[15]

Additionally, assessments such as the Minimum Data Set (MDS) often underreport oral health conditions like gingivitis and tooth loss, resulting in unmet needs. Improving staff training and adopting better assessment tools, as recommended by the American Dental Association (ADA), could significantly improve oral health outcomes in these settings.[16]

In the U.S., Medicare, the national health insurance for older adults and those with disabilities, does not cover routine dental care. As a result, most older adults lack dental insurance, limiting access or leading to high costs. For

Figure 1. Areas with dental care provider shortages and nursing homes that provide onsite dental care. Red dots represent counties experiencing full shortage. Orange and green dots indicate partial shortage areas and non-shortage areas, respectively. Nursing homes are marked with building icons encircled in white, where red signifies those without onsite dental services, and green indicates those that do offer dental services.

Medicaid recipients, including about 70% of long-term nursing home residents, dental coverage varies by state. In 2016, roughly one-third of states offered extensive dental benefits, including a wide range of services with annual expenditure caps of $1,000 or more. Another third offered limited benefits and a few states provided no dental coverage, while the rest offered emergencyonly benefits.[1]

Another challenge is transportation to the dental office. Older adults with travel times greater than 30 minutes to see a dentist are more likely than others not to utilize oral health services when needed.[26] Inability to travel to a dentist was cited by 65.7% of older adults, and difficulty in finding a dentist was cited by 63.1% of older adults as barriers for those who needed but were unable to get services.[26]

Dental Care Provider Shortage Areas and Mobile Dental Vans in New York State

In October 2023 and October 2024, the New York State Dental Foundation organized mobile dental clinic events that underscored the crucial role of mobile care in addressing dental access issues. These events were especially important after the closure of two local dental clinics, which left nearly 4,000 individuals, many of whom were Medicaid recipients, without access to dental care. A total of 120 patients registered to attend the event in 2023, and 26 of those individuals received emergent care on the mobile dental vans. The 2024 event saw an increase in registrations, with 137 patients signing up to attend the event and a waiting list of more than 30 additional patients. These numbers highlight the significant demand for dental care and the critical need for improved access.[20]

Despite the success of these events, logistical challenges remain, such as the high costs of contracting with out-of-state organizations to bring dental vans onsite due to the lack of in-state units available, limiting the consistency of care delivery. To address these issues, the New York State Dental Foundation is hoping to start tracking which of New York’s 603 licensed nursing homes provide onsite dental services, while also monitoring mobile dental van operations to identify service gaps. These efforts would ensure that future community dental events are scheduled in areas with the most critically underserved populations.

Significance

In 2018, 56-year-old Brenda Bidwell, a medically fragile resident of Waverly, NY, moved to a nursing home for rehabilitation. Living with multiple chronic conditions—diabetes, a double amputation, lymphedema and obstructive sleep apnea—Brenda required specialized care and was especially vulnerable to infections. When COVID-19 hit, her situation became dire. Limited access to dental care during the pandemic led to rapid oral health deterioration, painful decay and infections that compromised her overall health.

Brenda’s case illustrates the urgent need for mobile dental units in nursing homes, as her complex needs made regular visits to a distant hospital dental clinic an overwhelming challenge. Mobile dental vans could provide onsite, essential care for nursing home residents like Brenda, helping to prevent severe complications, reduce travel stress and ensure continuity of health care in familiar, supportive environments.

Methods

This study employed a mixed-methods approach, integrating geospatial analysis with a review of publicly available datasets to assess dental care resources and service gaps in New York State. This combination allowed for a comprehensive understanding of the distribution of dental services, particularly in nursing homes and underserved rural areas.

Figure 2. Areas with dental care provider shortages and locations of mobile dental vans currently in operation. Red dots represent counties with full shortage. Orange and green dots indicate partial shortage areas and counties without shortages, respectively. Vehicle icons encircled in white mark locations of organizations that operate their own mobile dental vans and provide mobile dental services.

Data Collection

To analyze the distribution of dental care resources in nursing homes and mobile dental services, we compiled a comprehensive dataset using publicly available information from key sources, including:

• The U.S. Census Bureau

• Centers for Disease Control and Prevention (CDC)

• Health Resources and Services Administration (HRSA)

• New York State Department of Health

These sources provided demographic data, such as population distributions (urban vs. rural), prevalence of disabilities and the number of individuals residing in nursing homes, which are all pertinent to understanding dental care needs. A list of 603 licensed nursing homes was obtained from the New York State Department of Health. This dataset included the names, addresses and ZIP codes of each facility.

Each nursing home was then assessed for the availability of onsite dental care services. Facilities were coded as offering onsite dental services if this was explicitly mentioned on their official websites. Facilities where no information was available or where clarification could not be obtained through virtual chat systems (when present) were coded as “no.” This verification process was necessary due to the lack of comprehensive, publicly available datasets on onsite dental care in nursing homes.

To supplement our assessment of mobile dental services, we used data from the New York State Department of Health’s extension clinic list,[23] which identified seven organizations operating mobile dental clinics. This list was further expanded by reviewing the websites of other organizations providing mobile dental van services across the state.

Geospatial Analysis

We used ArcGIS software for geospatial analysis to visualize and analyze the distribution of dental care services. ArcGIS was chosen for its ability to process and map large datasets, providing a clear spatial representation of service disparities across New York State. Using geocoded ZIP codes, we mapped the locations of nursing homes, mobile dental clinics and areas designated as dental health professional shortage areas (HPSAs) by HRSA. This geospatial approach enabled us to identify geographic disparities in dental care, with a particular focus on rural and underserved regions. Detailed maps were generated to illustrate the distribution of nursing homes offering onsite services, the reach of mobile dental clinics and areas where shortages of dental professionals are most acute.

Limitations

Several limitations of this study must be acknowledged. First, our assessment of onsite dental services relied heavily on the availability of information from nursing home websites. This approach may have led to underreporting or inaccuracies, as not all facilities update their websites regularly or provide detailed information about their dental services online. Additionally, facilities coded as “no” for onsite services may, in fact, offer dental care, but this cannot be confirmed through publicly available information.

Another limitation is the scope of the mobile dental services data. While our dataset included information from official state sources and additional organizations, it is possible that some smaller or less formalized mobile dental services were not captured. Future studies could address these limitations by conducting direct surveys with nursing homes or partnering with county health departments to obtain more reliable data. Despite these limitations, the combination of geospatial analysis and the comprehensive review of publicly available data provided critical insights into disparities in dental care access across New York State.

Results

Of the 603 licensed nursing homes in New York State, only 198 facilities offer onsite dental services. The remaining 405 either do not provide these services, or their status remains unclear. This disparity becomes even more pronounced when cross-referenced with data on dental health professional shortage areas (HPSAs). Currently, 24 counties in New York are designated as full shortage areas,[24] meaning these entire counties lack sufficient dental care providers.

Within these 24 shortage-designated counties, 111 nursing homes operate. Alarmingly, 81 of these homes do not provide onsite dental services, leaving just 30 nursing homes with dental services available. This highlights a substantial gap in dental care access for residents in areas where the shortage of dental professionals is most severe.

Compounding this issue, only 17 organizations statewide offer mobile dental services, a critical resource for reaching

underserved populations. The shortage of mobile dental vans further underscores the barriers to quality dental care faced by nursing home residents, particularly in rural and underserved counties. These mobile services are vital in regions with a limited presence of dental professionals, yet their scarcity exacerbates the challenges in addressing the significant disparity in care access.

Discussion

A

“silent epidemic” of oral diseases is ravaging nursing home residents, representing a critical yet overlooked gap in healthcare with severe consequences for this vulnerable population. Despite the Oral Health Strategic Framework outlining important steps to eliminate oral health disparities, it notably lacks specific attention to nursing home residents, who are disproportionately affected by this crisis.[1] Federal regulations require nursing homes to assess and address the oral health needs of their residents, but there is little oversight or data on compliance. This lack of accountability exacerbates the issue, as many facilities may not be fulfilling their mandated responsibilities. Additionally, the absence of a centralized database of dental care in nursing homes, as well as mobile dental clinics operating in New York, complicates efforts by nonprofit organizations like the New York State Dental Foundation, which works to improve oral health across the state. More accessible information about where services are most needed would help organizations like the foundation to more efficiently and strategically allocate resources and begin to address the significant inequities in dental care access for this vulnerable population.

One proposed solution is the introduction of a dedicated mobile dental van to serve populations in dental health professional shortage areas (HPSAs), particularly nursing home residents and individuals with disabilities. These clinics eliminate the need for transportation, reduce costs and provide a higher quality of care.[17] Mobile dental services are especially beneficial for frail, elderly individuals with limited mobility, offering treatments such as fillings, extractions and routine cleanings. These services are also cost-effective, reducing hospitalizations caused by untreated dental conditions and eliminating transportation-related expenses.

Programs such as Gerodent in Belgium have demonstrated substantial improvements in oral health outcomes for nursing home residents. Additionally, mobile clinics have been shown to improve the oral health knowledge and daily care practices of nursing home staff. Mobile dental vehicles (MDVs) present a strategic solution for expanding dental care in underserved and rural areas. These vehicles

can provide a range of services, from routine cleanings to extractions, in areas with limited access to dental professionals.[18,19]

A phased implementation approach is recommended, beginning with nursing homes in areas facing complete dental provider shortages, then expanding to homes in partial shortage areas and, finally, to those without onsite dental services. This phased approach ensures that the most underserved areas are prioritized. Success will depend on building collaborative partnerships with local dental providers for staffing, dental schools to assist with training, and community dental health coordinators and faith-based organizations to facilitate outreach and raise awareness. However, financial barriers pose a significant challenge. The estimated cost of acquiring a dedicated mobile dental van is $479,728.[25]Beyond the initial acquisition, securing ongoing operational funding—including staff salaries, vehicle maintenance, storage and insurance, and medical supplies—will be essential. Grants, donations and partnerships will be pivotal in ensuring the sustainability of the program.

The consequences of inadequate dental care in nursing homes extend beyond oral health, leading to systemic issues

such as malnutrition, pain and a heightened risk of infections, further diminishing the quality of life for residents. Expanding the use of mobile dental units is, therefore, crucial to addressing these widespread disparities in New York State. By targeting vulnerable populations and focusing on coordinated, community-driven care, this initiative has the potential to significantly improve oral health outcomes for New Yorkers in nursing homes and other high-need settings.

Conclusion

Addressing the significant gaps in dental care for nursing home residents, particularly in underserved and rural areas, is essential to improving overall health outcomes. Contemporary data on oral health among long-stay nursing home residents is urgently needed to inform targeted interventions. Research into the association between organizational characteristics (e.g., staffing, presence of a full-time medical director, cited deficiencies in oral health care) and area-based factors (e.g., market-level racial segregation of nursing homes, Medicaid generosity, availability of dentists) will help pinpoint causes of oral health decline and guide solutions.

Expanding access through mobile dental clinics and enhancing onsite services in nursing homes, particularly in states like New York, can address these disparities and make significant strides toward equity in oral healthcare. This must be paired with effective community engagement and robust financial and logistical planning to ensure the long-term success of these initiatives. Additionally, understanding the barriers and facilitators of oral healthcare for nursing home staff, such as employer-based oral healthcare training and daily care practices, will be crucial in supporting care improvements.

Ultimately, by addressing the pressing need for equitable dental care and focusing on both organizational and area-based factors, these models can serve as a blueprint for broader systemic changes in healthcare delivery to underserved populations. p

Queries about this article can be sent to Ms. McIlduff at smcilduff@nysdental.org.

REFERENCES

1. Sifuentes, Andriana M Foiles, Kate L Lapane. Oral health in nursing homes: what we know and what we need to know. Journal Nursing Home Research Sciences 2020. https://www. ncbi.nlm.nih.gov/pmc/articles/PMC7286629/#R53.

2. Uninsured and in need. CareQuest Institute for Oral Health. Accessed September 26, 2024. https://www.carequest.org/resource-library/uninsured-and-need.

3. Janiya. Nysarh. NYSARH, July 7, 2024. https://nysarh.org/blog/2024/07/07/oral-health-disparitiesin-new-york-by-bridget-walsh/.

4. The State of Rural New York Report. Accessed July 31st, 2024. https://ruralhousing.org/wpcontent/uploads/2023-State-of-Rural-New-York-Report.pdf.

5. Designated health professional shortage areas statistics. Accessed July 31st, 2024. https:// data.hrsa.gov/Default/GenerateHPSAQuarterlyReport.

6. Northridge ME, Anjali Kumar, Raghbir Kaur. Disparities in access to oral health care. Annual Review of Public Health April 2, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7125002/.

7. Dental issues plague America’s nursing home residents. Accessed September 26, 2024. https://www.usnews.com/news/health-news/articles/2023-09-15/dental-issues-plague-americas-nursing-home-residents.

