June/July 2020 NYSDJ

Managing Patients Undergoing Radiation Therapy the new york state dental journal

Volume86 Number 4

June/July 2020

Inside:

Failure of Business Interruption Insurance

PRESIDENT Craig Ratner & Amy Lessons Learned

2019-2020

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the new york state dental journal

Volume86 Number 4

June/July 2020 18 From Now On Meeting the challenges of an altered world. A conversation with NYSDA President Craig Ratner, D.M.D.

23 The Dentist’s Role in the Pre-Radiation Assessment and Management of a Patient Undergoing Head and Neck Radiation Therapy Shyam A. Shah, D.M.D.; Vincent B. Ziccardi, D.D.S., M.D. Dentists may be called upon to evaluate patients about to or undergoing radiation therapy for head and neck cancer. An understanding of patient’s diagnosis and planned therapy is essential to developing an effective treatment plan.

28 Dental Management of Adolescents and Young Adults Living with HIV/AIDS Cover: For 2020-21 President Craig Ratner, leading the Association during a pandemic presents a unique opportunity to move forward with renewed purpose.

2 Editorial

Dentistry in the Age

of a Pandemic 5 Attorney on Law

Interruption Insurance Elusive 11 Perspectives

What the Virus has Wrought 15 Association Activities 40 Component News

Danny A. Kalash, D.M.D., M.P.H.; Kavita P. Ahluwalia, D.D.S., M.P.H.; Burton L. Edelstein, D.D.S., M.P.H. Because HIV/AIDS increases the risk for various oral conditions, it is imperative that dentists become familiar with its presentation and clinical management, particularly among adolescents and young adults, a population for which it remains a significant health problem.

32 What Happened to the Bismuth Line?

Qing C. Zeng. D.D.S.; Louis Mandel D.D.S. Common to patients ingesting bismuth—historically used to treat syphilis—is a dark blue/black line on the marginal gingiva and lateral ventral tongue surface.

An explanation for the deposition is provided.

35 Effect of Irrigants on the Dislodgement Resistance of Two Root Repair Materials in Furcation Perforation Ruchi Agrawal, M.D.S.; Tina P. Purayil, M.D.S.; Kishore Ginjupalli, M.Sc., Ph.D.; Nidambur V. Ballal, M.D.S., Ph.D. Study undertaken to evaluate the effect of sodium hypochlorite and chlorhexidene irrigants on dislodgement resistance of EndoSequence Root Repair Material Fast Set Putty and Endocem MTA in furcation perforation.

45 Books 46 Read, Learn, Earn 48 Classifieds 51 Index to Advertisers 52 Addendum

EDPAC Supporters

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

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Use your smartphone to scan this QR Code and access the current online version of The New York State Dental Journal.

Humbled and Dismayed, But Strengthened Politics Gone Viral

S

While not fully appreciated or acknowledged—and despite mystifying obstacles— dentists have provided a blueprint for how to safely navigate a pandemic.

ociety’s response to the COVID-19 pandemic has humbled and dismayed, but strengthened the dental profession. Humbled to helplessly observe state-of-the-art science struggle to treat and prevent the disease and to discover the depths of unpreparedness and mismanagement of many of our institutions. Dismayed that, in some states, particularly New York, our political leaders failed to trust the profession of dentistry to make the final call on the timing of our ability to safely return to the delivery of comprehensive services after prolonged restrictions. Strengthened, as a result of our courage initially to place the public good above selfinterest and voluntarily limit the scope of our practices and the evidence that will again confirm dentists’ competence to safely render all aspects of oral healthcare during a pandemic.

For several weeks after our self-imposed and necessary suspension of elective care, practicing dentists stood equipped to safely render comprehensive care. During this time, organized dentistry diligently communicated evidence of its readiness to the office of the governor, his “Reopening New York” task force, the Deputy Majority Leader of the Senate, Speaker of the House, members of the State Senate and Assembly, Department of Health and county officials, on multiple occasions and on vari-

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ous platforms. We repeatedly called on the governor to rescind his emergency order limiting dental practice to emergency and urgent care, but to no avail.

Our profession received no cogent explanation for the unwarranted delay in reopening. In fact, we received no response at all from our state government, which, in effect, locked itself down when dentists and the public most needed decisive action.

As a result, state mandates blindly forced dentistry to the sidelines as one of the few groups of medical professionals precluded from exercising its professional judgment for the full benefit of patients for too long. Ultimately, in order to force the state’s hand, the New York State Dental Association made the unilateral assertion that, despite not being part of a phase, dentists would reopen as a professional service in Phase 2, since continuing the restriction was arbitrary and capricious. Almost immediately thereafter, the governor rescinded his executive order and sanctioned our reopening.

Whether related to the ongoing COVID-19 pandemic, a second wave or future crises, our political leaders could learn from the dental profession’s response over the past few months. Dentists respected and relied upon the knowledge and expertise of the scientific community and the evidence it generated regarding the virus and den-

THE NEW YORK STATE DENTAL JOUR­NAL

tistry’s own past history of success in safely rendering care during prior pandemics to guide our decision-making. We created more stringent infection-control guidelines and embraced protocols from all relevant agencies to prepare dental practices for a safe return to comprehensive care. We courageously refused to succumb to unfounded panic and fear when society needed us to perform at a high level. Our lawmakers and leaders must remember our state educates, trains and licenses dental professionals precisely to make these evidence-based decisions on the safe rendering of oral healthcare. Politicians waste a valuable resource and deny the public an essential service when they override the professional judgment of their own experts trained for this very purpose.

The state political machinery, in ignoring our profession’s position, relied upon two fatally flawed premises. First, that the only way to protect the public health during a pandemic is by shutting down most of the economy, including the healthcare professionals who support the public’s health. Second, that the only way to protect the economy, including dental practices, requires sacrificing public health.1 Overreaction as a response to underpreparation is still overreaction and a mistake that creates new dilemmas without solving the original problem. We, as a country, do not close other areas of society to deal with inherent risks. We do not shut down the roads because people die in traffic accidents. We do not prohibit air travel due to the risk of death in plane crashes. We do not lock down hospitals because patients acquire and die from hospital-related infections.2 Rather, we call on our ingenuity to develop stringent standards and successful preventive protocols. We trust trained professionals with proven track records to act responsibly in the face of the specific challenge. Finally, we enforce accountability to comply with these measures. We always have a choice on how to respond to risk. As we continue to navigate the COVID crisis, or in any future pandemic, our leaders must refocus their mindset away from tactics that force dentists and patients to stay at home to measures that facilitate dentists’ ability to continue to render comprehensive care.

Overbroad and destructive shutdowns create unnecessary risks to the oral and general health of our patients and to the financial viability of our practices that, together, outweigh the risks of the disease.

A “one-size-fits-all” lockdown ignores the evidence that individuals are not equally susceptible to severe COVID symptoms. “In New York as of May 28, 2020, almost 40% of the 23,700 reported deaths occurred in people over 80.”3 Narrowly tailored restrictions that protect vulnerable populations with compromised immune responses would more effectively reduce fatalities, with less collateral damage. This applies even more when dealing with a profession such as dentistry, which has a history of successfully dealing with prior pandemics and has authored national and state comprehensive plans for reopening offices for all dental services. In fact, studies show the actual risk of developing infections in dental practices appears very low.4 Hence, during a pandemic, most dentists can safely treat most patients for most conditions utilizing their professional judgment.

EDITOR Chester J. Gary, D.D.S., J.D.

MANAGING EDITOR Mary Grates Stoll

ADVERTISING MANAGER Jeanne DeGuire

ART DIRECTORS Kathryn Sikule / Ed Stevens

EDITORIAL REVIEW BOARD Frank C. Barnashuk, DDS. Clinical Assistant Professor, Department of Restorative Dentistry, School of Dental Medicine, University at Buffalo, The State University of New York, 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. Alexander J. Corsair, DMD. Periodontic/Implantology Private Practice. Rockville Centre, NY. Joel M. Friedman, DDS. Associate Clinical Professor Dental Medicine. Columbia University College of Dental Medicine, New York, 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, School of Dental Medicine, University at Buffalo, The State University of New York, Buffalo, NY. G. Kirk Gleason, DDS. General Dental Practice, Clifton Park, NY. Kevin Hanley, DDS. Orthodontic Private Practice, Buffalo, NY. Violet Haraszthy, DMD, DDS, MS, PhD, Professor, Chair, Department of Restorative Dentistry, School of Dental Medicine, University at Buffalo, The State University of New York, Buffalo, NY. Stanley M. Kerpel, DDS. Diplomate, American Board of Oral and Maxillofacial Pathology, Associate director, Oral Pathology Laboratory, Inc. Attending, section of Oral Pathology, New York Presbyterian, Queens, NY. Elliott M. Moskowitz, DDS, MSD. Diplomate American Board Orthodontics; Clinical Professor.

Department Orthodontics, NYU College Dentistry; Orthodontic Private Practice, New York, NY. Eugene A. Pantera Jr., DDS. Past Director, Division of Endodontics, Department of Periodontics and Endodontics, School of Dental Medicine, University at Buffalo, The State University of New York, Buffalo, NY. Robert M. Peskin, DDS. Dental Anesthesiology Private Practice. Garden City, NY. Pragtipal Saini, BDS, DDS, MSD. Private practice. Scarborough, ON. Robert E. Schifferle, DDS, MMSc, PhD. Professor Periodontics, Endodontics and Oral Biology.

School of Dental Medicine, University at Buffalo, The State University of New York, Buffalo, NY. Jay Skolnick, DMD. Board-certified pediatric dentist. Attending dentist, Rochester General Hospital. Private practice, Webster, NY.

PRINTER Fort Orange Press, Albany NYSDJ (ISSN 0028-7571) is published five times a year, in January, March, April, June/ July and August/September, by 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. Periodicals postage paid at Albany, NY. Subscription rates $25 per year to the members of the New York State Dental Association; rates for nonmembers: $75 per year or $12 per issue, U.S. and Canada; $135 per year foreign or $22 per issue. Postmaster: Please send change of address to the New York State Dental Association, Suite 602, 20 Corporate Woods Boulevard, Albany, NY 12211. Editorial and advertising offices are at Suite 602, 20 Corporate Woods Boulevard, Albany, NY 12211. Telephone (518) 465-0044. Fax (518) 4653219. E-mail 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.

The New York State Dental Journal JUNE/JULY 2020 3 ●

Regretfully, in this instance, dentists’ autonomy became a casualty of political panic. Panic grounded, not on a legitimate respect of the virus and its unknowns, but on our leaders’ self-interested fear of losing political power and influence as a result of any blame the government could incur if dental offices somehow, against the weight of all prior evidence, became hotspots for transmission of a viral disease. Even worse, panic based on a fear that, as politicians, they would lose their newfound emergency authority, which they opportunistically use to advance their own political and social agendas in areas unrelated to the pandemic. Finally, the most destructive, panic designed to incite fear in the public through government and media outlets to compel compliance with overbroad and unsubstantiated restrictions. This fear further threatens our public health when it misleads patients to postpone routine care which, when left untreated, causes preventable pain, damage and infection that will require more invasive and costly treatment.

Organized dentistry must counter statistics flooding media outlets designed to promote unfounded fear. We need to document the inequities suffered by our patients and our profession as a result of draconian shutdown mandates and report the lack of evidence of virus transmission in dental offices to the public and government officials. The media’s broadcast of the number of COVID cases, hospitalizations and often misleading number of deaths in the daily newspapers and on the nightly news, like running statistics of a football game, fans the flames of fear. It irresponsibly and opportunistically uses the victims to paint a distorted picture of reality, since it publishes the raw numbers without the caveat that they are arbitrarily coded and fraught with inaccuracies. Washington State included five deaths from gunshots in a group of approximately 1,000 deaths.5 In addition, most distribution channels failed to put these occurrences into context with the collateral and unnecessary damage caused by the prolonged lockdown response to the virus. Dentistry should compile the following statistics and communicate them to the public and our government leaders: • Number of coronavirus infections transmitted between dentists, auxiliaries and patients and cross-transmissions among dental patients….. None documented.

• Number of undiagnosed cases of oral cancer and other oral diseases and pain, damage and infections due to delay of what was labeled as “nonessential” treatment… Too numerous to count.

• Number of dentist and auxiliary layoffs, lost jobs, forced retirements, bankruptcies and dental office closures… Too numerous to count.

New York’s response to the pandemic called for, at most, a three- to four-week pause in comprehensive dental care, only to conserve PPE and reserve hospital facilities and services for COVID-19 patients. Our leaders’ misconceptions and fears overcame their duty to act in the best interests of the public. As a society,

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we must ensure our lawmakers and politicians refuse to panic again in the face of a similar future challenge. Dentistry, while dismayed that we put our trust in our leaders, and our leaders failed to reciprocate, stands empowered by its own response.

D.D.S., J.D.

REFERENCES 1.

2.

3.

4.

5.

Roy A. Reopening the US economy even if the pandemic endures. Wall Street Journal April 24, 2020. https://www.wsj.com/articles/reopening-the-u-s-economy-even-if-the-pandemic-endures-11587740529.

Roy A. Round Table of the US Congress Senate Committee on Homeland Security & Government Affairs. COVID-19 How New Information Should Drive Policy. FREOPP.org. May 6, 2020. https://www.hsgac.senate.gov/imo/media/doc/Testimony-Roy-2020-05-06.pdf.

Berenson A. Unreported Truths about COVID-19 and Lockdowns, Part 1: Introduction and Death Counts and Estimates, 2020, citing https://covid19tracker.health.ny.gov/views/ NYS-COVID19-Tracker/NYSDOHCOVID-19Tracker-Fatalities?%3Aenbed=yes&%3Atoolba r=no&%3Atabs=n Laheij A, Kistler J, Belibasakis G, Välimaa H, Soet J. European Oral Microbiology Workshop (EOMW) 2011. Healthcare-associated viral and bacterial infections in dentistry. J Oral Microbiol Published online 2012 Jun 12. doi: 10.3402/jom.v4i0.17659, p.7.

Berenson A. Unreported Truths about COVID-19 and Lockdowns, Part 1: Introduction and Death Counts and Estimates, 2020, citing https://www.clarkcountytoday.com/news/ washington-department-of-health-clarifies-covid-19-death-numbers/

Dentistry after the Pandemic Manuscripts Sought for Special Issue The New York State Dental Journal is planning a special issue devoted to “Dentistry after the Pandemic.” It will be an exploration of the legal, regulatory and public health changes taking place in practice operations and transitions in the wake of the COVID-19 pandemic. The Journal is inviting submissions of original manuscripts for that issue, which is planned for early 2021. The deadline for submitting manuscripts is Oct. 31, 2020.

All submitted manuscripts will be subject to review by members of The Journal Editorial Review Board. Interested authors are advised to read the Author’s Guidelines, found in the Publications section of the NYSDA website, www.nysdental.org.

Please direct manuscripts and questions to Mary Stoll, managing editor, at mstoll@nysdental.org.

ATTORNEY ON LAW

COVID-19 and the Failure of Business Interruption Insurance The problem with the virus is it affected people, not places.

T

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

here’s a commercial for a home warranty product where a homeowner’s insurance company representative carefully explains to the insured that while a volcano erupting or a zombie apocalypse would be covered under its policy, the failure of the insured’s home air-conditioning system was not. The insurance representative today would have added that neither is COVID-19 damage covered (zombies, presumably, do not carry the disease being that they are already dead).

One of the least appetizing aspects of the COVID-19 pandemic has been the realization that business interruption insurance coverage is virtually useless for this type of catastrophic event.

Many questions have come into NYSDA about coverage in general liability insurance policies for business interruptions and the loss of income they engender. Unfortunately, in a classic illustration that no insurance policy should ever be read superficially and taken at face value, it turns out that typical business interruption coverage is for physical harm to a business premises—not to harm caused by a virus like COVID-19. Some policies specifically exclude viruses, but it turns out that such exclusions are not even necessary to block coverage. Even without such language, there has to be an element of physical harm to trigger coverage.

Who knew that all business interruptions were not created equal? Insurers, of course.

To the alleged rescue came clever lawyers crafting arguments that COVID-19 was a form of physical damage because it could cling to surfaces for substantial periods of time and make surfaces dangerous transmitters of the disease.

Surely, the courts would compel insurance coverage in the face of sympathetic plaintiffs and

such an excellent argument from their attorneys. Alas, not so, according to the United States District Court for the Southern District of New York in Social Life Magazine Inc. v. Sentinel Insurance Co., which ruled in favor of the insurer on this issue. However, Judge Valerie E. Caproni granted that the policyholder’s attorney deserved “a gold star for creativity,” but the COVID-19 loss was not covered under the policy issued by the Hartford Financial Services Group, Inc. In the case, the plaintiff’s attorney argued what could be more physically harmful than the death potentially caused by COVID-19. Judge Caproni responded that while this did indeed raise the potential for harm to the plaintiff’s person, it did not result in any harm to the business premises itself that were the subject of the insurance policy coverage. The plaintiff’s attorney has filed an appeal with the United States Court of Appeals for the Second Circuit, possibly hoping for another gold star.

“E” for Effort Next to the alleged rescue was the New York State Legislature with several bills to mandate insurers retroactively cover business interruptions caused

by COVID-19, even if the insurance policy had expressly excluded such coverage. O frabjous day!

Callooh! Callay! Sponsors flocked to these bills to demonstrate their support for the small business owners devastated by COVID-19, knowing, of course, that the bills would never pass and become law. But it was a good show for the public.

Why were these bills doomed? For several reasons, and not just the intense lobbying opposition of the insurance industry. The foremost reason was that the United States Constitution

The New York State Dental Journal JUNE/JULY 2020 5 ●

contains a provision known as the Contracts Clause, which forbids states from passing any laws that impair the obligations of existing contracts. Thus, attempts to rewrite insurance policies to force coverage for something that was never intended to be covered by the policy contract would be unconstitutional as an attempt to alter the obligations of the insurance contract—and the insurance industry had already threatened litigation on that point even if any state did pass such a law. Interestingly, the Contracts Clause applies to states, not to Congress. But in Congress, the insurance industry was lobbying extensively to make sure the Contracts Clause shield was expanded even further.

The second reason these bills were doomed was because in writing these business interruption policies to limit their exposure to physical damage to a premises, the insurance industry had not made actuarial calculations to take into account something like COVID-19 liability. Thus, the entire premium rate setting for such policies, and the allocation of expected costs, were completely divorced from accounting for COVID-19 liability exposure. Insurers argued it was inherently illogical and unfair to suddenly impose such massive liability coverage on them when they had done nothing to plan for that in crafting their policies.

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The New York State Dental Journal

To get around some of these issues, the proposed New York legislative bills established a system where New York State would set up a fund to reimburse insurers for their coverage expenses.

There was some hope that this reimbursement idea would evade the Contracts Clause problem with a compensation substitute (it’s not clear that it would have solved that constitutional dilemma) and would definitely cure the insurers’ unanticipated liability expense issue. Of course, with New York pleading poverty and devastating budget cuts still looming, the idea that the state would take on hundreds of millions of dollars in added debt to reimburse insurers was unrealistic and foredoomed. Were these bills even a serious attempt to solve the COVID-19 crisis for small businesses? They were not meant to deceive the public as just phony public relations ploys, but they were so poorly thought through that the legislative vorpal blade went more snicker than snicker-snack.

Go Ahead and File Many other lawsuits on this entire issue are pending around the country, but New York is not off to an auspicious start for plaintiffs seeking COVID-19 business interruption coverage. However, if you do not file a timely claim, there is no hope of any

NYSDA coverage. Thus, lawyers advise clients to file claims even if it seems hopeless to do so. You cannot benefit from a favorable court ruling, if one ever comes, if you never filed a timely claim.

Some policies contain civil authority clauses that provide coverage for business interruptions resulting from orders of civil government authorities that compel the closure of a business. Ironically, those clauses, too, have always been deemed to relate only to physical damage to premises where the order of a civil government authority acts to close a premises. Nevertheless, some insurers have been more willing to at least entertain the possibility of civil authority coverage for COVID-19. Others have definitely rejected such civil authority claims for the same reasons as in Social Life Magazine Inc. v. Sentinel Insurance Co. That case will surely not bode well for any claims if not reversed on appeal. We can well expect that this case could go all the way to the United States Supreme Court and take years to finally resolve.

Some people have asked, how could insurers be so insensitive and government so unable to address that insensitivity? The unusually catastrophic nature of COVID-19 may supply its own answer. Institutions were not prepared for the scope and damage COVID-19 caused. The sheer magnitude of the calamity in New York State, in particular, may have worked to help insurers. The potential for massive liability exposure for them on something they traditionally never covered inhibited efforts to hold them accountable.

They were able to play their own fairness card against what even Judge Caproni admitted were extremely sympathetic plaintiffs who had suffered real harm from COVID-19. But she held she still had to rule in favor of the insurer denying business interruption coverage.

Beware of insurance policies, for business interruption coverage does not always cover business interruptions, the courts have now told us—beware the insurance Jabberwock, with the jaws that bite, the claws that catch—often doing so to its own insureds. 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.