8. Jenny Yang. Number of Residents in Certified Nursing Facilities by State U.S 2023. Statista, November 30, 2023. https://www.statista.com/statistics/1168843/number-residents-certified-nursing-facilities-state/.

9. Directory of 606 nursing homes. Accessed September 26, 2024. https://profiles.health. ny.gov/directory/nursing homes.

10. Black K. Patients with special needs and complex conditions: addressing the need and provider shortage. URMC Newsroom, July 18, 2024. https://www.urmc.rochester.edu/ news/story/patients-with-special-needs-and-complex-conditions-addressing-the-need-andprovider-shortage#:~:text=EIOH%20patient%20David%20Goodnough,residents%20training%20across%20New%20York.

11. Dental Care. Alzheimer’s Disease and Dementia. Accessed August 2, 2024. https://www.alz. org/help-support/caregiving/daily-care/dental-care#:~:text=Good%20dental%20care%20 is%20important,a%20more%20hands%2Don%20approach.

12. Hmpgloballearningnetwork.com. Accessed September 26, 2024. https://www.hmpgloballearningnetwork.com/site/altc/articles/meeting-oral-health-challenges-long-term-carefacilities.

13. Chalmers P. Oral hygiene care for residents with dementia: a literature review. Journal of Advanced Nursing. Accessed September 26, 2024. https://pubmed.ncbi.nlm.nih.gov/16268845/.

14. U.S. Government Accountability Office (U.S. Gao). Accessed September 26, 2024. https:// www.gao.gov/.

15. Zhang Y, Punnett L, Gore R. Relationships among employees’ working conditions, mental health, and intention to leave in nursing homes. Journal of Applied Gerontology: Official Journal of the Southern Gerontological Society. Accessed September 26, 2024. https:// pubmed.ncbi.nlm.nih.gov/24652941/.

16. Zimmerman S, Austin S, Cohen L, Reed D, Poole P, Ward K, Sloane PD. Readily identifiable risk factors of nursing home residents’ oral hygiene: dementia, hospice, and length of stay. Journal of the American Geriatrics Society, November 2017. https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC5800408/.

17. Gao, S, Shiqian M, Jun Yu Yon, Chen KJ, Duangporn D, Chin E, Man Lo, Chun Hung Chu. Utilization of a mobile dental vehicle for oral healthcare in rural areas. International Journal of Environmental Research and Public Health April 7, 2019. https://www.ncbi.nlm.nih. gov/pmc/articles/PMC6480282/#:~:text=High%20start%2Dup%20cost;%20low,patients;%20 weather%2Drelated%20problems.

18. Alsaadi MG, Abdulmajeed HA, Hamed EM, Alshamrani ZK, Alharbi HY, Almahyawi HH, Ameen RM, et al. Oral health needs of the geriatric patients and the role of mobile dentistry. International Journal of Community Medicine and Public Health Accessed September 26, 2024. https://www.ijcmph.com/index.php/ijcmph/article/view/10616.

19. Janssens B, Vanobbergen J, Petrovic M, Jacquet W, Schols JM, De Visschere L. The impact of a preventive and curative oral healthcare program on the prevalence and incidence of oral health problems in nursing home residents. PloS one. Accessed September 26, 2024. https:// pubmed.ncbi.nlm.nih.gov/29894494/.

20. McIllduff S. When one door closes, another opens. The New York State Dental Journal 2024;90(1):12-14. https://drive.google.com/file/d/1GBZOKoyizv5-8SPZNkp3fc81kWo3VZmt/ view?usp=sharing.

21. Louis CS. In nursing homes, an epidemic of poor dental hygiene. The New York Times August 4, 2013. https://archive.nytimes.com/well.blogs.nytimes.com/2013/08/04/in-nursinghomes-an-epidemic-of-poor-dental-hygiene/.

22. Black K. Woman with multiple medical issues travels three hours one way for dental treatment. URMC Newsroom, June 13, 2023. https://www.urmc.rochester.edu/news/story/woman-with-multiple-medical-issues.

23. Department of Health. List of Extension Clinics. Accessed September 26, 2024. https://www. health.ny.gov/regulations/hcra/provider/provexthos.htm.

24. Map of Health Professional Shortage Areas: Dental Care, by County, July 2024. Rural Health Information Hub. Accessed September 26, 2024. https://www.ruralhealthinfo.org/charts/9.

25. Key Costs to Consider for Launching a Mobile Dental Clinic. FinModelsLab September 13, 2024. https://finmodelslab.com/blogs/startup-costs/mobile-dental-clinic-startup-costs.

26. Langelier M, Moore J. Oral Health of Older Populations: Implications for the Oral Health Care Delivery System. Presented at the New York State Oral Health Coalition Meeting, Troy, NY, March 1, 2019. Center for Health Workforce Studies, School of Public Health, University at Albany, SUNY. Accessed October 18, 2024. oralhealthworkforce.org.

Apeksha Phulgirkar, B.D.S., PGCert, M.P.H.-Global HealthTrack, Vanderbilt University, Nashville, TN.
Stacy McIlduff, CFRE, is executive director of the New York State Dental Foundation.
Ms. McIlduff
Ms. Phulgirkar

Dental Management of a Talon Cusp on a Permanent Incisor in Traumatic Occlusion

ABSTRACT

The purpose of this paper is to report the case of an 8-year-old female with occlusal interferences involving the permanent maxillary right central incisor (PMRCI) due to a Type 1 dens evaginatus, also known as a talon cusp (TC), causing displacement of the affected tooth. Clinical concerns related to TCs include occlusal interferences and increased risk for dental injury, displacement of the affected tooth, caries, tongue irritation and esthetic concerns. The TC in this report was reduced periodically over two months. Following each reduction, 5% topical sodium fluoride varnish was applied as a desensitizing agent. Upon completion and removal of the TC, sealant (Ultra Seal XT R plus TM, Ultradent Products, Inc. USA) material was applied to the lingual surface of the affected tooth. The patient was evaluated five weeks after treatment completion, during which time, no clinical signs or symptoms related to the reduction were reported.

Dens evaginatus, also known as talon cusp (TC), is a relatively uncommon dental anomaly in which an accessory cusp-like structure projects from the lingual or facial surface of the crown of a tooth. A TC resembles an exuberant tubercle of tooth structure that includes an enamel outer surface, dentin core and an inner extension of pulpal tissue

of varying size. While TCs are thought to be more prevalent in males, both sexes are affected, with an overall incidence of 1.67% and a greater predilection in the maxillary permanent dentition.[1,2]

Although these dental tubercles range in size, several clinical problems can result from TCs, including but not limited to, tongue irritation, occlusal interferences, esthetic concerns, malocclusion and displacement of the affected tooth, cusp fracture, caries, and pulpal inflammation and necrosis.[3,4]

Talon cusps may also present diagnostic and resulting treatment complications, as the radiopacities of the cusps in unerupted dentition may bear resemblance to a compound odontoma or a supernumerary tooth, which may lead to unnecessary surgical procedures.[1,6]

The purpose of this report is to document a case of Type 1 dens evaginatus involving an 8-year-old girl with increased risk for displacement of the affected tooth and dental injury.

Case Description

An 8-year-old female of Hispanic origin with an unremarkable medical history presented to the community dental clinic for children at a large academic medical center with a referral for comprehensive dental care with a chief complaint of odontogenic pain. The parent also reported a “tooth-like horn” extending from the palatal gingiva of the permanent maxillary right central incisor (PMRCI) (Figure 1a).

The patient’s medical and family history was noncontributory. Extraoral examination revealed a convex facial profile with no marked signs of pathology. Intraoral

examination revealed a Class 1 molar occlusal relationship, unremarkable soft tissue and normal eruption pattern in the early mixed dentition with mild crowding of the mandibular arch. Hard-tissue examination revealed generalized carious lesions of the primary molars (International Caries Detection and Assessment System classes four and five), as well as a prominent cusp extending from the palatal gingiva of the PMRCI. The palatal cusp extended to the incisal edge of the PMRCI and was in traumatic occlusion with the opposing permanent mandibular right central incisor.

The permanent right maxillary central incisor was distally rotated and was approximately 2 mm less erupted than the partially erupted permanent maxillary left central incisor. The permanent right maxillary central incisor presented with a slightly increased overjet relative to the permanent left maxillary central incisor. Figure 1a shows the patient at initial new patient examination with occlusal interferences. Radiographic examination shows a radiopaque V-shaped structure arising from the cementoenamel junction of the PMRCI with what appears to be a slight extension of the pulpal tissue into the inner region of the V-shaped radiopacity (Figure 2a).

The patient reported symptoms consistent with reversible pulpitis in the areas of the carious posterior primary molars. The patient denied any symptoms involving the maxillary anterior teeth, but did complain of frequent trauma to the anterior tongue when eating.

Beyond addressing the patient’s symptomatic carious teeth, the providing dentist was also concerned with the occlusal interference and resulting malocclusion due to the TC of the PMRCI. Treatment options were provided and the decision was made to move forward with gradual reduction of the TC to minimize risk of pulpal exposure and to remove the source of occlusal interference and lingual trauma. Incremental reduction of the TC was planned to accompany appointments for simultaneous comprehensive dental rehabilitation of the carious dentition.

Roughly 1.5 mm to 2 mm of tooth structure was removed with a football-shaped fine diamond bur on a high-speed handpiece, with copious irrigation, at each visit roughly sixweeks to two months apart from each other. Local anesthe-

Figure 1. (a) Patient at initial visit with talon cusp extending through palatal gingiva to incisal edge of partially erupted permanent right maxillary central incisor. Talon cusp of permanent right maxillary central incisor is in traumatic occlusion with opposing permanent right mandibular central incisor. Permanent right maxillary central incisor is very slightly distally rotated and observed to be roughly 2 mm less erupted than adjacent permanent left maxillary central incisor. Primary caries is also visualized on occlusal view of maxillary primary posterior dentition. Figures 1a, 1b, 1c, 1d, 1e document patient’s evolving occlusion and continued dental growth and development with each incremental reduction of patient’s talon cusp.

sia was not administered in the area of the PMRCI, though a combination of 30% nitrous oxide (N2O) and 70% oxygen (O2) was utilized for TC reduction.

Figures 1b, 1c, 1d and 1e show the patient’s improving occlusion after each incremental 2 mm reduction, revealing the patient no longer with occlusal interferences and with improved eruption pattern and alignment of the PMRCI. Figure 2b also reveals the radiographic appearance of the PMRCI roughly halfway through the treatment protocol after two incremental reductions of the TC were complete, with no signs of radiographic pathosis. Five percent topical sodium fluoride varnish was applied locally to the reduced TC after each visit to minimize tooth sensitivity.

Discussion

Figure 3a shows the patient after complete reduction of the TC with no occlusal interferences and improved overbite and overjet relationship. The lingual surface of the PMRCI was sealed after the fifth and final reduction to ensure a sealed and smooth surface (Figure 3b). Total time of treatment was roughly eight months.

Figure 1e illustrates the patient’s occlusion one month after final TC reduction. The patient was asymptomatic at this visit and no signs or symptoms of pulpal inflammation or sensitivity were noted. Further eruption of the PMRCI was observed after removal of the interference. The patient also reported no additional trauma to the tongue following removal of the patient’s TC. A radiograph was taken to confirm no pathosis (Figure 2c). Subsequent clinical and radiographic examination revealed no adverse signs or symptoms of the permanent right maxillary central incisor, and the patient was recommended for sixmonth routine oral hygiene maintenance visits.

Though the precise etiology of dens evaginatus is unknown, TCs are a rare odontogenic malformation that are thought to result from environmental or genetic factors during the morphodifferentiation phase of tooth development.[5,6] TCs are also associated with Sturge-Weber syndrome, RubinsteinTaybi syndrome, Mohr syndrome, incontientia pigmenti achromens, Ellis Van Creveld syndrome and BerardinelliSeip syndrome.[7] Environmental factors (i.e., trauma or ectopic tooth positions) that could interfere with the morphodifferentiation stage of tooth development or genetic components are also suspected to be an associated factor in the etiology of TC presentations. The patient in the present case, however, had none of the above-mentioned syndromes, no known environmental stress at the time of morphodifferentiation and no known family history of TC.