Directory

OFFICERS

Craig S. Ratner, President

7030 Hylan Blvd., Staten Island, NY 10307

Kevin A. Henner, President-Elect

163 Half Hollow Rd., Ste 1, Deer Park, NY 11729

James E. Galati, Vice President

1758 Route 9, Halfmoon, NY 12065

Frank C. Barnashuk, Secretary-Treasurer

3435 Main St., UB School of Dental Medicine, Buffalo, NY 14214

Steven Gournades, Speaker of the House

351 87th St., Brooklyn, NY 11209

Mark J. Feldman, Executive Director

20 Corporate Woods Blvd., Albany, NY 12211

BOARD OF TRUSTEES Payam Goudarzi, Immediate Past President 310 Reynolds Rd., Johnson City, NY 13790 Paul R. Leary, ADA Trustee

80 Maple Ave., Ste 206, Smithtown, NY 11787

NY – David M. Shipper

101 Central Park West, Ste 1D, New York, NY 10023

2 – Mitchell D. Mindlin

30 West End Ave., Ste 8, Brooklyn, NY 11235

3 – Steven L. Essig

Emblem Health, 1873 Western Ave., Albany, NY 12203

4 – Wayne S. Harrison

8 Medical Arts Ln., Saratoga Springs, NY 12866

5 – Margaret Madonian

600 Oswego St., Ste B., Liverpool, NY 13088

6 – Luis T. Mauleon

501 N. Cayuga St., Ithaca, NY 14850

7 – Jay Skolnick

39 W. Main St., Webster, NY 14580

8 – Kevin J. Hanley

959 Kenmore Ave., Buffalo, NY 14223

9 – Christopher M. Tota

34 Frankford St., Hawthorne, NY 10532

N – Frank J. Palmaccio

875 Old Country Rd., Ste 101, Plainview, NY 11803

Q – Viren L. Jhaveri

14031 Cherry Ave., Apt. 18, Flushing, NY 11355

B – Amarilis Jacobo

824 E. 181st St., Bronx, NY 10460

COUNCIL CHAIRPERSONS Council on Awards

Joel M. Friedman 185 E. 85th St., New York, NY 10028

Dental Benefit Programs

Alyson K. Buchalter 388 Avenue X, Ste 1J, Brooklyn, NY 11223

Dental Education & Licensure

Keith S. Margulis 3424 Kossuth Ave., Ste 2A, Bronx, NY 10467

Dental Health Planning & Hospital Dentistry

Carl H. Tegtmeier 359 E. Main St., Ste 2C, Mount Kisco, NY 10549

Dental Practice

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

Ethics

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

Governmental Affairs

Sharon A. Pollick 4 Quail Ct., Medford, NY 11763

Membership & Communications

Maurice L. Edwards 30 E 60th Street, Ste 1401, New York, NY 10022

Nominations

Payam Goudarzi 310 Reynolds Rd., Johnson City, NY 13790

Peer Review & Quality Assurance

Christian E. Mathiesen 154 West Ave., Saratoga Springs, NY 12866

Professional Liability Insurance

Chester J. Gary 2197 George Urban Blvd., Depew, NY 14043

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

Executive Director

Lance R. Plunkett

General Counsel

Michael J. Herrmann

Assistant Executive Director Finance-Administration

Grazia A. Yaeger

Assistant Executive Director Marketing and Communications

Laura C. Stedman

Assistant Executive Director

Mary Grates Stoll

Managing Editor

Jenna Bell

Director of Meeting Planning

Betsy Bray

Director of Health Affairs

The New York State Dental Journal JUNE/JULY 2020 7 ●

LETTERS Crisis was a Teachable Moment Congratulations, everyone. New York State dental offices are finally open. I, for one, will take the win. I am grateful that part of this ordeal is over. However, all New York State dentists have been put on notice. We need to prepare. We need to engage with one another, with our local components and with NYSDA directly.

My hope is we can start a productive dialogue, learn from our mistakes, and be a force to be reckoned with in the future.

My purpose in writing this letter is not to criticize or single out any individuals for blame but, rather, to stress that we need to learn from our mistakes, or we will be doomed to repeat them. I realize this is a cliché, but it is the truth. I don’t know about you, but when I have a less-than-ideal outcome clinically, I perform a self-review to see if I can improve and avoid mistakes in the future. This is no different.

We cannot afford to be complacent. When an anticipated “second wave” hits New York, what is the plan? Many people have criticized NYSDA for its response to this crisis. A voluntary closure for the public good became a three-month mandate. We were blindsided. But this time, we know it is coming. We need a prepared protocol, a public outreach campaign and a strong lobbying position beforehand. We are professionals and a critical part of healthcare. It is hard not to take the blatant lack of respect displayed to our profession personally. We deserve and should demand more dignity then we received. What is the plan for when the governor wants to impose another mandated restriction? We cannot tolerate further disruption to patient care.

Media coverage of our situation was abysmal. We watched with dismay as auxiliary dental staff spread fear and doubt about our ability to protect them and our patients. We saw individual dentists brag about updates to their offices, unsubstantiated gadgets they had purchased and idiosyncratic procedures they had adopted. My interpretation of these reports was no more than sly, or not-so-sly advertising intended to sow fear and distrust of other dental offices. NYSDA needs to launch a PR campaign that will start to heal the damage caused by the recent depiction of our profession in the media. We need to look back and see why we were not controlling the message. We need to be prepared to advocate for our profession as a block. The small gains we can make as individuals pale in comparison to the cost of eroding public trust in dentistry.

I am concerned also about lack of transparency. My hats are off to NYSDA for getting the job done. I am incredibly grateful to the individuals, almost all of whom are volunteers, who took time away from their own personal and professional struggles to fight for all of us. Let those of us who sat on the sidelines show some gratitude. But that doesn’t mean we shouldn’t ask questions.

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I have seen a lot of talk online about people’s concerns about organized dentistry. Some people have even said they want to terminate their membership. I understand, and at times during this crisis, I felt the same way. I have decided that for me, the solution is to become more involved. There is too much at stake to become jaded and non-contributory. My generation needs to rise up and take its rightful place at the highest places of power within NYSDA. I hope we can be a source of dramatic change—not one that seeks to dismantle and destroy but one that revitalizes and restores. We owe nothing less to ourselves and, more importantly, to the patients we serve.

Joseph P. Denning, D.D.S. Schenectady, NY NYSDA was there for its Members and will be in the Future Thank you for your letter, Dr. Denning. We appreciate all input— positive and negative—from our members as we strive for continuous improvement at NYSDA. I know you wrote out of some frustration, but also out of passion for the Association and the profession of dentistry.

The seven weeks that dental offices were open only for urgent and emergency services were difficult for all of us, but all the while, NYSDA was advocating continuously on your behalf. The work was tenuous and delicate on many occasions, and we chose to keep our communications with state, regional and local leaders somewhat quiet so as not to confuse or threaten any of the progress being made. I take your point that we could have been more transparent throughout the negotiation process. Let me try to partially remedy that by sharing the steps that, ultimately, led to a successful reopening on June 1.

Beginning on March 16, when Gov. Cuomo issued an executive order limiting dentists to only “emergency and urgent” care, NYSDA got right to work advocating on behalf of our members. Our primary focus was always on speeding up the adoption of state guidelines and laying out the quickest possible timeline for dentists to reopen their offices. All the while, we advocated non-stop against phased reopening and on behalf of a broad statewide reopening.

Behind the scenes, we were in constant contact with the governor’s and lieutenant governor’s offices, the Speaker of the House, the Deputy Majority Leader of the Senate, the Health Department, health policy leaders in the administration, legislators across the entire state, and other elected officials at the county and local levels, as well as the governor’s “Reopening New York” advisory task force, on which Dr. Amarilis Jacobo serves. Over the course of our discussions, we learned that these decision makers

held many misconceptions about the dangers of dental offices, which we were able to counter very effectively, while emphasizing our long-standing record of safety.

In the meantime, our Association began daily communications with you, our valued members, about resources available to you—PPP, EIDL and other small business loans, tax ramifications, PPE availability, and the Cares Act, to name a few. We also extended to members who needed it a grace period on their dues.

Although the NYSDA team is working at home and communicating remotely, our employees put in long hours, fielding 3,200 calls, responding to over 5,000 emails, filling our website and social media with relevant news and sending out over 35 messages updating members on any new developments. In addition, we provided “how-tos” and “FAQs” from our own headquarters, as well as from organizations like the ADA and the SBA. We also offered webinars on all aspects of management, including furloughs, layoffs and benefits. In preparation for reopening, we helped develop our “back-to-work” guide, which supports CDC, OSHA and ADA directives, and made a comprehensive reopening toolkit available to all of our members.

While we waited—increasingly impatiently—for the guidelines and timeline to be issued, we achieved a number of big and small victories. We advocated for, and were successful in getting, the DOH to move the status of dentists from “emergency only” to the inclusion of “urgent” care. With ADA guidance, we were given more latitude in using our professional judgment to define urgent care and to make decisions about treating conditions that could advance to emergency level if left untreated. Also, with the assistance of the ADA, we managed to move dental practices up on the FEMA priority list, from seventh to fourth, and, now, to first priority to receive PPE. We helped secure PPE, vetted vendors and educated members on the availability and usage of PPE. In early May, we decided the time was right to garner more public and media attention to our cause, and many positive stories and public communications resulted. We also coordinated a grassroots campaign helping our members deliver letters to over 6,800 legislators. We can quibble as to whether that operation should have started earlier and, perhaps, we were too conservative, but we chose not to overplay our hand on that front.

Now that dental practices have reopened, there are still many steps we will take to help you work successfully. We will continue to translate what governmental actions mean to your practices. We’ll help further increase the supply and reduce the prices of PPE. We will assure that you have the ability and the right equipment to administer point-of-care testing when it

comes online. As new programs, funds, loans, tax write-offs and other forms of relief become available, we will help you navigate through them.

We will continue to answer your questions, find resources for you, and do everything we can to help you and your teams succeed, as we do our best to put the COVID-19 pandemic behind us.

I firmly believe that all of our efforts paid off with the governor’s announcement that dentists across the state—not phases— could reopen on June 1. Given all of the decisions and actions in play, it was understandable that this declaration wouldn’t be made overnight, but we agree that it took far too long. That said, I will argue that without NYSDA’s constant advocacy, the process would have taken even longer.

Going forward, we will heed your advice to be more open and transparent about the efforts we are taking and the progress we are making as we focus on the future.

Mark Feldman, D.M.D. NYSDA Executive Director

Eric J. Ploumis, DMD JD Attorney at Law

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The New York State Dental Journal JUNE/JULY 2020 9 ●

Are we Truly Prepared?

I have practiced dentistry for almost 13 years. I am a member of the ADA, NYSDA and Fifth District Dental Society, but that is all I am—a member. I consider myself a dentist who prefers to sit on the sidelines rather than be directly involved with the organizations. As a woman, my life is busy running a dental practice and taking care of my family. I’m always trying to fit the roles society has given me and those I have chosen; but being involved has never been one of them.

After reading Dr. Joseph Denning’s letter “Crisis was a Teachable Moment” and Dr. Mark Feldman’s response, “NYSDA was There for its Members and will be in the Future,” for the first time in my career I felt moved to be involved. So, I write this letter because I feel there is another view to this discussion that was not represented by either side.

Before voicing my concerns, I agree with Dr. Denning; I wasn’t satisfied either with NYSDA’s response to this unforeseen situation. I would like to thank Dr. Feldman for clarifying how much NYSDA advocated for us. I no longer feel like my membership dues was money down the drain.

I also agree that we should have a plan in place, not just as individuals, but as an organized profession to deal with the “second wave,” which is expected to come in the coming months. I believe, as professionals with doctorate degrees and as specialists in our field, we should be able to understand the risks of dealing with communicable, infectious agents, such as airborne pathogens. We should also understand the necessary changes in protocols and safety precautions as we adjust to this “new normal.”

That being said, I disagree with Dr. Denning’s statement on “unsubstantiated gadgets they had purchased and idiosyncratic procedures they had adopted.” Until COVID-19, our profession was prepared to treat patients with pathogens in blood and saliva, pathogens that were not transmitted by respiratory droplets or airborne in nature. We established protocols to disinfect surfaces, and we cover ourselves with a gown to protect our clothes, a surgical mask to protect the patient from us, gloves to protect both parties and goggles to prevent objects from hurting our eyes. But, in these protocols, what do we have to protect ourselves from these newer respiratory pathogens? The answer is none of the above; we simply didn’t see the patient. Most patients with serious respiratory, infectious illnesses are only contagious when symptomatic, and we prevented exposure by cancelling or rescheduling the patient.

But today, we are presented with COVID-19, a virus that is not only a respiratory pathogen but contagious as well before symptomatology is evident. As a dentist who completed two years of GPR at Bronx-Lebanon Hospital and who is experienced checking for oral pathologies on patients hospitalized with active respiratory/airborne pathogens, I truly believe a dentist in a private office setting can no longer safely see patients following pre-

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COVID-19 procedures. New protocols and equipment are needed to lower the risk of exposure from active COVID-19 patients, including the asymptomatic carrier.

Although there are no exact dental protocols for dealing with COVID-19 in the private sector, I believe we should use those that have been previously established in hospitals for treating patients with respiratory/airborne pathogens and tweaking them to fit our private offices. I believe that organizations, like NYSDA, should create a temporary “COVID-19 dental task force” with the purpose of developing standardized safety guidelines for dentists practicing in New York State instead of leaving it to each business to purchase “unsubstantiated gadgets” and create “idiosyncratic procedures.” By doing this, we won’t leave the safety of all New Yorkers in the hands of those who may be less prepared.

I would like to make clear that I am in no way suggesting that any dentist or organization follow my belief in the need for additional protocol and equipment. But given the urgency to be ready for a possible second wave and knowing there are dentists who might believe we are already prepared concerns me.

I applaud those dentists who have attempted to take the initiative in establishing new protocols and acquiring new equipment in their offices to better protect staff and patients from COVID-19. I have done the same and believe that by doing so, I have, to the best of my abilities, reduced the risk of transmission of respiratory and airborne pathogens. At the end of the day, I have protected the people who matter to me the most—my staff, patients and family.

Mireille Cruz, D.M.D. Camillus, NY The editor replies. Thank you, Dr. Cruz, for your comments. NYSDA welcomes your involvement. Every dentist has the duty to do his or her best to minimize the risk of transmission of pathogens, including the coronavirus, to patients and auxiliaries. All equipment on the market that may reduce this risk should be considered and evaluated for efficacy in the oral healthcare setting. While NYSDA does not have the ability to directly undertake such a task, we can and will try to work with the ADA to clarify the uncertainties associated with various new products and protocols, and continue to focus and standardize safety guidelines.

We recommend that all dentists monitor the ADA, CDC and New York State Department of Health guidelines for the provision of dental care, and NYSDA will continue to provide updates to our members. To date, we are not aware of documented clusters of cases among dental healthcare professionals or their patients, but organized dentistry intends to remain vigilant and willing to explore any and all methods that could increase the safety of the services we deliver.

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Do You have Your “COVID Card?”

Welcome to the new normal. Living and practicing during a pandemic.

Sharon Pollick, D.D.S.

It’s the question we may be asked in the course of everyday exchanges in the future. And we may be requesting the same from our patients once normal commerce has returned. The coronavirus pandemic has brought new challenges around the world, including for healthcare workers everywhere.

Healthcare workers have the innate capacity to adapt and use the knowledge we have gathered through evidence-based medicine. We do this to change the way we analyze and treat a patient’s disease, all for the betterment of the public and their health. During this pandemic, experts1 from around the world and in all specialties are leading the way in educating the rest of us who will be following in their footsteps.2 We are using evidence-based dentistry, because that’s what we have been taught. It is the new buzz phrase, synonymous with “Tell/ Show/Do.”3 Proof and Importance of Immunity Americans may one day be asked to show their immunity certificate4 for access to public activities. By, essentially, declaring “I have COVID-19 immunity,” they will be allowed entrance to shopping malls, theaters, cruise ships and into our offices. Such a measure would, at least for the short term, attenuate transmission.

The most vulnerable population—those with co-morbidities and over age 65—have accounted for 8 out of 10 deaths in the United States.5 Freeop.org reports that, according to the Centers for Disease Control and Prevention, 2.1 million people live in nursing homes or residential care facilities, representing 0.6% of

the U.S. population. And, yet, residents in such facilities account for 42 percent of all deaths from COVID-19, in states that report such statistics.”6 Countries like Sweden, with a large nursing home population, have weathered the high mortality rate associated with this virus in the elderly,7 while avoiding a stay-at-home order and quarantine8 like what was implemented in New York and many other states.

New York State has seen a high mortality rate,9 with at least 5,596 confirmed and presumed COVID-19 nursing home deaths,10 which excludes those who were transferred to hospitals and died.

Conversely, Florida, with a high elderly population, has had a much lower mortality rate, comparatively speaking, and their nursing home population has had 1,230 deaths.11 This difference may be attributed to state policies enacted during the pandemic. On the other hand, Swedish epidemiologists predicted that their approach would propel them over the top of the curve to, ultimately, achieve herd immunity in the near future,12 a status no other country has achieved. As of reports from early June, Sweden continues to maintain its plateau.

It’s important to understand that in the absence of personal and herd immunity, infection can’t be prevented; quarantining just delays it. This is what many have called “flattening the curve,” or postponing infection and deaths into the future, a measure that would potentially prevent a large spike of cases all at once, which would overwhelm our hospitals and result in higher mortality. Sweden avoided a stay-at-home measure and kept schools and busi-

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JUNE/JULY 2020 11

nesses open with social distancing and other measures. Other much smaller countries, like Iceland, with approximately 19 million fewer people than New York State, have been successful in controlling the COVID-19 outbreak. Their approach included identifying and tracing people who were infected and instituting a two-week quarantine. They never imposed a stay-at-home-order, nor did they enforce mask wearing or closing schools or businesses. However, if you visit these countries, evidence of immunity is required.

Detecting Infected Patients Just a couple of months ago, before there was evidence that this virus was a pandemic, there were millions of asymptomatic COVID-19 carriers gathered in public spaces and using public transportation. During this latent period, before symptomatology occurred, the virus had an opportunity to spread.13 It was and is where many other countries focused their enforcement of social distancing. For this reason, some Asian cultures reported they had the ability to control the spread during this latent phase by “monitoring” their citizens and ejecting sickly people from public arenas.

Their governments use heat sensing technology from hand-held or overhead monitors through an infrared thermal detection system (ITDS), which scans citizens as they enter the public transportation system. Sensors screen their bodies to determine if they are febrile.14 These systems have been perfected and are very sensitive

and accurate.15 However, this technology can’t determine the cause for a person’s fever and determine if he or she has COVID-19.

The United States has not instituted such measures, which may be considered an act against civil liberties if done without people’s consent and uses the information obtained to remove people from public. Yet, it is a measure that could prove helpful in reducing the spread now and in future epidemics.

Personal Protective Equipment Data from Singapore suggest that wearing masks has drastically eliminated spread, particularly among healthcare workers.16 Caution should be used in extrapolating this statistic to the general population, because this is a multifactorial problem. Wearing a surgical mask while outside in the open air is much different than wearing a surgical mask in an enclosed car with the windows up or in a face-to-face setting positioned just a couple of feet from an infected person, or in a hospital setting with COVID-19 infected patients in a room. Additionally, comorbidities like lung and heart disease or advanced age put this population in a much higher risk category.

Surgical masks are used primarily in an operating theater to protect the patient from the healthcare provider, whereas respirators, such as the N-95, are worn to protect the provider from the infected patient.17 Currently, the CDC recommends the use of surgical masks in enclosed public domains, where social distancing is not possible.

Dentists Want to Test Their Patients Serological testing of IgM, acute response antibodies, and IgG, latent response antibodies to the coronavirus antigen, determines a person’s immunity status and is critical for outbreak response efforts.18 Dental professionals are in one of the highest risk categories for exposure, and for that reason, some have advocated testing patients at the point-of-care (POC), before treatment is initiated.19 A certificate from Clinical Laboratory Improvement Amendments 1988 (CLIA) is a requirement for any testing. Two certificates are available during this COVID-19 emergency: an Emergency Use Authorization (EUA) waiver from the FDA, a Certificate of Waiver (COW); and a Certificate of Compliance (COC), required for laboratories performing moderate- to highcomplexity testing.20 Once the (COW) application is complete, additional information is required, including proof of practice ownership, dental license number, Tax ID and IRS forms. A (COC) certificate for laboratories performing more complex tests

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requires a 20-hour course and a director pathologist. The three tests currently available are for use in commercial labs only and not in dental offices.

Newer iterations of tests are being evaluated that provide (POC) results, mainly for hospitals or urgent care facilities.

These tests are less sensitive and have higher false negative results, and as of this publication are not FDA-approved.21 Note that two viral strains have been identified with limited knowledge about their activity.22 Data from the FDA23 and China24 show a significant number of false negative tests in patients exhibiting mostly mild symptoms and in some severely ill patients.

The viral testing process, referencing to the steps involved in obtaining the sample and then testing the sample must be performed accurately and skillfully and is the primary cause of false negative results.25 Understanding the Immune Response Immunity occurs after infection in most immunocompetent patients. Once inoculated with the virus, patients either become ill by showing signs of the disease, with most of them recovering,26,27 while other patients become carriers.28,29 Either way, most healthy individuals without comorbidities ward off the infection. And even among those who do become sick, over 99% recover. Evidence reported by the CDC shows improving weekly mortality rates as more data is collected.30 Practice Guidelines Practicing dentists, acting as the team leader, have a duty to follow what are scientifically proven policy and procedures. The New York State Dental Association (NYSDA)31 and the American Dental Association (ADA)32 have been working closely to monitor and ameliorate the situation. The team leader, the dentist, and his or her staff are on the front lines protecting our patients and each other while delivering urgent care as safely as we can.

Screening Patients before Their Appointment The CDC,33 the ADA and NYSDA have made available guidelines for providing urgent care safely during this pandemic, while elective care is put on hold. When patients call the office, the reception staff should be asking the following questions to assess the potential for infection and transmission: l What is your temperature now? l Are you experiencing coughing or symptoms of upper respiratory infection? l Have you traveled to countries (Asia, Far East, etc.) with this viral infection? l Have you been in the presence of a COVID-19 infected or symptomatic individual? l Have you been within close proximity—less than six feet—to an infected person, unmasked for 10 minutes or more?

Determine and document the patient’s medical history with “yes” or “no” answers. If it’s determined that the patient may be infected, he or she is to be triaged to the hospital emergency room. Advise the patient to wear a face covering before heading out into public.