Hattab et al., in 1995, evaluated and categorized the features of TCs into three distinct subtypes based on the de-

Figure 3. Clinical photograph after full reduction of talon cusp with sealant material (Ultra Seal XT R plus TM, Ultradent Products, Inc. USA) applied along grooves revealing no occlusal interference and improved alignment of dentition.
Figure 2. Maxillary occlusal radiographs documenting gradual and incremental reduction of patient’s TC with no signs of pulpal or periodontal pathology and disappearance of V-shaped radiopacity initially indicative of patient’s TC.

gree of cusp formation and extension.[8] Type 1, also known as a TC, consists of a well-defined, exaggerated accessory cusp-like structure projecting from the palatal surface to at least half the distance between the cementoenamel junction and the incisal edge of the affected tooth. Type 2, also known as a semi-TC, characterizes a dental tubercle that is greater than 1 mm in size, but extends less than half the distance from the cementoenamel junction to the incisal edge. Type 3, also known as a trace TC, is a diffuse and not well-delineated enlargement of the cingulum that may have a conical, bifid or tubercle-like appearance.[8]

TCs may be unilateral or bilateral, in primary or permanent dentition, and can affect both males and females. It is rarely present in mandibular teeth, and rare on the facial surfaces. According to Decaup et al., TCs occur in approximately 1.67% of the population.[2]

The patient in the reported case presented with occlusal interference secondary to the prominent Type 1 TC. Occlusal interferences produce injury to the periodontium and pulp, which can cause tooth mobility, tooth displacement, temporomandibular joint pain, pain on mastication and periodontal disease.[9] There is also increased risk for caries development with the additional grooves present and an increased risk of fracture of these accessory structures. Early diagnosis and treatment of occlusal interferences can help prevent associated signs and symptoms.

Many treatment modalities are discussed in the literature depending on the size and disturbance(s) created by each TC. Gradual reduction of a TC is a safe, conservative and effective treatment for problematic TCs. Other proposed treatment modalities include pit and fissure sealants, pulpal therapy, restorative treatment, full-coverage crowns, extraction or no treatment.[9,10] Treatment should be determined only after careful evaluation of the size and configuration of each TC, as well as after in-depth discussions with patients and parents to assess the optimal approach for each individual.

Little information is known about TC anatomy and how the pulp communicates with the main chamber.[11] Due to concern for pulpal extension, gradual reduction of the affected cusp was considered the best treatment option for this patient. With gradual reduction, reparative or tertiary dentin is allowed adequate time to form between treatments. The tertiary dentin is formed by odontoblasts in response to a stimulus (i.e., manual reduction of the TC with a high-speed handpiece).[12]

According to Stanley et al.,[13] the average rate of tertiary dentin formation is 1.49 um/day and is highest in the interval between 27 to 48 days. By waiting six to eight weeks between cusp reductions, the provider allowed for suffi-

cient tertiary dentin formation prior to subsequent reduction, to avoid iatrogenic pulp exposure.

Early diagnosis and intervention were instrumental in eliminating this patient’s occlusal interference, which if left untreated, could have progressed to more extensive malocclusion and irreversible pulpal and periodontal harm. This case report supports the use of gradual reduction as a safe and effective treatment for TCs. It is a minimally invasive procedure that can successfully relieve symptoms with nominal preparation of the tooth and no local anesthetic. This is particularly important for dentists who may be among the first oral health providers to identify TCs in young patients and for whom cooperation and possibility of continued growth and development may make full coverage crowns difficult. p

All authors have made substantive contribution to this case report and all have reviewed the final paper prior to its submission. Queries abut this article can be sent to Dr. Lesavoy at bretlesavoy@gmail.com.

REFERENCES

1. Kalpana R, Thubashini M. Talon Cusp: a case report and literature review. J Oral Maxillofac Pathol 2015;6(1):594-96.

2. Decaup PH, Garot E, Rouas P. Prevalence of talon cusp: systematic literature review, metaanalysis and new scoring system. Arch Oral Biol 2021;125:105-112.

3. Yoon RK, Chussid S. Dental management of a talon cusp on a primary incisor. Pediatr Dent 2007;29(1):51-5.

4. Mellor JK, Ripa LW. Talon cusp: a clinically significant anomaly. Oral Surg Oral Med Oral Pathol 1970;29:225-8.

5. Babaji P, Sanadi F, Melkundi M. Unusual case of a talon cusp on a supernumerary tooth in association with a mesiodens. J Dent Res Dent Clin Dent Prospects 2010;4(2):60-3.

6. Sharma G, Mutneja AR, Nagpal A, Mutneja P. Nonsyndromic multiple talon cusps in siblings. Ind J Dent Res 2014;5(2):272-74.

7. Davis PJ, Brook AH. The presentation of talon cusp: diagnosis, clinical features, associations and possible aetiology. Br Dent J 1986;160:84-88.

8. Hattab FN, Yassin OM, al-Nimri KS. Talon cusp in permanent dentition associated with other dental anomalies: Review of literature and report of seven cases. J Dent Child 1996;63:368-78.

9. Saravanan R, Babu PJ, Rajakumar P. Trauma from occlusion: an orthodontist’s perspective. J Indian Soc Periodontol 2010;14(2):144-145.

10. Liu JF, Chen RJ. Talon cusp affecting the primary maxillary central incisor in two sets of female twins: report of two cases. Pediatr Dent 1995;17:362-4.

11. Tsai AI, Chang PC. Management of talon cusp affecting the primary central incisor: a case report. Chang Gung Med J 2003;26:678-83.

12. Smith AJ, Cassidy H, Perry H, Begue-Kirn C, Ruch JV, Lesot H. Reactionary dentinogenesis. Int J Dev Biol 1995;39:273-80.

13. Stanley HR, Conti AJ, Graham C. Conservation of human research teeth by controlling cavity depth. Oral Surg Oral Med Oral Pathol 1975;39:151-6.

Yoon

Bret Lesavoy, D.M.D., is a private practitioner in Pennsylvania. He is a former postdoctoral residency fellow (in pediatric dentistry), Columbia University Medical Center, Pediatric Dentistry Division, College of Dental Medicine, New York, NY.

Richard Yoon, D.D.S., is associate professor of dental medicine (in pediatric dentistry) at Columbia University Medical Center, Pediatric Dentistry Division, College of Dental Medicine, New York, NY.

Dr.
Dr. Lesavoy

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Second District cont.

FOURTH DISTRICT

Outstanding Moments from 2024

Crystal Arpei-McHugh, D.D.S., M.S.

BRONX COUNTY

Closing the Year on a High Note Don Safferstein, D.D.S.

The Bronx County Dental Society ended 2024 with a high-spirited Holiday Party. Thanks to our sponsors—MLMIC, DDS Match, Kuraray Dental and Bank of America—for helping us have a great evening.

Preparing for the New Year

Mark your calendars for the following events.

February 25: Dinner lecture with Dr. Larry Holtzman on “Digital Workflow for Implants with 3D Printing.” This evening will be sponsored by Nobel Biocare/Envistaco.

March 20: Job Fair for all dental residents looking for opportunities and older dentists looking for associates or forming an exit strategy.

April 8: Dinner lecture with Dr. Lauren Levy on “Dental Sleep Medicine 101.”

Dr.

BRONX COUNTY

A Sad Farewell

The Bronx County Dental Society mourns the passing of our longtime member and friend Dr. Madeline Ginzburg. Madeline was a leader throughout her dental career and lived a life of giving back to her profession and community.

Madeline graduated from Cornell University in 1975 and went on to the University of Pennsylvania School of Dental Medicine. After graduating with a D.M.D. in 1979, she entered the GPR program at Penn. She opened her own dental practice in Riverdale and practiced there for over 30 years.

Madeline became the first female president of the BCDS in 2013. During her tenure, she developed the Men-

BRONX COUNTY

BCDS members get in mood for season at Holiday Party.
Honors Achieved. Fourth District member Dr. Adrienne Korkosz, far left, was inducted as a fellow in the American College of Dentists during ACD meeting in October in New Orleans. Sharing spotlight with her are Third District immediate past president Kendra Zappia, center, and Third District Vice President Chris Arena.
Women Meet. NYSDA President Prabha Krishnan, center, traveled to Capital District in November to join with Fourth District members at Women Dentist Meeting at Hudson Valley Community College Hygiene Clinic. The meeting, organized by Drs. Jennifer Kluth and Maybelle Hwang, included tour of clinic and student meet and greet, and presentation by local speech pathologist Kate Chatigny.
Athletes Screened. Volunteers from Fourth District provided oral screenings and fluoride varnish treatments to hundreds of athletes participating in Special Olympics New York Fall Games in October in downtown Glens Falls. They included HVCC hygiene student Malak Gawdat, below, who appeared as toothbrush mascot, and Dr. Jonathan Schutze, above, who was accompanied by staff members: Patricia Carota, Geri Feeder and Trista Zawartkay.
Madeline Ginzburg

tor Program for NYSDA and served as its director. Madeline was a volunteer faculty member of the Columbia University School of Dental Medicine and recipient of the prestigious Pierre Fauchard Academy membership award.

Madeline was a constant presence at Give Kids A Smile and other community education events. She served on the Community 8 School Board and sponsored local school initiatives.

Madeline was married to Dr. Joel Delfiner for over 40 years. The pride of her life were her children—Leslie, Alexandra and Matthew—and her grandchildren—Samara, Hudson, Tessa, Hazel and Rowan.

May her memory be a blessing.

SUFFOLK COUNTY On Air

On Nov. 20, Suffolk and Nassau County Dental societies were at Connoisseur Media studios to record a 30-minute interview on dentistry on Long Island for their Island Outlook program. It aired on Dec. 15 on five stations—97.5 WALK-FM, 98.3 WKJY-FM, 103.1 The Wolf-FM, 94.3 The Shark-FM and 104.7 WHLI-FM.

Full Agenda

We had a great turnout and a wonderful time at our last General Membership Meeting of 2024 on Nov. 13. We honored our veterans, heard from NYSDA President-Elect Dr. Maurice Edwards, recognized new members and handed out CE awards. And we heard a great lecture, delivered by Dr. David Scharf. All of this was made possible with the support of our sponsors: Healthfirst, Dentaquest, MLMIC, Straumann, Garfield Refining, Rivkin Radler and Long Island Speech.

New Dentist Outing

A nice time was had by all at our Nov. 6 new dentist event at the Stateroom in Patchogue. Dr. Publio Silfa presented “Emotional Dentistry and Digital Smile

SUFFOLK COUNTY

More than 100 members turned out for General Membership Meeting in November.
Dr. Publio Silfa provides insight into Emotional Dentistry at meeting of new dentists in Patchogue.
Dr. Steven Feigelson,Suffolk County; SCDS Executive Director Bill Panzarino; and Nassau County Executive Director
Dr. Eugene Porcelli recording Island Outlook, which aired on five radio stations.

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Suffolk County cont.

Design.” Attendees enjoyed a hot buffet and drinks, made possible by our new dentist sponsors, TargetRock Wealth Management, Bank of America Practice Solutions, MLMIC and Straumann. Watch for our new dentist mentorship event coming in early 2025 and other new dentist events.

Of and For Women

The 2024 edition of the Long Island Women’s Dental Symposium, Scrubs and Stilettos, was a standout event at the Heritage Club in Bethpage. We had 14 women speakers, including Brooke Fukuoka, D.M.D., FSCD, who provided the lead course on Specialty Care Dentistry.

This joint Nassau and Suffolk County Dental Society event honored NYSDA Vice President Dr. Amarilis Jacobo and featured lectures by Dr. Chanelle Small, Dr. Michele Equinda, Dr. Natalia Elson, Dr. Vera Tang, Dr. Stacy Spizuoco, Dr. Nicole Teehan, Dr. Monica Bebawy, Michele Gabriel, Patricia Ribeiro Wolfson, Dr. Sarah Khan, Dr. Sheeba Kurian, Kimberly Kellar and Dr. Nicole Bell. None of this would have been possible without the unwavering support of our sponsors, Heartland Dental, Bank of America Practice Solutions, Pulpdent, TD Bank Healthcare Practice Solutions Group, Garfield Refining, Long Island Speech Centers, DDSMatch.com, Carestream and the Law Offices of Alan C. Stein, PC.

Don’t Miss a Thing

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, X, Instagram, LinkedIn and, even, Spo-

tify, in addition to our traditional www. SuffolkDental.org presence. Be sure to like/follow us.

THIRD DISTRICT

Education Assistance

Tancredi, Executive Director

On Dec. 5, Dr. Robert H. Hill II, chairperson of the Scholarship Committee and namesake of the Robert H. II Dental Clinic at Hudson Valley Community College, awarded scholarships to student recipients.

Congratulations to first-year students Anastasia Lewitinn-Barker and Rekha Gauchan and second-year students Gina Tumminello and Kymanni Stevens. Each received a $400 scholarship from the Third District Dental Society to continue their education in the field of dental hygiene in good academic standing.