How has this changed the way we approach healthcare and our lives today and possibly in the future? l Social distancing and quarantining are behaviors most Americans have only read about in history books.34 They have been crucial in mitigating the transmission of this virus. Historically, quaranta giorni, or quarantine as the Italian phrase implies, is 40 days, and it was imposed on sailors to protect against imported disease, like the coronavirus. l Just a few weeks ago, New York State was one of 45 states35 under a state-of-emergency, with only essential businesses36 operating, as per Gov. Cuomo’s decree. Initially, the stay-at-home order was to be used to “flatten-the-curve” or when the number of hospitalizations remained steady or declined. l Dentists had their offices shuttered for over two months and were advised to triage dental emergencies accordingly. The governor allowed dental offices to reopen on June 1, following all CDC, OSHA and ADA guidelines. Prior to that date, patients requiring high-risk procedures or intervention to stop bleeding or a traumatic emergency were told to go to the hospital, where adequate infection-control and other measures were more readily available. l All patients are prescreened by phone, eliciting their temperature, how they are feeling and triaging them to your office or the ER based on their answers. l Grocery stores are better stocked now but were limiting customers to no more than two of particular items, to prevent hoarding. In addition, when smaller or popular grocery stores are filled to capacity with patrons, they prohibit more shoppers from entering until they fall below that crucial number of occupants. l There have not been any published cases of infection related to dental care.

Follow all Guidelines 1. Wash your hands often especially after touching surfaces like doorknobs, pens, signage pads, phones and clipboards.

2. Avoid touching your face.

3. Disinfect frequently used items and surfaces.

4. Use a face covering while in public and unable to social distance.

5. Follow all CDC37 and state and local guidelines.

6. If you feel sick, stay home to prevent spreading.

7. Utilize social distancing.

8. Do temperature checks of you and your staff.

9. Develop a policy for workforce contact tracing.

The New York State Dental Journal JUNE/JULY 2020 13 ●

Salient Points about Transmitting Coronavirus l One in every five New York City residents were positive for antibodies.38 l Research shows that certain ultraviolet light, like sunlight, kills the virus on contact.39 l Proper handwashing kills the virus. l Social distancing is a behavior that has slowed the transmission of the disease. l Shielding facial mucus membranes with a mask and eyewear reduces spread.

We are all doing the best we can, complying and enforcing the recommendations set forth by local state and federal agencies. As days and weeks pass, more information is available, which is used

by NYSDA and the ADA to set guidelines that we are to follow.40 Widespread testing is an important tool and needs to continue. Clinical trials with new coronavirus vaccinations are in progress, but they take time. It took until November of 2019 for an Ebola virus vaccination to be approved for widespread use, almost five years from the start of the most recent outbreak. Many experts say that was lightning speed for a vaccine to be studied, created and approved. In the meantime, knowing a patient’s immunity status, along with behavior modifications, are the tools we have to fight this disease and remain safe. p

Queries about this article can be sent to Dr. Pollick at girldoc@aol.com.

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Sharon Pollick is an oral and maxillofacial surgeon who, as liaison from the Suffolk County Dental Society Executive Board, serves as the director of member benefits at AAWD and chair of the NYSDA Council on Governmental Affairs. She is a member the NYSDA Information Technology Committee, chief of dentistry, Long Island Community Hospital, and author of the blogs Girldocdds. blogspot.com and GirldocDDS.com.

Association Activities Former Association Officer Dies JOHN P. ASARO, D.D.S., M.A., secretary-treasurer of the Dental Society of the State of New York (now, NYSDA) from 2003 to 2007, died May 24 at the Silverado Excondido Memory Care Community in California, where he had lived since 2015. The immediate cause of his death was COVID-19.

A periodontist, Dr. Asaro practiced in the Town of Tonawanda, Erie County, for over 30 years. In Dr. John Asaro that time, he was active at all three levels of organized dentistry, as president of the Eighth District Dental Society, member of the Dental Society Board of Governors, chair of the Society Council on Insurance and delegate to the ADA House for 15 years. Dr. Asaro was an active member also of the American Academy of Periodontology, holding a variety of positions, including trustee.

His academic credentials included clinical assistant professor in the postdoctoral periodontics clinical advanced education program and predoctoral periodontics at the University at Buffalo School of Dental Medicine.

In 2014, he was honored by NYSDA as recipient of the Association’s Distinguished Service Award.

Dr. Asaro was notable as well for his extracurricular activities. He was an avid fly fisherman, an official for the U.S. Cycling Federation, a motorcyclist, the owner of six Jack Russell Terriers, which he entered in dog agility trials across the Northeast, and an accomplished chef.

Dr. Asaro was a graduate of Georgetown University and SUNY Buffalo. He is survived by his wife of 51 years, Eileen; daughter, Tricia, and son, Christopher; and two grandchildren. Contributions in his memory can be made to the Alzheimer’s Association (alz.org) or the New York State Dental Foundation (www.nysdentalfoundation.org).

NYSDA Endorses OnPay as Preferred Payroll Provider THE NEW YORK STATE DENTAL ASSOCIATION has named OnPay as its exclusively endorsed payroll solution for NYSDA members.

OnPay provides a full-service payroll solution, along with support, available via chat, email and phone. The platform integrates with accounting, time keeping and attendance software, and was recognized as a top payroll solution by PC Magazine and Entrepreneur.

With the endorsement, NYSDA members can take advantage of preferred pricing and services to help make the switch to the solution smooth and easy.

“OnPay has a great product,” said Joseph Caruso, chairman of NYSDA Support Services. “The company really impressed our Board with its extensive features and ease of use. We think that dentists will appreciate the simplicity of the platform and their excellent customer service.”

NYSDA members can expect to save 50 percent or more— with an average of over $1,500 a year—with OnPay compared to traditional payroll solutions. In addition, OnPay’s fee includes the automated processing of all state and federal tax payments and filings. Users also receive an error-free guarantee.

As a special endorsement launch promotion, a practice that wants to switch to OnPay will have all of its employee data migrated and receive the first month of payroll for free. Users have access to unlimited pay runs for a $36 monthly base charge, plus $4 per active person, with no additional hidden fees.

For more information or to sign up for OnPay, visit onpay. com/ada; or call 1(877) 328-6505.

It’s an Honor ADA President and past NYSDA President Chad P. Gehani added to his long list of honors and accomplishments in May when he was named an honorary member of the Hispanic Dental Association. Dr. Gehani was recognized for his support of HDA over the past years. He was previously honored by the New York Chapter of HDA.

The New York State Dental Journal JUNE/JULY 2020 15 ●

Association Activities Academy Honors New York State Dentist MARC W. HERMAN, D.D.S., general practitioner from Woodbury, Nassau County, was awarded the Kathleen Uebel Leadership Award by The American Academy of Dental Practice (AADP). It is AADP’s highest honor.

Dr. Herman is a past president of AADP. He has filled many other roles within the organization, including on the Membership Committee, Board of Directors, secretary, treasurer, program chair, and as a member of the AADP Applied Strategic Planning Committee.

In June, Dr. Herman was named Attending of the Year by the residents at North Shore University Hospital-Long Island Jewish Medical Center, Hofstra School of Medicine, Department of Dental Medicine. A 40-year volunteer attending, he serves as chief, Division of Practice Administration; chief, Division of Orofacial Pain (TMJ); chief, Division of General Dentistry; chief, Division of Medical Ethics; and chief, Division of Sports Medicine/Dental Sleep Medicine.

Dr. Herman has practiced dentistry in the same location in Woodbury for 40 years. His practice specializes in restorative,

Nassau County dentist Marc Herman, at right, with American Academy Dental Practice Leadership Award. With him are Ariet Dunsworth, AADP President, and Kathleen Uebel, executive director. implant and cosmetic dentistry. He currently teaches “How to Inhibit and Understand and Mitigate the COVID-19 Virus” and “Aerosols in the Dental Office.”

Cyber Insurance Program — NYSDA Members Only For more information about this and other Endorsed Programs call: 800-255-2100

NYSDA has worked with Gallagher Insurance to introduce a comprehensive Cyber Liability policy with an annual premium of just $400/dentist. Just some highlights of this plan: • • • •

Full regulatory coverage including HIPAA Paper and electronic records are covered Retentions start at $2,500 BCS Insurance Company, A.M. Best Rating A- VIII

This policy provides First and Third Party coverage of $1 million and includes Business Income coverage.

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Association Activities

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In Memoriam NEW YORK COUNTY

Joseph Capuana

Gerald Lenkowitz

University at Buffalo ‘79

Temple University ‘61

103 Linwood Avenue

14 Daisy Court

Buffalo, NY 14209

Nanuet, NY 10954

June 27, 2020

April 4, 2020 Joseph Panebianco SECOND DISTRICT

Georgetown University ‘55

Joseph Taitelbaum

4555 E. Mayo Boulevard, Unit 3205

Marquette University ‘71

Phoenix, AZ 85050

169 Washington Avenue

August 1, 2019

Hyde Park

We’ve got you covered.

Fishkill

Robert Sippel

Middletown

Georgetown University ‘55 THIRD DISTRICT

232 Cerromar Way S.

Bruce Sorrin

Venice, FL 34293

New York University ‘68

April 24, 2020

Poughkeepsie

Walden

Staten Island, NY 10314 June 7, 2020

Kent

Ellenville

Carmel

NINTH DISTRICT Donald Scharoff New York University ‘54

FOURTH DISTRICT

2 Candlewood Road

John Ida

Scarsdale, NY 10583

Tufts University ‘85

April 18, 2020

19 Valencia Lane Clifton Park, NY 12065

NASSAU COUNTY

June 14, 2020

Jerome Cohen New York University ‘68

FIFTH DISTRICT

316 Riviera Drive S

Michael Impaglia

Massapequa, NY 11758

University at Buffalo ‘52

September 22, 2019

Newtown

Monroe

Milford

Story Point

Warwick

New City

June 20, 2020

New Milford

Danbury

PO Box 158 Hurley, NY 12443

Patterson

Ringwood

Newton Bloomingdale

Wanaque Pompton Lakes

Ossining

Mount Kisco

Wilton

Stamford

Tarrytown White Plains

Greenwich

Yonkers Rye Wharton Hackensack New Rochelle Clifton Mount Glen Cove Centereach Selden Vernon Morristown Commack Port Washington Mendham Medford Jersey Deer Union City East Jericho Park City Brentwood Madison Orange Mineola Bernardsville Bay Shore Hempstead Union Newark West Plainfield Elizabeth Bayonne Brooklyn Massapequa Babylon Rockaway

Paterson

New York

Somerville

Iselin Middlesex

New Brunswick

Lynbrook

Perth Amboy

Long Beach

Milltown

Union Beach

101 Kimberly Drive Syracuse, NY 13219

QUEENS COUNTY

June 27, 2020

Eli Landau New York University ‘81

Robert Vitkus

141-12 72 Crescent

Georgetown University ‘78

Kew Garden Hills, NY 11367

516 E Genesee Street

April 5, 2020

Fayetteville, NY 13066 June 22, 2020

SUFFOLK COUNTY Lloyd Simonsen

SIXTH DISTRICT

University at Buffalo ’85

Richard Gardner

187 N Ontario Street

University at Buffalo ‘70

Ronkonkoma, NY 11779

1825 Mooringline Drive

May 11, 2020

Vero Beach, FL 32963 April 23, 2020

Paul Sullivan Tufts University ‘77

EIGHTH DISTRICT

14 Renwick Avenue

John Asaro

Huntington, NY 11743

University at Buffalo ‘73

April 28, 2020

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The New York State Dental Journal JUNE/JULY 2020 17 ●

Family Vacation. President Ratner; daughter, Lindsay; son, Ben; wife, Amy, enjoy Alaskan cruise.

From Now On Meeting the Challenges of an Altered World A Conversation with NYSDA President Craig Ratner, D.M.D. NYSDA’s 2020-2021 President, Craig Ratner, D.M.D., feels like he’s straddling two realities. There’s life before COVID-19, and the new, altered state that has followed. What a time to be taking the helm of the Association! To his colleagues who have remarked on the difficulties he is facing, Dr. Ratner responds: “I saw firsthand how our Association came through the fire— stronger in some ways and in other ways, learning what we must change. As we put these lessons into motion, we must not look back over our shoulder. For me, it is all about what we will achieve in the future. And that’s why the theme I’ve established for my tenure as president comes down to three simple words: ‘From Now On.’” Three words. And three proposals for strengthening NYSDA to meet the challenges of a future—which Dr. Ratner describes as having been forever changed. “There will be new challenges and crises ahead,” he forecast in his address to this year’s House of Delegates, “and we will prepare ourselves to meet them head on.”

18 JUNE/JULY 2020 The New York State Dental Journal ●

The “how” comes down to what Dr. Ratner describes as the three proposals, or, platforms, that will define his presidency. They are: Participation—Everyone needs to be actively involved in our Association. As Dr. Ratner sees it, “More participants working together toward any goal ensures that the goal is reached faster, with better results.”

Communication—Making every effort to ensure that members are not only kept informed about matters, but that the information is delivered to them through their preferred medium—whether it be traditional print, online or a new medium yet to be identified.

Advocacy—Building on NYSDA’s record of successes advocating for dentistry in the halls of government and among regulatory agencies. Dr. Ratner wants to go further, making sure that members are kept apprised of ongoing efforts and progress being made.

Dr. Ratner knows he’s on an accelerated timeline. “One year may not seem like a lot of time to make real change,” he wrote in

An avid cook, Dr. Ratner handily handles pepper mill during cooking class in Ravello, Amalfi Coast, Italy.

Always time for golf. Craig on course outside of Denver, CO, during break in ADA House Meeting.

a recent letter to members. “But your officers and trustees have hit the ground running. Together, along with our local leadership and members, we will effect real change in our organization to make it stronger and more successful than ever.”

A graduate of New Jersey Dental School-UMDNJ (now, Rutgers) in Newark, NJ, Dr. Ratner is owner of Exceptional Dentistry on Staten Island. He completed his residency at Staten Island University Hospital. He has been active in organized dentistry for over 25 years, beginning while in dental school as an American Student Dental Association representative to the New Jersey Dental Association House of Delegates. Since then, he has held numerous positions with the Second District Dental Association (president in 2008), NYSDA and the ADA. Among the leadership roles he has filled are: chair, ADA Council on Dental Practice; chair, NYSDA Information Technology Committee; chair, NYSDA Audit Committee; editor, Second District Bulletin; president, Richmond County Dental Society; and chair, Second District Constitution and Bylaws Committee.

He has been a delegate to the ADA for 12 years, is a member of the MLMIC Underwriting Claims Review Committee, chair of the Second District Loan Forgiveness Program, member of the Second District Publications Committee, and he has managed to find time to serve as a member of the Staten Island Economic Development Corp.

What follows is more information about Dr. Ratner, gleaned from a recent conversation.

Craig and Amy on small boat tour of Lake Garda, Italy.

At year 25, Ratners renewed wedding vows in Antiqua.

Getting fortified for Clemson Tigers football home game, Craig presides over one his family’s “famous” tailgate BBQs.

The New York State Dental Journal JUNE/JULY 2020 19 ●

Where did you grow up?

Staten Island, NY. My dad, Steven Ratner, was a dentist on Staten Island for over 50 years. My mom, Faith, was a counselor with the literacy program at the College of Staten Island (CUNY). My brother, Howard, still lives on Staten Island with his family. We lost mom and dad just a few years ago. I think of them everyday. Their guidance, love and support molded me into the person I am today.

Great friends and colleagues stop for photo during NYSDA 2014 Mission of Mercy. From left, James Sconzo, Paul Albicocco, Dr. Ratner, father, Steven Ratner.

Union College alumni get together at NYSDA 2018 House of Delegates meeting in Saratoga.

From left, Mitch Mindlin, Dr. Ratner, Larry Busino, Bill Karp, Fred Wetzel, Joseph Giovannone.

Dr. Ratner’s Exceptional Dentistry team celebrating team member’s birthday with dinner out. From left, Kathy Rao, Dr. Ratner, Debra Yaceda, Chrissy Cyriacks, Deanna Salerno, Roxann Verdi.

20 JUNE/JULY 2020 The New York State Dental Journal ●

What about the rest of your immediate family?

My wife, Amy, also grew up on Staten Island. We met in high school. We were high school sweethearts. We continued dating through college and got married between my second and third years of dental school. I moved to New Jersey to attend dental school in 1988, settled in suburban New Jersey, and have lived here ever since. We have two wonderful children—Ben, 26, and Lindsay, 23. Ben works in New York City as a software engineer for Peleton Interactive. He writes the code for the interactive software used in the Peleton exercise equipment. Lindsay is starting her third year at the University of North Carolina Eshelman School of Pharmacy. She will graduate with a Pharm D and become another Dr. Ratner.

Where did you go to school?

I received a B.S. in Computer Science/Biology from Union College in Schenectady, NY. I received my D.M.D. from the University of Medicine and Dentistry of New Jersey, now Rutgers University Dental School, in 1992. I then completed two years of general practice residency at Staten Island University Hospital—was chief resident during my second year.

I joined my father in practice after my residency. My practice concentrates on complex restorative, implant and rehabilitative dentistry. We also help a lot of patients suffering with TMJ dysfunction and sleep-related breathing disorders. I have invested a lot of time and resources educating myself in the advanced procedures and techniques necessary to provide this type of treatment.

How did you weather the initial weeks of the pandemic? Did you continue to go into the office? How often? Did you treat any patients? Were you and/or your patients apprehensive?

What about staff?

The 10-week “hiatus” was particularly stressful for me. Not only was I worrying about my family’s health and safety, I was concerned about my team and their well-being as well. On top of that, the NYSDA officers, staff and Board all had the added pressure of working to get the other 17,000 dentists in New York State reopened.

Like everyone else, I managed patients remotely as best I could during that time. I did treat some emergency and urgent problems in the office. The number and severity of those problems seemed to increase as the crisis continued.

Now that we are back to work, my team has been great. We are working together to provide care in a safe environment for our patients. We have met several times to come up with solutions to the safety issues. As of this writing, we have just begun to see our patients. So far, everyone has been great, and they are happy to return to our office.

How did you prepare for reopening your office? What should dentists do to get patients back in their chairs? Can the Association help?

This time of transition is very important for our members. Being the 49th of 50 states to have dentistry reopen has been a curse and a blessing. To be sure, we were hurt financially while not allowed to practice. Our patients suffered with increasing problems that could have been mitigated if we had been allowed to practice. However, since we were late to reopen, we have benefitted and learned from the examples of dentists in other states whose practices reopened before us. We were aided by the fact that guidelines from the ADA, CDC and OSHA were in place for a while before we were allowed to open. That gave us time to interpret them and prepare for them. We were also able to spend more time acquiring PPE for the office. This continues to be a struggle. But as time goes on, I am hopeful the supply chains will come back online.

Getting patients to view dentistry as safe is a top priority of the New York State Dental Association now. Our communications team and NYSDA officers are speaking to as many media outlets as we can to get that word out. I have done television, radio and print interviews to drive home that message to our patients. Dentistry is open, and it is safe!

In your report to the House of Delegates, you expressed disappointment that members are too often unaware of what organized dentistry does to help dentists succeed. The COVID-19 crisis did turn a spotlight on the Association and how it responded to the crisis and to its members. What did it do right? What could it do better during the duration of this crisis and should another catastrophe take hold?

You never know how well you are responding to a crisis while you are in the midst of it. Afterwards, it is much easier to see what we could have done better. It is important that we not point fingers but that we learn from this crisis and adapt.

To that end, I have formed a”lessons learned” ad hoc committee. This committee will be chaired by Dr. Goudarzi, our distinguished immediate past president. No one is more familiar with the events that occurred during the crisis than he is. Everything will be examined. Not only do we have to look back, it is critical that we examine how this crisis is going to affect us in the future as well. What are going to be the ramifications to membership, finances, participation, meetings, education programs, etc.? This committee will take

a look at what transpired, analyze the sequelae and generate cogent recommendations for the future of our Association. These recommendations will then come to our Board, councils and House for action in the coming year. We will emerge from this better, stronger and more prepared for any future issue that may arise.

It is expected that the pandemic will take a heavy toll on membership. What can be done to halt the slide? What, specifically, can the Association do to persuade dentists to join and/or renew their membership especially if they have fallen behind financially?

I truly hope that our membership does not decrease as a result of the pandemic. But financial pressures may force dentists to make some difficult future decisions. I get that. However, to my mind, I can think of no time in history that our Association, on all three levels, has proven its worth. No one can deny our Association’s value, as evidenced by our successful advocacy and informational resources.

Dental offices in New York State would not be reopened for practice at this time if not for NYSDA. Our advocacy had a definitive, direct effect, and led to practices reopening sooner. We did everything we could to get legislators and regulators to advocate with the governor on our behalf. We met with countless New York Legislators via Zoom and by phone, all with one goal in mind: get dentistry reopened in New York. In the end, it was this full-court press that won the day.

Since the beginning of the pandemic, the ADA, NYSDA and all our local components worked tirelessly to communicate the latest information. As the pandemic evolved, we issued endless and continuous communications on government assistance loans, staffing, human resources, legal issues, stress relief and well-being resources, reopening guidelines, restaffing suggestions, infection-control information, and so much more. ADA HPI statistics stated that over 80% of members relied on the ADA as their primary source for information about COVID-19 and their practice. Over 60% of nonmembers said the same thing!

Does it all come down to communication? If so, what is effective communication and how do you achieve it?

I cannot say that it all comes down to communication. There are so many foundational parts to a successful organization. But figuring out the communication disconnect will be a priority for me in the coming year. I cannot tell you how frustrating it is to know how many email blasts and notifications were sent, the resources we spent on them, only to hear from members that they are not receiving enough information. I hope there is a way to figure it out. Wasting precious resources cannot happen with the pressures we will have in the coming months. And having a membership that feels it is not getting adequate communication is unacceptable as well. Maybe it is the way we communicate? I

The New York State Dental Journal JUNE/JULY 2020 21 ●

Craig and son, Ben, on tour in Alaska.

Craig and daughter, Lindsay, in front of Clemson bench in Death Valley Memorial Stadium before Clemson home game.

will be exploring various methods of disseminating information.

I will also be polling our members on their preferred method. Is it possible that we just need to ask how they want to receive information to maximize our effectiveness? Perhaps. I think it’s worth the effort to find out.

tional sales manager for Samsung Ultrasound. She kept me sane throughout. I was very busy during the quarantine period with countless Zoom meetings and phone calls dealing with the Association and our response to the pandemic. NYSDA officers, staff and trustees worked tirelessly throughout on behalf of our members.

When not talking on the phone or Zoom, I was in the kitchen. I have a passion for cooking. I was able to take advantage of the “at home” time to sharpen and broaden my cooking skills.

Unfortunately, I believe I may have enjoyed the fruits of my labor too much. The diet and exercise must begin immediately. Hopefully, I can work those extra pounds off on the golf course in the coming months. p

How did you cope with the quarantine? What activities were particularly helpful in providing normalcy and stability to your life?

I, thankfully, have a wonderful wife and family that helped me through the pandemic. My wife, Amy, has had a long and prominent career in ultrasound sales and education. She currently is na-

Thank You! BEHIND EVERY LEADER is a host of people who helped propel him to the top. NYSDA President Craig Ratner is mindful of that fact and anxious to express his gratitude as he begins his term of office. “There are so many people I want to thank, I hesitate to try. I know I will forget someone. But here goes.”

From his home component, the Second District Dental Society, Dr. Ratner lists the society’s past leaders—his dad, Steven Ratner; Arthur Puglisi; Robert Seminara; James Sconzo; Michael Cali. And its current leaders—Bernard Hackett; Mitch Mindlin; Steven Gounardes; and Paul Albicocco.

On the state level, Dr. Ratner is especially grateful for the assistance he has received from Steve Snyder, Paul Leary,

22 JUNE/JULY 2020 The New York State Dental Journal ●

Kevin Henner, Rick Andolina, Andy Vorrasi, Mark Feldman, Mike Breault, Steve Gold, Mark Bauman, Brendan Dowd, Payam Goudarzi, Jim Galati, and all the NYSDA staff—“I’ve grown through NYSDA with them,” he said.

And among his ADA contacts, Dr. Ratner cites Terry O’Toole, Stacy Van Scoyoc, Rudy Liddle, Duc Ho, Andy Brown, Julia Mikell, Pam Porembski and Dave Preble.

“They have all been mentors,” Dr. Ratner said, “but, more importantly, friends. Over the years, it has been the lifelong friendships that I most treasure from my participation in organized dentistry.”

dental cancer disease/infection patient care

The Dentist’s Role in the Pre-Radiation Assessment and Management of a Patient Undergoing Head and Neck Radiation Therapy Shyam A. Shah, D.M.D.; Vincent B. Ziccardi, D.D.S., M.D.

ABSTRACT An understanding of a patient’s head and neck cancer (HNC) diagnosis and planned cancer therapy is required to effectively develop a dental treatment plan. Dentists are often asked to evaluate patients who are about begin or are already undergoing radiation therapy for HNC. With adequate assessment and management of the HNC patient, radiation-related complications, such as osteoradionecrosis and radiation caries, can be minimized. This manuscript is intended to help all dentists become comfortable with current protocols in managing patients undergoing radiation therapy.

A patient about to embark on treatment for head and neck cancer (HNC) has begun a journey that involves a multidisciplinary team of healthcare providers, as well as family and friends. HNC and its treatment are often accompanied by both short-term and long-term changes to a patient’s physical, mental and oral health.1 Squamous cell carcinoma is the most common malignancy of HNC cases, at a rate of 90% of all oral and oropharyngeal malignancies.2 An estimated 51,540 new cases of oral cavity and pharynx cancer and 53,990 new cases of thyroid cancer were projected in the United States in 2018, with incidence rates

more than twice as high in men than in women. The estimated numbers of deaths in 2018 from these two cancers are 10,030 and 2,060, respectively.3 Whether or not these cancers physically manifest themselves within the oral cavity, the dental provider often plays a crucial long-term role in their identification and management.

HNC can be treated by any or a combination of surgical resection, chemotherapy and radiation therapy (RT). For early stage disease, single-modality treatment, with either surgery or RT, is preferred. For more advanced disease, combined therapy is recommended. In such cases, surgical resection is encouraged first, followed by adjuvant RT, which generally allows for a lower dose.4 We are all aware of the oral manifestations and complications of HNC RT. These well-documented complications include xerostomia, mucositis, trismus, caries and, potentially, radiation osteonecrosis, with greater predilection for the mandible.

Dentists play an active role in the management of patients undergoing HNC RT and should be consulted by the oncology team prior to initiation of radiation therapy to prevent and minimize post-radiation complications. Consequently, dentists are often asked by the oncology team to provide some form of “dental clearance” or assessment prior to the patient beginning radiation therapy. An understanding of the HNC diagnosis and planned cancer therapy is required to effectively develop a dental treatment plan.

This manuscript will review the dental management of a patient undergoing RT for HNC, as well as the anticipated dental needs during and after therapy.

The New York State Dental Journal JUNE/JULY 2020 23 ●

Figure 1. CT slices showing osteonecrosis of anterior mandible resulting in pathologic fracture.

Effects of Radiation Therapy in Head and Neck Cancer Radiation therapy, while acting to damage cancer cells, can also have detrimental effects on adjacent healthy cells. Radiation does not destroy cancer cells right away but, rather, repeated doses of radiation damage DNA to the point where these cells are no longer able to replicate. Doses of ionizing radiation are measured in Grays (Gy) and vary widely based on the type of therapy and staging. To put these units into perspective, the average dose of radiation exposed to a human at sea level is about 0.27 mGy per year, primarily attributable to cosmic radiation (1000 mGy = 1 Gy). The average emergency room plain film radiograph exposes a patient to about 0.15 to 15 mGy, and the average CT scan exposes a patient to about 20 to 70 mGy. A single 1 to 2 Gy dose to the entire body results in acute radiation sickness, and 8 Gy is a lethal dose to the human body.5 To eradicate a cancerous growth, a lethal dose must be targeted only to the involved cancer cells. To minimize damage to adjacent healthy tissues, modern radiation therapy is split into smaller doses over time. These fractionated doses are usually 1-2 Gy/fraction, with 1 to 2 fractions/day.6 It is crucial for the dentist managing an HNC patient to reach out to the patient’s radiation oncologist to learn the total dose and field of radiation. The radiation modality should also be clarified. This radiation modality is usually intensity modulated RT (IMRT) or 3D conformal RT (3DCRT). IMRT distributes the radiation dosage gradient to adjust for high-risk ORN areas, thereby decreasing risk.7 In general, patients undergoing IMRT receive less total radiation doses than if they were receiving 3DCRT. Full-mouth extractions were once considered normal pre-radiation treatment for patients about to undergo 3DCRT. With improvements in RT, such as IMRT, patients are fortunately no longer subjected to this treatment and are now able to receive comprehensive dental care, removing any pathology.

With high-radiation doses, irradiated tissues see a decrease in blood supply and healing ability. Invasive dental procedures such as extractions create open wounds, which may form chronic wounds, exposing bone and, eventually, leading to osteoradio-

24 JUNE/JULY 2020 The New York State Dental Journal ●

Figure 2. Clinical appearance of same patient, with exposed bone present at extraction site.

necrosis (ORN).8 Consequently, there is a higher risk of ORN with extractions performed after RT than before RT. Over the years, multiple studies have shown the risk of ORN significantly increasing as the cumulative mandibular dose exceeds 50 Gy.1,8 Compared to the maxilla, the mandible is more susceptible to developing ORN and its complications due to its reduced blood supply (Figures 1, 2). Even with smaller doses, other complications of radiation therapy occur in a majority of patients, including dental caries, xerostomia, mucositis, and trismus due to muscle fibrosis.9 The majority of radiation caries occur on the cervical and incisal edges of teeth due to the increased susceptibility of dentin to demineralization by a combination of decreased salivary flow, decreased pH, changes in the composition of saliva, changes in the microscopic tooth structure, and a shift in the oral flora towards cariogenic microorganisms.10-12 Xerostomia manifests as changes in the oral flora, decreased remineralization of teeth, reduced breakdown and clearance of food and microbes, reduction in antibody and enzyme effects in the oral cavity and reduction in prosthesis retention.13 This situation may make it uncomfortable for patients to tolerate removable prostheses. In turn, other conditions can be exacerbated, such as dental caries, candidiasis, mucosal atrophy and mucositis, compromised speech and altered tastes. RT doses greater than 30 Gy can cause permanent salivary gland dysfunction. Gland destruction is dose-dependent and reversible depending on the dose. It is important for the dental provider to be aware of late-effect xerostomia that can result months later from irreversible damage.4 Oral mucositis (OM) initially manifests as erythema within the first four to five days of therapy.14 As cumulative radiation doses approach 30 Gy, usually by two to three weeks after initiation of therapy, painful ulcers develop, predominantly affecting non-keratinized tissue. This is followed by ulceration and frank erythema by the fifth week. Patients will report difficulty with mastication and swallowing, resulting in odynophagia and dysphagia. After the completion of RT, healing begins and ulcerations are improved within four to six weeks. However, patients may soon develop chronic mucosal pain and sensitivity.4,9,14

Pre-Radiation Dental Assessment A recently diagnosed cancer patient, having seen multiple specialists and having undergone multiple tests, may or may not understand the complexity of the cancer and the anticipated treatment.

The dentist will be just one of the many professionals the patient will see from the time of diagnosis. It is important for the dentist to understand and anticipate the patient’s psychological state from when he or she first presents asking for the dental clearance.

Adequate time should be allotted to the first appointment to establish a positive doctor-patient relationship.

The pre-radiation dental assessment begins with a comprehensive oral evaluation, with increased attention given to the teeth within the field of radiation, which should have been identified by consultation with the radiation oncologist. While the general facets of this exam are similar to those in patients without cancer, consideration should be given to developing an efficient treatment plan that will enable the patient to begin RT in a timely manner.15 A complete set of records should be taken, including a fullmouth series and panoramic radiograph if no recent studies are available. Full-arch impressions should also be taken, especially in anticipation of fabricating fluoride trays. The oral and perioral hard and soft tissues should be examined. A head and neck examination should be completed with evaluation of facial

asymmetries, lesions, enlargements, lymph nodes and temporomandibular areas. Soft tissues should be evaluated, including the tongue, floor of mouth, palate and oropharynx. For all teeth, the following should be evaluated: periodontal condition (including mobility, pocketing, furcation involvement), extent of caries, erosion, abrasion and sharp cusps/restorations.16 For patients with removable prostheses, the fit, retention and stability of the appliances should be evaluated.17 Patients should be advised to avoid wearing ill-fitting or newly fabricated prostheses during RT, which can induce soft-tissue trauma, especially in the presence of xerostomia.18 After the exam, a treatment plan should be developed that incorporates the oncologist’s desired cancer treatment timeline. If there is not enough time before the HNC medical team desires to proceed with radiotherapy, any restorable teeth with carious lesions should be provisionalized with a glass ionomer restoration.19 If there is more time, the prognosis of the teeth should be weighed heavily in the plan and all carious restorations should be restored prior to the initiation of RT. When advanced procedures, such as endodontic or periodontal treatments, are indicated, but there is insufficient time to complete them, the involved teeth should be considered for extraction.

In deciding whether teeth should be extracted, prognoses of “questionable” and “poor” should be correlated with other risk fac-

The New York State Dental Journal JUNE/JULY 2020 25 ●

tors, including the patient’s oral hygiene, age, cancer stage, total anticipated radiation dose, medical history, salivary flow, overall socioeconomic status and diet, as well as the patient’s approach to dental care. If it is likely that a tooth within the field of radiation will be extracted within the next few years, it should be considered for extraction prior to the initiation of radiation therapy. Such teeth often have deep or subgingival caries, large compromised restorations, pocketing greater than 5 mm, severe abrasion, mobility, furcation involvement, severe pulpal or periodontal infection, or a failing endodontic treatment. In general, a tooth with “severe dental decay with questionable restorable treatment success” should be extracted.8 Also, unopposed teeth that may irritate opposing gingiva should also be considered for removal.

The pre-radiation treatment should begin with a dental prophylaxis or, if necessary, nonsurgical periodontal therapy. As there is greater risk of ORN with extractions performed after RT than before RT, extractions should be completed as soon as possible, with as little trauma as possible. Protocols for extractions prior to HNC RT have been developed.20,21 This should then be followed by restoration of carious lesions, endodontic therapy and recontouring of restorations.10 Radiation therapy should begin no sooner than 14 days after extractions, but may be initiated sooner by the oncology team when the benefits outweigh the risks.21,22 The dentist should

26 JUNE/JULY 2020 The New York State Dental Journal ●

reinforce that the patient complete the treatment plan prior to RT, including restorations.23 However, it is important to note that in certain late-stage carcinomas, the oncology team may proceed with radiation therapy without dental clearance. In that case, the dentist should provide recommendations during treatment.

Management during Radiation Therapy While this manuscript focuses on dental assessment and clearance prior to radiation therapy, it is important to reinforce that the patient should be followed throughout the course of radiation therapy with a more frequent follow-up schedule, with routine re-evaluation at least every three months.11,15 During the process of assessing and treating the patient, it is also important to set expectations about what RT-related sequelae the patient may face. The patient should be motivated to improve his or her compliance throughout radiation therapy, with a goal of preventing the incidence of new caries.

Fluoride trays should have been fabricated and provided to the patient for use prior to the initiation of RT. A topical fluoride formulation should be prescribed to the patient for the custom trays for use at least once a day during RT.24,25 At follow-ups, the provider should identify any new caries. Unlike typical caries, post-radiation carious lesions often present with total enamel delamination, followed by decay of the underlying dentin, usually at cervical and incisal/cuspal areas.26

Xerostomia leads to the majority of oral RT complications, with changes in oral flora and colonization, decreased remineralization of teeth, reduced breakdown and clearances of food and microbes, reduction in antibody and enzyme effects in the oral cavity and reduction in prosthesis retention.27 These all may, consequently, lead to dental caries, candidiasis, mucosal atrophy and mucositis, compromised speech and altered tastes, with a generalized decreased quality of life. Salivary flow can also be improved by physical means, such as sugar-free hard candies, and sialogogues, such as pilocarpine. When saliva flow cannot be adequately stimulated, wetting agents and other commercial saliva substitutes, such as Biotene and Oral Balance, are also often used.27 The patient should be monitored for the development of oral mucositis. Maintenance of oral hygiene and reduction of sources of mucosal irritation should be reinforced for prevention of OM. This includes minimizing use of oral prostheses, brushing softly with fluoride toothpaste, and maintaining a soft, non-cariogenic diet. Early signs of OM include erythema, edema, burning sensations and increased sensitivity to hot or spicy food. These can then progress into white desquamative patches, followed by painful ulcers that can be secondarily infected.28 Mouthrinses with topical anesthetics and anti-inflammatory agents have been successful in managing patients who develop OM. Since smoking and alcohol use during and after RT increases the patient’s risk of developing ORN, it is important that the patient avoid these substances.7 For patients who present with a dental emergency during or after RT, priority should be given to avoiding extractions, and other options, such as endodontic therapy, should be attempted first.

If unsure how to proceed with dental emergencies and invasive treatment, the radiation oncologist should be consulted or the patient should be referred to a specialist with advanced experience in managing patients undergoing RT. Conclusion The risk of ORN can be reduced by appropriately managing a patient with HNC from the time of diagnosis. Frequent communication and follow-up with the patient and his or her medical team should enable the dentist to provide optimal care during radiation therapy. With proper assessment and planning, management of a patient undergoing radiation therapy for head and neck cancer need not be a daunting task for the dentist. p

5.

6.

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8.

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Miller V. Natural and medical radiation dosages. 2012 [cited 2019] Available from: http:// large.stanford.edu/courses/2012/ph241/miller2/.

Popovtzer A, Eisbruch A. Radiotherapy for Head and Neck Cancer: Radiation Physics, Radiobiology, and Clinical Principles. In Cummings Otolaryngology. 2015. p. 1109.e4.

Owosho AA, et al. The prevalence and risk factors associated with osteoradionecrosis of the jaw in oral and oropharyngeal cancer patients treated with intensity-modulated radiation therapy (IMRT): The Memorial Sloan Kettering Cancer Center experience. Oral Oncology 2016;64:44-51.

Hentz C, et al. Establishing a targeted plan for prophylactic dental extractions in patients with laryngeal cancer receiving adjuvant radiotherapy. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology 2016;122(1):43-49.

Sroussi HY, et al. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva change, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Cancer Medicine 2017;6(12):2918-2931.

Gupta N, et al. Radiation-induced dental caries, prevention and treatment: a systematic review. National Journal Maxillofacial Surgery 2015;6(2):160-166.

Fattore L, Rosenstein HE, Fine L. Dental rehabilitation of the patient with severe caries after radiation therapy. Special Care in Dentistry: Official Publication American Association of Hospital Dentists, Academy of Dentistry for Handicapped and American Society for Geriatric Dentistry 1986;6(6):258-261.

Andrej MK, et al. Radiation-related damage to dentition. The Lancet. Oncology 2006;7(4):326-335.

Porter SR, Fedele S, Habbab KM. Xerostomia in head and neck malignancy. Oral Oncology 2010;46(6):460-463.

Murdoch-Kinch CA, Zwetchkenbaum S. Dental management of the head & neck cancer patient treated with radiation therapy. Today’s FDA:Official monthly journal of Florida Dental Association 2011:40.

Beech N, et al. Dental management of patients irradiated for head and neck cancer. Australian Dental Journal 2014;59(1):20-28.

Schuurhuis JM, et al. Evidence supporting pre-radiation elimination of oral foci of infection in head and neck cancer patients to prevent oral sequelae. A systematic review. Oral Oncology 2014;51(3):212-220.

Joshi VK. Dental treatment planning and management for the mouth cancer patient. Oral Oncology 2010;46(6):475-479.

Toljanic JA, Saunders VW. Radiation therapy and management of the irradiated patient.

Journal Prosthetic Dentistry 1984;52(6):852-858.

De Moor R, et al. Two-year clinical performance of glass ionomer and resin composite restorations in xerostomic head- and neck-irradiated cancer patients. Clinical Oral Investigations 2011;15(1):31-38.

Sulaiman F, Huryn JM, Zlotolow IM. Dental extractions in the irradiated head and neck patient: a retrospective analysis of Memorial Sloan-Kettering Cancer Center protocols, criteria, and end results. Journal Oral and Maxillofacial Surgery 2003;61(10):1123-1131.

Ben-David MA, et al. Lack of osteoradionecrosis of the mandible after intensity-modulated radiotherapy for head and neck cancer: likely contributions of both dental care and improved dose distributions. International Journal Radiation Oncology, Biology, Physics 2007;68(2):396-402.

Wahl MJ. Osteoradionecrosis prevention myths. International Journal Radiation Oncology, Biology, Physics 2006;64(3):661-669.

Brennan MT, et al. Dental disease before radiotherapy in patients with head and neck cancer. Journal American Dental Association 2017;148(12):868-877.

Kanchan PD, et al. Effectiveness of fluoride varnish application as cariostatic and desensitizing agent in irradiated head and neck cancer patients. International Journal Dentistry 2013:824982-5.

Thariat J, et al. Compliance with fluoride custom trays in irradiated head and neck cancer patients. Supportive Care in Cancer 2012;20(8):1811-1814.

Walker MP, et al. Impact of radiotherapy dose on dentition breakdown in head and neck cancer patients. Practical Radiation Oncology 2011;1(3):142-148.

Epstein JB, et al. A double-blind crossover trial of Oral Balance gel and Biotene ® toothpaste versus placebo in patients with xerostomia following radiation therapy. Oral Oncology 1999;35(2):132-137.

Kostler WJ, et al. Oral mucositis complicating chemotherapy and/or radiotherapy: options for prevention and treatment. CA: A Cancer Journal for Clinicians 2001;51(5): 290-315.

Neither of the authors reported any conflicts of interest. Queries about this article can be sent to Dr. Shah at shah82@sdm.rutgers.edu.

REFERENCES 1.

2.

3.

4.

Kufta K, et al. Pre-radiation dental considerations and management for head and neck cancer patients. Oral Oncology 2018;76:42-51.

Chi AC, Day TA, Neville BW. Oral cavity and oropharyngeal squamous cell carcinoma—an update. CA: A Cancer Journal for Clinicians 2015;65(5):401-421.

Cancer Facts and Figures 2018. 2018, American Cancer Society: Atlanta.

Epstein JB, et al. Oral complications of cancer and cancer therapy. CA: A Cancer Journal for Clinicians 2012;62(6):400-422.

Dr. Shah

Dr. Ziccardi

Shyam A. Shah, D.M.D., is a general dentist and clinical instructor, Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ. Vincent B. Ziccardi, D.D.S., M.D., FACS, is professor and chair, Department of Oral and Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ.

The New York State Dental Journal JUNE/JULY 2020 27 ●

dental disease/infection

Dental Management of Adolescents and Young Adults Living with HIV/AIDS Danny A. Kalash, D.M.D., M.P.H.; Kavita P. Ahluwalia, D.D.S., M.P.H.; Burton L. Edelstein, D.D.S., M.P.H.

ABSTRACT HIV, both diagnosed and undiagnosed, remains a significant health problem among U.S. adolescents and young adults. Since HIV/AIDS increases the risk for various oral conditions, it is imperative that dentists become familiar with its presentation and clinical management within this unique population. This brief paper details the occurrence, elevated risk for oral diseases, and clinical management of HIV/AIDS among adolescents and young adults.

Epidemiology The prevalence of HIV among U.S. children has declined, since vertical transmission at birth is now rare. Yet, HIV among adolescents and young adults remains persistently high: nearly onein-ten people living with HIV (8.6%) are under age 20, and an additional 29% of HIV-infected persons are ages 20 to 24. The Centers for Disease Control (CDC) also reports that among newly diagnosed HIV cases, one-in-five (21%) occurred between the ages of 13 and 24, with most (87%) in males.1 Among adolescents and young adults, disease incidence is greatest among African-American and Latino males aged 19 to 24.2

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Oral Health Adolescents and young adults living with HIV/AIDS present with unique oral health needs. They experience particularly high risk for dental caries, periodontal diseases, and oral soft-tissue pathologies due to compromised immunity and medication side effects that compound poor oral health behaviors. The specific oral effects of long-term, highly active antiretroviral therapy (“HAART”) remain unknown. However, early, as opposed to latelife initiation of antiretroviral therapy, predisposes this population group to greater susceptibility of any long-term systemic and oral side effects.