Ulster-Greene Dental Study Club

Thank you to Dr. Mario Catalano for reforming the Ulster-Greene Dental Study Club. The Study Club sponsored its first CE course in June, and had its first official meeting on Oct. 15 at the Wiltwyck Golf Club in Kingston, with over 40 dentists in attendance. Attendees enjoyed happy hour, dinner and a two-credit CE course in periodontics. Anyone not

able to attend the updated mandatory child abuse reporter course presented at the Third District Annual Meeting could follow up with the course offered by Ulster-Greene Dental Study Club on Dec. 9. Both courses were offered free to Third District members.

All Ulster-Greene Dental Study Club courses are presented free to members of the Third District practicing in Ulster or Greene counties; they are discounted to all other members. For more information regarding the Study Club, contact the Third District at director@third-district.org.

Preparing for a Practice Transition

The Third District Dental Society once again partnered with Henry Schein and TD Bank to meet with doctors to discuss practice transition. The event, held at Common Roots in Albany, was well-received.

Upcoming

The Third District Dental Society is again partnering with the Fourth District for three CE courses. They are:

• January 31. “Newer than New: Surprising Changes and Dental Inflation Busters.”

• March 7. Oral Surgery Panel via Zoom.

• March 31. A Pediatric Dental Refresher for the General Dentist.

THIRD DISTRICT

Preparing for future, members took advantage of practice transition presentation offered by Henry Schein and TD Bank.

For more information and to register, visit https://www.third-district.org/copyof-2025-ce-courses-in-person.

SEVENTH DISTRICT

District Event Brings in $500,000 for MCC

Seventh District Dental Society members, with the support of EDPAC, organized and held a highly successful event with Sen. Jeremy Cooney this summer. Members shared concerns about issues impacting dentistry and the Rochester community, including access to care and utilization, workforce shortage and insurance complexities.

When Monroe Community College (MCC) came to Sen. Cooney asking for help, the senator took what he learned at this meeting and successfully worked to secure an additional $500,000 of state funding to support the college’s Dental Studies Program, which graduates dental assistants and hygienists. The money will be used to begin the first phase of the modernization of the current dental studies teaching clinic to include a design build study and an upgrade to the dental chairs and teaching equipment.

The ultimate goal of the modernization and future expansion of the MCC dental studies teaching space is to expand the program to address dental hygiene and dental assisting workforce shortages in Monroe County. This is the true value of grassroots advocacy!

Seventh District Donates to Local Charities

Each year, representatives from various counties in the Seventh District nominate a local charity to receive a yearend contribution. The district believes in acknowledging and supporting charitable organizations that contribute to the betterment of the communities in which our dentists live.

Monroe County Dental Society (MCDS) Board member Dr. Katie Strong and her husband dropped off gifts for

an adopted family at the Rochester YWCA. The YWCA provides direct services, empowerment programming and advocacy to support women and families experiencing housing insecurity. MCDS Board member Dr. Steven Damelio purchased toys and sporting equipment for the Boys and Girls Club of Rochester, an after-school youth program for young boys and girls in the city of Rochester.

SEVENTH DISTRICT

SEVENTH DISTRICT

Drs. Michael Keating and Theresa Casper-Klock, at center of photo, present check to Brian Bisgrove Home of Courage and Champions for Life.
Dr. Katie Strong and husband leave off their gifts for adopted family at Rochester YWCA.
Taking break during Livingston County Annual Meeting.

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Cayuga County dentists and Seventh District Board members Drs. Theresa Casper-Klock and Michael Keating delivered a check to the Brian Bisgrove Home of Courage and Champions for Life. The Bisgrove Home offers children with life-altering conditions and illnesses and their families a quiet retreat from daily life.

Livingston County selected the Teresa House to receive its charitable contribution. Teresa House, a two-resident bedroom home, offers a comfort care ministry to residents who are nearing the end of a terminal illness.

Camp Good Days & Special Times was the recipient of the Steuben County year-end donation. The organization provides free year-round programs and weeklong summer camping events for children and families who have been touched by cancer or sickle cell anemia.

Scholarship Luncheon for Area Dental Students

Monroe County Dental Society hosted its annual scholarship luncheon for area dental students. This year, students applied from the University at Buffalo, University of Pittsburgh and Case Western Reserve University. The county provides financial grants to deserving second-, third- and fourth-year dental students who had been legal residents of Monroe County prior to entering dental school.

A committee of diverse member dentists from various specialties speak with students about the profession, practicing in the Seventh District and the benefits of being involved in organized dentistry, in the hope they will return to practice in the county.

Many students have formed bonds with our committee members that last throughout their careers.

Livingston County Hosts Annual Meeting

Dr. Carlo Ercoli presented on “Anterior Implants: The Crossroads of Treatment Planning, Esthetics, Biomaterials Selection and Digital Technology” during the Livingston County Annual Meet-

SEVENTH DISTRICT

ing, held at Peppermint’s Restaurant in Avon.

Dr. Xiomara Restrepo-Jaramillo was elected 2025 President during the business meeting held prior to the lecture. Thank you to Dr. Rosemeire Santos-Teachout, outgoing president, for her years of service to the county.

Open Mic Night

Great conversation and plenty of laughs were had at the third new dentist/resident event held in 2024. Members and friends attended Open Mic Night at the Lovin’ Cup in Rochester in mid-November.

Thank you to our sponsors: Bryan Gray, CPA; DDSmatch; Vision Financial; and Walsh Duffield.

NINTH DISTRICT Going Virtual in 2025

Monica Barrera, D.D.S.

It’s hard to believe it’s 2025 already. How time flies when you’re scheduling fullday meetings, CE courses, new dentist socials and shredding days!

In the 9th District, we’ve fully embraced the virtual era for most of our CE courses and committee meetings. The convenience has been a game changer, allowing more members to participate, while saving the district money on utilities and catering— because who really misses those questionable buffet dinners?

This has also made our in-person events all the more cherished. General meetings, Frills & Drills, new dentist gatherings and the like have seen attendance return to near pre-pandemic levels. After all, nothing beats catching up with colleagues over a handshake and a smile—or a good cup of coffee.

Looking Back on 2024

In 2024, we continued our popular June shredding days, in partnership with MedXWaste/Legal Shred, our trusted company for HIPAA-compliant disposal of patient records. This well-attended event has quickly become a must out-

Enjoying Open Mic Night are, from left, Dr. Peter D’Elia, Michael Zobel, Dr. Caitlin Hewitt, 2025 District President Matthew Valerio.

ing for members who appreciate the chance to declutter responsibly.

The 9th also hosted several highly successful Give Kids A Smile (GKAS) events, spreading dental health awareness and good cheer. Our partnership with the Virginia Road School has allowed us to educate their over 300 children on oral health. We’ve also been to two HeadStart programs to screen and educate their students. If there’s one thing we’ve learned, it’s that nothing brightens a room like a child’s smile— and maybe a sugar-free lollipop.

The installation of the 9th’s 2025 President was the crowning moment of our final General Meeting in 2024, held at the Westchester Country Club in Rye.

Dr. Renuka Bijoor’s inauguration was a celebration of leadership and vision, with enthusiastic support from the Executive Committee and membership. Her call for suggestions to grow and strengthen the 9th District and the dental profession at large was met with applause. Kudos to Dr. Bijoor and our stellar team of executives and committee chairs for their tireless efforts.

The 2024 NYSDA House of Delegates Annual Meeting, hosted by the 9th, was an astounding success, with the final act, our drone show, still being talked about! The 9th District pulled out all the stops with sponsored events, including a golf outing and a dinner/ cocktail party. The meeting took place

NINTH DISTRICT

at the Turning Stone in Verona.

Coming Your Way in 2025

Our March General Meeting will return to the Villa Borghese in Wappingers Falls, a venue favored by members from all corners of the district. Even Westchester members are fans of the reverse commute and, perhaps, the Villa’s desserts.

The 2025 Frills & Drills event is set for May 21, with several new dentist events planned throughout the year.

Stay tuned for updates as venues are finalized. These gatherings are fantastic opportunities for younger members to connect with seasoned colleagues, share laughs and, maybe, even swap a few dental war stories.

Open to Ideas

Our committees, Board and executives remain as active as ever, tackling the needs and concerns of our members. Study groups are hard at work bringing courses closer to home for local members, and our CE courses continue to thrive as webinars, offering the mandated courses needed for relicensure.

Remember, if you attended a course that knocked your socks off— or at least your lab coat—let Diane at headquarters know. She’s always on the lookout for great ideas to benefit all 9th members. After all, sharing knowledge is like flossing—good for everyone and highly recommended.

NEW YORK COUNTY Recognizing Leaders within the Profession

Egidio Farone, D.M.D.

The evening lecture at our November General Meeting was delivered by Dr. James Burke Fine, recipient of the prestigious Henry Spenadel Award, which honors individuals or organizations for significant contributions to advancing the dental profession. The award was presented by Awards Committee Chair Richard Rausch.

Dr. Fine’s lecture, “Strategies for Predictable Minimally Invasive Surgi-

President Bijoor receives well wishes from guests at General Meeting, from left: NYSDA Secretary-Treasurer Paul Leary; Janis Moriarty of Massachusetts, ADA Council on Membership; Dr. Bijoor; NYSDA President Prabha Krishnan; Gary Scharoff, Ninth Past President and NYSDA Trustee.
Newly installed officers, from left, Secretary/Teasurer Monica Barrera, Immediate Past President Duraid Sahawneh, President Renuka Bijoor, President-Elect Bharat Joshi, Vice President Michael Smith.

New York County cont.

cal Therapies Utilizing Bone Cement,” offered members valuable insights into innovative approaches to minimally invasive periodontal surgery. His engaging presentation left attendees impressed and inspired by the topic.

President Suchie Chawla presented NYCDS Past President David Shipper with the Mark Mintzer Award for Service, honoring his outstanding dedication to NYCDS and the dental community through leadership and volunteerism. While accepting the award, Dr. Shipper shared his passion for NYCDS and organized dentistry.

As part of the leadership updates, Drs. Mina Kim and Gabriela Lee were thanked for their service on the Executive Committee and Board of Directors. Members also approved the following 2025 slate of officers: President Vera W. L. Tang, President-Elect Andrew S. Deutch, Vice President Egidio A. Farone, Secretary Jaskaren Randhawa and Treasurer Ada S. Cooper. Drs. JoAnna Pufnock and Gregory Shank will serve on the Board of Directors, and Dr. James Jacobs will serve as NYSDA Trustee starting in June.

New Dentists Mix Banking & Cocktails

New dentists gathered at the New York County Dental Society for “Demystifying Banking for New Dentists,” an event hosted by Bank of America. Attendees gained valuable insight into the loan process from experts Rob Malandruccolo and Jarrett Mathews. To cap off the evening, mixologist Kevin Falatko led a cocktail-making session, teaching participants how to craft creative drinks. The event combined practical banking tips with a fun, hands-on mixology experience.

NYU Fall Networking Night at NYCDS On Nov. 13, NYCDS paired with NYU

NEW YORK COUNTY

NYCDS members, NYU alumni and NYU residents gather at NYU Fall Networking Night at NYCDS headquarters.
Celebrants at GNYDM 100th Anniversary include, from left, ADA President Brett Kessler, NYCDS President Suchie Chawla, ADA President-Elect Richard Rosato.

College of Dentistry Alumni Affairs to host a networking event for dental students. This event was designed to connect current New York University dental students with experienced dentists from various specialties, as well as NYU alumni. Attendees enjoyed an evening of speed networking sessions and conversations about dental careers. They left the event with valuable insights into residency experiences, career paths and strategies for success in dentistry.

GNYDM 100th Anniversary

The Greater New York Dental Meeting celebrated 100 years as the largest dental convention and event in the United States. The meeting registered 37,631 attendees, including 13,470 dentists, 2,803 dental students and residents, and 2,226 dental hygienists from 148 countries. Dental professionals explored thousands of exhibit booths, had access to more than 245 seminars, 250 scientific poster sessions and free educational programs at the all-new Main Stage.

In honor of 100 years of GNYDM, the Javits Center was decked out with festive balloons, stilt walkers, a marching band and a Broadway matinee featuring famous performers from hit musicals Jersey Boys and Mama Mia.

Special Olympics Special Smiles

On Dec. 7, a group of NYCDS members, NYU dental students and local high school students volunteered at Special Olympics Special Smiles. During the event, 58 athletes were screened, identified for urgent dental concerns and received comprehensive oral hygiene instructions.

A heartfelt thank you to all the volunteers for their dedication and support in making this event a success!