Dentist Engagement Dentists play a leading role in the healthcare of young patients with and at-risk for HIV by providing services, from identification of possible HIV infection, to prevention, diagnosis and management of related oral diseases. The CDC reports that few at-risk youth have been tested for HIV (only 15% of male students who have sexual contact with other males have been tested), and youth with HIV are the least likely of any age group to obtain timely healthcare.1 As adolescents may utilize dental care more Section of Population Oral Health, College of Dental Medicine, Columbia University, New York, NY

TABLE 1.

HIV Stage and Dental Considerations for Antibiotic Prophylaxis5,6

HIV Stage

Opportunistic Infection

CD4 count (cells/ul)

Antibiotic prophylaxis

Stage 2

Absent

200-499

Optional

Stage 3 (AIDS)

Present

# 200

Indicated

frequently than medical care, and since early manifestations of HIV infection often occur in the mouth, dentists may be the first to suspect immunosuppression and be positioned to subsequently initiate referrals for appropriate medical care.3 According to the National Institute for Dental and Craniofacial Research (NIDCR), “Some of the most common oral problems for people with HIV/AIDS are: chronic dry mouth, gingivitis, bone loss around the teeth (periodontitis), canker sores, oral warts, fever blisters, oral candidiasis (thrush), hairy leukoplakia (which causes a rough, white patch on the tongue) and dental caries.”4 Patients with HIV/AIDS can be safely and effectively treated by dentists using universal precautions. However, management of the HIV+ patient requires special consideration of its unique oral and soft-tissue disease sequela among this patient population.

Dosage (Single dose 30 to 60 minutes prior to appointment) Children Adults

Agent

Amoxicillin Clindamycin Ampicillin Cefazolin

50 mg/kg 20 mg/kg 50 mg/kg (IM or IV) 50 mg/kg (IM or IV)

2g 600 mg 2g (IM or IV) 1g (IM or IV)

Dental Management of Adolescents and Young Adults Living with HIV Antibiotic Therapy Well-managed HIV alone does not require antibiotic prophylaxis prior to dental care. However, advanced HIV status, reflected in CD4 counts under 500 (obtained from a complete blood count [CBC] test) may result in sustained immune suppression, necessitating antibiotic prophylaxis prior to dental treatment. Table 1 lists HIV stage and related dental considerations for antibiotic prophylaxis, according to the Dental Alliance for AIDS/HIV Care (DAAC) and the American Academy of Pediatric Dentistry (AAPD).6,7 Salivary Function and Hard-Tissue Management HIV may result in increased risk for dental caries due to decreased salivary function, side effects of HIV drug therapy and disease-

TABLE 2.

Salivary Function and Dental Considerations of HIV Adolescents and Young Adults7 Condition

Salivary function Impaired salivary function may result from a direct effect of HIV on salivary gland tissue, or as a side effect of HIV drug therapy.

In addition to difficulty with mastication and swallowing, declines in salivary function may result in increased risk for dental caries.

Oral Presentation/ Signs and Symptoms Symptoms: mouth dryness, thick ropy saliva, difficulty eating and/or swallowing; patients may complain of distortion or loss of taste, loss of smell, and loss of appetite.

Management Sugar-free candy/chewing gum; lubricating agents/saliva substitutes; topical fluorides; hydration with water.

Systemic therapies: Total daily dose should not exceed 30 mg.

Signs: pale oral mucosa, dorsal tongue depapillation, secondary candida involvement.

• Salagen (Pilocarine): 5 mg tablet four times/day one hour before meals.

Changes in composition of saliva and microbial flora may also be observed.

• Pilocarpine HCl: 1 mg/ml concentration; 1 to 2 tsp four times/day one hour before meals and at bedtime.

• Document medication sucrose concentration

Sucrose-based medications Antiretroviral drug therapies for young children and adolescents often have sucrose rich formulations, which may increase the risk for dental caries.

Symptoms: dental pain; difficulty eating/drinking hot and cold foods and drink Signs: increased dental caries rate

• Recommend a diet low in sugars and processed carbohydrates.

• Tailor daily care and recall protocols to dental caries experience.

• Recommend topical fluorides and use of water.

• Encourage individual/family support services.

Personal behaviors / attitudes Acquiring HIV in adolescence presents numerous psychosocial burdens for patients and their families. Coupled with medication side effects this may result in poor daily oral and health behaviors.

Apathy towards self-care; poor oral health behaviors.

• Encourage a daily oral care regimen that is tailored to patient’s medical and psychosocial condition.

• Establish a formal relationship with all members of the patient’s medical/support team to ensure care management is optimal.

The New York State Dental Journal JUNE/JULY 2020 29 ●

TABLE 3.

Soft-Tissue Dental Considerations of HIV Adolescents and Young Adults8 CONDITION

PRESENTATION

DIAGNOSIS

MANAGAMENT

Oral Candidiasis

Most prevalent oral lesion of HIV/AIDS and is an important indicator of immune deficiency and progression towards AIDS. This condition should resolve with antifungal therapy.

Pseudomembranous

White diffuse lesion that wipes off to reveal erythema.

Erythematous

Flat, red, irregular painful macules; present on the soft palate/oropharynx/ dorsal tongue

Angular Cheilitis

Erythema or fissures of the labial commissures; frequently accompanies intra-oral candidiasis.

Oral Hairy Leukoplakia

Associated with the Epstein-Barr virus (EBV). It is less common in young children.

White, corrugated, irregular lesion of lateral/dorso-lateral tongue. May be unilateral or bilateral.

Definitive diagnosis made by microscopic examination of cytologic smears/biopsy or by resolution to antifungal therapy

Distinct clinical presentation.

Consider biopsy

Clotrimazole Troches, 10mg (slowly dissolve one 10-mg troche in mouth 5 times/day, for 14 days) Nystatin Oral Suspension, 100,000 units/mL (hold 1 teaspoon in mouth for 5 minutes, 4 times/day, for 14 days).

Ketoconazole 20mg/mL (200mg once daily, for 14 days)

Lesions spontaneously resolve and/or recur; specific treatment not needed.

Oral Ulcers

The most common oral ulcers are Herpes Simplex Virus and apthous ulcers. They may develop due to opportunistic disease (CMV infection/histoplasmosis/herpes zoster/ lymphoma).

Primary Herpetic Gingivostomatitis/ Herpes Labialis

Crop of vesicles form an irregular ulcer on the vermillion of the lips or on keratinzed mucosa.

Viral culture, mucosal smear, biopsy.

Acyclovir 200mg Tabs (1-2 tablets 5 times/day for 10 days. Dosage may very upon severity).

Apthous Ulcers

Yellow-white ulcers surrounded by halo of erythema, single or multiple lesions, often painful.

Characteristic clinical appearance, viral culture, mucosal smear, or biopsy.

Fluocinonide Ointment 0.05% Hydrocortisone Acetate paste (2-4 week supply)

Cytomegalovirus

May occur anywhere in the oral cavity; no unique clinical appearance.

Establish by biopsy/histological examination

Refer to physician for further evaluation and treatment.

Kaposi Sarcoma

Most common malignant tumor associated with HIV; Herpes virus implicated in the etiology of Karposi sarcoma.

It is less common in young children.

Multifocal flat purple plaques or raised nodules; present on the palate or maxillary gingiva.

Confirmed by distinct clinical appearance or biopsy.

No consistent therapy; can be treated with systemic chemotherapy or intralesional injections.

Lymphoma

Common malignancy of HIV; most lesions develop in sites other than the lymph nodes. The development of lymphoma is an AIDS-defining event.

Presentation varies from irregular, necrotic, ulcerated masses to non-ulcerated masses; often painful

Salivary Gland Disease

Impaired salivary function may be due to HIV-induced salivary gland disease or a side effect of HIV medications.

Bilateral parotid gland enlargement may occur in children.

Impaired Salivary Function

Frothy saliva; absence of salivary pooling; loss of dorsal tongue papillae, altered gingival architecture; glassy oral mucosa; lobulated/deeply fissured tongue

Patient report of subjective symptoms.

Measurements of salivary flow.

Mucosal lubricants/saliva substitutes/ sugar-free chewing gum/candy; hydration with water; increase nighttime humidity; avoidance of irritating dentifrices/hard foods.

Parotid Swelling

Asymptomatic bilateral swelling of parotid glands, frequently common in young children rather than adolescents.

Clinical examination with distinct intra- or extraoral swelling of both parotid glands.

Resolves and recurs spontaneously

Papillary lesions that may be mucosal erythematous, or hyperkeratotic.

Established by biopsy and histological examination

Surgical excision; however recurrence is common.

Established by biopsy and histological examination

Refer to a physician for further evaluation and treatment.

Human Papilloma Virus

Periodontal Pathology Linear Gingival Erythema

Necrotizing Ulcerative Gingivitis/ (Acute)

Seen in upper and lower anterior dentition; distinct red line several millimeters in width adjacent to the free gingival margin; not associated with plaque.

Ulceration of inter-dental papillae with "punched-out" appearance; spontaneous bleeding, erythematous and painful attached soft gingiva.

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Chlorhexidine 0.12% suspension twice daily for 10 days.

Established by clinical examination, characteristic intraoral presentation, or biopsy.

Metronidazole (250mg tabs) every 8 hours for 7 days.

related decline in daily oral self-care. In addition to restorative therapy, dentists should provide targeted counseling regarding diet, oral health-related behaviors, and homecare. Table 2 lists salivary function and dental considerations, according to the DAAC.7

6.

7.

8.

Soft-Tissue Management Dentists should also be able to recognize, diagnose and manage soft-tissue lesions associated with HIV/AIDS. Table 3 lists the most common HIV-related mucosal conditions among adolescents and young adults, according to the New York State Department of Health AIDS Institute.8 p REFERENCES 1.

2.

3.

4.

5.

HIV/AIDS. Centers for Disease Control and Prevention (CDC), 19 June 2019, http://www. cdc.gov/hiv/group/age/youth/index.html.

Diagnoses of HIV infection in the United States and dependent areas, 2017. HIV Surveillance Report 2018;29.

Bloom B, Jones LI, Freeman G. Summary Health Statistics for U.S. Children: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Statistics.

2013; 10(258).

HIV/AIDS Overview. National Institute of Dental and Craniofacial Research, U.S. Department of Health and Human Services, 19 June 2019, https://www.nidcr.nih.gov/healthinfo/hiv-aids.

Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas—2016. HIV Surveillance Supplemental Report 2018;23(4).

Antibiotic Prophylaxis for Dental Patients at Risk for Infection. American Academy of Pediatric Dentistry (AAPD). Web. 19 July 2020. https://www.aapd.org/media/Policies_Guidelines/BP_Prophylaxis.pdf Abel S, Croser D, Fischman S, Glick M, Phelan J. Principles of Oral Health Management for the HIV/AIDS Patient. Dental Alliance for AIDS/HIV Care, 2000. Web. 19 July 2019. https://aidsetc.org/sites/default/files/resources_files/Princ_Oral_Health_HIV.pdf Oral Health Care for People With HIV Infection. New York State Department of Health AIDS Institute. 2001. Web. 19 July 2019. https://aidsetc.org/sites/default/files/resources_ files/oral_guidelines.pdf

Dr. Kalash

Dr. Ahluwalia

Dr. Edelstein

Danny A. Kalash, D.M.D., M.P.H., is a dental public health resident, Columbia University College of Dental Medicine, New York, NY. Kavita P. Ahluwalia, D.D.S., M.P.H., is associate professor of dental medicine, Columbia University College of Dental Medicine, New York, NY. Burton L. Edelstein, D.D.S., M.P.H., is professor of dental medicine and health policy, Columbia University College of Dental Medicine, New York, NY.

The New York State Dental Journal JUNE/JULY 2020 31 ●

dental history

What Happened to the Bismuth Line?

Qing C. Zeng, D.D.S.; Louis Mandel, D.D.S.

ABSTRACT The historical use of bismuth in the treatment of syphilis is reviewed. Attention is called to a patient’s development of dark blue/black bismuth deposits that involved the marginal gingiva and lateral ventral tongue surface.

A mechanism is described to explain the presence of bismuth deposition in these two oral areas. The explanation for the deposition is based on modern concepts of the pathophysiology of inflammation.

Before penicillin was discovered to be a safe and efficacious treatment for syphilis, many treatment modalities were promulgated, each with its own adverse effects. In the late 19th and early 20th centuries, when syphilis affected a significant portion of the population, mercury was the treatment of choice. Many mercurial preparations were utilized, but it soon became apparent that the drug’s serious side effects outweighed its benefits. Patients often developed kidney failure, neuropathies and mouth ulcers. Mercury poisoning also could occur and lead to death.1,2 Following the discovery of the causative spirochete, Ehrlich’s investigations resulted in the use of arsenics for the treatment of syphilis.3 Ehrlich was awarded the Nobel Prize for the introduction of the therapeutic arsenical Salvarsan. Salvarsan proved to be more effective for the treatment of syphilis than the previ-

32 JUNE/JULY 2020 The New York State Dental Journal ●

ously used mercury formulations. Nevertheless, it, too, caused side effects, and soon reports of liver failure and seizures were received.3 The more successful use of bismuth in the treatment of syphilis was first advocated by Balzer in 1889 and then confirmed and popularized by Salzerac and Levaditi in 1921.4 Almost immediately after the introduction of bismuth for syphilis therapy, it was widely adopted by syphilologists as a substitute for mercury, and for patients who had problems with the arsenicals.4,5 Bismuth proved to be an effective agent for the treatment of congenital and acquired syphilis.6 Unfortunately, bismuth also proved to have side effects with its prolonged use. These included excessive salivation, stomatitis, diarrhea and albuminuria.5 The side effects were usually transient and hardly necessitated discontinuing treatment.7 A major objection of patients focused on the formation of a blue/black line along the gingival margins. The bismuth gingival line was first reported by Balzer in 1889, and then in 1921 by Salzerac and Levaditi.4 Reports indicated that 56% to 70% of patients undergoing bismuth treatment developed this gingival manifestation of bismuth therapy.8-10 The line was also observed when the bismuth was administered for conditions such as chronic discoid lupus erythematosus, lichen planus, scleroderma and granuloma annulare.10 An increased bismuth line incidence is directly correlated with increased dosages of bismuth.11 Of interest is the

fact that the gingival lines were shown to disappear in about one month after bismuth treatment ended.11 Although many investigators have written about the line’s clinical presentation and histopathology, its etiology has not been clearly defined. The discoloration usually appears along the gingival margin of the teeth, particularly the mandibular incisors, and at any time during treatment.6 Silverman9 reported that the lines appear where there is pre-existing inflammation of the gingival tissues. He had observed that the marginal gingival bismuth pigmentation was first seen adjacent to heavy deposits of calculus, ill-fitting crowns and bridges, or around restorations that impinge upon the gingiva. The greater likelihood of a tissue irritating calculus build-up in the lower anterior region was thought to explain the commonly observed bismuth line presentation in this region.10 Poor oral hygiene and gingival inflammation have often been noted to be associated with the line’s presence.4,6,9-12 It is believed that the interaction of bismuth with hydrogen sulfide in the oral cavity forms bismuth sulfide.4,10,11,13 The hydrogen sulfide is generated as a result of the decomposition of food and bacteria,10 and may explain the halitosis often associated with the onset of bismuth lines. Similarly, Burton’s line, a clinical sign of chronic lead poisoning, results from the reaction of sulfur ions in the oral cavity with lead.13 Histopathological examination and microchemical analysis have demonstrated that the bismuth, in the form of bismuth sulfide, is present in the endothelial walls of capillaries and also in the surrounding connective tissue.8,10,12 Through the courtesy of Dr. Edward Zegarelli, an old pictorial record of a patient, who had undergone bismuth treatment for syphilis, was made available. An examination had revealed the characteristic bismuth line along the gingival margins of the dentition (Figure 1). Both the lingual and buccal gingival margins were affected. Calculus and debris along the gingival margins and a marginal gingival inflammation were also noted. In a more surprising presentation of bismuth deposition, the patient also had the characteristic bismuth deposition and discoloration on the right lateral ventral surface of the tongue (Figure 2). It was obvious from the oral examination that this portion of the patient’s tongue was being traumatized by the fractured and unrestored margins of the carious lower right first molar. It is this additional presence of bismuth precipitation in the tongue that allows us to postulate a mechanism for the formation of the bismuth line based on the pathophysiology of inflammation.

Inflammation can be a response to many challenges to the human body. It is designed to combat the effect of any irritant, bacterial or traumatic, and to initiate potentiate tissue repair. As previously reported by investigators of bismuth lines, inflammation of the gingival tissues is closely associated with this sign.4,6,9-12 Our patient had both a gingival inflammation (marginal gingivitis) from a bacterial infection originating from the gingival sulcus, and a traumatically incited inflammation from the irrita-

Figure 1. Bismuth line involves inflamed marginal gingiva of mandibular and maxillary teeth.

Figure 2. Diffuse bismuth deposition along lateral ventral tongue surface. Note tongue’s relationship to lingual margin of cariously destroyed mandibular right first molar.

tion caused by the margins of the carious molar. Whether the inflammation is from bacteria or trauma, the classic inflammatory response is vasodilation, increased vessel permeability and exudation of protein-rich plasma.14 The inflammatory process involves arterioles, capillaries and the opening of new microvascular beds. Edema from the increased capillary permeability is an integral aspect of inflammation. The edema results from the transvascular flux of proteinrich fluid from the intravascular component to the interstitium, and is caused by vasoactives, such as histamine and bradykinin.14 The permeability of capillaries and venules for both water and protein molecules is increased as a result of these factors. The loss of plasma proteins decreases intravascular osmotic pressure.

The combined effects of the increase in vascular permeability, increase in capillary hydrostatic pressure, and fall in plasma osmotic pressure induce a gradient of fluid and protein flow into the inflamed interstitium.14 It is likely that this gradient of fluid and protein flow created by inflammation allows the precipitation of bismuth into the capillary walls and its escape and deposition into the subepithelial layers of the oral tissue. The enhanced vascularity and vessel permeability enabled bismuth to collect in greater concentration in our patient’s areas of inflammation. The increased concentration of bismuth along the gingival margins and along the traumatized tongue area react with the sulfide in the oral environment, and resulted in the gingival bismuth line

The New York State Dental Journal JUNE/JULY 2020 33 ●

and simultaneously discolored the physically inflamed region of the tongue.

Conclusion We briefly reviewed the history of the use of bismuth for the treatment of syphilis. Emphasis was placed on a bismuth side effect, a dark blue/black line involving the marginal gingivae. Bismuth deposition was also noted in the tongue. It was these oral bismuth depositions, from two different causes of inflammation, that offer an explanation for its occurrence that fits into the modern concept of the pathophysiology of the inflammatory process. p

6.

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Gross CJ. The new bismuth therapy of syphilis. Can Med Assoc J 1923;13 (4);265-8.

Lomholt S. Notes on the pharmacology of bismuth, with reference to its employment in the

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therapy of syphilis. Br J Vener Dis 1925;1 (1):50-7.

Milian and Périn. La stomatite bismuthique. Rev Internat de Méd et de Chir 1922; 32:15.

Silverman SS. Bismuth stomatitis during the treatment of syphilis in the Army. Military

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Surgeon 1944;95(6):486-9.

Robinson HM. An evaluation of the bismuth blue line. J Invest Dermatol 1952;18 (4):341-64.

Klauder JV. Bismuth in the treatment of syphilis: report of clinical and experimental studies.

Arch Derm Syphilol 1923:7 (6):721-44.

McCafferty LK. Bismuth in the treatment of syphilis. Arch Derm Syphilol 1923;8 (4): 469-82.

Babu Ms, Murthy KV, Sasidharan S. Burton’s line. Am J Med 2012;125 (10);963-4.

Sherwood ER, Toliver-Kinsky T. Mechanisms of the inflammatory response. Best Pract Res Clin Anaesthesiol 2004;18(3);385-405.

The authors report no commercial associations, current and within the past five years, that might pose a potential, perceived or real conflict of interest.

Queries about this article can be sent to Dr. Mandel at lm7@columbia.edu.

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2.

3.

4.

5.

Dr. Zeng

Marshall J. Penicillin treatment of syphilis. Nature 1945:156:769-72.

Frith J. Syphilis – its early history and treatment until penicillin, and the debate on its origins. J Mil Vet Health 2012;20 (4):49-58.

Williams KJ. The introduction of “chemotherapy” using arsphenamine—the first magic bullet. J R Soc Med 2009;102 (8):343-8.

Levaditi C. The therapeutic action of bismuth in syphilis. Can Med Assoc J 1923;13 (5):17-9.

Lomholt S. Different preparations of bismuth in syphilis therapy: rate of absorption as a guide to their employment. Br Med J 1929;2 (3593):887-91.

Dr. Mandel

Qing C. Zeng, D.D.S., was a fourth-year student at Columbia University College of Dental Medicine and a research assistant in the college’s Salivary Gland Center, New York, NY. He is a resident, oral and maxillofacial surgery, University of Alabama, Birmingham.

Louis Mandel, D.D.S., is director, Salivary Gland Center, associate dean and clinical professor, oral and maxillofacial Surgery, Columbia University College of Dental Medicine, New York, NY.

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34 JUNE/JULY 2020 The New York State Dental Journal ●

3/16/2020 1:34:20 PM

dentalroot disease/infection repairs

Effect of Irrigants on Dislodgement Resistance of Two Root Repair Materials in Furcation Perforations An In Vitro Study Ruchi Agrawal, M.D.S.; Tina P. Purayil, M.D.S.; Kishore Ginjupalli, M.Sc., Ph.D.; Nidambur V. Ballal, M.D.S., Ph.D.

ABSTRACT Aim: To evaluate the effect of 2.5% sodium hypochlo-

Statistical Analysis: The data was analysed using one-

rite (NaOCl) and 2% chlorhexidine (CHX) irrigants

way ANOVA and independent t-test.

on dislodgement resistance of EndoSequence Root Re-

Results: Results showed that ERRMF had higher push-

pair Material Fast Set Putty (ERRMF) and Endocem

out bond strength than Endocem MTA (p<0.05).

MTA in furcation perforations.

However, none of the root canal irrigants had signifi-

Materials and Methods: Sixty mandibular molars were

cant influence on the bond strength of ERRMF and

decoronated, and perforation was carried out by us-

Endocem MTA.

ing a #1.2 bur perpendicular to the furcal floor and

Conclusion: ERRMF as a root perforation material ex-

was further enlarged by #4 Peeso reamer. The speci-

hibited superior push-out bond strength compared to

mens were divided into two groups (n=30) and the

Endocem MTA. Use of NaOCl and CHX did not affect

furcal perforations were restored with ERRMF and

the push-out bond strength of these materials.

Endocem MTA.Then the specimens of each material were further divided into three subgroups (n=10) according to irrigation solution used (2.5% NaOCl, 2.0% CHX and distilled water control group). Later, push-out bond strength was measured using universal testing machine.

Endodontic therapy aims to maintain the integrity of the natural dentition, to achieve proper form, function and esthetics. Root perforation is one of the most common mishaps during endodontic tooth preparation. A perforation is any communication between the root canal space and the periradicular tissues which may be iatrogenic or pathological in nature.1 Perforations that are present in the pulp chamber floors and cervical third of the root have a poor

The New York State Dental Journal JUNE/JULY 2020 35 ●

prognosis compared to those present in the middle or apical third of the root. It has been suggested that furcation perforations be repaired immediately with a suitable material, to reduce contamination with bacteria and infection of periodontal tissues.2 An ideal material for perforation should have adequate sealing ability, dimensional stability, insolubility, biocompatibility and radiopacity.3 It should also not dislodge under mechanical stresses of occlusion or from forces used for condensing permanent restorative materials.4 To date, many materials have been used to repair perforation defects, including amalgam, composite resin, glass ionomer cement, intermediate restorative material, super EBA and mineral

trioxide aggregate (MTA). Leakage, solubility, handling properties— especially longer setting times—biocompatibility and moisture incompatibility are some of the problems encountered with the use of these materials.5 More recently, two fast-setting cements, namely, pozzolanbased MTA (Endocem, Maruchi, Wonju, Korea) and EndoSequence Root Repair Material Fast Set Putty (ERRMF) (Brasseler USA, Savannah, GA) were introduced to overcome the drawbacks of longer clinical setting times. Pozzolan MTA consists of pozzolan particles, which increase the surface area on mixing with liquid, whereas ERRMF is a calcium silicate–based material and consists of calcium silicates, zirconium oxide, tantalum oxide, monobasic calcium phosphate and fillers.

After furcal perforation repair, routine endodontic treatment is performed with various irrigants, like 2% chlorhexidine gluconate (CHX) and sodium hypochlorite (NaOCl).6 However, this can cause unavoidable interaction between irrigants and repair materials.

Guneser et al. have shown that NaOCl and CHX have no significant effect on the dislodgement resistance of Biodentine, Dyract AP, IRM and amalgam.

However, CHX was shown to decrease the microhardness and alter the surface morphology of ProRoot MTA, thereby reducing its push-out bond strength.7 Kogan et al. found that NaOCl gel decreased the setting time of ProRoot MTA, improved its strength and hence push-out bond strength.8 There has been increased acceptance of Endocem TM MTA and ERRMF for endodontic applications. Jang et al.9 demonstrated that irrigation protocol significantly influences the washout resistance of Endocem, whereas A FREE TELEMENTORING PROGRAM Alsubait et al. showed that NaOCl irrigation increased FOR NEW YORK STATE MEDICAL PROVIDERS the push-out bond strength of ERRMF to the tooth.10 The existing literature lacks sufficient evidence to suggest the ABOUT THE DRUG USER HEALTH ECHOTM The Hepatitis C and Drug User Health Center of Excellence, Clinical Education Initiative (CEI) funded by the New effect of irrigants on the performance of these materials York State Department of Health AIDS Institute is excited to announce the Drug User Health ECHO™. This tele-mentoring program is intended for NYS medical providers with the goal to learn strategies to provide care to people who use as root furcation perforation repair materials. Hence, the drugs, including in the primary care setting. purpose of this study was to evaluate and compare the effect of various endodontic irrigants (ie, 2.5% NaOCl, DURING CEI’s DRUG USER HEALTH ECHOTM THE RESULT? SESSIONS 2% CHX, distilled water) on the dislodgement resistance Discuss cases from your practice with Drug User Learn strategies to provide care to people Health experts who use drugs, including in the primary of ERRMF and Endocem MTA in furcation perforations.

Clinical Education Initiative DRUG USER HEALTH ECHO

Discuss new developments relating to your patients Specialists serve as mentors and colleagues A community of providers learn from specialists and each other

care setting

Boost confidence in dealing with a wide variety of clinical situations Forge connections with other providers who care for patients who use drugs

CEI’s DRUG USER HEALTH ECHOTM is held the 4th Wednesday of every month from 12:00pm-1:00pm

FOR MORE INFORMATION Contact Emily Scognamiglio at emily.scognamiglio@mountsinai.org or 212-731-3790

36 JUNE/JULY 2020 The New York State Dental Journal ●

Institute for Advanced Medicine

Materials and Methods Ethical clearance was obtained from Institutional Ethical Committee (IEC 647/2015). Sixty human mandibular molar teeth with divergent roots and completely formed apex were selected. Teeth with carious lesions, development defects, fused roots, fractured or cracked teeth and endodontically treated teeth were excluded.

After surface debridement with the scaler, the samples were stored in 0.2% sodium azide (Sigma-Aldrich, Germany)

until the experiment at 4˚C. Teeth were decoronated using diamond disk (Horico, Germany) at cementoenamel junction, and a perforation was created perpendicular to the furcal floor and parallel to the long axis of the teeth by using round bur (#1.2) (SS White Burs, Inc, USA). Further, the dimension of the perforation was increased to a diameter of 1.3 mm using #4 peeso reamer (Mani, Tochigi-ken, Japan). The height of the perforated area was measured using a periodontal probe (Hu-Friedy Mfg. Co. UK) for all the samples to standardize the height to 2 mm. The samples having less than or more than 2 mm dentin height were excluded. Subsequently, samples were mounted in acrylic molds (DPI-RR Cold Cure, DPI, India) such that clearance between the furcal area and the acrylic mold was 3 mm. Space was left to place Gelatamp (Roeko-Coltene, Germany), which would act as a matrix to pack materials.

Teeth were then randomly divided into two groups based on root repair material used: in Group I, the perforation site was repaired with ERRMF; in Group II, it was restored with Endocem MTA. ERRMF, the premixed paste, was injected into the perforation site completely and any excess material was removed using a moist cotton pellet. Endocem MTA was mixed, as per the manufacturer’s instructions, and was placed incrementally in the perforation site and condensed using a hand plugger (Manipal Acharya, Manipal, India). A wet cotton plug was placed in contact with both of the materials to allow the material to completely set.

The samples in both groups were placed in an incubator at 37°C and 100% relative humidity. After the materials were set, each group was further subdivided into three groups (n=10) based on irrigation solution used over the perforation site: Group A-2.5% NaOCl; Group B-2% CHX; and Group C-distilled water (control group).

Each sample was irrigated using 20 mL of test irrigant to the perforation repair site from a disposable syringe with 27‑gauge Monoject needle (Ultradent Products Inc., USA) for five minutes. Then the perforation site in all samples was finally irrigated with 5mL of distilled water to counteract the prolonged effect of irrigants.

Samples were stored for 24 hours at 37°C and 100% humidity.

The push-out test was performed using a universal testing machine. The specimens were mounted on the lower platform of the machine (Instron 3366, Inston Corp., USA), and a plunger of 1 mm diameter was allowed to push out the root-repair material under compressive force at a crosshead speed of 1mm/min. Maximum force required for the dislodgment was recorded in newtons. The dislodgement resistance was calculated in megapascals using the following formula: Bond strength (MPa) = Force required for dislodgment (N)

Bonded surface area(mm2)

Bonded surface area = Diameter of the perforated area height of perforation



The data was analysed using One-way ANOVA, and the significant differences were compared using post-hoc Tukey’s tests for intra-group comparisons. Inter-group comparisons were made using independent t –test at a confidence interval of 95%. A p value less that 0.05 was considered significant.

Results The mean push-out bond strength values, along with standard deviations for both groups after irrigation, are presented in Table 1.

From the results, it was observed that the differences among the push-out bond strengths after irrigating the repaired root canal with ERRMF were not statistically significant, irrespective of the irrigating material used. This suggests that 2.5% NaOCl and 2.0% CHX did not significantly reduce the push-out bond strength (p>0.05). Similar results were observed with the Endocem MTA group as well (p>0.05).

However, a significant difference in the push-out bond strength between the root canal repair materials was observed (p<0.001). Among the materials, ERRMF showed higher pushout bond strength values than Endocem MTA did.

Discussion The repair process of the root perforations should involve sealing the defect with a biocompatible material. The success of the repair depends on various factors, such as adhesion of the root repair material to the surrounding dentine, adequately sealed coronal restoration and the resistance of the material to dislodgement forces. In addition, the ability of the root repair material to set to a hard and rigid material and resist condensation forces of various restorative materials, such as amalgam, is also an important consideration. It is estimated that a force of approximately 8.9MPa is applied during the condensation of such restorative materials. To withstand these forces, the root repair material should exhibit sufficient elastic modulus without failure.11 A material with low elastic modulus or weaker adhesive bond with dentine could be displaced from the furcal repair site during the subsequent restoration.4 Thus, the dislodgement reTABLE 1

Comparison of Dislodgement Resistance of ERRMF and Endocem MTA after Irrigation with NaOCl, CHX and Distilled Water GROUP I

(ERRMF)

GROUP II

(Endocem MTA)

Mean

SD

Mean

SD

P value

2.5% NaOCl

8.15a

1.92

2b

0.79

<0.001; Sig

2% CHX

8.89a

2.36

3.02b

4.06

<0.001; Sig

Distilled Water

9.91a

1.05

2.64b

1.29

<0.001; Sig

Subgroups with similar alphabet as superscript indicate no significant difference

The New York State Dental Journal JUNE/JULY 2020 37 ●

sistance of the perforation repair materials is an essential parameter to consider in routine clinical practice. The push-out bond test is widely used to measure the displacement resistance, as it is more practical, efficient and reliable for assessing the bond strength.2 This study evaluated the effect of the irrigants 2.5% NaOCl and 2% CHX on two different root repair materials (ERRMF and Endocem MTA). Both of these materials were selected because the use of MTA for endodontic application is on the rise, especially with the advent of fast-setting versions. The results showed that irrigating with 2.5% NaOCl and 2% CHX had no significant effect on the dislodgement resistance of root-repair materials. This indicates that the setting reaction of the selected root-repair materials progressed sufficiently so that the irrigants did not have any effect on these materials. It is also possible that irrigants did not interfere with the setting of the MTA materials.

Yan P et al. showed that CHX and NaOCl irrigation had no negative effect on the bond strength between MTA and dentin.6 Similar findings were reported by Adl et al. with the use of 2% CHX. Endocem MTA used in the present study has similar chemical composition as that of the one used in Adl et al., and the observations of the present study are in agreement with their study.12 Moreover, Jang et al. reported a higher washout resistance when

irrigated with NaOCl compared to the saline and CHX-treated groups for Endocem.9 This could be attributed to the different methodologies used in both studies. In the previous study, the material was placed into an acrylic mold instead of human teeth, which was then immersed in the irrigants for five minutes.

This study also revealed that dislodgement resistance of ERRMF was significantly more than Endocem MTA irrespective of the irrigants used, i.e., 2.5% NaOCl and 2% CHX. This significant difference between the materials can be attributed to the differences in their chemical composition, the setting reaction of the individual material and interaction with the dentine.

ERRMF consists of dicalcium silicate, tricalcium silicate, zirconium oxide, tantalum pentoxide and calcium sulfate.13 It is produced as a premixed product to help the clinician with a homogeneous, predictable material. This bioceramic material is manufactured with nanosphere particles (10–3 mm in its greatest diameter), which allows the material to penetrate into the dentinal tubules forming a micromechanical bond to adjacent dentin.14,15,16 The higher push-out bond strength may also be attributed to its slow hydration process and small size of porosity, which is known to play a crucial role in the association between compressive strength-modulus of elasticity relationship.17,18

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The filler and thickening agents added to make it a putty form may be also be responsible for higher bond strength.19,20 Moreover, it was seen that zirconium oxide presence can also enhance certain physical properties of the material.21 Products that require chairside mixing of powder liquid components may have inconsistencies with respect to P:L ratio because of variations in operator mixing, leading to decreased bond strength.19,20,22 Hence, the higher push-out bond strength obtained for ERRMF might be attributed to the delivery system of this material.

On the other hand, Endocem MTA is chemically related to commercially available MTA. It is based on pozzolan reactions, the free calcium hydroxide that is formed at the time of hydration is used, leading to reduced calcium-releasing ability. Thus, less calcium/phosphorous proportion precipitates are formed, causing the bioactivity to reduce.23,24 As the bioactivity process has been found to be responsible for strong micromechanical bonding to dentin in case of MTA cements,25 the reduced push-out bond strength values for Endocem MTA can be attributed to its decreased bioactivity. Thus, ERRMF exhibited better resistance to dislodgement when compared to Endocem MTA after irrigation, owing to its inherent properties.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

Conclusion Within the limitations of this ex-vivo study, it can be concluded that EndoSequence Root Repair Material Fast Set Putty (ERRMF) can be a better alternative to Endocem MTA for repair of furcal perforations, as it exhibited superior bond strength. Further, irrigants (2.5% NaOCl and 2% CHX) had no effect on the bond strength of this material to the tooth. p

23.

24.

25.

Lussi A, Brunner M, Portmann P, Burgin W. Condensation pressure during amalgam placement in patients. Eur J Oral Sci 1995;103:388-93.

Adl A, Sadat Shojaee N, Sobhnamayan F, Sadat Shojaee N. The effect of chlorhexidine on push-out bond strength of mineral trioxide aggregate. Avicenna J Dent Res 2014; 6:e21195.

Hansen S, Marshall G, Sedgley C. Comparison of intracanal Endosequence root repair material and ProRoot MTA to induce pH changes in simulated root resorption defects over 4 weeks in matched pairs of human teeth. J Endod 2011;37:502–6.

Damas BA, Wheater MA, Bringas JS, Hoen MM. Cytotoxicity comparison of mineral trioxide aggregates and Endosequence bioceramic root repair materials. J Endod 2011;37:372–5.

Jiang Y, Zheng Q, Zhou X, Gao Y, Huang D. A comparative study on root canal repair materials: a cytocompatibility assessment in L929 and MG63 cells. Sci World J 2014;2014:463826.

Jeevani E, Jayaprakash T, Bolla N, Vemuri S, Sunil CR, Kalluru RS. Evaluation of sealing ability of MM-MTA, Endosequence, and Biodentine as furcation repair materials: UV spectrophotometric analysis. J Conserv Dent 2014;17:340-3.

Barralet JE, Gaunt T, Wright AJ, Gibson IR, Knowles JC. Effect of porosity reduction by compaction on compressive strength and microstructure of calcium phosphate cement. J Biomed Mater Res 2002;63:1-9.

Guo YJ, Du TF, Li HB, Shen Y, Mobuchon C, Hieawy A, Wang ZJ, Yang Y, Ma J, Haapasalo M. Physical properties and hydration behavior of a fast-setting bioceramic endodontic material. BMC Oral Health 2016;16:23.

Shokouhinejad N, Razmi H, Nekoofar MH, Sajadi S, Dummer PM, Khoshkhounejad M. Push-out bond strength of bioceramic materials in a synthetic tissue fluid. J Dent (Tehran) 2013;10:540-7.

Shokouhinejad N, Yazdi KA, Nekoofar MH, Matmir S, Khoshkhounejad M. Effect of acidic environment on dislocation resistance of Endosequence root repair material and mineral trioxide aggregate. J Dent (Tehran) 2014;11:161-6.

De Aza AH, Chevalier J, Fantozzi G, Schehl M, Torrecillas R. Crack growth resistance of alumina, zirconia and zirconia toughened alumina ceramics for joint prostheses. Biomaterials 2002;23:937–45.

Walsh RM, Woodmansey KF, Glickman GN, He J. Evaluation of compressive strength of hydraulic silicate-based root-end filling materials. J Endod 2014;40:969-72.

Askarinejad A, Pourkhorshidi AR, Parhizkar T. Evaluation of the pozzolanic reactivity of sonochemically fabricated nano natural pozzolan. Ultrason Sonochem 2012;19:119-24.

Han L, Kodama S, Okiji T. Evaluation of calcium releasing and apatite forming abilities of fast-setting calcium silicate based endodontic materials. Int Endod J 2015;48:124-30.

Reyes-Carmona JF, Felippe MS, Felippe WT. The biomineralization ability of mineral trioxide aggregate and Portland cement on dentin enhances the push-out strength. J Endod 2010; 36:286-91.

Queries about this article can be sent to Dr. Purayil, corresponding author, at tina.pp@manipal.edu.

REFERENCES 1.

2.

3.

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6.

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Gorni FG, Andreano A, Ambrogi F, Brambilla E, Gagliani M. Patient and clinical characteristics associated with primary healing of iatrogenic perforations after root canal treatment: results of a long-term Italian study. J Endod 2016;42:211-5.

Loxley EC, Liewehr FR, Buxton TB, McPherson JC. The effect of various intracanal oxidizing agents on the push-out strength of various perforation repair materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:490-4.

Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Endod Dent Traumatol 1996;12:255-64.

Hashem AA, Wanees Amin SA. The effect of acidity on dislodgment resistance of mineral trioxide aggregate and bioaggregate in furcation perforations: an in vitro comparative study. J Endod 2012;38:245-9.

Johnson BR. Considerations in the selection of a root-end filling material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:398-404.

Yan P, Peng B, Fan B, Fan M, Bian Z. The effects of sodium hypochlorite (5.25%), chlorhexidine (2%) and Glyde File Prep on the bond strength of MTA-dentin. J Endod 2006;32:58-60.

Guneser MB, Akbulut MB, Eldeniz AU. Effect of various endodontic irrigants on the pushout bond strength of Biodentine and conventional root perforation repair materials. J Endod 2013;39:380-4.

Kogan P, He J, Glickman GN, et al. The effects of various additives on setting properties of MTA. J Endod 2006;32:569-72.

Jang GY, Park SJ, Heo SM, Yu MK, Lee KW, Min KS. Washout resistance of fast-setting pozzolan cement under various root canal irrigants. Restor Endod 2013;38:248-52.

Alsubait SA. Effect of sodium hypochlorite on push-out bond strength of four calcium silicate-based endodontic materials when used for repairing perforations on human dentin: An in vitro evaluation. J Contemp Dent Pract 2017;18:289-94.

Dr. Agrawal

Dr. Purayil

Dr. Ginjupalli

Dr. Ballal

Ruchi Agrawal, M.D.S., is a former postgraduate student, Department of Conservative Dentistry & Endodontics, Manipal College of Dental Sciences Manipal. Manipal Academy of Higher Education, Manipal, Karnataka, India.

Tina P. Purayil, M.D.S., is associate professor, Department of Conservative Dentistry & Endodontics, Manipal College of Dental Sciences Manipal. Manipal Academy of Higher Education, Manipal, Karnataka, India.

Kishore Ginjupalli, M.Sc., Ph.D., is associate professor, Department of Dental Materials, Manipal College of Dental Sciences Manipal. Manipal Academy of Higher Education, Manipal, Karnataka, India.

Nidambur V. Ballal, M.D.S., Ph.D., is additional professor, Department of Conservative Dentistry & Endodontics, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India.

The New York State Dental Journal JUNE/JULY 2020 39 ●

Component

FIFTH DISTRICT

Getting the Message Out Janice Pliszczak, D.D.S., M.S., M.B.A. The Fifth District Dental Society launched an ad campaign June 5 focused on public awareness. It was aimed at letting people know that dental offices were open and safe. The campaign was scheduled to run for one month on Facebook and Spectrum’s local cable television channel. Members were asked to share the ad to their own personal or business Facebook pages. Many members took advantage of the suggestion and were thrilled to get the message out.

We are also working on ads to be placed in newspapers that are delivered throughout the entire Fifth District region. County dental societies will be given the sized ads, which they can place in appropriate newspapers.

could be said that the duties of the district president are predictable and rather routine—which is not meant to minimize the

president’s importance. But this year, the president’s tenure has been anything but routine.

Leaders throughout organized dentistry have faced a crisis like no other. President Burgart, with his executive committee and team at the district office, has charted a course through this pandemic, ever reacting and modifying. Their actions have enabled our members to persevere together.

Dr. Burgart’s vision, persistence, organizational skills and work ethic have been most important and much appreciated.

President Steven Burgart, third from right, honored for his work bringing dental care to underserved residents of Haiti, at site of his clinic with colleagues.

Conference is a Go As of the time of this submission, the Central New York Dental Conference (CNYDC) is set to take place as planned on Sept.

24-25 at the OnCenter in Syracuse. We have been in contact with the OnCenter, and there may be a few changes, but nothing that health practitioners are not already familiar with. The headliner this year is Gordon Christensen. Register now at www. cnydc.org.

SEVENTH DISTRICT

Rising to the Occasion H. Bradley Davidson, D.D.S. The Seventh District Dental Society would like to take this opportunity to recognize its president, Steven Burgart. Most years it

SEVENTH DISTRICT Treating patient at Haitian clinic founded by Dr. Burgart.

40 JUNE/JULY 2020 The New York State Dental Journal ●

These same skills are what allowed him to earn NYSDA’s highest honor, the JarvieBurkhart Award, which he received in May at the HOD meeting. This award is presented “in recognition of great service rendered in the field of dentistry” and, in Dr. Burgart’s case, “for philanthropic endeavors in the field of dentistry.”