Give Kids A Smile

This year, NYCDS’s Give Kids A Smile event will take place on Feb. 7. Join us in making it our biggest and most impactful yet! GKAS brings together dentists, team members and volunteers from across the dental community to provide essential oral care to under-

NYSDA Endorsed Services

BANKING

Bank of America

800-932-2775

800-497-6076

US Bank

888-327-2265

FINANCIAL SERVICES

CareCredit

800-300-3046 (#5)

Altfest Personal

Wealth Management

888-525-8337

Best Card

877-739-3952

Laurel Road Student

855-245-0989

INSURANCE SERVICES

MLMIC

800-683-7769

888-263-2729 Brooklyn, Queens, Nassau & Suffolk

888-744-6729

Arthur Gallagher Other Business

888-869-3535

Long-term Care

844-355-2596

OTHER

Henry Schein

Long-term Care Insurance

Electronic Prescribing 800-734-5561

Prosites

Mercedes

Website Development

888-932-3644 & Patient Reviews https://www.prosites.com/nysda

Vehicles 866-628-7232

Lands’ End Apparel for Staff 800-490-6402

UPS

800-636-2377

iCoreExchange

888-810-7706

The Dentists Supply Company

888-253-1223

Volvo

800-550-5658 ada.org/volvo

OnDiem

https://hub.ondiem.com

Practice Mojo

888-932-3644

https://practicemojo.com

For further information about NYSDA Endorsed Programs, call Michael

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New

York County cont.

served children. Sign up today at www. nycdentalsociety.org, or call (212) 5738500 for more information.

Winter/Spring Continuing Education

• Feb. 12: Lasing is Amazing! 9:30 a.m.-3:30 p.m.

• Feb. 26: Basic Life Support/CPR Certification Course 9:30 a.m.-1:30 p.m.

• Feb. 28 Infection Control and PostExposure Prophylaxis 9:30 a.m.1:30 p.m.

• Feb. 28: Update to HPV and Oral Cancer 2-5 p.m.

• March 3: Unleashing the Future: Metahumans and Artificial Intelligence in Digital Dentistry 9:30 a.m.-12:30 p.m.

• March 7: Immediate Implant Placement and Restoration “The Esthetic Zone” 9:30 a.m.-4:30 p.m.

• March 12: Dental Sleep Medicine, a View from 30,000 Feet 7-9 p.m. (Zoom)

NEW YORK COUNTY

• March 21 Cutting Edge Technology with Digital Design and Real-World Cosmetic Dentistry: Faults, Failures, and Fixes 9:30 a.m.-4:30 p.m.

• April 4: Be Your Own Prosthodontist 9:30 a.m.-12:30 p.m.

• April 23 Innovations in Aesthetic Dentistry: Everything You Need to Know About Veneers 9:30 a.m.4:30 p.m.

• April 24 Workshop on Veneers 9:30 a.m.-4:30 p.m.

• May 1: Better, Faster, Stronger: Tips to Up Your Game 4-7 p.m.

• May 2: Please Doc, Not Another Crown! Modern Full-Coverage Alternatives 9:30 a.m.-12:30 p.m.

• May 14: Basic Life Support/CPR Certification 9:30 a.m.-1:30 p.m.

• May16: Practical Oral Pathology 10 a.m.-3 p.m.

• May 21: Contemporary Implant Removable Protheses: A Clinical Update 9:30 a.m.-3:30 p.m.

• May 22: Workflows for Conservative Cosmetic Dentistry 6-8 p.m. (Zoom)

• May 30: Sleep Apnea: Wake Up to the Problem 9:30 a.m.-3:30 p.m. New courses are added regularly, so be sure to visit www.nycdentalsociety.org for the latest schedule.

NEW YORK COUNTY

Dr. David Shipper receives Mark Mintzer Award, presented by President Suchie Chawla.
NYCDS members joined with other volunteers to screen athletes participating in Special Olympics at Javits Center.
New dentists at start of evening devoted to gaining banking insights and having fun making cocktails.

SECOND DISTRICT

Installation and Awards Luncheon

Congratulations to Dr. Paul Teplitsky, SDDS 2025 President. On Jan. 5, an impressive event took place at the University Club in Manhattan. Close to 200 people, SDDS members, invited dignitaries, friends and family, gathered to celebrate his installation and that of our line officers: President-Elect Dr. Valerie Venterina, Vice President Dr. Phyllis Merlino, Secretary Dr. Cherry Libramonte and Treasurer Dr. Joseph Merola.

Following a moving invocation, delivered by Dr. Charles Mistretta, Dr. Tricia Quartey-Sagaille, our immediate past president, accompanied by her best helper—her son, Kendrick—gave inspiring welcoming remarks.

Dr. Teplitsky was escorted to the podium by his wife of 40 years, Joanne, where he took the oath of office, delivered by our installing officer, Dr. John Demas. True to form, Dr. Teplitsky gave a moving yet funny acceptance speech highlighting his path to the SDDS presidency. He thanked the many colleagues, who he credited (blamed?) for bringing him to this moment. Most importantly, he thanked his wife for encouraging and supporting him in his journey to this day. He also spoke of the importance of our transition to the next generation of leaders.

Dr. Teplitsky has played a very active role in our society. He joined the SDDS Board of Trustees in 2017 and has served on multiple SDDS committees. He has been a delegate to both the NYSDA and ADA House of Delegates. For two terms, he has been SDDS’s representative to the NYSDA Council on Ethics and currently serves as council chairman. From 2019 through 2023, Dr. Teplitsky was SDDS’s appointee to the Greater New York Dental Meeting’s Organization Committee and continues to volunteer as a troubleshooter for the meeting.

The SDDS was proud to acknowledge our newest life members: Drs.

SECOND DISTRICT

Newest Life Members stand for round of applause.
President Paul Teplitsky, at lectern, recognizes Dr. Mitchell Mindlin, left, and Dr. Stuart Segelnick for years of service to SDDS.
Trio of new line officers include, from left, President-Elect Valerie Venterina, Vice President Phyllis Merlino, Secretary Cherry Libramonte.

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Second District cont.

Yakov Eisenberger, Michelle Giumenta, Keith Landsman, Bruce Lish, Marina Magid, Phyllis Merlino, Constantine Pavlakos, Stuart Segelnick, Paul Teplitsky, Alfred Witko and Leonard Zhukovsky.

This luncheon continued Second District’s tradition of recognizing those whose efforts on behalf of the SDDS are truly appreciated. We thanked Drs. Natalie Mohadjeri and Marc Gainor for their years of service on the Greater New York Dental Meeting Organization Committee. Also: Dr. Man-Sing Chung, for his hard work on the NYSDA Peer Review Council; and Drs. Mitchell Mindlin, Raymond Flagiello, Ronald Turchak and Stuart Segelnick, for their years as members of the SDDS Board of Trustees. Dr. Segelnick was also recognized for his 10-year tenure as editor of our Bulletin.

A highlight of the afternoon was when the SDDS acknowledged Dr. Tricia Quartey-Segaille for her remarkable tenure as 2024 president. Her time in

SECOND DISTRICT

office was marked by her great leadership, navigating us through a complicated year. It cannot be said enough: Thank you, Tricia, from all of us!

GNYDM Marks 100th Anniversary

They did it again! The 2024 Greater New York Dental Meeting continued the upward growth of the meeting since the COVID shutdown. With over 38,000 attendees, the GNYDM continues to be this country’s preeminent dental conference. Congratulations to the following SDDS members serving on the Organization Committee: Drs. Saad Butt, Charles Mistretta, Natalie Mohadjeri and Steven Gounardes, along with our immediate past general chair, Dr. Richard Oshrain. Your hard work was very evident.

Thank you also to our New York County Dental Society partners, including this year’s general chair, Dr. John Young, for their efforts and dedication.

In 2024, the GNYDM celebrated its 100th Anniversary. A highlight of the celebration was a free Broadway matinee at the Javits Center starring the casts of Jersey Boys and Mama Mia. Attendees raved about the performance. As usual, the GNYDM hosted several alumni events from dental schools around the region, as well as the everpopular Pre-Dental Conference, linking the next generation of dental students with schools of their dreams.

The Sunday morning ribbon-cutting featured entertainers on stilts. The International Reception was bigger than ever. Also, in honor of its 100th Anniversary, the meeting held daily giveaways for attendees. A highlight of the meeting is always the Saturday night cocktail reception. Dignitaries from around the world and country mingled with members of SDDS and NYCDS over good food and fun. A special surprise for the 100th Anniversary was a fabulous performance by professional singers and dancers at the reception, a gift from our friends at the Marriott Marquis.

The meeting’s success is dependent on its hundreds of volunteers. Thank you to all who volunteer their time and energy. You are the special ingredient that makes the GNYDM successful.

Pizza

On Nov. 21, SDDS and our New Dentist Committee held a unique and fun event called “Pizza Making and Practice Planning!” True to the title’s promise, an in-depth discussion of ways to grow a practice and career was combined with pizza making. SDDS members received advice from bankers, attorneys, practice marketers and real-estate professionals about strategies and tips for starting or expanding their practice. This was combined with the fun of pizza making alongside their peers aka— new friends!

SECOND DISTRICT

Runners

The SDDS has a serious group of runners. Congratulations to Dr. Cherry Libramonte for completing this year’s New York City Marathon—the first of many—and to Dr. Richard Oshrain for being a medalist in the Long Beach, NY, 2024 10K Turkey Trot. SDDS is proud of both of you.

Immediate Past President Tricia Quartey-Sagaille shares spotlight with son, Kendrick.
Dr. Richard Oshrain with silver medal awarded at completion of Long Beach Turkey Trot.

Read, Learn and Earn

Readers of The New York State Dental Journal are invited to earn three (3) home study credits, approved by the New York State Dental Association, by properly answering the following 30 True or False questions, all of which are based on articles that appear in this issue.

When you have completed the questionnaire, return it to the New York State Dental Foundation, along with the appropriate fees: $35/dentists; $25/hygienists. Nonmember fees are: $65/dentists; $45/hygienists. All those who achieve a passing grade of at least 70% will receive verification of completion. Credits will automatically be added to your CE Navigator account.

For a complete listing of online lectures and home study CE courses sponsored by the New York State Dental Association, visit www.nysdentalfoundation.org.

The Open Apex Challenge—Page 14-20

1. An open apex is relatively easy to treat endodontically. q T or q F

2. A tooth with an open apex usually has thin root structure.

q T or q F

3. Radiographs are the most accurate method for measuring working lengths in teeth with open apices.

q T or q F

4. Calcium hydroxide (CH) was used to induce an apical hard-tissue barrier.

q T or q F

5. CH dressing changes were never needed for an apical bridge to form.

q T or q F

Continued on following page

q Enclosed is a check for the full amount. Members’ fees are $35/dentists; $25/hygienists. Nonmember fees are $65/dentists; $45 hygienists. (Make checks payable to the New York State Dental Foundation.) Mail to NYSDF, 20 Corporate Woods Boulevard, Suite 602, Albany, NY 12211. Questionnaires must be received within 90 days of Journal publication.

Please charge my: q VISA q MasterCard q American Express

NYSDA Member? q yes or q no

Local/State Dental Society

6. The major challenge for an open apex case is over filling the canal.

q T or q F

7. Pulp regeneration (pulp revascularization) has gained popularity in treating open apex cases.

q T or q F

8. In modified regeneration, only the apical 3 mm to 5 mm is used as a scaffold for the blood clot.

q T or q F

9. Hertwig’s epithelial root sheath is not responsible for stimulating root development at the apex.

q T or q F

10. Apexification is no longer the endodontic treatment of choice for immature and necrotic teeth.

q T or q F

Pathological Changes in Soft Tissues Associated with Radiographically Normal Impacted Teeth—Page 22-31

1. The article seeks to improve our clinical management of treating impacted teeth by hypothetically classifying the pericoronal follicular space.

q T or q F

2. Odontogenic cysts were not documented in the study.

q T or q F

3. The data from the study does not justify the complement removal of all asymptomatic impacted teeth.

q T or q F

4. Once the tooth has fully developed inside the jaw, the coronal part of the follicle is termed pericoronal sac or follicle (PF).

q T or q F

5. Radiographically, dental follicles are abnormal developmental structures.

q T or q F

6. The overall consensus seems to be that pericoronal cysts and tumor development are rare when associated with impacted teeth.

q T or q F

7. Radiographic examination is not important in identifying an enlarged pericoronal space suggestive of process.

q T or q F

8. Dentigerous cysts are the most common abnormality associated with pericoronal tissues showing pathological change.

q T or q F

9. The study found no correlation between the incidence of cystic change in follicular tissues and age.

q T or q F

10. According to the present results, cystic changes may develop in both clinically and radiographically asymptomatic teeth.

q T or q F

Dental Management of a Talon Cusp on a Permanent Incisor in Traumatic Occlusion—Page 42-45

1. A Type 1 dens evaginatus is also known as a talon cusp (TC).

q T or q F

2. A TC does not have a dentin core.

q T or q F

3. A TC may cause pulpal inflammation and necrosis.

q T or q F

4. A TC may resemble a compound odontoma in an unerupted dentition.

q T or q F

5. TCs have a greater predilection in the maxillary permanent dentition.

q T or q F

6. Incremental reduction of a TC is a recommended treatment.

q T or q F

7. Applying topical sodium fluoride varnish to a reduced TC is not recommended.

q T or q F

8. TCs are a common odontogenic malformation.

q T or q F

9. TCs may be associated with various syndromes, such as Sturge-Weber syndrome.

q T or q F

10. Many treatment modalities are discussed in the literature depending on the size and disturbance(s) created by each TC.

q T or q F

To complete the questionnaire online, scan QR code above

AUTHOR’S GUIDELINES

THE NEW YORK STATE DENTAL JOURNAL

AIMS AND SCOPE

The New York State Dental Journal is a peer-reviewed journal which publishes original research, scientific reviews and case reports in all areas of the oral health sciences, clinical dental practice and dental practice-related social, political, practice management, ethical and legal commentary. The Journal strives to be of interest to dental clinicians, educators, researchers, residents and students.