In June 2010, Dr. Burgart traveled to Haiti to assess the dental care needs of people living in the island country. He returned home committed to helping the town of Borgne, an impoverished community of 80,000 on Haiti’s north shore. The people living in this remote location had never received dental care. As described in the HOD minutes, “Since his first trip he has designed, planned, organized, fundraised and installed what is known as the best-equipped dental clinic in the north of Haiti. The clinic operates with local staff and is augmented by in-service dentistry clinics organized by Dr. Burgart and many of his colleagues on visits to Haiti.”

The members of the Seventh District are most appreciative of Dr. Burgart’s efforts on our behalf this year and for his remarkable work in Haiti these past 10 years.

We are proud he is one of us!

SECOND DISTRICT

SDDS and NYCDS Members Help with PPE Allocation Effort In late May, the Second District Dental Society (SDDS) secured a large allocation of personal protective equipment (PPE) from the New York City Department of Health and Mental Hygiene, which was distributed to SDDS and New York County Dental Society members over a seven-day period.

Members of both components signed up for specific time slots, during which they picked up PPE kits containing surgical masks, face shields, gloves and N95 masks at SDDS headquarters in Brooklyn. Over 25 volunteers assisted with the distribution effort, gathering at SDDS headquarters to break down multiple pallets of PPE and apportion their contents into individual kits.

Both Bronx County Dental Society and Queens County Dental Society also re-

ceived shares of the PPE allocation, which was delivered to SDDS with the help of three trucks and pallet movers.

SDDS Adopts Virtual CE Model Because of the government-mandated shutdowns caused by the COVID-19 pandemic, SDDS revamped its continuing education format to include live webinars. This move allowed SDDS to deliver nearly all of its cancelled in-person CE programming using a “virtual classroom” model, enabling members to obtain much-needed CE credits during the lockdown.

To date, four continuing education presentations have been held via Webex, with more scheduled through June and July. The most recent of these were two sessions of the mandatory opioid prescribing course, which were offered on June 11 and June 14 as a free member benefit. In total, close to 200 members registered for the presentations.

Preparations for Greater New York Dental Meeting Underway Our Greater New York Dental Meeting (GNYDM) Organization Committee is hard at work as it prepares for the 96th session of this annual event, the premier dental continuing education and exposition in the country, to be held from Nov. 27 through Dec. 2. Led by General Chairman James Doundoulakis, Advisory Chair Lauro Medrano-Saldaña and Executive Director Robert Edwab, the committee consists of eight other members—four from SDDS and four from New York County Dental Society. They are Paul Teplitsky, William Bongiorno, Ian Lerner and Lorna FlamerCaldera (SDDS); and Richard Lewensen, Steven Moss, Maurice Edwards and Irvind Khurana (NYCDS).

nounced the reopening of dental offices as of June 1. Headquarters staff continued to work from home to provide members with the most up-to-date information and to be available to answer a myriad of calls for clarification and confirmation of the reopening and the protocols for doing so.

The Ninth District Dental Association is grateful to NYSDA leaders—President Payam Goudarzi, his officers, the Board of Trustees, and Dr. Mark Feldman, along with his staff—who worked tirelessly contacting the governor’s office and that of the lieutenant governor to advocate for the safe reopening of offices for all dental procedures.

In a joint effort with NYSDA and the ADA, the Ninth provided members with information about FEMA resources to use to access no- and low-cost PPE, enabling them to reopen their offices as safely as possible.

In the words of Winston Churchill: “Never was so much owed by so many to so few.”

Education Continues

NINTH DISTRICT

The Ninth moves further into the digital world hosting a webinar or two a week throughout April, May and June. A very timely webinar presented by Howard Pactovis, “Up-to-Date COVID-19 OSHA, Infection Control and Board-Specifics for Dental Offices,” was presented to members at no-charge on June 11. B. J. Mistry, Edward Feinberg and Bharat Joshi will also be presenting webinars in the next couple of weeks, as will Altfest. And the founder and CEO of ePractice Management is presenting a course entitled “Boosting Practice Recovery” in a webinar sponsored by Nobel Biocare for Ninth members. Ever hopeful, we are in the process of putting together an in-person fall CE course listing for our members.

Olga Lombo-Sguerra, D.D.S.

Town Hall Meetings

After months of round-the-clock advocacy on behalf of our members and dentistry in general, our executives, delegates and trustees, working hand-in-hand with NYSDA and the ADA, finally heard from Gov. Cuomo on May 31, when he an-

We had very positive feedback regarding our weekly virtual Town Hall meetings, which provided a platform for members to interact with one another, with the Ninth District Executive Committee and, on occasion, NYSDA leaders. Members were free to ask any questions they had, to share their

Good to be Back

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NEW YORK COUNTY

PPE Distribution Effort is a Success Ioanna Mentzelopoulou, D.D.S.

Ninth District

cont.

experiences during this unprecedented time, and to use these meetings to interact and exchange ideas with colleagues.

Online CPR With the ADA’s announcement that it was allowing CPR courses to be done primarily online (there is a required hands-on skills assessment as well), the Ninth has provided members with the ability to register through the American Red Cross at a facility closest to them in order to meet the CPR requirement for relicensure. We have contacted the AHA to schedule in-house courses for the fall, as well.

New York County Dental Society worked with the Second District Dental Society, NYSDA and the New York City Department of Health to get a large shipment of PPE for distribution to members. In total, approximately 1,600 bags of PPE (which included at least 20 NIOSH-approved N95 masks, a face shield and a box of gloves)

were handed out to members. This was a huge undertaking that involved sorting, reorganizing and, eventually, distributing the free PPE to members over a three-day period in early June.

Many thanks to the Second District Dental Society for the use of its space and support. We also appreciate and thank the following NYCDS volunteers for their help in making this member benefit possible: Yakir Arteaga, Suchie Chawla, Joshua Chubak and his two staff members, Ada Cooper and daughter Avery, Elaine Gonzales, Lois Jack-

Timely Bulletin Our May Bulletin, released on May 29 in digital format, was chock-full of relevant information, which was well received and appreciated by the membership.

Fingers Crossed We are hopeful that our September General Meeting will be able to go ahead as planned.

We will make a determination a bit closer to the meeting date. It is scheduled for Wednesday, Sept. 16, at The Grandview in Poughkeepsie. Denise Foran is set to present “Endodontic Diagnosis and Treatment Planning: A Multidisciplinary Approach.” If we cannot have it in-person, it will be held virtually. More information to follow.

The New Dentist Committee is planning its fall reception, currently scheduled for Tuesday, Sept. 22, at a restaurant in Rockland County. The Frills & Drills event was rescheduled to Oct. 28 at Saltaire in Port Chester. We are hopeful these events will be able to take place in-person. Fingers crossed.

If not, they will be held virtually. Be on the lookout for eblasts with information.

Dr. Mina Kim, second from left, bottom row.

NEW YORK COUNTY First in new webinar series titled “Contemporary Issues: Starting the Conversation” aims to bring dentists together to discuss and learn about today’s social issues.

42 JUNE/JULY 2020 The New York State Dental Journal ●

son, Jim Jacobs, Mina Kim, Gabriela Lee, Michelle Lee, Ioanna Mentzelopoulou, George Pliakas, Jaskaren Randhawa, Sara Shahi, David Shipper, Robert Sorin, Lawrence Spindel, Stacy Spizuoco and Vera Tang.

Webinars Shortly after New York City dental practices were closed to only emergency/urgent care, NYCDS shared pertinent webinars, two of which it hosted, with member and nonmember dentists, to provide assistance and guidance in dealing with the financial, employment, health and legal impacts of the COVID-19 crisis. NYCDS appreciates the many webinars, post-event memos and individual legal guidance provided by Corporate Friend Mandelbaum Salsburg. We also welcome webinars provided by Altfest Personal Wealth Management, Henry Schein Inc., and LB Goodman & Co.

COVID-19 Impact on Infection Control NYCDS had over 125 attendees for our very first webinar, led by infection-control expert John Molinari on June 2. Attendees at this free webinar received 1.5 CE credits and a review of lessons learned from the response to another respiratory outbreak, SARS-CoV-2, and emerging recommendations from leading health agencies.

Functional Relations: Racial Diversity

titled, “Contemporary Issues, Starting the Conversation.” The first webinar, “Functional Relations: Racial Diversity,” was held on June 24. Panel participants shared their honest feedback to questions concerning the role race has played in their careers, how to have conversations about race, and how to move beyond talk and take action. Attendees expressed appreciation for the program as an important first step. Future webinars will address the needs and concerns of members in LGBTQ and disabled populations.

Thank you to NYCDS President Lois Jackson, Secretary Mina Kim, Treasurer Suchie Chawla, Past President James Jacobs, and Rico Short and Elizabeth Simpson for their participation as panelists in this important webinar. NYCDS was pleased to see the webinar mentioned in the ADA Morning Huddle and New Member News.

The first in a new webinar series titled “Contemporary Issues, Starting the Conversation” aims to bring dentists together to discuss and learn more about today’s social issues.

ADA 10 Under 10 Award Given to NYCDS Officer NYCDS is proud of Mina Kim, one of the ADA’s 10 Under 10 Award recipients. The award recognizes 10 new ADA dentists who graduated between 2010 and 2019 who demonstrate excellence early in their careers.

Dr. Kim was selected to be in the exclusive

“top 10” list by the ADA New Dentist Committee after reviewing 88 nominations. The winners were chosen for making a different in science, research and education; practice excellence; philanthropy; leadership; and advocacy. Dr. Kim is secretary of NYCDS, co-founded the Woman to Woman Dentist Network, is a graduate of the ADA Institute for Diversity in Leadership and currently serves on the dean’s Strategic Advisory Committee at New York University College of Dentistry. She also founded the NYCDS Give Kids A Smile Day event and provides pro bono dental services to sex trafficking victims. NYCDS is so pleased to see Dr. Kim recognized nationally!

SUFFOLK COUNTY

Give Kids A Smile Radha Sachdeva-Munk, D.D.S. At our Feb. 8th Give Kids A Smile event, Suffolk County Dental Society treated a record number of children, with a record number of volunteers. It was a flawlessly executed program, led by our chair, Jimmy Kilimitzoglou.

SCDS thanks its sponsors: FidelisCare, DentaQuest, Henry Schein Cares, Henry Schein Dental, MARVIL FIT, MLMIC, LI Suffolk Center for Speech, SDI Dental, Lions International (Mattituck), Syneos Health, Rotary International (Riverhead)

In an effort to bring dentists together to discuss and learn more about today’s social issues, NYCDS launched a new webinar series

NEW YORK COUNTY NYCDS volunteers preparing PPE for distribution to members.

SUFFOLK COUNTY Volunteers at 2020 Give Kids A Smile event at Long Island Aquarium.

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Component

Eastern Suffolk Board of Cooperative Educational Services (ESBOCES), St. Charles Hospital, Long Island Head Start, Sunrise Hi Railers, and the Riverhead Aquarium.

Suffolk County

cont.

and, of course, the American Dental Association.

We also owe a debt of gratitude to our 150 volunteers from SCDS, Stony Brook School of Dental Medicine, Dental Hygiene Care Center of Farmingdale State College,

General Membership Meeting SCDS held it first General Membership Meeting in February. One hundred twenty members attended and proudly looked on as President Claudia Mahon-Vazquez received a proclamation from Suffolk County Legislator William Spencer. Dr. Spencer had visited our Give Kids A Smile event ear-

lier in the month and was so moved that he returned to recognize us for this important community service.

Later in the meeting, Fred Ferguson provided a two-credit CE course on “Advancing Dentistry Value in Healthcare.”

Mid-Late Career Dentist Forum More than 60 members gathered for a SCDS Mid-Late Career Dentist Forum, Feb. 26, sponsored by Altfest, TD Bank Healthcare Practice Solutions and Henry Schein Dental. A six-expert panel covered pertinent topics and answered questions particularly important to mid-career and late-career dentists. They included preparing a practice for sale, selling a practice, taking on an associate, financial planning for the practice, retirement and personal finance, office investment, office design, practice transition, practice management/optimization, practice acquisition and more.

Attendees enjoyed food and drink, great company and received much helpful information.

Don’t Miss a Thing

Tending to youngster at GKAS event.

SUFFOLK COUNTY President Claudia Mahon-Vazquez receives proclamation from Suffolk County Legislator William Spencer.

44 JUNE/JULY 2020 The New York State Dental Journal ●

We continue to make a significant push toward better communication and connection with our members using methods that more easily integrate with their lifestyle.

You can now find us on Facebook, Twitter, Instagram, LinkedIn and, even, Spotify, in addition to our traditional www.SuffolkDental.Org presence.

SUFFOLK COUNTY Panelists address audience at career forum in February.

BOOKS

The Dentist’s Drug and Prescription Guide Second Edition Mea A. Weinberg, D.M.D., M.S.D., R.Ph.; Stuart J. Froum, D.D.S.; Stuart L. Segelnick, D.D.S., M.S. (John Wiley & Sons, Inc., Hoboken, NJ. 2020. 298 pages; including Appendices and Index. $79.99.)

Reviewed by Leonard B. Goldstein, D.D.S., Ph.D. The Dentist’s Drug and Prescription Guide, Second Edition, was written and edited by three New York periodontists and oral implantologists: Mea A. Weinberg, D.M.D., M.S.D., R.Ph.; Stuart J. Froum, D.D.S.; and Stuart L. Segelnck, D.D.S., M.S. It includes contributions from eight others (scientists, dentists and physicians), and is divided into eight important chapters.

This second edition provides the reader with a timely and important update to the original textbook and shows the scientific basis for the drugs used in dentistry. It contains an extremely useful reference and guide to drugs used and prescribed in dental practices. The initial 126 pages (Chapters 1-4) cover: l Pharmacology l Prescriptions and Drug Names l Basic Prescribing and Drug Dosing l Drugs Prescribed in Dentistry Chapter 5 covers the management of potential drug interactions in dentistry. As in all chapters, it utilizes an easy-to-read Q & A format, including multiple tables and references regarding the “what to do” in cases of drug interactions.

Chapter 6 explains the evidence-based theory for prescribing drugs in dentistry. This chapter includes sections specific to different dental specialties (e.g., periodontics, endodontics and oral surgery).

Chapter 7 describes, in detail, the management of medications taken by medically complex dental patients. It covers the proper utilization of pre-medication with antibiotics, treatment and management of patients with cardiovascular disease, pregnant and nursing patients, patients with thyroid disease, asthma and diabetes. It also includes the treatment and management of patients using psychiatric and neurological medications, anti-rejection medications for organ transplant

recipients, as well as recreational and illicit drugs. The chapter concludes with a section on HIV/AIDS research and medications. As in all chapters, it includes multiple tables and is written in the easy-to-read Q & A format.

The final chapter, #8, concludes with the use of herbals, dietary supplements and natural remedies. It includes drug interactions with these remedies, and their implications in dentistry.

The authors have provided three Appendices at the conclusion of the book. They cover: l Smoking Cessation Therapy l Oral Manifestations of Drugs l American Heart Association Antibiotic Prophylaxis Guidelines Each appendix is written in the same easy-to-read Q & A format, with multiple tables for reference.

This book provides the most current information, and is a “must read” for all dentists, dental residents and dental students.

The New York State Dental Journal • JUNE/JULY 2020 45

continuing education

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 Foundation, 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: $60/dentists; $40/hygienists. Nonmember fees are: $120/ dentists; $80/hygienists. All those who achieve a passing grade of at least 70% will receive verification of completion. Credits will automatically be added to the CE Registry for NYSDA members.

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

The Dentist’s Role in the Pre-Radiation Assessment and Management of a Patient Undergoing Head and Neck Radiation Therapy—Page 23-27 1. Radiation-related dental complications include osteoradionecrosis and radiation caries.

❑ T or ❑ F 2. Squamous cell carcinoma is the most common malignancy of head and neck cancer (HNC).

❑ T or ❑ F 3. HNC is not treated with chemotherapy.

❑ T or ❑ F 4. Radiation therapy (RT) of HNC can produce mucositis as a complication.

❑ T or ❑ F 5. Dentists are never asked by the oncology team to provide some form of “dental clearance” or assessment prior to a patient beginning RT.

❑ T or ❑ F

❑ Enclosed is a check for the full amount. Members’ fees are $60/dentists; $40/hygienists. Nonmember fees are $120/dentists; $80 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: ❑ VISA ❑ MasterCard ❑ American Express

Telephone

Card #

E-mail

Expiration Date

ADA #

Name

License #

Address

NYSDA Member? ❑ yes or ❑ no

City

State

Zip

46 JUNE/JULY 2020 The New York State Dental Journal ●

Local/State Dental Society

6. To minimize damage to adjacent healthy tissues, modern radiation therapy is split into smaller doses over time.

❑ T or ❑ F 7. Radiation caries does not occur on the cervical and incised edges of teeth.

❑ T or ❑ F 8. RT should begin no sooner than 14 days after extractions, but may be started sooner when circumstances warrant.

❑ T or ❑ F 9. Xerostomia is not a RT complication of HNC treatment.

❑ T or ❑ F 10. It is important for the dentist to follow the patient receiving RT throughout the course of treatment.

❑ T or ❑ F Dental Management of Adolescents and Young Adults Living with HIV/AIDS—Page 28-31 1. Nearly one-in-ten people living with HIV (8.6%) are under the age of 20.

❑ T or ❑ F 2. Among adolescents and young adults, HIV disease incidence is greatest among Caucasian males aged 19 to 24.

❑ T or ❑ F 3. Dentists play a leading role in the healthcare of young patients with and at risk for HIV by providing services from identification of possible HIV infection, to prevention, diagnosis and management of related oral disease.

❑ T or ❑ F 4. Early manifestations of HIV do not occur in the mouth.

❑ T or ❑ F 5. Patients with HIV/AIDS can be safely and effectively treated by dentists using universal precautions.

❑ T or ❑ F 6. HIV always requires antibiotic prophylaxis prior to dental care.

❑ T or ❑ F 7. Parotid swelling is a soft-tissue dental consideration of HIV in adolescents and young adults.

❑ T or ❑ F 8. Dentists should provide targeted counseling regarding diet, oral health-related behaviors and home care to HIV patients.

❑ T or ❑ F 9. Kaposi sarcoma is the most malignant tumor associated with HIV.

❑ T or ❑ F 10. Oral candidiasis is not seen clinically in patients with HIV/ AIDS.

❑ T or ❑ F

Effect of Irrigants on Dislodgement Resistance of Two Root Repair Materials in Furcation Perforations—Page 35-39 1. Root perforation is one of the most common mishaps during endodontic tooth preparation.

❑ T or ❑ F 2. Perforation of the pulp chamber floor has a good prognosis compared to perforations of the apical third of the root.

❑ T or ❑ F 3. Biocompatibility is an important factor for a material used to repair perforation defects.

❑ T or ❑ F 4. The purpose of this study was to evaluate and compare the effect of various endodontic irrigants on the dislodgement resistance of EndoSequence Root Repair Material Fast Set Putty (ERRMF) and Endocem Mineral Trioxide Aggregate (MTA) in furcation perforations.

❑ T or ❑ F 5. The study involved 120 human extracted mandibular teeth.

❑ T or ❑ F 6. The study used three different irrigation solutions: 2.5% NaOCl; 2% CHX; and distilled water (control group).

❑ T or ❑ F 7. Among the materials studied, ERRMF showed higher bond strength values than Endocem MTA.

❑ T or ❑ F 8. It is not important for a root repair material to exhibit sufficient elastic modulus without failure.

❑ T or ❑ F 9. ERRMF consists of dicalcium silicate, tricalcium silicate, zirconium oxide, tantalum pentoxide and calcium sulfate.

❑ T or ❑ F 10. The conclusion of the limited ex-vivo study is that ERRMF can be a better alternative to Endocem MTA for repair of furcal perforations.

❑ T or ❑ F

The New York State Dental Journal JUNE/JULY 2020 47 ●

CLASSIFIED INFORMATION

Online Rates for 60-day posting of 150 words or less: Members: $100—can include photo/im-

FOR SALE CENTRAL PARK SOUTH: Prime location. Oral surgery practice for sale in Midtown Manhattan with four operatories facing Central Park. Exclusively a medical building of condominiums fully occupied by multiple dental and medical offices. Current oral surgeon retiring.

Dental implant and wisdom teeth-based practice for sale with beautiful four-room office for long-term lease. Call Judit at (973) 936-3447; please leave a message with call back information.

CLASSIFIEDS

CENTRAL NEW YORK: Busy general practice with 11 operatories. Collections of $1.65M/adjusted EBITDA $285K. Real estate for sale. 5,000+ active patients and 100 new patients/month. Quick 30 minutes from downtown Syracuse in Forbes Magazine-rated area as one of top 10 places to raise family. Affordable housing, highly ranked schools and quick commutes that preserve family time. Experience small town, community feel, with easy access to Syracuse metro area. Contact Kaile Vierstra with Professional Transition Strategies. Email: kaile@professionaltransition.com; or call (719) 694-8320.

NASSAU COUNTY: 35-year general, FFS private practice looking for an associate to quickly transition into owner. Located on South Shore in shoreline community. Please email resume or CV: mmann215@aol.com.

age online. Non-Members: $150 + $40 fee for online photo. Corporate/Business Ads: $200 + $40 fee for photo/image/logo. Classifieds will also appear in print during months when Journal is mailed: Jan, March, April, July and Sept.

SULLIVAN COUNTY: 90 minutes from NYC. Longestablished family/cosmetic dental practice for sale by owner with option to buy or lease multi-unit mixed-use building. $370K collections, with easy paced, 4-day workweek and low overhead. Great equipment and tech. Few select (reasonably paying) insurances and fee-for-service. If you are looking for life change and great opportunity, please call (845)397-0633; or email: Sullivancountydental@gmail.com.

QUEENS: Fresh Meadows. 36-year-old general practice. PPO and private. Seeking to transition; willing to relocate. Current lease expiring at end of year. Would ideally like to work for several more years. Please contact to discuss options.