PEER REVIEW

The New York State Dental Journal subjects original scientific manuscripts, as described below, to a double-blind, peer-review process. Authors do not know who the reviewers are; reviewers do not know who the authors are. Review criteria include scientific merit and accuracy, writing style, subject appropriateness, quality of references, study design and statistical analysis. All manuscripts are assessed as rapidly as possible, and acceptance for publication is based on the peer reviewers’ comments. Results of the reviews are conveyed to the author(s). If major revisions are recommended by a reviewer, the revised manuscript is re-reviewed by the original reviewer.

PEER-REVIEWED ARTICLES

Original contributions. Articles with a clinical and practical focus covering topics, including esthetic and restorative care, oral systemic health, pharmacology, specialty dental practice, and informatics and technology; articles describing the results of clinical, laboratory and population-based research pertinent to dentistry and providing foundation knowledge for future application; articles regarding epidemiologic and policy issues.

NON-PEER-REVIEWED ARTICLES

Opinion-based editorial articles, “Dental Pearls,” and Letters to the Editor with comments on issues raised related to articles published in The NYSDJ. A letter about a particular article will be forwarded to the article’s author(s) for comment if the letter is selected for publication. The NYSDJ Editorial Staff reserves the right to edit the letters into a publishable format. Dental Pearls are clinical tips, techniques or unusual cases submitted by clinicians not familiar with research methodology, and may be exempt from the peer-review process.

CONFLICTS OF INTEREST

Financial contributions and any potential conflict of interest must be clearly acknowledged. Authors must list the source(s) of financial support for the conduct of research and/or preparation of the manuscript and describe the role of the sponsor(s), if any, in study design, in the collection, analysis and interpretation of data, in the writing of the report, and in the decision to submit the manuscript for publication. If the funding source(s) had no such involvement, then this should be stated. This information and acknowledgment must be obtained for each author.

PATIENT INFORMED CONSENT

The author(s) must be able to provide documentation of patients’ consent for research or participation in a study as per the applicable laws and regulations regarding the privacy and/or security of personal information, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other federal and state laws relating to confidentiality and security of personally distinguishable evidence.

The Editor may request that authors provide documentation for the formal review and recommendation from the institutional review board or ethics committee responsible for oversight of the study. The Editor reserves the right to reject manuscripts that do not comply with the above-mentioned requirements. The author(s) will be held responsible for false statements or failure to fulfill the above-mentioned requirements.

HUMAN RIGHTS

For all manuscripts reporting data from studies involving human participants, formal review and approval by an appropriate institutional review board or ethics committee are required.

ANIMAL STUDIES

The New York State Dental Journal does not publish animal studies.

UNETHICAL BEHAVIOR

Unethical behavior and misconduct by the author(s) in the undertaking of any research, study, systematic review or case report, or in the preparation of a submitted manuscript, may be pointed out with sufficient evidence by anyone to the Editor. The Editor, in consultation with the Managing Editor, will determine the need to initiate an investigation related to the alleged misconduct. Confidentiality will be maintained throughout any investigation and the author(s) will be given the opportunity to reply to all allegations.

USE OF INCLUSIVE LANGUAGE

It is recommended the author(s) use inclusive language that acknowledges diversity, conveys respect to all people, is sensitive to differences, and promotes equal opportunities.

MANUSCRIPT PREPARATION

The Journal accepts original manuscripts of up to 2,500 words (approximately five pages—excluding title page, abstract, references, legends and other related material). We regret we are unable to accept previously published manuscripts or manuscripts being considered for publication elsewhere. The manuscript must have an abstract of no more than 100 words, introduction, body and conclusion. Manuscripts missing any element may be returned for revision. Manuscripts should be prepared in Microsoft Word file format, single-spaced, fully justified, adding extra line space between paragraphs. Do not use indents, bold face, italics, underlines or tabs. If

AUTHOR’S GUIDELINES

THE NEW YORK STATE DENTAL JOURNAL

you use Track Changes, be sure you are sending a final document with all changes accepted.

Cover letter and/or title page should include principal author’s name, mailing address and email address and daytime telephone number. Names and email addresses for all other authors should be provided. If more than three authors, give nature and level of contribution of each, i.e., whether work was directed or independent.

Include an abstract of the article of no more than 75-100 words and, if available, head and shoulder photo(s) of author(s). Photos may be black/white or color. Jpeg files are preferred.

We encourage authors to make their submissions electronically. Submit manuscripts and related materials to Ms. Mary Stoll, Managing Editor, The New York State Dental Journal, Suite 602, 20 Corporate Woods Boulevard, Albany, NY 12211; mstoll@nysdental.org.

AI AND AI-ASSISTED TECHNOLOGIES

If authors use artificial intelligence (AI) and AI-assisted technologies in the writing process, authors must:

• Only use these technologies to improve readability and to check references, spelling and grammar, etc., not to replace key researcher tasks, such as interpreting data or drawing scientific conclusions.

• Apply the technology with human oversight and control, and carefully review and edit the result, as AI can generate authoritative-sounding output that can be incorrect, incomplete or biased.

• Not list AI and AI-assisted technologies as an author or coauthor or cite AI as an author. Authorship implies responsibilities and tasks that can only be attributed to and performed by humans. Authors are ultimately responsible for the content of the work.

• Disclose, in a separate section at the end of the manuscript, the use of AI and AI-assisted technologies in the writing process beyond the use of basic tools to check language and readability that includes the name of the tool or service utilized and the reason for use.

REFERENCES

References must be keyed to the text and numbered consecutively, beginning with 1. They should include, in the following order: author, title, name of periodical, date of publication, volume number, page number(s). For books, include the location and name of publisher before the publication date.

Do not cite unpublished works; personal communications are acceptable provided they are dated, signed and a copy made available.

ILLUSTRATIONS

Only one set of illustrations is required. The Journal accepts black/ white prints and radiographs, color prints and/or transparencies, charts and graphs. In all instances, the work submitted should be in its original form. If your illustrations are on disk, please identify the program used, and provide a laser print. With regard to electronic transmissions, we accept digital files only. We are unable to accept PowerPoint presentations or images embedded in Word

files; all figures submitted electronically must be sent separate from the text, as jpeg files.

If you are submitting images electronically, we request that you include a composite of the images with photographs, X-rays, charts, tables, etc., numbered and oriented with an arrow that will clearly identify how these images are to be oriented.

Each illustration should be identified with a figure number (Figure 1, 2, etc.) that corresponds to an accompanying legend. Figure legends should appear at the end of the prepared manuscript, not affixed to the illustration. Cite each figure in the text in consecutive order.

TITLES AND CREDITS

The title of the article and the names of the authors, along with their academic and professional degrees, should appear on the first page. Indicate the author’s university, hospital or other professional affiliation for use in author’s credit. Include concise information conveying professional background and standing. Please divulge any financial, economic or professional interests that may influence positions presented in the article.

COPYRIGHT AND REPRINTS

Upon acceptance of a manuscript for publication in The Journal, the author(s) will be asked to transfer copyright ownership and to assign all rights under ownership of copyright to The New York State Dental Journal The Journal reserves the right to edit manuscripts and revise titles.

The manuscript should not contain any such material or information that may be unlawful, defamatory, fabricated, plagiarized or which would, if published, in any way whatsoever violate the terms and conditions in the copyright agreement. The authors acknowledge that The Journal has the legal right to take appropriate action against the authors for any such violation of the terms and conditions of the copyright agreement.

ADDITIONAL INFORMATION

The Journal makes every effort to notify authors within 60 days of the acceptance of their articles. Authors should expect passage of up to a year from acceptance to publication of their articles. Authors will be notified when their articles have been scheduled, and they will receive final copy for approval prior to publication.

The Journal makes complimentary copies available to author(s), if requested.

ERRATA AND CORRECTIONS IN PUBLISHED ARTICLES

Authors and readers are encouraged to notify the Editor if they discover errors in published content, authors’ names and affiliations, or if they have reasons for concern over the legitimacy of a publication. In such cases, The Journal will publish corrections, in consultation with the Editor and authors of the article, and at the sole discretion of the Editor, replace or retract the article.

FOR SALE

NORTHEASTERN NY: Thriving general dental practice near greater Burlington, VT, metro area. 14 operatories, including three hygiene chairs, and serves 4,540 active patients, with 45 new patients monthly. Generating $2.7M collections and $507K EBITDA. Ideal for dentists seeking turnkey opportunity. Located in free-standing building, with real estate available. Practice combines strong financials with stunning location. Contact Professional Transition Strategies by email: bailey@professionaltransition.com; or call (719) 694-8320. Reference #NY122024.

CAPITAL DISTRICT AREA: Group practice for sale. Well-established, modern practice with pleasant patients. Sirona CBCT, 2 complete CEREC mills and scanners. Digital recordkeeping, digital X-rays. No insurance participation or Medicaid. Staff and doctor willing to stay. Please contact to discuss options. Dr. Jeffrey Backer, Scotia Glenville Dental Center, at (518) 526-0177.

BRONX: General family practice established 17 years ago. Conveniently located off main road. Open 4 days/week until 4 pm. 2022 gross collection $399K, with 2 operatories and 1 doctor. No advertising. Digital X-rays; completely paperless with dental software. Growing patient base with room to grow if opened more. Excellent opportunity to grow your own practice. To discuss, please call: (347) 661-6638.

ADIRONDACK REGION: Lake George. Excellent opportunity to purchase well-established general practice. Desirable location near Black Point Beach on beautiful Lake George and near Vermont skiing. Modern practice; 100% digital. New Carestream CS8200 3D, Dentrix software. Open four days per week; practice averages 2,500 visits per year. Owner retiring; willing to help transition. Call or email to discuss: (518) 585-2864; or email: ADKdent@gmail.com.

LONG ISLAND, SOUTH SHORE: Brightwaters/Bay Shore. Dental office building for sale. 3 ops plumbed and ready for equipment. 1,000-square-foot first floor, 500-square-foot second floor, dry basement. Vacant but has been dental office for over 60 years in prime location, with easy access to Southern State Parkway, Sunrise Highway and Sagtakos Parkway. Serious inquiries only. Reply to: tuthfixer@aol.com; or call (631) 383-9508.

NASSAU COUNTY: Successful Rosyln dental business for sale. Prime location on Northern Boulevard. State-of-theart facilities with hospital-grade sterilization room; 2,500 square feet and 6 operatories. Over $1M revenue on 2 days/week. Huge growth potential. Email for more info. Serious inquiries only. Contact: ddssale306@gmail.com.

GREATER NYC METRO AREA: General dental practice for sale, located just 20 miles northwest of Manhattan. Well-established dental practice offers unique opportunity to serve engaged, family-oriented community. Features 6 operatories, 5 fully equipped and 1 plumbed for future expansion. Strong patient base, with 2,760 active patients and around 55 new patients each month. Set up for continued success, with annual collections $1.5M and $400K EBITDA. Owner open to flexible transition, including 3- to 4-year phased exit or full transfer. For more details, reach out to Bailey Jones at Professional Transition Strategies via email: bailey@professionaltransition.com or call

CLASSIFIED

Online Rates for 60-day posting of 150 words or less — can include photos/images online: Members: $200. Nonmembers: $300. Corporate/Business Ads: $400. Classifieds will also appear in print during months when Journal is mailed: Jan and July.

(719) 694-8320. Reference #NJ10924.

WHITE PLAINS: General practice for sale in growing White Plains. Ground level, facing major road with street parking. Two ops with room for possible 3rd. Mostly FFS. Gross $400K with high net. Space includes kitchen, bathroom and zoned legal as residence. Practice and real estate for sale. Asking 50% net. Inquiries to: daisymolly2023@yahoo.com .

MANHATTAN: Midtown dental practice for sale. General practice offers prime ownership opportunity. With four operatories and nearly four decades of service, practice operates 3-4 days/week, serving 570 active patients. Collections $1.2M and EBITDA $330K all on fee-for-service basis. Real estate also available for purchase. Enjoy NYC’s vibrant culture and amenities while owning thriving practice. Interested? Contact Professional Transition Strategies: bailey@professionaltransition.com; or call (719) 694-8320. Reference #NY62624.

BINGHAMTON AREA: Must-see, profitable general practice near Binghamton. Practice grossing over $600k with only 28-hour workweek. Hygiene booked out till March ‘25. Low overhead. 4 operatories with room for 5th. Over 1,000 square feet. FFS/PPO. Digital modern office with streamlined systems. No marketing. Attractive commercial building/home/ office. No rent. All endo, oral/perio surgery, most ortho and implants referred. Fantastic opportunity for both new graduates and established dentists. Transition support will be provided. Inquire by email for more info: mail005@aol.com.

BRONX: Very well set-up and maintained full-time dental office for sale in Co-op City. Three operatories, lab, sterilization room, storage room. Equipment 5 years old and in excellent condition. Please call to discuss: (347) 831-3742.

BROOKLYN: Grand Army Plaza; prime location. 2-chair dental office for sale. No patients of record. Near subway lines 2, 3, B, Q. Rent under $2K, with remaining 4-year lease available for renewal. First floor with other medical offices and 24-hour doorman. Contact: ilo_36@yahoo. com; or call (929) 283-1110.

SOUTHERN TIER: General dental practice for sale, located in picturesque Southern Tier region. Well-established general dental practice boasting over 30 years of exceptional patient care and community service. 100% FFS. Excellent investment opportunity featuring 7 operatories (one plumbed but unequipped), allowing for immediate expansion and customization. Strong patient base of 3,350 active individuals, with 20-25 new patients monthly. Four-day workweek presenting significant growth potential by extending hours or services. Strategically positioned near major cities like Rochester, Syracuse and Scranton, benefiting from low competition and proximity to vibrant community known for cultural richness and outdoor activities. Recent remodeling enhances real estate value making attractive purchase. Collections $1.6M and EBITDA nearly

$300K. Prosperous venture for those aiming to continue legacy of success. For further details contact Professional Transition Strategies by emailing Bailey Jones: bailey@ professionaltransition.com; or calling (719) 694-8320, referencing #NY21424.

JEFFERSON COUNTY: Great opportunity. Longestablished, profitable practice is must-see. Located minutes from downtown Watertown. Well-equipped 4-operatory practice sits on busy road, with great curbside appeal. Large private parking lot. Practice fully digital with pano X-ray and utilizes Eaglesoft. Revenue $730K with one FT Hygienist. Doctor only works 3 days/week (20 hours max). Seller refers out all endo, ortho and oral surgery. Practice positioned for growth. Primarily FFS, with 2,000 active patients. 2-story building also for sale with vacant apartments upstairs. Contact Dental Practice Transitions Consultant Michael Damon at (315) 430-9224; or email: mike.damon@henryschein.com. #NY3385.

ONTARIO COUNTY: Long-established, highly productive practice with 2022 revenue of $1.4M. Nestled in backdrop of beautiful Finger Lakes wine-making country. Fully computerized, fully digital office with 7 well-equipped treatment rooms. Utilizes Dentrix Ascend PMS; Planmeca CBCT and digital impression systems added in recent years. 3,500 active patients and combination of insurance and FFS. Strong hygiene program. Well-trained team available for transition. Contact Dental Practice Transitions Consultant Michael Damon at (315) 430-9224; or email: mike.damon@henryschein.com. #NY3395.

ONEIDA COUNTY: Bright, immaculate, all-digital, 100% FFS practice with great curb appeal. Highly desirable location and convenient access to highways. $900K+ revenue on 4-day workweek. Seller in practice for 30 years and committed to aiding in very successful transition. Four wellequipped operatories and Dentrix, all in efficiently designed 1,100-square-foot space. Thriving general practice averages 30+ new patients per month. Excellent turnkey opportunity. Contact Transitions Sale Consultant Mike Damon at (315) 430-9224 or email: mike.damon@henryschein.com. #NY3513.

INDEX TO ADVERTISERS

SENECA COUNTY: Charming practice in heart of Finger Lakes region. 45-minute drive to both Rochester and Syracuse city centers. Digital practice offering 3 equipped ops with 2022 revenue $653K on 3 clinical days/week. Softdent, 2D pano and diode laser. 1,700-square-foot practice offers comprehensive dental care in welcoming environment. Full-time Hygienist and full administrative staff, all with excellent systems and training in place. 50% FFS. Refers out specialties. Real estate also available. Schedule to see this wonderful opportunity today. Contact Transition Sales Consultant Michael Damon at (315) 430-9224; or email: mike.damon@henryschein.com. #NY3572.

WESTCHESTER: Holistic general dental practice for sale. 4 ops in spacious 1,800-square-foot suite in medical building. FFS office on pace to gross over $1.7M in 2023. Cone beam CT, Dentrix software, Trios scanner, as well as digital X-rays, computers, TVs in every operatory. Open only 4 days/week. Amazing opportunity to purchase profitable practice with huge growth potential in wonderful community. For details contact Transitions Sales Consultant Chris Regnier at (631) 766-4501; or email: chris.regnier@henryschein.com. #NY3641.

WESTERN NEW YORK: Fantastic opportunity to own well-established, thriving practice in beautiful area. Wellestablished practice growing and has loyal patient base made up of 86% insurance and 14% FFS. Fully digital Pan, sensors, intraoral cameras and paperless charting, all integrated with Eaglesoft. Building with off-street parking and additional rental units also for sale or lease. Outstanding staff and established patient base make wonderful opportunity for new owner’s future. Contact Practice Transition Consultant Brian Whalen at (716) 913-2632; or email: brian.whalen@henryschein.com. #NY3665

JEFFERSON COUNTY: Well-established, spacious, 3,500-square-foot practice in beautiful historic building housing 7 equipped ops with 8th op plumbed. Utilizes Dentrix software. FFS/PPO; only in network with 2 insurances. Strong hygiene program with dedicated team ready to stay. All specialties referred out. Revenue $837K and positioned for continued growth. Stunning property also for sale includes 4 fully occupied residential apartment units. Doctor looking to stay for extended period. Contact Practice Transition Consultant Brian Whalen at (716) 913-2632; or email: brian.whalen@henryschein.com. #NY3719

CAPITAL REGION: Turnkey opportunity for well-established dental practice located in growing and desirable area, conveniently located to downtown Albany, Saratoga and Schenectady with revenue of $800K. Attractive, efficient 2,505-square-foot space with 5 fully equipped treatment rooms. Standalone building offers excellent visibility on busy two-lane main road and also available for purchase. Digital office using Dentrix with pano X-ray upgradable to 3D. Four dedicated full-time employees and three part-time willing to stay after transition. Doctor refers out most specialties on 39-hour week. Must-see opportunity for any interested buyer looking to acquire successful primarily FFS dental practice. Contact Transition Sales Consultant Michael Damon: (315) 430-9224; or email: mike. damon@henryschein.com. #NY3942

NORTHERN NEW YORK: High-grossing, high-tech 7-op operatory general dentistry practice located in standalone building. Located near Canadian border. Beautiful practice

offers great visibility and curb appeal. 3,000 square feet; 100% digital practice utilizes Eaglesoft with CBCT and CEREC. Highly trained, experienced team of professionals awaits, including 3 full-time Hygienists expected to transition with practice. Open 4 days/week with 3,300 active patients and healthy new patient flow. Doctor willing to stay to assist with transition. Great turnkey opportunity. Contact Transition Sales Consultant Michael Damon at (315) 430-9224; or email: mike.damon@henryschein.com. #NY3673

ONONDAGA COUNTY: Seize the opportunity to own wellestablished GP practice with rich 40-year history. 5-ops; spacious 2,751-square-foot office located in high-traffic area with ample parking lot. Advanced technologies, including imaging system, i/o camera, digital X-ray, digital pan and Softdent. Well-balanced revenue mix with 60% FFS and 40% PPO. Dedicated team willing to stay with 7 hygiene days and 4-day week. Located 7 miles from Micron Technologies, future site of largest semiconductor plant in NYS. Excellent growth opportunity. Don’t miss out on incredible chance to own your own practice and real estate. Schedule viewing today. Contact Transition Sales Consultant Michael Damon at (315) 430-9224; or email: mike. damon@henryschein.com. #NY3786

OSWEGO: General practice for sale. High-visibility, established practice with convenient access to I-81. Growing community located less than 10 miles from future Micron SemiConductor plant, which will be one of country’s largest. $1.1M revenue on just 28-hour week. 5 well-equipped operatories, with recent addition of new hygiene room. 100% digital practice with newly added pano X-ray and iTero scanner. Refers out all specialties. Mix of FFS/PPO. Don’t miss out on this growing practice with seller committed to very successful transition. Schedule visit today. Contact Transition Sales Consultant Michael Damon at (315) 430-9224; or email: mike.damon@henryschein.com #NY4023.

ST. LAWRENCE COUNTY: Well-established, highly profitable, 100% FFS general practice with just 52% overhead. Turnkey. Annual revenue $750K+ on 4-day week. Standalone building with large parking lot, located right on main road with excellent visibility. Building also available for sale with approximately 3,000 square feet of dedicated dental space. Room to double practice size based on recent clinic vacancy on other half of building. 4 fully equipped treatment rooms in 100% digital practice with Sirona Pan/Ceph imaging. Refers out some endo and oral surgery. Doctor willing to stay for extended period of time. Contact Transition Sales Consultant Michael Damon at (315) 430-9224; or email: mike.damon@ henryschein.com #NY4019.

MONROE COUNTY: Looking for well-established, standalone GP practice with wonderful curb appeal? Here it is. Conveniently located in front of Wegmans Plaza, 1,400-square-foot dental space with commercial renters downstairs available for sale or lease. Located in one of Rochester’s fastest growing suburbs. Digital practice offers four fully equipped treatment rooms and 4-day week with 6 days of hygiene. Primarily PPO with FFS. Motivated seller refers out all specialties. Don’t miss out. Contact Transition Sales Consultant Michael Damon at (315) 430-9224; or email: mike.damon@henryschein.com. #NY4035

SYRACUSE: Long-established, highly visible general practice in desirable neighborhood. $725K+ revenue practice with great curb appeal and ample parking. 2,100-square-

foot leased space just 10 minutes from downtown. Offers 4 well-equipped treatment rooms with ability to add 5th. 100% digital practice and CAD/CAM. Well-trained, experienced team awaits with strong full-time hygiene program. Mix of FFS/PPO. Refers out most specialties. Very motivated seller seeking retirement. To schedule visit or for more information, please contact Mike Damon at (315) 430-9224; or email: mike.damon@henryschein.com. #NY4142

BROOME COUNTY: Amazing opportunity to purchase well-established, highly profitable general practice in desirable city. Housed in attractive standalone building with ample parking; conveniently located less than one mile from shopping, restaurants and entertainment district. Spacious, 4,000 square feet, updated and well-designed for efficient workflow. 8 fully equipped treatment rooms with plumbed nitrous. 100% digital with modern technologies throughout. FFS with 3,425 active patients and steady new patient flow. Experienced, highly engaged team of 9 staff members awaits with robust hygiene program in place. Building available to buy or lease. Contact Transition Sales Consultant Michael Damon at (315) 430-9224; or email: mike.damon@henryschein.com. #NY4097

OSWEGO COUNTY: Perfect opportunity to own wellestablished $1M GP practice residing in remodeled brick building with gorgeous riverfront views. Vibrant office located less than 20 minutes from future site of $100B state-of-the-art Micron Technologies semi-conductor chip plant. Each wellequipped treatment room offers large windows overlooking river, with beautifully maintained public park surrounding office. Well-designed, 2,900-square-foot leased space offers 5 updated ADec treatment rooms with 6th op plumbed. 100% digital practice. Experienced team of professionals expected to stay after transition. 100% FFS with 7 days of hygiene on 30-hour work week. Primed for growth. Contact Transition Sales Consultant Michael Damon at (315) 430-9224; or email: mike.damon@henryschein.com. #NY4185

SYRACUSE AREA: Attractive general practice in desirable, vibrant suburb of Syracuse is primed for growth. Situated on busy main road with ample parking. 15 minutes to downtown Syracuse and one mile to Township 5, where shopping, dining and entertainment options abound. Top-rated school district. 4-op digital practice is a must-see, with affordable, 2,300-square-foot leased space. Room to expand to 2 more ops. Utilizes Eaglesoft PM with Schick sensors and 100% paperless. Refers out most endo, implants, perio and some extractions. Experienced team of professionals await post-transition. PPO-based practice open just 3.5 days per week. Very motivated seller. For more information, please contact Mike Damon at (315) 430-9224; or email: Mike. damon@henryschein.com. #NY4235