Email: Molarman54@gmail.com.

HERKIMER COUNTY: Time for some fresh air. Twostory building; 1,400 square feet. Apartment upstairs.

New Hartford schools are 20-minute commute. Ranked #8 in upstate NY. Practice grosses $400K on 4-day work week. Doctor retiring. Building/practice $290K. Inquiries to: FXMDDS@aol.com.

BROOME COUNTY: Practice for sale. Dentist retiring. GP practice in area with very favorable patientto-dentist ratio of 5,112:1. Collections $585K/Net $235K. 6 well-equipped operatories. Digital, Pan and 3,000 active patients. Standalone building. Real estate for lease or sale. Contact Deanna Eiss, Hudson Transition Partners (610) 312-7120; or email: deanna@hudsontranstions.com. Listing #2638.

SARATOGA: Highly rated general practice in prime location with significant opportunity for growth as practice is currently set up for quality of life and 4-day weekends. Office and premium-level equipment, lightly used; excellent ergonomic flow and very low fixed overhead. Contact Robert Stanbery with Practice Transition Partners at (888) 789-1085, Ext. 1; or by email: contact@practicetransitions.com.

ALBANY: General practice with 3 associates, parttime periodontist and 25 new patients/month.

Productive hygiene. High-quality, family restorative/ prosthetic practice. Located in heart of major corporate business area and UAlbany. Contact Henry Schein Professional Practice Transitions Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY239.

SUFFOLK COUNTY: Mature private GP practice in desirable, suburban downtown village location. Open 26-30 hours/week with 3 operatories and 1,000 square feet. Referring out all specialty services. Contact Henry Schein Professional Practice Transition Sales Consultant Michael Apalucci at (718) 213-9386; or email: michael.apalucci@henryschein.com. #NY280.

BUFFALO: Well-established, thriving, two-doctor general practice. One doctor willing to stay post sale. Located in medical building attached to hospital, near college campus. On main bus route and near train station. Working 41 hours/week with 5 ops, digital and PracticeWorks. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY283.

FAYETTEVILLE: 6 ops; one is surgical room. 2 days/week. Standalone building on main road.

Eaglesoft, Pelton Crane chairs, Triangle Sterilization center. Staff does not stay. Location, location.

Building also for sale or lease. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY277.

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CENTRAL NEW YORK: Established Endodontic practice serving area for 50 years. Seeking goaloriented graduate or seasoned doctor. State-of-the art. 3 ops; high-tech. Very lucrative office on 10-12 days/month. Strong referral network. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY278.

ADIRONDACKS: Experience the beauty of outdoors.

General practice with 6 ops. Busy, productive practice; most all procedures kept in-house. Dentrix, Pan and new digital scanner. 2,700 active patients; mainly FFS. Long-term staff working 32 hours/week. Building also for sale. Contact Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY172.

ONEIDA COUNTY: Terrific opportunity. Well-established practice in urban community. Converted residence; ample parking; busy main street with professional businesses. Five operatories. Dentrix, Dexis and experienced staff. Real estate available. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY219.

FINGER LAKES AREA: 6-op digital practice in desirable location; using Eaglesoft. 1,500+ active patients; refers out specialties. Satellite office available for purchase in PA, 45 miles away. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY286.

BROOKLYN: General practice in desirable location with 5 equipped ops. Grossing $890K in digital, hightech, updated modern office using Dentrix software.

Strong hygiene program exists. Turnkey opportunity.

Contact Henry Schein Professional Practice Transition Sales Consultant Linda Zalkin at (631) 357-1003; or email: linda.zalkin@henryschein.com. #NY288.

SYRACUSE SUBURB: 4 equipped ops in desirable location. Fully digital, paperless, with strong hygiene program and EagleSoft. Refers out specialties. Gross revenue $773K. Contact Henry Schein Professional Practice Transitions Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY291.

SCHENECTADY: 3-op general practice with Dentrix, digital and 5 days/week of hygiene. Gross $543K. Located in Historic District. Shared waiting room, lab and leased space. 5,645-square-foot building with rental apartments for sale at $300K. Contact Henry Schein Professional Practice Transitions Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY294.

EAST SYRACUSE: Productive, 3-op general practice with room for expansion to 4. Located in Minoa.

Building for sale with rental apartment in 1,400 square feet. 5-10 new patients/month and 4 hygiene days/ week. Grossing $527K. Participates with some insurance; refers out specialty services. Contact Henry Schein Professional Practice Transitions Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY299.

QUEENS: Strong oral surgery practice with $1.2M+ gross revenue. 3 ops, equipped treatment rooms.

Desirable location. Digital, paperless, modern office using WinOMS software. 25 years goodwill. Contact Henry Schein Professional Practice Transitions Consultant Linda Zalkin at (631) 357-1003; linda.zalkin@henryschein.com. #NY302.

SUFFOLK COUNTY: North Fork. General practice with 3+ 1 treatment rooms. Digital, modern, updated and in growth area. Specialties referred out. Gross revenue $664K. Contact Henry Schein Professional Practice Transition Sales Consultant Mike Apalucci at (718) 213-9386; or email: michael.apalucci@henryschein.com. #NY304.

HUDSON VALLEY: General practice with 25 years goodwill. Digital; 3 equipped treatment rooms utilizing Dentrix. Specialties referred out.

Huge growth potential. Contact Henry Schein Professional Practice Transitions Consultant E. Scott Weinberger at (518) 257-9737; or email: scott.weinberger@henryschein.com. #NY306.

CAPITAL REGION: Stunning, six-treatment-room general practice in desirable location. Digital, hightech, updated and using Eaglesoft in modern office with strong hygiene program. Gross revenue $1M. Real estate also available. Contact Henry Schein Professional Practice Transitions Consultant E. Scott Weinberger at (518) 257-9737; or email: scott.weinberger@henryschein.com. #NY307.

SUFFOLK COUNTY: Pediatric practice. Highly respected and in operation 40 years. Established 21 years by current owner. 1,600 square feet in lovely community with 4 ops. 4-day workweek. 10% FFS; 70% PPO; and 20% Medicaid. Solid staff members will stay with new owner. Motivated seller. Please contact for more information; interested in all offers.

Henry Schein Professional Practice Transition Sales Consultant Linda Zalkin at (631) 357-1003; or email: linda.zalkin@henryschein.com. #NY308.

SULLIVAN COUNTY: Very successful, established crown & bridge/restorative practice located near both medically based growth area and vacation wonderland. Professionally designed 8-op office in 3,500-square-foot condo. Open 40 hours/ week; adding 20 new patients/month. Mix of FFS and PPO. SoftDent, digital X-rays, intraoral camera, Pan, Ceph and full professional grade lab in house. Suburban property is handicap accessible and has easy freeway access. For details contact Henry Schein Professional Practice Transition Sales Consultant Mike Apalucci at (718) 213-9386; or email: michael.apalucci@henryschein.com. #NY309.

FAYETTEVILLE: Central New York general practice in desirable community. Outright sale or available for Associate leading to buy-in. High visibility building with 7 ops. Digital, Dentrix, 2 full-time hygienists.

Over 2,200 active patients and no state insurance.

Referring out many specialty procedures. For details contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY310.

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

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

WILLIAMSVILLE: General practice. Opportunity to generate income immediately. State-of-the-art, 4-op practice. Professional office park, with ample parking and fully handicap accessible. 4.5 days; 1,500 active patients; over $500K+ gross revenue.

FFS/PPO; no Medicaid. Fully booked with growth options as oral surgery, implant placement and perio referred out. For details contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY314.

SARATOGA COUNTY: Practice located on busy road. Twenty new patients/month. Facility updated and modern, with 6 ops, digital X-rays, Pan, Eaglesoft.

Grossing $660K. For details contact Henry Schein Professional Practice Transition Sales Consultant E. Scott Weinberger at (518) 512-9988; or email: escott.weinberger@henryschein.com. #NY315.

ROCKEFELLER CENTER: Modern office. 4 operatories. CBCT, digital radiographs (2 Dexis sensors). Fully computerized and networked. For sale or rent. Great long-term or short-term lease available. Please act quickly. Contact by email: rockcenteroffice@gmail.com; or call (516) 589-0772.

The New York State Dental Journal JUNE/JULY 2020 49 ●

CLASSIFIEDS

CAMDEN: 4-op modern practice with associate buyin opportunity. Digital, high tech, paperless; utilizes EagleSoft. Strong hygiene program. Contact Henry Schein Professional Practice Transitions Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY285.

HAMPTONS: High-quality FFS general practice in highly desirable community. Practicing 30+ years.

2,300-square feet. 4 ops and room for expansion.

Practice is digital; CBCT Scan, Trios scanner and Pan. Specialty procedures referred out. Showplace office; won’t last long. Contact Henry Schein Professional Practice Transitions Consultant Linda Zalkin at (631) 357-1003; linda.zalkin@henryschein.com. #NY296.

CLASSIFIEDS

SYRACUSE: Exceptional ownership opportunity.

Seeking dedicated Holistic dentist to purchase highquality, well-established, biocompatible dental practice with long history of excellence. Patients are interested in “safe” mercury amalgam removal and placement of suitable dental materials based on reactivity testing results. They also seek nonsurgical periodontal treatment and quality restorative options. Well-respected practice supported by caring, highly skilled and devoted team of professionals, with strong emphasis on CE and professional growth. Owner will assist with quality introduction period to ensure smooth transitions.

Please reply in confidence with your objectives and CV to The Sletten Group, Inc. Office (303) 699-0990; fax: (303) 699-4863; or email: pam@lifetransitions.com.

QUEENS: Corona. Immediate occupancy. Hightraffic location next to LIE Exit 20. Near E, F, R trains; Q-88 bus stop in front of building. Available Mon, Wed, Fri, Sat and Sun. 800 square feet. Equipped operatory. Tenant welcome to bring whatever you need. Darkroom, lab, reception and large waiting area. Parking spot for dentist. Excellent opportunity.

Inquiries to: richardsnyderdds@gmail.com; or call: (516) 659-0310.

ORANGE COUNTY: 60 minutes from NYC. 40 years in town. Four equipped ops + 3 more plumbed.

2,000 square feet. Mostly PPO; no Medicaid. Open 3 days/week. 2019 = $320K; 2018 = $380K; 2017 = $400K. Asking price $110K; negotiable. Inquiries to: doctorylee@yahoo.com.

PLATTSBURGH: Beautiful practice for sale. Busy practice located in heart of Adirondacks, right off Lake Champlain. Dentist owner retiring after 40 years of practice. Well-established and well-known in community.

Office includes digital X-ray, Pan, 4 spacious operatories with 2 fully equipped. Onsite parking; excellent maintenance and great patient base. Owner is looking to sell to the right dentist at a more than reasonable price. For further inquiries, please email: nadiadmd@gmail.com.

FOR RENT MIDTOWN MANHATTAN: 1-2 operatories available full time or part time. Renovated, sunny, windows with private office in 24-hour doorman building.

Reasonable. Call (212) 581-5360.

NORTH DAKOTA: $3M practice for sale or associate. Work smarter not harder. Current owner relocating.

Produced $3M in 2019 and on pace to do same in 2020 despite COVID-19. Collections are 99%. Current doctor works 9-2 Mon-Friday and approximately 185 days/year. Seeking dentist who can place implants, endo, crown & bridge and complex cases. Overhead 34% and small hygiene practice. Perfect for doctor looking to get off the rat wheel; no 16-hour days; no weekends. Travel, enjoy family, save for retirement.

Current doc paid off $2M in student and practice debt in 3 years while enjoying monthly schedule of 3-day weeks. Commuting an option. Contact drbobsmithynotminot@gmail.com.

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

QUEENS: General dental practice for sale. Dentist retiring but will stay on to transition to new practitioner.

Office is FFS and better PPO insurances. No capitation or Medicaid. Fourteen months left on assignable lease.

Email owner at: skidoc1955@aol.com.

ROCKEFELLER CENTER: Modern office. 4 operatories. CBCT, digital radiographs, 2 Dexis sensors. Fully computerized and networked. For sale or rent. Great long-term or short-term lease available. Please act quickly. Contact by email: rockcenteroffice@gmail.com; or call (516) 589-0772.

ROCKVILLE CENTRE: Dental office building for sale.

Located on major intersection at 364 Merrick Road.

2,300 square feet. 5 treatment rooms; expandable.

Onsite parking; full basement with lab; 2-zone HVAC gas/heat. Equipment included. Taxes $20K annually.

Price $725K. Contact owner at (516) 652-9238; or email: alexandercorsair1941@gmail.com.

LOWER WESTCHESTER: General dental practice. Two clean, beautiful, fully equipped operatories; plumbed for third. Gross $215K on 3 half days. 650 active patients. PPO insurance and private patient base.

Great central location with parking lot. Reasonable rent. Ground-floor entrance; storefront office. Please email: maxillaryarches1@gmail.com.

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

NORWALK, CT: Norwalk dental suite for lease.

1,591 square feet; 4 ops. Fully equipped. Literally move in and start the next day. Perfect for start-up or satellite. Nice interior. Computerized; Dexis. Longterm lease available with reasonable terms. Will help new dentist with free or discounted rent period. For more info, email: NorwalkCTOffice@gmail.com; or call (203) 807-4507.

MANHATTAN: Rockefeller Center Conservatory.

Available for rent. 2 operatories; one consult room available for full time/part time in the prestigious Rockefeller Center Conservatory. Doorman building and convenient location. Fully equipped and ready to use.

Please inquire at: advperio28@gmail.com.

50 JUNE/JULY 2020 The New York State Dental Journal ●

JERICHO: Space share opportunity. Are you a specialist looking for place to start? Or are you looking to slow down and merge with another office. Let’s talk. Brand new office with space to share. Digital,with Pan in office and completely paperless. 4 ops; 3 plumbed. Please contact me and let’s make this work. Call (516) 592-1555; or email: info@pdmfamilydental.com.

PARK SLOPE: Ready-to-use dental operatory and personal office available for rent in Park Slope, Brooklyn. Established medical complex. Easy to build and grow your own practice.

Optional help with dental assistants, billing services and insurance assistance, etc., if needed. Flexible lease terms (per hour, per day, etc.). Great neighborhood. Street access, with lots of foot traffic. Easy to commute to and from with public transportation. Please call/text (917) 605-9496; or email: doc@centralparkdentalservices.com.

MANHATTAN: Dental office for rent. 1-3 operatories for sublease, full time only, in prime Midtown location.

Front desk space, private office, supply and file storage space. Part of 6-operatory, 2,500-square-foot facility in high security, Class A office building. Beautifully appointed, architecturally designed office with all new equipment in windowed treatment rooms. Air filtration systems and PPE available to comply with CDC Best Practices during pandemic. Subtenant will have option to take over entire space and purchase owner’s practice under new 10-year lease at current market rate. Reply to ddsnow28@aol.com and leave your contact information for more details and to schedule an appointment for viewing.

MANHATTAN: Grand Central Area. Madison Avenue.

State-of-the-art office with FFS practice has 1-2 operatories available FT or PT. Option for private office. Perfect for someone who needs to move their practice and wants to feel at home. Specialist or 1-day/week rental with good references will be considered. Please contact for more info.

Call (914) 806-1122; or email: lsarettdds@aol.com.

SERVICES DENTAL PRACTICE SALES & PURCHASING: 3PercentDental.com is dental practice brokerage service with very simple goal: helping you sell your dental practice without the standard 8% to 10% commission typically charged. We charge just 3.99% commission. Are you selling real estate with your practice? We charge absolutely nothing to sell your real estate. Are you buying? Pay us absolutely nothing. That’s correct. Our brokerage services are FREE to buyers. Dentists are beginning to refer to 3PercentDental. com as the Costco of dental practice brokers. We are very proud of that fact. Please visit us at www.3PercentDental. com to see our current practice listings.

TAXES: Your office, business or personal. Specialty dentists. Personable CPA. Call Stuart A. Sinclair, CPA. Visit our website: www.dentaxsolutions.com. Offices located at 1120 Old Country Road, Plainview, NY 11803.

Contact: Stu Sinclair, CPA, at (516) 935-2086; or email: stusinclair@yahoo.com.

OPPORTUNITIES AVAILABLE SEEKING WESTERN SUFFOLK OPPORTUNITIES: General dentist. Looking to get out but cannot abandon your patients? COVID-19 has drastically changed the way we are going to practice. Highly trained and experienced dentist looking for opportunities in western Suffolk area. Only interested in DDS or PPO situations.

Would have interest in several types of situations, including taking over an existing practice. Contact: dds411746@gmail.com.

UPPER EAST SIDE: Seeking quality general dentist with nucleus of patients to sublet an operatory leading to future opportunity for purchase of long-established practice in very desirable location. Serious inquiries only.

Call (914) 714-3784.

NORTHERN NY: Multi-specialty practice looking for FT periodontist with Board Certification for partnership.

No competing periodontist in 70-mile radius. FT schedule day one. CBCT, all digital, CO2 Laser, Trios3 shape scanner. Modern building and great staff, with full benefits.

Contact Henry Schein Professional Practice Transitions Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY297.

CENTRAL NEW YORK: Established Endodontic practice serving area for 50 years. Seeking goal-oriented graduate or seasoned doctor. State-of-the art, 3 ops, high-tech, very lucrative office on 10-12 days/month. Strong referral network. Contact Henry Schein Professional Practice Transition Sales Consultant Donna Bambrick at (315) 430-0643; or email: donna.bambrick@henryschein.com. #NY278.

NASSAU COUNTY: 35-year general private practice, fee-for-service, looking for associate to quickly transition into owner. Practice located on South Shore in shoreline community. Please email resume or CV: mmann215@aol.com.

SYRACUSE: Seeking endodontist. Immediate availability. Full-time position as associate at busiest Endo practice around. CNY dental community fixture for 36 years. Large, single-office 5-star setup. Early partnership as soon as you are ready. Senior associate with 35 years experience, willing to fly you up and pay expenses. Let’s talk. Peter S. Ceravolo, DDS, Endodotic Specialist. Call (315) 345-2404.

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JERICHO: Seeking associate or specialist to share space. Are you a specialist looking for space? Or General dentist looking to decrease overhead? I have brand new, 4-op practice. Looking to add another dentist as associate or bring in specialist to share space. Call to see how we can help each other at (516) 592-1555; or email: info@pdmfamilydental.com.

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The New 2York State Dental Journal JUNE/JULY 2020 51 NYSDA-TDSC Journal Ads_3.625" x 4.75"_finalBleeds.indd 3/21/19 9:49 AM ●

CLASSIFIEDS

ONEONTA: Bassett Healthcare Network seeks full-time Pediatric Dentist and an Endodontist for its group practice. Applicants must possess outstanding communication/documentation skills, be able to function independently and as part of a team, and be competent in all aspects of general dentistry, including behavior management for children and special needs patients. This practice includes 9 operatories, 3 general dentists, 4 hygienists, and 1 oral surgeon. We use Eaglesoft dental records, digital radiography and Panorex. Practice management, administrative, and IT support are provided. Minimal evening and weekend phone calls shared among network dentists. Contact: debra.ferrari@bassett.org; or call (607) 547-6982.

SARATOGA COUNTY: With the opening of our brand new office, we seek full-time associate. If you love people, are driven and desire to advance your skills on a daily basis, we need you. Utilizing CEREC, 3D printing, CBCT, guided implant surgery and all facets of general and cosmetic dentistry. FFS patients and handful of PPO plans. Emphasis on restorative, fixed, cosmetic and implant surgery. All Endo referred out to specialist.

Offering: competitive compensation; percentage-based compensation, which may range from $1K-$3K per day; health; dental; malpractice; CE; mentorship; leadership training; office system training. Additional information at: www.salvatoredental.com/associate. Inquiries to: drvera@salvatoredental.com.

ADDENDUM

EDPAC Boosters The New York State Dental Association salutes its members and friends who have generously contributed to the Empire Dental Political Action Committee (EDPAC). Each person listed here made a voluntary contribution between January 1 and June 8 of this year. Those whose names appear at the Liberty Level gave $500 or more. Honor Roll members donated $250 or more. And Capitol Club members gave $100 or more.

Andolina, Richard (07) Barnashuk, Frank (08) Breault, Michael (04) Caruso, Joseph (Q) Doherty, Robert (09) Dominger, Martin (S) Dowd, Brendan (08) Feldman, Mark (N) Friedman, Joel (B) Galati, James (04) Grazina, Victor (S) Leary, Paul (S) Mahon-Vazquez, Claudia (S) Meyer, John (07) Volland, Lawrence (08)

Biller, Harold (Q) Callahan, John (05) Cheung, Man Sing (02) Dunn, Mary Beth (08) Ehlers, Michael (08) Hart, Paul (06) Herzog, Robert (08) Jhaveri, Viren (Q) Joshi, Bharat (09) Soule, Scott (04) Tegtmeier, Carl (09) Verma, Binod (N)

52

JUNE/JULY 2020 â&#x20AC;˘ The New York State Dental Journal

Wolfgang, Lawrence (08) Abellard, Beauvoir (02) Behrman, Jeni (07) Behrman, Joseph (07) Best, Jed (NYC) Bryan, Amy (08) Burgart, Stephen (07) Burlingame, Michelle (04) Cocozzo, Christina (04) Cuomo, Anthony (09) Cuomo, Christopher (09) Davidson, H Bradley (07) Edwards, Adam (03) Faber, Zackary (S) Fass, Stuart (03) Feinberg, Michael (02) Fialkoff, Bernard (Q) Giller, Jeffrey (N) Iofin, Aleksander (NYC) Karol, John (03) Koch, Keith (07) Marchese, Robert (08) Mc Grath, Terence (09) McIntyre, John (02) Meitner, Sean (07) Miller, Edward (09) Mintz, Alan (02) Reszel, Robert (08) Roger, James (07) Romano, Richard (02) Saunders, Ralph (07) Smith, Herbert (09) Sullivan, Ellen (Q) Travagliato, Charles (08) Twist, John (08) Utterback, Madeline (09) Valerio, Matthew (07)

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