ROCHESTER AREA: Wonderful opportunity to own wellestablished, profitable practice in desirable, growing part of Monroe County. Immaculate, thriving general practice situated in professional office park, with ample parking and conveniently located to major highways. Spacious 5,800-square-foot leased space updated and well-designed for efficient workflow. Features 12 fully equipped treatment rooms. 100% digital, paperless practice with modern technologies throughout, including CBCT. FFS with 2,900+ active patients and steady new patient flow. Experienced, highly engaged team awaits with robust hygiene program in place. Don’t let this opportunity slip away. For more information, please contact Mike Damon at (315) 430-9224; or email: Mike.damon@henryschein.com. #NY4234

ONTARIO COUNTY: Long-established, efficiently designed 1,800-square-foot leased space with 4 fully equipped treatment rooms and plumbed room for additional 5th room. Located in scenic community described as gateway to beautiful Finger Lakes Region and just 25 minutes from downtown Rochester. Insurance-based practice. Utilizes Eaglesoft PM software. Refers out all specialties. Averages 15-20 new patients per month with zero marketing. Strong hygiene program, with practice positioned for growth. For more information, please contact Practice Transition Consultant Mike Damon at (315) 430-9224; or email: mike.damon@henryschein.com. #NY4198

NASSAU COUNTY: Modern general practice built out less than five years ago in a standalone building. 5 operatories, with plumbing in place for 6th, and equipped with state-of-the-art technology, including an iTero scanner, CBCT imaging and digital X-rays. Located on high-visibility main road. Practice experiencing rapid growth, making it excellent opportunity for doctor just starting out or seasoned practitioner looking to expand their portfolio. For more information, please contact Practice Transition Consultant Jim Higgins at (914) 496-4856; or email: jim. higgins@henryschein.com. #NY4134

JEFFERSON COUNTY: Well-established, spacious, 3,500-square-foot general practice in beautiful, historic building. 7 equipped treatment rooms, with 8th op plumbed. Utilizes Dentrix PM software. FFS/PPO and only in-network with 2 insurances. Strong hygiene program, with dedicated team ready to stay after transition. All specialties referred out. $837K revenue and positioned for continued growth. Stunning property also for sale includes 4 fully occupied residential apartment units. Doctor looking to stay for extended period. For more information, please contact Practice Transition Consultant Mike Damon at (315) 430-9224; or email: Mike.damon@henryschein.com. #NY3719

LIVINGSTON COUNTY: Wonderful opportunity to own well-established, thriving GP practice residing in beautiful, historic building with great curb appeal. $1.8M practice located in heart of town center in Western NY. Located less than 1 hour from downtown Rochester. 3,0000-squarefoot clinical space offers 5 updated treatment rooms. Additional 1,500-square-foot space upstairs for apartment rental. Building for sale. 100% digital practice utilizing Dentrix software and other technologies. 60% FFS/40% PPO mix. Must-see. For more information, please contact Mike Damon by email: Mike.damon@henryschein.com; or call (315) 430-9224. #NY4251

ONEIDA COUNTY: Excellent opportunity to purchase bustling $1.2M general practice. Located in high-traffic shopping plaza in attractive suburb of Utica. Great visibility on main boulevard with ample free parking. 4,500-squarefoot space houses 9 fully equipped operatories. Utilizes Dentrix and 100% digital practice with 3D Pan/Ceph. Robust hygiene program in place. Affordable lease. Primarily PPO practice. Schedule showing today. Contact Practice Transition Consultant Mike Damon at (315) 430-9224; or email: mike.damon@henryschein.com. #NY4269

ONEIDA COUNTY: Wonderful opportunity to own profitable, efficiently run practice with beautiful 2-bedroom apartment upstairs. Located on main road with attractive curb appeal. Attractive standalone building is must-see. Immaculate 3,200-square-foot space offers 5 well-appointed treatment rooms. 100% FFS, digital office utilizes Dentrix.

Open 4 days/week. Refers out most specialties. Building for sale. For more information, please contact Practice Transition Consultant Mike Damon by phone: (315) 430-9224; or email: Mike.damon@henryschein.com. #NY4277

WYOMING COUNTY: Turnkey opportunity to purchase well-established, highly profitable general practice. Office generates annual collections of $800K+ on 4-day/week. Located in Western NY in prominent, standalone building with ample parking and situated right on main road with excellent visibility. 2,400-square-foot building with full basement and lot to expand also available for sale. Thriving practice offers 5 fully equipped treatment rooms with 6th unequipped room for future growth. 100% digital practice with CEREC, lasers and 2D Pano. 90% FFS with one in-network provider. Refers out most specialties. Incredible opportunity; schedule visit today. For more information, contact Practice Transition Consultant Mike Damon by phone: (315) 430-9224; or email: mike.damon@ henryschein.com. #NY4273

CHEMUNG COUNTY: Wonderful opportunity to own 100% FFS general practice housed in attractive standalone building. Great visibility on busy main road with ample parking and less than one mile from major interstate. Just 10-minute drive to nearby regional airport. Well-designed 2,500-square-foot space offers 6 fully equipped operatories with modern A-dec equipment in relaxing atmosphere. Digital practice utilizes Eaglsoft PM & CBCT. Well-trained, experienced team of professionals awaits, including 2 full-time hygienists expected to transition with practice. Building available for purchase too. Schedule visit today. For more information, contact Practice Transition Consultant Mike Damon by phone: (315) 430-9224; or email: mike.damon@ henryschein.com. #NY4297

FOR RENT

MIDTOWN MANHATTAN: Newly renovated office for rent. Please call to learn more about this opportunity. Phone: (212) 223-3005.

MIDTOWN MANHATTAN: Newly decorated office with windowed operatory for rent FT/PT. Pelton Crane equipment, massage chair, front desk space available; shared private office, concierge; congenial environment. Best location on 46th Street, between Madison Avenue and 5th Avenue. Please call or email: (212) 371-1999; karenjtj@aol.com.

MANHATTAN: Dental operatories/chairs available for rent in multiple locations on Central Park South in Manhattan and Tribeca. Ready to use, state-of-the-art facility. Flexible lease terms (per hour, per day, etc.). We can provide dental assistants, billing services and insurance assistance, etc., if needed. Great street access with lots of foot traffic. Easy to commute to and from with public transport. Please call/text (917) 605-9496; or email: doc@ centralparkdentalservices.com.

ROCKLAND COUNTY: Suffern. Space available for Specialist. 1 or 2 operatories in professional building with general dentist. Office has X-ray equipment, sterilization, dental chairs, reception area, large parking area, easy access to highways. For more information, please call or email: Phone: (845) 300-2283; or email: Nicoletta51347@gmail.com.

BRONXVILLE: Second-floor dental office in historic building available for rent. Floor-to-ceiling windows with views of Pondfield Road. 1-3operatories available Tuesday, Wednesday, Friday and Saturday. Tenant would need their own dental assistant and access to their own laptop for patient charts and X-rays. Terms negotiable. Please contact to further discuss options: bronxvilledental@gmail.com.

SERVICES

INTRAORAL X-RAY SENSOR REPAIR/SALES:

American Sensor Tech. We repair broken sensors. Save thousands in replacement costs. Specializing in Kodak/Carestream, and major brands. We also buy/sell sensors. American SensorTech (919) 229-0483. Online at: www.repairsensor.com.

OPPORTUNITIES WANTED

CAPITAL DISTRITCT AREA: Experienced NY-licensed dentist available for supervision of hygienists in Capital District to Saratoga areas. Licensed dentist, currently not practicing due to disability, available to assist your practice by supervising hygienists. Free up your schedule and ensure profitable patient flow. Open to discussing flexible employment options that would be mutually beneficial.  Please feel free to contact to explore how we can collaborate.  Call (516) 810-8555; or email: bboddrmatthyde@gmail.com.

OPPORTUNITIES AVAILABLE

CLINICANS/ATTENDINGS: Brooklyn Hospital Center. Community-based hospital (located near Brooklyn Bridge in Brooklyn) with longstanding, approved Oral and Maxillofacial Surgery 4-year training program. Seeking clinicians with New York State license that are Board-eligible or Board-certified by American Board of Oral and Maxillofacial Surgery interested in direct-supervision in education of OMS residents. No direct patient care required. Clinician should be comfortable with providing outpatient general anesthesia /sedation, as well as supervising in operating room on variety of trauma/pathology/reconstructive surgical cases. Position is all day Monday or Friday, with competitive salary. If interested, please reach out to Dr. Harry Dym via email: DrHarryDym@gmail.com.

CAPITAL DISTRICT AREA: Associate sought for modern, friendly well-established dental practice. Pleasant working conditions. Great, helpful staff. Everything digital. We do not participate with dental insurance or Medicaid.  I am here to ensure your success! Please contact to discuss: Dr. Jeffrey Backer, Scotia Glenville Dental Center, at (518) 526-0177.

MANHATTAN: Periodontist needed for large, well-established, fee-for-service practice. One or two days per week. Position available immediately. Recent graduate acceptable. Call or email for details. Email: drjlevy@earthlink.net; or call: (212) 582-5808.

NYSDA Life Members

NYSDA Salutes its Newest Life Members

The New York State Dental Association recognizes its members who are achieving Life Member status in 2025. They have dedicated many years to the profession, and we are grateful for their continued participation in organized dentistry. Each year, NYSDA grants life membership to dentists who as of Dec. 31 of the previous membership year have attained 30 consecutive or 40 nonconsecutive years of membership.

Please join us in congratulating and thanking the NYSDA members listed here for their years of dedication and support. These 124 dentists together have accrued more than 3,802 years of membership.

New York County

Babick, Peter Borrell, Luisa Chass, Sharon

Cherches, Barbara Goldstein, Dalia Jankowski, Peter Jutkowitz, Steven Lanzetta, John Levine, Lawrence Li, Xiang-Long Marin-Rojas, Nancy Muzzi, James Pacis, Carlo Rubin, Esther Sanchez, Sonia Tai, Jung-Kuan Vokshoor, Moe Wang, Bobby

Second District

Eisenberger, Yakov Giumenta, Michelle Landsman, Keith Lish, Bruce Magid, Marina Merlino, Phyllis Pavlakos, Konstantinos Segelnick, Stuart Teplitsky, Paul Witko, Alfred Zhukovsky, Leonard

Third District

Cubano, Vladimir Evangelista, Sandro Froehlich, Kurt Lapinski, Joseph Polsinello, Mark Sementilli, Amy Taranto, Robert Zembroski, Laura

Fourth District

Cotugno, Aaron Davis, Gordon Popielarski, John

Rizzuto, Bart Shah, Rajnikant

Fifth District

DiMento, Vincent

Hobert, Katherine Kothari, Jagdish McGarvey, Michael Scutari, Pasquale

Sixth District

Dore, Dennis Westcott, Mark

Seventh District

Drabik, Stanley Giangreco, Terry Hall, Wendell

Lipschitz, Wayne Malmstrom, Hans Meyer, Marychris Nicholas, Suzanne Olivares, Marianela Ramjattansingh, David Romano, Paul Sansone, Thomas Skalyo, Teresa Skeels, David Stein, Scott Vitagliano, Samantha

Eighth District

Balazs, Thomas Ball, David Boyczuk, Michael Dantonio, John Ecker, J. Bradley Fiorella, Vincent Johnson, James Karam, Brian Kupka-Moore, Susanne Kuracina, Jennifer Lauciello, Frank Margarone, Joseph O’Donnell, Kurt Ortolano, Salvatore Peppy, Anthony Peppy, Samuel Stiegler, Daniel Wieland, James Zimdahl, Walter

Ninth District

Baeuerle, Nina Hanswirth, David Landa, Robert Ordaz, Leonor Schwanderla, James Torres, Vicky Vigliotti, Frank Whalen, Richard

Nassau County

Collura, Connie D’Ambrosio, Joseph Flores, Florence Frucci, Yolanda Leavy, Karen Milord, Fabiola Nastasi, Michael Schweighardt, Erika Verveniotis, Steven Zaffos, Jeffrey Zapantis, Madeleinne

Queens County

Elsharouny, Magdy Every-Degel, Carmen-Louise Halberstam, Susha

Larraga, Grace Parker, Hugh Seaman, Richard Valins, Lisa

Suffolk County

Berger, Al Burns, Holly Dobbs, Debra Eannaccone, Matthew Eliades, Maria Helfner, Bonnie Logan, Keri

Montazem, Alex Narain, Kanak Raphaelson, Todd Reale, Michael Wilkens, Nancy

Bronx County

Badner, Victor Mark, Leonard Taller, Samuel

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